A manual for re-education of aphasia patients

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A MANUAL FOR RE-EDUCATION OF APHASIA PATIENTS

A Project Presented to the Faculty of the School of Education The University of Southern California

In Partial Fulfillment of the Requirements for the Degree Master of Science in Education

by Maurice Sklar June 1950

UMI Number: EP46066

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TABLE OF CONTENTS CHAPTER I.

II.

PAGE

INTRODUCTION ...................

1

Nature of the P r o b l e m .................

2

Neurological Implications .............

3

NATURE OF A P H A S I A ....................... The Specific Nature of Aphasia

. . . .

Classification of Typesof Aphasia

III.

8 9

. .

10

Description of the Classification . . .

11

DIAGNOSIS

........ ..

.

.............

Case H i s t o r i e s ............

16

Psychological T e s t i n g ..............

IV.

V. VI.

16

.

21

Evaluation of Testing .................

31

SPEECH T H E R A P Y ............................

32

Retraining in Reading .................

bO

Retraining in Writing .................

b2

LANGUAGE RETRAINING AND PHYSICAL MEDICINE R E H A BILITATION

if9

SUMMARY AND C O N C L U S I O N S .................

58

BIBLIOGRAPHY . . . APPENDIX

............................

..................................

.

Case S t u d y .................................. Glossary

.

................................

62 6b 6if 101

CHAPTER I INTRODUCTION It has been estimated that there are over M-00,000 people in the United States today who are -unable to use language symbols because of brain damage.

Each year about

20,000 additional people become disabled in a similar manner and this number is on the increase with the greater percentage in the population of those over fifty.

Until

recently, the neurological aspects of aphasia patients were concerned with a very extensive and minute neurological examination and the arrival at a diagnosis.

Psychological

investigations then focused the attention on personality and behavior disorders but the patients were relegated to a hospital bed and permitted to vegetate for ten, fifteen or twenty years until released by death. That the majority of patients can be rehabilitated to lead a fairly normal, useful life is a recent concept in medicine.

Of these neurological patients, those suffer­

ing with aphasic manifestations are the most challenging to the therapist.

In order for a therapist to approach

the problem of treating aphasic patients, there are several areas of information necessary for a complete orientation., He should be acquainted with the neurological implications, the psychological tools that can be used in determining

personality aberrations and the therapeutic methods that have been used successfully.

In order to help these

patients achieve a maximum amount of economic and social adjustment, a well integrated program of physical medicine rehabilitation is necessary.

The speech therapists in

the aphasia clinic spearhead the rehabilitation program and for them, as well as others interested in aphasia therapy, this .project is intended. NATURE OF THE PROBLEM If we should suddenly be deprived of the ability to speak, read, write or in any way express our needs, pains or aspirations, we would be in the predicament of the person afflicted by a cerebro-vascular-aceident.

The

soft gray mass of tissue inside the cranium which assumes the controlling influence of intelligence is disrupted from its accustomed function and the individual is sudden­ ly thrown back to a lower level of human functioning.

The

brain is the organ of consciousness, of ideation and voluntary muscular control, receiving impressions necessary to life, such as respiration and circulation.

Any damage

to any part of the brain reflects itself in the altered reaction of the individual to himself and to his environ­ ment.

3

Neurological Implications.

Brain tissue is very

delicate and may be injured by disease or accident.

One

of the most common causes of brain damage, especially o among older people, is the bursting of a blood vessel in the brain, called a "stroke". z,

Another type of damage

frequently occuring in the brain is an embolism or blood clot in one of the blood vessels feeding the brain.

A

3 third type of injury may be caused by a tumor which also acts like an embolism by creating pressure and disturbing or destroying the functions of the adjacent areas. f

The

brain may also be damage by physical accidents which cut

5- or tear parts of the delicate tissues.

Infection or

disease is another cause of possible damage to the brain. All these organic changes in the brain cause corresponding changes in total personality functioning depending upon the degree and severity of the damage. During the process of learning, people favor the development of one side of their bodies.

In most people

the right side of the body is-stronger than the left. side. The brain is likewise divided into two distinct hemi­ spheres.

The right hemisphere controls the left side of

the body and the left hemisphere controls the right side of the body.

The person who uses his left hand for

writing, throwing, etc. has developed a dominance in the

if right hemisphere of the brain.

The right handed person

develops cerebral dominance in the left hemisphere.

When

the dominant hemisphere of the brain is injured, aphasia usually results and the extent of damage determines the type and degree of dysfunction. The brain acts as a control tower or switchboard for all physiological, emotional, psychological and intellectual functions.

The three major communication

lines controlled are: 1.

Sensory nerves:

Lines reporting sensation from

all the sense organs of the body such as ear, eye, nose, skin, etc. and viscera organs such as stomach, heart, etc. 2.

Motor nerves:

Lines originating in the brain,

extending to all the muscles to control and stimulate them for bodily activity. 3.

Association nerves:

Lines solely within the brain

to correlate and integrate the functions of the different sections of the brain.

Although the

nervous system is divided into three distinct parts, it is well to remember that they are mutually dependent and cooperative.

The central

nervous system which comprises the brain and spinal cord, serves to correlate and integrate the various parts of the body to make them work

as a good team.

The peripheral nervous system con­

tains the nerve fibers that pass from the receptors, to the central nervous system, to muscles and glands. The autonomic nervous system controls the unconscious actions of the visceral organs such as chest, abdomen and glandular tissue. The nervous system reacts at three levels of com­ plexity.

The spinal cord contains switching centers that

make simple acts possible.

The brain-stem which is in part

a continuation of the spinal cord controls the more complex behavior patterns.

The cerebral cortex controls complex

behavior such as learning, thinking and conscious exper­ ience.

Connections between the elements of the nervous

systems appear in three different ways. certain connections already functioning.

We are born with Others become

functional through a process of maturation independent of learning.

The complex connections become functional only

through a process of learning and adaptation. An important aspect of the nervous system to consider in retraining is that many duplicate pathways are provided for the simplest stimulus response act.

Often the duplicate

connections lie side by side but there are many instances in which the duplicate nerve path takes quite a different course from the receptor of the sense organ to the effect­ ors.

This is biologically advantageous since injury

6 resulting in loss of function is greatly reduced by the possibility of compensation.

Injuries to the brain need

not bring permanent disability since the brain is especially rich in duplications which may be fertile for training to assist or take over the impaired function. The nervous system provides a means for the formation of new connections between receptors and effectors. When specific items of motor or sensory behavior become modified or exaggerated due to brain lesion it can be inferred that the damaged area is solely responsible for the behavior in question.

The electrical currents

employed- to stimulate the brain can to some extent help us' localize the areas of the brain that dominate specific activity.

The use of drugs applied directly to cortical

tissue can also be used to destroy or exaggerate certain types of responses.

The doctrine of Johannes Mueller

states that a given sensory nerve will produce a certain type of experience no matter how it is stimulated.

The

sensation produced depends upon the nerve cells that have been stimulated and not upon the stimulus applied.

When

the area of the cortex immediately in front of the fissure of Rolando is stimulated some voluntary muscles respond. The long motor neurons lead down from this area through the spinal cord to the muscles of the body and extremities. Any damage to this area of the brain produces an impairment

in some part of the body functions by lack of muscular control or paralysis.

This area dominates in controlling

motion of the feet, trunk, hands, face and tongue. A great deal of research has been done by neuro­ logists, physiologists, psychologists to determine localization of function of the more complex mental processes.

Both sides of the cerebrum have association

areas that are richly connected to each other, to the motor areas and to the sensory areas.

The association

areas of the cerebral cortex seem to be the dominating influence in correlating and integrating the simpler sensory and motor functions.

Damage to the association

areas results in defects of speech and understanding of words.

It is the controlling center of ability of people

to learn new skills, to solve new problems and to see new relationships.

Any traumatic or degenerative changes in

the cells of the cortex result in distortions and alterations of behavioral patterns.

The association

centers in general are essential for symbolization and learning, to be able to visualize absent objects and events in speech and thought.

Damage to any of the

association centers or nerve fibers results in a relative degree of loss to correlate certain sensory and motor functions.

When the damage occurs to the association fibers

that control language functions^ the patient exhibits aphasia.

CHAPTER II THE NATURE OF APHASIA General nature of the problem.

With the increase in

the number of aphasia patients in our hospitals, the problem of decreasing the amount of human suffering and cost of bedside care has-become an urgent one.

There is a need to

reverse the trend of relegating the chronic neurological patient to a vegetative existence with the resulting social and psychological maladjustments.

For many years, rehabil­

itation measures have been instituted for a few chronic neurological disabilities such as poliomyelitis and cerebral palsy with fairly good results.

Only recently has there

been any advance in the understanding and treatment of aphasia patients. Because of their varied manifestations, it is impossible to adequately describe the disorders resulting in aphasia.

Some of the outstanding symptoms encountered

are: (1)

inability to understand spoken language,

(2)

inability to understand written language,

(3)

inability to find the proper words in speaking,

(*+)

inability to formulate words into sentences phrases,

(5) inability to speak or write.

and

In addition to the above symptoms, one may see sub­ stitutions of incorrect words, repetition of a word which has previously been used (perseveration) and jargon speech. These symptoms will be elaborated upon in discussing possible broad classifications.

the

It becomes obvious that

the treatment of a patient with language disorders of this type will depend upon the specific nature of his speech loss and can only be carried out by a planned program of therapy. During the past few years, it has been demonstrated that the rehabilitation of aphasia patients is both feasible and worthwhile in terms of re-education for social integra­ tion.

In the general field of neurology, rehabilitation

measures for aphasics frequently meet with considerable resistance..

This resistance is due, in a great measure,

to the lack of realization of how much can be accomplished even in the most severe involvements.

The great financial

savings that may be achieved by rehabilitation has not been recognized.

Then there is the lack of understanding of how

retraining techniques can be applied.

In order to discuss

the possible methods that can be used in aphasia re-educa­ tion, it is necessary to review the nature of the illness and the classification of types. The specific nature of aphasia.

Aphasia is the term

10 most commonly used to describe loss or impairment of the ability to comprehend or use spoken or written language, as a result of a cerebro-vascular accident.

The resultant

damage to certain areas of the brain is usually located in the domin^it hemisphere.

The problems of the aphasic

f

patient mhnifest themselves in both neurological and psychological aspects.

In addition to the language dis­

ability, the aphasic patient also shows signs of other neurological disturbances such as hemiplegia, cranial nerve palsy, and sometimes convulsive siezures.

Super­

imposed on the basic neurological disorder, there may exist psychological manifestations of depression, hostility, anxiety and tenseness due to frustrating experiences in attempting to overcome the disability.

The extreme diffi­

culties encountered in attempting to make personal and social adjustments often give rise to low morale and may /hinder any possible automatic recovery. Classification of types of aphasia.

No standard

system of classifying aphasic patients into specific types has yet become universally acceptable since no two patients •ever present identical symptoms.

A pure classification for

each individual patient is difficult to achieve because the disorder may manifest itself in a wide variety of complicated mental functions including both language and non-language functions.

The difficulty of classification lies in the

11 attempt to isolate the different types of disorders into separate and distinct categories.

When the language

process breaks down the resulting consequences are such that all interrelated mental functions are affected.

Thus,

there exists considerable overlapping among the various disturbed functions which precludes a pure classification. However, for purposes of re-education patients may be broadly classified into four main groups representing the * preponderance of aphasic symptoms:

the expressive group,

_

the receptive group, the expressive-receptive group, and the amnesic group. DESCRIPTION OF THE CLASSIFICATION Expressive disturbances.

In this group are included

patients whose major aphasic symptom is an inability to express himself in thoughtful, meaningful sentences.

This

impairment of expressive functions includes speaking or writing or both.

The degree to which the patient’s ability

is disturbed varies widely from patient to patient.

The

disturbance may range from a slight defect to one in which there is a complete loss of function.

In cases of complete

inability of expression, there may be certain emotional responses which automatically arise in place of language. The repetitive use of one or two words and the use of profanity as a speech pattern are typical examples.

The patient has great difficulty in controlling articulation and in some cases the sounds and speech that may be expressed usually lack rhythm and proper inflection. Sometimes there occurs a fragmentary type of sentence structure in which grammatical errors (Agrammatism) such as omission of words,

incorrect use of words, transposition

of subject and object are common. Expressive disturbances are often accompanied by various degrees of loss of ability to write (Agraphia). This loss may take the form of an inability to form letters or words for writing purposes due to the inability to remember the movements which form letters.

When the patient

is unable to revisualize the words he wishes to write, agraphia may also be due to a receptive type of aphasia. Often the patient will immediately forget the words he wishes to write and exhibits an amnesic type of aphasia. The expressive disturbancescan between motor aphasia and apraxia.

be differentiated

In motor aphasia, the

patient is unable to produce desired language patterns by a purposeful control of his articulatory system.

The vocal

cords can be made to vibrate but the mandible, lips and tongue and velum cannot be molded into familiar speech sounds even though they evidence full range of motion. is an absence or loss of muscular coordination.

It

In Apraxia

the range of motion of one or more of the articulatory organs

13 may be limited or. seriously impaired.

The patient can

revisualize language but cannot innervate the speech organs. Receptive disturbances.

The patient whose pre­

dominant dysfunctions are receptive, manifest disturbances in the comprehension of spoken language or written material. His ability to understand his environment, follow directions, initiate action or participate in social relations may be seriously impaired.

His understanding of situations may

vary in accordance with the familiarity of circumstances to which he has been exposed.

The patient may understand

single words of a concept but may be unable to grasp the meaning of the entire concept due to an inability to make the proper associations between the words and their symbol­ ization.

This disturbance becomes apparent in the patient’s

inability to follow directions and instructions, to make proper responses to questions and to follow ordinary con­ versation.. The receptive disturbances also manifest themselves v by defects in recognition and perception of letter and word formations.

When the recognition of letters and words is

not disturbed, the defect consists in the inability to establish the relationship between each letter and the complete word.

Although this type of patient is still

capable of experiencing the normal elementary sensations,

lb the grouping of these elements into normal perceptions is difficult. The receptive disturbances exist when the inability to recognize meaning in language is predominant and the patient may be said to have sensory aphasia.

x

In severe

cases the patient may react to speech sounds without any overt sign of recognition.

There may be degrees of

recognition and response, from the concrete to the abstract, depending upon the degree of damage to the association fibers and other factors necessary to understand the individual performance of a patient. The expressive-receptive disturbance.

This group

of patients manifest multiple types of disturbance both expressive and receptive.

In global aphasia, they exhibit

the complete inability to understand or respond to spoken language or use language to express even elementary needs. No direct communication is possible and the patient ex­ hibits only vegetative functions.

In less severe cases,

the patient may exhibit emotional responses of automatic speech like swearing or perseveration of one or two words. However, the use of language for expressive and receptive purposes is almost non-existent. Amnesic aphasia.

This group of patients is chiefly

characterized by his inability to find the correct word to

15 name an object.

In addition, the patient's speech is often

lacking in other parts of speech besides nouns.

The patient

may try to compensate by circumlocution and other indirect methods of expressing himself to overcome the inability to find the correct word.

The defect in expression may not be

specific, but seems more like a constant groping for the correct word.

The compensating mechanism may manifest it­

self by the use of slang expressions and colloquialisms which are essentially automatic responses.

A typical

characteristic in this type of patient is the method in which he reacts to a word he has suddenly recognized.

He

reacts to the word with some degree of satisfaction, but eventually forgets it again.

This predominant amnesic

difficulty sometimes manifests itself in the other areas of language such as reading or writing.

CHAPTER III DIAGNOSIS Total rehabilitation of the aphasic patient requires a complete clinical case study of the individual from every aspect of his social, physical and psychological functioning.

It should include:

A.

Medical case history.

B.

Social case history.

C.

Neurological examination.

D.

Psychological testing.

E.

Physical medicine rehabilitation scoring.

F.

Planning the program for corrective re-education

G.

Systematic language instruction.

A.

The medical case history is compiled by the ward

physician and the neurologist.

A thorough physical and

neurological examination will include the patient's pretraumatie medical history, possible causes of trauma and associated physical and mental symptoms.

Pre-traumatic

symptoms, extent of these symptoms, the possible signifi­ cance of disease and drugs on the trauma will all have bearing on the course of treatment. B.

The social case history will attempt to make a

complete study and analysis of the patient's pre-aphasic

17 background by interviews with patient, his family or friends, and employers.

This information will include the

patient's family history, left handedness or ambidexterity, educational background, speech handicaps, language back­ ground, vocational background, reading and writing proficiency, special interests and hobbies and social relationships.

All of this information is valuable in

planning an individualized program of re-education for the patient because of the individual differences involved. C.

Neurological examination.

The neurologist is

responsible for the overall rehabilitation of the patient. The neurologist will be responsible for determining an aphasia diagnosis by: a.

Discovering the presence of a focal cerebral

lesion or lesions and to establish a diagnosis of aphasia resulting from such a lesion. b.

Differentiating aphasic language disturbances

from other language disorders, such as found in acute and chronic organic confusional states, certain degenerative and vascular brain diseases as dysarthria, pseudo bulbar palsy, hysteria, and non-aphasic apraxias and agnosias. c.

Determining the nature and extent of neuro­

logical disability independent of aphasia arising from the same cerebral lesion or lesions, the presence of which

18 might have important implications for the type of rehabilita­ tion and retraining the patient will receive. - d.

Supplying the basis for planning a program of

physical rehabilitation and speech retraining. e.

Determining the need for special aphasia tests,

x-rays, electroencephalographic studies, brain operations, etc. D.

Psychological Testing.

The clinical psychologist

assumes the responsibility for the administration of a battery of tests to aphasic patients to determine the intellectual and linguistic capacity of the individual patient and also to evaluate other important aspects of his personality.

The selection from a large number and

variety of specific educational, intelligence, and per­ formance tests is required so that performance in all language and personality areas can be covered.

During

the course of treatment additional tests can be given by the clinical psychologist to measure the progress made by the patient and to prescribe modification in future tech­ niques as is indicated by success or failure of current treatment.

The psychological tests serve an extremely

important function in the overall planning of the program for retraining. E.

Physical medicine rehabilitation.

The program

19 of physical medicine rehabilitation includes a wide variety of services that can be integrated in the total rehabilita­ tion of the aphasic patient.

They include:

(a) Physio­

therapy, (b) Occupational Therapy, (c) Corrective Therapy, (d) Educational Therapy, (e) Manual i.rts Therapy, (f) Social Service, (g) Recreation.

The members of this

rehabilitation team should be willing to acquaint them­ selves with the special problems that are involved in aphasic rehabilitation and the important services each member can render to reeducation.

Since speech is primarily

a social function it gets its stimulus under a variety of circumstances and with a variety of activities.

Speech

should be a part of all rehabilitation activities and not solely a function of the speech therapist.

The exchange of

progress notes by all therapists concerned will give each one a better perspective for continued therapy. F.

Planning the urogram for corrective re-education.

In setting up the program for the aphasic patient the language retraining instructor has several responsibilities. (a)

To help the patient make the best possible

adjustment personally, socially and economically by using the patient’s remaining assets. (b)

To plan a re-education program that will bring

about maximum recovery of language abilities.

20 (c)

To develop and check the patient's progress in

order to achieve the best possible results in the shortest possible time. (d)

To consult with the neurologist, clinical

psychologist and Chief of Physical Medicine regarding the overall objectives established for the patient and his rate of progress. (e)

To maintain clinical data and progress notes,

supervise the individual retraining program and maintain liason with the ward doctor and therapists involved in the ease. G.

Systematic language instruction.

The speech

clinic is responsible for orienting the aphasic patient to a program of speech reeducation that is tailored to the individual patient.

The information gathered from the ward

doctor, neurologist, psychologist, social ease history and the therapists forms the basis for a comprehensive speech analysis and points to the direction of re-education. Systematic language retraining will be considered in detail in Chapter IV.

21 PSYCHOLOGICAL TESTING On the basis of a complete medical and neurological examination, a prognosis is attempted for the patient and he is referred to the speech clinic for a more thorough analysis of aphasic symptoms.

The detailed findings of an

aphasia examination should bear a relationship to the actual procedures of aphasia therapy.

The great range of individual

variations in the pattern of dysfunctions to be found in aphasic patients imposes great limitations on any attempt to standardize the aphasia examination or to express the results in quantitative forms.

Whenever feasible, a

standardized battery of tests are used for diagnosis and evaluation of training progress and procedures.

Some of

the more frequently used tests include: (a) Eisenson Test for Aphasia; (b) Halstead-Wepman Screening Test for Aphasia; (c) Wechsler-Bellevue Intelligence Test; (d) Bender-Gestalt Visual Motor Test; (e) Goldstein-Schlerer Cube Test; (f) Rorschach. The most important element of testing is the establishment of rapport with the patient.

The testing

procedure should evolve from an interview with the patient where the patient’s problems and complaints become the concern of the examiner.

The patient is made to feel that

the examiner is interviewing and examining him, because he

22 wants to help him.

The interview method will often result

in bringing to light many aphasic manifestations that can later be more fully tested by more standardized methods. In addition, the interview can also check the patient’s personality and orientation as to time and space, his age, education, family relations, personal and family history and any other information the patient.may volunteer that may be significant to retraining. If the* patient seems disturbed at a demand or question,'it is best to transfer to something else.

It is

best in the beginning to avoid areas that are frustrating to the patient and present tasks at which he can succeed. Fatigue and perseveration are two common symptoms that guide the examiner in the extent of the examination.

A recommended

initial interview would be for the examiner to become thoroughly familiar with the patient’s pre-traumatic social situation, his family life, friends, occupation and educa­ tion in order to be fortified with enough meaningful stimuli for successful responses.

There is no easier way to establish

rapport with the patient than to restore verbally part of his world that- he has lost so suddenly.

It Is valuable

to the patient and to the examiner if the patient can be informed that the speech disturbances are not as severe as they seem at the time and will improve with training.

The

pattern may be established by having the patient experience

a successful speech pattern even if it is only a word or recitation of automatic speech (e.g., numbers, letters, O.K., etc.).

In the interum, the examiner is making a

detailed study of the general appearance of the patient, the manner of his reactions, his behavior in general, expression of his face, body, gestures accompanying his speech, expressive movements as to fear, pain, satisfaction and emotional stability.

This should lead to a general

impression of the major areas of retraining and point to more specific tests that can be used on a more standardized basis. Eisensen Test for Aphasia. The Eisensen Test for Aphasia attempts to analyze the manifestations due to cerebral injury or dysfunction. The test differentiates two major areas of cerebral functions I. II.

Predominantly receptive disturbances Predominantly expressive disturbances

In the realm of receptive disturbances are listed the following areas and sub-areas: A.

Agnosias - visual (objects), pictures,

colors, forms, letters, numbers, words). Auditory (varied sounds, words) Tactile - variety of familiar objects as pen, knife, fork, marble, etc.

2h B.

Aphasias - auditory verbal comprehension (sentences, oral reading) silent reading-eomprehension (sentence-paragraph).

In the predominantly expressive areas of disturbances, the test listed for examination the following areas and sub-areas: A.

Apraxias - non-verbal (body parts, simple skills, pretended action); verbal: repetitive speech (numbers, words, sentences).

B.

Aphasias - automatic speech, spelling, writing, arithmetic (computation, problems), oral reading, clock setting.

All of the above impairments are judged qualitatively by the examiner in terms of complete, severe, moderate, little or no aphasia.

With each test blank is also attached an

interpretive report of the individual's performance in compliance with the criteria stated in the introductory paragraphs of this section of the paper. Halstead-Weoman Test for Abhasic Disturbances This test for aphasia has only recently been introduced on an experimental basis.

The authors of the

test state that the purpose of the test is to serve as a "screening test for aphasia which could be applied at frequent

25 intervals throughout the course of aphasia therapy."

The

test, according to its authors, is an approximation of a controlled-piro jective test.

In the authors* words:

"Tests of this type are perhaps less permissive in admin­ istration and scoring than such strictly projective tests as the Rorschach, for instance, yet are more permissive in these respects than psychometric tests yielding an intelligence quotient." The test form (Record Form

A

) is unique because of

the opportunity it allows the examiner in constructing a workable profile of the individual under consideration. The test material is also in itself unique.

It is in the

form of a cardboard wheel with a window that is utilized by the patient in performance of the items.

The test is

adequate for a screening test in terms of the amount of time spent in its administration and the utilization of a single item, for a number of manifestations that may be observed in the patient.

VA Form 10-2526 The purpose of this test is two-fold since it attempts to indicate the various manifestations of the patient's impairment and it is standardized to indicate the damaged anatomical area of the brain.

The test allows

the examiner to interpret the severity of disturbance in

26 the following areas: Agnosia:

Visual non-symbolie (animate, inanimate) Visual symbolic (letters, words, mathematical symbols, musical symbols) Auditory (words, pitch, music) Tactile (objects, letters and numerals, parts of the body).

Apraxia:

Ideational, Ideokinetic, Cortical Motor Pattern (limb, speech, others), Revisualization and Visual Motor Guidance Disturbance of the Body Scheme.

Aphasia:

Formulation (anomia, amnesic) Semantic (spoken language, written language, written mathematical symbols, written musical symbols, acalculia), Motor (speaking, singing, writing, musical instrument).

Test Form 10-2526 is by far the most complete and lengthy of the single tests used for aphasia.

Because of

its length and the time involved, it may be used most in situations requiring a test in addition to the screening type of the Eisensen Test and Halstead-Wepjlman Test. Bender-Gestalt~ Test Performance on this test is the resultant of the subject's total functioning at the time of the test, an

27 equilibrium between the stimulating pattern (a chosen set of Dr. Wertheimer's original figures used to explain the various Gestalt principles, such as closure, etc.) and the "action tendencies of the sensory-motor conceptional person."

The examiner uses the test in one of the follow­

ing two significant clinical procedures: (1) A search for clues correlated with clinical syndromes or pathological datum; (2) An evaluation of the personality in process as it seeks to adapt to a postulated task. The patient is urged to reproduce figures shown him. In the Bendqr-Gestalt test the following behavior and performance is observed:

(It must be borne in mind that

the manifestations shown by the individual's behavior var

T

according to the nature and extent of the brain

damage.)

Partial rotations of figure when observing,

vagueness and sketchiness of drawn figure, exclamations and behavior involving impotency, perplexity, and in­ competence, marked perseveration, loss of detail, fragmenta­ tion, difficulty with acute angles, concreteness and over­ simplification, overlapping.

The above .observed behavior ;

integrated with the information obtained in all tests given seem to act as a synthesizer.

The test may be

considered to give indication of the patient's capacity of perception.

28 Goldstein-Sheerer Cube Test According to Goldstein, in his book "Language and Language Disturbances” , the cube test serves the purpose of determining whether and to what degree a patient is impaired in abstract behavior.

Following are statements

made by Goldstein in his book concerning cube test:

"The

patient has the task of copying colored designs with blocks. These blocks are colored cubes.

Each of the cubes bears

the same colors in identical arrangement and distribution on all six sides . . . The task of reproducing the colored design models with the blocks may be attempted on an abstract or on a concrete level.

Concretely, the subject

may try to reproduce his impression of the design model by arranging the block sides until he feels that they match the model design as a whole.

He follows the design

model without a deliberate act of analytic reasoning and reproduces his impression of a unitary configuration by matching the block sides to it in a naive, unreflective manner.

By this concrete procedure, only a few designs

can be successfully copied.

There is a definite turning

point for the concrete approach:

no longer can one, by

turning up and arranging the block sides, build the pattern of the model.

. . The resulting confusion can be solved

only by a shift in attitude to the problem.

This approach

(shift in attitude) consists essentially toward abstraction by the individual."

Rorschach Personality Test The purpose warranting the use of the Rorschach test, which is entirely projective, is mainly for the observation of the individual's attitudes toward himself.and others, his social adjustments and ability to do so.

The Rorschach

may indicate personality changes (over-all) of the aphasic barring the language disturbances.

Used in conjunction

with the other various tests described, the examiner may obtain a fairly well rounded description of the individual in the clinical situation allowing interpretation and prediction of future behavior and available synergies for further training. Wechsler-Bellevue Test of Intelligence The Wechsler-Bellevue test is an I.Q. test of general mental capacities that may be used as a standard for measur­ ing verbal and motor performance.

When it is possible to

get a motor and verbal estimate of the patient's capabilities, it is an invaluable aid in finding a level for reeducation. The data derived from the Wechsler-Bellevue includes; Verbal I.Q. Performance I.Q. Full Scale I.Q. Impairment coefficient The careful observation of the patient in his arrival to the answers of the items and sub-items will give valuable

information for the retraining program'.

It is important

to try to achieve a qualitative^analysis of the way the patient comes to the result in each subtest.

It may be

noted that the aphasic often may not have a defect in his performance of a subtest but an impairment in the procedure used to solve the test.

These suggestions in observation

on the performance of the Wechsler-Bellevue test may give a fair indication that the patient’s inability to solve certain areas of the test may not be due to specific defects such as reading, writing and speaking, but to impairment of ’’so-called general mental capacities.” When applicable, this test can be of invaluable aid in planning a therapeutic process. Evaluating psychological testing.

In general,

psychological tests are not used to verify or validate the findings of the neurologist, but to uncover, in detail, emotional and psychological factors that are important in the process of retraining.

The psychometric evaluation

of the aphasic patient cannot be a routine battery of tests by a disinterested psychologist.

The potentials for re­

training are difficult to evaluate in terms of ordinary psychometric devices.

The results of psychological tests

must be useful to the therapists in facilitating the retraining program of the patient.

Psychological testing

is also desirable as an original evaluation of the patient

31 and a method of checking patient progress, or lack of progress.

The major areas of concern of a psychometric

evaluation are: 1.

Level of intellectual efficiency

2.

Amount and type of deterioration

3.

Emotional and personality make-up

b.

Behavior manifestations

5.

Degree and type of language disturbances

The tests included in this chapter have been found most useful for the evaluation of the above items. they are not the only ones that may be used.

However,

Any tests

that are useful to the therapist in preparing a more ef­ ficient program of rehabilitation are applicable.

The

various therapeutic situations provide important test elements for the therapist who must ever be on the alert for them.

In converse, the testing situation can be of

immense therapeutic benefit to the patient by indicating the nature and extent of impairment and the areas of re­ training.

The danger of the testing situation becoming a

traumatic experience to the patient is always present and must be carefully guarded against.

For this reason, psycho­

metric devices cannot be used with aphasia patients the way they are used with normal clients.

CHAPTER IV SPEECH THERAPY Methods and Techniques of Treatment., The daily

^

attendance of the aphasic patient in the speech clinic forms the basis for language reorientation.

An important

principle in re-education and rehabilitation is that the work in each instance must be especially adapted to the individual patient.

Each case is a problem which requires

careful and continuous study and training especially adapted to overcome specific defects.

The training program

is based on a thorough knowledge and understanding of the patient’s abilities and limitations so that the greatest utilization of special abilities can be made- to compensate for the limitations.

Thus the training program is based

upon careful analysis and study of the medical and social ease history, the neurologist's findings, psychological tests and all pertinent information.

The retraining

instruction involves a variety of exercises specially adapted for each patient.

In the initial stages of train­

ing, the therapist utilizes several preliminary techniques prior to the application of basic speech techniques: 1.

Selective relaxation is a method of teaching

the patient to control his exerted efforts toward attempting to articulate.

He is taught to inhibit voluntary random

movements, sounds and phrases.

Emphasis in training is

placed upon the patient being calm and relaxed before making additional attempts to speak.

The speech therapist

tries to make him understand that he must not try too hard. He must rest before trying again.

He is taught to accept

frustration as a natural part of the retraining process, although frustrations in the clinic are avoided as much as possible. 2.

Developing muscular control of voluntary move­

ments and the ability to imitate is a forerunner to speech training of many aphasic patients.. They are taught to *

imitate and control gross muscle movements such as move­ ments of the arm and hand.

Following the learning of such

gross movements, the more specific muscular movements related to speech are taught, such as movement of the mouth, tongue, lips and jaw. 3.

Every possible sensory aid is employed in order

to compensate for a particular language faculty in which the patient is deficient.

Patients who have difficulty in

understanding speech can profit from lip reading associated with the visual and tactile familiarization of objects. A basic principle in speech re-education is that the practise should be as closely related as possible to the performance which the patient has to regain.

Artificial

exercises such as the learning of nonsense syllables are

sometimes puzzling to the patient, and they never arouse his interest and cooperation as do exercises which are directly related to his particular difficulties.

Because

the aphasic patient does not necessarily present a pure classification type, the various combinations of techniques may be used with particular emphasis on the individual needs. Retraining for predominately receptive disorders. In receptive disorders (Agnosia) the patient has lost the ability to discern and comprehend the meaning of the sound he hears.

The basic problem is not one of defect in hearing

but the ability to associate language symbols with their meaning and speech has become like a foreign language.

The

problem of retraining is more challenging when the patient has receptive aphasia due to the fact that it is difficult to explain the situation to him because of his comprehensive disorientation.

Slow and distinct articulation of simple

speech patterns free from harsh or unpleasant vocal

.—

characteristics or colloquialisms is necessary of the therapist.

Since imitation is one of the basic speech tools

used, it is important that basic speech symbols be presented to the patient in a manner and at a rate that he can adjust to. One way of teaching patients the names of objects is

35

-

by demonstrating the objects and utilizing all the avenues of sensory perception such as sight, sound, touch, smell and taste to develop and fix permanent impressions.

This

will aid the patient to recall readily, and use voluntarily, the word which the object represents. At first, simple commands as ’’Pick up the pencil” , "Copy your name", "Give me the book" are used repetitiously until the response pattern is established.

These commands

are accompanied at first with gestures so that the patient will comprehend them more easily.

As comprehension increases

fewer gestures are used. The patient's most immediate needs are considered in the initial stages of speech therapy.

He needs to know his

name, his ward number, how to call the doctor, the nurse, the ward attendant, the parts of his body and phrases like "Hello", "How are you", "I'm fine".

In treating the patient

for body agnosia (Topagnosia) the therapist points to differ­ ent parts of the body, has the patient repeat the name and point to the parts named until an independence of symboli­ zation is developed. A significant aspect of retraining is the utilization of techniques which are designed both to improve the particular faculty involved and to restore the patient's feeling of prestige, social value and self-confidence.

By

asking the patient to do simple favors as "Close the door",

"Give me the pencil", there is accomplished a dual function of increasing comprehension and enhancing the patient's feel­ ing of being socially useful as an individual. Retraining in motor speech.

By applying a knowledge

of the various tongue and lip movements used in the enunciation of letters and diphthongs, the instructor teaches the patient the different tongue positions necessary for producing the sounds of speech.

In this phonetic approach,

movements are taught by having the patient imitate the speech movement of the instructor's mouth.

In this process, the

patient may observe these movements, or he may utilize his tactile sense by touching the teacher's mouth and larynx for control.

He is also shown, if necessary, pictures

which demonstrate the position of the tongue, mouth, etc. in reproduction of sounds. these positions. this activity.

The patient tries to reproduce

Mirror imitation is also utilized in Another method of learning to pronounce

a sound is by applying purposeful movements to be learned. For example, the patient may learn the "ng" sound by performing the act of swallowing, or he may learn to produce the "p" sound by blowing out a match or by puffing smoke.

In teaching the patient the production of the

various sounds, the training technique proceeds from sounds which are easily produced to those which are more difficult.

37 As soon as the progress of the patient makes it seem advisable, emphasis is placed on utilizing learned sounds to form complete words.

The drill words are used as much

as possible by correlating them with the actual performance of daily activities such as greetings, introductions and naming of surrounding objects.

Thus, emphasis is placed

on speech patterns related to real life situations. Repetitive exercises are employed in repeating the heard word or sounds over and over again.

Words produced as an

automatic or emotional response which usually arise from the patient's emotional reactions to a situation, e.g., expressions of joy or grief, are learned as early as possible so they can be employed voluntarily in ordinary communication.

The learning of words involve as many

sensory approaches as possible.

Thus, whenever the reading

or writing faculty has not been impaired, it is advantage­ ous in the retraining process to have the patient read and write each individual word as he speaks.

Words which have

a meaning for the patient are used as much as possible. Such exercises as series recital including number series, days of the week, months of the year, aid in articulation and in placing words in right sequence. Having achieved a degree of success in the formation of words, the patient may begin to combine these words into short meaningful sentences.

In starting these exercises,

it is not necessary that the patient learn immediately to build complete and correct sentences including articles, pronouns, prepositions, etc.

Rather, he may begin by

employing words to convey general, rather than specific meaning.

More precise organization of words is attained

at a later stage in the retraining process.

In the initial

sentence training activity, such exercises sometimes over­ tax the patient's efforts.

It is usual for the patients to

be provided with sentence exercises which involve reading aloud as much as possible and, in addition, the writing patients do is often accompanied by speaking for practice in articulation. When successful sentence production has been acquired, it is often necessary to teach the patient how to achieve the proper emphasis and rhythm required for conversational speech.

Recitation may be utilized and singing may be

employed to give the patient the sense of rhythm in speech. Although a patient may have progressed to a stage where he has learned to say words and express his thoughts verbally, agrammatism may persist; the syntax and grammatical construction of his speech may remain poor.

Specialized

exercises are utilized to improve mistakes of syntax, that is, incorrect sentence construction.

One way for the

instructor to begin is to ask the patient questions which require a one-word response.

Another technique is to employ

39 words which can be translated into movements such as walking, sleeping, eating, etc.

The instructor makes the movement

of walking and says, "I am walking." this.

The patient repeats

Later the patient says the words when the instructor

performs only the movement of walking.

The instructor may

speak a simple sentence as, '’The man reads the book" and then repeats each word singly associating each word with one finger.

Later the patient says each of the single words

as the instructor points to the corresponding finger.

Then

he says the words in a sentence without referring to fingers. Another method is to give the patient single words of a sentence in no particular order and ask him to put them into grammatically correct and meaningful sentences.

If

the patient is able to read, he is given little cards on which words of a sentence are written.

The patient is

given the' task of arranging them in correct syntactic order. In secondary agrammatism, training techniques are utilized to improve the grammatical forms such as mistakes in verb forms, omission of articles, suffixes, prepositions, etc.

An attempt is made to restore the use of correct

grammatic form such as tense or case which in normal people does not require deliberation but is automatically expressed. The patient may learn with the help of grammatical rules or drill in parts of speech.

As soon as possible, he uses

what he has learned in meaningful sentences.

Constant drill

ho in composition writing and sentence completion tests is often valuable. In cases of amnesic aphasia the training techniques are utilized to overcome what is essentially a disturbance in word-finding.

One method of treatment is to show the

patient a picture, name it, and have him repeat the name and write it down.

Another method utilized is to have the

patient recite a series of words in which a word which he is seeking appears.

After repeating the series, he common­

ly recognizes the word he has been unable to recall.

The

form of the Ebbinghaus completion test may be used in exercises.

The patient is given the task of completing

meaningful sentences in which some words are left out. First, sentences familiar to the patient are used, from whicl^, words the patient should know are omitted.

Constant

use of such exercises and tests builds the patient’s vocabulary.

A further possible technique to improve word-

finding is to have the patient recall all possible situations which might serve to set up an association between the word sought and the situation.

For example, he may remember that

it is the same as the first name of his friend. Retraining in reading.

Among techniques which may

be applied in the retraining of reading skills are various indirect methods.

In one case a visual association may be

*fi established between the form of a letter and the form of a known object.

In the other case, a motor association may

be established between the picture of the letter and a definite movement. recall the sound.

These associations will, in turn, The patient establishes an association

between a seen letter and a particular movement that in itself evokes the making of the sound.

For example, in

learning to read "O'*, the patient imitates with his mouth the form of the letter, and makes a blowing movement to produce the sound of "O'*.

To produce the sound 11A*', a

picture of an apple is shown with the written letter ’’A1' traced around the apple.

Thus is established the associa­

tion between the shape of the object and the shape of the letter. Having the patients memorize the alphabet may facilitate their learning to read letters.

Patients may

be instructed to learn the alphabet in groups of five letters, e.g., a, b, c, d, e; f, g, h, i, j.

Each group

can be represented by the five fingers of the hand, each finger symbolizing one letter. .First, the patient listens to the instructor recite the letters, counting them off on his fingers.

The patient then repeats the procedure,

making the association between finger and letter. If the patient is able to read some letters, it is possible to begin his training by reading syllables of short

words.

He is taught to combine the sounds of single letters.

Singing is a helpful technique that may be utilized here. A more advanced technique in training attempts to have the patient learn to read words as a whole.

In this

activity the patient's attention is directed to discerning similarities and differences in the visual form of words. A group of words which appear to be similar in visual form are listed in order, one under the other; for example, bow, brow, brew.

The patient is taught to make the distinctions

of similarities and differences in the three words.

After

learning groups of words in such series, an association between the word he sees and the word he hears is set up. Finally, having familiarized himself with the various groups and series of words, he reads aloud the words as wholes which are easily recognized visually. In cases of broad outline and form of letter, a training technique utilized is to have the patient trace letters in the form of anagram blocks or raised printed material. Retraining in writing.

Aphasic patients whose

writing capacity is impaired often find difficulty beginning the formation of letters. slow and laborious one.

Hence, the writing process is a The retraining process attempts

to develop a spontaneous expression of letter and word

&3 formation. In cases of paralysis of the right hand, the instruc­ tor proceeds to teach the patient to write with his left hand, initial exercises utilizing gross arm movements which later are differentiated into more specific finger move­ ments.

Exercises in blackboard writing, tracing mimeo­

graphed letters and words, and painting letters with a brush may be utilized in the primary stages of retraining.' Another technique for training is to place under­ neath a piece of clear plastic a series of letters.

The

patient is then told to trace and copy these letters, as he sees them, over the glass. In order to furnish the patient with the opportunity to follow and imitate the movement required in the formation of letter, the instructor may write the letter in the air in front of the patient’s eyes.

The patient then imitates this

movement on paper as he follows the instructor. Additional techniques involve exercises in the formation of circles, lines, etc.

As the patient progresses

and shows improvement, exercises in the copying of words, sentences, and paragraphs are given.

Having the patient

write as the instructor dictates a passage slowly and clearly is an advanced drill exercise to be utilized in retraining. If the patient is capable of using the typewriter,

the instructor often teaches him typewriting.

Where

printing equipment is available, the instructor may use typesetting as a training aid. To give the patients exercise and drill in meaning­ ful sentences, they may be supplied with flash cards from which they can copy such sentences as, ’’How are you feeling?” , ”1 am feeling fine” , etc. The following technique for retraining may be utilized in patients who possess a fairly good visual imagery.

The patient is taught to make associations between

the form of a letter and the form of an object which may be either apparent or visualized.

For example, in attempting

to make the letter ”0” , the patient might visualize a hole; in attempting to make the letter ”S” , the patient might visualize a snake. .Another technique is to have the instructor guide the hand of the patient in accordance with the bhape of the letter. -The simplest writing movements are thus taught. This activity is repeated over and over again, until the instructor slowly and gradually releases the patient's hand and allows him to write independent of control. Psychological factors in retraining.

It is of

primary importance that a satisfactory relationship be established between the instructor and the patient.

In view

of the fact that aphasia may present certain psychological problems such as depression, anxiety, and tenseness, the in­ structor employs specific techniques to reduce such mani­ festations to a minimum. The instructor maintains a calm and patient attitude toward the aphasic.

He continuously stresses the importance

of having the patient adopt a cheerful and optimistic attitude in his efforts to regain the lost faculties..

The

chances of possible successful recovery are impressed upon the patient so that the highest degree of motivation can be achieved.

The instructor often expresses approval and sat­

isfaction and praises the patient's efforts when he has per­ formed a particular drill or exercise successfully.

If no

success is achieved, the instructor should offer some encouragement and hopes for success at future attempts. In administering the various drills and exercises, the instructor is ever on the alert to observe if the patient is showing signs of fatigue.

It is unwise to continue such

exercises if the patient is fatigued because such a state is not conducive to successful treatment.

Having the patient

take intermittent rest periods during treatment will decrease the tenseness which the patient usually experiences in making the various attempts at speech, reading, or writing. The instructor encourages the patient to manifest an interest in his own personal appearance, to shave regularly

1+6 and to dress neatly. patient’s self-esteem.

Such interest would enhance the It would indicate that the patient

is conscious of his social surroundings and is not isolat­ ing himself. As much as possible, the instructor tries to see to it that the patient is busily occupied in some form of activity throughout the day.

When the patient is engaged

in some form of productive work, he possesses a feeling of importance and social usefulness.

Thus, also would the

patient be prevented from becoming too preoccupied with his own troubles. Whenever the patient manifests a knowledge of and in­ terest in a particular field, the therapist shouj3> encourage such interest by engaging the patient in conversation and asking him questions in this area.

In this manner, the

instructor is giving the patient a feeling of prestige and self-confidence, which, in turn, may reflect itself favorably in the patient’s attempts at expressing himself. Although the neurologist and speech pathologist are responsible for planning the program of therapy and indicating, generally, the types of exercises, drills, and tests to be administered, the instructor maintains continuous contact with the patient while administering the various drills and exercises.

As such, the instructor arranges the

working exercise and drills so that the patient is able to

&7 recognize some degree of progress.

Learning usually goes

on at a more rapid rate if the patient experiences the sat­ isfaction of a relative degree of success in his efforts. Thus, the exercises are so graded in difficulty that the learning process will be built upon a series of successful performances. The ability to accept frustration is a significant factor in increasing the patient's morale.

In this capacity,

the instructor impresses upon the patient the fact that the road to recovery is one in which there will be constant thwarting and the patient should not become overwrought or discouraged if he does not immediately achieve success. Rather than have the patient apply a continuous effort, the instructor makes the patient relax and rest before trying again. In addition to the psychological problems indicated above, there may appear in the aphasic patient complicated emotional disturbances manifesting themselves in deep-seated personality conflicts.

In view of the fact that the specific

nature of the aphasic ailment is such that normal means of expression and communication are defective, it, is quite apparent that the patient's predominant conflict would ex­ press itself primarily in social situations.

He may become

extremely self-conscious as a result of his handicap and tend to withdraw from social contacts.

He may isolate himself

completely, even denying himself the opportunity for therapy. In addition, as further complications of social maladjust­ ment, severe feelings of anxiety, insecurity, and inferior­ ity may develop, as well as psychoneurotic symptoms such as compulsions, obsessions, and delusions. It is of primary importance to recognize that inasmuch as the social relationships of the patient are markedly altered by his aphasia, the problem of retraining takes on added difficulties when the patient manifests these complex emotional disturbances.

The retraining

process, therefore, frequently calls for the application and utilization of the most advanced psychological and psychiatric theory and therapy for psychoneurotic person­ ality disorders which can be carried out by the neuro­ psychiatrist or clinical psychologist.

CHAPTER V LAHGUAGE RETRAINING AND PHYSICAL MEDICINE REHABILITATION Language is an expression of the total personality by means of which the individual reaches self-realization and facilitates his reactions to the outer world.

It is

the medium by which the individual structures his unique world and relates it to hi*s sphere of social conformity. The acquisition of meaningful and useful speech sounds evolve as the result of visual, auditory, tactile and kinesthetic experiences.

Speech develops with the

application of varied and meaningful stimuli that result in the conditioning of complex response mechanisms.

The

speech therapy clinic attempts to reorient the patient to the basic production of meaningful language symbols, but the conditioning of speech should be integrated in the total therapeutic process.

For this reason, it is necessary that

the rehabilitation team have periodic patient conferences in order to coordinate and follow the progress of the individual patient.

During these conferences some of the

therapeutic processes being applied to the patient are examined in relation to the total effort. The patient’s progress is examined in terms of the original neurological, psychiatric, medical, social and vocational evaluations.

These evaluations are examined in

50 relation to the individual goals set by the Medical Rehabilitation Board.

The treatment program is then

adjusted and integrated to accomplish the objectives in the most effective way. Therauv and Speech.

The neurologist assumes the

responsibility of the total evaluation of the patient and referral to specific therapeutic procedures.

He reviews

the detailed admissions examination and complicating factors such as hypertension, gastro-intestinal disease, cardiac complaints, orthopedic disabilities and psychiatric evaluation.

The neurologist diagnoses the location, nature

and extent of the lesion and recommends corrective medical or surgical procedures which may include measures to control pain, reduce spasticity or decrease rigidity.

A prerequisite

for rehabilitation requires a thorough analysis of the functions that the patient can use as assets.

The patient

may be considered hopeless in terms of disability until all the remaining strengths and resources are compiled in terms of rehabilitation.

Making the patient aware of his assets

will do much to prevent severe depressive reaction to his disabilities and help him adjust to the rehabilitative phase.

All the therapists involved in the rehabilitation

process are made aware of these depressive and regressive tendencies and guard against it.

In the early stages of

rehabilitation, the patient is given maximum required support

51 until he can be encouraged to assume more self-activity and self-care.

A calm, cheerful and patient attitude is a

necessary basis to motivate the patient to gain more control. Nursing Care.

The emotional readjustment of the

patient to his disability can be greatly facilitated by an understanding nurse.

In disoriented and confused patients,

it is important for the nurse to recognize the patient's needs and assist him to associate the necessary symboliza­ tion to his needs.

In the speech clinic, the patient will

be given the basic orientation to speech in relation to the dysfunction and the nurse made aware of his program of re­ education.

In administering the nursing functions, there

is an excellent opportunity for the nurse to help the patient develop association and symbolization patterns related to repetitive activities.

The patient's likes and

dislikes can form the nucleus for speech re-education on the ward.

Patience and attention to these needs can do

much to facilitate the speech therapy program and make it meaningful to the patient in terms of immediate application of relearned language.

In teaching the patient self-care

activities on the ward, the constant association of simple speech with desirable activity will help the patient develop those speech patterns as a basis for further progress.

Occupational Therapy.

The role of the occupational

therapist in the physical and social adjustment of the aphasic patient is important.

Although the treatment in

occupational therapy is based on individual needs, the activities bring the patient together with social situations where desirable speech habits can be developed.

When the

occupational therapist is made aware of the patient's speech progress, she can integrate them in the individual or group activities of the patient.

Where specific media

are used for kinetic activities, the symbolization of those activities servej£as a basis for development and improve­ ment of speech.

A patient whose primary.speech dysfunction

is receptive can learn to associate the word "rug" with his weaving activity and learn to associate the color symbols with the material he is using.

His facility in finding

proper words for objects in speaking can be improved by constant repetition of the word with the object in the activity process.

Simple printed words placed near objects

they represent will help 'the patient associate the printed words with the objects.

A patient's difficulty in formu­

lating words and sentences can be helped by the carefully formulated example of the therapist in the occupational therapy situation.

53 Phvsio-therapy.

The aphasic patient usually associates

physio-therapy with procedures used to alleviate pain, relieve muscle spasms and re-educate weakened muscles. These activities are started as soon as it is possible to institute-therapeutic procedures during the subacute phase of the patient's illness.

Heat and massage are applied to

the hemiplegic side to improve circulation and to maintain the involved parts in the best condition for the possible return of voluntary function.

The patient is instructed

in proper bed posture and exercise necessary to avoid the deteriorating effects of inactivity.

The physical therapist

makes an early contact with the aphasic patient and, there­ fore, shares in the responsibility for a favorable beginning in the process of rehabilitation.

By allaying apprehensions,

diffusing resentments and hostility he can instill the proper motivation for recovery.

Since the physical therapist

is constantly concerned with body mechanics and the patient's motor reactions, he is in a position to associate repetitive language patterns associated with the attempted restoration of functions, and induce the patient to imitate and develop appropriate language responses.

The physical therapists,

because of their early and frequent contact with the patient, are in a favorable position to detect any additional physical defects that may be developing and emotional symptoms and problems that might arise early in the treatment process.

9+ Evidence of skin lesions and early contractures can be called to the attention of the doctor and treated.

Family

and personal problems that are troubling the patient and perhaps retarding recovery can often be discovered by the therapist during the treatment period and referred to Social Service.

The speech activities that can be in­

corporated into the physio-therapy treatment are naming of involved body parts, directions, laterality, number and letter recitation and relaxation functions. Corrective Therapy.

From the time the patient

leaves his bed to the time he leaves the hospital the corrective therapist applies reconditioning exercises to restore maximum function.

The reconditioning program may

begin with bed exercises including ’’quadriceps", back and abdominal exercises and active movement of all joints when possible.

The early emphasis of reconditioning stresses

reambulation and self-care activities.

The initial stages

of ambulation will require considerable assistance and moral support from the therapist.

Any mechanical or arti­

ficial aids that may be applicable are used in this process. The gymnasium is outfitted with simulated obstacles that will be encountered by the patient after discharge from the hospital like stair climbing, street crossing, picking up objects from the floor, and self-care and ambulation

55 activities required of daily living.

All of these activities

when administered individually and in group situations lend themselves to language re-education.

They are effective

means of providing motivation, creating high morale and encouraging voluntary participation.

In the gymnasium,

the patient has the opportunity of observing and working with men of like disabilities in all stages of recovery. Singing, counting and reciting used to accompany ambulation exercises adds to morale, provides a rhythmic synthesis to the activity and involves more than one sensory-motor association pattern.

The corrective therapy program lends

itself to the application and utilization of speech im­ provement involved in the speech therapy clinic. Manual Arts Therapy.

Patients with hemiplegia and

residual motor aphasia can often find activities in the manual therapy shops related to their former occupation or hobby that can be used as motivation for prevocational exploration as well as kinetic extension.

Although manual

arts, when serving prevocational exploration, are more adapted to the younger patient, many activities can be adapted to patients of all ages to provide tasks at which they can succeed.

By stimulating the demands of various

types of work in industry or trade, objective data jMsf^made available to the medical staff so that they may advise

56 patients for post-hospital goals commensurate with their disabilities.

Manual therapy projects can be adapted to

aid patients with flaccid paralysis and hemiplegia and to reduce residual disabilities that may affect their capacity for employment.

There is also presented opportunity for

socialization with patients of different degree of dis­ ability and accomplishment in a work situation.

Manual arts

activities present additional social and industrial oppor­ tunities for the patient to apply and test speech therapy.

progress in

The materials and projects the patient is

working with supply the necessary motivation and stimula­ tion for specific responses which can be integrated with the nature of the speech disability and the objectives for total treatment. Educational Therapy.

During the course of treatment

for language disturbances, it is important that an adequate description of the patient's educational level be achieved. The patient's past educational achievements are correlated with his present functioning for an analysis of educational interests and areas of remaining abstract abilities. Possible vocational direction may point to an educational deficiency that can be eliminated during course of treat­ ment.

The patient may have to change from an active type

of occupation to a more sedentary type that has greater

57 educational requirements which he can meet.

Appropriate

courses can be selected for both vocational and diversional aims at a level of difficulty with which the patient can cope successfully.

In view of the disability, it is

desirable that new study and work habits be inculcated. Since organic brain damage affects the patient's abstract attitude most severely, educational courses will be the most difficult to administer and will require the utmost patience and perseverance.

The selection of material for

educational therapy will be based on the level of abstraction at which the patient can be most successful and, at the same time, show tangible evidence of progress.

Since speech is

closely related to the abstract attitude related to motor coordination, the patient's progress in speech therapy will determine the overall educational course of study. Integrated services.

In addition to Physical Medicine

Rehabilitation, essential services required to treat the patient are:

Social Service - to provide complete social

case work facilities; Vocational Testing and Counseling; Special Services activities important for socialization; Music Therapy for group and individual participation, and miscellaneous services as Canteen, Library, etc. to provide the patient with normal stimuli for growth and adaptation.

CHAPTER VI SUMMARY M D

CONCLUSIONS

In order to realize the goals of aphasia retraining, basic attitudes toward neurological rehabilitation have to be established.

That rehabilitation of aphasic patients is

possible has been proven in recent years providing a total program of therapy is instituted.

The initiation of such

measures frequently meetiwith considerable resistance due to a lack of realization of how much can be accomplished even in the most severe cases.

The financial savings of

rehabilitation and the lack of understanding of retraining techniques have been additional factors that need clarifi­ cation. The neurological implications of aphasia have shown that a great deal of further study is required in order to arrive at a scientific understanding of cerebral functioning When the motor, sensory and association patterns of cerebral functioning break down, the best evidence of localization and integration of functions are presented.

All of the

areas discussed need further study and research before a comprehensive and pragmatic classification can be arrived at The pragmatic approach to aphasia has thus far proved the feasibility of therapy to rehabilitation.

The most

successful therapeutic process is the one that is the most

59 comprehensive and all inclusive.

However, each of the

therapies must be oriented to the specific dysfunction so that the treatment can be specific as well as general.

The

neurological and psychological examinations can, to a great extent, offer detailed information of the patient’s assets that form a basis for retraining. The more comprehensive the rehabilitation team of therapeutic services offered to the patient, the more effective will be his recovery.

It allows the patient to

test and apply language functions under a variety and range of social, emotional and physical stimuli.

The neurological

board meetings permit periodic evaluation of patient progress and determination of necessary changes of treatment.

Periodic

aphasia screening tests of the type mentioned serve an additional function of evaluating language therapy and determining its relationship to the overall rehabilitation picture. All of the services

d is c u s s e d

provide diagnostic

techniques and specialized therapies to restore the patient to the maximum physical, mental, social and economic status. They will act to reduce the length of hospitalization by stimulating restoration of physical and mental functions in preparation for return to active community life.

The

patient is furnished with practical and effective motivation for rehabilitation.

In addition, the therapies and services

60 will prevent or minimize the physical deeonditioning phenom­ ena, the lethary, the general deterioration and regression which so frequently result from prolonged periods of inactivity. The basic philosophy of re-education for aphasia is the essential characteristic of life in activity, change, achievement, action and reaction with environment. Any organ or function whether physical or mental, whether a group of muscles immobilized by paralysis or language process disturbed by organic damage will tend to deteriorate until it is no longer recoverable.

Only by guiding the

patient through a comprehensive activity program can desirable processes be influenced and restored.

New goals

can be established for patients with organic brain damage that were never before thought possible.

61

BIBLIOGRAPHY A..

BOOK REFERENCES

Eisensen, Jon, The Psychology of Speech. N.Y., 1938, Chapt. 8-9 Ewing, A. W . , Aphasia in Children. Press, 1930

F.S. Crofts & Co.,

London Oxford University

Froschels, Emil, Psychological Elements in Speech. Boston, Mass. Expression Co., 193!? Goldstein, Kurt, After-effects of Brain In.iuries in W a r . Grune & Stratton, New York, 19*42 Goldstein, Kurt, Language and Language Disturbances. Grune & Stratton, New York, 19*40 Granich, L . , Aphasia: A Guide to Retraining. Stratton, Inc., New York, 19*4? Halstead, Ward C., Brain and Intelligence. of Chicago Press, Chicago, 19*47

Grime

&

The University

Head, Henry, Aphasia and Kindred Disorders of Speech. Cambridge: At the Univ. Press., 1926, Vol. 1 and II. Huber, Mary, Re-education of Aphasics. Vol. 7, p. 289-293

Q.V.S., Dec. 19*42,

Nielsen, J.M., Agnosia. Apraxia. Aphasia: Their Value In Cerebral Localization. New York, Paul L. Hoeber, Inc., 19*4^ Travis, Lee E., Speech Pathology. Co., 1931

New York, D. Appleton &

War Dept. Technical Bulletin, T.B. Med. 1 55» Aphasia Language Disorders. Washington, D.C. War Department, War Dept. Circular, Results of Conference on Aphasia of Clinical Psychology and Neurology Branches. Washington, D.C. Neuropsychiatry Consultants Division, Surgeon General's Office, 19*45.

62 BIBLIOGRAPHY A.,

BOOK REFERENCES (Cont'd)

Weisenberg, Theodore, Katharine E. McBride, Aphasia. New York, The Commonwealth Fund, 1935 West, R., L. Kennedy, A. Carr, The Rehabilitation of Speech. Harper & Bros., New York, 1937 /

Wilson, S.A.K., Aphasia. B.

London, Trubner & Co., 1926

JOURNAL REFERENCES

Anderson, J.O., "Aphasia from the Viewpoint of a Speech Pathologist," J. S . Disorders« Sept. 19*+^, pp. 209-226 Franz, Shepherd Ivory, "Cerebral-Mental Relations," reprinted from the Psychological Review. Vol. 28, No. 2, March, 1921. Franz, Shepherd Ivory, "The Evolution of an Idea — How The Brain Works," Faculty Research Lecture at University of California in Los Angeles. delivered May 19, 1926. Published by U.C.L.A., 1929Franz, Shepherd Ivory, "The Relation of Aphasia," Offprinted from the Journal of General Psychology. 1930, pp. *+01-*fll. Franz, Shepherd Ivory, "The Re-education of an Aphasic," reprinted from Journal of Philosophy. Psychology and Scientific Methods, Vol. II, No. 22, October 2o, 190!?. Goldstein, K . , M. Scheerer, "Abstract and Concrete Behavior: An Experimental Study with Special Tests," The American Psychology.Association. Inc., Northwestern University, Evanston, 111. Vol. 53, >2:239, 19*+1. Huber, M., "Re-education of Aphasics," J ournal of Speech Disorders. 7:112-116, 17-12. Meyers, R., "Aphasia: A Problem in Differential Diagnosis and Re-education," Q.V.S., October, 1937, Vol. 23, No. 3, pp. 357-377

63 BIBLIOGRAPHY B.

JOURNAL REFERENCES (Cont'd)

Nielsen. J. M . , "Epitome of Agnosia, Apraxia and Aphasia wit;h Proposed Physiologic Anatomic Nomenclature," Q.V.S., Vol. 7, June 19^2, p. 105-153, Journal of Speech Disorders. Veterans' Administration Pamphlets 10-29. "Rehabilitation of the Chronic Neurological Patient," Veterans' Administration, Washington, D.C., May 19^9* C.

TEST REFERENCES

Bender, Laurette, "A Visual Motor Gestalt Test and Its Clinical Use," Research Monograms. American Psychiatric Association, No. 3, 1938-19^+3• Eisensen, Jon, "Examining fpr Aphasia and Related Disturb­ ances," Psychological Corp.. 522 Fifth Avenue, New York. Goldstein, K., M. Sheerer, "Abstract and Concrete Behavior: An Experimental Study with Special Tests," Psychological Monograms. Vol. 53, 2:239, 19^1 Halstead, W.C., J. M. Wepman, "The Halstead-Wepman Aphasia Screening Test," J ournal of Speech and Hearing Dis­ orders. Vol. 1*+, No. 1, March 19*+9 Klopfer, B., D. M. Kelley, "The Rorschach Technique," Yonkers, World Book Co., 19^2 Wechsler, D., "A standardized memory scale for clinical use," J ournal of Psychology. 19:87-95, 19*+5

6

*+

CASE STUDY *+3 year old veteran was referred to the aphasia clinic by the Chief of the Physical Medicine Rehabilitation section for aphasia testing and therapy. Medical Diagnosis: 1) Thrombosis, left internal carotid artery 2) Hemiplegia, right, secondary to 3) Aphasia Clinical Record:

Patient was siezed suddenly on

August 30, 19^9 with right hemiplegia.

There was no

history of hypertension, valvular heart disease, or lues. He was unconscious for five days and then began to improve gradually.

When examined on September 21, 19i+9, there was

evidence of central 7th nerve palsy and a right hemiplegia. Patient was also aphasic and there was evidence of astereognosis and agraphia.

EEC impression:

A small circum­

scribed focus in the left temple lead, in keeping with a cerebrovascular accident.

EKG was suggestive of incomplete

right bundle branch block, otherwise negative. Consultation in Neurological Surgery on 9/26/J+9 showed a typical picture of complete right hemiplegia where the patient was unable to use the arm or leg.

All the deep

reflexes were increased on the right side as compared to the left.

There was positive Babinski and ankle clonus on the

65

right side.

A common carotid angeogram on October 3, 19*+9

revealed no filling of the internal carotid artery.

On

October 10, 19^9, a second angeogram was performed and left common carotid bifurcation explored.

The internal carotid

artery was noted to have no pulsation or visibility of palpation and on repeated puncture no blood could be aspirated from the lumen of the vessel.

Neither angeo-

graphies showed any filling of any of the branches of the internal carotid artery.

Impression of Consultants:

Thrombosis of the left internal carotid artery and its branches. and

Neurological consultations on

10/ll/h9

9/28/h9,

10/h/%9

corroborated and confirmed the above findings.

The patient was referred to the Physical Medicine Rehabilitation section for scoring and intensive thera­ peutic measures.

It was felt that due to the patient’s

age and physical condition, he should be returned to a normal home environment in as short a time as possible. Physical Therapy:

Before the patient became ambulatory,

bedside therapy was instituted to maintain good body alignment and relieve tension on the hemiplegic side. Heat and massage were used to relieve muscle spasm and preparatory to exercise and re-education. Therapy:

Corrective

As soon as feasible, the patient was put on a

wheelchair and taken to the Corrective Therapy section for re-ambulation exercises and restoration of function for

66 maximum physical activity.

Occupational Therapy gave the

patient a chance to develop avocational interests through kinetic projects of his choice.

Prosthetic devices were

used whenever feasible to attempt restoration of function in the hemiplegic side.

In the Manual Arts Therapy section,

the patient was gradually introduced to the use of hand tools and power tools for plastic and wood projects*.

The

Educational Therapy section tested the patient for educa­ tional level of instruction in his vocation which had been approved as feasible by the Vocational Rehabilitation section.

Speech Therapy was instituted as a result of

psychological testing and evaluation.

A complete set of

tests used are included as typical of results obtained by aphasia patients. PSYCHOLOGICAL TEST SUMMARY Clinical Behavior. in a wheel chair.

Patient was brought into clinic

When the reason for his visit was

explained to him, he gave no indication as to his liking or disliking the situation.

Patient’s overall pre-traumatic

physique, disregarding the hemiplegic side, gave indication of being of excellent proportions, good posture and about six feet tall.

Right side of patient’s face seemed partially

immobile especially around the jaw and the right arm and leg seemed completely immobile.

He regarded the whole examining

procedure passively becoming annoyed at his inability to

67 answer some of the test items, particularly those requiring motor response and the use of his hands.

On the whole,

the patient was highly cooperative throughout the whole test situation and seemed to gain confidence and ability to respond to the stimuli as the testing proceeded. The patient's educational history included completion of two years of college.

His latest pre-morbid vocation

was management of a sales promotion agency.

68 APHASIA PATIENT TEST SUMMARY NAME:

Case Study A

WARD D

REGISTER NO.

DIAGNOSIS: 1.

Age: ^3

Sex: W: White

Male Single DATES

Right Hemiplegia With Aphasia

APHASIA TEST (name) : Eisenson Aphasia Test Receptive Disturbances:

10/22A9

Patient's right hand

is insensitive to tactile stimulation in recognizing objects.

He has a moderate dis­

ability in comprehending sentences which he reads and has somewhat more difficulty in the comprehension of the meaning of short para­ graphs and abstract interpretations. Expressive Disturbances:

Patient is able to

say three or four word,, sentences but blocks on anything more difficult.

He has had fair

automatic recovery of speech but will need help.

He is unable to write with his right

hand and it will be necessary for him to learn to write with his left hand.

He will have to

be motivated for accuracy in performance in expressive abilities.

APHASIA PATIENT TEST SUMMARY (Cont’d)

DATES WECHSLER-BELLEVUE INTELLIGENCE TEST, FORM NO.I Verbal I.Q.

97

Performance I.Q.

97

Full Scale I.Q.

96

Impairment Coefficient

Comment:

10/2*+A 9

30%

The zig-zag profile is fairly

typical of most of the brdin damaged cases tested.

Apart from the organic picture,

the test presents sufficient evidence to indicate strong neurotic conflicts with considerable anxiety and some hysterical manifestations.

Attention difficulty because

of preoccupation is indicated by the relation, of digit span to arithmetic.

Picture arrange­

ment as indicated by a score of

h

is typical

of an organic involvement. There is evidence that this is too low an estimate of the patient's highest capabil­ ities, since there were many items where it was evident he knew the answer but could not find the proper words.

He was also handi­

capped on some of the performance tests by poor motor coordination and awkwardness with his left hand.

70 APHASIA PATIENT TEST SUMMARY (Cont’d) DATES 3.

BENDEH-GESTALT VISUAL MOTOR TEST: Perceptual Impairment:

Patient performed task

with left hand so that some consideration must be given to the unsteadiness of lines.

The

salient features of performance are the strong perseveration tendencies as indicated

^

by making circles of the dots in the test items.

These are also considered regression

tendencies.

Difficulties in closure are

also considered distortions resulting from brain injury. Motivation for accuracy in performance seems to be lacking.

Patient did not take

task too seriously, performing rapidly with indifference to detail.

Although the patient

indicates moderate perceptual impairment, enough Gestalt remains to apply motivating stimuli for re-education. *f.

GOLSTEIN-SCHEERER CUBE TEST: Conceptualization Impairment —

10/27A 9 Patient shows

moderate impairment in conceptualization.

He

has some difficulty in achieving the correct result and becomes very angry and impatient because of this.

71 APHASIA PATIENT TEST SUMMARY (Cont'd) DATES RORSCHACH: Current Personality Description:

Patient

seems perplexed and apprehensive by his disability and lacks a real awareness of what has happened.

Though he is making

a marked effort to maintain self-control, it is indicated that with sufficient emotional stimulation he gives way to impulsive, uncontrolled behavior.

Patient

is constricted and very fearful in making close inter-personal relationships. Becoming emotionally involved is threaten­ ing to him, therefore he tends to avoid emotionality. 6.

SUMMARY AND CONCLUSIONS FOR RETRAINING: There is evidence that the patient's feelings of inadequacy are in part impeding his own spontaneous recovery.

Training in using his

left hand for writing, etc. and practice in reading have helped him markedly.

Patient

should make a good recovery but it may be necessary for him to seek somewhat lower goals than those to which he has previously

72 APHASIA PATIENT TEST SUMMARY (Concluded) been accustomed.

Patient will be given

intensive training in reading, left-hand writing, and speech prior to discharge and provided with some clinical materials for continued home practice.

EXAMINING FOR APHASIA AND RELATED DISTURBANCES , Jon E isenson RECORD FORM* Name

Age

C ase A

Date of E xam ination Pathology: i . 2. 3.

N ov. 1 , 19U-9

Sex __m

E xam iner M. S k l a r

T h ro m b o s is , l e f t i n t e r n a l c a r o t i d a r t e r y H e m ip le g ia , r i g h t , s e c o n d a r y t o A p h a s ia ' *

P h y sical D efects: R t . arm an d r t .

l e g - a l l down th e r t .

s id e

O r i g i n a l l y r i g h t h an d ed

Handedness:

E stim ate o r M easure of Intelligence: A. P r io r to A phasic D isturbances B. P re s e n t Functional Intelligence E ducational H istory and In te re sts: H ig h s c h o o l: B u s in e s s S c h o o l Language Background:

120

96 2 y r s . o f c o l l e g e - M.U. (1 9 2 5 -6 )

E n g lis h

Occupational H istory and Vocational In te re sts: S a l e s p ro m o tio n - owns a g e n c y

*To be used with the m anual, EXAMINING FOR APHASIA, by Jon E isenson. The Psychological C orporation, New York, 1946.

P rin ted in USA

Copyright 1946 The Psychological C orporation 522 Fifth Avenue, New York, NY

46-135 AS

7

*+

B . APHASIAS 1. Auditory V erbal C om prehension 1 -a S e n te n c es. \

Make an X through the p atien t’s r e sp o n se. C orrect a n sw ers are capitalized.

•

4-

1. What do people w ear on th eir heads ?

■4-

2. What do bird s m ove when they fly ? fe e t..........WINGS .

s h o e s .............sto ck in g s.......... s h ir ts ......... HATS

3. What i s a sm a ll ch ild c a lle d ?

lam b.............. BABY.......

4. In what month i s C h ristm as ?

D E C E M B E R ......... June

-h

5. Which se a so n h as the w arm est w eather ?

~h

6. Which se a so n has the c o ld est w eather ? WINTER........ •Sum m er...... 7. Which i s the f ir s t month of the y ea r ?

■+-

8. What i s the co lo r of snow ?

-4-

9. What i s the co lo r of a c le a r sky ?

W inter........

June......... A p ril..........D e c e m b er ......... JANUARY

black........... g reen ............. WHITE......... w h ite...........BLUE.

10. What day co m es right after T uesday ?

Sunday........ WEDNESDAY..

..F rid a y

N otes: 1-b O ral Reading.

Check the p atien t’s c h o ic e s if he resp on d s to oral q u estion s. L et patient s e e the printed q u estions below if he f a ils with oral p resen ta tio n of q u estion s. M ark h is r e p ly with a check.

(1) x) What part of farm ing do bovs m ost enjoy? 4— —

y) B ovs lik e m aking m aple sugar b e c a u se :

B lackberrying Making of m aple sugar Plow ing P ick in g w eed s

•— -+~

T hey w ork hard at it Som eone e ls e d oes m ost of the work It m akes them hungry It k eep s them outdoors

z) Making m aple sugar i s alm ost a s good a s : — ~

Blackberrying Pitching hay Plow ing F ishin g

(2) w) What w as the nam e of the bird? x) What kind of a bird i s it ?

Tom Jackie

____ Canary

v) What w ord b est d e sc r ib e s the bird ? z) W here w as the bird brought up ? y/ooo

If I

C o Ka

>-e_ h

M ft

P a rro t L azy

7

D ick ie

-h B lue Jay

L iv e ly

In the w oods On the s tr e e ts

C harlie

L on ely On a farm In a house

Sparrow Quiet

75

(2) The purpose of a new law m ay be adm irable and y et the law its e lf may be v ery bad. Bad law s have such se rio u s and la stin g e ffects that it is b est not to adopt a new law until it i s c e rta in that it i s a good one. — When should a new law be adopted?

__

When it s purpose i s adm irable

When it i s c erta in ly a good law

When it has se rio u s e ffe c ts

When it has lastin g e ffects

What have se rio u s and la stin g e ffe c ts? Bad la w s

Good law s

A ll law s

No law s

(3) The life of a trapper in the fo r e st i s a lon ely one. The country i s w ild. He m ay tra v el for d a y s . through tr a c k le s s fo r e s ts without ever seein g another p e r so n . Only the sh r ill c r y of som e bird or anim al breaks the s tilln e s s . > -f-

What i s a good title for th is paragraph ? F ish in g

Trapping

Farm ing

Hunting

L onely

Adventurous

Cows m ooing

B ird c r ie s

What w ord b e st d e sc r ib e s the trap p er's life ? Social

.

D angerous

What sounds does the trapper hear ? P eop le talking

Laughter’

(4) N aturally, after the United States becam e independent, those of our people who w ere engaged in m anufacture and com m erce sought a d egree of protection from foreign com p etitors in the m ark et of the United S tates. On the other hand, people who had to buy m anufactured goods wanted to get them a s cheap a s p o ssib le , and on that account they w ere content to have our m anufacturers m eet som e r e a l com p etition from foreign m anufacturers. T h ese people lived ch iefly in the South, w here v ery little m anufacturing w as done. In what part of the country w ere few m anufactured a r tic le s produced ? North

E ast

South

W est

From whom did A m erican m anufacturers want p rotection ? F arm ers ■—

A m erican labor

F oreign m anufacturers

C hinese labor

The people from what part of the country w ere m o st anxious to get m anufactured goods a s cheap a s p o ssib le ? North

E a st

South

’

W est

-f— Com petition with foreign m anufacturers lo w ers the p r ice of what kind of goods ?

Farm products

Raw m a te r ia ls

M anufactured products

Luxury ite m s

P ro tec tiv e tariff

C om m erce

The b e st title for th is paragraph is T axes

M anufacturing

Notes: -T«

0! / Qf ' u d oird

A

p-tri-G

be-a-d

f « - « T ff l

L eft H and to R ight Ear Z 0

t m

u n A

u

t t m

d d it io n a l

n s t r u c t io n

V

e r b a t im

R

esponse

I

tem

C

ode

27.* 4 W rite 27.* Ic, Id, IIo, l i e 28. ■4 Read-repeat 28. Id, IA, 116, IV 29.* 4 W rite 29.* Ie, Id, I la , l i e 30. IA, 116, IV 30. 4-R epeat ntr-tr-tri angle1* 31. 4 Read-repeat 31. Id, IA, 116, IV ~ 32.* 32.* 4 W rite Ic, Id, H o , l i e 33. 33. 4 R epeat IA, 116, IV , V 34. 34. R epeat IA, 116, IV , V 35.* 4 Com pute Uses pencil first-then answers, 16, I la , H e, lid , l i e 36. 4 Com pute *'17 x 36. Ij, 116, lid , H e is ‘Jl" 37. 4 Compute "it's seven times" 37. Ij, 116, li d , H e 38. 4 Read Silent 38. Id 39. 4 Indicate 39. II? 40. 4 R ead Silent verbalizes 40. Id 41. -4 Indicate 41. this here II? It's a man in the snow in 42. -r Explain ground & looking at the ai«r Ia, 116, IV , V plane-there's a steeple looks like water there. 43. 4 Explain It's a key 43. la , 116, IV , V 44.* 44.=* 4 Draw la , I la , 11/

SQ UARE

00 O* 1

I

tem

notes

and

Explain

4 Explain

47. 4 48.* 4 49. 4 50. 4 51. 4

It's a penny-it represents the smallest portion of mo|^y Id, we have-won1t be much-kids like pennv-sales tax in most states now. Used on all our postage in the Id, government. Used in order 46. to mail first class.

Repeat-E xplain W rite Read Place Place

co m m ents

To me it would mean an accident.

4748-* 49. 50. 51.

116, IV , V

116, IV , V

IA, 116, IV, V IA, I la , H e Id, 116, V H, II? IA, 11, l l g

:

35 - tends to verbalize method or process of math he used or uses. *+7 - and he was telling us to get out of the way - he was telling us.

80 WECHS LER-BELLEVUE Form I Observations and Comments:

This test shows the subject to have an I.Q. of 9 6 , at the 35th percentile compared with the general population, with I.Q.'s of 97 on both the verbal and performance halves of the test. There is evidence that this is too low an es­ timate of his highest capabilities, since there were many items where it was evident he knew the answer but simply could not find the proper words. He was also somewhat handi­ capped on some of the performance tests (particularly Digit Symbol) by poor motor coordination and awkwardness with his left hand. Motor control is so poor he would not even at­ tempt to write his name. Mental deterioration index shows a loss of 28 per cent which becomes 1^ per cent when corrected for normal deterioration. This is a sign of possible de­ terioration. Highest score was in Arithmetic which is a test ordinar­ ily not holding up well under deterioration. By far the lowest score was on Digit Span where b digits were repeated forward and 2 backward, indicating lack of concentration. Picture Arrangement test was also extremely low, indicating possible lack of ability to size a situation up as a whole and possible lack of skill in social situations. Subject uses a wheelchair though he is able to get in and out of the chair by himself with the use of a cane. Somewhat concerned because he thinks he should be getting out of the hospital soon. Did not seem to need as much encouragement as some sub­ jects nor was he visibly disturbed by failure. Appeared to be interested in the test and to try to perform well. Great deal of blocking and searching for words often un­ successfully and resulting in rather strange answers, e.g., "chimneys11 for smokestacks and "both sympathize our nature" for "symbolize". Marked stammer which became worse as he had difficulty in finding a word. Frequently would repeat the question before giving his answer and would "talk all around" a subject in trying to get at the answer. He could remember that the airplane was invented by "two boys from Dayton, Ohio" but could not remember their names. Vocabulary is full of responses where he seemed to be aware of what the word meant but could not pin it down. His definition of affliction is revealing: "Person has an affliction of some kind, either in his speech or something."

81

W E C H S L E R - B E L L E V U E INTELLIGENCE S C A L E

RECORD

FO R A D O L E S C E N T S A N D A D U L T S

Case_A____________________

nam e

.a s e

ocr.tiP.Owner of Sales Promotion Agncy pl a c e o f

exam

Wadsworth Hosp.

fxam

by

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X?l»

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13-14 25-26 12 22-24 20-21 II

ro-ii

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9 7-8

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10-11 7-9 5-6 3-4 1-2 0

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(VO CABULA RY )

(

VERBAL S C O R E *

Id

) (

q -i

P. A R R A N G E M E N T

v-

)

* 7 7

H-

P. C O M P L E T IO N

1o

7

B LO C K D ESIG N

h f

7

O B JE C T ASSEMBLY

H

//

D IG IT SYM BO L

L

P tR F O R M A N C fc SC O R fc*

i n

TOTAL SC O R E

1L

•Proration is necessary if four or six Verbal tests are given or four Perfomanca tests.

‘t'Z.

IQ .

PER FO RM . S C A I F

3 7

I.Q .

FULL S C A L E

77

I.Q .

VERBAL S C A I E