CHAPTER SIX:  LANGUAGE DIFFERENCES



Definition Of Language

     The term "language" encompasses a vast territory.  A fairly

simple, straightforward definition is "any means, vocal or other,

of expressing or communicating thought or feeling" (Travis, 1971,

p.15).   Language has also been described as "a socially shared

code or conventional system for representing concepts through the

use of arbitrary symbols and rule governed combinations of those

symbols (Owens, 1986, p.3).  I'm going to use a bit more succinct

definition, but one that I think is helpful to understanding this

thing called "language."  The definition I prefer for language is

"a set of arbitrary symbols that represent experience."  That may

sound a bit vague, but analyzing that definition is a good way to

approach the task of defining the act of language.

     For a better understanding of the overall territory

encompassed by language, let's look more carefully at the words

in the definition above. The word "symbol" means something that

is used to stand for something else.   A symbol can be something

that is spoken, written, or in the case of some deaf individuals,

the hand movements of sign language.   In other words, symbols

are anything that is coded to mean something else.

     The word "arbitrary" is an important part of the definition.

"Arbitrary" means that something is the way it is not because of

any particular logic, but simply because someone decided it would

be so.  For example, the word "dog" is an arbitrary symbol

because there is nothing about the production of the word "dog"

that suggests the person is communicating about a furry four-

legged creature.  There is nothing about the sounds 'd-o-g' which

causes us to think of a "dog."  If we were to point, gesture, and

say "woof-woof," the observer would probably realize that we are

talking about a dog.  However, the use of something associated

with the topic, in this case the sound the animal makes, is a

"signal," as opposed to a "symbol."  Words that relate to

something associated with the event are called >imitative= words.

Examples are "tinkle," "ding-dong," "clang," and "meow".

     Our definition of language as a set of arbitrary symbols

that represent experience cannot be complete without a discussion

of the word "experience."  The ability to communicate is based on

individuals having learned the same set of symbols.  Children

learn to speak the language to which they are exposed.  If you

grow up where English is spoken, you will speak English.  If you

grow up where Spanish is spoken you will speak Spanish.  People

must have had the same experiences with words to be able to

understand others who are using those words.  People must have

"experienced" hearing the word "dog" in connection with the

animal many times before the association is complete and

consistent.



The Importance Of A Common Experiential Base

     Even if we speak the same basic language, common experiences

are important for us to understand each other.  The word "snow"

has much greater value to a person living in Minnesota than it

does to a person living in Alabama.  The phrase "y'all" is unique

to the South and may elicit a puzzled expression from a person

from another part of the country.  (For those of you who are from

other parts of the country, the closest translation for "y'all"

is "you guys.")

     The more common our experiences with another person, the

more efficient our communication will be with that person.

However, it is important to realize that language is totally

unique to each individual.  We build our language as individuals

by listening to the people around us, but in the end, we develop

our own system.

     This is a tremendously important concept to understand for

persons who will be working in professions in which communication

is an integral part.  If you just realize that everyone's

experiences are different, you can create better understanding by

building common experiences on the topics you are discussing.

     To understand the significance of this, ask a group of

people to tell you what is the first picture to enter their

thoughts when you say the word 'cat.'  I do this regularly with

classes and I'm amazed at the variety of descriptions I get.

They report different colors, sizes, shapes, and characteristics.

Often they respond with the name of a cat they have, or had, and

discuss some experience about it.

     To translate this into effective communication, try using

this knowledge with some one with whom you are trying to

communicate some idea.  Let's take an example to which many young

people can relate.  You need a new car.  You want your parents to

help you purchase it.  You might want to lay the ground work by

getting a basic communication strategy together.  If you initiate

the request by saying something of the nature "I'd like you to

give me some money to buy a car," parents may react negatively by

associating the word "money" with their own daily budget

concerns.  Even if they don't have concerns about money, the word

"car" may elicit the vision of a conservative sedan to the

parents, which may be very different than your vision of what you

want in a car.

     The strategy should be to get them thinking about the

problem from your "experience" base.  A discussion of how you are

having transportation problems, and how this affects your

functioning (grades, health, time schedule) will help to develop

the common "experience" base that will lead your parents to the

belief that you need a car.  In other words, even though you know

the solution, start by discussion the problem so the persons with

whom you are trying to communicate will see the problem from your

perspective.  That will make your solution seem more logical.  In

fact many times, if you explain the problem well enough, the

listener will have reached the conclusion you want them to reach

before you state it.  That should a high point for you as a

communicator.  If someone states a solution for a problem you

have raised, before you have gotten to that point, you are an

excellent communicator.  If the solution they raise is the

solution you wanted, don't announce that it was your idea all

along.  They will be much more likely to resolve things in your

favor if you let the solution be one of their own making.

     

Spoken Language Differences

     Language has an extremely broad base.  As indicated before,

it includes spoken as well as written forms, and can include

alternative forms such as sign language.  For purposes of this

book, we will discuss disorders related to the spoken form of the

language.  These, we will find, are as broad in scope as the

definition of language itself.  I'll use case histories to

illustrate the range of language differences you might expect.



How Children Develop Language

     As I have indicated before, one of the miracles of

communication is the early age which children learn language, and

the speed and ease with which they learn it.  When I began in the

profession, we would normally not identify children with

communication disorders until they were school age.  Now we

realize that this is much too late to get the optimum benefits

from intervention.  On an average, children learn 75% of the

speech and language they will use as adults by time they are

three years old (Hannah, 1974; Boone, 1987, p.92).

     That means a three-year-old can produce 75% of the speech

sounds and understand 75% of the rules of language.  You can say

to a three year-old "when you finish lunch, you can go outside

and play.  But don't go out of the yard."  And the child will

understand you.  If you analyze those two sentences carefully,

you will find they contain some of the most sophisticated rules

of the language.

     The development of communication skills continues to

progress at a torrid pace until age five.  By then children have

90% of the speech and language they will have as adults.  They

will continue to polish and refine skills for the rest of their

lives, but their basic communication skills are virtually

complete by the time they start formal school at age six.  We now

know that it is incredibly important that we identify children

with communication disorders as early as possible.  The ease and

rapidity with which children learn communication diminishes

progressively after age six.

     It is important to recognize the value of early

identification in terms of implications for education.  The fact

that formal education begins at approximately the same time that

communication skills are almost fully developed is not by

coincidence.  Age six is the opportune time for most children to

start formal education because at this time they have a fully

functional communication system.  And a fully functional

communication system is critical for optimum learning.

     Note that I said age six is best for most children.  That

qualifying word carries a great deal of significance.  Children

learn communication skills at different paces.  Some precocious

three year-olds can produce all of the sounds of the language

correctly and easily carry on conversations with adults.  Other

children do not achieve that level of functional skills until age

seven years or later.

     We talk about children developing "within normal limits."

We have to understand that children can develop at very different

rates and still be "within normal limits."  It is often difficult

to determine whether an incorrect communication feature is the

result of a slow development pattern or some other factor.  If it

is simply because the child is developing more slowly, the

child's use of the feature may correct itself through maturation.

It is not unusual for parents to be advised to delay intervention

on a communication difficulty because "the child may grow out of

it."  As mentioned earlier, however, this attitude can be

hazardous.

     Early intervention, or the delay of intervention, becomes a

matter of choice, with advantages and disadvantages attending

each choice.  If the cause for an incorrect communication feature

in a child's speech is a different rate of development, then

choosing to provide treatment would be a waste of time and money.

However, if the incorrect feature doesn't change as a result of

maturity, the pattern will become more fixed and resistant to

change.  The child will be starting treatment at a later age,

meaning that the desired change may take longer and the chances

for a satisfactory correction are not as good.  Deciding whether

or not to work with a preschool child is a difficult decision,

even for the professional.  Parents need to have the options

explained fully before making the decision.



Language Differences In Adults

     Adult language disorders are discussed separately from the

language disorders of children as they represent two distinct

entities.  There are adults who have language disorders that

began in childhood.  However, the majority of adult language

disorders are caused by damage to the neurological system, that

is, stroke, head trauma, and aging.

     The diagnosis and treatment of language disorders in adults

does not have as much history as childhood disorders.  In the

early days of our profession, school systems were the primary

employer of persons who worked with communication disorders.  At

that time they were called "speech correctionists."  It was not

until the advent of World War I that the profession became

focused on adult language (Scheull, Jenkins, Jimenez-Pabon, 1967,

p.29).  Adult language problems became an issue at that time

because many injuries sustained in war are to the head.  The

country was especially concerned about providing services for

those injured in battle.  Head injury often results in language

deficits, so a great number of soldiers were in need of services.

     Since that time, the demand for individuals to work with

language deficits in adults due to neurological damage has grown.

There are few war related injuries now, but high-speed vehicles

on the highways have greatly increased the occurrence of head

injury and the language disorders that may result.  In addition,

I understand that violent crime is adding to the caseload of head

trauma patients.

     Also, people are living longer.  The longer people live, the

most likely they are to have a stroke or to suffer the loss of

neurological integrity that occurs with aging.  Alzheimer's

disease is a well-publicized problem that is associated with

aging.  Aging, in general, compromises the integrity of the

nervous system.

     The distinction between adult and childhood language

disorders is not so much a matter of age, but of previous

disposition.  Children with language disorders have never had

normal language and the treatment process is one of teaching them

new concepts.  The treatment process for adults who have suffered

neurological damage is different.  They have had language skills

and, due to the neurological damage, lost those skills.  There is

a major difference in teaching a skill to a child who has never

had it and re-teaching a skill to an adult.  The goal of

treatment for adults is to stimulate them to re-learn the lost

patterns, as opposed to learning new skills.  Later in this

chapter I'll discuss two adult cases with whom I was associated

that provide a glimpse of the range of adult language disorders.



Classifications of Language Disorders

     The varieties and degrees of language differences that can

exist are tremendous.  Let's spend some time discussing various

aspects of language behavior, starting with classification

protocols.



                     Classification by Age

     There are several ways in which to classify language

disorders.  In our discussion thus far we have divided them into

“child” and “adult” language disorders.  The actual age division

is arbitrary, with below 18 years being classified as child and

about 18 as adult.  Some sources will use adult to refer to the

time at which the nervous system is fully matured, when may be

between 15-20 years of age.



                    Classification by Degree

     We also talked about classification by degree.  Degree

usually ranges from mild to moderate to severe.  A mild language

disorder would be one that is noticeable, but has little or no

effect on the ability of the individual to communicate.  A

moderate language disorder would be one that interferes with the

persons ability to communicate, but does not disrupt the overall

communication effect.  A severe language disorder would be one in

which spoken communication is difficult, or perhaps not even

possible.



            Classification by Communication Function

     Language disorders can be classified on a continuum that

includes the landmarks of expressive, integrative, and receptive

language.  The continuum is indicated below:

receptive           integrative          expressive

|                        |                        |
 - - - - - - - - - - - - - - - - - - - - - - - - -

Some sources use just two terms, expressive and receptive.

Expressive language, as the name implies, indicates that the

reference point for the communication is the speaker, or the

person initiating the communication.  Receptive refers to a

reference point of the individual receiving the communication.

Integrative is sometimes added to label the processes that take

place between expression and reception.

     The most peripheral act of expressive verbal communication

is speech.  By peripheral, I mean it is the most observable,

definable event that occurs in the individual that indicates the

individual is expressing a unit of communication.  Hearing, or

perceiving the sounds that were generated by the speaker, is the

most peripheral act of receptive communication.  However, the act

of speaking and the act of hearing are only a small part of the

overall process.

     Let's examine what happens before a person speaks a

communication unit.  First the person must formulate an idea.

Then the words to express the idea must be selected.  Next, the

speaker must determine the order in which the words will occur,

and then select the sounds that make up the words.  Once all of

this is accomplished, the brain sends impulses to the muscles of

the speech mechanism where the movement causes speech sounds to

occur in the correct sequence.

     All of the preliminary activity is not observable.  It

occurs in the brain and rest of the nervous system of the

speaker.  We know it has to occur, but the exact mechanism by

which it occurs is not known.  The same thing is true of hearing.

Hearing the sounds is only the first event that occurs in

receiving a communication unit.  The sequence of sounds must be

matched with the listener's vocabulary and the correct words

selected.  The words 'cat' and 'tack' have the same sounds, they

are just in a different order.  The sequence of words has to be

analyzed to determine meaning.  The sentences "you did go home"

and "did you go home" contain the same words, they are just in a

different order.  Occasionally even the words are in the same

order, but the inflection of the voice is different.   The

sentence "he went home" can be made as a statement, or asked as a

question "he went home?"  The meaning is based not only on the

words, but on the inflection of the voice.

     There is a great deal of difference between the acts of

hearing, listening, and understanding.  You can listen to and

hear a foreign language being spoken, but not understand it.

Communication is only meaningful if the person listening has had

language experiences in common with the person speaking.



       Classification Of Language Difference By Attribute

     There are several attributes of language that can be given

names in the classification of language.  Among the most common

attributes are vocabulary (semantics), word order (syntax), word

modification (morphology), and context application (pragmatics).

These can be subdivided, but we will restrict our discuss of

language attributes to these.



Semantics

     Semantics refers to word meaning.  Vocabulary is probably

the most straightforward aspect of semantics.  We develop a

storehouse of words in our minds.  As speech is received, we

compare the sequences of sounds with the words we have in memory

to find matches.  It is estimated that vocabularies of normal

adults range from 5,000 to 50,000.  Environment and education are

the primary determinants of vocabulary size.  However, semantics

also generally includes using and understanding subtle

variations, or "shades of meaning."

     Often semantics reflects the current state of society.  The

semantics of war is a good example.  Are "war", "armed conflict",

and "peace keeping mission" really different in meaning?  Some

would say it is a matter of semantics.  It is more politically

advantageous to report "our troops were killed by friendly fire"

than to report "our troops were killed by guns fired by their

fellow soldiers."  Semantic manipulations such as the above are

examples of the malleability of the language.



Morphology

     Morphology is closely related to vocabulary in that it deals

with meaning at the word level.  Morphology refers to making

changes in root words that change some aspect of the

communication unit.  For example, the words "cat" and "cats"

conjures up images of the same basic animal.  The difference is

the number.  "She goes to the store" and "she went to the store"

both indicate the same action.  The difference is in time.  "The

grass is tall" and "the grass is taller" both refer to height.

The difference is degree.  "The story is true" and "the story is

untrue" represent a dichotomy.  One is it opposite of the other.



Syntax

     Syntax refers to the rules that are applied in chaining

words together in a meaningful unit, the sentence.  The primary

aspect of syntax is word order.  Some words occur in certain

positions relative to other words.  You would never say "cow a,"

but "a cow."  The rule is that articles must precede nouns.  To

make it more complex, articles must not only precede nouns, but

adjectives.  You must say "a brown cow," not "brown a cow."

Adjectives have an order of their own.  The phrase "a big, brown,

friendly cow" will sound awkward if any of the adjectives are in

a different order.  The order of adjectives and the use of

articles such as “a” is arbitrary.  Why do you need the article

“a?”  You know what the sentence means without it.  You need it

because it is the rule.  This is often a concept non-native

English speakers wrestle with when trying to learn English.

     Syntax also refers to grammatical rules.  "The boys playing"

as a sentence isn't complete.  An additional word is needed to

fulfill the meaning of the sentence, such as "the boys are

playing," "the boys were playing," or "the boys like playing."



Pragmatics

     This is an attribute that differs slightly from the ones

above in that it does not refer to rules for specific words or

other utterance units.  Pragmatics has to do with the socio-

linguistic value of language.  An individual can use perfect

language, but use it in such a way that it is inappropriate for

the setting and disruptive to the communication process.

     A good example of that is the person that always has to

talk, never giving anyone else a turn to talk.  Or conversely,

the person who always listens, but seldom responds can be said to

have a problem with pragmatics.  A person with good language

"pragmatics" knows how to initiate a conversation, maintain it,

and end it when appropriate.  They make the communication process

a balanced one, with equal import and activity assigned to each

person in the communication act.  If you have ever said the wrong

thing at the wrong time to the wrong person, you know how it

feels to be "pragmatic language challenged."



   Classification Of Language Disorders By Associated Problem

     Language is such an integral part of people that it is

difficult to dissociate it from the rest of the make up of the

individual.  Any mental, neurological, physical, behavioral,

emotional, or learning disorder that significantly affects the

functioning of an individual as a whole will affect language.



Hearing Loss

     Hearing is the primary sensory feedback source for language.

People who cannot hear their own speech, or hear it with

distortion, may not develop the rules of the language as

expected.  For example, people with a high frequency hearing

losses may be able to hear most of the sounds, but cannot hear

the high frequency 's' sound.  Because of this they may not learn

some of the rules of language.  For example, they may not learn

that an 's' is added to “cat” to make “cats” because they can't

hear the sound.  They may learn "she go to the store" instead of

"she goes to the store" for the same reason.

     Language is greatly affected by the loss of hearing.  This

will be discussed in a later chapter in which we will talk about

people with hearing loss.



Mental Retardation

     Mental retardation, or deficits in the development of

intelligence, also results in profound changes to the language

system.  As might be expected, the delays and differences in the

language of the retarded individual are closely linked to the

degree of deficit.  Mentally retarded individuals tend to follow

a relatively normal course of development, except it is delayed.

Also, the most sophisticated forms of language are not attained

and vocabulary is limited.

     Working with language development in the mentally retarded

population is a unique challenge.  Often there is encouraging

short term learning of language rules, but the learning does not

find its way into long-term retention.  Children will seem to

have mastered a skill, only to lose it.  Language concepts must

be presented in many different contexts for long-term retention

to occur.  It takes a creative person designing the treatment

programs for this population.

     There are notable successes in working with the mentally

retarded population, if the intervention occurs at an early age

and there is a coordinated learning plan that is conscientiously

applied by the agencies providing both the educational and

rehabilitation support to the family.  Many of the language

concepts that other children learn by just being in the

communication environment must be taught to the mentally retarded

population in a carefully structured learning situation.



Autism

     Autism is one of the most dramatic disorders of which

language is an associated problem.  There are several different

characteristics that can be present for a child to be diagnosed

as autistic.  Below is one list:Kanner, Leo

----List---- [ref here]

The autistic child I describe later in this chapter [Max] is

representative of the autistic population.  However, autism comes

with different sets of characteristics, varying degrees of

severity, and cuts across all social, economic, and educational

boundaries.  Communication, or perhaps I should say lack of

communication, is the most noticeable characteristic.  It is

probably the one characteristic that is most valuable in making a

prognosis for improvement.  The less communication exhibited by

the autistic child, the poorer the prognosis.

     Language that is heard from autistic children who do not

have concomitant mental retardation is often normal, or may even

be superior, in quality.  Those autistic children learn the rules

and content of communication, but do not learn how to use

communication to manage their lives.  That is, they lack

pragmatic skills.  The goal of treatment for them is to use

communication to achieve desired responses from others in their

environment.



Childhood aphasia

     Childhood aphasia is a term used to describe children who

have difficulty understanding and/or using the symbols of the

language system.  The problems are basically the same as those

experienced by adults with aphasia.  You will remember that adult

aphasia is usually associated with stroke or other cortical

lesions.  Children who are aphasic may have global problems of

reception and expression, or they may have very specific

problems.  The problems may be as noticeable as not understanding

words or not being able to select the correct words to use.  Or

the problems may be extremely subtle; inability to distinguish

shades of meaning, not recognizing humor or sarcasm, problems

associating names and faces, etc.  Michael, described later in

this chapter, could have been classified as having aphasia.

     While childhood aphasia is very similar to adult aphasia in

characteristics, the treatment is very different.  The treatment

for adult aphasia is basically a matter of stimulating recall.

The adult is stimulated to use the language possessed before the

onset and so it was a matter of regaining lost skills.  The

treatment for children, however, is different in that they have

never learned the language skills, so it is a matter of

acquisition of new skills.

     Intervention for childhood aphasia is often structured with

cues.  The written language is often used to promote the spoken

language.  Color coding and other association techniques are

commonly used in teaching written and spoken language.  The

written language may be taught first to these children, and then

the concepts generalized to spoken language.



Learning disorders

     A learning disorder is a disorder that is present when an

individual has normal intelligence, but has specific difficulties

in formal learning (Wiig & Semel, 1980, p. 17-18).  For example,

persons with learning disorders may have excellent reasoning

skills, may be good at math and sciences, but have weaknesses in

specific language skills.  One of my adult friends has a specific

learning disorder associated with direction.  Early in our

association I learned that I had to point when giving him

directions, as he had difficulty retaining even basic ones.  He

did not automatically go to his 'right' when told to do so.  He

made a small writing motion with his hand which apparently was a

cue for himself to determine that hand (his writing hand) was the

'right.'

     Learning disorders associated with reading are relatively

common.  They are often associated with language disorders.  Part

of treatment is to help the person understand the problem and how

to cope with it.  Although the learning disorder may stay with

the individual throughout life, many learn to cope well enough

that the disorder does not significantly affect their lives as

adults.  Many people with significant learning disorders become

well-adjusted adults who are successful in their vocation.

     Persons with learning disorders are a real puzzle for that

reason.  Why would someone with normal intelligence in most areas

of daily functioning have deficits in others?  The best guess is

that there are differences in the nervous system which determine

which will be the areas of difficulty.  However, much more

research needs to be conducted in this area.



Case Histories:  Children

                            Michael

     Michael was referred by a physician who was attending him

for injuries sustained in a motorcycle accident.  He was

seventeen, friendly and outgoing.  The physician's reason for

referral was "something doesn't seem right, but I don't know what

it is."  As I have indicated before, this is not an unusual

statement of referral.

     I was working with the hospital, which included a

rehabilitation facility for children with physical disorders, to

develop a program for evaluating and treating children whose

language and learning performance were not at their full

potential.  Most of the children we were seeing were severely

impaired with cerebral palsy or some other serious neuromotor

disorder.  It was unusual for us to get a referral of a less

severe problem, such as Michael's seemed.

     I took a student clinician with me and we went to Michael's

room directly from our work with the severely impaired, so upon

initial interaction Michael’s communication skills appeared to be

within normal limits.  However, when we started talking about the

motorcycle accident, the conversation went something like this.

     "How did you get injured?"

     "I got hit by a truck."

     "What kind of truck?"

     "Oh....you know, some of those big trucks."

     "You mean like a semi?"

     "No, one, you know, like carries potato chips."

     "A delivery truck?"

     "Yeah, a delivery truck?"

     "How did it happen?"

     "Well, this guy wasn't looking where he was going and

      the other guy didn't see him."

     "Which guy wasn't looking where he was going?"

     "The guy in the street."

     "A pedestrian?"

     "I think so."

     "So this man was walking across the street and wasn't

     looking.  Is that right?"

     "Yeah.  He wasn't looking where he was going."

     "And so the other guy, who was the driver of the truck,

      didn't see him?"

     "That's right."

     "And when the driver swerved to miss the man walking, he

      hit you?"

     "Yeah.  Boy, it was a mess!"

     Michael was relaxed, smiled, and worked the way through the

rest of the conversation as efficiently as he did the first part.

All through the conversation we found ourselves filling in the

words for him and often completing the sentences.  It became

obvious that Michael had a problem expressing himself clearly.

In particular, his word finding skills were weak.  However, it

was also equally obvious that Michael knew his limitations and

was very skilled in directing the listener to the desired end.

     We did an assessment of general academic skills and found

severe deficits in all areas.  We asked him if he had any type of

special placement in school and he indicated that he did not.  He

was from a small school district and the only placement available

other than the regular classroom was a class for the mentally

retarded.  It was our impression that Michael probably would have

scored low enough to be placed in that class, had he been tested

with conventional, standardized instruments.  This would have

been especially true if the intelligence test included a

substantial component on verbal intelligence.

     He indicated to us with some pride that he was a trainee in

a meat-cutting program.  The program was sponsored by a meat

packaging plant that was the economic mainstay of the community.

If he completed the training, he was guaranteed work there full

time when he completed high school.

     After assessing his academic skills and identifying a severe

reading deficit, we asked if there was any reading involved in

his training.  He reluctantly acknowledged there was an

instruction manual.  At this point Michael started getting

nervous.  He talked around the reading aspect of training for a

while, but finally confessed that he didn't understand most of

the book.  However, it was "no big deal" because he could watch

the others do the meat cutting and learn it by copying them.  He

didn't have trouble remembering how to do things ("it's just them

words," he said), and he said he was considered as good as any

trainee in the program.

     By this time Michael was aware of where the conversation

might be going.  He definitely did not have a problem with basic

intelligence.  He realized we were exposing a problem that he had

become adept at hiding and he became more uncomfortable with each

new question we asked.  He asked if we sent reports to schools on

our findings at the hospital.  I believe he realized that when we

reported what we had found to the schools, he would probably be

tested there.  The student clinician and I exchanged a look of

"what do we do next?" which did not escape Michael.  "You know,"

he said quietly with his head down, not looking us in the eye,

"you have to be in regular classes to be in the program

[referring to the meat cutting program]."

     We spent more time talking with Michael to get a better idea

of how he coped with communication in general.  He was good-

natured and it did not bother him that he didn't have good

command of the language.  "People like to finish what I say " he

told us.  He was evidently a bit of a class clown, a good guy

that everyone liked, and he made a point of being attentive in

class and treating the teachers with great respect, even though

he didn't really know what was going on in class.  When we asked

him if people realized he was different he indicated that

everyone knew he had trouble with words, but they figured that's

“just the way he was.”

     I thought the last concept was a treasure-accepting a person

simple because “that’s the way he was.”  Evidently the people in

the small town in which he lived simply associated the difficulty

with words as a characteristic that identified Michael as unique,

rather than "disordered."  What a simple, but great concept!

Professionals can recognize a "disorder" and can provide a

quantified and definitive description of the type and degree of

the "disorder."  However, by doing so in this case, Michael would

have a "label" attached to his "uniqueness."  To the people of

the town this "uniqueness" was just "Michael."  This is one of

the experiences that lead to my belief that "differences" is a

better semantic choice than "disorders."

     There was a good deal of discussion about Michael between by

our program staff, the physician who identified the problem, and

the Chief of Staff of the hospital.  The Chief of Staff was an

accomplished surgeon.  Much of the surgery at the hospital was

designed to help patients walk, some who had never walked before.

His skill at doing so was unquestioned.  However, his interest in

his patients did not end there.  Our program was the result of

his interest in treating patients beyond their physical being.

     Most patients were from sparsely populated areas with few

resources.  He had worked to establish our program so we could

make suggestions to the school systems as to how to deal with the

severely involved individual.  This was at a time during which

there were no laws requiring special school services for children

with special needs.  In many schools, children like Michael were

simply "passed on" through the school after being failed two

years, regardless of performance.

     I had great respect for the surgeon and his attitude.  Many

resident surgeons passed through the hospital and the Chief of

Staff imbued them with the same spirit.  One of his favorite

lines was  "If we're going to get them walking, let's make sure

they have some place to go."  That statement became a motto of

our program at the hospital.

     Back to Michael.  Michael obviously had a "problem" and

treatment "might" help.  However, Michael was nearly an adult.

He did not view himself as a person with a "problem," nor did his

family or community.  By sending a report to the school system,

we would likely have set into motion a series of events that

would have led to Michael being labeled as having a "problem."

That could have resulted in his educational program being changed

and his job training being terminated.  We gave the situation a

lot of thought.

     We never sent the report to his school system.  While it

would have been "correct" to do so, it might have jeopardized his

position in the training program and the community.  Other

professionals might challenge our decision.  However, any

decision made about the lives of people who we provide services

for as individuals should always be made on the basis of what is

best for the welfare of the individual as a person.  In this case

we did not feel that intervention would be in his best interest

as an individual.

     Michael's problem would now probably be identified fairly

early as a "language disorder."  His type of language problem is

often associated with learning disorders, to the extent that some

texts refer to the problem as a "language/learning disorder."  It

is my impression that had Michael lived in a time in which good

intervention was available, his problem would have identified

early, a treatment program would have been provided to minimize

his limitations, and he would have been able to stay on, or close

to, grade level in school.  Many language disorders fall into

that category.  They are not so far out of the range of normal

that they require a separate program, but they do need additional

help.

     It isn't hard to identify with Michael's problem.  All you

have to do is recall some incident in which you had trouble

remembering a word.  Most commonly we have trouble remembering

names.  The sentence "you know, that movie actor who was in...."

or "you know, that part that you have to have to make it work"

tells you the speaker is having word finding problems.  Imagine

how frustrating it would be to have to deal with that everyday

and you can appreciate the skill with which Michael handled his

"uniqueness."  The next time you face yourself searching for a

word that is "on the tip of your tongue," but not coming out your

mouth, consider what your life would be like if you experienced

that challenge day in and day out.



                              Max

     Max was a three and one-half year-old child referred to our

clinic by a pediatric neurologist in a city some one hundred

miles distant.  His family lived slightly closer to our clinic

than to that city, so the referral to our facility was for the

convenience of the family.  The report indicated that Max had a

"specific language deficit."

     Max did nothing during the evaluation but make repetitive

hand gestures and repeat some television jingles that were

current at the time.  He did not pay attention to me, nor did he

respond to his parents commands when they asked him to do things.

He was easily physically manipulated into doing things (such as

sitting down), but did not follow directions.

     I had nothing related to it in my background and training as

a speech-language pathologist, so I scheduled a second

evaluation.  Between the first and second evaluation I combed the

literature and learned that the characteristics Max exhibited

were those of an autistic child.  This incident occurred before

the disorder of "autism" received the attention that it now gets.

     I confirmed the original observations at the second visit

and explained the problem to the parents.  I was not prepared for

the explosion that followed.  Let me give some background by

saying that both parents were very intelligent and had training

in professions.  Both Max's mother and father were high school

teachers and had a solid background in education.  The explosion

came from came from his mother.  The pediatric neurologist had

told her it was a "specific language deficit" that should be

easily corrected by some short-term treatment.  Autism was a new

and scary term.  The term “short-term treatment” didn’t fit with

the diagnosis of “autism.”

     Max's father took the news calmly and said nothing.  He

seemed to be more aware of the severity of the problem, however,

he did not dispute his wife.  He followed his wife as she stormed

out of the door of my office.  This happened fairly early in my

career and I was not yet adept at breaking bad news to families

of individuals with severe disorders.  I realize now I should

have handled it with much more sensitivity.

     I heard nothing for two months.  The next contact came in

the form of a telephone call from a psychologist at a well known

medical center in New Orleans.  He had evaluated the child and

agreed with my diagnosis.  The parents had asked him to call to

see if I would work with the child.  Evidently, there was concern

that I might not care to deal with the family after the scene at

the clinic.  I was just delighted that my diagnosis was

confirmed.

     Max started coming to the clinic the following week.

Because the family lived over an hour's drive away, we scheduled

him only once a week.  At that time we would work with the

parents on things to do with him at home.  They were quick to

learn and extremely conscientious.

     Initially Max said nothing other than mumbled jingles that

he had obviously learned from television.  As many autistic

children, he treated people as objects no different from other

objects in his environment.  He was compliant with physical

manipulation, but would scream if he became upset.  Treatment for

autism was not well structured at that time.  I would suggest

that it is still very much an individual matter.

     The first goal of working with Max was to develop some means

of expressing himself other than verbal.  Some of the activities

we chose were drawing with crayons, painting with watercolors,

and finger painting.  This proved to be an "interesting" approach

in that autistic children such as Max have a strong aversion to

new experiences.  They feel most comfortable in a routine.

Putting a crayon in his hands sent him into a screaming episode.

He had a piercing scream that could easily be heard two blocks

distant.

     Our routine for introducing him to an activity was to seat

him on our lap, put whatever it was we wanted him to experience

in his hands, and manipulate his hands through the act.  Student

clinicians were taken aback when I demonstrated the procedure.  I

had to wrap him in my arms to keep him from running away,

introduce the media, such as putting a crayon in his hand, and

manipulate his hand through the act and tolerate his screaming.

I decided on this technique as I had read that autistic children

accommodate to tasks that initially disturb them if they are

repeatedly exposed to the activities.

     The first time I tried it I could barely believe the

ferocity with which he resisted.  My ears were ringing after the

hour visit.  I vowed to myself that I would continue this

strategy only if results were better when he came back the

following week.  The parents were asked not to try anything we

did with him until we were getting the behavior we wanted in the

clinic.

     The second visit was the real eye-opener.  Max came into the

room, walked over to where I was sitting so I could put him on my

lap, and made only whimpering noises, none very loud or of a

protesting nature.  His movements seemed almost self-directed.

With him calm, it gave me the opportunity to talk with him while

we went through our exercises.  I talked the whole time,

describing what we were doing and how well he was doing it.  The

third visit he only whimpered slightly, and picked up the crayons

himself and started the activity without prompting.

     And so it went with each new media introduced.  Finger

painting was the supreme test.  I did not realize that "gooey"

and "messy" textures elicited strong reactions from autistic

children.  We got our loudest protest of the whole training time

when we put his fingers in the paint and started moving them.  A

student clinician had been trained to work with him at the time

of the activity.  I was in the observation room behind a one-way

mirror that allowed his parents and myself to see what was

happening, but did not allow Max to see us.  Tears were rolling

down his mother's cheeks as she watched him scream and struggle

to get away from the horrors of finger painting.  To her credit,

she never said a word or protested what must have been a

particularly disturbing scene.

     There was still some protest to the finger painting in the

second week of the exercise, but it was largely subdued.  The

third week both parents smiled and gave a sigh of relief when Max

walked into the treatment room, got the powder to be mixed into

finger paint off the shelf, and positioned himself in the

clinician's lap to participate.  He was still whimpering to

himself, something that became more meaningful to us later.

     As time progressed, we exposed Max to more and more novel

experiences-different rooms, walks around the campus, different

people.  All of this was to generalize his ability to deal with

new situations.

     Max still reacted strongly to changes in routine.  One week

he came to the clinic in an almost uncontrolled rage.  We had to

chase him through the waiting room and it took half of the visit

to calm him down.  His father knew what the problem was and had

the explanation ready for us.  "We had to take a detour on the

way here."  Max was accustomed to coming to the clinic following

a certain route.  The change in route caught him off-balance.  We

had discussed the structure that autistic children create for

themselves with Max's parents, so they were not surprised when

such things happened.

     Max's father also related an incident that happened one day

when they had returned home from the clinic that showed the

extent to which Max needed structure in his life.  Max's mother

had stayed home and cleaned house while they came to the clinic.

She cleaned Max's room and changed the position of some of his

favorite toys in doing so.  When Max returned home and saw his

room changed, he commenced a screaming scene that abated only

after everything had been returned to its “proper” place.

     Max continued to make excellent progress throughout the

year.  He began making eye contact and treating people

differently from objects.  I can still remember the thrill we

experienced the first day he came into the waiting room and

climbed into his father's lap, rather than simply walk aimless

around the waiting room as he had previously done.  Being able to

hold him and have him respond with a smile was one of the gains

that his parents appreciated most.

     As I indicated earlier, we talked with him all the time we

were working on any activity.  Progressively we noticed that his

"whimpering" was becoming more like speech, but speech to which

the listener had to attend carefully.  A major break-through in

communication came the day on which we first could relate things

he was saying to a real event in his life.  He was using speech

from a Sesame Street show in which the character Big Bird had

hurt himself.  Max was holding his finger, which we could see had

been injured, and his parents confirmed that it had been hurt on

the way to the clinic.  He was using someone else's speech to

convey his hurt, but at least he was communicating something

related to himself.

     We continued to encourage his "mumbling," or “whimpering,”

and were eventually rewarded with speech of his own creation.

The first such instance was a sketchy description of a visit he

had made to his grandparents.  About all we got were "grandma,"

"grandpa," "farm," "cows," and "pigs."  We were not even sure we

had heard it all correctly, until we met the parents coming from

the observation room.  They were beaming.  It was the first

instance in which he related an event using his own words.

     Max progressed to a point at which he could enter into a

regular preschool room.  He was still "different" in that he had

a hard time dealing with changes in routine, his speech was

"mechanical" to the listener and lacked the normal intonation

patterns.  He sometimes wandered from the other children during

group exercises.  However, the fact that he could function at all

in a classroom setting was a major achievement as far as his

parents, and those of us who worked with him at the clinic, were

concerned.  I did not have a chance to follow Max's progress past

the first year away from the clinic.  But given the love and

concern of his parents, I felt that he would only improve.



The Range Of Language Differences

          The case histories above are examples of the extremes

of the continuum on which language differences occur.

Differences may be limited and present minimal problems for which

the persons may learn to compensate effectively without

intervention, as in the case of Michael, or differences may exist

to the degree that they completely impede the individual's

ability to interact with the environment, as in the case of Max.



Case Histories:  Adults

                             Betty

     Betty was a 70 year-old lady who experienced the

characteristics of Alzheimer's disease.  Her husband, Herbert,

was a jovial, supportive man whose good cheer and outgoing nature

made him the center of attention wherever he was.  At times I

believe he made an extra effort to be that center of attention,

not because he craved the spotlight, but because it drew

attention away from his wife's condition.

     Betty was an attractive lady who demonstrated behavior that

suggested she was somewhat confused and unsure of herself.  When

she first came to the clinic she was in the earlier stages of

Alzheimer's, and could participate in a mundane conversation.

However, if asked questions about her children, such as how old

they were, where they lived, what they did for a living, etc.,

she could not respond and would become anxious.  If pressed, she

would become agitated.

     She experienced the confusions of most Alzheimer patients.

Time concepts became difficult for her.  First it was in the form

of not being able to remember birth dates.  This seemed to cause

her a great deal of anxiety because she had always been the

parent who remembered the birth dates of their children and

grandchildren, and the anniversaries of their grown children.

She feared her children would be upset if she forgot.

     She later had a great deal of difficulty remembering faces

and names.  The clinic was a University training program and the

University was on a quarter system of course scheduling.  This

meant that Betty had a new student clinician working with her

every few months.  She would just get the name of one student

straight and then be assigned another.  And she was always

embarrassed when a student who had worked with her formerly

stopped to say 'hello' and she couldn't remember that person’s

name.  It seemed actually more difficult for her to cope with in

the early stages of the disorder, because at that time she was

aware of her problems and the mistakes she made.  It upset her

that she could not do the things she had taken for granted all of

her life.

     As the disease progressed, she had more and more difficulty

with the memory.  First, it was things like forgetting what she

had gone to a store to get.  Later it was going to another room

to retrieve something and forgetting what she had gone there to

retrieve.  She had loved travel and going places, but couldn't

take a walk in the neighborhood unattended because she might

forget her way back home.  Later Herbert had to be extremely

careful of her working in the kitchen, as she would start

something, such as turning on a stove, and forget what she was

doing.

     She had always been a meticulous housekeeper.  Herbert

related one day how he found her weeping at the kitchen table.

When he asked her what was wrong, she swept her finger around the

room, pointing to the accumulation of unwashed dishes, pots, and

pans, and the general disorganization of the room.  It seemed

that she had had a lucid moment in which she realized that she

was no longer capable of maintaining cleanliness and order in her

kitchen.  The realization was obviously upsetting.

     Treatment for her condition was multifaceted, with primary

emphasis on helping her maintain life skills.  One of the routine

items included in the treatment program was talking to her about

her children.  She brought pictures of children and

grandchildren.  We wrote names and birth dates on the back and

talked to her about them.  It was not just working on her

remembering the dates, but keeping the dates and reminding her

when a birthday or anniversary was imminent.  We would make sure

Herbert knew when one of the dates was approaching and he take

her directly from the clinic to get a card to send.  We talked to

her about the ages of her children and grandchildren, what they

looked like, and recorded stories she told us about them.  Later

we would discuss something she had told us and she couldn't

remember it.  While the constant discussion could not stop the

course of her memory loss, it helped her to remember more than

she would have otherwise.

     We worked on attention, concentration, sequencing, and other

basic mental tasks.  We would turn over pictures and have her try

to remember where different pictures were, much like the game of

'concentration.'  For sequencing we would have her line up

pictures of her children from oldest to youngest, or vice versa.

Also, we would talk through recipes from cookbooks to help on

sequencing.  First you put the flour in the bowl, then you add

milk, then you stir in an egg, etc.  On one occasion the student

clinician met with her at her house and they baked a cake.  We

generally talked in every session about the activities in which

she had been engaged that day and sequenced them from rising in

the morning to going to bed at night.

     We made simple maps of the places she visited regularly.  We

talked with her about the names of streets in her neighborhood,

directions for going from her house to a friend's, and directions

to any other place she visited on a regular basis.  Games were a

much-used device with her.  She had played cards a great deal.

Card games can be excellent tools to use in exercises involving

mental skills such as the above; attention, concentration,

sequencing, and problem solving.

     Much of the time was spent eliciting speech from her to

maintain her conversational skills.  We talked about different

times in her life, special events she had recently attended, and

discussed television shows she liked to watch.  Students were

often amazed that she could remember in great detail a play she

had been in during her third grade in elementary school, and then

not be able to recall what she had eaten for breakfast.

     There was a great deal of inconsistency in performance.  One

session she would seem to remember everything from the past few

sessions only to seem to forget everything the next session.  The

inconsistency in performance was like a cruel joke to Herbert.

He would see periods in which Betty seemed to be doing better and

think that there might be a hope for permanent improvement.

However, he eventually learned that there would be good days and

there would be bad days, and as time passed the bad days would

progressively increase while the good days decreased.

     There finally came a time when Herbert was not capable of

managing the daily routine with Betty and she was placed in a

facility that provided continuous management.  Patients who

suffer from Alzheimer's do not recover.  It is one of the most

difficult disorders to accept because of that.

     A second aspect that makes it difficult to accept is the

time at which it occurs.  It comes at a time in life when many

couples have raised the family and have the resources to do

things they were unable to do before, such as travel.

Alzheimer's robs the couple of one of the most important times in

their lives.

     You will notice that throughout the description of Betty's

treatment I have referred a great deal to Herbert. Alzheimer's is

a disorder that has a tremendous debilitating effect on the

spouse, or other family members who are the caregivers for the

patient.  Herbert managed good humor through all the time he came

to the clinic.  His enthusiasm for her short term gains in the

treatment program diminished over time as he became more aware

that no amount of treatment would change the course of the

disorder.

     I do not know how Herbert fared after placing her in the

care facility, but it was obviously a choice that took its toll

on him.  Placing a loved one in a care facility is often

accompanied by feelings of guilt in the person who makes the

arrangements.  It is an admission that the caregiver can no

longer be responsible for the individual.  The admission to a

care facility usually comes after the caregiver has exhausted the

available financial and physical resources.  But no matter how

good the care facility, or how necessary it is to place the

person, there is no sense of relief for those admitting the

patient.

     You might ask why we would work with a patient who we knew

would not achieve long term gains from treatment.  It is a

question often asked.  Our philosophy as a profession is to help

stimulate the remaining faculties of persons with progressive

disorders in order for them to maintain independence and quality

of life as long as possible.  We refer to this as maintenance

treatment.  It is one of the most challenging forms of treatment

because the end result of the illness is a foregone conclusion.

It is also one of the most rewarding because families of those

patients are exceptionally grateful for the attention and support

provide during a most difficult time.



                             Grant

     Grant was a twenty-seven year-old male who came to the

clinic four years post trauma.  He was diagnosed as being

aphasic.  He could manage a routine conversation, could remember

important dates and facts about himself, and presented the image

of an adult whose mental processes were diminished.  People who

met him assumed he was slightly retarded.

     Grant had been an exceptional undergraduate student in

college.  He had majored in pre-law and upon graduation he had

been accepted to the premier law school in the state.  He was

traveling to the university to start his program when he had the

automobile accident that caused his problems.  The accident left

him with massive injuries.  Many bones were broken, there was

internal bleeding, and there were significant head injuries.

     He had an extended recovery period during which he had to re-

learn to walk, feed, and care for himself.  He eventually managed

a daily routine of independence.  The physical recovery was close

to a year in duration.  At the end of that time he was able to

function independently and was even able to drive an automobile.

     The primary concern during the initial recovery period was

his physical condition.  Unfortunately, there was little

counseling in the initial stages for resuming his life.  He was

married at the time of the accident.  His wife, Maria, stayed

with him and provided support.  She began working after the

accident and with the support of their families (both of whom

were, fortunately, able to contribute financially), they were

able to employ a housekeeper to watch him and help manage the

home while Maria worked.

     A child was born in the second year after the accident and

Grant helped with the child at home.  The housekeeper was

retained because Grant could not care for the child alone.  One

of the results of the accident was a significant motor impairment

to his dominant side (right).  He could not maintain a grip nor

lift anything that weighed more than a few pounds.  Both he and

his wife expressed concern for him being able to care for the

child (a pretty and active daughter).  He could watch the child

only for short periods of time and only if either Maria or the

housekeeper was close by.

     Grant had spent a significant amount of time during the

first two years trying to reconstruct his life and what had

happened.  He understood that he had been a good college student.

Comments from the family indicated that they believed he might be

able to return to college at some time.  When he came to us it

was obvious to all concerned that college was an unlikely

possibility.  He still held some hope, however, that he might

some day rehabilitate to his former self.

     After the maximum physical recovery period, Grant was

reported to have become 'melancholy' and did nothing but sit

around the house.  He watched some television, but the greater

part of his day was spent listening to classical music.  That had

been a special part of his previous existence and it was

something that he still related to in a very personal way.  He

played with his daughter, but seemed almost afraid to interact

with her.  He had been told soon after she was born to be careful

not to hurt her.  The family meant the caution in terms of

holding her, but Grant took it to mean any interaction.  That

fear was ingrained in his consciousness.

     Initially we did a thorough evaluation of Grant's

communication, intellectual, and learning abilities.  The maximum

time for spontaneous recovery of mental processes for a head

injured patient is normally less than one year, so he was well

beyond the time during which natural recovery would be expected.

     Because he still had an interest in academics, we worked on

basic reading and writing skills.  He made rapid gains to achieve

a functional reading and writing level (about fourth-fifth grade

level).  After that he reached a plateau and the indication was

there would be little academic progress beyond that point.

     Communication-wise, we went back to the basic tenant of

working with stroke or head injury patients, and that is to

stimulate, stimulate, stimulate.  We tried to have a schedule for

friends and relatives to visit him as often as they could.  They

were to continually engage him in conversation and ask him

questions.  We suggested that interaction last as long as he

could handle the emotional aspect.

     At this point I need to discuss briefly the emotional

lability that usually accompanies brain damage.  Persons who are

recovering from stroke/head injury often have impaired emotional

inhibitory systems.  Basically, this means that they may over-

react to situations.  One too many questions can bring tears or

start uncontrolled laughter.

     I remember one unfortunate gentleman patient whose response

to any emotionally distressing event was laughter.  Upon being

told that his brother had died, he broke into laughter.  His

reaction shocked the family.  They never forgave his

'callousness,' even after the problem was explained to them.

     Grant was very labile and his general reaction was crying.

The first session I was to work with him I took a test with me.

It is an imposing test with many materials stored in a specially

designed, very official looking briefcase.  When I opened the

briefcase and told him we were going to do a test, he became very

anxious and broke into tears.  It was the end of the session for

that day and I learned to introduce any new test or procedure

more carefully.  We discussed this with members of the family to

try to minimize any misunderstandings that might have occurred as

a result of his emotional breakdowns.

     In the early stages of Grant's treatment, we dealt mainly

with basic living skills; making out a list to take to the store,

planning a day out, preparing a simple meal, writing checks,

reading a map, and a myriad of other things that most of us take

for granted.  However, the main thrust of treatment was still to

get as many people in his environment stimulating him as

possible.  As I have suggested before, constant stimulation

appears to be one of the most successful techniques for re-

establishing behavioral patterns that have been lost as the

result of brain damage.

     We worked with Grant for several months, making solid

progress in most areas.  Each gain was followed a plateau beyond

which he could not continue to achieve.  A physical therapist was

also working with him.  We met with the physical therapist after

having had the success with Grant and it was the feeling of both

the physical therapist and our clinical staff that Grant could

assume a more direct role in childcare and begin to look for a

structured work environment.  He could now watch his daughter

alone, he could prepare breakfast and lunch for her, and his

judgment was good enough for him to determine limits of the

child's behavior.  (Did I say she was an 'active' child?  She was

an active child.  She would have been a challenge for any adult

to manage.)

     Maria was skeptical at first.  She had come to believe that

Grant would never be able to be actively involved in caring for

their child.  She had not thought that he would ever be able to

work again.  She had come to think of him as child-like himself.

It took some time for her to accept his gains and let him try.

Grant was very careful in responding to his daughter.  Active

children can try the patience of even the most patient parents.

He was aware of what he had to do and became a good and loving

caregiver.  He responded with a level of patience that most

parents would envy.  It didn't take long for Maria and their

parents to acknowledge his new role as a full parental partner.

     The next step was to get him out of the house and into some

environment in which he could feel productive.  The community did

not have a sheltered workshop, so clinic personnel worked with

the state's vocational rehabilitation department to find work

appropriate for his skills.

     The first three jobs attempted did not last long.  The first

was as a ticket taker at a movie theater.  The next was custodial

work in an office building.  I forget the nature of the third

job, but it was a setting in which there was a great deal of

unstructured activity.  None of these interested him and all had

situations in which it was difficult for him to cope.

     We hit the jackpot on the fourth job.  It was doing outside

work in a nursery, planting and tending to plants.  It was not

something he had had an interest in before the accident, but he

immediately liked it.  There were only four people in the nursery

with whom he had to communicate, and only two of them worked with

him all the time.  They were working men with limited education

whose communication skills were not much different from Grant's.

Grant was accepted and shown no special attention either positive

or negative.

     Many of the behaviors that had reached a plateau earlier

spurted forward.  They reached a plateau in them again, but at a

higher level.  His personality changed dramatically.  It was as

if the new job gave him a purpose.  He developed a tan from

working outside that greatly improved his appearance from the

pallor caused by the years of not being outside.  He put on

muscle weight and the strength in his hands and legs improved

remarkably.  His wife was amazed at the changes that occurred

over the period of time he worked at the nursery.  It was

definitely not the life that either had envisioned when they were

first married, but it was also not the life they had come accept

after the accident.  He was a complete, whole productive adult

who learned to take pride in his work.

     He was released from both treatment for language and

physical therapy after six months on the job.  He brought about

the termination by pointing out to us that he was doing as well

as he could, and, with some pride, that they needed him to be at

the nursery during the times he had been coming for treatment.



A Practical Guide To Helping The Person With Aphasia

     A “must” reading for anyone who is interested in the optimum

intervention program for an individual who has had a stroke can

be found in a book entitled Pat and Roald (Farrell, 1969). Pat is

Patricia Neal, a well-known actress who suffered a stroke.  Roald

is her husband.  Roald researched the problems associated with

stroke and the challenge of bringing the patient back as close to

normal as possible.  He made his wife's rehabilitation an all-

consuming project that involved not only himself, but many

friends, neighbors, and family.

     Roald's hypothesis for Patricia's recovery was that she

would relearn skills more quickly if she were constantly

stimulated.  He recognized that he could not do this by himself,

so he enlisted the help of everyone who could, and would, spend

time with Patricia.  Her stimulation was intensive for almost all

of her waking hours.  She later recalled how painful it was to

have to keep trying to do things that were difficult.  Self-pity,

sorrow for the loss of the former self, and depression are major

obstacles to the recovery process.  She combated it while having

to deal with a constant stream of visitors, each of whom had been

counseled to talk to her constantly and engage her in

conversation as much as possible.

     She was fortunate.  Her recovery was nearly complete.  Her

speech was slower and more studied after the recovery, but she

could participate in conversation with ease and she returned to

her acting career.  The fact that she had enjoyed a successful

career to which she wished to return was a major motivation for

her.  But it was the intensity of the rehabilitation plan forged

by her husband that made the recovery as complete as it was.

     Remember that I said Grant made the most progress when he

became involved in the nursery work?  It was something that

lifted his self-esteem and kept him stimulated.  I believe that

most speech-language pathologists who work with stroke patients

are at a major disadvantage.  Most treatment programs focus on

communication skills as communication skills are supposed to help

the individual return to an active, productive life.  However,

for maximum success in the area of rehabilitating communication

skills, it is critical to get the individual involved in doing

something productive.  Not only will communication skills improve

as a result, it will help re-build self-esteem.





How To Treat People With Language Differences

     The Golden Rule applies in dealing with individuals with all

types of communication differences, but none more so than

language.  When encountering an individual with a language

problem, consider how you would want to be treated if you were

experiencing that kind of difficulty.  Dealing with individuals

with language problems may be a bit more complex than dealing

with individuals with other types of communication differences,

because language itself is more complex.  Perhaps the best way to

approach it is to break it down into the following steps:

     1.   Identify the type(s) of language problem(s) being

          experienced by the person and any associated problems.

     2.   Consider the level of communication competence you need

          to establish with the individual.

     3.   Think of compensatory communication strategies that may

          be needed.

     4.   Adjust your communication technique to suit the needs

          of the person with whom you are trying to communicate.

We'll look at each one of these individually.



                Identifying the specific problem

     This may be the most difficult, because the cause of

language problems is not always obvious.  A severe communication

disorder that appears to be the result of mental deficiency may

in fact be due to a hearing loss or a motor dysfunction.  Hearing

loss should be one of the first characteristics to check.  Is the

person wearing a hearing aid?  Does the person position the head

in an attentive listening posture?  Does the person look directly

into the face of the speaker?  All these things may indicate the

person has a hearing loss.  Watch the person's response when you

increase and decrease the intensity of your voice.  Also, cover

your mouth on key words in a sentence.  Persons will often swear

that the hearing impaired person to whom they are speaking hears

perfectly fine, when, in fact, that person may be an excellent

lip reader.

     Another possible involvement to check out early is

neurological impairment.  Is there an obvious physical

impairment, such as a difference in the walking gait of the

individual?  Is there unusual extraneous movement such as head

turning, shoulder positioning, or frequent posture changes?  Are

the sides of the face symmetrical e.g., does one side seem

smaller, or seem to sag?  Are there facial tics or tremors?  Is

the individual's speech slow and studied?  While many types of

motor dysfunction are obvious, many are of a subtle nature that

can only be detected with careful attention.

     Assess the mental capabilities of the individual.  This can

be very tricky and misjudging intelligence can result in

embarrassing scenes.  Consider the complexity of the language the

individual is using.  How long and how complex are the sentences?

What kind of vocabulary does the individual use?  Structure some

questions that you feel may give you some insight into the

individual's mental abilities.  It can be very helpful to know

the educational achievement level of the individual.

     Determine whether the problem the individual is experiencing

is primarily receptive or expressive.  Severely physically

impaired people may have normal or above normal intelligence and

no problem understanding others.  However, because their own

output is limited, people interacting with them may not realize

this.

     Identifying the underlying basis for the communication

difference is the most important step in deciding how to interact

with the individual.



    Consider the Level of Communication Competence You Need

     The next aspect of the communication process to consider is

the level of communication skill you need to fulfill the

communication act specific to this individual.  One scenario

might be two people standing in line at a movie theater and

discussing the length of the line, the price of admission, and

some critic's appraisal of the film.  One person finds the other

has a communication difference.  The people haven't met before

and the communication act is not one of significant import.  The

individual would not be as formal in approaching the task of

assessing communication skills in this case.

     Another scenario would be that of a lawyer, banker, or

physician working with a client/patient.  It would be critical

for all of the elements of the discussion to be understood by the

client in this scenario.  Under these circumstances, a great deal

of effort should be devoted to establishing a communication

process that assures accuracy of content.



     Consider Compensatory Strategies for Communication

     Mild and moderate language problems may present only a

limited modification to the communication process.  However, if

there is concern that you might not being able to completely

understand the person with the language problem, or if there is a

concern that the person with the language problem may not be able

to completely understand you, compensatory communication

strategies may be employed.  These may require the addition of an

alternative communication process, such as gestures, physical

movement, and facial expression to convey a message.  Writing is

a form of compensatory communication.  Unfortunately, the written

communication skills of many people with language differences is

often no better than their spoken communication skills.  Drawing

can be form of compensatory communication, also.

     The most basic compensatory technique to communicate with

individuals who have severe expressive skills, but good receptive

skills is the 'yes-no' approach (as in the age-old game of twenty

questions).  If the person understands you, they need only be

able to signal 'yes' or 'no' to you to communicate.  We once

conducted a one and one-half hour interview with a four year-old

who had sustained a head injury as a result of falling off his

tricycle onto a concrete patio.  He was virtually paralyzed right

after the accident, but could blink his eyes voluntarily.  We

conducted the interview a week after the accident.  We set up a

“wink if the answer is yes” protocol.  From the interview we were

able to obtain a great deal of information about him-how old he

was, where he lived, what was the composition of the family, what

he like to eat, his brother's name, and what he liked to watch on

television.  "Yes-no" interaction can be a time-consuming

technique, but it is very effective in communicating with persons

with severe expressive, but normal, or near normal, receptive

skills.



            Adjusting Your Communication Techniques

     As communicators, we have a tendency to phrase things in

ways that are comfortable to us.  We speak at speeds that are

compatible with our own nervous systems, and talk at loudness

levels that seem appropriate to us.  Often that is the most

difficult thing to overcome in communicating with language-

impaired persons.  You may need to speak more slowly, more

rapidly, softer, or louder, depending on the needs of the person

with whom you are trying to communicate.

     I see this common mistake often in students who are working

with children with language differences for the first time.

Typically the session will start by the student clinician asking

the child a question such as "how old are you?".  The child is

language impaired, so it takes longer to process the question.

However, when the child doesn't respond in the time frame that

the student clinician feels is appropriate, the student clinician

may repeat the question.  The child has to pause and process this

repeated question, wondering why the big person is asking the

question again.  About the time the child has the answer

formulated and is ready to respond, the student, thinking that

the child is not going to answer the question, will ask another

question such as "did you come here with your mother?"  The child

starts formulating a new answer, but before getting it out there

is yet another question.

     It is important to understand that processing communication

may take significantly longer by persons with language

differences.  You must be able to sit and wait, making sure that

you give ample time for them to formulate responses.

     This is good to remember in dealing with very young children

who are just learning the language.  It takes them longer to

process questions and they often are frustrated trying to talk

with adults who don't give them enough time to formulate

responses.

     It may sound strange, but sometimes the communication act is

facilitated by increasing the rate of speech.  I have found this

to be true with many children who have a deficit that became

known as “attention deficit disorder” or “ADD.”  According to the

American Psychiatric Association ADD is characterized by

ADevelopmentally inappropriate degrees of inattention,

impulsivity, and hyperactivity@ (APA, 1987, p.50).

The children I am describing may talk fast, they are easily

distracted, and it is hard for them to keep their attention on a

task.

     I found that I could get good efforts from some of them by

increasing the pace of interaction as much as 50%.  This meant

that I had to adjust my own speaking and materials presentation

rate to one faster than I normally used.  Many children with whom

I have done this could maintain their attention to a task for a

fifteen-minute period, accomplishing about the same amount of

work it would take me a half-hour to accomplish with most other

children.  I believe the effectiveness was the result of the

material being presented at a rate that did not allow them to

become distracted.  The kids were very proud of what they had

accomplished during the time.  And I was very tired.  It is

fatiguing to adjust our neurological clock to a faster beat.

     I observed these same children in classrooms where the rate

of material presentation was much slower.  At the beginning of

the period I noticed they would blurt out the answer before the

rest of the children had even processed the question.  Sometimes

the answer would come out before the teacher finished the

question.  This was distracting to the teacher, so the children

were told to not answer until the question was finished.  It

appeared to me that these children did not have the inhibitory

responses needed to maintain the response latency the teacher

demanded, so eventually they tuned out altogether.

     A positive footnote to the children I have described above

is that for most of them there was a continuing adjustment of the

nervous system to the environment.  Many of the children who had

good home and school support in the early grades could function

in regular classrooms by middle grades.  In other words, the

children learned to pace their own nervous system to meet the

needs of the classroom.  All of our clocks are set to different

rates, and it seems somehow unfortunate that the rate of

presentation of material in the classroom is dictated by the

teacher, rather than the learner.

     Talking at slightly different intensities may also elicit

better responses from the language-disordered person.  Usually if

there is improvement by manipulation of this parameter, it is

gained by speaking slightly louder.  However, I have seen many

situations in which speaking more quietly improved communication.

     Some persons who have difficulty with language are

uncomfortable asking others to repeat when they don’t understand.

So they nod, smile, and act like they understand even when they

don’t.  If you are speaking to a person who you think may not

understand you, stop occasionally and ask the person a question

about something you have said.  This is particularly important

when clear and complete understanding is critical, such as in a

medical, legal, or business matter.



        Adjusting Communication to Personal Circumstance

     Most persons are aware of the adjustments they make in

talking with persons of different ages and stations in life.  We

talk to our friends and family in a more familiar manner than

when talking to a stranger.  We speak differently to children

than we do to adults.  Sometimes, however, we do not make those

adjustments when speaking with persons with limited language.

This can be a real problem in dealing with adults.

     Another mistake I see made by persons talking to adults with

limited language is that they talk with the same inflection and

speaking style that they would use with children of a comparable

language level.  It is important for adults to maintain dignity

in the communication act, or they will tend to withdraw from it.

Older persons who are starting to lose communication skills are

often embarrassed by the problems they experience.  The person

who responds to them in language that is child-like with find

that this is a most effective way to further diminish the

communication efforts of an adult.

     Regardless of the age or station in life of the person with

the language disorder, it is important to help them maintain the

dignity of the act of communication.  It is easy for those with

normal communication to become frustrated, feel that their time

is being wasted, and project the negative feelings to the person

with the language disorder.  It is more difficult to maintain the

patience, attention, and positive attitude that is needed for

effective communication.  It is much to the credit of the person

who can do so.



Summary of Adjusting Techniques

     In summary of adjusting techniques to situation, be

conscious of the fact that the speed, intensity, and manner in

which you communicate is distinctly yours and is optimum for you.

However, it may not be optimum for the other person.  Learn to

adjust your own communication style and observe the effect the

changes have on others.



Conclusion

     Interacting with individuals with language differences can

be one of the more difficult communication situations.  It can

also be one of the most rewarding, if it is managed effectively.

Not only do you win the confidence of the persons to whose

language style you are adjusting, you also earn the gratitude of

the family and friends of that individual.  They will recognize

the thoughtfulness of your actions.