Daniel P. Hallahan, University of Virginia, & Cecil D. Mercer, University of Florida
Learning Disabilities Summit: Building a Foundation for the Future White Papers
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By about the 1920s, clinicians and researchers in the United States began to take an interest in the work of the Europeans who had been studying brain-behavior relationships and children and adults with learning difficulties. The U.S. researchers focused their efforts on language and reading disabilities and perceptual, perceptual-motor, and attention disabilities.
In the United States, there were several key figures from medicine, psychology, and education during this period who used the research of Hinshelwood and other Europeans as a springboard for their own work. Primary among these were Samuel Orton, Grace Fernald, Marion Monroe, and Samuel Kirk.
Samuel Orton. Samuel Orton was arguably the key figure in setting the stage for the study of reading disabilities in the United States. The primary professional society devoted to reading disabilities, the International Dyslexia Association, was originally named the Orton Dyslexia Society.
In January of 1925, Orton, then a neuropathologist at the State Psychopathic Hospital in Iowa City, set up a 2-week, mobile clinic in Greene County, Iowa. As a part of this "experiment," local teachers were invited to refer students "who were considered defective or who were retarded or failing in their school work" (Orton, 1925, p. 582). Fourteen of the 88 students were referred primarily because they had great difficulty in learning to read. Orton highlighted the fact that many of these students scored in the near-average, average, or above-average range on the Stanford-Binet IQ test--one had an IQ of 122, four had IQs between 100 and 110, five had IQs between 90 and 100, one had an IQ of 85, and four had IQs between 70 and 80.
Hinshelwood had also noted that many of his cases of congenital word-blindness were intelligent, but with the advent of IQ tests Orton was able to lend a certain degree of objectivity to this notion. Furthermore, presaging later references to the Matthew effect, Orton speculated that the IQ score might not always reflect true intellectual ability in students with reading disabilities. In describing what he termed a typical case, a student with an IQ of 71, he stated: "I was strongly impressed with the feeling that this estimate did not do justice to the boy's mental equipment, and that the low rating was to be explained by the fact that the test is inadequate to gage the equipment in a case of such a special disability" (Orton, 1925, p. 584).
After his seminal article in 1925, Orton continued to study children with reading disabilities over the next several years, with his work being summarized in his classic book, Reading, Writing, and Speech Problems in Children (Orton, 1937). Although he relied heavily on Hinshelwood's prior work, Orton's views differed from Hinshelwood's in at least three important respects. First, Orton had a much more liberal view of the prevalence of reading disabilities. Whereas Hinshelwood had bristled at the notion that one per thousand of students in elementary schools might have "word-blindness," Orton offered that "somewhat over 10 per cent of the total school population" (Orton, 1939, p. 59) had reading disabilities. He noted that Hinshelwood had argued for restricting the diagnosis of word-blindness to those cases in which there would be no question about whether there was pathology present. Orton argued, however, that Hinshelwood:
did not...offer any usable criterion as to how such a separation of the pathological cases could be made, and our experience in studying and retraining several hundred such cases over a period of years has convinced us that [they] cannot be so divided but rather that they form a graded series including all degrees of severity of handicap. (Orton, 1937, pp. 71-72)
Second, although they both thought reading disabilities were often inherited, Hinshelwood pointed to agenesis of the angular gyrus in the dominant hemisphere as the site of the problem. Although Orton considered the angular gyrus of the dominant hemisphere as "essential to maintaining a normal reading skill" (Orton, 1937, p. 39), he viewed reading as a complex activity that involved several areas of the brain. Rejecting the idea of defects in brain development, Orton focused instead on the inheritance of mixed cerebral dominance, or motor intergrading, as being behind many cases of reading disabilities.
Orton linked mixed dominance to the major symptoms he frequently observed in the clinic: (a) reversals of letters such as p and q and b and d; (b) confusion of palindromes such as was and saw; (c) reading from right to left, manifested by reversals of paired letters, syllables within words, or whole words within sentences; and (d) a propensity to "mirror read and/or write." He theorized that the nondominant hemisphere of the brain stored mirror engrams of the engrams recorded in the dominant hemisphere. For example, in reading the word was, the dominant hemisphere would store was in the dominant hemisphere while at the same time storing saw in the nondominant hemisphere. In those who have complete hemispheric dominance, the dominant hemisphere controls language and, therefore, the mirrored engrams are suppressed. In the case of mixed dominance, however, the mirrored engrams often emerge causing the child to reverse letters or words.
Third, Orton's emphasis on cerebral dominance and reversals led him to propose a different term than word-blindness to describe the children whom he was seeing in his clinic:
The term "congenital word-blindness" because of its association with the acquired condition and the implications therefrom, does not seem to be properly descriptive of this disability, and I would therefore like to offer the term "strephosymbolia" from the Greek words, [strepho], twist, and [symbolon], symbol.... The prefix "strepho" has been chosen to indicate the turning or reversals.... "Symbolon" is used in its original meaning of "word," "sign" or "token,".... Strephosymbolia thus seems nicely suited to our cases in which our analysis points to confusion, because of reversals, in the memory images of symbols resulting in a failure of association between the visually presented stimulus and its concept. (Orton, 1925, p. 610)
Ironically, neither term--word-blindness, strephosymbolia--fared well historically, the former primarily because of its focus on the visual aspect of reading, the latter primarily because of its emphasis on mixed cerebral dominance and reversals. Although few subscribe to Orton's views on cerebral dominance and reversals today, he has had an enduring influence in the realm of remediation techniques in at least two respects. First, he was one of the first to advocate focusing on phonics instruction with students with reading disabilities. He criticized the then-current "look and say" or "sight reading" method of reading instruction for the general population and proposed that:
logical training for these children [those with strephosymbolia] would be that of extremely thorough repetitive drill on the fundamentals of phonic association with letter forms, both visually presented and reproduced in writing, until the correct associations were built up and the permanent elision of the reversed images and reversals in direction were assured. (Orton, 1925, p. 614)
Orton later emphasized that teaching letter sounds was not enough, that there was a need for sound blending:
We have repeatedly seen children referred to us as reading disability cases with the statement that the phonetic method had been tried but had failed. In these cases examination has revealed the fact that while the teaching of the phonetic equivalents may have been fairly complete, the next step, that of teaching the blending of the letter sounds in the exact sequence in which they occur in the word, had not been attempted or had been poorly carried out. It is this process of synthesizing the word as a spoken unit from its component sounds that often makes much more difficulty for the strephosymbolic child than do the static reversals and letter confusions. (Orton, 1937, p. 162)
Second, Orton was one of the first to introduce the idea of multisensory training. In particular, he stressed the use of the kinesthetic function by having students trace letters while sounding them out (Orton, 1937). And Orton's ideas served as a stimulus for the work of Anna Gillingham and Bessie Stillman, whose book, Remedial Work for Reading, Spelling, and Penmanship (1936) emphasized building the following linkages: visual-auditory, auditory-visual, auditory-kinesthetic, and kinesthetic-visual. Gillingham and Stillman believed "it is essential to establish each linkage with patient care, even into the thousandth repetition" (Gillingham & Stillman, 1936, p. 36).
Today, practitioners still use many of the ideas of Orton and Gillingham and Stillman. These practices have come to be referred to as the Orton-Gillingham Approach. Basically, the Orton-Gillingham Approach is a phonics-based, multisensory method using the visual, auditory, and kinesthetic modalities for reading-decoding and spelling instruction.
Grace Fernald. Fernald was another figure associated with a multisensory approach to reading disabilities. As part of her rationale, she provided a brief history of the use of the kinesthetic modality to teach reading, including references to Plato in the third century B.C. Horace in 65 B.C., Quintilian in 68 A.D., Charlemagne in the 8th century, and Locke in the 17th century (Fernald, 1943).
Fernald differed from Orton and Gillingham, however, in her opposition to a phonics-based emphasis on sounding out letters and words. Instead, she emphasized reading and writing words as wholes.
Fernald actually predated Orton with respect to advocating for a multisensory approach to reading disabilities. In 1921, she coauthored an article describing remedial treatment of six cases of students with reading disabilities at the University of California-Los Angeles (UCLA) Clinic School (Fernald & Keller, 1921). Fernald and Keller developed what came to be known as the VAKT (visual-auditory-kinesthetic-tactual) method, which is composed of five stages. First, the teacher asks the child to pick some words that he or she would like to learn. The teacher then writes the word on the board, and the child says the word to him- or herself and traces the letters with the first two fingers of the dominant hand. Once learned, the teacher erases the word and the student writes the word, saying the syllables. The second stage is the same as the first except sentences are used rather than individual words. In the third stage, the child selects a book he wants to read. The student and teacher work through the book, one paragraph at a time. Words the student has not already learned are exposed through an adjustable slit in a piece of cardboard. If the student is unable to read the word, the teacher reads it aloud, and then the student says the word and writes it without looking at the copy. If the student still has problems writing the word, the teacher writes it and the student learns it as in the first stage. In the fourth stage, the slit is widened to include phrases, and the exposures are so brief that the student is not able to read word by word. After achieving recognition of the phrases, the child reads the entire paragraph to himself and reports on what he read. In the final stage, the teacher has the child read alone.
Over the years, the UCLA Clinic School expanded and by the early 1940s there were about 20 children admitted each academic year, with an additional 60 to 80 cases seen in the summer. Students received intensive instruction in basic school subjects, with a focus on reading instruction. In 1943, Fernald authored Remedial Techniques in Basic School Subjects, in which she summarized work in the clinic as well as in "experimental" classrooms established in the public schools, s
ome of which contained a high concentration of children for whom English was a second language (Fernald, 1943).Fernald kept extensive records on the progress of the students. Although lacking control groups, she reported notable gains for reading, spelling, penmanship, foreign language, and arithmetic. In addition, she reported follow-up data for many of the students, which were equally impressive. Whether Fernald's results warrant the following assertion she made in the preface to her book is arguable, but it is interesting to contrast her confident optimism with some of the present-day lamentations about the ineffectiveness of special education:
Since no abilities are required for the mastery of reading, writing, and arithmetic which are not already possessed by the ordinary, normal individual, it seems obvious that there is no such thing as a person of normal intelligence who cannot learn these basic skills. The follow-up records of our cases over a period of years show that the application of established psychological principles makes success in the fundamentals possible for any normal individual. (Fernald, 1943, p. v.)
Marion Monroe. Having served as Orton's research associate for his mobile clinic, Marion Monroe tried out his methods along with the methods of Fernald and Keller. While in Iowa, she developed diagnostic tests and used the results to guide instruction. Using a combination of kinesthetic tracing techniques and sound blending, she reported success with 29 children with reading disabilities (Monroe, 1928).
From Iowa, Monroe took a position at the Institute for Juvenile Research, a residential facility for delinquent boys with mental retardation. At the Institute, Monroe developed a synthetic phonetic approach, which began with having the child identify initial consonants and then vowels for pictures mounted on cards. After success with this, the teacher introduced sound blending and had the child read stories. In addition, the teacher used tracing whenever it was deemed necessary.
In her book, Children Who Cannot Read (1932), Monroe reported on several "experiments" in which she tested out her methods. In the first study, she compared three groups: Group A (89 students) was referred to the clinic and received instruction under close supervision there or in their home school, Group B (50 students) received instruction in their home school from teachers who came regularly to the Institute for teaching suggestions, Group C (50 students) received ordinary instruction in their home school. The major differences between Groups A and B with respect to treatment was that the teachers for the latter group delivered instruction more sporadically (before or after school or during free periods) and under less supervision: "The remedial work done in Group B, therefore, was not so intensive as that of Group A, and was subjected to a greater variety of disrupting influences" (Monroe, 1932, p. 138). Group A's mean IQ was 101, Group B's was 89, and Group C's was 92. Over the course of the year, Group A gained 1.39 years in reading achievement, Group B gained 0.79 years, and Group C only gained 0.14 years.
Monroe also reported on four field-based projects in cities near Chicago where she was invited to train teachers to work with students with reading disabilities. In the first two, teachers were trained to provide one-on-one instruction. In City A, 15 teachers worked with 15 children over 2 months, providing an average of 13.8 hours of one-on-one instruction. The group made an average gain of 0.67 years in reading achievement. In City B, after 5 weeks of instruction and an average of 10.1 hours of one-on-one instruction, 30 children averaged 0.81 years growth in reading achievement.
In the last two field-based projects, students were taught in small special classes, which met with a trained teacher two or three times a week for 30- to 40-minute periods. In the first one, 41 students from grades 2 through 8 in City B made an average gain of 0.7 years in 2 months. In the second one, 10 students from a special school for truant children met daily in two groups of five for 3 months, which resulted in an average gain of 1.0 year in reading achievement.
Monroe's summary of the studies is prescient with respect to what many learning disabilities researchers today report, especially concerning the need for intensive instruction by well-trained teachers:
Two hundred and thirty-five children were given remedial training by one hundred and thirty-one teachers. Progress in reading was made in a large percentage of cases studied, not only when children were trained under carefully controlled laboratory conditions, but also under conditions possible in public schools. Progress in reading was made under individual instruction and also in small groups of children....
The remedial-reading methods were found to be direct and readily understood. Public school teachers learned to apply the methods in the course of conferences and demonstration lessons.
The rate of progress in reading under remedial instruction was found to be a function of the child's intelligence, his age, the number of hours spent in training, the number of months during which treatment was continued, the severity of the disability, the personality and behavioral difficulties encountered in applying the remedial training, and the closeness of supervision of the remedial techniques. Children and teachers varied greatly with regard to these factors....
The children with whom the remedial work failed were those whose reading difficulties were complicated by behavior disorders which the teachers were unable to control, or those to whom the remedial work was given irregularly and without persistent, systematic, or sympathetic treatment. (Monroe, 1932, pp. 157-158)
Although Monroe's studies lacked the kind of methodological rigor demanded by today's standards, e.g., random assignment and limited use of control groups, the impressive gains she reports are difficult to disregard completely. She was far ahead of her time with respect to the care she took to document the efficacy of her methods. Furthermore, in addition to furthering the work of Orton and Fernald through systematic investigation, she pioneered two practices that are fundamental to the field of learning disabilities today.
First, Monroe introduced the notion of discrepancy between actual achievement and expected achievement as a way of identifying students with reading disabilities. She calculated a "reading index" by comparing the student's reading grade (the average of four tests: Gray's Oral Reading Paragraphs, reading comprehension as measured either by the Haggerty Test for cases less than third grade achievement or by the Monroe Test, word analysis from the Iota Word Test from the Monroe Test, and word discrimination from the Word Discrimination Test from the Monroe Test) to an average of the student's chronological, mental, and arithmetic grade. For example, a boy who chronologically is at a grade of 3.6, who on the basis of the Stanford-Binet has a mental grade of 4.0, and who has an arithmetic grade of 3.5 would have an average of 3.7. If his grade scores on the four reading tests average 2.0, then his reading achievement would only be 2.0/3.7, or 54%, of his expected achievement. Monroe advocated using 80% as a cut-off for having a reading disability, and using this cut-off she estimated that about 12% of the population had reading disabilities.
Second, Monroe went beyond using standardized tests just to identify children with reading disabilities. She advocated analyzing the specific types of reading errors children made on the tests in order to guide instruction, thus introducing the notion of what would later be called diagnostic-prescriptive teaching. She developed individual profiles of errors made on three reading tests (Gray's Oral Reading Examination, the Iota Word Test, and the Word Discrimination Test from her own test). The errors included faulty vowels, faulty consonants, reversals, addition of sounds, omission of sounds, substitution of words, repetition of words, addition of words, omission of words, refusals, and words aided. Based on the types of errors the child presented, Monroe had specific remedial training suggestions.
Samuel Kirk. In 1929, Samuel Kirk began graduate school in psychology at the University of Chicago. As part of his training, he spent time as a resident instructor at the Institute for Juvenile Research, where Marion Monroe worked. Kirk's duties were varied, but there was one fortuitous experience that was life-changing for Kirk and the eventual field of learning disabilities:
At this school I taught in the afternoon and served as a recreational worker after school. In the evenings I helped the nurses put the boys to bed and see that they stayed there. In reading the clinical folders of one of these children from the famous Institute for Juvenile Research, I noticed that the boy was labeled as "word blind," a term I had never heard before in my psychology courses. He was ten years old, a nonreader, and had a recorded IQ of 82. This clinical folder referred to Marion Monroe's monograph [Monroe, 1928] on reading disabilities, Hinshelwood's book [1917] on congenital word blindness, and Fernald's kinesthetic method. After reading these references, which I found the next day in the university library, I arranged to tutor the boy at nine o'clock in the evening, after the boys were supposed to be asleep. This boy, who was eager to learn, sneaked quietly out of bed at the appointed time each night and met me in a small space between the two dormitory rooms..., actually, in the doorway of the boy's toilet. By making this arrangement we both knew we were violating a regulation, since the head nurse had directed me not to allow the boys out of bed after nine. In the same vein as the Boston Tea Party, and knowing the consequences of civil disobedience, I decided to take a chance and violate the directions since the cause was good. I often state that my first experience in tutoring a case of reading disability was not in a school, was not in a clinic, but in a boy's lavatory. (Kirk, 1976, pp. 242-243)
After 7 months, the boy was reading at the third grade level and he was released from the Institute to attend regular school. Monroe, hearing of Kirk's success, invited him to confer with her about his tutoring. She then tutored Kirk in diagnosing and remediating severe cases of reading disabilities.
For his master's thesis, Kirk (1933) compared the Fernald kinesthetic method with the look-and-say method, finding them equal with regard to number of trials required for learning but retention being better for the manual tracing method. Kirk was then employed as a psychologist at another residential facility for children with mental retardation, Wayne County Training School in Northville, Michigan, an institution that was to become a testing ground for many instructional techniques used for children with learning disabilities.
While at Wayne County, Kirk pursued his doctorate at the University of Michigan. Influenced by a number of theoretical notions coming out about the brain and learning, including Orton's theory about cerebral dominance, Kirk studied brain-behavior relationships, with his dissertation focused on surgically creating lesions in rats and testing them for handedness and strephosymbolia (Kirk, 1935, 1936). Kirk later noted that this foray into neurophysiology had little direct bearing on his future work in learning disabilities other than to result in an aversion to terms such as "brain dysfunction," "strephosymbolia," and "dyslexia": "I feel that it is more parsimonious to give a designation in behavioral terms by stating, for example, that the child has not learned to read" (Kirk, 1976).
Kirk teamed up with Thorleif Hegge, who had recently emigrated from Norway and was brought to Wayne County as the director of research. Hegge and Kirk, along with Kirk's wife, Winifred Day Kirk, coauthored Remedial Reading Drills (Hegge, Kirk, & Kirk, 1936). Influenced by Orton, Fernald, and Monroe, as well as the principles of learning from the school of functional psychology at the University of Chicago, the approach taken in the remedial drills was a
carefully programmed phonic system which emphasizes sound blending and kinesthetic experiences. The program is based upon the following principles: minimal change; overlearning; prompting and confirmation; one response for each symbol; and social reinforcement. Kirk (1940) followed up this earlier interest in reading with a book on teaching slow-learning children to read. (Wiederholt, 1974, p. 32)
Kirk moved on to the Milwaukee State Teachers College and then to the University of Illinois in the late 1940s to head up the special education program. In 1949, he established the first experimental preschool for children with mental retardation. In so doing, "to be able to analyze the communication problems of younger children at the outset or before the remediation, it became necessary for us to develop tests to isolate some of these abilities and disabilities" (Kirk, 1970, p. 108).
Kirk worked for the next decade on refining an assessment approach for pinpointing specific disabilities in children. Influenced by Monroe's use of profiles (Kirk, 1976), he aimed to come up with an instrument that would provide profiles of intra-individual differences on key psycholinguistic abilities. The result was the first edition of the Illinois Test of Psycholinguistic Abilities (ITPA) (Kirk, McCarthy, & Kirk, 1961). We return to the ITPA in our discussion of the next time period (c.1960 to 1975).
As with the research on language and reading disabilities, the early research on perceptual, perceptual-motor, and attention disabilities was focused on adults with brain injuries, and much of it was conducted by Europeans, many of whom had immigrated to the United States. Key figures during this period were Kurt Goldstein, Heinz Werner, Alfred Strauss, Laura Lehtinen, William Cruickshank, and Newell Kephart.
Kurt Goldstein. As a physician and director of a hospital for soldiers who had incurred head wounds during World War I, Kurt Goldstein studied many cases of brain injury over several years. Studying his patients, whom he referred to as "traumatic dements," within a clinical framework, he reported that they tended to display a consistent constellation of behaviors: hyperactivity, forced responsiveness to stimuli, figure-background confusion, concrete thinking, perseveration, meticulosity, and catastrophic reaction (Goldstein, 1936, 1939).
Forced responsiveness to stimuli was characterized by the soldiers' indiscriminant reactions to stimuli, a seeming inability to distinguish essential from inessential. It was as though they were driven to respond to things in their environment, thus displaying a high degree of distractibility.
One can consider figure-background confusion as a particular manifestation of forced responsiveness to stimuli. Being from the German Gestalt School of psychology, Goldstein was interested in his patients' perception of form and figure-ground relationships. He interpreted much of the soldiers' distractibility as a deficiency in discriminating figure from background. In the case of reading, for example, they would have problems focusing on a word or phrase in the context of hundreds of words on a page of print.
Goldstein hypothesized that abstract thinking, because of its primary place in the hierarchy of intellectual behaviors, was one of the first aspects of cognition to be affected by brain injury. He noted that whenever one of the patients
must transcend concrete (immediate) experience in order to act--whenever he must refer to things in an imaginary way--he then fails.... Each problem which forces him beyond the sphere of immediate reality to that of the "possible," to the sphere of representation, insures his failure. (Goldstein, 1939, p. 29)
Goldstein's patients had a tendency to repeat the same behaviors over and over again. This perseveration could be verbal or motor. Goldstein conjectured that it was a way that the damaged organism could rescue itself from disorganization.
Another symptom used to ward off disorganization was meticulosity. Many of the soldiers became very rigid in their daily living habits, structuring their time schedules and objects in their environment. Goldstein theorized that this penchant for routine was used by the patients to protect themselves from overstimulation and disorganized perceptions. If the patients were unsuccessful in dealing with overstimulation and disorganization, they could experience a "catastrophic reaction," a total emotional breakdown similar to a severe temper tantrum. Goldstein attributed such outbursts to the patients' inability to make sense of the chaotic perceptual world in which they lived.
Goldstein highlighted the resiliency of the brain-damaged organism in automatically being able to compensate for disturbed functions. His conceptualization of the brain was in the Gestalt tradition of looking at the total array of behaviors rather than individual symptoms, which was in contrast to those seeking to localize specific functions with particular areas of the brain.
Heinz Werner, Alfred Strauss, Newell Kephart, and Laura Lehtinen. Goldstein's findings served as the basis for the research of Heinz Werner, a developmental psychologist, and Alfred Strauss, a neuropsychiatrist. With the rise to power of Hitler, Werner and Strauss both fled Germany, with Werner going first to the Netherlands and Strauss to Spain. Eventually, both ended up in the United States at the Wayne County Training School. There they teamed up to focus on whether brain damage in children with mental retardation resulted in the same symptoms as what Goldstein had found in adults who were not retarded.
Using a dichotomy introduced earlier by Larsen (1931), Strauss and Werner divided residents at Wayne County for their studies into those with exogenous versus endogenous mental retardation. Children with exogenous mental retardation were considered to have a brain disease or injury of some kind whereas those with endogenous mental retardation were presumed retarded because of heredity or a poor learning environment.
Through a series of laboratory-based studies, Werner and Strauss found the exogenous group to exhibit more forced responsiveness than the endogenous group to visual and auditory stimuli (Strauss & Werner, 1942; Werner & Strauss, 1939, 1940, 1941). For example, in one study (Werner & Strauss, 1941) they presented children with a series of slides, exposing each slide for only a fraction of a second. Each slide contained a drawing of a familiar figure such as sailboat or a cup, embedded in a background such as wavy or undulating lines. After each slide, the child was asked to identify what he or she had just seen. The exogenous group was more likely to refer to the background and was less able to identify the figure correctly. In addition to their laboratory studies, using a behavior rating scale they found children classified as exogenous to be more disinhibited, impulsive, erratic, and socially unaccepted (Strauss & Kephart,5 1939).
Werner and Strauss's studies did not go without criticism. The focus of the criticism was on the procedures used to identify participants as exogenous versus endogenous mentally retarded. They diagnosed the child as having exogenous mental retardation if none of the immediate family members was retarded and if there was a history of prenatal, natal, or postnatal disease or damage to the brain. Additionally, a child could be diagnosed as exogenous mentally retarded purely on behavioral characteristics that previous research (e.g., Goldstein's studies) had found associated with brain injury. For example, if the child was hyperactive and distractible in the classroom, then he or she was considered to have exogenous mental retardation. This reliance on behavioral symptoms for the diagnosis of exogenous mental retardation caused some to point out the possible circularity of forming their groups on the basis of symptoms that were very similar to the ones on which they were then attempting to differentiate the children (Sarason, 1949).
Criticisms of Werner and Strauss's work were undoubtedly valid with respect to their attributing brain disease or injury as the cause of forced responsiveness to stimuli, hyperactivity, distractibility, and so forth. However, this does not deny the fact that Werner and Strauss had found consistent behavioral differences between the exogenous and endogenous groups, regardless of whether the differences were caused by brain injury or not:
It is important to point out here that up until this time mental retardation was perceived as a relatively homogenous state.... Consequently no differential or individual educational or psychological programming was initiated on their behalf. Dispelling the long-standing notion that there were no individual differences among the retarded, the work of Werner and Strauss, therefore, had revolutionary impact. (Hallahan & Kauffman, 1976, p. 6)
This impact was manifested in the form of differential educational programming for the exogenous group. Prompting the Wayne County researchers to look at individualizing instruction for the exogenous group was a survey they did of the first 500 admissions to Wayne County (Strauss & Kephart, 1939). They found that 4 or 5 years after admission to Wayne County, the IQs of the exogenous group declined 2.5 points whereas the IQs of the endogenous group increased 4.0 points. Furthermore, they investigated those children whose IQ scores could be traced back prior to institutionalization and found that the exogenous group showed a steady decline before and after institutionalization; but the endogenous group showed a decline in IQ until admittance, whereupon the trend was reversed and their IQs rose (Kephart & Strauss, 1940).
The Wayne County research team hypothesized that the endogenous group, in contrast to the exogenous group, was receiving an appropriate education. Noting the highly stimulating nature of the educational program at the school, they concluded that it was not a good fit for children who were highly distractible, impulsive, and hyperactive. Their first primary recommendation was to provide an environment in which inessential stimuli were attenuated and essential stimuli were accentuated (Werner & Strauss, 1940). This was followed by more elaboration on the teaching methods (Strauss, 1943), culminating with two classic volumes: Psychopathology and Education of the Brain-Injured Child (Strauss & Lehtinen, 1947) and Psychopathology and Education of the Brain-Injured Child: Progress in Theory and Clinic (Vol. 2; Strauss & Kephart, 1955). The first volume, in particular, described a number of educational recommendations for children with exogenous mental retardation. The focus of the recommendations was on providing a distraction-free environment for the students:
The class group is small--twelve children is the maximum number.... The classroom for these children is large enough to permit each child to be seated at a considerable distance from any other. There is only a minimum of pictures, murals, bulletin boards, and the usual stimulating visual materials of the average classroom. (Strauss & Lehtinen, 1947, p. 131)
To avoid auditory distractions, they recommended the class be on the second floor where the windows were in front of a little used court, and to avoid visual distractions, they suggested covering the lower part of the windows with paint. In addition, they discouraged the teachers from wearing "distracting influence of ornamentation such as bracelets, earrings, dangling necklaces, and flowers in the hair" (Strauss & Lehtinen, 1947, p. 131).
In addition to focusing on manipulating the environment, Strauss and Lehtinen placed a heavy emphasis on remediating students' perceptual disturbances:6
We cannot state too strongly that all these factors [e.g., emotional disturbance, immaturity, boredom, absence from school] can and do contribute toward reading difficulties in brain-injured children but beyond these factors one should seek for evidence of general or perceptual disturbances which, if present, should be clinically regarded as the primary causal agents and therefore the ones to be attacked. (Strauss & Lehtinen, 1947, p. 174)
William Cruickshank. While pursuing a doctorate at the University of Michigan, Cruickshank worked on research at Wayne County. There, he was heavily influenced by the ideas of Werner and Strauss:
There were others, but two...became particularly significant in my life: Dr. Heinz Werner and Dr. Alfred A. Strauss. These two men, along with their wives, became important persons to me and my wife, professionally and socially, and so remained until the two died. Strauss, the idea man, Werner the laboratory scientist so well epitomized in Sinclair Lewis' Arrowsmith. Both were patient; both were thoughtful to suggest and to raise questions which had to be answered. Both were energetic and constantly pointed other directions in which my professional life might go--theirs! The inoculation took well, and their thinking has been mine for more than thirty years. (Cruickshank, 1976, p. 102)
Cruickshank was key in building a bridge from the Wayne County research group's work with children with mental retardation to children of normal intelligence, many of whom today would be identified as learning disabled. The construction of this bridge began with research on children with cerebral palsy.
After receiving his doctorate, Cruickshank took a position at Syracuse University in 1946. Along with his first doctoral student, Jane Dolphin, Cruickshank embarked on a series of studies. They found that students with cerebral palsy and near-normal, normal, or above-normal intelligence performed similarly to Werner and Strauss's children with exogenous mental retardation (Dolphin, 1950; Dolphin & Cruickshank, 1951a, b, c, d). These studies were followed by even more extensive studies of perceptual and figure-background abilities in children with cerebral palsy of near-normal, normal, or above-normal intelligence (Cruickshank, Bice, & Wallen, 1957; Cruickshank, Bice, Wallen, & Lynch, 1965). Again, the children with cerebral palsy displayed more forced responsiveness to the background than did a control group who did not have cerebral palsy.
Finding the same behavioral characteristics in children with cerebral palsy as had been found in children with exogenous mental retardation led Cruickshank and Dolphin (1951) to recommend the same educational program for students with cerebral palsy as had been developed for those with exogenous mental retardation a la Strauss and Lehtinen (1947). In particular, their recommendations focused on the provision of a distraction-free environment.
In the late 1950s, Cruickshank took the notion of educational programming for distractible and hyperactive children one step further, a step that placed his work right in the middle of the developing field of learning disabilities. He initiated a demonstration-pilot study, the Montgomery County (Maryland) Project, for 1 year. The results, along with extensive descriptions of the students and teaching methods used, were published in A Teaching Method for Brain-Injured and Hyperactive Children (Cruickshank, Bentzen, Ratzeburg, & Tannhauser, 1961). The project included four classes (two experimental and two control) of 10 children each. The 40 children (37 males) were matched on chronological age, IQ, instructional or achievement levels, previous experience in special education, perseveration, hyperactivity, and evidence of neurological damage. At the beginning of the year, the students ranged in age from about 6 to 9 years and had IQs from 51 to 107. Thus, several of the students had IQs in the normal range, and several more were thought to have depressed IQ scores because of behavioral characteristics such as distractibility. Cruickshank et al. wrestled with criteria to use for inclusion in the study and ended up focusing on hyperactivity:
The authors of this study and members of the Diagnostic Team struggled for many hours to obtain a meeting of the minds regarding definitions. They were hindered by the stereotypes of the several professions and by the literature which employed such terms as brain injury, brain damage, and brain disorder....
The children about whom this monograph is concerned are those who are defined as hyperactive, with or without the diagnosis of brain damage. Specific brain injury is difficult to delineate in every instance....
Hyperactivity is herein defined to include...short attention span, visual and auditory distractibility, and disturbances of perception leading to dissociative tendencies. (Cruickshank et al., 1961, pp. 9-10)
Even though they focused on hyperactivity, the extensive case histories Cruickshank et al. presented indicate that many of the children, today, would be considered learning disabled and/or learning disabled with comorbid attention deficit hyperactivity disorder (ADHD).
Similar to the educational program recommended by Strauss and Lehtinen (1947), the Montgomery County Project focused on providing an environment that would help students cope with their distractibility and hyperactivity. Thus, the program emphasized (a) reducing irrelevant stimuli, (b) enhancing relevant stimuli, and (c) providing highly structured assignments. For example, students frequently used cubicles to shield them from irrelevant stimulation; windows were opaque; the classrooms were painted in a uniform color; closets and cabinets were enclosed; and materials such as calendars, handwriting charts, paintings, murals, and so forth were only put on display when needed. On the other hand, there was an attempt to make teaching materials used during instruction as colorful and stimulating as possible:
...what is meant by a structured program? For example, upon coming into the classroom the child will hang his hat and coat on a given hook--not on any hook of his choice, but on the same hook every day. He will place his lunch box, if he brings one, on a specific shelf each day. He will then go to his cubicle, take his seat, and from that point on follow the teacher's instructions concerning learning tasks, use of toilet, luncheon activities, and all other experiences.... The day's program will be so completely simplified...that the possibility of failure experiences will be almost completely minimized. (Cruickshank et al., 1961, p. 18)
It is fair to say that the primary focus of the Montgomery County project, at least as described in the 1961 publication, was on controlling the learning environment in comparison to academic instruction. The academic instruction recommendations tended to be dominated by readiness training in the form of perceptual and perceptual-motor exercises, handwriting, and arithmetic, with relatively little attention devoted to reading. Also, there was relatively little reference to phonics instruction.
Results after 1 year indicated that the program was effective in increasing perceptual-motor abilities as measured by the Bender-Gestalt test and in reducing the degree of distractibility as measured by a visual figure-background test. However, no effects were found for academic achievement or IQ. A 1-year followup found the perceptual-motor and attention advantages for the experimental group students had been eliminated.7
Funding for NRCLD is provided by the U.S. Department of Education, Office of Special
Education Programs. Award No. H324U010004. Opinions expressed herein are those of the National
Research Center on Learning Disabilities and do not necessarily represent the position of the U.S.
Department of Education.
© 2007 National Research Center on Learning Disabilities
Last Updated: November 19, 2007
Contact: nrcld@ku.edu