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Applications for keyboarding with students with motor dysfunction 1987

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APPLICATIONS FOR KEYBOARDING WITH STUDENTS WITH MOTOR DYSFUNCTION By LAURIE MARGARET SNIDER B.Sc. (O.T.), McGill University, 1975 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES (Department of Special Education) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA June 1987 © Laurie Margaret Snider, 1987 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date -Jc^Q /3 /98" cv Department DE-6(3/81) i i ABSTRACT This study used the word processor as a tool for wr itten output to examine the ef fects of an exper ient ia l 'Write to Read1 program on typing performance, decoding strategies and successive processing in learning disordered chi ldren with motor dysfunction. A case history approach was taken in view of the small number of subjects ava i l ab le , and in order to adequately describe each i nd i v i dua l ' s unique and complex cognit ive motor p r o f i l e . Subjects involved in the study were three male students in a Junior Learning Assistance Class in a Lower Mainland B r i t i s h Columbia school d i s t r i c t elementary school. Each of the students had a h istory of poor motor performance, poor handwriting and delayed reading a b i l i t y . The three subjects were involved in an eight week intervent ion program which taught keyboarding and word processing techniques using the 'Write to Read' program, a systematic method of t ra in ing the motor s k i l l s required. It was hypothesized that , i f the learning disabled student with poor motor s k i l l s could use the word processor as an adjunct to handwriting, the improved l e g i b i l i t y would f a c i l i t a t e consistent decoding by the student of his own work, re in forc ing acqu i s i t i on of early reading s k i l l s . Within the case history format, a theoret ica l frame of reference based on the simultaneous - successive information processing model was chosen and a l im i ted time series design measured the effects of the intervention on successive processing as determined by a block sequencing task (Das, Kirby and Jarman, 1980). i i i The data was collected for each student and graphed for visual inspection, graphic analysis and s tat i s t ica l analysis. One subject showed a stable and signif icant intervention effect, and no stable trends or signif icant results for successive processing were found in the other two subjects. Rates of word processing output increased over the course of the study and the number of errors declined. All subjects made progress in measures of decoding and word analysis. Implications for future research and professional practice were descri bed. i v ACKNOWLEDGEMENT I would l i k e to thank the ind iv iduals who guided and supported me throughout the preparation of th i s thes i s . My committee members have contributed the i r experience and knowledge with patience and c l a r i t y . I extend my sincere thanks to Dr. David Kendal l , my major advisor, and Dr. Rita Watson. Dr. Walter Boldt acted as a consultant to the study and I great ly value the precious hours he spent with me. My thanks to Paula da Luz and Glenys Cameron for the typing and word processing of the manuscript. Ms. Meredith Kezar graciously welcomed me into her classroom, allowing me to work with her students who acted as subjects in the study and provided me with a venue to appreciate the f ine art of classroom teaching. J u l i a Zarudzka, my dear fr iend and valued colleague, acted as my insp i ra t ion at th i s and many other leve l s of my l i f e . My husband, David Vowles, provided his i r replaceable fr iendship with patience and encouragement. V TABLE OF CONTENTS Page Abstract i i Acknowledgement iv L i s t of Tables vi L i s t of Figures v i i i L i s t of Appendices ix CHAPTER 1. Introduction 1 2. Review of the L i te rature 9 H i s to r i ca l Perspective 9 Computer-Aided Instruct ion and Word Processing Appl icat ions 15 Written Language 17 Attention and Reading 19 Applications of the Word Processing Model 20 Remediation Approaches 24 Summary 26 3. Statement of the Problem 29 4. Method 31 Subjects 31 Design 36 Measures 38 Procedures 42 5. Results 46 Subject #1 46 Subject #2 63 Subject #3 77 6. Conclusions 96 Discussion 96 L imitat ions of the Study 103 Implications for Future Research and Professional Pract ice 104 Appendices Bibliography 107 286 vi LIST OF TABLES Page TABLE I Subject #1 Mean Rates (letter/minute) of Word Processing and Handwriting Samples 53 II Subject #1 Mean Number of Errors in Word Processing and Handwriting Samples 53 III Subject #1 Error Types in Word Processing Samples 54 IV Subject §1 Error Types in Handwriting Samples 55 V Subject #1 Corre lat ion of Block Sequencing Scores Between Baseline and Intervention Phases 56 VI Subject n Mean Rates (letter/minute) of Word Processing and Handwriting Samples 68 VII Subject #2 Mean Number of Errors in Word Processing and Handwriting Samples 68 VIII Subject #2 Error Types in Word Processing Samples 69 IX Subject #2 Error Types in Handwriting Samples 70 X Subject #2 Corre lat ion of Block Sequencing Scores Between Baseline and Intervention Phases 71 XI Subject #3 Mean Rates (letter/minute) of Word Processing and Handwriting Samples 82 XII Subject #3 Mean Number of Errors in Word Processing and Handwriting Samples 82 vi i LIST OF TABLES, cont'd. TABLE XIII Subject #3 Error Types in Word Processing Samples XIV Subject #3 Error Types in Handwriting Samples XV Subject #3 Correlat ion of Block Sequencing Scores Between Baseline and Intervention Phases vi i i L I S T O F F I G U R E S Page FIGURE 1. Data for Block Sequencing Task - Subject 1 57 2. Trend Lines for Block Sequencing Task - Subject 1 58 3. Mean Level Lines for Block Sequencing Task - Subject 1 59 4. Data for Block Sequencing Task - Subject 2 72 5. ' Trend Lines for Block Sequencing Task - Subject 2 73 6. Mean Level Lines for Block Sequencing Task - Subject 2 74 7. Data for Block Sequencing Task - Subject 3 86 8. Trend Lines for Block Sequencing Task - Subject 3 87 9. Mean Level Lines for Block Sequencing Task - Subject 3 88 i x L I S T OF APPENDICES Page APPENDICES A Subject #1: Case History 107 B Subject #1: Data: Block Sequencing Task 133 C Subject #1: Test Results ., 135 D Subject #1: C l i n i c a l Observations 138 E Subject #1: Motor S k i l l s : Video Discussion 159 F Subject #2: Case History 162 G Subject #2: Data: Block Sequencing Task 167 H Subject #2: Test Results 169 I Subject #2: C l i n i c a l Observations 172 J Subject #2: Motor S k i l l s : Video Discussion 187 K Subject #3: Case History 190 L Subject #3: Data: Block Sequencing Task 203 M Subject #3: Test Results 205 N Subject #3: C l i n i c a l Observations 208 0 Subject #3: Motor S k i l l s : Video Discussion 219 P Subject #1: Output Samples 222 Q Subject #2: Output Samples 239 R Subject #3: Output Samples 256 1 CHAPTER 1 INTRODUCTION Typing as an adjunct to manuscript wr i t ing in the development of " s p e l l i n g , reading and composition" (Conrad, 1935, p. 264) has been perceived as a va l id educational tool in the l i t e r a t u r e since the early 1930s. It i s not c lear why the use of typing as an ins t ruct iona l mi l ieu has not received a more enthusiast ic response in programming for basic s k i l l s i n s t r uc t i on , although the pragmatic reader can make tentat ive hypotheses. What i t may r e a l l y boi l down to is that the mighty pen was on the scene long before Underwriter designed the f i r s t typewriter. This inexpensive, replaceable, low maintenance tool i s usable by the majority of the school- aged population. Since school programs do not require keyboarding s k i l l s , there has not been real reason to learn these s k i l l s for performance of school tasks. One cannot overlook the curriculum planning with in the school system in which the academic students take academic courses and the vocational students learn to type. It seems l og i ca l to assume that the demand for keyboarding s k i l l s has been l im i ted to a spec i f i c population of business students and that , unt i l recent ly, the majority of students had no real need to learn these s k i l l s , as there was no arena for t he i r app l icat ion in the work place. The e f fect s of the microcomputer on the da i l y l i v e s of the population has, however, created that demand. Future-minded parents now send the i r 2 chi ldren o f f to computer camp to learn BASIC instead of canoeing and reef knots. The myriad appl icat ions of the microcomputer are becoming c lear to educators in business, mainstream teaching and special education. Increased frequency of computer teaching in the schools has benefited many students. This paper w i l l address the appl icat ions of the microcomputer and word processing programming to the reinforcement of basic reading and wr i t ing s k i l l s of students with h i s to r ie s of motor dysfunction and attent ional d e f i c i t s which manifest as poor pr int ing s k i l l s and delayed reading s k i l l s . The development of pr int ing s k i l l s , which can act as an a c t i v i t y for the development of attent ion in reading for normal ch i ld ren , i s a slow and laborious process for the chi ldren with motor dysfunction and presents no c e i l i n g for success. However, ch i ldren with educational diagnoses of visual motor and attent ional d e f i c i t s are often placed on an exper ient ia l wr i t ing to read program in order to es tab l i sh a meaningful framework for the focus of attent ion on decoding and comprehension in reading. Despite marked e f f o r t , the qua l i ty of performance in wr i t ing i s never equivalent to the peer group performance. It would seem that continuous pract ise does not necessar i ly or ient the ch i l d to the task, but, rather, feeds into underlying impuls iv i ty through f a i l u r e and diminishing f ru s t ra t i on tolerance. The c l e a r , consistent resu l t offered by the use of a keyboard eliminates t h i s v isual motor performance aspect of the wr i t ing task and may f a c i l i t a t e the process of attent ion to decoding in reading through wr i t i n g . 3 The nature of typing on a keyboard i s such that i t presents the simultaneous visual stimulus of the l e t t e r s , enabling the student to focus attent ion on the features of one letter/st imulus at a time rather than laboring through the motor sequence of creating the aspects of the le t te r s and words. Theoretical Models In order to develop a consistent approach for development of strategies for remediation of dysfunction, i t i s helpful to adopt an appropriate theoret ica l framework in order to explain observed behavioral responses. Simultaneous and Successive Synthesis Model The work of Das, Kirby and Jarman (1979) and Lur ia (1966a, 1966b) provides a theoret ica l and empi r ica l l y sound model of information processing and task analysis based on a simultaneous and successive synthesis approach to learn ing. Kirby and Das (1978) del ineate the d i s t i n c t i v e elements of th i s approach: "Simultaneous processing can be characterized as involv ing the synthesis of separate elements into groups that generally have spat ia l overtones, with a l l the portions of the synthesis being surveyable or access ible without dependence on the i r pos it ion within the synthesis. This type of processing i s required, for instance, in the formation of any h o l i s t i c ge s ta l t , or in the discovery of the re lat ionships among two or more objects. Successive processing on the other hand, involves the integrat ion of separate elements into groups whose essent ial nature i s temporal. Portions of th i s synthesis are access ible only in the temporal order of the ser ies - each element i s dependent on the 4 preceding elements. Successive processing is necessary for the formation or production of any ordered series of events" (p. 59). The model l inks successive synthesis with motor and auditory modal i t ies, and simultaneous synthesis with the visual modality. Further research hypothesizes that the simultaneous, spat ia l modality may be a function of the r ight bra in, while the sequent ia l , temporal modality may be based in the l e f t bra in. K ra f t , et al (1980), in invest igat ing EEG records of ch i l d ren , reported greater r ight hemispheric processing during as s imi lat ion of information with a de f i n i t e s h i f t to the l e f t during re t r ieva l and verbal/ log ica l expression of information. High reading scores were related to greater inter-hemispheric processing, or the a b i l i t y to s h i f t from one mode of processing to the next. Jarman (1980) argued, however, based on his analysis of paradigmatic and syntagmatic associations within the study of language funct ion, that th i s hemispheric interpretat ion of brain function was unsophisticated. His f indings indicated that these functions were not cons i s tent ly l a t e r a l i z ed into consistent and predictable hemispheric locat ions . Gordon (1980) hypothesized a developmental lag in l e f t brain function as the basis for dys lex ia . The a b i l i t y to perceive the s e r i a l order of auditory or visual s t imul i was thought to be dependent on temporal or sequential processing. Dysfunction with in the sequential modality created learning d i f f i c u l t i e s in reading, mathematics and other a b i l i t i e s involving ana ly t i ca l processes. Learning-disabled ind iv idua l s were " locked i n " to a simultaneous mode of processing, thereby rendered unable to u t i l i z e the intermodal s h i f t required for successful learn ing. 5 The key to sequential learning was proposed to l i e with the a b i l i t y to se l ec t i ve l y attend to c r i t i c a l variables of presented s t imul i (Reid and Hresko, 1981). A longitudinal study based on the simultaneous and successive synthesis framework used task analysis and empirical va l idat ion to establ i sh a series of tasks designed to tap simultaneous and successive a b i l i t y in an early i d e n t i f i c a t i o n of learning-disabled chi ldren project (Jarman and Das, 1980). This theoret ica l model proposed that task information i s presented to sensory modal it ies in a successive or simultaneous manner. The tasks themselves were categorized as mnestic, perceptual and conceptual. The nature of output or task response can also be simultaneous or successive. "Simultaneous output depends at a l l points on what has already been done, such as in the drawing of a c i r c l e ; even though some of the c i r c l e may be complete, the balance of the drawing depends upon the completed part in order to produce a correct f igure. Successive output i s temporal in nature and does not depend upon previous responses as d i r e c t l y ; for example, r eca l l of a d i g i t in a set does not depend funct iona l l y upon a l l of the previously reca l led d i g i t s " (Jarman and Das, 1980, p. 30). Process Disorder Model Reid and Hresko (1981) proposed a process disorder model in the theoret ica l discussion of learning d i s a b i l i t y . These were divided into modal and non-modal disorders. Modal disorders manifested themselves as dysfunction at the i n t e r - sensory integrat ion level or d i f f i c u l t y with the in teract ion between input and output. These were related to sensory modes of reception. 6 Non-modal disorders were based on the a b i l i t y to attend to c r i t i c a l variables of presented s t i m u l i . This dysfunction of se lect ive attent ion may be the basis for the academic learning behaviors of the learn ing- disabled population. The cons te l l a t ion of these learning behaviors included the i n a b i l i t y to process sequentially-presented information, lack of general izat ion between learning s i tua t i on s , lack of awareness of cause and e f f e c t , and the i n a b i l i t y to learn by inference. Select ive attention d e f i c i t s prevented the indiv idual from synthesizing a meaningful network out of d i sc rete , symbolic or non-meaningful information received from the envi ronment. Using the theoret ica l frame of reference described, the c l i n i c a l remediator can proceed to devise strategies for teaching the learn ing- disabled i nd i v i dua l . One of the e f fec t i ve strategies described by Reid and Hresko (1981), has been to switch the order of presentation of information. Rather than teach in a temporal, sequential way, the remediator presented the information in a simultaneous way. For example, teaching through experience, learning by doing, emphasized the simultaneous mode of learning (Wittrock, 1978). Once the meaningful framework evoked by the exper ient ia l s i tua t ion was establ i shed, the addit ional data was applied to i t . In th i s way, conceptual learning took place. Task Analysis of Printing and Keyboarding Using the Model of Simultaneous and Sequential Synthesis The underlying process of handwriting i s v isual motor integrat ion (Beery, 1982). According to the task analys is of Jarman and Das (1980), the process of visual motor integrat ion i s simultaneous in nature. 7 The nature of the motor aspect of handwriting i s sequential (Kirby and Das, 1978) and impaired motor performance loads an addit ional sequencing variable on to the requirements for successful task performance. Changing the motor nature of printed output by placing the l e t te r s on a keyboard format el iminates the sequenced motor aspect of pr int ing and changes the motor task into targett ing the appropriate l e t t e r choice, a much simpler motor requirement. By s impl i fy ing the motor requirement, the task emphasis returns to the visual simultaneous input and conceptual simultaneous processing output described by the Jarman and Das (1980) task analys is chart (F ig. 1, p. 3). This places the learning disabled student in an area of r e l a t i ve strength: simultaneous synthesis. The letter-symbol choices are arranged in a visual display which can be translated into a meaningful framework using strategies described in Chapter 2 of th i s paper. By breaking the task into i t s component parts and problem-solving for f a c i l i t a t i o n according to the theoret ica l framework of simultaneous and successive synthesis, the complex task of printed output can be brought within the processing capacity of the c h i l d with motor dysfunction and learning d i s a b i l i t i e s . Use of keyboard and word processing combinations cannot el iminate the sequential aspects of pr int ing words. Words are, by the i r nature, a sequence of l e t t e r s . It remains for the remediator to discover a meaningful way to present a reading and wr i t i ng task which allows motor s k i l l automation (Stelmach and La r i sh , 1980) to re inforce the sequenced aspects of the task. 8 The "Write to Read" typing program i s a written reading program which uses a word family and phoneme recognit ion approach. Finger positions are al located on the keyboard and typing of word fami l ies involves consistent finger/key a l l o ca t i on . For example, in the f i r s t lesson, the student must type, RED, FED, LED, WED, BED repeatedly and then type the sentence "Ted had a red bed". The program emphasizes the goal of "ed" sound symbol sequence being reinforced by the motor " e -d " becoming more automatic with pract i se. The use of the word processor technology to back up the keyboard is a further s imp l i f i c a t i on of a complex task. In i t s simplest form, the word processing function allows the student to correct his errors on the monitor and f a c i l i t a t e s er ror - f ree printed output. The conventional typewriter does not o f fe r such ease of error correct ion and, as i t does not o f f e r the more complex edit ing functions of the word processor, can be considered a more l im i ted keyboard m i l i eu . As learning disabled students c h a r a c t e r i s t i c a l l y f a i l to generalize between learning environments, i t seems wise to i n i t i a t e the students onto a keyboard system that w i l l taken them as far as possible into the area of written language, making the word processor the technology of choice to re inforce basic reading and wr i t ing s k i l l s . Summary The use of microcomputer and word processing technology to re inforce basic reading and wr i t ing s k i l l s can be task-analyzed according to the simultaneous-successive synthesis model of information processing described by Das, Kirby and Jarman (1979), and applied to a population of students with motor dysfunction and attent ional d e f i c i t s . 9 CHAPTER 2 LITERATURE REVIEW Historical Perspective It i s s t i l l necessary to learn to type in order to 'keyboard ' . T r ad i t i ona l l y , typing i s taught at the secondary l e v e l . Some educators have advocated for i t s inc lus ion in primary grades on the basis that gains can be achieved in motor a b i l i t y , w r i t i n g , spe l l i ng and language s k i l l s (Whitmi l l , 1973; Er ikson, 1972). Evidence points out that f ine motor s k i l l s necessary for typing are intact in primary students (Whitmi l l , 1973) and that elementary students can compete successfu l ly with high school students on various complex tasks " inc lud ing a six-page manuscript with quotations, footnotes and bibl iography" (Whitmi l l , 1973, p. 41). In order for these s k i l l s to be taught at the elementary l e v e l , performance object ives need to be establ i shed. Erikson (1972) proposed a ' c r i te r i on - re fe renced ins t ruct iona l model' which emphasized: " 1 . s pec i f i ca t i on of performance goals 2. pre-assessment of the learner 3. provis ion of adequate ins t ruct ion that includes va l idat ion of the learning through proper repet i t i on and with measurement against some c r i t e r i o n 4. se lect ion of appropriate evaluation procedures that emphasize s e l f - motivation of the learner through the reinforcement that he gets from his own learning and progress as measured by his a b i l i t y to meet minimum performance goals as well as i nd iv idua l i zed performance goals" (p. 20). 10 Erikson (1972) pointed out that "at the elementary school level the notion pers i sts that a l l that i s necessary i s to put the youngster at a typewriter with a typing book, and perhaps some tapes, and he can learn to typewrite. Anyone who has ever worked with elementary school youngsters w i l l a t tes t to the fact that they are eager learners and that they are espec ia l l y motivated when the learning involves a thing to be manipulated such as a typewriter. The fact i s . . . that elementary school pupils learning to typewr i te . . . need the . . . guidance of a . . . teacher i f they are to achieve at a level that bears a re lat ionsh ip to t he i r potential to achieve. To do less i s to short change the learner" (p. 20). Performance goals were related to : 1) basic typing s k i l l , 2) selected typing app l i cat ions , 3) typing and language arts learning (Erikson, 1972). Use of a keyboard for output with regular stream chi ldren was advocated for on the fol lowing basis: " 1 . Learning to type fascinates ch i ldren bored with regular c la s s . 2. A typing program adds uniqueness to remedial reading. 3. Incidental reading takes place in the typing lessons such as reinforcement of the basic sight words. 4. Spel l ing i s aided through the typing lessons. 5. The ch i l d experiences frequent success through short lessons and praise" (Se l tzer , 1978, p. 13). The use of the keyboard in the classroom as a motivator in the pract ice of basic s k i l l s has been recognized (Se l tzer , 1978; Er ikson, 1978; Tet rau l t , 1970). Despite the general a i r of pos i t iv i sm, few studies were ava i lab le for analys i s . Tetrault (1970) studied fourteen f i r s t graders using performance within the 24 to 54%i^ e on the Gates Reading Readiness Tests as c r i t e r i o n for inc lus ion in the study. 11 Pos i t ive resu lts from th i s p i l o t study (using e l e c t r i c typewriters and d i c ta t ion equipment with a regular phonics program and basal readers) led to a longer study in the fol lowing year. Students were randomly assigned to two groups. One group received regular reading i n s t ruc t i on , the other group used technical aids to re inforce reading. At mid-term, a ' s i g n i f i c a n t gap' between groups in s pe l l i n g , l e t t e r recognit ion, word reading and study s k i l l s as measured by the Stanford Achievement Test, was noted in favor of the technical aids group. It i s not evident what c r i t e r i a were used to measure s ign i f icance or i f the Standard Achievement Test was an appropriate measure to be administered three times in s ix months. At mid-term, the groups switched programs and went on to complete the term. Findings indicated that the "group using the equipment during the second half of the term was about even with the group that had used i t in the f i r s t hal f " (p. 116). No attempt was made to d i f f e ren t i a te results in terms of r e l a t i ve gains made by the f i r s t group who may have had an i n i t i a l benefit in having c lear reinforcement of basic s k i l l s through technical aids at the outset of the program. One wonders what the progress of a group who received only one or the other types of intervention would have been under s im i la r condit ions. Empirical nightmares such as th i s character ize the l i t e r a t u r e , but are usual ly followed by educational ly sound, pragmatic ideas for program implementation. While t h i s i s , indeed, helpful to the educator in the classroom, the use of keyboarding as an adjunct to manuscript wr i t ing remains subject to 12 the whims and passing fancies of the art of education without an empirical basis for th i s kind of intervent ion. Tate (1935) reported a study she carr ied out with ' retarded* students to "determine the usefulness of the typewriter in remedial ins t ruct ion in reading and language in the intermediate grades" (p. 481). Two matched groups (on grade equivalents of the Standard Achievement Test and i n te l l i gence quotients from the Ca l i f o rn i a Test of Intel l igence) were selected from Grades 4, 5 and 6. Groups were i den t i f i ed by choosing the chi ldren f a l l i n g below the 50th%1* 1 e of each class group. Scores on subtests of Paragraph Meaning, Word Dictat ion and Language Usage and D ictat ion (Spell ing) were compared between groups. While differences did not achieve s t a t i s t i c a l s i gn i f i cance, . the experimental group fared better than the controls in ranked order of Language, D i c ta t i on , Paragraph Meaning and Word Meaning. The author concluded that, although s t a t i s t i c a l l y i n s i g n i f i c a n t , the study indicated the merits of keyboard use as an intervention tool in the remediation of reading and s pe l l i n g , mentioning student motivation and teacher pa r t i c ipa t ion as another pos i t ive aspect of the study i t s e l f . Conrad (1935) conducted a two-year study on typing in the primary grades. Her rat iona le was straightforward and precise: " - ch i ldren are interested in the machine, i t requires 1 i t t l e muscular development, i t does not s t ra in immature muscles, ch i ldren can express ideas in wr i t ing by a motor pressure rather than a more contro l led movement, i t should help the ch i l d with poor motor con t ro l , i t should a s s i s t the left-handed ch i l d - the resu l t s are accurate, quickly obtained and are very s a t i s f y i n g , i t apparently t i e s up c lo se ly with reading" (p. 256). 13 The study sampled 150 chi ldren in the Horace Mann School in the northeastern United States. Two classes of Grades 2, 3 and 4 were paired on chronological and mental age (no measures reported). One group used typewriters for wr i t ten work, the other group used manuscript wr i t i ng . Gains in favor of the experimental group were reported in written speed and output speed, however, grade differences were noted and att r ibuted to general maturational progress. The Grade 2 ch i l d ren ' s performance was not as c l ea r l y d i f fe rent ia ted between typing and manuscript w r i t i n g , while the Grade 4 group showed a greater d i spa r i t y of output rate in favor of the typewriter. Merrick (1941) found that students with low handwritten composing rates made the greatest "growth and f a c i l i t y of expression" (p. 294) when handwritten and typewritten composing rates were compared. This author did observe that "pup i l s at the younger l e v e l , p a r t i c u l a r l y the l i t t l e boys, l o s t time ear ly in the year part ly through inattent ion and part ly because they ran out of something to say before f i ve minutes passed" (p. 295). Cowles (1983) pointed out that, in the rage for applying technology to education, the basic issues of whether chi ldren can develop adequate keyboarding s k i l l s had not been addressed to his s a t i s f a c t i on . In a study designed to examine the re lat ionsh ip between typing s k i l l development and motor prof ic iency, a random sample of 24 ch i ldren was selected with equal numbers of f i v e , s i x , seven and eight year o lds , and equal numbers of males and females in each group. The group was assessed for motor prof ic iency on the Bruininks- Oseretsky Test of Motor Prof ic iency and the teaching program used was "Touch to Type" by Nash and Geyer (1983). 14 The students' work was co l lected da i l y and 30-second timings were scored for speed and accuracy, and recorded at regular i n te rva l s . Students were observed da i l y over 20 observations on task behavior. Pearson r ' s and Spearman rho's were calculated to determine the nature of the re lat ionsh ip between motor prof ic iency and typing performance. S t a t i s t i c a l l y s i gn i f i c an t corre lat ions were not found. C l i n i c a l observations indicated more o f f task behavior in the f i ve and s ix year old group, but that the typing program experience was generally pos i t i ve . The students were motivated and enjoyed the c lass . Students were able to learn to type cor rect l y (th is typing program stresses f inger placement and speed). The f i ve to s ix year old group were able to output words, the seven to eight year olds were able to type words and sentences. This seemed to be more related to reading a b i l i t y than to motor s k i l l , however, motor s k i l l was more related to the success of the seven to eight year old group in output rate. This study was one of the more a r t i c u l a t e ones in terms of experimental design. The group was selected randomly and matched for sex and age. Further examination of o f f task behavior in the f i ve to s ix year old group would have given the reader more ins ight into the basis for the o f f task behavior. Was the task too demanding or not meaningful enough? Was the behavior seen in other learning s i tuat ions? Did i t improve with increased teacher ' s v i l igance? The s ize of the sample was r e l a t i v e l y smal l . Further studies could include matching across the groups for reading a b i l i t y in order to examine the ef fect of motor prof ic iency on typing s k i l l more c l e a r l y . 15 These studies indicated that the motor prof ic iency for acquiring keyboarding s k i l l s was intact in elementary school-aged chi ldren and that these chi ldren were able to approach the complex task of using the typing process to increase speed of output. The development of typing prof ic iency seemed to correspond with a general maturational process of motor s k i l l as well as reading a b i l i t y in the age range selected for the study, and was not just related to motor prof ic iency. The l i t e r a t u r e stressed the pos i t ive ef fect of keyboard use on student motivation and emphasized the f a c i l i t a t i v e e f fect on output for students with poor motor control (Conrad, 1935; Tate, 1935). However, no studies were done with students with poor motor cont ro l . Related Research Computer-Aided Instruction and Word Processing Appl ications Kol ich (1985) discussed the advent of the microcomputer in the school system and described the incorporation of technology into the in s t ruct iona l curriculum. Three areas of computer-aided ins t ruct ion (CAI) were i d e n t i f i e d . D r i l l and pract ise from the f i r s t stage was bu i l t upon in the second stage by the incorporation of the aspect of decision-making which can be programmed into software. The t h i r d stage was determined to be t u t o r i a l , an in te ract i ve systematic in s t ruct iona l sequence. The author indicated that th i s format placed the student at the controls of his own learning experience. Hummel (1985) reported on the function of computer appl icat ion to d r i l l and pract ice. When using the microcomputer/word processor combination for wr i t ten output, he notes that "these chi ldren need 16 systematic t ra in ing in typing and word processing in order to rea l i ze the potential benefits of integrat ing word processing in composition i n s t ruc t i on " (p. 559). Hoffman (1986) used a Piagetian frame of reference to suggest that the microcomputer created an environment for learning which allows the ind iv idua l to in teract with the information in a se l f - d i r ec ted way. This provided the basis for increased gene ra l i z ab i l i t y of knowledge. Rosegrant (1985) described an ongoing four-year study in which word processing software was used with 12 learning-disabled students ( c r i t e r i a unknown for determining diagnosis of learning d i s a b i l i t y ) . The students were ranged in age from s ix to ten years of age. The purpose of the intervent ion was to f a c i l i t a t e acqu i s i t ion of basic reading and wr i t ing s k i l l s . These ch i ldren demonstrated poor mastery of handwriting, were general ly unhappy about t he i r handwriting appearance, were often unable to read what they had wr i t ten , and showed poor spat ia l organization of the text on the page. The group was also noted to "often lose t he i r t r a i n of thought when wr i t ing and showed fatigue in the wr i t ing process" (p. 113). This f r u s t r a t i on led the author to suggest that the group demonstrated "decreased amounts of r i s k - t ak i ng , explorat ion, strategy-creat ing and hypothesis t e s t i ng " (p. 113). The study involved use of a word processing program which had been interfaced with a synthesized speech program as the c l a s s ' pr inc ipa l reading and wr i t ing instrument. Children were encouraged to be as s e l f - directed as poss ib le, with a "read - text " mode which highl ighted the words on the screen as the voice synthesizer reproduced the wr i t ten t e x t . 17 During the f i r s t s ix months of th i s program, each ch i l d had made 12 months of gain in reading l e v e l , however, the measures used were not indicated. Reading sub - sk i l l s showed improvements in increased use of phonics in decoding s k i l l s as well as an increase in sight word vocabulary. It would have been more enlightening for the reader i f the author had described the measures used to assess progress in reading l e v e l . Rosegrant discussed four essential factors in the use of the microcomputer to f a c i l i t a t e acqu i s i t ion of the basic s k i l l s of reading and wr i t ing in learning-disabled students: " 1 . To provide v i s u a l , auditory and motoric modes of support... use of the cursor provided da i l y exercise at visual tracking without any sense of pract ice. 2. To lower r i sks encountered in making errors. 3. To provide a high degree of control over reading and wr i t ing tasks. 4. To provide a meaningful learning context in which exploration and analysis of wr itten language can occur" (p. 115). While concrete resu lts were not reported in the study, weaknesses can be noted in the wide age range of students and the small sample of students studied. This study was valuable in i t s descr ipt ion of the students' task approach as well as the detai led explanation of the intervent ion program. Written Language Fredriksen (1981) viewed language as the essential component in learning to write and breaks down the task of wr i t ing into i t s component parts as fo l lows: " 1 . a cognit ive a c t i v i t y 18 2. a pa r t i cu la r form of language and language use 3. a communicative process 4. a contextual ized, purposive a c t i v i t y " (p. 2). From the perspective of th i s study, i t seems expedient to add a f i f t h consi deration: 5. a s pec i f i c and precise motor a c t i v i t y . Fredriksen drew on the work of Piaget when he proposed that "cognit ive demands of wr i t ing are s im i l a r to those required by other symbol-making a c t i v i t i e s . . . wr i t ing might be s im i l a r to ( i . e . continuous with) symbolic a c t i v i t i e s in pretend play, drawing and story t e l l i n g , and d i s s im i l a r to ( i . e . discontinuous with conversational language... that d i f f e r s in i t s social in teract iona l support for sustained language production" (p. 10). and went on to d i f f e r en t i a t e further between oral and wr itten language. Without the immediate l i s t ene r react ion, and socia l and conversational cueing inherent in conversational language, the wr i ter must c l ea r l y d i f f e r en t i a t e between an intended meaning and what i s actua l l y stated in p r in t . He must ant ic ipate the reader 's reaction in absentia and determine " l eve l s of communicative competence (which) are re f lected in young w r i t e r ' s a b i l i t y to estimate the leve l s of inference required to read what they wr i te " (p. 11). From th i s perspective, wr i t ten language was presented as a d i s t i n c t and separate i den t i t y evolving as a resu l t of increas ingly complex cognit ive and l i n g u i s t i c i n te ract ions . Woodruff (1986) studied the e f fect s of word processing on the wr i t ing a b i l i t y of students in an enriched program in order to determine what the differences in focus of attent ion between enriched and average students was 19 within the framework of the task, and determined that the wr i t ing s k i l l of the student was the determining factor in the qual i ty of assistance offered by the word processor. Enriched students focused on compositional s ty le and theme development, however, the average students performed better on punctuation. The enriched students were more able to use the advanced edit functions of the word processor to organize and develop the i r compositions. The overlapping parameters of cogn i t ion, language and wr itten language and motor s k i l l presents a complex p ic ture. The authors who are pursuing l i n g u i s t i c and cognit ive consequences of wr i t ing are not addressing the motor-disabled group of writers and motor s k i l l in wr itten output is taken for granted in th i s f i e l d of l i t e r a t u r e . This focuses the need for the development of basic wr i t ing and reading s k i l l s even more s a l i e n t l y for the motor dysfunction population when the v i t a l i t y of written output i s examined. The development of written language to i t s f u l l e s t extent would seem to be a basic academic goal, however, i t i s i n i t i a l l y dependent on the physical wr i t ing process i t s e l f . Attention and Reading The normal reader spent less attent ional capacity in decoding of indiv idual words and thus was able to go beyond th i s into reading for comprehension and meaning. The microcomputer's inherent a b i l i t y to be programmed for a c t i v i t i e s which sustain attent ion made i t a method of choice in reading in s t ruc t ion for learning-disabled populations (Torgeson, 1983). 20 Torgeson (1983) in establ ishing p r i o r i t i e s for appl icat ion of microcomputers for education of the learning disabled i den t i f i ed "the primary locus of d i f f i c u l t y for poor readers... at the indiv idual word rather than discourse level of processing" (p. 235). Major word reading d i f f i c u l t i e s of the learning disabled reader were i den t i f i ed as poorly-established phonetic basis for decoding new words and a low rate for reading of indiv idual words including f am i l i a r words (Torgeson, 1983). Appl icat ions of the Word Processing Model MacArthur (1986) found that app l icat ion of the word processor for wr itten work in the classroom resulted in increased motivation for wr i t ing as a resu l t of the neat copy achieved as well as the immediate results offered by the edi t ing power of the computer. He noted that: "students work by typing rather than handwriting... producing better looking copy... ( th i s i s ) easier for LD and other students with poor handwriting." Various authors (MacArthur, 1986; Woodruff, 1986) have observed pr imit ive technical s k i l l s for typing and edi t ing in students using word processing in the classroom, but th i s did not i n te r fe re with motivational aspects, and as th i s was a s k i l l and not an a b i l i t y , i t was proposed that these s k i l l s could be developed in order to contr ibute to a higher level of integrated funct ioning. It would be naive to assume that the learning disabled (LD) student with poor handwriting could switch to another mode of output with ease. This overlooks the basic process disorder inherent in the student 's approach to cognit ive and organizational tasks. 21 MacArthur (1986) examined types of errors made by LD students in using two d i f fe rent word processing software programs. The subjects were two groups of four LD students from a summer remedial reading c l i n i c . Age range was 9.6 years to 12.2 years, spanning grades 4 to 6. These chi ldren were of average in te l l i gence as measured by the WISC-R, PPVT and Detro it Tests of Learning Aptitude with a l l scores (except two i nva l i d scores from two English as a Second Language (ESL) students f a l l i n g within one standard deviation of the mean. Standardized test ing of reading a b i l i t y (tests not described) showed that the students were 1.9 to 3.2 years behind t he i r age peers. A l l the students, except two who attended pr ivate schools, had been i den t i f i ed by t he i r schools as learning d isabled. None of the students had previous experience with word processing. The two programs which were examined were Mi H i ken Word Processor (M i l l i k en , 1984) and Cut and Paste (E lectronic Ar t s , 1983). Mi 11 iken used a desk top graphic analogy as a four choice menu for wr i t ing t oo l s , f i l e s , typewriter and help. This was better for the students who understood that they could press the escape button (ESC) un t i l they got back to the desk graphic for menu choices. In contrast , Cut and Paste presented highl ighted menus and the students manipulated the arrow keys to h igh l ight the menu of the i r choice and then pressed the return button to choose. This was a more complex sequence and also required more reading s k i l l s . The students had more d i f f i c u l t i e s . Ove ra l l , the Mil 1iken program was more suited to the group's organizational a b i l i t i e s , although one student took the desk top analogy 22 quite literally and tried to file two stories in the same computer file (as in file folder) thereby erasing his first story. The investigators kept detailed notes on planned and actual instruction as well as narrative notes detailing student errors, questions, successful use of word processing functions and affective responses. Typing skills were at the two-handed "hunt and peck" level resulting in an output speed of 10 to 20 letters per minute, although this rate was not frustrating for the children. Typing errors included spacing errors and the use of CAPS LOCK instead of SHIFT for single capital letters. The children also adopted inefficient habits when using the cursor. They found it hard to switch to the ^ or ̂  arrows preferring to use the —• or *v— arrows repeatedly to get to other lines. No problems were encountered using the delete key (DEL), although once the students figured this function out, they tended to ignore the arrow functions for individual word correction and deleted entire words for retyping when single letters could have been replaced using a more sophisticated approach using the arrow keys. Other error types involved the concepts of space on the screen. Some children felt they had to use the space bar in order to create a space for a letter to be inserted and would then erase it instead of trusting the computer function to manipulate the spaces. The abstraction of the three types of empty space on the computer was difficult for the students. There were spaces as defined by the space bar, no visible representation of "return" and null spaces at the ends of lines where the words wrapped around. 23 The authors noted four error types which indicated the student 's confusion about manipulating space: 1. Attempted to move the cursor into the nul l space and then did not understand why i t would not work. 2. Typing ' r e tu rn ' at the end of a l i n e instead of re ly ing on the wrap around feature. 3. Use of the space bar instead of ' r e t u rn ' to get to the next l i n e . 4. Typing a series of spaces to make a blank l i n e instead of ' r e t u r n ' . These errors make the screen format look acceptable, but do not reproduce in pr int ing and reformatting. Insertion of blank l ines and s p l i t t i n g l i n e s , and paragraphs was most d i f f i c u l t for these students to comprehend. Based on these observations, the authors f e l t that the programs which employ modeless ed i t ing were most appropriate for these students as the system was always in i n se r t , the arrow keys directed the cursor and the delete key erased the l e t t e r to the l e f t of the cursor. Programs which employed separate modes for cursor movement or delete functions were not appropriate as they were confusing to the students (Apple Bank Street Wr i ter ) . Structure of the program was best when simplest so students can "create a mental map". This was consistent with the f indings of Gordon (1980), and Reid and Hresko (1981) who suggested a simultaneous visual mode of learning for chi ldren with learning d i s a b i l i t i e s . Students had pers istent d i f f i c u l t y with confusion about the space aspects of the computer and i n s i s ted on reta in ing approaches which made the text on the screen look presentable but were unable to predict or plan ahead based on what the printout would look l i k e . 24 The students ' responses continued to be enthusiast ic and they wrote continuously a l be i t at a slow rate. Compositions were longer on the word processor than when using handwriting. The excitement of being able to pr int e r ro r - f ree work had a compelling ef fect on these students, and they maintained an enthusiast ic approach to the task throughout the study. This study provided spec i f i c anecdotal data on task approach and task behavior. More numbers of subjects could have generated more information on ind iv idual differences and smal l , well matched groups could have contributed some s t a t i s t i c a l data using methods designed for ' smal l populations (Hersen and Barlow, 1976; Revusky, 1967). The descr ipt i ve nature of the study was appropriate and provided ins ight into the problem solving d i f f i c u l t i e s experienced by students with learning d i s a b i l i t i e s . Remediation Approaches The l i t e r a t u r e does indicate some support for use of word processing to re inforce basic reading and wr i t ing functions in chi ldren with learning d i s a b i l i t i e s . Insight into the nature of process disorders when formulating the organizational framework for the software program for word processing was instrumental to the success of student task approach. It i s important to maintain th i s ins ight into the nature of process disorders when teaching the learning-disabled ch i l d with motor dysfunction to or ient himself to the keyboard. The "Touch to Type" (Curriculum Associates, 1981) program presented a color-coded layout to a s s i s t with l e t t e r key l oca t ion . The ch i ldren may 25 also wear colored dots on the fingers a l located to each colored area of the keyboard in order to re inforce correct use of a l l f ingers in typing. "Keyboard Town" (Gallagher, 1961) reinforced keyboard layout memory by using the analogy of a community with a Home Keys Street, uptown and downtown, and way up town to correspond to the four rows of keys. Fingers rested i n i t i a l l y at Home Keys Street and the i so lated f inger movement was taught by having the character associated with the l e t t e r name move to uptown and downtown locat ions which employed the i n i t i a l consonants of the l e t t e r keys. For example, the f i f t h f inger rested on "A" in middle town. Ann went downtown to feed the zebras at the zoo and uptown to v i s i t Mr. QWERT's house, a large house which occupies half of the space in uptown. Visual maps were presented to re inforce the image of Keyboard Town and a diagonal road intersected the town to indicate the d i f f e r en t i a t i o n between keys struck by the l e f t hand and keys for the r i gh t . Given the d i f f i c u l t i e s with f inger sequencing a b i l i t i e s of learn ing- disabled students with motor dysfunction (Gaddes, 1980), i t may be un rea l i s t i c to expect the students to use a l l f ingers , pa r t i c u l a r l y the fourth and f i f t h f ingers which are d i f f i c u l t to i s o l a t e ; however, the use of two hands to s p l i t the keyboard may ass i s t in speed of l e t t e r key locat ion and an ordered sequence of d i g i t introduction may proceed as fo l lows: b i l a t e r a l index f ingers , index fingers and thumbs, leading to the introduction of the t h i r d f inger as automaticity of f inger-key associat ion develops. Techniques which re inforce memory of the spat ia l organization of the keyboard and encourage b i l a t e r a l hand use would seem appropriate for th i s 26 population in order to reinforce speed and accuracy of typing, and. in order for the student to progress at his own maximal rate in developing competence on the keyboard. Use of the word processor would provide a neat, consistent, error- f ree, wr i t ten output for students with motor dysfunction. The student would be taught strategies with which to approach the task of learning keyboarding s k i l l s and these strategies should be consistent with the student 's cognitive-motor p r o f i l e . The visual motor aspect of output is thus de-emphasized and the anxious or discouraged student may proceed with the cognit ive aspects of the task in a r e l a t i v e l y motor-free environment. Summary The review of the l i t e r a t u r e showed a majority of studies to have poorly defined parameters regarding student populations studied. The use of vague and subject ive measures of c l i n i c a l change ref lected a paucity of academic r i go r , p a r t i c u l a r l y in the e a r l i e r studies on the development of keyboarding s k i l l s in elementary school ch i ldren (Tate, 1935; Conrad, 1935). The f a c i l i t a t i v e e f fect of keyboard use on written output for students with poor motor control was discussed by the e a r l i e r authors (Conrad, 1935; Tate, 1935), but no data were reported for th i s spec i f i c population. Studies describing microcomputer/word processor combinations for written output are more spec i f i c in describing student populations as being learning disabled or from the normal student population. Rosegrant (1985) described her learning disabled student 's poor handwriting mastery, but did 27 not give any deta i l s regarding any h istory of motor incoordination or physical d i s a b i l i t y . It i s not known whether any consideration was given to these factors when determining the most appropriate means for i ntervention. MacArthur (1986) provided a valuable ins ight into error types made by LD students in using two d i f fe rent word processing software programs. Typing s k i l l s were described at the two-handed 'hunt and peck1 l e v e l . The study focused on the conceptual nature of the task and did not examine or i so la te any student d i f f i c u l t i e s which may have been motor in nature. None of the studies examined or described a systematic method of t ra in ing the motor s k i l l s required for teaching chi ldren with learning d i s a b i l i t i e s and motor dysfunction keyboarding s k i l l s on a word processor. This approach would require ins ight into the nature of the c h i l d ' s learning d i s a b i l i t y as well as the nature of his motor dysfunction. The studies did describe a motivational factor inherent in word processor use which seemed to be related to the production of perfect copy. This i s valuable to the t eache r - c l i n i c i an , but no spec i f i c measures related to motivation and self-esteem were reported, and the findings were based on •general observation (Tetraul t , 1970; Se l t ze r , 1978; Erikson, 1978; Rosegrant, 1985; MacArthur, 1986). None of the studies interpreted t he i r data or analyzed the tasks required of the students according to a theoret ica l framework such as the simultaneous-sequential information process model. The use of a descr ipt ive approach i s invaluable in programming e f f e c t i v e l y for ch i ldren with complex learning needs, as demonstrated by MacArthur (1986) and Rosegrant (1985). 28 Several authors commented on motor maturation as a factor in keyboarding s k i l l s development (Conrad, 1935; Cowles, 1983) as well as suggesting that a b i l i t y in written language and reading were factors a f f l i c t i n g output rate. Cowles (1983) also indicated that o f f tasks behavior was one of the c r i t i c a l var iables a f fect ing the development of speed and accuracy of output. Information on effects of keyboarding on reading, wr itten language and attention was inadequate and required further study. Erikson (1972) and Kol ich (1985) both commented on the need for a structured and systematic t ra in ing in order to maximize keyboard s k i l l s , although neither compared performance between groups of students who were trained and students who practised the i r own 'hunt and peck1 methods. Indeed, most studies of learning disabled students on keyboards tended to allow the students to randomly approach the keyboard without any l e t t e r key locat ion or ientat ion except for random visual scanning and h i t or miss ta rget t ing . It would seem important to minimize the f rust rat ions inherent in th i s method. As no studies reported any d i f f i c u l t y , the question raised i s was there r e a l l y no d i f f i c u l t y or has the foundation task of motor t ra in ing of LD students in keyboard use been overlooked? 29 CHAPTER 3 STATEMENT OF THE PROBLEM This study undertook to examine-the appl icat ions of teaching keyboarding s k i l l s on a word processor to learning-disordered chi ldren with motor dysfunction. There has been much discussion in the l i t e r a t u r e regarding use of the word processor as a tool for wr itten output. Studies have examined the appl icat ions for the g i f ted student population in development of wr i t ing s k i l l s and wr i t ten language (Woodruff, 1986, 1982b) as well as the d i f f i c u l t i e s encountered by the learning-disabled population when learning to use the word processor (MacArthur, 1986). Although Rosegrant (1985) described the qua l i ty of handwritten output of her learning-disabled population as i l l e g i b l e and lacking in spat ia l organizat ion, there i s a paucity of information ava i lab le which describes the app l i cat ion of word processing techniques for the learning-disabled student with motor dysfunction whose wr i t ten output i s compromised by the i n a b i l i t y to grade motor responses, poor postural cont ro l , f ine motor dysfunction, d i f f i c u l t y with b i l a t e r a l motor coordination and motor sequencing. It was hypothesized that , i f the learning-disabled ch i l d with motor dysfunction could be taught to use the word processor as an adjunct to pract ise of handwritten output, the improved l e g i b i l i t y of the l e t t e r s and words would f a c i l i t a t e consistent decoding by the student of his own work, re inforc ing acqu i s i t i on of early reading s k i l l s . 30 A systematic t ra in ing method which incorporated knowledge of the c h i l d ' s learning d i s a b i l i t y as well as the nature of motor dysfunction was required in order to f a c i l i t a t e the student 's approach to the complex task of keyboarding and word processing. 31 CHAPTER 4 METHOD Subjects Three boys, aged 6.9 to 8.10 years of age served as subjects. The diagnosis of motor dysfunction was based on each c h i l d ' s medical h i s tory, medical diagnosis and motor assessment. A l l three boys had h i s tor ies of slow motor development and poor academic performance. Two of the boys had been diagnosed with minimal cerebral palsy and were receiving weekly occupational therapy at school from a community-based therapy agency. A review of the records of the school performance of each student showed discrepant s k i l l s in psychological test ing and documentation of e r r a t i c c l i n i c a l p ro f i l e s of learning and a t tent ion . The boys' handwriting s k i l l s were poor and reading levels were two years behind for two of the subjects, and showed delayed acqu i s i t i on for the youngest subject, who was in Grade One. Written approval for conducting the study was obtained from the pr inc ipa l of the school which the subjects attended. Once wr i t ten approval was obtained, the parents were sent information l e t t e r s and consent forms. In order to comprehend the nature and et io logy of the c h i l d ' s motor dysfunction, a deta i led examination of each c h i l d ' s medical and developmental h istory was undertaken. The de ta i l s of the case h i s to r ie s are presented in the Appendices (see Appendix A, F and K), and the relevant features w i l l be presented in th i s chapter. 32 Subject #1 Name: C M . Date of B ir th: July 28, 1977 Chronological Age: 8.10 years Date: June 1, 1986 C M . was apprehended at birth as a result of his natural parents' non- compliance to methadone therapy for their heroin addiction. He was treated for severe heroin withdrawal during his f i r s t weeks of l i f e and was discharged from Intensive Care to foster care. C M . had neurological and behavioral sequelae as a result of his prenatal birth history and was followed closely during infancy and early childhood by a medical team of special is ts . He was diagnosed with minimal cerebral palsy and exotropia of the left eye, receiving ongoing physiotherapy, infant stimulation and speech therapy. C M . demonstrated ongoing delays in motor, adaptive, language and behavioral s k i l l s . He was noted to be i r r i t a b l e , resistant to introduction of new toys or different ways to manipulate familiar materials. C M . developed nocturnal seizures at 2% years of age and was placed on medication. He is s t i l l on medication for seizure control . C M . attended special needs pre-school, but went onto an integrated day care setting with a 1:1 special needs worker. He spent his kindergarten year in the day care program and was integrated into the kindergarten class at his local school for the last three months. He then repeated kindergarten on a ful l-t ime basis, the following year. C M . was referred to occupational therapy for evaluation of his fine motor and perceptual motor development. He was noted to be d is tract ib le in school, had problems with prehension, and poorly established hand dominance and poor basic concepts. Visual motor s k i l l s were s ignif icantly poor (VMI: 33 2.10 years, at a chronological age of 5.6 years and Motor Accuracy scoring at 2.1 standard deviation below the mean). CM. was referred for ongoing occupational therapy at a community therapy agency. Psychological testing (September 1983) found the boy's behavior and functioning pattern to resemble that of a severely learning-disordered youngster. His educational needs required a highly individualized program in a setting designed for students with multiple learning handicaps. Pr ior i t ies for planning were on controll ing behavior, increasing attention span, development of perceptual and cognitive ab i l i t i e s and acquiring basic academic s k i l l s . The recommendation was made that the multisensory approach be used extensively. CM. was placed in a small class setting at his local school the following year. He continued to demonstrate poor printing and visual motor s k i l l s . Reversals and sequencing errors persisted in his printing and organization of letters into word groupings, and spacing between words were areas of d i f f i c u l t y . Attentional def ic i t s continued to interfere with learning and output. Subject 12 Name: O.R. Date of Birth: August 3, 1979 Chronological Age: 6.10 years Date: June 1, 1986 O.R. is the youngest son of a single parent who has a university education and works in the Computer Systems Technology f i e l d . 34 When O.R. was i n i t i a l l y diagnosed with minimal cerebral palsy and b i l a te ra l club feet , his mother raised funds from various service clubs in order to take him for patterning therapy at the In s t i tu te for the Achivement of Human Potential in Ph i lade lph ia, Pennsylvania. O.R. spent his kindergarten year at a Special Needs Day Care where he exhibited a discouraged approach to tasks and had d i f f i c u l t y with a c t i v i t i e s requir ing f ine motor cont ro l . Day Care recommendations on graduation noted that areas for improvement were w r i t i n g , pencil con t ro l , se l f -conf idence, and alphabetic and numerical sequences. Psychological test ing placed O.R. with in the normal range with poor perceptual motor performance and visual motor in tegrat ion . At the end of Grade One, O.R. s t i l l required 1:1 assistance for f i ne motor s k i l l s , had no real understanding of numbers greater than ten, and was reading at the th i rd level of the Ginn Reading program. The ch i l d was s t i l l quite play- oriented and the school-based team recommended retent ion. Subject #3 Name: I.R. Date of B i r t h : October 18, 1977 Chronological Age: 8.7 years Date: This boy's h istory of English as a second language, b i l a t e r a l conductive hearing loss and extended school absenteeism have complicated the in terpretat ion of his results of psychological and language te s t i ng . His performance s k i l l s were noted to f a l l into the low average range and verbal performance was affected by his ESL background and was not f e l t to be i nd i ca t i ve of his potent ia l . I.R.'s visual motor a b i l i t i e s f e l l at the 3 r d % i l e on the Test of Visual Motor Integration at a chronological age of 5.10 years. He had d i f f i c u l t y fol lowing instruct ions and had poor coordination in c ra f t a c t i v i t i e s . He was noted to have spec i f i c weakness in language and f ine motor areas. I.R. was placed in an Observation Class a f te r an unsuccessful kindergarten year and was placed in a Junior Learning Assistance Class the fol lowing year, as he required a small c lass se t t i ng . Pr int ing was poor and he had trouble with spacing between the words. He was described as d i s t r a c t i b l e and continued to work at a low reading l e v e l . Summary Three boys with learning d e f i c i t s , motor dysfunction, visual motor integrat ion d i f f i c u l t i e s and poor p r i n t i ng , who were reading at an early Grade One l e v e l , acted as subjects in th i s study which took a case history approach to examine the appl icat ions of teaching keyboarding s k i l l s on a word processor to chi ldren with learning and motor dysfunction. Subject #l ' s medical history revealed the most severe motor involvement with abnormal ga i t , immature prehension, poorly established hand dominance and severe d i f f i c u l t y with visual motor in tegrat ion. Subject #2 had a moderate amount of motor d i f f i c u l t y with f ine motor d e f i c i t s , poor pencil s k i l l s and visual motor delay. Subject #3 presented with a motor s k i l l delay in f ine and gross motor areas, but the medical and developmental h istory did not ind icate spec i f i c neurological involvement. 36 Design Given the unique cognitive-motor prof i le s of the population under consideration, an experimental design approach to the problem was i n s u f f i c i e n t . The number of students in the study was very smal l , and on close scrut iny of the academic and developmental h i s tor ies of each student, they were poorly matched in et iology and severity of motor dysfunction as well as academic performance. A case h istory approach was chosen to place a l l the c r i t i c a l factors a f fect ing the students into perspective. This approach also allowed the invest igator to generate insights into new hypotheses based on c l i n i c a l observations and s i tuat iona l analyses during the study. The observational data were gathered in a na tu r a l i s t i c s e t t i ng , the classroom, and provided for documentation and interpretat ion of a broad range of phenomena. A s ingle case l im i ted time series was u t i l i z e d to examine the ef fects of the word processing intervention on a block sequencing task, measuring successive processing. These results formed one aspect of the data obtained during the study. The design was chosen because of the small number of subjects as well as the unique nature of the cognitive-motor p ro f i l e s of the indiv idual subjects (Hersen and Barlow, 1976). The study was presented with in the case history format and included an ABAB intervent ion design. Each phase lasted two weeks and eight contacts were made with the students in each phase. The A phase provided a baseline measurement of performance on the dependent va r i ab le , Knox Cubes, a block sequencing task. Testing of the dependent var iable was administered da i l y . 37 During the B phase, the block sequencing task administration continued and the 'Write to Read' intervention (Nash and Geyer, 1981) was introduced using the classroom word processor as a wr i t ing t o o l . The effects of the intervention are ref lected i f performance on the dependent variable shows a stable, pos i t ive trend during the B phases of the design (Towney and Gast, 1984). The intervent ion was withdrawn a f te r two weeks and the A phase was reintroduced for the next two weeks in order to reestabl i sh baseline performance of the dependent var iab le. The l a s t B phase reintroduced the 'Write to Read' in tervent ion, in order to determine i f the student 's a b i l i t y to perform a sequencing task would be affected by the keyboarding task. Comparison between phases was afforded by the ABAB design. Spec i f i c data co l l e c t i on as to b i l a t e r a l hand use, pos i t ion ing, appl icat ion of word processor command sequences and visual recognition of errors was made da i l y during the intervent ion B phases and recorded under ' C l i n i c a l Observations ' . Daily scoring of l e t t e r s per minute and errors in typed and handwritten samples was also done during the B phases of the design. The students were assessed to determine baseline performance on the Bruininsks-Oseretsky Test of Motor P ro f i c iency , Durrel l Reading Analysis and the Developmental Test of Visual Motor Integration (VMI). The Word Analysis subtest of the Durrel l Reading Analysis was readministered at the end of the study. In order to teach the word processing and keyboarding s k i l l s e f f e c t i v e l y , and to develop an approach consistent with theoret ica l considerations for teaching learning-disabled students, a task analysis approach based on the simultaneous and successive processing model was 38 taken. A meaningful, conceptual framework was applied to the keyboard display and reinforced by cueing to reinforce motor learning. Measures The Bruininsks-Oseretsky Test of Motor Proficiency was used to provide a comprehensive battery of subtests to assess motor function. The Developmental Test of Visual.Motor Integration (VMI) was used to provide a measure of visual motor integration. The Durrell Analysis of Reading Difficulty was used to assess reading levels and to provide insight into the children's word analysis ability. The word analysis subtest was readministered at the end of the study. Knox Cubes, a subtest of the Arthur Point Scale of Performance, was utilized to act as a measure of successive processing. Bruininsks-Oseretsky Test of Motor Proficiency This battery is comprised of eight subtests which measure gross and fine motor aspects of motor development. The subtests measure: Running Speed and Agility, Balance, Bilateral Coordination, Strength, Upper Limb Coordination, Response Speed, Visual Motor Control, and Upper Limb Speed and Dexterity. Performance on these subtests is expressed as a gross motor composite, a fine motor composite and a battery composite. These scores can be expressed in standard scores or percentiles. Performance on subtests is expressed in standard scores, age equivalents and stanines. The mean of the standard score measurement is 15 with a standard deviation of 5. 39 Evidence of construct v a l i d i t y i s presented in the manual based on cor re la t ion of test scores with chronological age (.57 to .86 with a median of .78), internal consistency of the subtests (between item point scores and subtest point scores: median range of .65 to .87 and between item point scores and tota l point scores: median range of .86 to .56, and factor analysis of the subtest items with varimax ro tat ion . The manual presents studies which indicate that normal subjects perform s i g n i f i c a n t l y better than populations of mi ld ly retarded, moderately to severely retarded and learning disabled subjects. These learning disabled students were c l a s s i f i e d on the basis of enrollment in special education programs and were two years below grade leve l in reading. Populations in these studies were small (^ 100 subjects). R e l i a b i l i t y was established through te s t - re te s t r e l i a b i l i t y coe f f i c i en t s and standard error of measurement. These were found to be sa t i s fac tory (Bruininsks, 1978). Developmental Test of Visual Motor Integration (VMI) This i s a measure of visual motor integrat ion and " i s a sequence of twenty-four geometric forms to be copied with pencil on paper (Beery, 1982, p. I D . Studies to determine i n te r ra te r r e l i a b i l i t y , t e s t - re te s t r e l i a b i l i t y have found the r e l i a b i l i t y to be good (Beery, 1982). The VMI correlates well with chronological age (.89) and motor s k i l l (.76). The cor re la t ion between the VMI and readiness tests has ranged around .50 (Beery, 1982). 40 Raw scores are converted into percent i le ranks, standard scores and age equivalents. Standard scores have a mean of ten with a standard deviation of three. Durrel l Analysis of Reading D i f f i c u l t y This comprehensive assessment allows the examiner to observe and analyze the student 's d i f f i c u l t i e s in oral reading and word recognit ion. The analysis provides assessment and measurement of ten areas of reading a b i l i t y : Oral Reading, S i l en t Reading, Listening Comprehension, Word Recognition/Word Analys is , L istening Vocabulary, Pronunciation of Word Elements, Spe l l i ng , Visual Memory of Words, Auditory Analysis of Words and Word Elements, and Prereading Phonics A b i l i t i e s Inventories. The authors state that i t s v a l i d i t y i s attested to by i t s widespread c l i n i c a l use since i t s inception in 1932. Studies involving subtests used in Grade 1 reading measurement in September found corre lat ions with reading achievement at the end of the school year as fo l lows: Syntax Matching (.60), Writ ing Letters (.60), Ident i fy ing Phonemes (.60) and Naming Letters (.55). R e l i a b i l i t y studies for the grade leve l s of Oral and S i l en t Reading using reading rate as the factor for determining grade level found corre lat ions between Oral Reading of .85 and between S i l en t Reading of .80. The Kuder-Richardson Formula #21 was used to establ i sh the r e l i a b i l i t i e s of the rest of the subtests and presented a range of corre lat ions from .97 (Spell ing-Intermediate) to .63 (Visual Memory of Words-Primary). The population studied was a randomly chosen group of 200 chi ldren taken from Grades 2 to 6. 41 Knox Cubes Knox Cubes test i s a subtest of the Arthur Point Performance Scale, a measure incorporating f i ve subtests. Each subtest i s separately standardized and the scores are combined into a s ing le point scale (Buros, 1953). Jarman and Das (1980) task analyzed the Knox Cubes subtest and found i t to be a measure of successive visual processing. The dependent var iable was a s t r a t i f i e d sample of 55 items. These items were based on the Knox Cubes sequencing task. Block sequence patterns incorporating sequences of 2, 3, 4, 5 and 6 were generated at random from the pool of possible combinations and each level was equally represented in the sample. The patterns were placed on cards, shuff led and selected at random during each administration of the dependent var iab le. In th i s way, the pract ise ef fect was el iminated. The materials consisted of four 1" square cubes made out of plain wood and glued to a wooden base at ha l f - inch i n te r va l s . Verbal d i rect ions were chosen to make the instruct ions as c lear as possible. The examiner tapped the top of the f i r s t block and the second block with the index f inger and sa id: "You tap the blocks I tap. I f I tap th i s one (#1), then you tap th i s one too. " If the c h i l d did not automatically tap, then his f inger was phys ical ly moved to tape the f i r s t block and the examiner sa id : " I f I tap these (#1, then #2), which ones do you tap?" 42 The blocks were tapped at a rate of one per second. Once the ch i l d c l ea r l y understood the d i rect ions , the examiner proceeded with the test items saying: "Touch the blocks just l i k e I do." ( M i l l e r , 1982) Procedures Working at the Computer An Apple He computer and pr inter with Mi 11 iken word processing software (M i l l i k en , 1984) comprised the equipment used. The keyboard was divided into two halves, l e f t and r i gh t , by a red pencil held diagonally between T and Y, G and H, B and N. This physical bar r ie r provided t a c t i l e cueing for red i rect ing the students toward correct b i l a t e r a l hand use. A visual reinforcement of the l e f t - r i g h t keyboard s p l i t was reinforced by placing red adhesive dots on the keys "Y" , "H" and "N " . The r ight hand did not cross th i s l i n e and the l e f t hand typed a l l the keys to the l e f t of i t . At the beginning of each sess ion, the software was in place and the i n i t i a l desk graphic of the M i l l i k en program was on the screen. Students were required to access the wr i t i ng mode of M i l l i k e n , a two stage sequence including select ing the ' w r i t e ' menu from the i n i t i a l menu and then choosing ' w r i t e ' , once the menu appeared. The 'Write To Read' (Nash & Geyer, 1981) program card was placed in a stand to the l e f t of the monitor and angled for easy v i s i b i l i t y . The tutor was seated to the student 's r i ght . The student 's attent ion was then drawn to the f i r s t word of the 'Write to Read' card and he was asked to say the word in order to place the l e t t e r sequence of the word into the meaningful framework of language. I f the 43 student was successfu l , he was asked what the meaning of the word was and to put i t into a sentence i f th i s was appropriate to the understanding of the c h i l d . For example, to explain ' l e d ' as the past tense of ' l e a d ' was considered too complex. The student then typed a l i n e of each word fol lowing the same procedure. As he typed the tutor provided the phonetic associat ion with the i n i t i a l consonant or blend and the word ending in order for the student to hear the sound-symbol assoc iat ion. For example, the word ' r ed ' was sounded out ' ruh-ed ' by the tutor for the f i r s t three t r i a l s of the typing of the series of the word. This method was consistent with the Glass analysis method for decoding which was being used in regular classroom work. I n i t i a l blends, such as ' b r i m ' , were sounded out as ' b r ' as the student typed the corresponding l e t te r s and not as ' b u h ' - ' r u h ' . The student then typed the sentence from the 'Write to Read' card, having f i r s t sounded out and read the sentence. Errors in spacing or typing were brought to the student's attent ion i f he did not observe them himself and he was asked to use the arrows to move the cursor and the delete functions in order to correct the sentence. The student then typed the sentence again without intervention from the tutor and was expected to recognize his own errors in typing and spacing and correct them. This sentence was timed by the tutor and scored for errors of l e t t e r s and spacing. The student then printed his work on the p r in te r , a four stage sequence which involved going back to the desk graphic menu, se lect ing 'T ' for type menu, se lect ing the correct response on the type menu (#4) and pressing ' r e t u r n ' to act ivate the pr in ter . 44 Once the work was typed, the student then wrote the sentence again in his own handwriting and th i s was also timed by the tutor and scored for errors of l e t t e r s and spacing. If the student could not say the word, i t was decoded by the tu to r . For example, " 'RED 1 , The f i r s t l e t t e r says ' r u h ' . These l e t t e r s say ' e d ' . Ruh-ed. Red." I f the student did not know the meaning of the word, the tutor gave him an example, in order to place the l e t t e r sequence of the word into a meaningful framework of language. I f the student was unable to provide a sentence using the word, the tutor provided a sentence in order to give meaning to the word in the context of a sentence. The students were oriented to the visual map of the keyboard by t e l l i n g a s imp l i f i ed version of the Keyboard Town Story (Gallagher, 1961) at points B#l and B#5 of each B phase a tota l of four times during the intervention phases, placing emphasis on the i n i t i a l consonant of the words chosen to represent the l e t t e r keys (banana, buh; tough, tuh) . Directions regarding the way, way uptown keys were not given (%, $, #). The major emphasis was on the locat ion of the downtown, Home Keys Street, uptown and the diagonal road cutt ing through the town. The cues 'downtown, Home Key Street, uptown and Mr. Qwert's house' were used when necessary to l i m i t the scanning time taken by the ch i l d to locate the l e t t e r keys. Detai ls of the Keyboard Town l e t t e r keys ( i . e . , Sad Sam, Frank and George) were not used as cues during the typing of the Write to Read words 45 and sentences, as th i s was judged to be potent ia l l y confusing to the students. Cueing for which hand to use for which l e t t e r key was provided by presenting the physical bar r ie r to the hand as i t t r i e d to cross the l i ne and the words, 'Try the other hand'. I f necessary, the words "This hand types on the l e f t side of the l i n e , th i s hand types on the r ight side of the l i n e , " were reinforced with a tap on the dorsum of the corresponding hands. Verbal and t a c t i l e cues were provided together or simultaneously or not at a l l , according to the judgement of the tu to r . Later on in the program, the students were asked to decide themselves which hands were to be used co r rec t l y . 46 CHAPTER 5 RESULTS Analysis of Dependent Variable Data This evaluation was done through visual analysis of mean level lines and trend lines (using the s p l i t middle method) for stability or vari a b i l i t y . The effects of the intervention were reflected i f performance on the dependent variable showed a stable positive trend direction during the intervention (B) phases of the design (Towney and Gast, 1984). The data from measurements of the dependent variable were plotted on line graphs to allow visual inspection of changes of levels and trends of performance across the phases of the time series. Using a fifteen percent (15%) s t a b i l i t y criterion, the acceptable s t a b i l i t y range for levels and trends was calculated on the highest data point value of each of the phases. Eighty-five percent (85%) of the data points must f a l l within the acceptable criterion range for the trend to be considered stable (Towney and Gast, 1984). Statistical analysis was done using the "C s t a t i s t i c " treatment of the data (Tryon, 1982). Subject #1 Discussion of Test Results CM. scored below the f i r s t percentile of the battery composite of the Bruininsks-Oseretsky Test of Motor Proficiency. Gross and Fine Motor Composite scores also f e l l below the f i r s t percentile. He had a history of 47 epilepsy and continued to take medication. He had retained some pr imit ive movement patterns associated with minimal cerebral palsy (see video, Appendix E). A l l subtest scores were markedly below the mean (see Appendix C) and ind icat i ve of gross and f ine motor coordination d e f i c i t s . The Developmental Test of Visual Motor Integration placed CM . below the th i rd percent i le (see Appendix C). The Durrel l Reading Analysis placed C.M.'s reading s k i l l s at the low Grade One level with the exception of the Sounds in I so lat ion subtest which was performed at the mid Grade One l e v e l . CM. was given a l e t t e r grade of ' B ' in the Pre-reading Phonics A b i l i t i e s Inventories (see Appendix C). Performance on the Word Recognition/Word Analysis subtest showed that CM . recognized two words on the f lash phase and no further recognition of any words on the analysis phase, although he was able to reca l l the i n i t i a l consonant of each word during the f lash phase. CM. pronounced the phoneme of the i n i t i a l consonant and then substituted another word beginning with the same i n i t i a l consonant during the analysis phase of the word l i s t . The Word Recognition/Word Analysis subtest was readministered at the end of the study. CM . recognized seven words in the word l i s t and decoded one more word (morning) during word analys i s . His approach to analysis was e r r a t i c , but he attempted to break the words down, being unable to combine the sounds back into words (father = f a t - r ) . On other examples, CM . added extra sounds (tree = t-o-eek, name - nam-k-eek). 48 On one example, CM. looked at the f i r s t and l a s t l e t t e r , and made a guess based on that configuration (sleep = stop. 'That ' s s, tha t ' s p, s t o p . ' ) , subst i tut ing one of his sight words. On retest ing at the end of the program, C.M.'s overal l performance on th i s subtest placed him at the low Grade One level with a quant itat ive gain in decoding s t rateg ies , but no r e l i a b l e word analysis s k i l l s emerging. His sight word vocabulary had improved. Cl in ica l Observations During Word Processing CM. a C.M.'s task approach was impulsive, and he demonstrated an i r r i t a b l e and f rustrated a f fec t which swung quickly to recognition re f lex laughter when he was successful with a strategy or made a connection between events. He was d i s t r a c t i b l e and fatigued ea s i l y . I n i t i a l l y , he started every statement with a refusal to attempt the task, followed by an immediate attempt at the task. CM. was re t i cent to t r y a new approach to problem-solving and th i s was pa r t i c u l a r l y noted in his d i f f i c u l t i e s conceptualizing the function of the return key to i n i t i a t e the next l i n e as opposed to the use of the d i rect iona l arrows, preferred use of the CAPS LOCK key instead of the sh i f t key for c a p i t a l i z a t i o n , and delet ion of ent i re words for correct ion in l i e u of the use of the d i rec t i ona l arrows to move the cursor in and out of the words, with delet ion and in ser t ion of s pec i f i c l e t t e r s or spaces using the space bar. He struggled to master cursor movement using the d i rec t iona l arrows as he had d i f f i c u l t y with grading his pressure on the keys, and th i s made locat ing the cursor at s pec i f i c locat ions on the screen i n i t i a l l y quite 49 d i f f i c u l t . He had no d i f f i c u l t y understanding where to place the cursor in order to make a change on the screen. C.M.'s f a c i l i t y with cursor movement increased steadi ly throughout the study. At the end, he was observed to make appropriate choices between correct ional s t rateg ies . CM. preferred to use one hand for typing, but could be directed toward b i l a te ra l hand use in order to f a c i l i t a t e targett ing speed. This intervention was withdrawn on days when CM . was pa r t i c u l a r l y ag i tated, as i t was judged to be too intense and complex for CM. to cope with on these days. C.M.'s d i f f i c u l t y with b i l a t e r a l coordinat ion, seen in formal te s t ing , may have been the basis for th i s ret icence. He was able to coordinate hand movement for three l e t t e r words which had the i n i t i a l consonant l e t t e r key on one side of the keyboard and the other two l e t te r s on the s ide. He had d i f f i c u l t y with three l e t t e r words which required R-L-R or L-R-L sequenced hand use. CM . also appeared to be guided by the auditory, phonetic decoding strategy used during the intervent ion. For example, PEN was decoded as P-EN and CM. seemed to use one hand for P and the other for EN, typing EN as a un i t . Words of four l e t t e r sequences which were s p l i t in hal f by the L/R keyboard or ientat ion were subject to l e t t e r reversals and CM . eventually in s i s ted on a one-handed approach to these l e t t e r s in order to get them in the r ight sequence. He rejected his newer keyboarding strategy as the degree of d i f f i c u l t y of the l e t t e r sequence increased. CM. was able to correct his errors by visual inspect ion. During the f i r s t intervent ion phase he overlooked errors in spacing, c ap i t a l i z a t i on and s pe l l i n g , but by the end of the second phase, he was typing error - f ree copy. 50 This was in marked contrast to his pr int ing which was e r r a t i c , d i s torted and characterized by reversa l s , mixed upper and lower case l e t t e r s , and poor spacing between words. Inspection of errors in the handwritten sample was impulsive and unre l i ab le . CM. had mastered the word processing commands at the end of the second intervent ion. The command sequences required reinforcement at the beginning of the second intervent ion, as they had not been retained completely during the second baseline phase. D i f f i c u l t i e s with l e t t e r recognition (b/d, 1/i) persisted during word processor use, but output of reversed l e t t e r s was eliminated and the- consistent appearance of the l e t t e r s allowed CM . a better opportunity to correct his errors by visual inspect ion. The r e l a t i ve f a c i l i t y of correct ion on the word processor served as a basis for motivation in correct ion of errors. CM. i n i t i a l l y was confused about typing lower case l e t t e r s from upper case keys. He had some d i f f i c u l t y scanning for l e t t e r key locations and seemed to be assisted by Keyboard Town cues. At the end of the study, CM. was spontaneously using two hands for typing. He did switch into a one-handed approach (preferr ing r i gh t , but also using l e f t ) , and was a l ternat ing one-handed and two-handed approaches during sentence copying. CM . did not show much enthusiasm for placing the words on the word l i s t into language contexts. These words and sentences were not pa r t i cu l a r l y meaningful for him. He used verbal mediation spontaneously as a strategy to guide himself through sequenced operations. 51 Mean Rates, Number of Errors and Error Types in Word Processing and Handwriting Each intervent ion phase was divided in half and the mean rate (letters/minute) for word processing and handwriting was ca lcu lated. The mean rates with in intervention phases were then compared. In the f i r s t intervention phase, Subject #l 's rate of word processing decreased by a mean rate of -0.43 l e t t e r s per minute. This r e f l ec t s a minimal decrease. In the second intervention phase, the mean rate increased by 5.37 l e t t e r s per minute (see Table I ) . The rate of word processing at the end of the second phase was highest of a l l previous rates. The word processing rate had f a l l e n o f f at the i n i t i a l phase of the second intervention (see Table I). These resu lts r e f l e c t an overal l improvement in rate of word processing and a drop in rate of output fol lowing the second baseline phase. The mean number of errors in word processing increased s l i g h t l y (0.75) during the intervention phase. No errors were noted in the B£ intervention phase ind icat ing an overa l l decrease in errors over the course of the study and mastery of the word processing aspect of the task (see Table I I ) . The mean rate of handwriting increased in intervent ion phase Bi by +2.16 l e t t e r s per minute but decreased in intervention phase 63 by -1.73 l e t t e r s per minute. The mean rate of handwriting at the end of the B2 intervent ion was the lowest of a l l previous mean rates. This represents a decl ine in handwriting speed over the course of the study (see Table I I ) . 52 The mean number of errors in handwriting increased during intervention Bi and decreased during intervention B2. The mean number of errors represents a trend of fewer errors in handwriting over the course of the study (see Table I I ) . 53 Subject #1 Table I Mean Rates (letters/minute) of Word Processing and Handwriting Intervention Phase Bl B2 (Day (Day Mean Rates X 1 9-12) X? 13-16) (Day (Day X 3 25-28) X 4 29-32) Word Processing 11.37 10.94 Handwriting 10.97 13.13 8.23 13.60 10.42 8.69 Difference Between Means ( X j - X2) ( x 3 - x 4 ) Word Processing -0.43 Handwriting +2.16 +5.37 -1.73 Table II Mean Number of Errors in Word Processing and Handwriting Samples Intervention Phase Bl B2 Mean Number _ (Day _ (Day of Errors X 1 9-12) X* 13-16) (Day (Day X 3 25-28) X 4 29-32) Word Processing 1.25 1.25 Handwriting 5.5 6.0 0 0 6.75 4.0 Difference __ _̂ Between Means ( X j - X2) ( x 3 - X 4 ) Word Processing 0.0 Handwriting +1.5 0 -2.75 54 Subject #1 Table III Error Types in Word Processing Samples Intervention Phase Bl B 2 Day 9 10 11 12 13 14 15 16 25 26 27 28 29 30 31 32 Error Free Reversals Upper Case Omissions Letter Errors Extra Letters Capi t a l i z a t i o n Errors Punctuation Errors Spacing Errors X X X X 1 1 2 2 2 1 X X X X X X X Total 1 2 0 2 2 1 1 1 0 0 0 0 0 0 0 0 55 Subject #1 Table IV Error Types in Handwriting Samples Intervention Phase Bl B 2 Day 9 10 11 12 13 14 15 16 25 26 27 28 29 30 31 32 Error Free Reversals 5 1 Upper Case 4 1 1 1 Omissions 3 4 2 Letter Errors 2 1 4 1 4 2 2 6 2 1 2 Extra Letters 1 1 Cap i t a l i z a t i on Errors 1 Punctuation Errors 1 Spacing Errors 3 2 3 5 1 3 4 5 2 1 5 2 Total 12 2 4 4 7 1 9 7 8 10 8 1 3 2 6 5 56 Subject #1 Table V Correlation of Block Sequencing Scores Between Baseline and Intervention Phases Bi B 2 .731 2.86* .92 3.10* *p .01 There was no s i gn i f i can t trend in the Ai baseline phase. There were s i gn i f i c an t trends between the f i r s t baseline and intervention phases, and between the second baseline and intervention phases. C s t a t i s t i c treatment of Ai B 2 phases was not carr ied out as th i s procedure only allows for comparison between adjacent phases (Tryon, 1982). 57 Data for Block Sequencing Task - Subject #1 Number Correct on Block Sequencing Ta«k 50 40 30 201 1« Baaelinei (A) H 1 1 1—4—| ! h Intervention) (B) H — I H 16 Baaeline? (A) Intervention? (B) H—I—h I ! 24 H — I 1—I—I 1 r 32 Days Figure 1 58 Trend Lines for Block Sequencing Task - Subject #1 Number C o r r e c t on B l o c k SO Sequencing Tank AO 30 20 10 Baoeline -J I—I—I 1 1 1 f-*-*—t i n t e r v e n t i o n ! I t Daya B a s e l i n e ? I n t e r v e n t i o n ? •4 1—1 1 1—t- - * — i — i — i — i — i — ^ — < - 16 32 Figure 2 Within Conditions Analysis Trend S t a b i l i t y Percentage S t a b i l i t y Al Stable (100%) Bl Stable (100%) A2 Variabl e (75%) B2 Variable (75%) Between Adjacent Conditions Analysis Bx/Ax A 2/Bi Change in Trend Direct ion Change in Trend S t a b i l i t y pos i t ive stable to s table negati ve stable to var iabl e B2/A2 pos i t ive var iable to var iable Percentage of Overlap of Data Points 25% 50% 12.5% 59 Mean Level Lines for Block Sequencing Task - Subject i l Ba«elinei I n t e r v e n t i o n ! B a a e l i n e i Number C o r r e c t on B l o c k SO Sequencing Teak I n t e r v e n t i o n - ; Days Figure 3 Within Conditions Analysis Level S t a b i l i t y Percentage S t a b i l i t y Range of Data Points Level Change Al Stable (100%) (21-23) +2 Bl Variabl e (62.5%) (23-34) +9 A2 Stable (87.5%) (22-26) -1 Between Adjacent Conditions Analysis Bl/Ai A2/Bx B2/A2 Change in Level (23-23) 0 (34-23) -11 (22-26) +4 B2 Variable (87.5%) (26-35) +4 60 Discussion of Visual Analysis of Graphic Data The data presented in Figure 1 represent a pos i t ive change in performance on the block sequencing task when the computer keyboard intervention (B) was i n i t i a t e d . The acceptable s t a b i l i t y range for leve l s and trends was calculated on the highest data point value of each of the phases of the time series using a f i f t e e n percent (15%) s t a b i l i t y c r i t e r i o n . E ighty- f ive percent (85%) of the data points must f a l l within the acceptable c r i t e r i o n range for the trend to be considered stable (Towney & Gast, 1984). Subject #1 established a baseline with a stable trend and stable level in the k\ phase. Introduction of the computer keyboard intervent ion (B) in the Bi phase resulted in a stable improving trend in performance on the block sequencing task. Days 9 and 10 r e f l e c t continued baseline performance. On the t h i r d day of intervention (Day 11), there was improved performance on the block sequencing task when compared to the l a s t day of the baseline condition (Day 8). Performance on the l a s t day of the f i r s t intervention (Day 16), was higher than on the f i r s t day of the intervent ion (Day 9). This indicated a pos i t ive e f fect on block sequencing during the intervent ion phase. Withdrawal of the computer keyboard intervention (B) resulted in a decaying, var iable trend in performance on the block sequencing task. There was an abrupt deter iorat ion in performance between phase Bi and phase A 2 r e f l e c t i n g a return to baseline performance upon withdrawal of the intervention program (B). This i s re f lected in the mean leve l s of both baseline phases. 61 Re-introduction of the intervention program (B) resulted in an improving var iable trend in performance on the block sequencing task. The f i r s t day of the second intervention phase (Day 26) indicated an improvement in block sequencing over the l a s t day of the second baseline phase (Day 24). The f i na l day of the second intervention phase (Day 32) showed higher performance than on the f i r s t day of the second intervent ion phase (Day 25). The mean level of the second intervention phase was higher than the f i r s t intervention ind icat ing a stronger performance in block sequencing in the second phase (Figure 3). The l a s t three data points (Days 30, 31, 32) ind icate a s t a b i l i z i n g level in performance on the block sequencing task during the second intervent ion. There was a 25% overlap in the number of correct response on the block sequencing task between conditions k\ and B j . The data points from the f i r s t two days of intervent ion (Days 9 and 10) r e f l e c t a continuation of baseline performance and thus overlap with data in condition A]_. El iminat ion of these data points from the range of data points in condit ion Bi resulted in a 0% overlap in data points and a strong pos i t ive e f fect on the block sequencing task performance during the f i r s t intervention phase. A 50% overlap in data points between conditions A 2 and Bi was seen. Data points from Days 17, 19 and 20 overlap with the i n i t i a l baseline level of condition Bi causing a greater percentage of data point overlap. El iminat ion of the baseline data points from the range of data points in Bi resulted in a 12.5% overlap. This was interpreted as a return to baseline performance and, given the change in trend d i r e c t i o n , strong negative ef fect on performance on the block sequencing task a f te r withdrawal of the intervention program. 62 Twelve and one-half percent of the data points between phases B 2 and A 2 overlapped and re f lected a marked improvement in block sequencing performance with the re- introduct ion of the intervention program (B), given the change in trend condit ion. 63 Subject #2 Discussion of Test Results O.R.'s performance on the Bruininsks-Oseretsky Battery Composite placed him below the l % i ^ e rank. The Gross Motor Composite was also below the l % i ^ e rank and the Fine Motor Composite score was at the 8 t h % ^ e . These scores were ind ica t i ve of gross and f ine motor dysfunction. Tonal anomalies consistent with minimal cerebral palsy with club feet were observed (see video, Appendix J ) . The Visual Motor Control and Upper Limb Speed and Dexterity subtest scores were within the average range; however, the Fine Motor Composite Score was pulled down by the score on the Response Speed subtest, which measures hand response to a moving visual stimulus. The Developmental Test of Visual Motor Integration resu l t s placed O.R. at the 2 5 t h % i l e rank and his copied forms showed poor spat ia l o r ien ta t ion . Results on the Durrel l Analysis of Reading D i f f i c u l t y placed O.R. at the low Grade One level on a l l subtests with the exception of L istening Comprehension, which placed him at the low Grade Three l e v e l . The Pre-Reading Phonics Inventories were scored with a l e t t e r grade of A/B. I n i t i a l performance on the Word Recognition/Word Analysis subtest showed f i v e words recognized during the f l a sh phase with no further words recognized during the analysis phase. O.R. reca l led i n i t i a l consonants, but subst i tuted word guesses beginning with the same phoneme or gave up on the word. This subtest was readministered at the end of the study. 64 O.R. now recognized nine words in the f lash phase and eight more words during analys i s . His successful analysis attempts seemed to be based on sounding.individual l e t t e r s out and combining the sounds into words. Unsuccessful, but l og i ca l attempts revealing ignorance of i r r e g u l a r i t i e s or more complex phoneme combinations included: away: a-wee, ch i ld ren: k i l u n , other: on-er. O.R.'s overa l l performance on th i s subtest placed him at the low Grade One level with quant i tat ive and qua l i t a t i ve gains in word recognit ion and analys i s . His sight word vocabulary had improved. 65 Cl in ica l Observations During Word Processing O.R. n O.R. presented as a passive ch i l d with a f l a t unresponsive a f fec t . He tended to 'come a l i v e ' verbal ly in front of the word processor, but would revert into pass iv i ty when confronted with a complex task. He had great d i f f i c u l t y with maintaining postural tone when s i t t i n g at the keyboard. This, in turn, affected his a b i l i t y to grade his hand movements and he made a l o t of grading errors in the i n i t i a l stages of the study. As a re su l t , he was required to use the cursor frequently to delete long rows of repeated l e t t e r s and required the d i rec t ion of the cursor to spec i f i c locat ions. The rearrangements of O.R.'s seating helped him s i t upright and seemed to improve his a b i l i t y to grade his f inger pressure. This ch i l d took every opportunity to lean against something for postural support. O.R. i n i t i a l l y preferred to use one hand for ta rget t ing , but responded to cueing, seeming pa r t i cu l a r l y responsive to t a c t i l e cues in the ear ly stages of the intervent ion. He did not require any d i rec t ion for b i l a t e r a l hand use in the study. O.R. seemed to understand the word processing commands, but had some d i f f i c u l t y remembering the sequences. He frequently sought adult assistance and was subsequently encouraged to f i nd his answer on the visual d i sp lay, and even to make a few errors in order to f ind his way through the command sequences. O.R. had d i f f i c u l t y with three l e t t e r words requir ing a l ternate hand sequences and four l e t t e r word sequences were i n i t i a l l y subject to reversed order. O.R. managed to persevere with the two-handed approach and correct 66 reversal errors with visual inspect ion, using the d i rect iona l arrows to lcate the correct ive cursor at spec i f i c locat ions. On occasion, he used a tota l delete approach to correct, but generally used the more complex strategy. O.R.'s pr int ing was poorly organized in space, but did not include reversals or gross d i s t o r t i on s ; however, the lack of spacing made the handwritten samples d i f f i c u l t to read. He made errors in c ap i t a l i z a t i o n in the written sample and l e t t e r s ize was very incons istent, g iv ing the appearance of cap i ta l l e t t e r s in mid sentence. He tended to make punctuation periods into c i r c l e s and th i s added to the general confusion. On one lesson, O.R. used a dash between words on the wr i t ten sample to replace the space bar pos it ion in the typed copy. Most of his errors in the typed samples were spacing er rors , but at the end of the study, O.R. had typed er ror - f ree copy for four consecutive lessons. O.R. had no d i f f i c u l t y scanning for l e t t e r s on the keyboard. He enjoyed the Keyboard Town story, but never required addit ional cueing for l e t t e r key l oca t i on . O.R. read through the word l i s t s using the decoding strategy modelled by the tu to r . This evolved into a sight word response. Increased a b i l i t y on the Write to Read word l i s t s did not general ize into the classroom, according to his teacher. O.R. seemed to enjoy placing the words into a meaningful language context, and often came up with several meanings for the words. 67 Mean Rates, Number of Errors and Error Types in Word Processing and Handwriting Each intervention phase was divided in half and the mean rates (letters/minute) for word processing and handwriting was ca lcu lated. The mean rates within intervention phases were then compared. In the f i r s t intervention phase, Subject #2's rate of word processing decreased by a mean rate of -0.3 l e t t e r s per minute. This re f l ec t s a minimal decrease. In the second intervention the mean rate increased by 2.14 1etters/minute. The word processing rate had increased at the i n i t i a l phase of the second intervention and the rate of word processing at the end of the second phase was the highest of a l l the previous rates. These results r e f l e c t a steady gain in rate of word processing throughout the study. The mean number of errors decreased s l i g h t l y (-0.5) over the course of the study. 68 Subject #2 Table VI Mean Rates (letters/minute) of Word Processing and Handwriting Samples Intervention Phase B l B2 Mean Rates (Day (Day X l 1-4) X* 5-8) (Day (Day X 3 1-4) X* 5-8) Word Processing 10.51 10.81 12.53 14.67 Handwriting 12.41 9.68 10.72 16.77 Di fference Between Means (Xl - X2) (x 3 - x 4) Word Processing -0.3 +2.14 Handwriting -2.73 +6.05 Table VII Mean Number of Errors in Word Processing and Handwriting Samples Intervention Phase B l B2 Mean Number of Errors (Day _ o (Day X l 1-4) X 2 5-8) (Day (Day X 3 1-4) X 4 5-8) Word Processing 0.75 1 0.25 0 Handwriting 2 2.25 2.5 0.25 Difference Between Means (Xi - X~2) (x"3 - M) Word Processing +0.25 -0.25 Handwriting +0.25 -2.25 69 Subject 12 Table VIII Error Types in Word Processing Samples Intervention Phase Bl B 2 Day 9 10 11 12 13 14 15 16 25 26 27 28 29 30 31 32 Error Free X X X X X X X X X X Reversal s Upper Case Omissions Letter Errors 1 Extra Letters Capitalization Errors 1 1 Punctuation Errors 1 Spacing Errors 1 2 1 Total 2 1 0 0 1 2 0 1 0 0 0 1 0 0 0 0 70 Subject §2 Table IX Error Types in Handwriting Samples Intervention Phase Bl B2 Day 9 10 11 12 13 14 15 16 25 26 27 28 29 30 31 32 Error Free x X X X X X Reversals Upper Case 2 1 1 Omissions 1 1 Letter Errors 1 1 Extra Letters Cap i t a l i z a t i on Errors 1 1 1 1 Punctuation Errors 1 Spacing Errors 1 1 2 5 Total 4 1 0 3 1 0 2 1 0 6 0 1 1 0 0 0 71 Subject 12 Table X C o r r e l a t i o n o f Block Sequencing Scores Between B a s e l i n e and I n t e r v e n t i o n Phases Bl B 2 1.92* 1.03 - 1.13 .235 *p < .05 There was no s i gn i f i cant trend in the baseline phase (p .05). No other s i gn i f i c an t trends were noted between phases of the dependant var iab le. Because of the trend in the i n i t i a l basel ine, a comparison series between the k\ and B 2 phases was created to determine i f the trend in the treatment phase departed from the trend set in the baseline phase. No s i gn i f i can t trend was found. C s t a t i s t i c treatment of Ai B 2 phases was not carr ied out as th i s procedure only allows for comparison between adjacent phases (Tryon, 1982). 72 Data for Block Sequencing Task - Subject #2 Baseline (A) Number Correct on Block 501 Sequencing Task AO 30 20 1« Interventioni (B) Baseline? Intervention? CB) i 6 .24 36 Days Figure 4 73 Trend Lines for Block Sequencing Task - Subject #2 Baseline) timber Correct oo Block SO Sequencing Task 40 30 20 10 - 1 — i — i — * — i — r - Interventioni -I 1—t r- Days Baseline-? Intervention? H—<r 16 -* 1 r- 24 Figure 5 Within Condition Analysis 32 Trend S t a b i l i t y Percentage S t a b i l i t y Al Stable (100%) Bl Variabl e (50%) A 2 Variabl e (50%) B 2 Variable (52.5%) Between Adjacent Conditions Analysis Bl/Ai A 2 /B i Change in Trend Direct ion Change in Trend S t a b i l i t y negative stable to var iable pos i t ive var iab le to var iable B 2 /A 2 pos i t ive var iable to variabl e Percentage of Overlap of Data Points 87.5% 62.5% 100% Mean Level Lines for Block Sequencing Task - Subject #2 74 B a a e l i n e i I n t e r v e n t i o n B a a c l i n c ? Intervention-) lumber Correct in B l o c k 50 Sequencing :««k Daya Figure 6 Within Conditions Analysis Level S t a b i l i t y Percentage S t a b i l i t y Range of Data Points Level Change Al Variable (50%) (23-32) +9 Bl Variabl e (37.5%) (25-36) -6 A 2 Variable (0%) (15-31) -15 B 2 Variable (62.5%) (18-30) +3 Between Adjacent Conditions Analysis B l / A l A 2 /B! B 2 /A 2 Change in Level (32-32) (26-31) (16-23) 0 +5 +7 75 Discussion of the Visual Analysis of Graphic Data The data presented in Figure 4 do not represent any pos i t ive change in the performance of the block sequencing task when the computer keyboard intervention (B) was introduced. Subject #2 was i n i t i a l l y intr igued by the block sequencing task, but lo s t interest during the course of the study. The data seemed to r e f l e c t his motivation or attent ion to the task rather than his block sequencing a b i l i t y . The acceptable s t a b i l i t y range for levels and trends was calculated on the highest data point value of each of the phases of the time series using a f i f t een percent (15%) s t a b i l i t y c r i t e r i o n . E ighty- f ive percent (85%) of the data points must f a l l within the acceptable c r i t e r i o n range for the trend to be considered stable (Towney & Gast, 1984). The data points in the k\ phase showed a stable improving trend with the data on Day 8 showing a higher value than the data on Day 1. This indicated that Subject #2 f a i l e d to estab l i sh a baseline performance on the block sequencing task pr ior to the f i r s t intervent ion phase. Introduction of the intervention program (B) produced a var iab le , decaying trend in block sequencing performance. The data on Day 15 reached an i so lated peak, but did not r e f l e c t the overal l change in trend d i rect ion between phases: pos i t ive to negative. This did not r e f l e c t a change in the d i rec t ion of the intervent ion object ive. Performance on the l a s t day of intervention (Day 16) was lower than on the f i r s t day of intervent ion (Day 9). This indicated a negative e f fect on block sequencing performance during the intervention phase. 76 Withdrawal of the computer keyboard intervention (B) resulted in an improving var iable trend in block sequencing performance. Again, th i s contrary to the ant ic ipated d i rect ion of trend of data. There was a drop in performance on Days 17, 18 and 19, but th i s improved only to drop o f f again on Day 24. Subject #2 f a i l e d to establ i sh a baseline in e i ther baseline phase of the time series design and the mean level in the second intervention was lower than the mean level of the f i r s t intervent ion. The second intervention phase showed an improving but var iable trend in performance on the block sequencing task. The data point of f i r s t day of the second intervention phase (Day 25) was higher than the data point of the l a s t day of the second baseline (Day 24), and performance continues to improve on Day 26, which was in the d i rec t ion of the ant ic ipated trend of data points, but performance deteriorated in the fol lowing days. Although there was some improvement in performance, the mean level of performance in the second phase never reached the mean level of the f i r s t phase ind icat ing poorer performance on the block sequencing task in the second intervent ion phase. 77 Subject #3 Discussion of Test Results IR scored at the 4th percentile on the battery composite of the Bruininsks-Oseretsky Test of Motor Proficiency and this was indicative of significant dysfunction. The Gross Motor Composite score was at the l /o 1 "' e . Balance being a subtest of particular weakness and strength subtest falling within the average range. All other gross motor subtests fell below the mean (see Appendix M). Upper Limb Coordination was within normal limits, this subtest measures ball skills and fine coordinated hand movement. The Fine Motor Composite placed IR at 7%^e, with visual motor control, and upper limb speed and dexterity scoring in the average range. The score on response speed was very low and may have affected the composite score. Given IR's history of middle ear infection, the observer may question if there were longlasting effects on IR's balance and if this could be the basis for IR's poor gross motor performance. Bilateral coordination was also an area of weakness. Complex language demands of the test instructions may have played a part in the subtest performance, but clinical observation (see video, appendix) indicates difficulty with motor planning and motor sequencing. Results on the VMI place IR below the 3rd percentile. Although IR's printing is appropriately sized and fairly legible, this ability does not seem to have generalized to the copying of unfamiliar forms. IR was slightly impulsive and tended to rush through the task and this may have affected his performance somewhat. 78 Form 11 on the VMI revealed segmentation at the mid point, ind icat ing some d i f f i c u l t y with crossing midl ine (Beery, 1982). Raw scores convert to an age equivalent of 5.7 years at a chronological age of 8.7 years. The majority of subtests on the Durrel l Reading Analysis place IR at the low to mid Grade One l e v e l , with L istening Comprehension and Listening Vocabulary, as areas of re l a t i ve strength, scoring at the low Grade Two l e v e l . It should be noted that these areas came out as strengths in a 1:1 test ing s i tuat ion and may not r e f l e c t the boy's classroom performance in view of his documented conductive hearing l o s s . IR performed at the low Grade One level on the subtests measuring sounds in I so lat ion and Sounds in Words. Visual Memory of words and word recognition subtests were s l i g h t l y better at the mid Grade One level and ind icat ing that IR may have made most gains using a sight word approach to reading. IR scores at the low Grade One level on the Word Recognition/Word Analysis subtest. He recognized f am i l i a r sight words on the i n i t i a l recognition phase, but did not succeed in reading any other words on the analysis phase of the subtest. While IR recognized and reca l led the i n i t i a l consonants of the words, he was unable to i den t i f y in the recognition phase. He tended to subst i tute another word beginning with the same consonant with no regard for word form (father = fun, mother = morning, tree = the). He did t r y 'away' ( 'ow') but was unable to complete the word. IR did not recognize consonant blends (sleep = see, tree = the) or ' c h ' (chi ldren = c ) . 79 IR tended to be anxious and impulsive throughout th i s part of the assessment, and th i s may have affected his performance. Reassessment on the Word Recognition/Word Analysis subtest at the end of the intervention placed IR at the low Grade One l e v e l . Qua l i tat ive examination of his approach to the task reveals that he was able to recognize four more words on L i s t A (Grade One reading leve l ) and made enough progress on the analysis of L i s t A to begin L i s t 1 (above Grade One reading leve l ) where he recognized three words. IR tended to look at the whole word (father = fa - r ) and to attempt more d i f f i c u l t words (morning) during ana lys i s . He made more e f fo r t to work through words using consonant blends during analys is (seep = s leep, drets = dress) and t r i e d to work out the ' c h ' sound (chair = cup-ch-chop), although not always co r rec t l y (pleased = p l a s t i c , p l a s te r ) . IR was w i l l i n g to r i s k making errors . He s t i l l u t i l i z e d his o r i g ina l strategy of i n i t i a l consonant recognition and guessing the rest of the word (around: afternoon), but th i s had extended to use of consonant blends (breakfast; b r - b i r d , pleased; p l a s t i c , p l a s te r ) . He was very attent ive and impul s iv i ty had diminished. IR was w i l l i n g to r i s k making errors on the reassessment of Word Analys i s , although his performance s t i l l placed him at the low Grade One reading l e v e l . 80 Cl in ica l Observations During Word Processing IR #3 I.R. i n i t i a l l y presented with a f l a t a f fect and made l i t t l e eye contact with the tutor. As he experienced success on the word processor, he became more spontaneous in his manner. He mastered the word processing sequences rap id ly , having had some previous experience on the classroom computer. I.R. i n i t i a l l y preferred a one-handed approach, but switched eas i l y to b i l a t e r a l hand use. He required minimal cueing, and typed three and four l e t t e r sequences with equal f a c i l i t y , a l ternat ing hands ea s i l y . I.R. tended to type rapidly and made i n i t i a l spacing er ror s . These were corrected by visual inspection without cueing. He tended to delete the whole word i f he discovered the error before he had typed ahead any distance. I f his error was imbedded in the middle of a sample, he used the more complex method of cursor movement, using the d i rect iona l arrows. This strategy was quite pragmatic. I.R.'s handwriting was l eg ib le and well spaced. He tended to mix upper and lower case l e t t e r s in his wr itten samples. I.R. frequently l e f t out ent i re words in the handwritten sentence and could not recognize his errors on visual inspect ion, although he recognized them eas i l y on the typed sample and did not omit words at a l l when typing. I.R. part ic ipated well in placing the words in a meaningful language framework. He was quite concrete in his approach to sentence formation, tending to choose one format and apply i t to every word (I am a . . . . , A can . . . . ) . I.R. enjoyed the Keyboard Town story, but did not require further cueing for l e t t e r key loca t ion . 81 Discussion Each intervention phase was divided in hal f and the mean rate ( le t te r s /minute (1pm)) for word processing and handwriting was ca lcu lated. The mean rates within intervention phases were then compared. In the f i r s t intervention phase, Subject #3's rate of word processing was stable (-.03 1pm) and handwriting rate decreased by -6.39 1pm. In the second intervent ion, the mean rate of word processing increased by 7.24 1pm and handwriting increased by 3.09 1pm. The word processing and handwriting rates had increased at the i n i t i a l phase of the second intervent ion, and the rate of both handwriting and word processing at the end of the second phase was the highest of a l l previous rates. These results r e f l e c t a steady gain in rate of word processing and an overa l l gain in rate of handwriting. It i s not c lear what may have caused the drop in handwriting rate at the end of the f i r s t intervent ion, although Subject #3 may have been overly precise in his handwriting attempts during th i s time and th i s may have taken more time. The mean number of errors remained f a i r l y stable across the intervention phases with a minimal gain (+0.25) in error rates in handwriting and word processing in the f i r s t intervent ion phase and error free copy in the word processing sample of the second intervention phase. There was a s l i gh t gain in error rates in the handwriting sample (+0.5) in the second intervention phase and th i s may have ref lected some small error increases due to increased speed of output in handwriting. 82 Subject #3 Table XI Mean Rates (letters/minute) of Word Processing and Handwriting Samples Intervention Phase Bl B2 (Day (Day Mean Rates X1 9-12) X? 13-16) (Day _ (Day X3 25-28) X4 29-32) Word Processing 13.47 13.44 Handwriting 21.67 15.28 18.58 25.82 25.17 28.26 Difference _ _ Between Means (X̂  - X2) (X~3 - H) Word Processing -.03 Handwriting -6.39 +7.24 +3.09 Table XII Mean Number of Errors in Word Processing and Handwriting Samples Intervention Phase Bl B2 Mean Number — (Day — (Day of Errors X* 9-12) X2 13-16) - (Day (Day X3 25-28) X4 29-32) Word Processing 0 0.25 Handwriting 2.5 2.75 0 0 1 1.5 Difference _ _ Between Means (Xj - X2) (x~3 - H) Word Processing +0.25 Handwriting +0.25 0 • +0.5 83 Subject #3 Table XIII Error Types in Word Processing Samples Intervention Phase Bl B2 Day 9 10 11 12 13 14 15 16 25 26 27 28 29 30 31 32 Error Free Reversals Upper Case Omissions Letter Errors Extra Letters Capitalization Errors Punctuation Errors Spacing Errors X X X X X X X 1 X X X X X X X X Total 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 84 Subject #3 Table XIV Error Types in Handwriting Samples Intervention Phase Bl B2 Day 9 10 11 12 13 14 15 16 25 26 27 28 29 30 31 32 Error Free Reversals Upper Case Omissions Letter Errors Extra Letters Capitalization Errors Punctuation Errors Spacing Errors X 4 3 2 2 1 2 1 1 1 1 1 1 1 X X X 2 1 1 1 1 1 Total 3 2 0 5 4 2 3 2 1 1 1 1 0 0 2 1 Subject #3 Table XV Correlation of Block Sequencing Scores Between Baseline and Intervention Phases Bl B 2 1.99* .812 - .482 .752 *p ^ . There was no s i gn i f i cant trend in the h\ baseline phase (p <C .05). This occurred because Subject #1 was not attending to the task and the examiner intervened strongly. Subject #1 then appeared to comprehend the language demands of the task. Because of the trend in the i n i t i a l basel ine, a comparison series between the A} and Bi phases was created to determine i f the trend in treatment phase departed from the trend set in the baseline phase. No s i gn i f i can t trend was found. 1 C s t a t i s t i c treatment of A 2 B 2 phases was not carr ied out as th i s procedure only allows for comparison between adjacent phases (Tryon, 1982) 86 Data for Block Sequencing Task - Subject #3 Figure 7 Lines for Block Seouenring Task - Subject #3 87 Base l i n e I I n t e r v e n t i o n i Number C o r r e c t on B l o c k 50 Sequencing T a l k 40 30 20 -I 1 1 1 ) I . . I 1- I 3 B a s e l inc? I n t e r v e n t i o n ? 16 Days Figure 8 24 . 32 Trend Di rect ion Trend S t a b i l i t y Percentage S t a b i l i t y Improving Variable (75%) Bl Improving Var iable (75%) A 2 Improving Variable (75%) B 2 Zero Cel1eration Variable (62.5%) Between Adjacent Conditions Analysis Change in Trend Di rect ion Change in Trend S t a b i l i t y Percentage of Overlap of Data Points Bl/A2 None Variable to Variable 12.5% A2/B1 None Variable to Var iable 37.5% B 2 /A 2 Decaying Variable to Variable 37.5% 88 Mean Level Lines for Block Sequencing Task - Subject #3 B a a e l i n e I n t e r v e n t i o n B a a e l i n e ? Nunber C o r r e c t on B l o c k SO Sequencing Task I n t e r v e n t i o n ? Figure 9 Level S t a b i l i t y Percentage S t a b i l i t y Range of Data Points Level Change Variable Var iable (0%) (25%) (1-20) (25-35) +20 +10 A2 B2 Stable Variable (87.5%) (50%) (22-29) (17-35) +7 +18 Between Adjacent Conditions Analyses B l / A l A 2/B! B2/A2 Change in Level (20-20) (26-29) (29-17) 0 +3 -12 89 Discussion of Visual Analysis of Graphic Data Subject #3 was often impulsive and of f task, and the data seemed to r e f l e c t his attent ion to the task rather than his block sequencing a b i l i t y . The data presented in Figure 7 indicate a pos i t ive change in the performance of the block sequencing task before the computer keyboard intervention (B) was introduced. There was no return to baseline in the second baseline phase (A 2) when the intervention (B) was withdrawn and reintroduct ion of the intervention (B) in the second intervention phase did not produce a pos i t ive change in trend d i rec t ion as ant ic ipated. The acceptable s t a b i l i t y range for leve l s and trends was calculated on the highest data point of each of the phases of the time ser ies using a f i f t een percent (15%) s t a b i l i t y c r i t e r i o n . E i ght - f i ve percent (85%) of the data points must f a l l within the acceptable c r i t e r i o n range for the trend to be considered stable (Towney and Gast, 1984). There were two apparent baselines established in the Ai phase. This phenomenon resulted from strong intervention by the tutor to ensure that the subject understood the language requirements of the task. This intervention occurred on Day 7. The f i r s t baseline phase (Day 1 to 6) showed a stable trend with zero ce le ra t i on , that i s , no pos i t ive or negative change in d i r e c t i o n , and a stable l e v e l . The l a s t phase of the baseline (Day 7 to 8) showed an abrupt level change (1 - 20) followed by trend of zero ce lerat ion and stable l e ve l s . This second baseline may have been a more accurate r e f l e c t i on of the baseline leve l s of Subject #3's performance as i t occurred a f te r the t u t o r ' s intervention to estab l i sh the language requirements of the task. 90 Introduction of the intervention program (B) on Day 9 produced a pos i t ive var iable trend with 75% s t a b i l i t y of data points. This ref lected an improvement in performance on the block sequencing task which was in the d i rec t ion of the intervent ion ob ject i ve ; however, the trend did not reach the percentage s t a b i l i t y c r i t e r i o n (85%). The level s t a b i l i t y was quite var iable (25%) ind icat ing peaks on data points for Day 10 and Day 14. Withdrawal of the intervention (B) on Day 17 f a i l e d to estab l i sh a return to baseline performance. A po s i t i ve , var iable trend continued, although the level s t ab i l i z ed considerably (87.5%) and the level change dropped from +10 in B̂  to +7 in A j , ind icat ing a smaller range of data points. These data seemed to r e f l e c t a learning curve or a pract ice e f fect on the dependent var iab le , as there was no return to the i n i t i a l baseline performance 1evel. The f i na l intervent ion produced a slope of zero ce lerat ion which indicated a decaying trend in performance which was not in the d i rec t ion of the intervention object ive. Subject #3 was often impulsive and o f f task at th i s point and the data seemed to r e f l e c t his attent ion to the task rather than his block sequencing a b i l i t y . Trend s t a b i l i t y (62.5%) and level s t a b i l i t y (50%) were var iable and there was a marked change in leve l (-12) between phases A 2 and B 2 . The recovery on Day 26 may have been associated with increased motivation associated with the reintroduction of the intervention (B), but the rest of the data points do not r e f l e c t any pos i t ive e f f ec t . 91 Summary of Main Findings Each subject was observed and measured in the fol lowing areas: decoding and word analysis as measured by the Durrel l Reading Analys is , sequencing a b i l i t y as measured by Knox cubes, rate of output and error number, and type in handwriting and word processing, the a b i l i t y to successful ly locate and target l e t t e r keys on the keyboard with b i l a t e r a l hand use using the Keyboard Town framework as well as motor t ra in ing technique, and the a b i l i t y to incorporate simple word processing commands required within the s i t ua t i on . Motor s k i l l s were assessed and a video recording was made of these. Subject f l Retesting and decoding of word analysis s k i l l s as measured by the Durrel l Reading Analysis subtest showed that CM. had gained several decoding s t rateg ies , but was s t i l l showing d i f f i c u l t y in using these strategies for r e l i a b l e word analys i s . His attent ion to the whole word had improved as he was able to go beyond the i n i t i a l consonant in sounding words out, but his tendency to guess impulsively and become anxious s t i l l interfered with decoding and word analys is s k i l l s . In contrast, sight vocabulary had improved over the course of the intervention and th i s may have been a function of using the consistent s c r ip t of the word processor for visual recognition of sight words instead of t ry ing to read his own, s pa t i a l l y confused, handwriting. CM. showed s t a t i s t i c a l l y s i gn i f i c an t pos i t ive trends in sequencing a b i l i t y as measured by Knox cubes during the intervention phases of the 92 l im i ted time series experimental design. His performance on Knox cubes returned to baseline when the intervention was withdrawn. The rate of output in word processing showed an overa l l improvement ind icat ing increased awareness of l e t t e r key locat ion and automaticity of targett ing responses. There was a decrease in the mean number of errors in the samples (see Tables I and I I ) . Error types in the f i r s t intervention phases including spacing er ror s , c ap i t a l i z a t i on errors and l e t t e r names. There were no uncorrected errors in output during the second phase and th i s re f lected C.M.'s improved a b i l i t y to recognize and correct his wr itten output using word processing strategies (see Table I I ) . At the end of the study, CM . was f am i l i a r with the required word processing commands, and was f a i r l y independent although he was unable to problem solve his way out of unfamil iar s i tuat ions (Appendix D). These resu lts ind icate some increased attent ion to some of the deta i l s of handwritten output (reversals, omissions, c ap i t a l i z a t i on and punctuation) during the intervention phases. Interest ing ly , the decrease of spacing errors in word processing did not generalize to handwritten performance. CM. responded to cueing from the Keyboard Town framework as well as to techniques for motor t ra in ing ( t a c t i l e cueing and a physical barr ier to s p l i t the keyboard to f a c i l i t a t e b i l a t e r a l hand use). CM. was the only subject who required cueing from Keyboard Town, and was only able to to le rate motor t ra in ing within the l i m i t s of his i r r i t a b i l i t y (see Appendix D). 93 At the end of the study, he was able in incorporate b i l a t e r a l hand use into his spontaneous approach to the task (see Appendix D). Motor s k i l l s f e l l below the f i r s t percent i le of the battery composite of the Bruininsks-Oseretsky Test of Motor Prof ic iency. Sequenced f inger opposition was pa r t i c u l a r l y poor, and th i s may have been ref lected in output rate on the keyboard. Subject #2 O.R.'s decoding and word analys is a b i l i t i e s remained at the low Grade 1 level with quant it ive and qua l i t a t i ve gains in word recognit ion and analys i s . His sight vocabulary had improved. He showed i n i t i a l gains in sequencing a b i l i t y as measured by Knox cubes in the baseline phase of the l im i ted time series but no stable trends or s t a t i s t i c a l l y s i gn i f i c an t resu l t s were noted during the intervent ion. The rate of output in word processing showed an improvement over the course of the study (see Table V) and the mean number of errors declined minimally over the period of the study, although error rate was minimal to begin with. O.R. did show a decrease in spacing errors (see Table VIII) as well as punctuation and l e t t e r drops having only one cap i t a l i z a t i on error for the ent i re second intervent ion. O.R.'s handwriting rate increased over the course of the study, and the mean number of errors dropped (see Tables V and VI). Misplaced upper case l e t t e r s as well as c ap i t a l i z a t i on errors decreased in the handwritten samples of the second intervent ion) . There was an i n i t i a l increase in spacing errors in the second intervention phase 94 but th i s dropped o f f immediately (see Table IX). O.R. used verbal mediation during handwriting to space his words and th i s may have been as a resu l t of having to make a target se lect ion on the keyboard for spacing between words and thus d i rect ing his attent ion to spacing. O.R. did not require addit ional cueing from the Keyboard Town framework, although he was interested in i t when i t was presented. He responded well to the cues intended for motor t r a i n i n g , and was able to perform b i l a t e r a l and hand approach without cueing a f te r several t r i a l s (see Appendix I ) . At the end of the study, he u t i l i z e d b i l a t e r a l hand use spontaneously for keyboarding. O.R.'s t imid a f fect was revealed in his approach to independence using the required word processing commands. He r e l i ed on adult d i r e c t i o n , but could i n i t i a t e some common sequences independently when required to do so. 0. R. overcame his postural d i f f i c u l t i e s by repos it ioning his chair as suggested by the tu to r . This arrangement was sat i s factory for the duration of the study, and improved grading of key pressure and targett ing considerably (see Appendix I ) . His motor s k i l l s were poor and sequenced f inger opposition was not i n t a c t , which may have affected the rate of word processing output (see Appendix J ) . Subject #3 1. R.'s performance on the Durrel l Word Analysis retest placed him at the low Grade 1 l e v e l , and showed an increase in word recognition and a wi l l ingness to r i sk making errors on more d i f f i c u l t words and sound blends. 95 He was very attent ive and impuls iv i ty had diminished. He showed a more spontaneous a f fect and increased eye contact. I.R. showed no stable or s i gn i f i c an t trends in sequencing a b i l i t y as measured by Knox cubes during the intervent ion phases of the l im i ted time series experimental design. Performance did not return to baseline upon withdrawal of the intervent ion and tended to level o f f over the phases of the experimental design. There was as a steady gain in handwritten and word processing output rate. Word processing errors were minimal throughout the study. I.R. produced er ro r - f ree typed copy throughout the study. The error rate in the handwritten samples-decreased (see Table XIV). I.R.'s tendency to omit l e t t e r s in copying decreased during the second intervent ion, as did his errors in c a p i t a l i z a t i o n . I.R. did not require addit ional cueing from the Keyboard Town framework and required minimal intervention for motor t r a i n i ng . I.R. was the least phys ica l ly - invo lved student of the three subjects (see Appendix M), and sequenced f inger opposition was in tact (see Appendix 0). This in tact a b i l i t y may have been ref lected in output rate on the keyboard. 96 CHAPTER 6 CONCLUSIONS Discuss ion This study explored the effects of teaching students with learning d i sab i l i t i e s and histories of motor dysfunction how to use the microcomputer/word processor combination to augment poor handwriting s k i l l s . Previous studies of learning disabled students using word processing made the assumption that a two-handed 'hunt and peck' approach was sufficient to learn keyboarding s k i l l s . On closer examination of the underlying requirements for successful keyboarding performance, several c r i t i c a l issues became evident. In order for the students to maximize their performance, i t seemed necessary to minimize the time spent 'hunting' for let ter key locations. To this end, the students were oriented to the Keyboard Town (Gallagher, 1961) program which placed the letter-key locations into a visual and anecdotal framework. This was an important step in organization of the task to suit the learning requirements of the student and was based on the information processing theory which indicated that learning disabled students functioned better when information was presented in a simultaneous, v i sual , experiential modality (Wittrock, 1978) and in as meaningful a context as possible (Reid and Hresko, 1981). The assumption that this group of students would be able to adopt a two-handed approach to the keyboard also seemed to be worthy of more 97 intensive invest igat ion. The b i l a t e r a l motor coordination required to use two hands successful ly i s not necessar i ly present in students with d i f f i c u l t i e s with motor planning and poor coordination. In order to f a c i l i t a t e motor performance for these students, a system of t a c t i l e , visual and verbal cues was establ ished. By d i r e c t l y addressing the in s t ruct ion of the motor requirements of the task, speed and accuracy of typing were improved. Since studies of regular students learning keyboarding s k i l l s had emphasized the need for d r i l l and pract ise the l i t e r a t u r e regarding learning disabled students did not, an e f f o r t was made to determine i f d r i l l and pract ice would help the LD student develop keyboarding s k i l l s . In order to keep the d r i l l as meaningful as possible for the students, the Write to Read program (Nash and Geyer, 1981) was selected as the program of choice. This series of wr i t ing and reading tasks adopted a decoding of word fami l ies approach to reading which was consistent with the reading program being taught in the classroom. Breaking down the keyboarding task into i t s component parts and restructur ing the task presentation in a way which incorporated knowledge of the student 's motor and learning disabled task approach was a v i t a l l i nk to establ i sh ing the foundation requirements of keyboarding, thus f a c i l i t a t i n g maximum mastery for the student. It was hypothesized that the unloading of the successive motor requirements of handwriting and the appl icat ion of a meaningful conceptual framework to the visual display on the keyboard would resu l t in improvement on successive processing, measured by a block sequencing task. 98 Subject #1, the most severely neurolog ica l ly involved student, showed s t a t i s t i c a l l y s i gn i f i c an t pos i t ive trends in successive processing during the intervention phases. The other two subjects showed i n i t i a l gains in the baseline but no stable trends were observed during intervent ion. This may have been due to the introduct ion of a new s i tua t ion or the i n i t i a l excitement of being in a 1:1 s i t ua t i on . In retrospect, the performance on the block sequencing task may have been a resu l t of the task i t s e l f , a r epe t i t i v e , meaningless exercise which focussed on the subject ' s weaknesses, diminishing motivation in task approach. This was pa r t i c u l a r l y evident in Subject #2's graphic data which was e r r a t i c and seemingly unrelated to whether the intervent ion was taking place or not. Subject #3's graphic data may have re f lected a gradual learning of the block sequencing task i t s e l f , since there was no return to baseline in block sequencing performance on withdrawal of the intervent ion. A comparison between rate of output and error types in word processing and handwriting was made and deta i led c l i n i c a l observations were made of how the students were able to master the word processing command sequences for the functions required in the 'Write to Read' program. It i s not c lear why, in that case, the resu lts of Subject #1 reached s t a t i s t i c a l s i gn i f i cance. Das, Kirby and Jarman (1979) point out the l im i ta t i on s of using a complex remedial program to improve processing a b i l i t i e s as there i s no way to account for the mutab i l i ty of factors within the remedial program. However, i t i s p laus ible that the treatment, broadly conceived, had an intervention e f f ec t . One way to test for th i s would be to allow the student to approach the keyboard in a random, 99 unsystematized way for wr itten output and measure the dependent var iable in a time series design. The intervent ion was carr ied out in a 1:1 t u t o r i a l s i tuat ion under maximum conditions of rapport and th i s may have provided Subject #1 with the impetus to persevere at the block sequencing task. The pattern of data may also r e f l e c t subject ' s motivation to stay on task during the computer intervention phases based on the strong motivating e f fect of working on the word processor (MacArthur, 1986). Cer ta in l y , a l l three subjects were delighted to work on the computer and, during the course of the study, performance of the block sequencing task was perceived as a necessary ev i l in order to get on to the word processor. A l l of the subjects made gains in the number of words decoded cor rect l y in the f i n a l administration of the Durrel l Word Analysis subtests, although none of the subjects progressed beyond an early Grade 1 reading level during the eight weeks of the study. The improvement observed may be at t r ibuted to a pract ise e f fec t . The gains made in reading were most encouraging, given the sever i ty of reading delay in each ch i l d and may have been related to the exper ient ia l wr i t ing to read using the consistent visual output of the word processor as a reading stimulus in l i e u of the student 's own handwriting. Subject #2 and Subject #3 were able to incorporate b i l a t e r a l hand use into t he i r keyboarding approaches, however, Subject #1 showed d i f f i c u l t y incorporating b i l a t e r a l hand use into l e t t e r sequences greater than three. He appeared more able to attend to the l e t t e r sequences when using a one handed approach and th i s f inding may be worthy of future consideration and 100 study for chi ldren with h i s tor ies of a marked delay in l a t e r a l i z a t i o n of hand funct ion. Subject #1's h i story of motor dysfunction indicated the most severe neurological involvement. This reinforces the importance of determining the nature of the student 's motor dysfunction and understanding how th i s a f fect s task performance. Subject #1 was also taxed by the t a c t i l e cueing in the intervention program, and became i r r i t a b l e , showing aversive reactions to l i g h t touch. Knowledge of the boy's neurological d e f i c i t s played an essential ro le in making the c l i n i c a l judgement of how to grade the intervention program in order to minimize th i s neurologically-based i r r i t a b i l i t y . A l l of the subjects made i n i t i a l errors in word processing which were consistent with those described by MacArthur (1986), pa r t i c u l a r l y errors which ref lected a lack of understanding of space and other errors which indicated an unwillingness to re l inqu i sh a f ami l i a r but pr imit ive strategy in favor of a new, more complex one. The subjects became f am i l i a r and competent with word processor commands, and there was an increase in speed of output as well as a low error ra te , r e f l e c t i ng mastery of the motor foundations of the keyboarding task which was the goal of the intervention program. The students were more l i k e l y to recognize errors in spe l l i ng or spacing on the word processor than in the handwritten samples. This may have re f lected an a b i l i t y to recognize errors when the l e t t e r s are cons i stent ly reproduced in typed format than in the e r r a t i c handwriting of the c h i l d . Cer ta in ly , attent ion to l e t t e r s on the screen was greater than to l e t t e r s in the handwritten sample and th i s i s consistent with Torgeson's 101 (1983) observations of the effects of the computer on attent ion in learning disabled ch i ld ren. The fact that the errors can be erased completely with a perfect copy of wr i t ten work produced may be the c r i t i c a l aspect for successful task performance by these students who have spent several years erasing and perfecting handwritten copy which i s never up to the peer standard established in the classroom. Subject #2 and #3 improved the qual i ty of handwritten performance in terms of spat ia l or ientat ion of l e t t e r s and words, and attent ion to errors. Subject #1, in contrast, showed no improvement in handwritten performance, showing increased f ru s t ra t i on at his handwriting. He r ea l l y preferred to use the word processor for i t s l e g i b i l i t y and consistent output. Word processing appl icat ions for wr itten output in learning disabled students with motor dysfunction should not be viewed as a panacea. The learning p ro f i l e s these chi ldren bring to the task determines that th i s task, l i k e a l l the others, i s subject to the l im i ta t i on s of se lect i ve a t tent ion , sequencing and temporal order. As Whitmill (1973) pointed out, keyboarding functions do require a spec i f i c teaching approach, to estab l i sh sound understanding and techniques. The mot ivat iona l , exper ient ia l and in te ract i ve nature of the word processor make i t a task which was well suited to the educational needs of the students who part ic ipated in th i s study. While the motor demands are not as complex as those required in handwriting, there are spec i f i c motor requirements in the task and these are affected by the motor a b i l i t i e s of the c h i l d . These include grading of key pressure, targett ing of l e t t e r keys and postural cont ro l . The degree of motor dysfunction w i l l determine how e f f e c t i v e l y the student w i l l function within these l im i t a t i on s . 102 Assessment of motor s k i l l s and techniques for motor t ra in ing play a major role in determining which students w i l l be able to use the word processing system e f f e c t i v e l y . Careful c l i n i c a l observation of the student 's task performance showed that the boys with h i s tor ies of neurological dysfunction (Subjects #1 and #2) did have d i f f i c u l t y learning the motor requirements of the keyboarding task and benefitted from spec i f i c t ra in ing procedures. Even very basic task requirements such as maintenance of good postural control required at tent ion. The ch i l d without spec i f i c neurological involvement but with a history of general motor delay and delay in handwriting development had less motoric d i f f i c u l t y , but was able to use the d r i l l and pract ice gained in the intervention program to improve speed and accuracy of wr i t ten output. Teaching problem-solving s k i l l s and planning strategies for i d e n t i f i c a t i o n and remediation of errors in wr itten output for word processing and formating reinforced the organizational s k i l l s and planning a b i l i t y of the students. Subject #1 began to demonstrate strategy formation by scanning the sentences for cap i ta l l e t t e r s before i n i t i a t i n g typing, ind icat ing i nh i b i t i on of impulse control and the development of strategies for task approach in appl icat ion of word processing commands. Subject #2 used verbal mediation to help him remember spacing on the word processor and also used th i s strategy in some of his l a t e r handwriting samples. Thus, the practice on the word processor improved handwriting performance in th i s student through increased attent ion to c r i t i c a l d e t a i l s . 103 Limitations of the Study The interpretat ion and gene ra l i zab i l i t y of the results of this study is l imited by the small number of subjects. A case history approach was taken to place a l l the c r i t i c a l factors af fect ing the students into perspective. While the findings cannot be generalized to subjects other than those involved in the study, the detai led c l i n i c a l observations did indicate that aspects of the keyboarding task did require spec i f i c t ra in ing . These observations may form the basis for future intervention with students with s imi la r d i s a b i l i t y p ro f i l e s . The case history approach i s observer subjective with no interrater r e l i a b i l i t y which predisposes the findings to d i s tort ions based on observer bias. However, in th i s case, detai led c l i n i c a l observations of task performance allowed the reader to assess the conclusions the author came to , thus l im i t i n g the amount of observer bias within the study. The study spanned a r e l a t i v e l y short period of time to measure well established changes in performance with regards to output rate and decoding in reading performance, however, a valuable intervention method for teaching keyboarding and word processing to learning disabled students with motor dysfunction was examined and found to have value for further study. The dependent var iable was too sens i t ive to subject motivation and impulsiveness, and th i s must be taken into consideration for the purposes of measuring successive processing in th i s study. Comparisons of error rate and output speed in handwritten and word processed writ ing samples generated data which ref lected changes in the subjects ' attention to c r i t i c a l deta i l s of the wr it ing task over the course of the study. 104 These changes may have become more marked over a longer period of intervent ion. Use of the information processing model for task analysis and in determining a method of intervention was useful for th i s descr ipt ive study. Implications f o r Future Research and Professional Practice The results of th i s study indicated that learning disabled students with motor dysfunction were able to learn simple word processing commands and keyboarding s k i l l s which enabled them to produce perfect copy in wr i t ing tasks. The d i f fe rent students benefitted in a var iety of ways from an intervention program designed to address t he i r learning and motor needs. Future research could establ i sh v a l i d i t y and r e l i a b i l i t y of these f indings using a larger population of learning disabled students with motor dysfunction. The dependent var iable should be more meaningful to the population. P i c t o r i a l memory as described by Jarman and Das (1980) was found to measure successive processing and may have provided a more motivating and appropriate stimulus as a dependent var iable with th i s population of learning disabled students. Testing could also extend to measures of a t tent ion. Students could be matched for a t tent ion , reading level and motor s k i l l l e v e l . This would necessitate a r e l a t i v e l y small number in the sample, but the nature of the abnormal cognitive-motor p ro f i l e s lend themselves to small ' n ' treatment (Hersen and Barlow, 1976) onto further descr ipt ive studies such as th i s one. The impl icat ions for professional pract ice involved the use of the word processor as a basic organizing tool for wr itten output. Students who were previously at a disadvantage in the i r a b i l i t y to perfect wr i t ten work 105 were better able to present l eg ib le work by learning a task which involves learning and applying organizational s k i l l s in a meaningful context. S k i l l mastery contributes to student self-esteem and may influence classroom behavior. In order to f a c i l i t a t e maximal success in task performance, i t i s essential that the motor s k i l l s of the ch i l d be assessed and, i f necessary, techniques which re inforce motor learning be u t i l i z e d to teach keyboarding s k i l l s . The occupational therapist with a professional background in task ana lys i s , motor t ra in ing and adaptation of technical aids and environmental factors to maximize motor performance plays a v i t a l ro le on the educational team for th i s purpose. Once the basic s k i l l s of word processing are establ i shed, i t remains to be seen i f there i s an ef fect on wr i t ten language as indicated by Woodruff (1986) or on attent ion and decoding in reading as suggested by Torgeson (1983). An intervention program which involved students typing and formatting t he i r own work, such as journal w r i t i n g , would be more in keeping a meaningful, exper ient ia l approach and be more s i gn i f i c an t to the c h i l d . This kind of intervention would be the l og i ca l follow-up to the 'Write to Read' intervention program examined in th i s study which emphasized the important techniques for learning keyboarding s k i l l s and could form the basis for an ongoing classroom program which u t i l i z e s the word processor as an adjunct to handwriting s k i l l s on a da i l y basis in order to re inforce and f i rmly estab l i sh fluency and automaticity of word processor use. 106 Summary The word processor program provided a motivating exper ient ia l and in te rac t i ve means for wr itten output for the students with learning and motor d e f i c i t s who par t i c ipated. Careful c l i n i c a l observation showed that the students did have d i f f i c u l t y with some aspects of motor learning associated with the task. These d i f f i c u l t i e s were dealt with in an intervention program designed to meet the students' s pec i f i c learning and motor needs. This intervention merits incorporation into educational programming for s im i la r chi ldren as i t s p e c i f i c a l l y addresses t he i r motor and cognit ive needs. The study represents a valuable addit ion to the study of microcomputer/word processor appl icat ions for chi ldren with learning d i s a b i l i t i e s and motor dysfunction. A P P E N D I X A S U B J E C T #1: C A S E H I S T O R Y 108 APPENDIX A Subject #1: Case History Name: CM. Date of B i r t h : July 28, 1977 Chronological Age: 8.10 years Date: June 1, 1986 CM. i s the only ch i l d of a couple addicted to heroin, the father in his m i d - f i f t i e s , the mother aged 19. The mother took eight to ten caps of heroin per day throughout the pregnancy. Both parents refused methadone therapy for t he i r addict ion and, because of th i s non-compliance, the ch i l d was apprehended at b i r th and placed in temporary foster care. The ch i l d was born by normal del ivery at 36 weeks gestational age by dates with a b i r t h weight of 2820 grams, length of 56.5 cm, head circumference of 36.5 cm. On examination, gestational age was found to be 37 weeks. Apgars were nine at one minute and ten at f i ve minutes, with no resusc i tat ion required. He was not j i t t e r y at b i r t h , but became extremely so a f te r 24 hours. He was treated with paregoric ( t incture of camphorated opium) which caused l i t t l e improvement, and th i s was replaced within a few weeks by Phenobarb, 3.75 mg, twice a day. He remained in intensive care in hospital for s ix weeks and was discharged to foster care. Physical examination (January 5, 1978) at s ix months of age by a paediatr ic neurolog ist , found minimal j i t t e r i n e s s and exaggerated pr imit ive re f lexes . The head was normocephalic with head circumference at the 2 5 % i l e , length at the 2 5 % i l e , weight at the 2 5 % i l e . Pap i l l a r y reactions 109 were normal, no external opthalmoplegia or f ac i a l assymetry were noted. Corneal ref lexes were normal. The head was well supported in s i t t i n g . The ch i l d was able to l i f t his head in prone to 90°. He engaged his hands at midl ine and was fol lowing objects through 180°. He had a spontaneous smile, made small throaty noises and did not laugh or exc i te . Sensation to pinprick was normal by withdrawal. Tone was s l i g h t l y increased in upper and lower extremit ies. Deep tendon ref lexes in a l l muscle groups in the upper extremities and knees were increased without asymmetry. Plantar responses in hands and feet were observed. Pr imit ive ref lexes of Asymmetric Tonic Neck (ATNR) and Symmetrical Tonic Neck (STNR) were noted, but var iable as were placing and supporting react ions. The stepping re f lex indicated a sc i s sor ing gait and the Landau response was p a r t i a l l y developed. Palmar creases were normal as were the anter ior fontanel le space and the inner canthal separation. The problem l i s t generated at that time included: "Problem #1 Minimal and improving signs of cerebral palsy with sc i s sor ing gait and increased deep tendon re f lexes . J i t t e r i n e s s and hypertonic ity (espec ia l ly marked during the Phenobarb medication period for 4.5 months un t i l the foster mother stopped i t ) had disappeared. Problem #2 Developmental assessment on the Gesell at s i x months of age showed gross and f ine motor s k i l l s of a 4 to 16 week old i n fan t , language s k i l l s of a four week i n fan t , and personal soc ia l s k i l l s of a 16 week o ld i n fan t . " The neurologist f e l t that these mild neurological signs would improve and would require long term neurological fol low-up. 110 CM . (at eight months) was seen by the orthopedic surgeon for external rotat ion of the r ight lower extremity. At that time i t was noted that he was unable to s i t and was beginning to r o l l in and out of prone and supine. Some pr imit ive crawling was noted and the foster mother f e l t that the baby was moving a l l extremities equally w e l l , and was easier to care for . Increased tone was noted in a l l j o i n t s with l imi ted abduction of both hips in f lex ion and in extension, and abductor l im i t a t i o n to 30°. Knees, ankles and feet a l l had f u l l range of motion. X-rays showed hips to be well located with good acetabular development. No intervent ion was recommended at th i s time, with a future plan of stretching exercises and Dennis Brown boots and bar, in which foot or ientat ion places the hips in internal r o ta t i on . A re fe r ra l to Opthamology (Apr i l 7, 1978) was made for an intermittent divergent strabismus being more marked on the l e f t . Medical advice at th i s time was that optimal timing for cor rect ive surgery was a f te r two years of chronological age and any consideration for surgery was to be postponed un t i l a f te r that time. CM. was eight months old at th i s time. Because of the question of adoption, the opthamologist advised that he ant ic ipated a good resu l t with surgery, good v i s ion from each eye and possibly normal depth perception. Electroencephalogram (EEG) Report of May 11, 1978 indicated some potent i a l l y abnormal cerebral potentials in th i s c h i l d with possible cerebral palsy. However, re s t ing , waking and sleep recordings were within normal l i m i t s . Paediatr ic cardiology assessment (May 16, 1978) took place when CM. was 9.5 months o ld . He was noted to be ce r ta i n l y slow with possible I l l cerebral palsy. He had been slow to gain weight although he ate well. He drank from a bottle over 30 minutes, played with the bottle but would not hold i t and was reluctant to hold food in his hands. He did not crawl and did not like i t on his tummy, had never turned blue and demonstrated at Grade I-II/Vi systolic murmur in the pulmonary area. Electrocardiogram (ECG) showed right ventricular hypertrophy. The cardiologist's impression was that some children had this ECG for no reason in infancy and there was some chance that this would change with time. The follow-up neurological report (June 27, 1978), when CM. was 11 months old, found mild signs of spastic deplegia with increased deep tendon reflexes in supinators, biceps and knees. Infantile postural responses for placing and supporting were intact and stepping s t i l l showed scissoring in vertical suspension. The Landau reflex was now present and parachute reactions were present forwards and laterally but not backward. This performance was consistent with a developmental age of seven months. Head circumference and weight were now at the third and length was at the 10$ i l e. CM. had been enrolled in the Infant Development Program (IDP) at this time. Medical problem l i s t at this time l i s t e d : Problem #1 Developmental Retardation Plan Continuation with IDP to reinforce parent's ideas. 112 Problem #2 Mild Cerebral Palsy Plan Physiotherapy assessment and home treatments. Problem #3 Left exotropia Plan Follow with the opthamologist A recommendation was made for x-ray for wrists for bone age in view of the f indings of short stature and developmental delay. The next follow-up neurological report (February 16, 1979) noted that there had been regular attendance at the Infant Development Program and a home physiotherapy program. The foster mother's only concern at th i s point was the c h i l d ' s const ipation which she managed well with suppositor ies. The foster parents were ind icat ing at th i s time that they wanted to adopt th i s boy. At a chronological age of 18 months, a Gesell assessment revealed personal/social s k i l l s at the 10 month l e v e l . He could only indicate his needs by cry ing. Fine motor s k i l l s were around 11 to 12 months. In Gross Motor areas he was able to s i t unsupported, stand holding on and could pull to stand. No nursing or unsupported standing (eight to nine month s k i l l s ) were noted on th i s examination. Language was the most delayed although hearing was f e l t to be c l i n i c a l l y i n tac t . The ch i l d was not vocal iz ing dada, baba, gaga, t a t a , e t c . , and used monosyllabic "ous" and aws", a s ix to eight month s k i l l . There was s t i l l evidence of mild spast ic d ip leg ia and hypertonic i ty, and hyper r e f l e x i a in the pelv i s and hips. 113 Medical Problem L i s t (February 16, 1979) Problem #1 Developmental Retardation Diagnosis of interuter ine growth retardation (IUGR) secondary to maternal heroin add ict ion, alcohol and other drugs. Inte l lectua l capacity was s i g n i f i c a n t l y compromised as a resu l t . Plan A refer ra l for audiogram was made secondary to language f indings. Problem #2 Spastic Diplegia Plan Continue with physiotherapy. Problem #3 Left exotropia Now resolving on i t s own. There was no amblyopia of the divergent eye c l i n i c a l l y . An EEG report (February 20, 1979) showed "abnormal and paroxysmal a c t i v i t y during sleep, espec ia l ly in arousal , without c lear cut discharges". These findings were s t i l l with in normal l i m i t s . On February 21, 1979 (chronological age 18 months), the x-ray for bone age showed a skeleta l age of 14 to 15 months, between 1.5 and 2.0 standard deviation below the mean for the c h i l d ' s chronological age. The opthamologist (Apri l 27, 1979) found the exotropia in reasonable control and no treatment was recommended. It was noted that the ch i l d was d i f f i c u l t to examine and would be seen again in one year. The Infant Development Program report (May 23, 1979) reported that the family had been involved in the program for 13 months and had been coming to the play group once a week over the past three months. Intervention had included bimonthly home v i s i t s by the infant worker and monthly j o i n t 114 v i s i t s with the consulting physiotherapist. C.M.'s chronological age was 21 months at th i s time. Test behavior on the Gesell indicated that CM. screamed when new a c t i v i t i e s were presented, needed time to adjust to new a c t i v i t i e s , needed lo t s of praise and would s t i l l only work when on the foster mother's l ap . Adaptive s k i l l s (18 months with scatter) documented his approach to new tasks: scream and throw. He could eventually watch and imitate but would perseverate on games l i k e dumping the pe l le t in and out of the bott le over and over again. Gross motor s k i l l s (s ix months with scatter) showed that he could now pul l to stand and c ru i se , walk with hands held and crawl up s t a i r s . He could kick the ba l l a f te r a demonstration and played catch (18 months s k i l l ) . Quality of movement was poor: he walked supported on s t i f f legs with arms flexed and hands f i s t e d . . In the f ine motor area, CM. was only able to complete a two cube tower as he knocked the tower over with the th i rd cube. He demonstrated a neat pincer grasp with a two finger-thumb pinch ind icat ing pr imit ive motor patterns. Language s k i l l s (15 months and scattered) showed non-selective looking at p ictures, no i d e n t i f i c a t i o n of picture card items. Consistent vocabulary consisted of four to s ix words and the ch i l d was jargoning and t ry ing other words. Personal Social s k i l l s (15 to 18 months with scatter) showed that he could drink from a cup (21 months) and feed himself with his f ingers or a spoon (24 months). CM. was able to use 'thank you' to give or receive, and was beginning to vocal ize his wants and d i s l i k e s . He offered toys to 115 others and interacted well with family and other f ami l i a r people. CM. did better when a c t i v i t i e s were made into games. The ch i l d was making slow, steady progress although he was s t i l l upset by changes in routine or changing a c t i v i t i e s too quick ly. It was f e l t that he needed time to adjust to new s i tuat ions and needed much praise and encouragement. The orthopaedic surgeon (July 23, 1979) commented that th i s two year old boy was s t i l l c ru i s ing without independent ambulation and that he was more cooperative. Minimal adducter spasm persisted in the lower extremities and x-ray showed excel lent development of femoral heads in the acetabular. No heel cups were prescribed based on th i s pos i t ive f inding and he was scheduled for review in s ix months. The IDP worker (July 26, 1979) indicated that CM. would now attend the play group two mornings per week with ongoing physiotherapy. Home v i s i t i n g was discontinued at th i s time. The paediatr ic neurologist saw C M . again for review on August 7, 1979. CM . was then two years o l d . Problem #1 Developmental Retardation Functioning at 15 to 18 months in most s k i l l s with the greatest d e f i c i t s in the gross motor area. He was now walking independently and using more language. The impression was that he was functioning s ix months behind his chronological age. The report from the tympanogram was normal and impedance test ing suggested normal hearing in both ears. There was a 'modestly abnormal EEG' and mum reported screaming attacks at night which brought up the questions of noctural epilepsy and/or nightmares. Plan" Repeat EEG 116 S t i l l evidence of mild spast ic d ip leg i a . Physiotherapy once a month. Left exotropia On examination, the visual axes were normal. Consultation with opthamology. Delayed Growth The boy had followed along the lowest percenti les since b i r t h . These ongoing f indings indicated that the c h i l d ' s ultimate growth would be small and s l i g h t . The findings of delayed bone age indicated that the pubertal growth spurt would be delayed when compared with his peers. The fol lowing EEG report (November 23, 1979) showed suggestions of 'paroxysmal a c t i v i t y on arousal from deep sleep, but no c lear cut epi lept i form discharges were seen ' . Otherwise, the recording was within normal l i m i t s . March 24, 1980: The neuro log i s t ' s medical problem l i s t notes: Problem #5 Epilepsy Findings of two suspicious EEGs during the l a s t 12 months, screaming spe l l s at night and wakening during the past s ix months, glassy-eyed, fr ightened and shaking, unsteady and i r r i t a b l e for up to 3/4 of an hour with some c lon ic movement of arms and legs seemed to indicate a diagnosis of nocturnal or post-nocturnal epi lepsy. Problem #2 Plan Problem #3 Plan Problem #4 Plan A therapeutic t r i a l of anti-convulsant was recommended of D i l an t in 3 to 5 mgs/kg/day in divided doses. D i l an t in was recommended as the drug of f i r s t choice with the p o s s i b i l i t y of a switch to Depakane in one year. June 4, 1980, CM . was admitted to hospital with c l i n i c a l signs of D i l an t in t o x i c i t y (one day history of vomitting and unsteadiness). His D i l an t in had been increased one week previously. The D i lant in dose was 117 withheld and the symptoms stopped. CM . was discharged a f te r a 48-hour admission with adjusted D i lant in leve l s and no further signs of t o x i c i t y . He was seen again for review of his cardiac status (paediatr ic cardiology report, July 17, 1980). The ECG showed "serious rhythm with a r ight axis and moderate r ight vent r icu la r hypertrophy". The card io log i s t f e l t that the murmur represented a mild valvar pulmonic stenosis which was a benign les ion and a low r i sk for i n fec t i ve endocardit is. No special precautions or r e s t r i c t i on s were advised at that time. On the next v i s i t to opthamology (September 12, 1980) C M . was prescribed glasses for myopia and control of intermittent divergent strabismus. The physician noted that the ch i l d had become easier to examine. CM. started pre-school at a loca l Day Care in September 1980 in the special needs c las s . He was referred for a speech and language assessment to the Vancouver Health Department. He was 3.2 years of age at the time. CM. was seen for speech and language assessment at Day Care. He had d i f f i c u l t y attending to tasks, decreased eye contact and was uncooperative. Speech assessment showed f a i r i n t e l l i g i b i l i t y of s ingle words and u n i n t e l l i g i b l e attempts at two word phrases. His speech contained vulvar stops. Imitation s k i l l s were good and some drool ing was noted. On the Pre-School Language Scale, C M . scored at 2 years, 15 months for auditory comprehension. Verbal a b i l i t y was not scored as the ch i l d was too uncooperative. He used mostly one word communication. His two word phrases used in the assessment period were 'no go ' , 'no more', ' l e t ' s go ' . 118 He was found to have expressive and receptive delay, and poor attending behavior based on an overa l l delay, and speech therapy was recommended once per week at Day Care. Orthopaedic examination (September 24, 1980) found C.M.'s hip exam and x-rays to be normal with remaining s l i gh t tightness of adductors. Hips and lower extemities had realigned s a t i s f a c t o r i l y , and CM . was walking w e l l . On December 18, 1980, the neurology report found the EEG to be abnormal in sleeping and waking. CM . was seen by the team from Chi ldren ' s Hospital Diagnostic Centre when he was three years, nine months old (Apr i l 28, 1981). The physician reported that he was attending the special needs group at Day Care and had been given permanent l i f e placement with the M. family. His adductors were t i g h t , there was valgus of the feet b i l a t e r a l l y , tendon ref lexes were brisk in the lower extremities with b i l a t e r a l downgoing Babinski re f l exes , but no ankle c lorus . The speech evaluation included a hearing assessment (20 db on the r ight and 20 to 40 db on the l e f t ind icat ing a mild decrease). There was a f l a t tympanogram which was f e l t to be ind ica t i ve of middle ear pathology. Poor a r t i c u l a t i o n was also noted and his spontaneous language consisted of short sentences appropriate to a three year o l d . On the Sequenced Inventory of Communication Development ( S . I .CD. ) , he scored at two years, eight months in expressive and receptive language with occasional successes at the three year l e v e l . Occupational Therapy evaluation made note of f luctuat ing a t tent ion , habitual s i t t i n g in reverse "W", immature ga i t with decreased muscle tone 119 and a knock-kneed stance, and poor depth perception related to ongoing opthamological status. Fine and gross motor, s k i l l s were from 2.0 to 2.5 years with scatter to the three year l e v e l . Perceptual awareness was f e l t to be from 2.0 to 2.5 years. Otology reported a normal ear, nose and throat exam (ENT) with b i l a t e r a l and retracted dul l ear drums and a history of mouth breathing. This was f e l t to be t rans ient , but i f i t persisted i t was f e l t that b i l a t e r a l myringotomies would be required. In the summary, the physician described a 3.8 year old boy with small stature along the 3 % ^ e in an appropriate placement at special needs pre- school. There were noctural seizures, hyper r e f l e x i a and attent ion de f i c i t s . He was referred to the Seizure C l i n i c , for a hearing assessment in Ju l y , for follow-up in one year and referred to occupational therapy for a multi-sensory approach to learning. He was seen at the Seizure C l i n i c (May 19, 1981) by a neurology fe l low who recommended that the D i lant in be discontinued as the seizure disorder had never been confirmed and the ch i l d had had no seizures for two years. The medication was stopped gradually over a s ix week period with a repeat EEG two weeks a f ter to ta l withdrawal of the medication. A recommendation was made for follow-up in three months' time. Vancouver Health Department Speech Pathology Services discharged CM . July 31, 1981 when he turned four years of age. Therapy had focused on noun-verb combinations, on present progressive verb form ' i n g ' and on ear ly semantic re la t ions (existence, non-existence, 120 recurrence, ac t ion ) , and l i s t en i ng and attending s k i l l s . He had made slow steady progress. The Goldman Fr i s toe Test of A r t i cu l a t i on indicated the fol lowing omissions in speech: /m/, /n/, /d/ and /r/medial; / z / f i n a l . He substituted t for k in the medial word pos i t ion, s for sh, t s/ch, g/1 i n i t i a l , w or y/r, s/th (vo ice less ) , b/v, t/th (voiced). Most consonant sounds were not present and many sounds were omitted in connected speech. His i n t e l l i g i b i l i t y was f a i r . The Test for Auditory Comprehension of Language (TACL) indicated an age equivalent of 3.1 years at a chronological age of 3.10 years. He used two and three word sentences cons i stent ly ("Wan r ide b i ke " , "/eat cook us", "where put t h i s ? " ) . The Seizure C l i n i c appointment for EEG follow-up (September 9, 1981) found ' d i f f u s e slowing and r ight portal sharp waves with no epi lept i form changes during a r ou sa l ' . The physician f e l t that further observation was necessary in order to diagnose epilepsy and plans were made to repeat the EEG in one year. There was no diagnosis of epilepsy made as no s i gn i f i c an t ep i lept i form a c t i v i t y was seen on EEG. CM . was seen for speech assessment and review of hearing at the Diagnostic Centre, September 30, 1981. He had made good progress with a r t i c u l a t i o n , was having d i f f i c u l t y with auditory attent ion and l i s t e n i n g . Speech was more i n t e l l i g i b l e with some use of id io syncrat i c words. He was now attending a d i f fe rent Day Care and follow-up by the speech pathologist at Day Care was recommended. Staf f at Day Care noted a seizure during his nap and he was seen again at Seizure C l i n i c (September 22, 1981). He was started on Tegretol as i t 121 was noted that D i l an t in causes cognit ive slowing and the doctor stated that he now f e l t more comfortable with the diagnosis of epilepsy since he had now ac tua l l y had a seizure and his roommates in the foster home confirmed that he clenched his f i s t s and made jerk ing movements during the night. The glasses prescribed by the opthamologist were found to be correct ing myopic astigmatism and con t ro l l i ng strabismus (November 6, 1981). Surgery was suggested as a p o s s i b i l i t y pr ior to grade school. Physiotherapy assessment by (January 29, 1982, chronological age 4.6 years) found CM . to be s o c i a l l y aware and lacking in gross and f ine motor s k i l l s . The Day Care was requesting that CM . spend his kindergarten year there and not in a regular kindergarten. He was referred to Occupational Therapy for assessment. This was carr ied out over January 29, February 12 and 18, 1982. The family now was running an eight bed emergency foster home. CM . was attending Day Care f u l l time with a one-to-one worker. CM . was referred to O.T. for evaluation of his f ine motor and perceptual motor development. He was noted to be d i s t r a c t i b l e in school, to be generally hypotonic and to have problems with prehension, poorly established hand dominance, and poor s i z e , number and shape concepts. The assessment took place over three sessions and each session was l im i ted to 20 to 30 minutes because of C.M.'s d i s t r a c t i b i 1 i t y and lack of cooperation. In one session he absolutely refused to do anything. He was d i s t racted by sound and movement around him and required frequent reminders to watch and attend to what his hands were doing. 122 In the gross motor area, he showed generally poor body strength. On a scooter board, he had d i f f i c u l t y extending arms and legs against gravity when in prone lying. He ran with some scissoring, caught and threw a large ba l l , and kicked a ball with good force, preferring the l e f t leg. Concept formation was c l i n i c a l l y adequate for size and shapes. He was able to assemble graduated barrels and match shapes correctly. He was able to name a circ l e and a square but was not able to count sequentially - naming several numbers in random order. He knew his own body parts, but found i t d i f f i c u l t to transfer that information onto a body image drawing. He did not i n i t i a t e a draw a person picture even after the head was drawn. Hand dominance did not appear to be established as he used the right hand for pencil work and the l e f t for other things (feeding, hammering). The right eye was preferred. No fine index-thumb pincer grasp had developed. CM. used a gross grasp with two to three fingers and the thumb. Associated reactions were seen in the l e f t hand when using the right hand in fine motor activity. He had poor pencil control, grasping high on the pencil with a four point right hand finger grasp. He required a hands-on intervention for dot-to-dot. Upper extremity and hand strength was poor. He fatigued quickly. Eye-hand coordination was variable and may have been a 'factor of behavior 1 as he was frequently distracted, looking away rather than at his hand during a task. Visual motor s k i l l s were significantly poor (VMI 2.10 years, Motor Accuracy-R, Right and Left scoring at 2.1 standard deviations below the 123 mean). He was able to copy horizontal and c i r c u l a r strokes with ve r t i ca l s c r ibb le s , and seemed to have a d i f f i c u l t time understanding the task. He had d i f f i c u l t y with dressing and would put his clothes on backwards unless aligned co r rec t l y . He could do pants, socks and boots when he was set up. In summary, CM . was found to have many problems in f ine motor and perceptual areas as well as behavior problems. Weekly OT appointments for O.T. at Chi ldren ' s Hospital were made with the fol lowing recommendations: "(a) f ine motor s k i l l s - hand dominance, dexter i ty and grasp, eye-hand coordinat ion, strengthening. (b) perceptual s k i l l s - body image, number, s i z e , shape. (c) perceptual motor s k i l l s - aim to improve drawing and cutt ing s k i l l s . (d) increase at tent ion, concentration and problem- solving a b i l i t y . Decrease impul s i v i ty and d i s t r a c t i b i l i t y . " The Assessment Summary of the B.C. Ch i ldren ' s Hospital Evaluation Team (May 17, 1982, chronological age 4.10 years) establ ished th i s Diagnostic P r o f i l e . " 1 . Psychological test ing showed cognit ive development in the slow learner range. 2. Attentional d e f i c i t s . 3. Soft neurological signs with perceptual d i f f i c u l t i e s and motor clumsiness, functioning at the level of a 4.0 to 4.5 year o l d . 4. Seizure disorder contro l led on Tegretol . 5. Congenital strabismus and estimated normal visual acuity with correct ive lenses." The recommendations were to continue on in the present day care set t ing for the kindergarten year with the 1.1 special needs worker, continue with O.T. at Chi ldren ' s Hosp i ta l , Central Screening for school placement within the Vancouver School Board and a reassessment by orthopaedics. 124 The Comprehensive Medical Report from the BCCH Chi ld Development Program (May 21, 1982) found global developmental delay with neurological signs and cerebral dysfunction at the borderl ine average range in mental development. In the parent conference, i t was made c lear that C.M.'s attent ion d e f i c i t s and problems with visual motor coordination could lead to more learning problems. On July 2, 1982, C M . was discharged from O.T. at BCCH. He had been seen on a weekly basis for f i ve months since February 1982 and would continue on at Day Care next year. His Day Care worker had attended some OT sessions at BCCH to f a c i l i t a t e fol low through within the program. He had become more cooperative, was s t i l l d i s t r a c t i b l e to sounds, ignored inst ruct ions and made up his own games. It was s t i l l d i f f i c u l t to d i rect CM . to a spec i f i c task. He was s t i l l slow and cautious in descending s t a i r s and was fear fu l of spinning or swinging too high. Weakness in prone and supine ant ig rav i ty posit ions pers i s ted. He was expressing himself in spontaneous speech, but found i t d i f f i c u l t to answer spec i f i c questions. There was s t i l l no de f in i te hand dominance, he pers isted in using the l e f t hand for larger movement and the r ight hard for f ine movement, and s t i l l switched. In dressing, shoe laces and buttons were s t i l l a problem. Recommendation was made for re fe r ra l for ongoing OT intervent ion with a community-based therapy team. 125 Seizure C l i n i c note (October, 1982) adjusted medication with a goal to discontinue anti-convulsant medication as seizures had not recurred. The M. family were seen May 5, 1983 by the community agency's Social Service Department. CM. had been placed in kindergarten at his loca l school for the l a s t three months of school according to his parents' wishes and against the recommendations of the Day Care s t a f f . His mother described him as a fear fu l c h i l d , reluctant to t r y new a c t i v i t i e s . "He i s a f ra id of animals and heights, and has d i f f i c u l t y moving his body in coordinat ion." OT assessment (May 24, 1983) found him to be act ive and anxious. He was quite d i s t r a c t i b l e and had d i f f i c u l t y completing tasks. The r ight hand was preferred but there were frequent s h i f t s to the l e f t . Crayons were held with a gross palmar grasp, although CM. could adapt to a more mature grasp with reminders. Human Figure Drawing was pr imit ive and disassociated, there was a tendency to scr ibb le and d i f f i c u l t y staying between l ines on color ing tasks. Problems were i den t i f i ed as: 1) Visual Motor Dysfunction, and 2) Attention D e f i c i t . He was seen once weekly in the home unt i l September 1985. Speech Pathology assessment (May 31, 1983) found that CM . f a i l e d the kindergarten screening which indicated some further work was required in language areas. CM. was unable to give his name or age, count animals, re la te a simple story through p ictures. He was able to name four co lo r s , point to ch in, knee, elbow (not ankle) and fol low three part commands. 126 The language sample was hard to e l i c i t and the ch i l d used simple, incomplete sentences: "Try again" "No good" "Can 1 t jump on i t " "Washing your teeth" Sentences and greater fluency included: "They s p i l l e d i t " "Cos i t might be s t i c ky " "I want to do my hearing" "I wanna go home" "I don 't want to see i t " "Look at the umbrella with the water in i t " "I don ' t , I have a cat " "He's pumping the gas" He used past tense, negatives and pronouns. Two questions were asked, "What's t h i s ? " , "That ' s you?" Mean length of utterance was d i f f i c u l t to evaluate because of the shortness of the sample. Performance on the PPVT was f e l t to r e f l e c t learning s ty le rather than auditory language a b i l i t i e s . He was unable to scan the pictures and select an answer, pointing to a l l four. Age Equivalent: 2.6 years. A r t i cu l a t i on was general ly good, with the existence of immature forms. C M . demonstrated an ongoing delay in a l l areas of language funct ioning. Weekly speech therapy sessions at the community therapy 127 agency were recommended. I f the family was unable to bring the ch i l d in for therapy, i t was recommended he be referred to the speech language pathologist at his loca l school to more f u l l y assess language a b i l i t i e s , l i a s e with teachers and give programming advice as necessary. The Physiotherapy Report (May 19, 1983) found t i ght heel cords, l i m i t a t i o n of abduction in both hips, f luctuat ing tone with a s l i gh t increase in lower extremities and minimally reduced tone in the trunk. He was found c l i n i c a l l y to have poor concentration, poor perception and poor f ine motor s k i l l s . OT was f e l t to be more benef ic ia l than PT and CM . could be seen again in s i x months at the request of the OT. The Kindergarten Report from the l a s t tr imester school placement (June 29, 1983) noted that CM . had made a f a i r adjustment to kindergarten. He was beginning to communicate with his classmates, l i ked the sandbox and the playhouse. Fine motor s k i l l s were poor in cutt ing and he was attempting to co lor . The teacher f e l t that f ine motor pract ise over the summer would enhance th i s performance. CM. attended f u l l - t i m e kindergarten the fol lowing year and was seen at school weekly for OT sessions. Speech therapy sessions at VNC were never rea l ized as the family were unable to make a weekly commitment for therapy sessions since the nature of the emergency foster home dictated that they could not leave i t . His performance on Psychological Testing (September 1983) placed him in the borderl ine range, however, his behavior and functioning pattern resembled that of a severely learning disordered youngster. His educational needs required a highly ind iv idua l i zed program in a sett ing designed for students with mult ip le learning handicaps. P r i o r i t i e s for 128 planning were on cont ro l l i ng behavior, increasing attent ion span, improving concentation, development of perceptual and cognit ive a b i l i t i e s and acquiring bas ic, academic s k i l l s . The recommendation was that the mu l t i - sensory approach be used extensively. The School Board Speech Assessment (September 1983) found good progress in acquiring language given the delay in i n i t i a t i o n of speech development. Grammatical forms were age appropriate with vocabulary and content de f i c i enc ie s . His attent ion span affected l i s t en i ng a b i l i t y . A recommendation for a l l day kindergarten was made for language s t imulat ion, motor s k i l l s and socia l development. The Psychological Report (Apr i l 26, 1984) summarized that th i s was C.M.'s second year in kindergarten and he had developed no readiness for Grade 1. He had attended LAC since September 1983. T e s t R e s u l t s 1. Ravens Colored Progressive Matrices - 10% 1 " ' e . 2. Good enough Draw-a-Man Age Equivalent 4.2 years 3. Boehm Test of Basic Concepts - Forms 28/50 4. PPVT-R (Form L) Age Equivalent 4.0 years l%^e 5. Expressive One Word Vocabulary Test Age Equivalent 4.5 years - 7 t h % i l e 6. Motor Free Visual Perception Test (MVPT) Age Equivalent 4.6 years 7. VMI Age Equivalent 4.9 years - 2 % i l e 129 A developmental delay was found in a l l areas assessed. There were visual perceptual and visual scanning d e f i c i t s , d i r e c t i o n a l i t y confusions, motor l im i t a t i on s and delays in the cognit ive domain, however, the impression was that CM. was more capable than his test results indicated. The learning assistance centre progress report (June 1984) reported that C M . now had basic language concepts of before, a f t e r , some, around, over, severa l , none, almost and d i f f e ren t . CM . had made steady progress, although readiness was not achieved. He had a pos i t ive a t t i t ude , good group pa r t i c ipa t i on and was enthusiast ic about new s k i l l s . There had been a gain in printed forms and copying tasks but with much l e f t to do. He needed to increase his personal data (did not know his birthday or address), extend rote counting, numerical and verbal memory s k i l l s , expand stored language and required an exper ient ia l approach to basic concepts. A small group sett ing was recommended as C.M.'s achievement was s i g n i f i c a n t l y below expectations. He was very demanding of teacher attent ion and tended to model other ch i l d ren ' s behavior. OT Report (Apri l 30, 1984, chronological age 6.9 years) found CM . to be ' ag i tated with a re lent less stream of chatter and questions, and nervous g i g g l i n g ' . Test behavior was e r r a t i c and impulsive which may have inva l idated re su l t s , pa r t i cu l a r l y on the Motor Free Perceptual Test (MVPT, Age Equivalent 5.0). Attention d e f i c i t s were found to i n te r fe re with performance. Visual memory was not an area of strength, and C M . had d i f f i c u l t y with auditory sequences. 130 A small class s ize was recommended with an experienced teacher sens i t ive to C.M.'s strengths and weaknesses. A multi-sensory approach was recommended to f a c i l i t a t e attent ion in task approach and learning as well as programming for language d e f i c i t s . CM . was placed in the Junior Learning Assistance Class at his loca l school for the school year 1984-85. The OT report dated Apr i l 11, 1985 (chronological age 7.9 years) indicated that progress had been made in wr i t ing s k i l l s although severe d e f i c i t s pers i sted. Organization of space, reversa ls , d i f f i c u l t y with l e f t - r i g h t progression continued to characterize C.M.'s work. Switching hands on f ine motor tasks had diminished, but was s t i l l observed on rare occasions. C l i n i c a l l y , balance had made progress as had b i l a t e r a l coordination and motor planning. CM. was enrol led in a sensory integrat ion program for the summer at the community therapy agency and was encouraged to par t i c ipate in a therapeutic r id ing program. The family were able to fol low through on both suggestions and he was enamoured with both these programs, asking re lent less questions as to when he would go to the Centre or to see the r id ing in s t ructor again. The School Report (1984-85) recorded progress throughout the year in Language Ar t s , Math and General Studies. At the th i rd report, CM. had taken more interesing comprehension of s to r i e s , was more focussed in speaking s k i l l s , knew his l e t t e r names and a dozen sight words. The sound-symbol re lat ionships were progressing. CM. was pleased with his progress and always did his best. 131 A recommendation was made for a f ine motor a c t i v i t y program over the summer. CM . had enjoyed a l l the units the class had part ic ipated i n : hel icopters and planes, dragons, seeds and trees. He was integrated into PE with the Grade 1 class and had had a good year. The school-based team report (May 2, 1985) recommended retention in the LAC class as he was learning to read slowly and was very scattered, requir ing small group placement. The school-based team report (January 1986) formulated an Indiv idual ized Education Program (IEP, chronological age 8.6). C.M.'s strengths included integrat ion with peers in Grade 1 gym and demonstration for readiness in some other Grade 1 a c t i v i t i e s . His general knowledge had improved and he had a good s e l f concept and good interpersonal s k i l l s . His needs were for improved f ine motor s k i l l s , organizational s k i l l s when working, constant r epe t i t i o n , much pos i t ive reinforcement and a mu l t i - modal or game approach. The goals set out were: 1. to complete the Grade 1 math program by June 1986, 2. to complete the level 2 Ladybird reading from the On Our Way, Ginn Seri es, 3. to reca l l a l l CBC words and most common combination sentences independently by June 1986, 4. know his personal information, 5. to cut accurately by June 1986. 132 The OT report dated Apr i l 9, 1986 generated the fol lowing problem l i s t : Problem #1 Fine Motor Dysfunction Rhythm, postural adjustment, b i l a t e r a l integrat ion and motor sequencing were s t i l l real areas of d i f f i c u l t y with progress seen. Score on Motor Accuracy (MAC-R) on the r ight and l e f t hands showed performance -1.7 standard deviations below the mean (an improvement since previous MAC-R scores of -2.1 in February 1982). Problem #2 Visual Motor Dysfunction Motor planning had improved and CM . was better able to organize tasks, approaching them in a step-by-step manner. Pr int ing had improved to a functional l e v e l , but had not generalized to copy of unfamil iar forms. Reversals pers i s t and sequencing, organization of l e t te r s into word groupings and between space guidelines were areas of d i f f i c u l t y . Problem #3 Attentional De f i c i t s These continued to i n te r fe re with learning and output, but CM . was less impulsive and better able to se l f -monitor. The plan was to continue weekly intervent ion at school with use of programs and games designed to develop visual motor integrat ion and to enrol l CM. in the sensory integrat ion program again during the summer. 133 APPENDIX B SUBJECT #1: DATA: BLOCK SEQUENCING TASK 134 APPENDIX B Subject f l : Data: Block Sequencing Test Day # 1 2 3 4 5 6 7 8 Baseline (Ai) 21 23 22 23 23 23 23 23 Intervention (Bl) 23 23 28 26 28 29 26 34 Baseline (A 2) 23 26 23 23 22 22 24 22 Intervention (B 2) 26 80 32 28 35 30 31 30 APPENDIX C SUBJECT #1: TEST RESULTS 136 APPENDIX C Subject #1: Test Results Tests Administered 1. Bruininsks Oseretsky Test of Motor Prof ic iency. 2. Developmental Test of Visual Motor Integration (Beery). 3. Durrel l Reading Analys i s . Test Results 1. Bruininsks-Oseretsky Test of Motor Prof ic iency. A battery of subtests to assess motor funct ioning. The mean of the standard scores i s 15 with a standard deviat ion of 5. The composite standard score mean i s 50 with a standard deviation of 10. Standard Gross Motor Subtests Score rank* 1. Running Speed and A g i l i t y 1 2. Balance 1 3. B i l a t e r a l Coordination 4 4. Strength 6 Gross Motor Composite -20 12P l e 5. Upper Limb Coordination 6 Fine Motor Subtest 6. Response Speed 6 7. Visual Motor Control 1 8. Upper Limb Speed and Dexterity 1 Fine Motor Composite -20 l % i l e Battery Composite -20 IX1"1 e 137 2. Developmental Test of Visual Motor Integration A sequence of geometric forms to be copied with pencil on paper. Standard scores have a mean of 10 with a standard deviat ion of 3. Standard Score: 3 % i l e Rank*: 3 % i l e 3. Durrel l Reading Analysis An assessment of ten areas of reading a b i l i t y . Grade Level Oral Reading Low Grade 1 S i lent Reading Low Grade 1 Listening Comprehension Mid Grade 1 Listening Vocabulary Low Grade 1 Word Recognition Low Grade 1 Word Analyses Low Grade 1 Spel1ing Low Grade 1 Sounds in I so lat ion Mid Grade 1 Visual Memory of Words Low Grade 1 Sounds in Words Low Grade 1 Pre reading Phonics A b i l i t i e s Inventories: B *A percent i le range (%^ e) indicates the percentage of the age peers scoring at or below the subject ' s test score. APPENDIX D SUBJECT #1: CLINICAL OBSERVATIONS 139 APPENDIX D Subject #1: C l i n i c a l Observations Day: B i l l CM: 'Are you going to play with me now? Am I f i r s t ? This i s going to be fun! ' LMS: 'Show me how to write on th i s computer.' CM: 'Dunno, ask JM.' (Starts to get out of his seat.) LMS: ' L e t ' s work i t out. We need a plan. Look at the screen. This looks l i k e a desk. We can write (W), type (T), or f i l e (F). What do you want to do?' CM: 'We want to w r i t e . ' LMS: 'Yes, we want the menu for w r i t i n g , so you need to press . . .?' CM: 'We press 'W 1 . ' (Write menu appears.) 'Oh no, tha t ' s wrong, where i s the thing? ' LMS: 'This i s the menu for wr i t i n g . Now you have to choose again. What do you want to do?' CM: 'Write? So I press 'W' again?' (Writing format appears.) 'Phew, there i t i s , I thought i t was broken, no I d i d n ' t , I always knew i t . Did you know i t , did you?' LMS: 'I f igured i t out. ' ( Indicate 'Write to Read' card, f i r s t word: RED.) 'Say th i s word. 1 CM: 'Uh. . . r r r . . . , nope, don 't know i t . ' LMS: 'This l e t t e r says r r r , you 're r i gh t . These l e t t e r s say? 1 (No response.) 'They say ' e d ' . ' CM: 'R-ed, red, I knew tha t . ' LMS: 'What does red mean?' CM: 'You mean l i k e the c o l o r red?' LMS: 'Yes, put i t into a sentence, please. ' CM: 'My new bike i s red . ' 140 LMS: 'Yes, and you can make a whole l i n e of the word red . ' (CM makes a complete, correct l i n e of r -e-d, use of space bar cor rect , use of (L) index for a l l l e t t e r s , appropr iately.) LMS: 'Say the next word.' (FED) CM: 'Dunno.' LMS: ' S ta r t s with . . . ' CM: «F.' LMS: 'And ' f says . . . ' CM: 'Fuh, I dunno.' LMS: 'The f i r s t l e t t e r says fuh, these l e t t e r s say . - . . ? ' CM: ' e d ' , fuh-ed, fuh-ed, fuh-ed. This i s hard, fuh-ed. ' LMS: ' I t says ' f e d ' . ' CM: 'Ok, ok, now where's ' f ?' LMS: 'Home Keys. Fuh.' CM: (Completes l i n e of FED, no er rors , using L index f inger. ) LMS: 'What does fed mean?' CM: ' L i ke when you are fed up?' LMS: 'Make a sentence with ' f e d ' in i t . " CM: 'We fed the ducks. ' LMS: 'Look at the next word.' (LED) CM: ' I t ' , t h a t ' s an ' i ' , t h a t ' s why i t says i t . ' LMS: ' That ' s an ' V , what sound does ' 1 ' make?' CM: ' l u h ' . (Pauses) 'I don't know.' LMS: ' Luh-ed ' . It says ' l e d ' . ' CM: (Completes l i n e of led, no er ror s , ' 1 ' on (L), ' ed ' on R index.) LMS: 'Say the next word.' (WED) CM: ' W u h - 1 1 1 1 . ' 141 LMS: 'What sound does i t s ta r t with? ' CM: 'Wuh.' LMS: 'And these l e t t e r s say. . . ?' CM: 'ed. . . wuh-ed, wuh-ed, dunno.' LMS: ' I t says 'wed ' . What does 'wed' mean?' CM: 'I said I don 't know!!!' LMS: 'When you get married, you wed someone, l i k e at a wedding.' CM: 'My parents are married. Where's 'w ' ? ' LMS: "Mr. Qwert's house.' CM: (Types wed with L index, no errors. ) LMS: 'You are working hard. Say the next word.' (BED) CM: 'Duh--, buh--, duh—, okay t e l l me, is that ' b ' or ' d ' . . . ?' LMS: 'The f i r s t l e t t e r says buh, and these l e t t e r s say . . . " CM: 'I said I fo rgot . ' LMS: 'They say ' - e d ' . Try i t . ' CM: 'Duh-ed. Can we play a game?' LMS: 'This word says ' b e d ' , you say i t . ' CM: ' ' B e d ' , l i k e you sleep i n . I sleep in a bed, you know.' (Confiding tone. Completes l i n e of ' b e d ' , L index used co r rec t l y . ) LMS: 'What does th i s sentence say?' (Ted had a red bed.) CM: 'The . . . ' LMS: 'The f i r s t l e t t e r says . . . ' CM: 'Tuh. ' LMS: 'And these l e t t e r s say . . . " CM: ' - e d , tuh-ed, tuh-ed, the . ' LMS: ' I t says ' T e d ' . ' 142 CM: 'I knew that. Ted had a red ded. What i s that? ' LMS: 'Bun. ' CM: " B e d ' , yeah, yeah. Ted had a red bed. ' LMS: 'Good work, the sentence says Ted had ( indicate 'had ' ) a red bed. Now you can copy the sentence.' CM: 'T-e-d space h-a-d space a space r-e-d b-e-d. ' (Verbal mediation, saying l e t t e r names.) LMS: 'Now you can copy i t again. ' CM: ' ' T e d ' , I remember that, i t ' s in my book.' (Continues to copy, gets to bed and types deb, recognizes error and corrects by delet ing and re-entering.) 'What do you want bed to s ta r t with? ' LMS: 'Buh. ' CM: 'But t ha t ' s a ' d ' ! ' (Bashes on the keyboard.) 'Oh! that word... Ok, I f ixed i t . Ok, what do we do, what do you want, what do I do?' LMS: 'Now you can p r i n t . Do you know how?1 CM: 'We have to ask JM.' LMS: 'I think we can work i t out. Press 'escape' to get back to the menu. There's the desk, what do you want to do?' CM: 'Type?' LMS: 'What sound do you hear in ' t y p e ' ? ' CM: ' ' Tuh ' - ' t ' . ' (Presses ' t ' and the type menu appears.) 'I remember, #4.' (Types #4 and next frame appears.) 'Now what?' LMS: (Indicates ' r e t u r n ' . ) ' I t says 'press r e t u r n ' . ' CM: 'I know, I know.' (Presses ' r e t u r n ' and copy i s printed.) LMS: 'Look at th i s good work!' CM: 'Yep! ' 143 Discussion CM's agitated manner i s evident in t h i s sample. He recognizes the i n i t i a l consonant and then guesses with another word beginning with the same consonant. Confusion between ' b ' and ' d ' and T and ' i ' pers i s t s . He i s able to problem-solve his way through the word processor command sequences, although unfamil iar s i tuat ions are met with horror-str icken responses and he requires d i r ec t i on . Fami l i a r i t y with sequence of word processor commands i s evident as he understands that ' t ype ' on the menu means ' p r i n t ' . The handwritten sentence contains b/d confusions and reversa ls , upper and lower case l e t t e r s and total reversal of BED (DE ). 144 Day: Bl#8 CM seats himself at the computer and goes through the sequence to get into the wr i t ing format of the word processing program independently. He ta lks his way through the sequence. CM: 'W.' (Types 'w ' . ) 'Wuh.' (Types 'w ' . ) 'Number four-four-four (repeats as he scans for the key) and re turn . ' (Checks the screen for the correct format.) 'OK, I'm i n , now what?' LMS: 'Say the f i r s t word.' CM: ' C an ' t . ' (Refuses before he looks at the word.) LMS: 'The f i r s t l e t t e r says . . . ' CM: 'gun. ' LMS: 'Yes, and these l e t t e r s say 'urn', 'guh-um'. You t r y i t . ' CM: ' 'Guh-muh'. I said I c a n ' t ! ! ' LMS: "Guh-um'. Gum.' CM: ' 'Gum, gum, gum'. Yep, I knew tha t . ' LMS: 'What does 'gum' mean?' CM: 'Means yeh ead i t . ' LMS: 'Can you use the word in a sentence?' CM: 'No! I have the gum and I eat i t . That 's what I s a i d . ' LMS: 'And you were r i gh t . Type a l i n e of 'gum'. ' (CM begins to type using the l e f t index for 'G ' and the r ight index for 'urn'.) 'GUh- um, guh-um, guh-um.' (CM stops typing when the verbal cueing stops and s tarts to play with the d i rect iona l arrow keys, moving the cursor back and fo r th across the screen.) 'Guh-um.' (CM i n i t i a t e s with cue and types an error: 'GTUM'.) CM: 'Oh, no! Did you see t ha t ! ' (Uses the d i rect iona l arrows to move the cursor to the r ight of 'T ' and deletes i t , but has d i f f i c u l t y re-a l ign ing the cursor at the end of the word and leaves a big space. LMS shortens the space with the d i rect iona l keys and CM continues working qu ick ly , now using the l e f t index for 'G ' and the r ight index for 'urn'.) CM: ' F i r s t I go slow and then I go f a s t . ' (Continues with 'u-m' sequence becoming more rapid.) 'Holy smokes! Am I f in ished? I 145 d idn ' t know!!' (Starts to use d i rect iona l arrows to move cursor on to the next 1ine.) LMS: 'Press ' r e t u rn ' for the next l i n e . ' CM: 'No! I don't wanna (beguiling impish g r i n ) . This works jus t as good.' LMS: 'The ' r e t u r n ' button t e l l s the pr inter to s ta r t a new l i n e . It w i l l a l l be on one l i n e when you pr int i t . ' CM: 'No i t won't! See, i t looks good now.' LMS: 'We talked about th i s yesterday. Your printout w i l l a l l be on one l i n e , unless you press ' r e t u r n ' . ' CM: 'So! Who cares! It looks good!!' LMS: ' I t ' s your work. We ' l l check i t when we pr int and you can decide. Say the next word.' CM: ' 'Ha-yuh-muh, ha-yah-muh, ha-yuh-muh'. What i s i t ? ' LMS: 'This l e t t e r says ' huh ' . These l e t t e r s say 'urn'. 'Huh-um'. 'Hum'. ' CM: 'Huh-um. Hum.' LMS: 'What does 'hum' mean?' CM: 'Means what you do when you hum. I don't know what i t means.' LMS: 'You ' re r i gh t , a hum i s l i k e t h i s . ' (Demonstrates hum.) CM: 'Yuh, l i k e t h i s : hum-hum-hum.' (Hums in a musical sort of way and then i n i t i a t e s 'H-U-M' with the r ight hand.) LMS: 'Huh-um, huh-um, huh-um.' (CM continues to end of l i n e and presses ' r e t u r n ' . He types with gross exaggerated staccato movement, typing faster and fas ter . ) LMS: 'What word are you typing? ' CM: 'Hum.' LMS: 'Can you make a sentence using 'hum'? ' CM: 'Don't know. I never hum!' LMS: 'You did i t . Say the next word.' 146 CM: "Buh-yuh-muh 1. I need help. Is that a ' b ' or a ' d ' ? ' LMS: 'This l e t t e r says ' buh ' , these l e t t e r s say 'urn'. 'Buh-um'. •Bum'.' CM: ' I t says 'bum'? 'Buh-um'. ' (Looks at the word.) LMS: 'What does 'bum' mean?' CM: ' I t ' s your bum. You go poo. You s i t on i t . 1 LMS: 'Yes, you ' re r i g h t . ' (CM i n i t i a t e s typing without cueing using the l e f t index for 'B ' and the r ight index for 'urn'. He turns on CAPS LOCK.) 'You don't need CAPS LOCK.' CM: 'Yes I do. Is that a ' B ' or a ' D ' ?' (Releases CAPS LOCK.) LMS: ' I t says ' b u h ' . ' CM: ' ' B u h ' . I hate 'buh*! ' LMS: 'Buh-um, buh-um, buh-um.' CM: (Breaks up laughing.) 'That ' s pretty funny, eh?' (Continues typing.) 'Buh-um, buh-um.' (Talks himself through the rest of the sentence and presses ' r e t u r n ' . ) LMS: 'Good work! Look at the next word. It says . . . ' CM: 'Buh-y-muh.' LMS: (Indicates word.) 'This i s the next word.' CM: ' ' Duh ' . I need help. ' LMS: 'These l e t t e r s say ' d r ' , these say 'urn'. 'Dr-um'. 'Drum 1. ' CM: 'That ' s drum, you mean l i k e a drum you h i t ? ' LMS: 'Yes, can you make a sentence?' CM: 'I h i t the drum!' (Proceeds to type, preferr ing to use the l e f t or r i ght index, but not a l ternat ing DR ( l e f t ) and UM ( r i gh t ) . No t a c t i l e cueing used as he appears agitated and i r r i t a b l e . ) LMS: ' 'Dr-um, dr-um, dr-um'. Try the l e f t f inger for 'DR' and the r ight f inger for 'UM'.' CM: 'I c a n ' t . ' (Continues to type, making sequencing and spacing er rors , t a l k ing to himself as he corrects.) ' Jus t use the 147 arrows.' (Completes an er ror - f ree l i n e and uses repeated d i rect iona l arrow key to bring the cursor to the next l i n e . ) LMS: 'Try ' r e t u r n ' . ' CM: 'No! ' (At th i s point the f i r e be l l rings and CM jumps up.) 'We've got to get out or w e ' l l burn!! ' (CM i s reassured and the f i r e d r i l l proceeds.) (Ten minutes l a t e r we return to the computer.) LMS: 'Say the next word.' CM: ' 'Puh-yuh-muh'. I need help. ' LMS: 'These l e t t e r s say ' p T , these say 'urn*. ' P l - um ' . ' P l um ' . ' CM: ' I t says plum?' LMS: 'Yes, what's a plum?' CM: 'Plum, you eat a plum.' LMS: 'Can you make a sentence using plum?' CM: 'Dunno. When you get one, you get one in your lunch. A pi urn is in my 1unch!' LMS: 'Good work. 'Pl-um, pl-um, p l -um ' . ' (CM types using the r ight index f inger and makes reversal er ror : ' p l um ' , recognizes i t and deletes. D i f f i c u l t y grading delete button and wipes out whole word.) 'Try again, ' p l - u m ' . ' (Re-enters and puts space between ' p i ' and 'urn'. Deletes and f in i shes co r rec t l y , pressing return.) LMS: 'Good for you, that was hard work! What does th i s sentence say?' (Keep the gum on the drum. CM skims through the sentence recognizing ' t he ' and subst i tut ing ' o f for ' on ' . ) CM: 'Don't know. Say i t so I can read i t . ' LMS: 'Keep. ' CM: ' . . . the . . . (looks) forgot . ' LMS: 'Gum.' CM: 'Gum of . . . ' LMS: 'On. ' CM: 'On the . . . (looks) forgot . ' 148 LMS: 'Drum.' CM: 'Drum. Keep the gum on the drum.' LMS: 'Good work, now you can copy the sentence.' CM: (Begins, using sh i f t -K for capita l K.) ' S h i f t - K . ' (Proceeds through the sentence and recognizes 'gum'.) 'I already did that one!' (Proceeds co r rec t l y , places a period at the end of the sentence and presses ' r e t u r n ' . ) LMS: 'That ' s r i gh t . Once more please. ' CM: (Proceeds co r rec t l y again, with an error in 'gum': 'gnm' and three extra spaces before ' on ' . ) 'Now I p r i n t , r i gh t ? 1 (Proceeds through the pr int sequence co r rec t l y and pr ints his copy.) LMS: ' L e t ' s look at your work.. CM: (Recognizes alignment d i f ference.) 'What happened?' (In absolute di smay.) LMS: ' L e t ' s look at the work on the screen. ' (Puts work back on to monitor. I t looks aligned co r rec t l y . ) CM: 'See! I to ld you i t was OK!' LMS: 'CM, i t looks OK on the screen, but not on the paper. What do you think happened?' CM: 'Return? Aw-w-w.' (Sheepish gr in and laughs.) LMS: 'See you next t ime. ' CM: 'Bye, see you . . . ' Discuss ion Several word processing functions are performed without errors . These are: access to wr i t ing format, pr int ing sequence and use of l e f t and r ight d i rect iona l arrows to move the cursor and delete extraneous l e t t e r s within words. Letter reversals are corrected by delet ing both l e t t e r s and re- enter ing. The ' s h i f t ' function for cap i ta l s i s used with verbal cueing, however, spontaneous c ap i t a l i z a t i o n i s done with CAPS LOCK. 149 CM uses phonetic decoding and verbal mediation to ta lk himself through the word processing sequences. He recognizes l e t t e r errors and visual format errors by visual inspection. CM attempts to decode by pronouncing a l l the l e t t e r s he sees, but did not decode any words independently. He asks for help appropriately on some examples and lashes out in f ru s t ra t ion on others. Confusion about ' b ' and ' d ' i s noted; CM prefers to deal with upper case l e t t e r s for 'B ' and ' D ' . He i s confused by the lower case printout using uppercase l e t t e r i n g on the l e t t e r keys. Use of ' r e t u rn ' i s sporadic, sometimes spontaneous, other times he pers ists with d i rect iona l arrows. He remembers the nature of his error when the results of not using ' r e t u r n ' are demonstrated. He i s able to use a l ternat ing hands on 3 - l e t t e r words, but has d i f f i c u l t y switching hands in 4 - l e t te r words. He demonstrates an i r r i t a b l e a f f e c t , but w i l l laugh and joke as w e l l . CM was unable to read the sentence in the lesson, recognizing ' t h e ' as a sight word. When he copied the sentence, he reca l led the sequence of ' gum'. The handwritten sample omitted the ' p ' in 'keep' as well as ' t h e ' . The ' u ' in gum was inverted and th i s may have been as a resu l t of copying the second typewritten sentence, which contained the same er ror . CM ran out of space and crowded 'drum' together with the 'urn' on top of the ' d r ' . CM was able to decode the i n i t i a l consonant of each word. When the word was broken down phonet ical ly, he was not able to produce the word from i t s parts. 150 Day: B2#l CM: 'Now the computer?' LMS: 'Get the computer ready, CM.' CM: 'Where's ' w ' , w-w-w.' (Scanning the keys hor i zonta l l y with his f inger . Keeps scanning, seems to be playing.) LMS: 'Try Mr. Qwert's house.' CM: 'Wuh, here i t i s and now I press again, r i gh t ? ' (Writing format appears.) LMS: 'What does th i s word say?' CM: duh. Nope. LMS: 'This l e t t e r says duh - these l e t t e r s say ' e n ' . Duh-in. It says den.' CM: ( I n i t i a te s typ ing, preferr ing one-handed approach.) LMS: 'Decide which f ingers to use, CM.' CM: (CM s tar t s using both pointers on each key, g iggl ing and making eye contact with LMS, i n v i t i n g LMS to go along with his ' s i l l y ' behavior.) LMS: (Tact i le cueing.) 'Duh-en, duh-en, duh-en.' CM: (Settles down, using both hands appropriately and locat ing l e t t e r s qu ick ly . ) Duh-en, duh-en (Completes a l i n e and uses arrows to send cursor to the next l i n e . ) LMS: 'What's another way to s ta r t the next l i n e , CM?' CM: 'Press re tu rn . ' (Giggles, eye contact with LMS.) LMS: 'How are they d i f ferent ? * CM: (Proud to display knowledge.) 'We l l , return t e l l s the pr inter when to s ta r t over, you know, or else i t can ' t know.' LMS: 'Do you want to t e l l the pr inter now?' CM: 'Yep. ' (Happily h i t s return, looks around at a d isrupt ion in the c las s . ) LMS: 'What does the next word say?' 151 CM: 'Demit ' . LMS: 'This l e t t e r says duh, these l e t t e r s say ' e n 1 . Tuh-en. Ten. What's ten? ' CM: 'You know, t en . ' Like counting. ' Geez, don't you know ten?' (Laughs.) 'Where's ' tuh ' ? * LMS: 'Mr. Qwert's house.' CM: (Use of r ight hand to reach for T, t a c t i l e cur ing, switches to l e f t hand for T and E, and responds to t a c t i l e cueing to switch to N with the r ight hand.) LMS: 'Tuh-en, tuh-en, tuh-en. ' CM: (Continues) 'Tuh-en, space, tuh-en, space.' (To end of l i n e , eye contact with LMS as his f inger hovers over the d i rect iona l arrows and he presses return.) LMS: 'You remembered! What a guy! What does the next word say?' CM: 'puh-n, puh-n-t. What time i s i t ? ' LMS: 'This l e t t e r says?' CM: ' puh ' . LMS: 'These l e t t e r s say ' e n ' . Puh-en. Pen. What's a pen?' CM: 'You wr ite with i t . Where's 'puh ' ? ' ( I n i t i a tes typing, unresponsive to t a c t i l e cueing, use of r ight index.) LMS: 'Try th i s hand (touch) for 'puh' and th i s one for ' e ' (touch) and th i s one for ' n u h 1 . ' CM: 'Nope. Too hard. Puh-en-space-puh-en-space-puh-en-space (to end of l i n e ) . Now return . ' (Smiles encouragingly at LMS.) LMS: 'You remembered. The next word says?' CM: MINEK LMS: 'This l e t t e r says ' m ' , these l e t t e r s say ' e n ' . M-en. Men. It says 'men'. CM: 'What's that mean?' LMS: 'You say one man, you say two men.' CM: 'Two of them?' 152 LMS: 'Yes. Can you make a sentence using men?' CM: 'Them.' LMS: 'Two men sat down in two cha i r s . ' CM: (Pensive.) 'Yeah. ' LMS: 'Try th i s hand ( t a c t i l e cue) for 'm-m', th i s hand ( t a c t i l e cue) for ' e ' and th i s hand for ' n - n ' ( t a c t i l e cue). CM: (Goes ahead with r ight index only, no response to cueing.) 'I want to just use one hand. Me. That spe l l s me.' LMS: 'You ' re r i gh t . Put an ' n -n ' at the end and i t says 'men'. Mm- en. Mm-en, mm-en.' CM: (Continues with correct sequence and spacing with one f inger . Presses return. Starts drawing his f inger along the keys, they make a c l i c k i n g sound, seem l o s t , waiting for in s t ruct ions . ) LMS: 'Good work, CM. This word says?' CM: 'hai yuh. ' LMS: 'This l e t t e r says ' huh ' , these l e t t e r s say ' e n ' . Huh-en. Hen. It says hen. Do you know what a hen i s ? ' CM: 'Nope. A hen i s a chicken. ' LMS: ' That ' s r i gh t . Have you ever seen a chicken? ' CM: 'Yeah, I 've seen one. A l ive and dead.' LMS: 'Which hands are you going to use to type the l e t t e r s ? ' CM: 'This one.' (Uses r ight hand to type, using a high elbow and staccato s t y l e , presses return.) 'Huh-en, huh-en.' LMS: 'Here ' s the sentence. What does i t say?' (Ten men chased the red hen.) CM: 'The. ' LMS: (Pointing to each word.) ' " T " - en . Ten. Ten-mm-en chased.' CM: ' t h e . ' LMS: 'You ' re r i gh t . Ten men chased the red hen.' 153 CM: 'Now I type? Sh i f t -T . Right? ' (Types slowly through, using the l e f t hand for 'ased ' and the r ight hand for a l l the other keys.) And a period at the end and return. Type again. Sh i f t -T . (Types slowly through again.) 'Now I p r in t . What do I do?' LMS: Escape to the desk.' CM: (Complies.) 'Now what? LMS: Do you want to wr i te , type or f i l e ? ' CM: 'Type?' (Look at LMS for approval.) LMS: 'Try i t . CM: (Presses T.) 'Now #4 and re tu rn . ' (Pr inter types work.) Discussion After a two-week period of no intervent ion, CM reca l l s the word processor sequence to get into the wr i t ing format. He recognizes i n i t i a l consonants and some indiv idual l e t t e r sounds within the word, but gives up on the rest of the word, or adds in extra sounds (puh-n-t). He recognizes sight words (me, the). CM requires d i rec t ion to stay on task and some ' s i l l y ' behavior i s noted throughout the session. He avoids a l ternat ing hands for each l e t t e r (MEN), but w i l l use hands together i f there i s a l e t t e r sequence using two l e t t e r s with the same hand He has retained the information regarding the function of ' Re tu rn ' , although spontaneously he reverts to d i rec t iona l arrow use. He requires d i rec t ion for th i s at the beginning of the session and then incorporates 'Return ' into the rest of his work for the remainder of the sess ion. (T/EN). 154 He has retained the sh i f t -T command for c ap i t a l i z a t i on and abandoned CAPS LOCK. Keyboard Town cues seem to a s s i s t with le t te r -key l oca t ion . CM requires guidance through the pr int sequence, but has retained the l a s t two stages (#4 and return). The handwritten sample contains e r r a t i c l e t t e r i n g with a reversed ' e ' in the f i r s t ' t h e ' . The word 'men' i s l e f t out altogether, represented by a s o l i t a r y ' e ' which a l l i e s i t s e l f to ' t e n ' g iv ing i t the appearance of ' t e n e ' . There i s e r r a t i c spacing between the words and the sample presents as an undi f ferent iated s t r ing of l e t t e r s . 155 Day: B2#8 CM: (Uses word processor commands to get into wr i t ing mode without d i r e c t i on , looks at f i r s t word.) ' S top. ' (Proceeds to type with his r ight hand.) 'You stop at a stop l i g h t . ' LMS: (Introduces d iv ider . ) 'Try two hands, CM.' CM: (Hesitates, ret icent to use two hands, but complies and continues cor rect l y with no spacing, targett ing or reversal er rors . Presses return.) 'Huh-y, op, huh-y-op. I don't know. You have to t e l l me.' LMS: 'This l e t t e r says huh, these say ' o p ' . Huh-op. Huh-op.' CM: 'Huh-op. So what!' LMS: 'The word says, ' hop ' , CM.' CM: 'We l l , why d i dn ' t you say so! Like a bunny hops. Now I have to do t h i s . Huh-op, huh-op.' (Uses verbal mediation, correct use of r ight hand and spacing. Presses return.) 'What does the next one say?' LMS: 'You look at i t . ' CM: 'How am I supposed to know? 'OP ' . There, I said i t . ' LMS: 'This l e t t e r says ' t ' , these say ' o p ' . Tuh-op.' CM: 'Tuh-op, tuh-op, what kind of word i s that? ' LMS: 'CM, I think you can t r y harder on these words.' CM: 'Ok, ok, top ! ' (Types with two hands co r rect l y . ) 'Tuh-op.' (Finishes l i n e without errors and presses return.) LMS: 'What does ' t op ' mean, CM?" CM: 'We l l , you have the bottom and you have the middle, and you have the top. The bottom's down here and the top ' s up here. ' LMS: 'Can you use the word ' t op ' in a sentence, CM?' CM: ' E rn ie i s on top of the computer.' (Points to muppet on top of computer and laughs.) 'That ' s a sentence!' LMS: ' I t sure i s . Good for you. ' CM: 'No one i s perfect, r i gh t ? ' (Looks anxiously at LMS.) ' ' c e p t for one. You know. Him!' 156 LMS: 'You mean God?' CM: 'Yeah. God's per fect . ' (Shakes his head sadly.) 'My legs don't work, you know.' LMS: 'They work ok, CM. Legs get better with p rac t i se . ' CM: 'I have! I have! I pract ise a l l the time. So I'm going to get a new pa i r . Cut 'em o f f r ight here ( indicates mid thigh.) 'and get a doctor to hook 'em up again, and then t h e y ' l l work bet te r . ' LMS: 'I don't think i t words that way, CM. The legs we get are the legs we always have. We keep them and do our best. 1 CM: (Sad) 'Yeah, my mom says that, too. She says ther ' good enough for her. ' LMS: 'They 're good enough, CM.' CM: 'Yep. ' (More matter of f ac t . ) 'Next word. Puh-op. OP? I need help. ' (Unable to combine the sounds into a meaningful word.) LMS: 'Pop. Puh-op. Pop.' CM: 'Oh, yeah, l i k e pop goes the weasel. ' LMS: 'Can you use 'pop' in a sentence?' CM: 'A balloon goes pop.' (Snickers) ' I t r e a l l y goes BAM!!' (Hi lar ious giggles.) 'And boy, they jump r ight up!' (Gales of laughter.) 'Oh, boy... ' (Recovers himself, wipes his eyes.) 'Now what do we do here Pop. OK.' ( I n i t i a te s with r ight hand cor rect l y and continues with accurate spacing, and no errors , presses return at the end of the l i n e . ) LMS: 'Puh-op, puh-op, puh-op.' CM: 'Next word. Muh-op. Mm-buh-op. Don't know.' LMS: 'Mop. Mm-op. Mop.' CM: 'Oh, year . . . Heh, I get to do i t with one hand.' (Types rap id ly making errors and a l ternat ing correct ion strategies between tota l word delet ion and use of d i rect iona l arrows. He f in i shes the l i n e co r rec t l y and presses return.) LMS: 'What i s a mop, CM?' CM: 'Oh, you clean with i t . Squeeze i t out in a bucket. ' LMS: 'Use the word 'mop' in a sentence.' CM: 'Mop up the mess.' LMS: 'Well done.' CM: (Scans the sentence.) 'The only word I know here i s ' t h e ' . ' LMS: ' S ta r t at the beginning. ' CM: 'Come ' LMS: 'Can. ' CM: 'Can op. ' LMS: 'Pop. ' CM: 'Can Pop hop oh-va iv. . . don't know ' LMS: 'Over. ' CM: 'Can Pop hop over the mop.' (Scans again.) ' S h i f t C, Sh i f t P, r i ght ? ' LMS: ' R i ght . ' CM: (Types accurately using ' s h i f t ' funct ion, uses d i rect iona l arrows to correct spacing error. On the second copying, he makes a targett ing e r ror , h i t t i n g the arrow. Impulsively he h i ts the return button and the whole display sh i f t s down one l i n e , breaking in the middle of the l i n e . Very calm.) 'I don 't think I can f i x t h i s , LMS.' LMS: 'That ' s a hard problem, CM. Let me help you. ' (LMS corrects error and CM proceeds with the rest of the sentence co r rec t l y . ) Discussion CM. i s quite confident with the word processing functions of the computer. He uses both word delet ion and d i rec t iona l arrow/space bar strategies to correct his errors. He has abandoned CAPS LOCK for c ap i t a l i z a t i o n and presses return cons i s tent ly at the end of each l i n e . CM . had d i f f i c u l t y combining l e t t e r sounds on th i s session and exhibited a discouraged approach to the task. He scanned the sentence for 158 f am i l i a r sight words f i r s t and then made a good attempt to read the whole sentence, f inding more fami l i a r words than he had seen at f i r s t . CM. used verbal mediation while typing two items (hop and top). He asked for help appropriately when his targett ing error reoriented the ent i re visual display and did not exh ib i t his usual i r r i t a b l e manner when he knew the s i tuat ion was beyond his con t ro l . He prefers to type with one hand, but can be directed into b i l a t e r a l hand use. The handwritten sample i s almost indecipherable with large scrawling l e t t e r s , perseverance on ' v 1 , making i t into a 'w' and no recognizable word groupi ngs. APPENDIX E SUBJECT #1; MOTOR SKILLS: VIDEO DISCUSSION 160 APPENDIX E Subject #1: Video Discussion These motor s k i l l s were selected to show balance, bi lateral motor coordination, movement patterns, eye/hand coordination and fine motor sequencing. The s k i l l s were based on selected subtests of the Bruininsks- Oseretsky Test of Motor Proficiency. C M . was fatigued and i r r i t a b l e on the day of the f i lming, and this may have affected his perseverance at d i f f i c u l t tasks. C.M.'s balance was poor, with poor trunk s tab i l i ty and foot placement in balancing tasks. His quality of movement was poor, showing internal rotation of the lower extremities and a scissoring gait . There was l e f t -r ight confusion on tasks requiring bilateral motor coordination, and d i f f i cu l ty following complex motor directions. C M . tended to lose his balance forward on these tasks and demonstrated a discouraged task approach. The jumping and touching heels tasks fed into C.M.'s primitive motor pattern of internal rotation and flexion of the lower extremities. He was unable to differentiate from this pattern by reaching down to his heels. Performance on the broad jump was adequate, but C.M.'s poor balance interfered with the necessary weight shift ing required to make any distance. Spontaneous movement shows s i t t ing in 'reverse W pattern and movement through 'bunny hopping', reflecting low muscle tone and persistent primitive movement patterns. Ball s k i l l s were performed more enthusiastically. Catching, throwing and bouncing the ball showed some performance success. 161 CM. was unable to keep his hips extended during the push-ups and used hip f lex ion to approximate task expectations. This, again, r e f l ec t s use of his pr imit ive movement pattern. He collapsed through his shoulders on th i s task, showing poor shoulder strength and s t a b i l i t y . Sit-ups re f lected poor abdominal strength, and CM . grasped the examiner's yard s t i c k to pull himself up rather than use his weak abdominal muscles. Running showed good a l ternat ing movement with some l i m i t a t i o n in s t r ide length, determined by lower extremity internal ro ta t ion . Targetting with a ba l l was poor and showed l im i ted success. There was no i so lated movement in thumb-finger touching. APPENDIX F SUBJECT #2: CASE HISTORY 163 APPENDIX F Subject #2: Case History Name: O.R. Date of B i r t h : August 3, 1979 Chronological age: 6.10 years O.R. i s the youngest son of two boys, the oldest son i s 12 years o ld . Mrs. R. was o r i g i n a l l y from Prince Edward Island and graduated from un ivers i ty in 1972 with a B.Sc. in Biology. When O.R. was i n i t i a l l y diagnosed with minimal cerebral palsy and b i l a t e r a l club feet , his mother raised funds from various service clubs in order to take him for patterning therapy at the In s t i tu te for the Achievement of Human Potential in Ph i lade lph ia, Pennsylvania. Mrs. R. i s a s ing le parent and has been on ass istance, taking t ra in ing in a Computer Systems Technology program. She i s presently employed. She was described as being knowledgeable about cerebral palsy, having r e a l i s t i c expectations, adequate parenting s k i l l s and receptive to par t i c ipat ing in O l i v e r ' s therapy (Social Services Report, July 3, 1985), with no problems to warrant Social Services intervent ion. The Day Care Report of May 1985 stated that O.R. had attended the Day Care since September of 1985. He was described as having mild CP with club feet . He wore a special brace and special shoes. There had been surgery for correct ion of the foot deformity and he had recovered w e l l . O.M. was reported to interact well with other ch i l d ren , having close re lat ionsh ips with male fr iends his own age with whom he enjoyed playing 164 Superman and Batman. He often f e l t that he could not do a task and exhibited a discouraged approach to d i f f i c u l t tasks. Cogn i t ive ly , the c l i n i c a l impression was that he was s l i g h t l y behind. He missed l e t t e r s in the alphabet song, having had a d i f f i c u l t time with alphabetical and numerical sequences. In May of 1985, he recognized a l l l e t t e r s by t he i r l e t t e r names except 'X ' and ' Z' and could count to "about 9 or 10". O.R. did not attend kindergarten with in the School Board, attending Day Care for his kindergarten year. His physical d i s a b i l i t y manifested as a limp in running and walking. He was not independent in taking his shoes on and o f f . He had an awkward and imprecise pencil g r ip . O.R. was described as a f r i end l y ch i l d who tended to attach to new s t a f f , and showed gentleness and concern for other ch i ldren. He tended to shy away from new s i tuat ions and to adopt a helpless a t t i tude. He preferred adult assistance but responded to pos i t ive enouragement. Language development was described as adequate, although there was some s lu r r ing of his words and drool ing as a resu l t of his cerebral palsy. He learned best in small groups and tended to be intimidated in a larger group with other chi ldren who ea s i l y grasped the material being presented. He required extra time from the teacher. Areas for improvement were w r i t i n g , pencil con t ro l , self-confidence and alphabetic and numerical sequences. The Day Care recommendations were that he receive l o t s of pos i t ive encouragement and l i t t l e assistance for w r i t i n g , dressing and shoes. Psychological assessment (School Board report, Apr i l 29, 1985) found O.R. to be functioning with in the normal range on the Weschler Preschool 165 and Primary Scale of Intel l igence (WPPSI) with scores for verbal performance f a l l i n g in the average range (subtest mean: 11) and performance a b i l i t y in the low average range (subtest mean: 8). There was a scatter of scores in the Performance area with lowest subtest scores of 6 on Mazes and Geometric Design, and the highest subtest score on Block Design. Overall performance was pulled up by Block Design, a more concrete task. Poor performance on the Geometric Design subtest was consistent with poor perceptual motor performance on the McCarthy Scales (16%i^ e) and the VMI with an age equivalent of 4.4 at a chronological age of 5.8, a delay of one year, four months. Recommendations at that time were for occuptional therapy for visual motor s k i l l s and pencil pract ice; puzzles, for experience in pieces to make the whole, looking for c lues, things that match; a program for gross motor s k i l l s . He was found to have some a r t i c u l a t i o n problems and some auditory sequencing d i f f i c u l t y in remembering things in order. He was referred for learning assistance in non-verbal s k i l l s and therapy services at a community-based therapy agency. The medical re fe r ra l l e t t e r to the community therapy agency (June 14, 1985) stated that O.R. would "benef i t from physiotherapy and occupational therapy for his hands and f e e t " . Therapy assessment went ahead and a Problem-Oriented Medical Record was generated (August 25, 1985). "Problem List Problem #1 Poor Gait Pattern 166 Problem #2 Decreased Strength and Endurance Plan To in i t ia te a physiotherapy program in September, after surgery on the l e f t ankle. Problem #3 Fine Motor Deficit Plan Varied exposure to manipulative materials such as construction paper and play dough, with emphasis on bi lateral input. A t r i a l of a triangular pencil grip to f ac i l i t a te pencil control was suggested as well as use of larger scale writing and drawing materials. Problem #4 Perceptual Motor Dysfunction Plan Kinesthetic input to f a c i l i t a te motor learning, especially in the area of pencil s k i l l development. Eye tracking exercises. Work sheets with mazes, dot-to-dot and tracing ac t i v i t i e s . Act iv i t ies requiring spatial discrimination and design, visual closure and visual memory." The speech and language report found some mild art iculat ion problems, but no language de f i c i t s , and concluded that no speech therapy was indicated (Speech and Language Report, August 15, 1985). The School Board Team report of March 13, 1986 indicated that O.R. s t i l l required one-to-one assistance for fine motor sk i l l s and had no real understanding of numbers greater than ten. His printing was showing some improvement and he had progress to the third level of the Ginn reading program. The team fe l t that the chi ld was s t i l l quite play-oriented and required a longer period in Grade 1, recommending retention. 167 APPENDIX G SUBJECT #2: DATA: BLOCK SEQUENCING TASK 168 A P P E N D I X G Subject #2: Data: Block Sequencing Test Baseline Intervention Baseline Intervention D f l y ' (Al) (Bi) (A 2) (B 2) 1 23 32 31 23 2 27 30 17 30 3 26 30 15 20 4 31 30 25 18 5 28 25 26 26 6 31 25 26 24 7 32 36 25 26 8 32 26 16 26 APPENDIX H SUBJECT #2: TEST RESULTS 170 APPENDIX H Subject #2: Test Results Tests Administered 1. Bruininsks Oseretsky Test of Motor Prof i c iency. 2. Developmental Test of Visual Motor Integration (VMI) 3. Durrel l Reading Analys is. Test Results 1. Bruininsks-Oseretsky Test of Motor P ro f i c iency . A battery of subtests to assess motor funct ioning. The mean of the standard scores i s 15 with a standard deviat ion of 5. The composite standard score mean i s 50 with a standard deviat ion of 10. Gross Motor Subtests 1. Running Speed and A g i l i t y 2. Balance 3. B i l a te ra l Coordination 4. Strength Gross Motor Composite 5. Upper Limb Coordination Fine Motor Subtest 6. Response Speed 7. Visual Motor Control 8. Upper Limb Speed and Dexterity Fine Motor Composite Battery Composite Standard Score 2 1 7 8 20 4 6 14 10 36 21 I 1 1 * rank* 1X11 e - W i l e 171 2. Developmental Test of Visual Motor Integration A sequence of geometric forms to be copied with pencil on paper. Standard scores have a mean of 10 with a standard deviat ion of 3. Standard Score: 7 SS^e Rank*: 24%ile 3. Durrel l Reading Analysis An assessment of ten areas of reading a b i l i t y . Grade Level Oral Reading Low Grade 1 S i lent Reading Low Grade 1 Listening Comprehension Low Grade 3 Listening Vocabulary Low Grade 1 Word Recognition Low Grade 1 Word Analyses Low Grade 1 Spel1ing Low Grade 1 Sounds in I so lat ion Mid Grade 2 Visual Memory of Words Mid Grade 1 Sounds in Words Low Grade 1 Pre reading Phonics A b i l i t i e s Inventories: A/B *A percent i le range ( % i l e ) indicates the percentage of the age peers scoring at or below the subject ' s test score. APPENDIX I SUBJECT #2: CLINICAL OBSERVATIONS 173 APPENDIX I Subject #2: C l i n i c a l Observations Day: Bl#l OR: ' I ' v e been on the computer before in the afternoon with Miss A.' LMS: 'Can you show me how to write on th i s computer?' OR: 'No. ' LMS: ' L e t ' s work i t out. This looks l i k e a desk. We can write ( indicate ' w ' ) , type ( indicate ' t ' ) or f i l e ( indicate ' f ) . What do you want to do?' OR: ' ' W r i t e ' , press ' w ' . ' (Presses and write menu appears.) 'Press 'w* again? ' (Presses and wr i t i ng format appears. He presses the l e t t e r ' r ' and del ights in the series of ' r ' s ' which zoom across the screen). 'I did a l o t of ' r ' s ' . ' LMS: ' L e t ' s s t a r t . You can push th i s button to erase those. ' (Indicates delete button.) OR: (Deletes ' r ' s ' and starts to s l i d e down in his cha i r . ) LMS: 'Can you say th i s word?' OR: 'REED.' LMS: 'This l e t t e r says ' r u n ' , these l e t t e r s say ' e d ' , ' r uh -ed ' . Try again. ' OR: 'RED.' (S l id ing down in his cha i r . ) LMS: 'What does red mean?' OR: (Looking up from slumped pos i t ion.) ' L i ke the color red?' LMS: 'And can you make a sentence with the word red?' OR: ' Red - i s - a -co lo r . ' (Staccato voice and further slumping with occiput now rest ing on the chair back.) "LMS: 'Before you type, you need to s i t up. ' (OR complies and slumps down again. LMS places OR upright in his cha i r . ) OR: (Scans keyboard quickly and types R-E-DDDD as he s l ides down in his chair and his hands h i t a l l the keys at once.) 174 LMS: (Replaces OR in upright pos i t ion.) 'You need to erase those ' D ' s ' . ' OR: (Uses delete button and erases the ent i re word, and s l ides back to his slumped pos i t ion.) LMS: (Removes ch i l d from cha i r , turns the back of the chair to the l e f t and reseats the ch i l d so he is s i t t i n g without a chair back.) 'Try again. ' OR: (Maintains correct posture and types series of 'RED ' s ' , i n i t i a l l y having trouble grading pressure on keys so that they repeat, but delet ing appropr iately. He chooses the r ight hand, but responds to nonverbal t a c t i l e cueing and i n i t i a t e s the l e f t . Does not verbal ly mediate and works s i l e n t l y with the occasional 'Oops' to ind icate an error in l e t t e r key se lect ion or spacing. Uses the spacebar co r rec t l y . Se l f -cor rect s without d i rec t ion . ) LMS: 'Now you press ' r e tu rn ' ( indicate ' r e t u rn ' button) to s ta r t a new l i n e . ' (OR complies and cursor moves to next l i n e . ) 'Say the next word.' OR: 'FEED.' LMS: 'This l e t t e r says ' f u h ' , these l e t t e r s say ' e d ' , ' f u h - e d ' . ' OR: ' ' F e d 1 , l i k e 'I fed the c a t . ' (Trouble grading pressure on keys, types f - f - f and deletes automatical ly.) LMS: ' Fuh-ed ' , ' f u h - e d ' , ' f uh -ed . ' (as the boy types the corresponding 1etters. ) OR: 'Oopsie. ' (Forgets to space and deletes whole word to replace the space, i n i t i a t e s with r ight hand, responds to t a c t i l e cueing and switches with l e f t , completes l i n e of 'FED'.) LMS: 'Now press ' r e t u r n ' . ' (OR f inds key immediately and moves cursor to the next l i n e . ) 'What does the next word say?' OR: 'Luh-ed. ' (Adopts decoding strategy, modelled in previous examples.) ' Led . ' ( I n i t i a te s ' L ' with r ight hand; t r i e s to cross red l i n e with r ight hand.) LMS: 'This hand types on the l e f t of the l i n e , th i s hand types on the r ight s i de . ' (Tact i le cueing to l e f t and r ight dorsum. OR completes 'ED' with the l e f t hand.) ' Luh-ed ' , ' l u h - e d ' , ' l u h - ed. ' (OR continues without errors and presses ' r e t u rn ' spontaneously.) 'This word says . . . ' OR: ' 'Wuh-ed ' , 'wuh-ed', 'wed ' . ' (Types immediately using l e f t hand appropr iately.) 175 LMS: ' 'wuh-ed ' , 'wuh-ed', 'wuh-ed ' . ' (OR f in ishes row.) 'Press ' r e t u r n ' . ' (OR complies.) 'This word says . . . ' OR: 'BEED.' (Reverts to previous word attack.) LMS: 'This l e t t e r says ' buh ' , these l e t t e r s say ' e d ' , 'buh-ed ' . Try again. ' OR: 'Bed. ' (Then types in 'Wed', seems to be confused by 'wed' l i n e above, s e l f - co r r ec t s , s tart s searching for ' B ' , t a c t i l e cue on r ight dorsum, immediately scans on l e f t side of l i n e to f ind ' B ' , using l e f t hand appropriately for a l l l e t t e r s and space bar.) LMS: "Buh -ed " , 'buh-ed ' , ' buh-ed ' . ' OR: (Scanning for 'D' and says 'duh' aloud as he scans, completing the l i n e of 'BED', presses ' r e t u r n ' . ) LMS: 'These words say . . . ' OR: 'Ted hed a red bed.' LMS: (Pointing to each word.) 'Ted had a red bed.' (Emphasizes the ' a ' in had.) OR: (Typing with l e f t hand only, cueing to r ight dorsum for ' H ' , makes an error on ' h ed ' . Se l f -cor rect s by deleting ' ed ' and subst i tut ing ' a d ' . Recognizes own error . ) ' Is i t recess yet? ' LMS: 'Press ' r e t u r n ' . ' (OR complies.) 'Now type the sentence again. ' (OR complies and repeats the 'hed ' error. ) 'Now you can pr int your work. Press 'escape' to get back to the menu.' (Indicates ESC and OR presses, desk menu reappears.) 'There 's the desk, you want to press 'T ' for type. ' (OR complies and 'Type' menu appears.) 'Press #4.' (OR complies.) 'And press ' r e t u r n ' . ' (OR complies and the work i s typed.) OR: 'I did that? ' (Observes work with pride.) LMS: 'You do good work, OR. Did you l i k e working on the computer?' OR: 'Yes, I l i k e i t better 'cos I don 't have to draw.' Discussion This ch i l d had had some experience on the keyboard doing computer games, but none using the word processor. He picked up quickly on the 176 appropriate l e t t e r commands (W = write) a f te r one demonstration and was able to repeat the 'W command again, ind icat ing some previous experience with menu se lec t ion . His i n i t i a l preference was to explore the way the l e t t e r s repeated themselves with continued pressure on the keys, but also had d i f f i c u l t y grading his own pressure on the board. He had th i s under control by the th i rd example. OR's tendency for poor postural control was most evident during th i s session and th i s also i n i t i a l l y affected his a b i l i t y to grade his pressure on the keys. The rearrangement of the chair was a sa t i s fac tory so lut ion and was adopted for the remainder of the time. OR started to verbal ize the t u t o r ' s decoding strategy on the th i rd example and used i t again on the fourth example. He reverted to his i n i t i a l in terpretat ion of a long ' E ' (e") on the f i f t h example. After LMS repeated the decoding procedure, he pronounced the word co r rec t l y and used a verbal phoneme cue (duh) himself while scanning for the correct l e t t e r key. The sentence example included a general izat ion of the word family into ' h ad ' . This was not pointed out as an e r ro r , but the sentence was repeated with spoken emphasis on the ' a ' in had. OR se l f -cor rected on the f i r s t t r i a l , but repeated the error on the second t r i a l as well as in the hand- written sample. He also omitted the word ' a ' in the handwritten sample. He displayed obvious pride in his work. 177 Day: Bl#8 OR: (Seats himself and looks at 'Write to Read' card.) 'Gum, hum, bum.' LMS: 'What a reader! ' Don't forget to set yourself up on the word processor. ' OR: 'What do I do?' LMS: 'Do you want to type, wr ite or f i l e ? ' OR: 'W, W again ' (presses appropriate keys and the wr i t ing format appears). LMS: 'Now you can type a l i n e of the f i r s t word. What does i t say?' OR: 'Gum.' LMS: 'Yes and what i s gum?' OR: 'Gums, here, a l l th i s red s tu f f and gum you chew.1 LMS: 'Make a sentence using the word gum.' OR: 'Gum i s bubble gum.' LMS: 'You did i t . I think you can use the l e f t hand for ' g ' and the r ight for ' urn'.' OR: (Complies using correct f inger ing , stopping frequently to look around the room.) LMS: 'G-um, g-um, g-um.' OR: (Responds to verbal pacing, but allows hands to lean on the keyboard causing mult ip le l e t t e r s to appear. He corrects these without d i r e c t i o n , using the delete button. Reaches the end of the l i n e and s i t s passively. Then starts to f i dd l e with the l ighted ' on ' button.) LMS: 'How do you move the cursor to s tar t the next l i n e ? ' OR: 'Re-turn, re - tu rn , r e - t u rn . ' (Presses once and looks at 'Write to Read' card.) 'Hum, what does that mean?' LMS: ' I t ' s a sound, hum-mm-m. Can you use i t in a sentence?' OR: 'You have a tune and you hum. Means you go m-m-m l i k e a bee.' LMS: 'Look and see which hands you should use. ' 178 OR: (Proceeds to type using the r ight hand appropriately, having d i f f i c u l t y grading pressure and creating mult ip le 'Hs' which he deletes.) 'And press re tu rn . ' (Presses return.) LMS: 'And the next word says ?' OR: 'Bum.' LMS: 'Yes. What does that word mean?' OR: ' L i ke a person who doesn't have any places so they sleep under old newspapers and pick out of garbage cans and pick bones and eat old ice creams.' LMS: 'Can you use i t in a sentence?' OR: 'There 's a bum who digs out of garbage cans and eats food that people don't eat and they ' re no good 'cos they drop on the f l o o r . ' LMS: 'Think about which hands to use. ' OR: (Uses the l e f t hand for ' b ' and the r ight for 'urn', forgets spacing and stops.) LMS: 'Try to use the arrows to f i x t ha t . ' OR: ' I t says ' bum-bum.1 LMS: 'Use the arrows and the space bar. ' OR: (Backs up the cursor using the l e f t d i rect iona l arrow, al igns i t to the r ight of 'm' and presses the space bar.) 'Now what do I do?' LMS: 'Move your cursor out of the word.' OR: (Complies and carr ies on to complete l i n e and presses return, looks at 'Write to Read' card.) 'Drum.' LMS: 'Look at the f i r s t l e t t e r . ' OR: 'Drum.' LMS: 'What i s that? ' OR: 'You have a drumstick and you whack a drum.' LMS: 'Yes. What sentence can you use drum in? ' 'Drum is a big circle, you take a drumstick and you whack it. It-i s-a-drum.1 'Decide which hands to use.' (Types "DR" with the left and "urn" with the right.) 'Drum-space- drum-space. 1 'DR-um, DR-um, DR-um.' (Reverses DR (RD) and forgets space. Uses delete to correct, finishes line and presses return.) 'Next word is ' 'Don't know. Last part says 'urn'.' Plum!! Purple fings you eat, but they're little bit messy.' (Decides without direction to use the right hand for all four letters. Has difficulties grading pressure and so creates multiple letters which he deletes. Then types pi - pi, recognizes error, corrects with delete button and goes on to finish line and press return.) 'You're working well, O.R.' (Reads sentence without prompting.) 'Keep the gum on the bum. Drum. Shift-K.' (K(R) EE(L) P(R) T(L) H(R) E(L) G(L) UM(R), forgets space on (R) T(L) H(R) E(L) DR(L) UM(R). Recognizes spacing error, uses directional arrows to correct, has difficulty grading when to stop the cursor to align it properly. Requires assistance. Moves cursor out without difficulty and presses return.) 'Is it recess yet?' 'Not yet. What do you do now?' 'Type again.' (Does so without crossing the red line saying 'space' out load.) 'Press return? How do I print?' 'Escape to the desk.' 'I want to type 'T', and #4 and return. (Printer types his work). 'Can I have another copy to show my mum?' (LMS complies.) 'I want to tear off the dots. (OR tears off the perforated sides of the computer paper, he is drooling slightly). 'Do I come back tomorrow?' 'Yes, I'll see you tomorrow. You worked hard today.' 180 Discussion OR has d i f f i c u l t y with grading his pressure on the keys, but s e l f corrects without cueing, preferr ing the delete key. Grading inter feres with his a b i l i t y to use the d i rect iona l arrows co r rec t l y , and he chooses to delete an ent i re l e t t e r sequence rather than use the arrows. He requires cueing to i n i t i a t e word processor sequences and needs reminding about the return funct ion. He is d i s t r a c t i b l e and can be passive and 'dreamy' during the lesson. He uses se l f -cueing for spacing and return which he forgets. The handwritten sample is poorly spaced and includes an upper case "T" in ' t h e ' . His l e t t e r s are s i t t i n g on the l i n e . 181 Day: B2I1 OR: 'Greg 's back! He has a cast on his elbow! He f e l l out of a window, you know. He looks l i k e a ch i cken ' . (Reads through 'Write to Read' word l i s t . ) 'Den, ten, pen, men, hen.' LMS: 'You read a l l those words. Do you remember how to write on the computer?' OR: 'No. #4? What number do I push?' LMS: 'Do you want to wr i te , type or f i l e ? ' OR: 'Wr i te. W.' (Presses) 'W again. ' (Presses) 'That was easy!' (Checks l i s t . ) 'Den. "D". ' (Proceeds) LMS: (Tact i le cues to reinforce DE on l e f t and N on r i ght . ) 'Duh-en, duh-en, duh-en.' OR: (Completes l i n e of typing with correct hand use, and spacing and return.) LMS: 'What i s a den, OR?' OR: 'A den is a big barn with draw in i t . Or maybe a wi ld animal l i v e s in i t , l i k e cow.' LMS: 'The next word says ' OR: 'Ten, l i k e ten f i nger s . ' (Holds up wide spread hands in demonstration.) 'Or l i k e a metal? ' LMS: 'The number ten i s the word.' (Types) 'The metal i s t i n e , l i k e t h i s . ' (Types) 'Are they the same?' OR: 'No, no, th i s has an ' e ' in there, an' th i s i s the other one, ' i " LMS: 'Which word are we typing now?' OR: 'Ten. 1 (Begins with use of two hands, space bar, completes correct l i n e and presses return.) LMS: 'Good work. Try the next word.' OR: 'Pen. That 's l i k e a sharp thing what can hurt you in the f i nge r . ' LMS: 'You mean a p in. That 's th i s word.' (Types) 'The word we're doing now is pen.' (Types) 'Are they the same?' 182 OR: 'Oh, no. I t ' s the " i " in here and the "e " there. ' LMS: 'Do you know what a pen i s ? ' OR: ' I t ' s a big f ing you write w i t h . ' LMS: 'That ' s r i gh t . Now you can type a l i n e . ' OR: (Types with both hands, P(R), E(L), N(R), uses delete to correct spacing er rors , completes l i n e , presses return.) 'The next word i s MEN. Like a l l men, not jus t one man. It i s not with one man, i t ' s with three, four, f i ve or s ix men.' LMS: 'Good for you. Go ahead.' OR: (Types M with r i g h t , EN with l e f t . ) LMS: 'This hand stays on that side of the l i n e . Try the "n " with th i s hand.' (Tact i le cue.) 'Try again. ' OR: (Completes the f i r s t t r i a l and reverse to the second. Tac t i l e cueing given again and OR completes the rest of the l i n e . Some d i f f i c u l t y with spacing a r i se s , he corrects with the delete bar and presses return.) LMS: 'You ' re working hard. Here's the l a s t word.' OR: 'Hen. ' (Distracted by disturbance in the classroom.) LMS: 'What's a hen, OR?' OR: 'I don 't know.' LMS: 'A hen i s a chicken, a female ch icken. ' OR: 'What lays eggs?' LMS: 'That ' s the one.' OR: (Types H(R) and EN(L), responds to t a c t i l e cueing for two t r i a l s , continues for two more t r i a l s and reverts to "EN" on the l e f t for next t r i a l , t a c t i l e cueing on next t r i a l , continues for l a s t t r i a l , presses return.) LMS: 'Here ' s the sentence.' OR: 'Ten men can, ken, ' LMS: 'Chased.' 183 OR: 'Chased the hen into the pen. 1 LMS: 'What a good reader. ' OR: 'Now I type? Sh i f t T?' LMS: 'Go ahead. You know how to do i t . ' OR: (Types sentence using both hands co r rec t l y throughout the sentence, using space bar co r rec t l y and presses return and retypes again without a reminder.) 'Now we pr int Oopsie, I fo rget . ' LMS: 'Escape to the menu.' OR: (Presses ESC x two.) 'Now "T" and then #4. Oh. What now?" LMS: ' T e l l the pr inter ' OR: 'Return! ! ' (Presses and material i s pr inted.) Discussion OR i s unfamil iar with the word processing commands a f te r two weeks without intervent ion. He retains some segments of the sequences, but requires cueing. He i s very eager and competent when reading through the word l i s t , and read a l l the words at a s ing le t r y with the exception of 'chased' in the sentence. He recognizes his typing errors v i s ua l l y without prompting and used the delete button to correct . He does not attempt to use the d i rect iona l arrows at a l 1 . OR i s happy to use two hands for typ ing, but tends to use one hand for the i n i t i a l consonant and the other for the rest of the word. This was consistent with the phonetic approach taken in previous lessons. OR responds to t a c t i l e cueing, i s able to sustain the sequencing pattern for 184 two t r i a l s and then reverts to his o r i g i na l strategy. Recueing results in a correct response for the next two t r i a l s . OR types the ent i re sentence with correct l e f t and r ight hand use. Without phonetic s t ructure, he follows the visual keyboard format for hand se lect ion. In th i s sample, he decodes 'chased' with the word fami l ies ru le , s l o t t i ng in the i n i t i a l consonant phoneme on to the word root being used in the lesson. OR is able to ant ic ipate the lesson sequence and remembers to type the sentence twice. He has retained some of the pr int sequence, requir ing some cueing and remembers the verbal explanation of the function of the return key. (It t e l l s the computer/printer you ' re ready.) . Some d i f f i c u l t y with auditory d i scr iminat ion between the ' i ' and the ' e ' sound was noted. OR i s able to recognize the d i f ference v i s ua l l y and make appropriate choices. The handwritten sample contains e r r a t i c l e t t e r i n g with reworking on the i n i t i a l cap i ta l 'T ' and the dotted ' i ' . There i s poor spacing between words and the sentence resembles an undi f ferent iated sequence of l e t t e r s . Letters are crowded in toward the end of the l i n e and OR does not use the next l i n e to wr ite on in order to avoid crowding. 185 Day: B2#8 OR: (S its down, stands up and rearranges his chair so the seat back i s to the l e f t , s i t s down again. Uses word processor commands to get into wr i t ing mode without d i r ec t i on . Looks at the Write to Read card.) 'STOP. You stop when you run and some one says ' s t o p ' , you stop. ' LMS: 'That ' s r i gh t , OR. Can you use ' s top ' in a sentence?' OR: 'Stop means f i n i shed . ' (Uses two hands to type appropriate l e t t e r keys without requir ing cues, he recognizes his spacing errors by visual inspection and uses the d i rect iona l arrows and space bar to correct, presses return.) 'Hop.' (Jumps up and down into the seat to demonstrate.) 'A bunny hops or a frog. R ibb i t , r i b b i t . ' (Types accurately with appropriate use of r ight hand, spacing and return button.) LMS: 'Good work, OR. Put hop into a sentence.' OR: 'A bunny can hop.' (Looks at next word.) 'Top. You know, you've got the sugar bowl and you take something o f f and tha t ' s the top. It means a roof. ' LMS: 'Can you use ' t op ' in a sentence?' OR: 'A roof is on top of a house.' (Types with b i l a t e r a l hand use, correct spacing and return. Looks at next word.) 'Pop. Popcorn pops. It f l i e s a l l over the place and makes a noice. And i t means you can drink pop.' LMS: 'Yes. Use 'pop' in a sentence, OR.' OR: 'Pop i s a noise. ' (Types with correct use of r ight hand and space bar, rapid and automatic movement, presses return.) 'Mop. What scrubs d i r t y s tu f f o f f the f l o o r . ' LMS: 'Good. Use mop in a sentence.' OR: 'You can mop the f loor with a mop.' (Types rapid ly and accurately, with correct r ight hand use and spacing without errors . Presses return.) LMS: 'What does the sentence say?' OR: 'Can Pop hop over the mop.' (Reads co r rec t l y . ) ' S h i f t C and Sh i f t P?' (Recognizes need for cap i t a l s . ) LMS: 'Yes, you go ahead.' 186 OR: (Types r i g h t through the sentence us ing c o r r e c t hand use w i thout e r r o r i n l e t t e r keys o r s p a c i n g . Uses S h i f t C and P to c a p i t a l i z e . ) 'Now type aga in? ' LMS: 'Go ahead . ' OR: (Presses r e tu rn and typs the sentence again p e r f e c t l y . ) 'Now what do I do? Oh, escape. Escape a g a i n . Now, Wr i t e ? ' LMS: (No response . ) OR: 'Type. ' T ' . Return? ' LMS: 'Look at the s c r e e n . ' OR: ' # 4 . Now what? ' LMS: 'Look at the s c r e e n . ' OR: ' R e t u r n . Now can I make two c o p i e s ? ' (Goes back through the menu s e l e c t i o n independent ly and makes a second copy f o r h i m s e l f . ) LMS: 'You worked hard today , OR.' Discussion O.R. types w i th c o r r e c t b i l a t e r a l hand use and does not r e q u i r e t a c t i l e c u e i n g . He uses the more complex s t r a t e g y of d i r e c t i o n a l arrow use , d e l e t e and space bar to make c o r r e c t i o n s r a the r than d e l e t i n g the whole l i n e up to the e r r o r and s t a r t i n g a g a i n . He tend to r e l y on LMS f o r d i r e c t i o n s re word processor commands, but manages when he has to do i t by h i m s e l f . He i s ab le to problem-solve how to p r i n t a second copy o f h i s work i ndependen t l y . OR read a l l o f the words on s i g h t and read the sentence w i thout a s s i s t a n c e . He knew the meanings of a l l the words and o f f e r e d a second meaning f o r ' p o p ' . He was ab le to use a l l o f the words c o r r e c t l y i n sen tences . The w r i t t e n sample con ta ins no e r r o r s and adequate s p a c i n g . APPENDIX J SUBJECT #2: MOTOR SKILLS: VIDEO DISCUSSION 188 APPENDIX J Subject #2: Video Discussion These motor s k i l l s were selected to show balance, b i l a t e r a l motor coordinat ion, movement patterns, eye/hand coordination and f ine motor sequencing. The s k i l l s were based on selected subtests of the Bruininsks- Oseretsky Test of Motor Prof ic iency. O.R.'s running showed l im i te s s t r ide length determined by a hip f lex ion pattern in his movement. His balance in standing was poor. He continued to demonstrate hip f lex ion in standing, and was unable to sustain his weight on one foot. Balance on the balance beam was poor, showing hip f lex ion and trunk i n s t a b i l i t y . There was internal rotat ion of the lower extremit ies. O.R. had d i f f i c u l t y keeping his balance on the narrow base of the balance beam. O.R. had d i f f i c u l t y fo l lowing the complex inst ruct ions required for b i l a t e r a l motor coordination. His performance consisted la rge ly of undi f ferent iated movement. The jump and c lap, and jump and touch heels tasks was poorly performed and O.R. tended to lose his balance in jumping. Sit-ups were poorly executed and demonstrated O.R.'s poor abdominal strength and muscle tone. Push-ups showed poor shoulder strength and s t a b i l i t y , and i n a b i l i t y to maintain his hips in extention. O.R. used his hip f lex ion to approximate task performance. Bal l s k i l l s of catching, throwing and targett ing were immature and unsuccessful. 189 Sequenced f inger opposition was hes itatnt i n i t i a l l y , but became more integrated af ter the i n i t i a l unsuccessful attempts. APPENDIX K SUBJECT #3; CASE HISTORY 191 APPENDIX K Subject #3: Case History Name: I.R. Date of B i r t h : October 18, 1977 Chronological age: 8.7 years This boy's f i r s t language i s Yugoslavian, and he has had extensive medical invest igat ions for severe psor ias is and severe o t i t i s media. He i s the youngest son of four chi ldren and has three older s i s t e r s . The family i s under f i nanc ia l s t ra in and the father is presently working in Aust ra l ia as he was unable to f ind employment in Vancouver. The oldest daughter has been apprehended by the Min istry of Human Resources (MHR) for al leged abuse and has been placed in a foster home. Mother i s described as anxious and well intent ioned. I.R. did not attend pre-school and had a l im i ted exposure to kindergarten because of s i gn i f i c an t absenteeism (44 days) for his various somatic complaints. He was assigned to Grade 1, even though his readiness was very low. He has been followed ca re fu l l y by the Hearing Disorders C l i n i c at B.C. Ch i ldren ' s Hosp i ta l , as well as by the psychological and speech and language services at the Vancouver School Board (VSB). Hearing tes t ing at the Western I n s t i tu te for the Deaf (WID) on November 25, 1982 revealed a mild conductive hearing l o s s . He was referred for an Ear, Nose and Throat (ENT) consu l tat ion, and he diagnosed an o t i t i s media. The family did not fol low up on the recommendation for a hearing re-evaluation at WID. 192 His Grade 1 year (September 1983) was a d i f f i c u l t one as his academics were affected by poor auditory and visual memory, receptive and expressive language delay, his English as a second language (ESL) background, immature f ine and gross motor delay and a f luc tuat ing hearing loss . The i n i t i a l psychological assessment at a chronological age of 5.10 years (VSB, September 8, 9, 1983) described a ch i l d who had d i f f i c u l t y fol lowing in s t ruc t ions , pa r t i c ipa t ing in class discuss ion, had poor coordination in c ra f t a c t i v i t i e s , was s o c i a l l y immature and depended on his parents to do his dressing for him. No problems with behavior were reported and he apparently got along well with his peers. Testing on the Weschler Preschool and Primary Scale of Inte l l igence (WPPSI) indicated borderl ine verbal s k i l l s and performance s k i l l s at the top of the low average range. It was noted that the c h i l d ' s ESL background would a f fect the verbal and f u l l scale resu l t s on the WPPSI and should not be considered to be i nd i ca t i ve of the c h i l d ' s potent ia l . Performance scores may also have been lowered by the boy's d i f f i c u l t y in understanding complex d i rect ions in Engl ish. The lowest subtest score was on Animal House (55»il e) r e f l e c t i ng diminished visual motor coordination and the highest subtest score was seen on Picture Completion ( 8 4 % ^ e ) , which requires minimal motor coordination and measures " de t a i l noting of information recognized from a visual format". Performance on the Developmental Test of Visual Motor Integration (VMI) placed I.R. at the 3 rd% i ^ e with an age equivalent of 4.1 years, while the Test of Motor Free Performance (MVPT) placed him at the 70%^e with an 193 age equivalent of 6.2 years. These results indicated adequate visual perception with f ine motor pencil control problems and d i f f i c u l t i e s with visual motor in tegrat ion. The Coloured Progressive Matrices placed I.R. at the 9 0 t h % i l e (although th i s was converted to the 70 to 7 0 % i l e for B.C. norms), which indicated good visual processing. Peabody P icture Vocabulary Test (PPVT-R) placed I.R. at the 3 % i 1 e with an age equivalent of 3.11 years and the vocabulary subtest of the WPPSI was at the 9th%i"l e. The Brigance Kindergarten Grade 1 Screening indicated weakness in reading readiness. The boy was referred for speech and hearing assessment (September 21, 22, 1983, Vancouver School Board) to determine the o r i g in of his language d i f f i c u l t i e s and to rule out any hearing problems. At that time, the mother reported a normal b i r th history and motor milestones. He began speaking s ing le words at nine months and combining two words at 18 months. Sentences were spoken by three years of age. Yugoslavian i s spoken in the home and the c h i l d had l im i ted exposure to English pr ior to his public school experience. The oral peripheral exam (VSB assessment, September 1983) found adequate tongue and l i p movement for speech sound production, although the boy found i t d i f f i c u l t to ra ise his tongue t i p . The examiner noted "mouth breathing and a f ronta l tongue pos it ion with tongue thrust and large ton s i l s being ev ident" . Testing of a r t i c u l a t i o n (Goldman Fr i s toe Test of A r t i cu la t ion ) showed i n a b i l i t y to imitate / t / , /ch/, /dz/, / j / , although the a r t i c u l a t i on errors were inconsistent when I.R. was asked to repeat. 194 The examiners also noted that he chose associated responses for words he could not reca l l (kitchen for stove, smoke for pipe). Language test ing was done with the fol lowing assessments, and the results are noted below. Peabody Picture Vocabulary Test (PPVT-R) Placed I.R. at the 3 r d % i l e for the English population. The I l l i n o i s Test of Psychol inguist ic A b i l i t i e s (ITPA) subtest of Auditory Association scored below the mean (standard score of 17 with average range of 36+6) showing d i f f i c u l t y r e l a t i ng oral concepts ( i . e . , Grass is green, sugar i s ). The Test for Auditory Comprehension of Language (TACL) found the c h i l d ' s English vocabulary and grammar to be 1.8 years below his chronological age and he was found to have d i f f i c u l t y with adject i ves , verbs and preposit ions. The Boehm Test of Basic Concepts placed I.R. at the 3rd5P"l e for beginning Grade 1 English students and he showed d i f f i c u l t y with concepts of quantity and number. The L i s t of Language Development (TOLD) showed a below average performance. The mean range for subtest scores i s 10+3. Picture Vocabulary (a measure of receptive vocabulary) scored at 6, oral de f i n i t i on of English words scored at 6, Grammatic Understanding scored at 1, Sentence Imitation scored at 8 and Grammatic Closure (completing a sentence with correct grammatical form) scored at 10. I.R.. required a long response time, gave l im i ted responses and l i t t l e information. 195 The examiner reported that informal" assessment of expressive language showed use of simple sentences with few complex structures. There were grammatical errors in sentences and inappropriate responses to questions. It was d i f f i c u l t at that time to determine i f the ESL background, hearing or lack of understanding was the basis for the extra time required to process and produce responses. The boy did not provide basic information regarding his age, birthday and address. He was unable to sequence simple picture s tor ies and word reca l l d i f f i c u l t i e s were evident in spontaneous speech. The Carrow Auditory Visual A b i l i t i e s Test (C.A.V.A.T.) showed weak auditory memory span and auditory sequential memory, although these f indings may have been confounded by hearing d i f f i c u l t i e s . I.R. scored a scaled score of 43 (mean 36+6) on the ITPA Auditory Sequential Memory subtest where he was able to repeat d i g i t ser ies in order of presentation. He was able to fol low four-step d i rect ions (touch the w a l l , clap hands, etc.) but not always in order. The examiner did not conclude whether there was a language delay above and beyond the boy's ESL background, but recommended that his progress be monitored fur ther . Recommendations at that time were: " 1 . Language a c t i v i t i e s such as story t e l l i n g in the home. 2. Classroom a c t i v i t i e s for vocabulary, spat ia l re la t ionsh ips , verbal expression and sequencing, concept knowledge (e.g. opposites), categor izat ion s k i l l s (things that go together), auditory, sequential memory (fol lowing d i rect ions ) and temporal concepts (before and a f t e r ) . " 196 Materials suggested were the Boehm Concept K i t , Language Remediation and Expansion (C. Bush), Of Course I Can, H.E.L.P. Vo l . 1 and 2, and M.E.E.R. No ongoing therapy intervention was recommended and i t was suggested that the boy's progress be monitored by the School Based Team. D i f f i c u l t i e s fol lowing d i rect ions in class secondary to vocabulary and memory problems were predicted and the suggestion was made to l i m i t the number of d i rect ions and to use visual cueing with oral i n s t ruct ions . The school-based team were cautioned that I.R. required a "longer time to process information and to produce a response". Further hearing assessment and monitoring at WID was also recommended as he had f a i l e d the audiometric screening. I.R. was seen by a Vancouver School Board (VSB) Speech Pathologist who was f luent in Yugoslavian (October 3, 1983) and who found that the ch i l d understood Yugoslavian w e l l , but preferred to respond in English within the interview s i t ua t i on . A nurse's memo (November 16, 1983) to the Grade 1 classroom teacher stated that the ch i l d had a "mild b i l a t e r a l hearing loss s i gn i f i can t enough to a f fect school performance". It was recommended that he be seated at the front of the class and that he would require addit ional a t tent ion. The boy was sent to Central Screening at the end of the Grade 1 year. A l e t t e r from the pr inc ipal at his loca l school (Apr i l 10, 1984) recommended a small group s i tuat ion as the boy i s described as " e a s i l y d i s t r a c t i b l e " and "a poor l i s t e n e r " . School absenteeism had continued and I.R. was apparently very embarassed about his skin condit ion. Financial stress was a f fect ing the emotional s t a b i l i t y of the home environment. 197 The Grade 1 teacher 's report (Apr i l 25, 1984) describes a ch i l d who could "not generalize or apply l ea rn i ng " , had " e r r a t i c learning behaviors and lack of motivation to succeed in school " . He was cooperative, volunteering for classroom tasks and responded to praise and pos i t ive rewards, working well with cueing and constant at tent ion. The boy was below class leve l in reading (no l e t t e r names, l e t t e r sounds, i n a b i l i t y to hear differences and s i m i l a r i t i e s of l e t t e r sounds in rhyming words and math (counting and making numbers, learning ar ithmetic vocabulary: la rge, smal l , more, l e s s , equal to) in the Math Their Way program. The l e t te r s to Central Screening from the Area Counsellor (May 10, 1984) recommended a "bet ter s i tuat ion for next year where he could be nurtured academically, s o c i a l l y and emotionally to estab l i sh more readiness s k i l l s for successful school experience in the fu ture " . It was f e l t that I.R.'s "strengths were masked by stress " and a "calm, small group sett ing with i nd i v idua l i zed teaching and ongoing assessment of acquired learn ing" with opportunity " f o r emotional support and development of self-esteem" would be optimal. Programming objectives were to include "language development usage and expression, gross and f ine motor s k i l l s development, visual-motor coordination a c t i v i t i e s and continuation in a general readiness program". I.R. was referred to an Observation Class. On Apr i l 13, 1984, I.R. was reviewed by a team of the Hearing Disorders Program at B.C. Ch i ldren ' s Hospital (BCCH). He was 6.5 years o l d . 198 A review of the medical h istory indicated that I.R. had been hospital ized for one month in Grade 1 (January 10, 1984 to February 10, 1984) for treatment of severe psor ias is under the care of a dermatologist. He had been on medication since November 1983 (ot ic drops of Cholemycin three times per day) for external o t i t i s . At that time, he had been seen for a hearing assessment and a borderline conductive hearing loss was noted in the r ight ear with normal hearing on the l e f t . Reassessment by the speech and language pathologist at BCCH found a mild b i l a t e r a l hearing loss with a " s i g n i f i c a n t a i r bone gap". Speech reception thresholds were 25 db on the r ight and 30 db on the l e f t . Speech discr iminat ion was 92% on the r ight and 80% on the l e f t . Impedance measurement showed "reduced eardrum mobi l i ty and absent re f lexes , suggestive of conductive involvement". Because of previous assessments, a b r i e f speech and language evaluation was carr ied out. I.R. was found to fol low simple d i rec t i ons , having d i f f i c u l t y with complex and abstract mater ia l . PPVT-R score showed an age equivalent of 4.6 years, which was "moderately low for his age" and placed him in the 8 % ^ e , an improvement from previous testing.. The Test of Early Language Development showed "strengths in repeating sentences, understanding of simple paragraphs" and "weakness in sentence completion or re l a t i ng concepts meaningful ly". Results showed an age equivalent of 5.2 years with scat te r . 199 Visual subtest of the ITPA were administered with the fol lowing re su l t s : The average range for standard scores i s 36+6 and a l l of these subtests f e l l in that range. In spontaneous speech, I.R. was able to use long sentences with grammatical errors " cha rac te r i s t i c of ESL" speakers. For example, "You open the l i g h t . A fireman has a hose. He got f i r e in the house. He get f i r e out." Tongue movements were found to be poor, continued d i f f i c u l t y with tongue t i p control and poor f ine oral motor control was noted. The psychologist carr ied out on an abbreviated assessment since he had had a complete assessment done by the school board psychologist in September 1983. The re fer ra l was for "assessment of s k i l l s in a c h i l d with mild b i l a t e r a l hearing lo s s , conductive in o r i g i n " . The psychologist agreed with the previous VSB assessment and noted that the ch i l d " lacked f a m i l i a r i t y with numerous age appropriate toys" and wondered i f th i s formed the basis for his delay. I.R. continued to demonstrate "poor academic readiness for his age", "matched l e t t e r s by form, not by name", showed " l i t t l e correspondence counting to 12 with random sequencing beyond t h a t " , had d i f f i c u l t y with the concept of 'more' and trouble with addit ion and subtract ion. He was able Age Equivalent Standard Scores Visual Reception Visual Association Visual Memory 5- 10 6- 10 5-10 31 41 34 200 to recognize numbers from one to ten. He had " s p e c i f i c d i f f i c u l t y in many f ine motor areas." The examiner noted that the ch i l d had the f l u and was " fever i sh and t e a r f u l , his i n t e l l i g i b i l i t y inter fered with by missing front t ee th " . The Draw-a-Person task was scored at the three year old level and "head and legs attached d i r e c t l y and minimal f a c i a l d e t a i l " . The drawing was constr icted and the examiner noted that th i s f inding could be associated with anxiety. I.R. was unable to pr int his f i r s t name and traced i t with poor cont ro l . He used his r ight hand for pr int ing and demonstrated correct pencil g r ip. Results from the Le i te r International Performance Scale which measures non-verbal conceptual development gave a score in the average range with a mental age of 6.0 years. This was f e l t to be a "minimal estimate of non- verbal potential secondary to i l l n e s s , poor e f fo r t and concentration and cu l tu ra l b ia s " . I.R. passed a l l test items at the f i ve and s i x year o ld level and none at the seven year old l e v e l . The team conference was attended by the community health nurse (CHN), the speech language pathologist and psychologist from the VSB and the MHR worker, as well as the Hearing Disorders Program Team. The VSB team reported that although I.R. attended the Learning Assistance Centre (LAC) d a i l y , he was f a l l i n g behind his classmates and required ind iv idual help. He had d i f f i c u l t y grasping information in a group sett ing and the amount of LAC help was f e l t to be i n s u f f i c i e n t . Preferent ia l seating in a small group sett ing was advised. 201 The medical impression described an anxious boy with severe psor ias i s , the management of which the family found d i f f i c u l t . He was functioning in the average range non-verbally "with spec i f i c weaknesses in language and f ine motor areas, and l im i ted exposure to readiness a c t i v i t i e s basic f a c t s " . The psor ias is had been complicated with external o t i t i s leading to accumulation of material in the ear canal , with resultant f luctuat ing hearing loss . There was delayed speech and language which was showing slow improvement. A l e t t e r to the Head of Student Service, VSB, from the classroom teacher of the observation class (March 21, 1985) suggested school placement for the fol lowing year in an "age appropriate LAC class with a supportive teacher and ongoing monitoring of academic, medical and emotional development". The teacher noted that the mother was excessively concerned with neatness and had, on several occasions, sent the boy to school wearing a three-piece s u i t . He was " s t i l l at a beginning Grade 1 l e v e l " , and despite " d a i l y mu l t i - sensory a c t i v i t y " and was s t i l l not c lear on the alphabet. His pr int ing had improved and he had a to ta l of 18 sight words in reading. He was able to do "add i t ion and subtration combinations up to t en " . The School Based Team (SBT) Report (June 12, 1985) found I.R. to be working at the early Grade One l e v e l . He was "unsure of alphabet names and sounds", and was working at leve l 2 of the Ginn 360 program. Math was "adequate" at the f i r s t grade l e v e l , pr int ing was c lea re r , although he had 202 d i f f i c u l t y with spacing between words. He was described as d i s t r a c t i b l e and quick to "check out the action in the h a l l " . Mother was t ry ing to be pos i t ive but troubled by d i f fuse anxiety, being "concerned about the boy drowning during class swimming per iod". The SBT report included Indiv idual ized Educational Plan (IEP) planning. 203 APPENDIX L SUBJECT #3: DATA: BLOCK SEQUENCING TASK 204 APPENDIX L Subject #3: Data: Block Sequencing Test Baseline Intervention Baseline Intervention Day # (Ai) (Bl) (A 2) (B 2) 1 2 20 29 17 2 3 32 26 35 3 3 24 22 30 4 3 24 27 28 5 2 29 27 22 6 1 35 27 28 7 20 24 28 30 8 20 26 29 32 APPENDIX M SUBJECT #3: TEST RESULTS 206 APPENDIX M Subject #3: Test Results Tests Administered 1. Bruininsks Oseretsky Test of Motor Prof ic iency. 2. Developmental Test of Visual Motor Integration (VMI). 3. Durrel l Reading Analys i s . Test Results 1. Bruininsks-Oseretsky Test of Motor Prof ic iency. A battery of subtests to assess motor functioning. The mean of the standard scores i s 15 with a standard deviat ion of 5. The composite standard score mean is 50 with a standard deviation of 10. Gross Motor Subtests 1. 2. 3. 4. 5. Running Speed and A g i l i t y Balance B i l a te ra l Coordination Strength Gross Motor Composite Upper Limb Coordination Fine Motor Subtest 6. Response Speed 7. Visual Motor Control 8. Upper Limb Speed and Dexterity Fine Motor Composite Battery Composite Standard Score 5 .1 6 16 27 11 2 15 12 35 32 1*1e rank* Ijile 7 * i l e 4 X i l e 207 2. Developmental Test of Visual Motor Integration A sequence of geometric forms to be copied with pencil on paper. Standard scores have a mean of 10 with a standard deviation of 3. Standard Score: 4 Jil-e Rank*: 3 % i l e 3. Durrel l Reading Analysis An assessment of ten areas of reading a b i l i t y . Grade Level Oral Reading Low Grade 1 S i lent Reading Low Grade 1 Listening Comprehension Low Grade 2 Listening Vocabulary Low Grade 2 Word Recognition Mid Grade 1 Word Analyses Mid Grade 1 Spel1ing Low Grade 1 Sounds in I so lat ion Low Grade 1 Visual Memory of Words Mid Grade 1 Sounds in Words Low Grade 1 Pre reading Phonics A b i l i t i e s Inventories: A *A percent i le range (%^ e) indicates the percentage of the age peers scoring at or below the subject ' s test score. APPENDIX N SUBJECT #3: CLINICAL OBSERVATIONS 209 APPENDIX N Subject 13: C l i n i c a l Observations Day: B i l l (IR stares s tern ly at the screen.) LMS: 'Have you worked on the computer before?' IR: 'Yep. ' LMS: 'Can you show me how to write on th i s computer?' IR: 'Yep. ' (Presses 'W and the wr ite menu appears. He presses 'W again and presses #4 and the wr i t ing format appears on the screen. S t i l l s i t t i n g with a very stra ight back, star ing s tern ly at the screen.) LMS: 'Thank you! What does th i s word say?' IR: 'Red. ' LMS: 'You ' re r i gh t . Make a whole l i n e of 'RED's, please. ' IR: (Complies, showing knowledge of l e t t e r key l oca t ion . He i n i t i a t e s with the r ight hand, responds immediately to t a c t i l e cueing and switches to the l e f t hand. Shows correct use of spacebar and ' r e t u r n ' . ) LMS: 'What does ' r e d ' mean?' IR: 'Red i s a co l o r . ' LMS: 'Would you put i t into a sentence, please?' IR: 'I am red. ' LMS: 'Say the next word.' IR: 'FED.' (Says ' fe-duh', emphasizing the l a s t l e t t e r sound, and types a complete l i n e without further verbal ins t ruct ions and presses ' r e t u r n ' . Uses l e f t hand a f te r one cue.) LMS: 'The next word says . . . ' IR: 'LED.' ( ' Le-duh ' , and types complete l i n e , using both hands af ter one t a c t i l e cue to do so, and presses ' r e t u r n ' . ) 210 LMS: 'The next word says . . . ' IR: 'WED.' (Stops emphasizing the f i na l l e t t e r , making errors in l e t t e r by se lect ion between 'B ' and ' D ' , laughing as his errors show up on the screen, and using the d i rect iona l arrows to correct his mistakes. He completes a correct l i n e with the l e f t hand and presses ' r e t u r n ' . ) 'BED.' (Going on to the next word by himself.) LMS: 'What does 'bed ' mean?' IR: 'Bed we sleep in? ' LMS: 'Can you put 'bed ' into a sentence, please?' IR: 'I am a bed. ' (Laughs) 'I sleep in a bed.' (Types complete l i n e with l e f t index f inger without cueing and presses ' r e t u r n ' . ) 'What are these dots? ' LMS: 'The r ight hand types on th i s side of the l i n e and the l e f t hand types on that side of the l i n e . ' IR: (Laughs and reads ahead.) 'Ted had a red bed.' (Goes ahead to type and makes an error - 'Ted had a red Ted ' , which he corrects . Tac t i l e cueing for 'H ' brings right-handing response and i n i t i a t e s with l e f t hand for a l l other l e t t e r keys. Presses ' r e t u r n ' . ) LMS: 'You ' re a fast worker. Type the sentence again, please. ' (IR complies.) 'Now you can pr int your work.' (IR moves sw i f t l y through the pr int sequence, becoming stern again, stands up and leaves abruptly.) 'Thanks for your good work. See you tomorrow.' Discussion IR was quite f am i l i a r with the word processing package and was quite a successful 'hunt and peck' t yp i s t using his r ight hand. He responded automatically to t a c t i l e cues for l e f t hand use. Phonetic emphasis on the f i na l l e t t e r of each word may have ref lected his classroom work in reading. IR tended to rush through the lesson, keeping ahead of the tu to r . He seemed anxious to please, t ry ing on various a f fects (e.g.* sternness and 211 then laughing at his own mistakes). This may have ref lected underlying anxi ety. His approach to sentence completion tended to be stereotypical ("I am a ") but he was able to recognize and correct errors in language ("I am a bed. I sieep in a bed.). The handwritten sample was neat and well spaced. IR used uppercase l e t t e r s for 'had ' and ' r e d ' , but did not i n i t i a t e 'bed ' with an uppercase 1etter. 212 Day: Bl#8 IR: (Seats himself at the computer, sets up wr i t ing format on word processor independently.) 'Gum.' LMS: 'What's that? ' IR: 'You chew i t . ' LMS: 'Use 'gum' in a sentence.' IR: 'I chew gum.' LMS: 'Which hands are you going to use?' IR: ( scrut in izes the keyboard) "G" with t h i s one (indicates l e f t index). "And then th i s one" ( indicates r ight index). Types rapid ly using two hands with swift t ransfer between ' u ' and 'm' in the 'urn' sequence. Presses return. 'Hum'. LMS: 'What's that? ' IR: 'Humming: m-m-m.' LMS: 'Yes! Use' i t in a sentence. 1 IR: 'I hum.' (Types a l l l e t t e r s with r ight hand without d i rec t ion and presses return.) IR: 'Bum.' LMS: 'Yes. What does i t mean.' IR: 'You mean l i k e a street bum?' LMS: 'That ' s a meaning for bum. Use i t in a sentence.' IR: 'I am a street bum.' (Grins) (Types with appropriate f inger ing and rapid s h i f t on the 'urn' sequence, presses return.) 'Dum.' LMS: 'Look again. ' IR: 'D-r-um. Drum. A drum what you go in a parade.' LMS: 'And a sentence?' IR: 'I am a drum' (smi les). LMS: 'Decide what hands to use. ' 213 IR: (Types co r rec t l y with rapid sequence on both hands, presses return.) 'Plum, a plum what you eat. I eat a plum.' (Types rapidly and correct hand use, and presses return, surveys his work.) That ' g ' looks l i k e a n ine. ' LMS: They look a b i t the same, don 't they? IR: 'Keep the gum on the dr-um.' (Types the ent i re sequence d i l i g e n t l y with proper hand use, presses return and types i t again. Carries on with word processor commands and pr ints his copy. The recess bel l rings and he i s gone.) Discussion IR is able to locate l e t t e r keys quickly and chooses correct f inger ing , carrying th i s on throughout the l i n e of the word. He is fami l i a r with the word processor control keys, command sequences and spacing. He i s able to use both hands at the keyboard once he decides which hands to use. He types four l e t t e r and three l e t t e r sequences with equal f a c i l i t y . He seems unfamil iar with blends and remembers on the next t r i a l within the context of the lesson. Sentence st ructur ing with concrete s ty le pers ists (I am a drum). The handwritten sample shows well spaced words with some crowding on letters , within words. A cap i ta l 'K ' i s superimposed over a lower case ' c ' at the beginning of the word ' keep ' . Letter ing i s s l i g h t l y e r r a t i c . 214 Day: B2#l IR: (Reads r ight through the 'Write to Read' card.) 'DEN, TEN, PEN, MEN, HEN.' (Smiles with s a t i s f a c t i o n . Continues into word processing commands and sets up wr i t ing format, looks at f i r s t word.) 'Den.' LMS: 'You ' re going quickly today, IR. You r ea l l y know your work.' IR: (Smiles in response, eyes r i vet ted to the screen.) 'A den i s l i k e a cabin and you l i v e in i t . ' LMS: 'Can you use den in a sentence?' IR: 'We l i v e in a den.' (Starts to type using appropriate hands and spacing i n te r va l s , continues without error to the end of the l i n e and presses return.) 'Ten. I am ten f e e t . ' (Smiles) LMS: 'I am ten feet? ' IR: 'I have ten f e e t . ' (Big smile. Types cor rect ly using appropriate hands, spacing i n t e r va l s , continues without error and presses return.) 'Pen. ' LMS: 'What's that? ' IR: 'You can write of i t ? ' LMS: 'You can wr ite with i t . How about "pen" in a sentence?' IR: 'I wr i te with a pen.' (Types without er ror , with correct spacing and presses return.) 'Men, l i k e two men.' LMS: 'Sentence?' IR: 'Two men were wrest l ing? ' (Gr in. Proceeds to type at a rapid automatic ra te , use of d i rect iona l arrows and space bar to correct spacing e r ror , correct f inger use and return.) 'Hen. A hen i s a pet, l i k e a farm hen, an orange hen.' LMS: 'Good! Use i t in a sentence.' IR: 'The hen i s on the farm. ' (Types without error and presses return.) LMS: 'Here 's the sentence.' 215 IR: 'Ten men k k.' (Stops in confusion.) 'What's th i s word?' LMS: 'Chased. ' IR: 'Chased the hen into the pen.' (Types i n i t i a t i n g with s h i f t T and continues with correct hand use. Uses d i rect iona l arrows and space bar for spacing errors , types the sentence a second time and goes through sequence to pr int without error. ) LMS: You remembered everything, IR! IR: (Smiles) Discussion IR had retained a l l of the information related to word processor sequences, hand use, c ap i t a l i z a t i on and punctuation. He typed rap id ly and quick ly, corrected the spacing errors he made as a result using the more complex system of d i rec t iona l arrows and space bar. He was able to read the ent i re word l i s t , but was unable to decode ' chased ' , but did not generalize i t into the word family format. He s t i l l used some concrete sentence structures 'I am ' when asked to use a word in a sentence, but was able to correct incorrect syntax when i t was repeated back to him and may have recognized his error before the r epe t i t i on , smil ing as a resu l t of his error. He was able to move away from 'I am a ' sentence structure. (Two men were wrest l ing.) The handwritten sample i s neat, l e g i b l e and well spaced. 216 Day: B2#8 IR: (Reads r ight through 'Write to 'Read' l i s t . ) 'STOP, HOP, TOP, POP, MOP. Can Pop hop Ol iver the mop? Does that say 01iver? ' LMS: ' I t says ' o v e r ' , o-ver. ' (Points to word.) IR: 'Over the mop. O l i ve r . Ha-ha!' (Grins to himself and i n i t i a t e s f i r s t word.) 'STOP.' (Begins to type using one-handed approach with the r ight hand.) LMS: (Places physical bar r ie r onto board.) 'Use two hands, IR. You can do i t . ' IR: (Complies, grinning widely and types the rest of the l i n e rapid ly and accurately, with correct spacing and presses return.) LMS: 'What does ' s top ' mean?' IR 'Red l i g h t . ' LMS: 'Can you use the word ' s top ' in a sentence?' IR: 'We stop at the red l i g h t . ' LMS: 'Great sentence, IR. What about the next word?' IR: 'Hop. Like you jump. A rabbit can hop.' (IR i s going rap id ly now and making spacing errors. He chooses i n i t i a l l y to delete the ent i re word instead of using the d i rect iona l arrows and the space bar.) LMS: 'Take your t ime, IR. Look at your work and use the arrows, pi ease. ' IR: (Continues at f renet i c pace, using r ight index appropriately and making no further errors.) 'Top. A top l i k e you spin? ' LMS: 'You can spin a top, and you put i t on top of a t a b l e . ' IR: (Makes eye contact with LMS and smiles.) 'A top can go on top. That 's my sentence.' (Types accurately, and l e f t and r ight index f ingers , and using d i rect iona l arrows and space bar to correct spacing errors. He does not make any targett ing errors or reversa l s . Presses return.) LMS: 'Good work. How about the next word.' (Removes physical ba r r i e r . ) IR: 'Pop, l i k e a balloon or your dad.' 217 LMS: 'What kind of sentence can you make using the word ' pop ' , IR?' IR: 'A balloon can go pop.' LMS: 'Good one! Keep going. ' IR: 'Mop. What you clean the f l o o r . ' LMS: 'You clean the f l oo r with a mop.' IR: (Types l e t t e r s accurately with r ight hand appropriately used. Some spacing errors occur. IR impuls ively hits the space bar before he removes the cursor out of the word.) 'Delete. Arrows.' (Use of verbal mediation to problem solve, continues to the end of the l i n e and presses return.) LMS: 'What does the sentence say?' IR: 'Can Pop hop Ol iver the mop. Ha-ha. Can Pop hop over the mop.' (Grinning from ear to ear, most amused by his 01 iver•joke.) LMS: 'You ' re very funny today, IR.' IR: (Breaks into giggles, regains control and begins to type. Spontaneously prefers one-handed approach with r ight index.) LMS: 'Keep t ry ing with two hands, IR.' (Indicates visual bar r ier of red dots.) IR: (Self corrects without d i f f i c u l t y and does not cross l i n e gain. Uses SHIFT-C function for ' c a n ' , but i s unsure about Sh i f t -P for Pop.) ' S h i f t - P ? ' LMS: 'Pop i s the man's name. You need a c a p i t a l . ' IR: (Completes sentence, presses return.) 'Now you time me. Go!' LMS: 'Try not to rush. Do your best. ' IR: (Rushes through the sentence a second time, forgett ing a cap i ta l 1 P ' for ' Pop ' . Recognizes his own error and, uses d i rect iona l arrows and space bar to correct i t . Presses ' r e t u r n ' and proceeds through word processor sequence without error . ) 'I went fast today. ' LMS: 'You ' re a hard worker, IR.' 218 Discussion IR s t i l l prefers to use a one-handed approach although he i s very capable of using two hands. He can use the word processing functions very w e l l , although he has begun to make spacing errors in his quest for speed. He does not make targett ing errors and can correct his spacing errors read i l y . IR has attached great importance to speed of output, although th i s was not emphasized by LMS. He does not attempt to decode words, but makes approximations based on a quick appraisal of the beginning and end of the word (Over = O l i ve r ) . IR has begun to show more spontaneous a f fect and has d i ve r s i f i ed into a var iety of sentence formations, moving away from 'I am a . . . . ' to 'A balloon can go pop,' 'You clean the f l oo r with a mop.' He s t i l l tends to stay with one form, however. "A rabbit can , a balloon can . . . . , a top can ) He seemed to enjoy the two appl icat ions of the word ' t op ' and came up with two meanings for the word 'pop' by himself. He understands the concept of c a p i t a l i z a t i o n at the beginning of a sentence, but fa l te red with the c a p i t a l i z a t i o n of a word in the middle of the sentence, not being sure of the rule and perhaps being r i g i d about the sentence format from previous examples, which generally do not have cap i ta l i zed words in mid-sentence. He i s proud of his a b i l i t y for speed and independence in sequencing word processor commands. He uses verbal mediation to problem solve spacing errors . The handwritten sample shows s l i g h t l y e r r a t i c l e t t e r i n g with adequate spacing between words. He omitted the cap i ta l ' P ' in 'pop' and did not recognize his error when asked to v i s u a l l y inspect his handwritten sample. APPENDIX 0 SUBJECT #3: MOTOR SKILLS: VIDEO DISCUSSION 220 APPENDIX 0 Subject #3: Video Discussion These motor s k i l l s were selected to show balance, bi lateral motor coordination, movement patterns, eye/hand coordination and fine motor sequencing. The s k i l l s were based on selected subtests of the Bruininsks- Oseretsky Test of Motor Proficiency. I.R. showed adequate standing balance on one foot when standing on the f loor , with good hip s tab i l i ty . He had more d i f f i cu l ty when standing on the narrow base of the balance beam, using trunk rotation and compensatory arm movements to try to keep his balance. Heel-toe walking on the floor and on the balance beam showed some task success. I.R. was able to coordinate the arm and leg of the same side of his body in bi lateral motor coordination tasks, but was unable to coordinate opposite sides of his body. Jumping tasks were attempted, but quality of performance was poor. I.R. was unable to l i f t his hips off the ground during push-ups, and shoulder strength was weak. Sit~ups were performed adequately, showing good abdominal f lexion. Ball s k i l l s were adequate for bounching and catching with two hands. Catching the ball with one hand was not performed successfully, and I.R. tended not to attempt to catch balls which did not come direct ly to him, indicating a lack of a b i l i t y to shift his weight l a t e r a l l y . Targetting was poor, showing poor eye/hand coordination. 221 Running performance was adequate with a l ternat ing arm swing showing body coordination. Thumb-finger touching was accurate and precise b i l a t e r a l l y . APPENDIX P SUBJECT #1: OUTPUT SAMPLES 6j *I. RED RED RED RED RED RED RED RED RED RED FED FED FED FED FED FED FED FED FED FED LED LED LED LED LED LED LED LED LED WED WED WED WED WED WED WED WED WED WED BED BED BED BED BED BED BED BED BED BED TED HAD ft RED BED TED HAD A RED BED / 224 d i d d i d d i d d i d d i d d i d d i d d i d d i d d i d k i d k i d k i d k i d k i d k i d k i d k i d k i d l i d l i d l i d l i d l i d l i d l i d l i d r i d r i d r i d r i d r i d r i d r i d r i d r i d h i d h i d h i d h i d h i d h i d h i d h i d h i d b i d b i d b i d b i d b i d b i d b i d b i d b i d S i d h i d t h e l i d . 225 dud dud dud dud dud dud dud dud dud cud cud cud cud cud cud cud cud cud bud bud bud bud bud bud bud bud bud mud mud mud mud mud mud mud mud mud Judd l e t the bud f a l l i n the mud. 226 r o d r o d r o d r o d c o d c o d r o d c o d c o d r o d r o d r o d r o d r o d r o d r o d r o d r o d s o d s o d s o d s o d =.cd s o d s o d =.nd s o d <r-:od DOd DOri n o d n o d n o d n n d n n d n n r l n n d Tho rnH 4. o 1 1 nn • ••Hon cKa i-»^HHoH T h e f-T>d -fel ) or? the 5 0 ^ Whe" «»*>e n o d d e d - i i DAD DAD DAD DAD DAD dad dad dad dad -fad f a d -fad -fad -fad -fad -fad -Fad -fad -fad had had had had had had had had had had mad mad mad mad mad mad mad mad mad sad sad s a d sad sad s a d s a d s a d sad bad bad bad bad bad bad badbad bad A bad l a d had a mad dad A bad l a d had a mad dad . Q ia 'd 1° A ( ) ft] 228 4 ^ jam jam jam jam jam jam jam jam jam ham ham ham ham ham ham ham ham ham ram ram ram ram ram ram ram ram ram tarn tarn tarn tarn tam tarn tarn tam tam yam yam yam yam yam yam yam yam yam pam saw the ram upset the jam. pam sawthe ram upset the jam.£ 4 *i dim dim dim dim dim r i m r i m r i m him b r i m b r i m b r i m b r i m Kim p u t t r i m on t h e Kim put f i n on t h e dim dim dim dim r i m r i m r i m r i m r i m r i m him him him him him him him b r i m b r i m b r i m t r i m t r i m t r i m t r i m t r i m t r i m t r i m b r i m o-f h e r h a t . a © b r i m o-f h e r h a t . I — ' 230 C 4 * e gum gum gum gum gum gum gum gum hum hum hum hum hum hum hum hum hum bum bum bum bum bum bum bum bum drum drum drum drum drum drum drum p l u m p l u m p l u m p l u m p l u m p l u m p l u m Keep t h e gum on t h e d r u m . Keep t h e g n u on t h e d r u m . I 231 CM B2 #1 den den den den den den den den den ten ten ten ten ten ten ten ten ten pen pen pen pen pen pen pen pen pen men men men men men men men men men hen hen hen hen hen hen hen hen hen Ten men chased the hen i n t o the pen. Ten men chased the hen i n t o the pen . CM / B2#2 •fin - fin f i n -fin -fin f i n - f i n - f i n f i n p i n p i n p i n p i n p i n p i n p i n p i n p i n t i n t i n t i n t i n t i n t i n t i n t i n t i n win win win win win win win win win b i n b i n b i n b i n b i n b i n b i n b i n b i n L i n w i l l - f l i p t h e p i n i n t o t h e t i n b i n . •3 L i n w i l l - f l i p t h e p i n i n t o t h e t i n b i n . A ' 233 fan fan -fan fan fan fan fan fan fan man man man man man man man man man ran ran ran ran ran ran ran ran ran can can can can can can can can can van van van van van van van van van pan pan pan pan pan pan pan pan pan Jan ran past the tan van. Jan ran past the tan van. C* ^QVQ e f t 234 fun -fun -fun fun fun -fun -fun fun fun gun gun gun gun gun gun gun gun gun run run run run run run run run run bun bun bun bun bun bun bun bun bun sun sun sun sun sun sun sun sun sun The g i r l had fun running i n the sun . The g i r l had fun running i n the sun. < j hat hat hat hat hat hat hat hat hat pat pat pat pat pat pat pat.pat pat bat bat bat bat bat bat bat bat bat vat vat vat vat vat vat vat vat vat cat cat cat cat cat cat cat cat cat Put the hat on the cat, Pat. Put the hat on the c a t , Pat. ,4f> ex' D . < a t f a t f a t f a t f a t f a t f a t f a t f a t r a t r a t r a t r a t r a t r a t r a t r a t r a t s a t s a t s a t s a t s a t s a t s a t s a t s a t mat mat mat mat mat mat mat mat mat t h a t t h a t t h a t t h a t t h a t t h a t t h a t The f a t r a t s a t on t h e mat. ,-The f a t rat. s a t on t h e mat. I I 237 C / o 5**1. d i p d i p d i p d i p d i p d i p d i p d i p d i p r i p r i p r i p r i p r i p r i p r i p r i p r i p t i p t i p t i p t i p t i p t i p t i p t i p t i p l i p l i p l i p l i p l i p l i p l i p l i p l i p h i p h i p h i p h i p h i p h i p h i p h i p h i p s h i p s h i p s h i p s h i p s h i p s h i p s h i p t r i p t r i p t r i p t r i p t r i p t r i p t r i p K'ip e n j o y e d h i s t r i p on a s h i p . 238 stop stop stop stop stop stop stop hop hop hop hop hop hop hop hop hop top top top top top top top top top pop pop pop pop pop pop pop pop pop mop mop mop mop mop mop mop map mop Can Pop hop over the mop? APPENDIX Q SUBJECT #2: OUTPUT SAMPLES 240 - Off RED RED RED RED RED RED RED RED RED FED FED FED FED FED FED FED FED FED LED LE D LED LED LED LED WED WED WED WED WED WEDD BED BED BED BED BED BED BED TED HAD A RED BED TED HED A RED BED. Qr c 5 \:\Q 241 OX 6j *<f. d i d d i d d i d d i d d i d d i d d i d d i d d i d k i d k i d k i d k i d k i d k i d k i d k i d k i d l i d l i d l i d l i d l i d l i d l i d l i d l i d r i d r i d r i d r i d r i d r i d r i d r i d r i d h i d h i d h i d h i d h i d h i d h i d h i d h i d b i d b i d b i d b i d b i d b i d b i d b i d b i d s i d h i d t h e l i d . 242 Of? 4 #3 dud dud dud dud dud dud dud dud dud cud cud cud cud cud cud cud cud cud bud bud bud bud bud bud bud bud bud mud mud mud mud mud mud mud mud mud Judd l e t the bud -fal l i n the mud. Judd l e t the bud -fal l i n the mud. 1 243 cO/f m n m n rrxi pnH rnH rnH rnri rnri rnri rnrt r nd for! rod rnH rnri rnd rnri r r\ri snri «5.nd «nrl «nH end end «;nrl end «;nri • Od DOd Dad OOd OOCf nnd nnd nnd nnrt nod nod "nri nnrt nnd nnd nnd nnrt nori Th#» rod ^ ' o° sod wn**n nQdd^d - The r rirf «rp 1 I nn thu end wn«=m «hp nnrtr(#»rf. i 1 ' / ' rod ^ % t V n W U 244 3 , dad dad dad dad dad dad dad dad dad fad fad fad fad fad fad fad fad fad had had had had had had had had had mad mad mad mad mad mad mad mad mad sad sad sad sad sad sad sad sad sad bad bad bad bad bad bad bad bad badb A bad lad had a mad dad. lO A bad lad had a mad dad . <! / 245 Of jam jam jam jam jam jam jam jam jam ham ham ham ham ham ham ham ham h u ramb ram ram ram ram ram ram ram ram tam tam tam tam tam tam tam tam tam yam yam yam yam yam yam yam yam yam Pam saw the ram upset the jam. Pamsaw the ram upset the jam. / :• 246 Of 4 dim dim dim dim dim dim dim dim dim r i m r i m r i m r i m r i m r i m r i m r i m r i m him him him him him him him him him b r i m b r i m b r i m b r i m b r i m b r i m b r i m t r i m t r i m t r i m t r i m t r i m t r i m t r i m Kim p u t t r i m on t h e b r i m o-f h e r h a t . Kim put t r i m on t h e b r i m of h e r h a t . 247 < 4 *8. g u m g u m g u m g u m g u m g u m g u m g u m g u m h u m h u m h u m h u m h u m h u m h u m h u m h u m b u m b u m b u m b u m b u m b u m b u m b u m b u m d r u m d r u m d r u m d r u m d r u m d r u m d r u m p l u m p l u m p l u m p l u m p l u m p l u m p l u m K e e p t h e g u m o n t h e d r u m . K e e p t h e g u m o n t h e d r u m . "j • i 248 4 '*>• d e n d e n d e n a e n d e n d e n d e n d e n d e n t e n t e n t e n t e n t e n t e n t e n t e n t e n p e n p e n p e n p e n p e n p e n p e n p e n p e n m e n m e n m e n m e n m e n m e n m e n m e n s e n h e n h e n h e n h e n h e n h e n h e n h e n h e n T e n m e n c h a s e d t h e h e n i n t o t h e p e n . J * * J y * aft <t . i<- T e n m e n c h a s e d t h e h e n i n t o t h e p e n . / l * * ^ o( » I e 249 f i n f i n f i n f i n f i n f i n f i n f i n f i n p i n p i n p i n p i n p i n p i n p i n p i n p i n t i n t i n t i n t i n t i n t i n t i n t i n t i n win win win win win win win win win b i n b i n b i n b i n b i n b i n b i n b i n b i n L i n w i l l f l i p t h e p i n i n t o t h e t i n b i n . 250 f a n f a n f a n f a n f a n f a n f a n f a n f a n m a n m a n m a n m a n m a n m a n m a n m a n m a n r a n r a n r a n r a n r a n r a n r a n r a n r a n c a n c a n c a n c a n c a n c a n c a n c a n c a n v a n v a n v a n v a n v a n v a n v a n v a n v a n p a n p a n p a n p a n p a n p a n p a n p a n p a n J a n r a n p a s t t h e t a n v a n . f u n - f u n - f u n g u n g u n g u n r u n r u n r u n b u n b u n b u n s u n s u n s u n • f u n f u n f u n g u n g u n q u n r u n r u n r u n b u n b u n b u n s u n s u n s u n f u n - f u n - f u n g u n g u n g u n r u n r u n r u n b u n b u n b u n s u n s u n s u n T h e g i r l h a d - f u n r u n n i n g i n t h e s u n . t h e g i r l h a d - f u n r u n n i n g i n t h e s u n in-'kr. i u n . 252 h a t h a t h a t h a t h a t h a t h a t h a t h a t p a t p a t p a t p a t p a t p a t p a t p a t p a t b a t b a t b a t b a t b a t b a t b a t b a t b a t v a t v a t v a t v a t v a t v a t v a t v a t v a t c a t c a t c a t c a t c a t c a t c a t c a t c a t P u t t h e h a t o n t h e c a t , P a t . P u t t h e h a t o n t h e c a t , P a t . ^ O . Ql-IM 253 • f a t f a t - f a t f a t - f a t - f a t - f a t - f a t - f a t r a t r a t r a t r a t r a t r a t r a t r a t r a t s a t s a t s a t s a t s a t s a t s a t s a t s a t m a t m a t m a t m a t m a t m a t m a t m a t m a t t h a t t h a t t h a t t h a t t h a t t h a t t h a t T h e - f a t r a t s a t on t h e m a t . T h e - f a t r a t s a t on t h e m a t . I—• 254 d i p d i p d i p d i p d i p d i p d i p d i p d i p r i p r i p r i p r i p r i p r i p r i p r i p r i p t i p t i p t i p t i p t i p t i p t i p t i p t i p l i p l i p l i p l i p l i p l i p l i p l i p l i p h i p h i p h i p h i p h i p h i p h i p h i p h i p s h i p s h i p s h i p s h i p s h i p s h i p s h i p t r i p t r i p t r i p t r i p t r i p t r i p t r i p R i p e n j o y e d h i s t r i p o n a s h i p . I * R i p e n j o y e d h i s t r i p o n a s h i p . ' s t o p s t o p s t o p s t o p s t o p s t o p s t o p h o p h o p h o p h o p h o p h o p h o p h o p h o p t o p t o p t o p t o p t o p t o p t o p t o p t o p p o p p o p p o p p o p p o p p o p p o p p o p p o p n < o p m o p m o p m o p m o p m o p m o p m o p m o p C a n P o p h o p o v e r t h e m o p . C a n P o p h o p o v e r t h e m o p . / APPENDIX R SUBJECT #3: OUTPUT SAMPLES 257 / //f RED RED RED RED RED RED RED RED RED FED FED FED FED FED FED FED FED FED LED LED LED LED LED LED LED LED LED MED MED WED MED WED MED MED MED MED BED BED BED BED BED BED BED BED BED TED HAD A RED BED . TED HAD A RED BED. 1 \ 258 //f 4 d i d d i d d i d d i d d i d d i d d i d d i d d i d k i d k i d k i d k i d k i d k i d k i d k i d k i d l i d l i d L i d l i d l i d l i d l i d l i d l i d r i d r i d r i d r i d r i d r i d r i d r i d r i d h i d h i d h i d h i d h i d h i d h i d h i d h i d b i d b i d b i d b i d b i d b i d b i d b i d b i d S i d h i d t h e l i d . S i d h i d t h e l i d . 259 d u d d u d d u d d u d d u d d u d d u d d u d d u d c u d c u d c u d c u d c u d c u d c u d c u d c u d b u d b u d b u d b u d b u d b u d b u d b u d b u d m u d m u d m u d m u d m u d m u d m u d m u d m u d J u d d l e t t h e b u d - f a l l i n t h e m u d . J u d d l e t t h e b u d f a l l i n t h e 260 4 C C K J C C N J C O d T * r t ' ~ r , H * ~ r , H " " o H ' " " ^ ' " r » r t p r i H f r » H r n H r n d e n d r - o / i r-nri r-r\ri r~r^ri oH crtH c riH •KOfi e nH cr»H «= cnH «= /-vH1 ' n o d n n r i n n r l o r v H n n r i n n r l n r w l n n r l r w r n - i ? O d D O d ' ~ * H n o r ) n n r l n n H n o r l n o d n r w i pod oc T h e r o d f e l l o n t h e s o d w h e n s h e , n o d d e d . T h e r a n * 4 e l l o n t h f > s o d w h e n « h * » n o d d e d . Tloe. Nod f o . l l on sad/ She VO/OCUP/I 261 //f SJ ^ d a d d a d d a d d a d d a d d a d d a d d a d d a d f a d f a d f a d f a d f a d f a d f a d f a d f a d h a d h a d h a d h a d h a d h a d h a d h a d h a d m a d m a d m a d m a d m a d m a d m a d m a d m a d s a d s a d s a d s a d s a d s a d s a d s a d s a d b a d b a d b a d b a d b a d b a d b a d b a d b a d A b a d l a d h a d a m a d d a d . A b a d l a d h a d a m a d d a d . 262 4 ^ j a m j a m j a m j a m j a m j a m j a m j a m j a m h a m h a m h a m h a m h a m h a m h a m h a m h a m r a m r a m r a m r a m r a m r a m r a m r a m r a m t a r n t a r n t a r n t a r n t a r n t a r n t a r n t a r n t a r n y a m y a m y a m y a m y a m y a m y a m y a m y a m P a m S « M t h e r a m u p s e t t h e j a m . P a m s a ? f i t h e r a m u p s e t t h e J^ 263 4 *1- d i m d i m d i m d i m d i m d i m d i m d i m d i m r i m r i m r i m r i m r i m r i m r i m r i m r i m h i m h i m h i m h i m h i m h i m h i m h i m h i m b r i m b r i m b r i m b r i m b r i m b r i m b r i m t r i m t r i m t r i m t r i m t r i m t r i m t r i m K i m p u t t r i m o n t h e b r i m o f h e r h a t . K i m p u t t r i m o n t h e b r i m o f h e r h a t . 6/ *8 g u m g u m g u m g u m g u m h u m h u m h u m h u m h u m b u m b u m b u m b u m b u m d r u m d r u m d r u m d r u m p l u m p l u m p l u m p l u m K e e p t h e g u m o n t h e d r u m . K e e p t h e g u m o n t h e d r u m . ^ 255 d e n d e n d e n d e n d e n d e n d e n d e n d e n t e n t e n t e n t e n t e n t e n t e n t e n t e n p e n p e n p e n p e n p e n p e n p e n p e n p e n m e n m e n m e n m e n m e n m e n m e n m e n m e n h e n h e n h e n h e n h e n h e n h e n h e n h e n 0'.Z>£~- T e n m e n c h a s e d t h e h e n i n t o t h e p e n . T e n m e n c h a s e d t h e h e n i n t o t h e p e n . Ten c W s c d i h f t h f t n i n t - n " t ^ f p-P \ \ 266 fin - f i n - f i n fin fin fin fin fin fin p i n p i n p i n p i n p i n p i n p i n p i n p i n t i n t i n t i n t i n t i n t i n t i n t i n t i n w i n w i n w i n w i n w i n w i n w i n w i n w i n b i n b i n b i n b i n b i n b i n b i n b i n b i n L i n w i l l f l i p t h e p i n i n t o t h e t i n b i n . L i n w i l l - f l i p t h e p i n i n t o t h e t i n b i n . I 267 mt' • f a n - f a n f a n f a n f a n f a n f a n f a n f a n m a n m a n m a n m a n m a n m a n m a n m a n m a n r a n r a n r a n r a n r a n r a n r a n r a n r a n c a n c a n c a n c a n c a n c a n c a n c a n c a n v a n v a n v a n v a n v a n v a n v a n v a n v a n p a n p a n p a n p a n p a n p a n p a n p a n p a n J a n r a n p a s t t h e t a n v a n . J a n r a n p a s t t h e t a n v a n . 268 f u n fun fun fun fun fun fun f u n f u n f v g u n gun g u n g u n g u n g u n g u n g u n g u n r u n r u n r u n r u n r u n r u n r u n r u n r u n b u n b u n b u n b u n b u n b u n b u n b u n b u n a i r l n a a , « n r u n n i n , * n tne s u n . T h e g i h a t h a t h a t h a t h a t h a t h a t h a t h a t p a t p a t p a t p a t p a t p a t p a t p a t p a t b a t b a t b a t b a t b a t b a t b a t b a t b a t v a t v a t v a t v a t v a t v a t v a t v a t v a t c a t c a t c a t c a t c a t c a t c a t c a t c a t P u t t h e h a t o n t h e c a t , P a t . P u t t h e h a t o n t h e c a t , P a t . Pn.t tnC n,nt QfO the. Ctit^^QLL^JJL. 270 r. K f a t - f a t - f a t - f a t - f a t f a t - f a t - f a t - f a t r a t r a t r a t r a t r a t r a t r a t r a t r a t s a t s a t s a t s a t s a t s a t s a t s a t s a t m a t m a t m a t m a t m a t m a t m a t m a t m a t t h a t t h a t t h a t t h a t t h a t t h a t t h a t T h e f a t r a t s a t o n t h e m a t . T h e - f a t r a t s a t o n t h e m a t . 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{[{ mDataHeader[type] }]} {[{ month[type] }]} {[{ tData[type] }]}

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