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Long term linguistic consequences of head injury in childhood and adolescence Mitchell, Gail A. 1985

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LONG TERM LINGUISTIC CONSEQUENCES OF HEAD INJURY IN CHILDHOOD AND ADOLESCENCE. A., The U n i v e r s i t y of B r i t i s h Columbia, 1981 THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES (Audiology and Speech Sciences) We accept t h i s t h e s i s as conforming to By G a i l A. M i t c h e l l the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA J u l y 1985 1985 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. I t i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of A j d i o l m u H f l c j S f P ^ O h P p i P n C Q S The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 i i ABSTRACT TITLE: Long-term l i n g u i s t i c consequences of t r a u m a t i c head i n j u r y i n c h i l d h o o d and a d o l e s e n c e . C o n s i d e r a b l e i n t e r e s t has been e x p r e s s e d r e g a r d i n g the i s s u e of r e c o v e r y of language f o l l o w i n g head i n j u r y i n c h i l d h o o d . The two q u e s t i o n s most f r e q u e n t l y a d r e s s e d a r e : 1) Do c h i l d r e n r e c o v e r l i n g u i s t i c a b i l i t i e s f a s t e r and b e t t e r than a d u l t s a f t e r s u f f e r i n g a head I n j u r y ? 2) Is the l i n g u i s t i c d i s o r d e r , i f e v i d e n t , m a i n l y s y n t a c t i c or l e x i c a l i n n a t u r e ? We have examined 8 c h i l d r e n from 6.510=17*0 who s u f f e r e d t r a u m a t i c head i n j u r y and who are i n v a r y i n g s t a g e s of r e c o v e r y . Each c h i l d has been matched w i t h a normal c h i l d of the same age. D e s p i t e r e p o r t s of complete r e c o v e r y from c h i l d h o o d a p h a s i a , our r e s u l t s i n d i c a t e p e r s i s t e n t word f i n d i n g problems, w i t h o t h e r w i s e normal language a b i l i t i e s . There'was no c o r r e l a t i o n between s e v e r i t y of d e f i c i t and age a t i n j u r y or l e n g t h of coma. i i i TABLE OF CONTENTS ABSTRACT i i TABLE OF CONTENTS i i i LIST OF TABLES v ACKNOWLEDGEMENTS v i CHAPTER ONE: INTRODUCTION 1 CHAPTER TWO: REVIEW OF LITERATURE 2.1 I n c i d e n c e .4 2.2 C e r e b r a l L a t e r a l i z a t i o n 6 2.3 P r e i n j u r y S t a t u s 10 2.4 S y m p t o m a t o l o g y - S i m i l a r i t i e s 10 2.5 S y m p t o m a t o l o g y - D i f f e r e n c e s 14 2.6 Course of Recovery ...20 2.7 F a c t o r s P r e d i c t i n g Recovery 22 CHAPTER THREE: PROCEDURES 3.1 S u b j e c t s 26 3 . 2 C o n t r o l s 26 3.3 Data Measures 26 3.4 P r o c e d u r e s 28 3.5 Data A n a l y s i s 28 CHAPTER FOUR: CASE HISTORIES 4. 1 S u b j e c t JB 29 4.2 S u b j e c t PB 30 4.3 S u b j e c t SK 32 4.4 S u b j e c t JA 33 4.5 S u b j e c t KP 35 4.6 S u b j e c t CG 37 4.7 S u b j e c t CY 38 4.8 S u b j e c t LD 39 CHAPTER FIVE: TEST RESULTS 5.1 Resu l t s 45 5.2 Token Test 45 5.3 W o r d - R e t r i e v a l 46 5.4 Sentence R e p e t i t i o n 49 5.5 R e s u l t s f o r I n d i v i d u a l S u b j e c t s 50 i v CHAPTER SIX: DISCUSSION 6.1 Statement of Problem 1 53 6.2 Word-Finding 54 6.3 G e s t u r e / F a c i l i t a t o r i n R e t r i e v a l 56 6.4 R e l a t i o n s h i p / Trauma and l i n g , d e f i c i t 57 6.5 P e r s e v e r a t i o n 60 6.6 Problem 2-Recovery 61 6.7 S c h o o l Performance,,,>,,,,,,,,,,,,,,>,,>,r t r,62 6.8 C o n c l u s i o n s 63 REFERENCES 66 APPENDIXES 71 V LIST OF TABLES TABLE 1-SUBJECT DESCRIPTIONS 40 TABLE 2-PERFORMANCE ON RECEPTIVE TASKS 41 TABLE 3-PERFORMANCE ON SENTENCE FORMULATION TASK 42 TABLE 4-PERFORMANCE ON WORD-FINDING TASKS 43 TABLE 5-PERFORMANCE ON C.E.L.F.-PRODUCTION TASK 44 v i ACKNOWLEDGEMENTS I w i s h t o e x p r e s s s i n c e r e thanks to Dr. John G i l b e r t who p r o v i d e d me w i t h m o t i v a t i o n and h e l p f u l c r i t i c i s m s throughout the workings of my t h e s i s . P a r t i c u l a r thanks are a l s o due to the c h i l d r e n whose language I t e s t e d , and to t h e i r p a r e n t s who were so c o o p e r a t i v e . I w i s h t o thank Lynn Brown and Peggy Chow, who h e l p e d to o r g a n i z e s u b j e c t s and p r o v i d e d feedback r e g a r d i n g my t h e s i s . A l s o thanks are due to Sandy C o l l i n s who k i n d l y o r g a n i z e d s u b j e c t s . F i n a l l y , I wish to thank my f r i e n d , G r e v i l l e Hampson, f o r the use of h i s computer. 1 CHAPTER ONE I n t r o d u c t i on: I t has been proposed t h a t a c q u i r e d a p h a s i a i n c h i l d r e n i s a d i s t i n c t c l i n i c a l d i s o r d e r , d i f f e r i n g from a d u l t a p h a s i a i n both : (1) symptomatology and (2) e x t e n t of r e c o v e r y . By the term " a c q u i r e d a p h a s i a " we r e f e r t o the language d i s o r d e r i n c u r r e d t h r o u g h b r a i n trauma a f t e r a p e r i o d of normal development. The a s s o c i a t i o n between b r a i n i n j u r y and a p h a s i a i s i n c o n s i s t e n t ; a p h a s i a i s not always p r e s e n t r e g a r d l e s s of s i te of 1es i on. In the l i t e r a t u r e i t has l o n g been h e l d t h a t the language d e f i c i t s of the h e a d - i n j u r e d c h i l d are d i s t i n c t from those of an a d u l t i n terms of symptomatology ( B a s s e r , 1962; Lenneberg 1967; Hecaen,1976; S h a p i r o , 1 9 8 3 ) . Some of the proposed d i f f e r e n c e s are as f o l l o w s : 1. ) R a r i t y of j a r g o n and p a r a p h a s i a s i n c h i l d r e n . 2. ) I n i t i a l phase of mutism i n c h i l d r e n ; subacute phase of f l u e n c y , n o n - f l u e n c y or mixed a p h a s i a i n a d u l t s . 3. ) F a s t e r and more complete r e c o v e r y of a u d i t o r y comprehension i n c h i l d r e n v e r s u s much s l o w e r and incomplete r e c o v e r y i n a d u l t s . Recent s t u d i e s , however, p o i n t t o a l e s s d i s c e r n a b l e symptomato1ogical d i f f e r e n c e between a d u l t and c h i l d . For example, p a r a p h a s i a s which were c i t e d as r a r e (Hecaen, 1983; G l o n i n g and H i f t 1970) are now b e i n g demonstrated ( V i s c h - B r i n k and Van de Sandt-Koenderman 1984) as a p r e v a l e n t component of spontaneous speech. D e f i c i t s i n a u d i t o r y comprehension a l s o 2 appear to be more f r e q u e n t than once thought (Hecaen, 1983; A l a j o u a n i n e and L h e r m i t t e 1965). The q u e s t i o n c o n c e r n i n g d i f f e r e n c e s between c h i l d and a d u l t a p h a s i c s may not be one of symptomatology, but r a t h e r one which concerns c o u r s e and e x t e n t of r e c o v e r y . To d a t e , the i m p l i c a t i o n has been t h a t i f a p h a s i a does e x i s t i n the c h i l d , r e c o v e r y of language i s more complete the e a r l i e r the l e s i o n i s s u s t a i n e d . T h i s b e l i e f has been enhanced by the numerous case r e p o r t s which p u r p o r t to show more r a p i d r e c o v e r y from a c q u i r e d a p h a s i a i n c h i l d r e n . (Guttman, 1942; Lewin, 1966; Mealey, 1968). Recovery has been c o n s i d e r e d p a r t i c u 1 a r i 1 y f a s t and complete f o r e x t e r n a l head trauma v e r s u s c l o s e d head i n j u r y . (Walker, 1969; S t . James R o b e r t s , 1979 f o r r e v i e w ) . An a l t e r n a t e e x p l a n a t o r y p o s i t i o n which f i n d s growing s u p p o r t c l a i m s t h a t r e c o v e r y i n c h i l d r e n i s not as complete as p r e v i o u s l y t h o u g h t . (Woods and Carey, 1979; Hecaen, 1983; K l o n o f f , 1977; Byers and Mclean, 1962). F u r t h e r m o r e , a number of c r o s s s e c t i o n a l s t u d i e s have f a i l e d t o f i n d age d i f f e r e n c e s i n r e c o v e r y from b r a i n trauma, and/or have shown b e t t e r r e c o v e r y i n a d u l t p a t i e n t s , and/or p o o r e r than p r e d i c t e d r e c o v e r y i n c h i l d r e n ( F u l d & F i s h e r , 1977; K e r s h n e r & K i n g , 1974; K e r t e s z & McCabe, 1977; R u d e l , Teuber & T w i t c h e l l , 1974; Van Dongen Loonen, 1977). I t i s suggested t h a t l o n g i t u d i n a l i n v e s t i g a t i o n of h e a d - i n j u r e d c h i l d r e n may show e v i d e n c e f o r p e r s i s t i n g l i n g u i s t i c d e f i c i t s . The m a j o r i t y of s t u d i e s of h e a d - i n j u r e d c h i l d r e n have 3 employed a n a l y t i c methods which gave o n l y a g r o s s i n d i c a t i o n of language performance. That i s , s c o r e s f o r v a r i o u s language s u b - t e s t s were t a b u l a t e d f o r comparison a g a i n s t c o n t r o l s u b j e c t s . F u r t h e r m o r e , i n many c a s e s , t e s t s used have been d e s i g n e d f o r a d m i n i s t r a t i o n t o a d u l t a p h a s i c s . In these i n s t a n c e s , the v o c a b u l a r y used and a b i l i t i e s t e s t e d , were c l e a r l y i n a p p r o p r i a t e f o r use w i t h c h i l d r e n . The purpose of t h i s i n v e s t i g a t i o n was to examine language i n c h i l d r e n who had s u f f e r e d e x t e r n a l head trauma ( e . g . m o t o r v e h i c l e a c c i d e n t s ) , a f t e r spontaneous r e c o v e r y had o c c u r r e d . The t e s t s which were used, f o c u s e d on d i f f e r e n t l e v e l s of l i n g u i s t i c f u n c t i o n i n g ; i . e . comprehension, word-r e t r i e v a l and e x p r e s s i o n of s y n t a c t i c s t r u c t u r e s . R e s u l t s were examined f o r p o s s i b l e r e s i d u a l language d e f i c i t s which might be c h a r a c t e r i s t i c of t h i s p o p u l a t i o n . P r i m a r y o b j e c t i v e s of the study were: 1) To o b t a i n d a t a on the language of e i g h t b r a i n - i n j u r e d c h i l d r e n , a t l e a s t 6 mos. p o s t - o n s e t , and t h e i r matched normal c o n t r o l s u b j e c t s . 2) To o b j e c t i v e l y examine r e c e p t i v e and e x p r e s s i v e s y n t a x and word r e t r i e v a l as e v i d e n c e d i n the d a t a . 3) To examine the d a t a i n r e l a t i o n t o documented symptomatology and e x t e n t of r e c o v e r y i n a d u l t s ' . NULL HYPOTHESES: 1 . There i s no d i f f e r e n c e between the language d e f i c i t s of head-i n j u r e d c h i l d when compared w i t h the h e a d - i n j u r e d a d u l t . 2. There i s no d i f f e r e n c e between the e x t e n t of r e c o v e r y i n the h e a d - i n j u r e d c h i l d when compared w i t h the h e a d - i n j u r e d a d u l t . L i t e r a t u r e Review: 2.1 INCIDENCE: 4 CHAPTER TWO Many r e s e a r c h e r s have c o n s i d e r e d c h i l d h o o d a p h a s i a t o be r a r e . ( B a y l e y , 1939; D e n c k l a , 1979). As S a t z and Bui l a r d - B a t e s (1983) p o i n t out "Does one mean t h a t the u n i l a t e r a l l e s i o n i s r a r e or the a p h a s i a g i v e n a u n i l a t e r a l l e s i o n ?" U n i l a t e r a l l e s i o n s , i n c u r r e d i n c l o s e d head i n j u r y are r a r e r i n c h i l d r e n than i n a d u l t s (Heilman and V a l e n s t e i n , 1979). P r i m a r y c e r e b r a l damage, however, caused by e x t e r n a l head i n j u r y i s e q u a l l y l i k e l y i n a d u l t s and c h i l d r e n . Secondary damage which i n f l u e n c e s r e c o v e r y outcomes has been shown to be unique i n brain-damaged c h i l d r e n v e r s u s a d u l t s . ( I s a a c a s o n , 1975; Smith and Sugar, 1975). Bruce e t a l . (1979) p o i n t o u t , t h a t secondary damage such as hyperemia and v a s o d i l a t i o n are u b i q u i t o u s r e s p o n s e s of the p e d i a t r i c b r a i n t o head trauma, w i t h the main cause b e i n g i n t r a c r a n i a l h y p e r t e n s i o n . Raimondi and H i r s c h a u e r (1984) found s u b d u r a l hematomas to be most common i n c h i l d r e n under l ; 0 y e a r . C o n s i s t e n t w i t h t h i s , B a c c h i (1980) showed e x t r a d u r a l hematomas to be l e s s common i n c h i l d r e n than i n a d u l t s g i v i n g e l a s t i c i t y of the p e d i a t r i c s k u l l as a r e a s o n f o r t h i s d i f f e r e n c e . The r i s k of a p h a s i a g i v e n an e t i o l o g y i s not r a r e i n c h i l d h o o d . Guttman (1942) p o i n t e d to the s i m i l a r f r e q u e n c y of a p h a s i a i n c h i l d r e n and a d u l t s . Hecaen (1983) i n summarizing 5 h i s s t u d y of a c q u i r e d a p h a s i a i n c h i l d r e n s t a t e s " A p h a s i a i s more f r e q u e n t , a t l e a s t among the youngest c h i l d r e n , than i n a d u l t s . " A r a i s e d i n c i d e n c e of a p h a s i a i n c h i l d r e n w i t h r i g h t b r a i n i n j u r y l e d to the p o s t u l a t i o n of the " E q u i p o t e n t i a l i t y H y p o t h e s i s " . ( F r e u d , 1897; Krashen, 1973; Hecaen, 1976; B a s s e r , 1962). That i s , d u r i n g c h i l d h o o d the c e r e b r a l s p e c i a l i z a t i o n of speech i s r e p r e s e n t e d i n both hemispheres, and hence b o t h are e q u a l l y s u s c e p t i b l e to a p h a s i a . A g r a d u a l development of c e r e b r a l dominance o c c u r s w i t h age. Support f o r t h i s h y p o t h e s i s i s based on a h i g h e r r i s k of a p h a s i a i n r i g h t handed c h i l d r e n w i t h l e s i o n s of the r i g h t hemisphere. Two f a c t o r s c o n t r i b u t i n g to t h i s r a i s e d i n c i d e n c e of r i g h t h e m i s p h e r i c a p h a s i a s a r e : a) vague d e f i n i t i o n s of a p h a s i a b) c r o s s e d a p h a s i a s Hecaen (1976) s t u d i e d a c q u i r e d a p h a s i a i n c h i l d r e n 3-15 years of age w i t h a view t o comparing r e s u l t s w i t h those a v a i l a b l e i n r e l a t i o n t o o n t o g e n e s i s of h e m i s p h e r i c s p e c i a l i z a t i o n . He found a r a i s e d i n c i d e n c e of language d i s o r d e r s w i t h r i g h t -s i d e d l e s i o n s (33%) a d m i t t i n g t h a t i t may be a r t i f i c i a l l y e l e v a t e d . F i r s t , the number of r i g h t h e m i s p h e r i c l e s i o n s i s very s m a l l t h e r e f o r e r e p r e s e n t i n g a s t a t i s t i c a l b i a s (2/6) . Second the d e f i n i t i o n of a p h a s i a i n these p a r t i c u l a r c h i l d r e n were l o o s e l y d e f i n e d and h a r d l y c h a r a c t e r i s t i c of a language d i s o r d e r . One had a t r a n s i t o r y a r t i c u l a t i o n d i s o r d e r , w h i l e 6 the o t h e r ( l e f t - h a n d e d ) had a w r i t i n g d i s o r d e r . Dunsdon (1952) employed vague d e f i n i t i o n s of a p h a s i a i n r e p o r t i n g h i s s t a t i s t i c s . He d e s c r i b e d speech d e f i c i t s of c h i l d r e n as a " l a c k of n e c e s s a r y c o n t r o l of speech mechanism muscles." A p h a s i a , however, i n c l u d e s comprehension and p r o d u c t i o n d i s o r d e r s but not motor problems r e l a t e d t o language o u t p u t . Crossed a p h a s i a s have a l s o c o n t r i b u t e d to t h i s r a i s e d i n c i d e n c e of r i g h t h e m i s p h e r i c a p h a s i a . By " c r o s s e d a p h a s i a s ' i s meant those cases i n which a r i g h t - h a n d e d s u b j e c t has r i g h t hemisphere d i s e a s e . B i l a t e r a l d i s e a s e ( i . e . trauma and neoplasms) can i n f l a t e the o v e r a l l i n c i d e n c e of a p h a s i a , p a r t i c u l a r i 1 y c r o s s e d a p h a s i a s . B a s s e r ' s s t u d y (1962) i n c l u d e d s u b j e c t s who had s u s t a i n e d l e s i o n s p r i o r to 1940 , b e f o r e the i n t r o d u c t i o n of a n t i b i o t i c s and mass i m m u n i z a t i o n ; hence b i l a t e r a l p a t h o l o g i c a l damage was p o s s i b l e . Hecaen (1976) and o t h e r s i n c l u d e trauma as a common e t i o l o g y f o r a p h a s i a ; s i n c e t h i s type of i n j u r y causes d i f f u s e e f f e c t s , i t i s i m p o s s i b l e t o e x c l u d e l e s i o n s i n the o t h e r hemisphere. 2_.2_CEREBRAL_LATERALIZ Recent l i t e r a t u r e p o i n t s to h e m i s p h e r i c dominance f o r language i n the i n f a n t i l e b r a i n r a t h e r than f u n c t i o n a l e q u i v a l e n c y d u r i n g a c r i t i c a l p e r i o d . R e s e a r c h e r s have i n d i c a t e d a g r e a t e r percentage of a p h a s i a f o l l o w i n g l e f t b r a i n i n j u r y than 7 f o l l o w i n g r i g h t b r a i n i n j u r y . S a t z and Bui l a r d - B a t e s ( 1983) c o n c l u d e d from t h e i r s t a t i s t i c a l e x a m i n a t i o n of the l i t e r a t u r e t h a t o v e r a l l mean i n c i d e n c e of a p h a s i a i s the same f o r l e f t b r a i n i n j u r y r e g a r d l e s s of ageJ the r i s k w i t h r i g h t b r a i n i n j u r y i s h i g h e r i n c h i l d r e n than i n a d u l t s but s i g n i f i c a n t l y lower than i n l e f t b r a i n i n j u r y . Woods and Teuber (1978) found 74% of t h e i r s u b j e c t s w i t h a l e f t hemisphere l e s i o n t o have i n i t i a l a p h a s i a w h i l e o n l y 13% w i t h a r i g h t hemisphere l e s i o n to have i n i t i a l a p h a s i a . Krashen (1973) i n h i s stu d y of c h i l d h o o d a p h a s i a found t h a t the percentage of r i g h t s i d e d l e s i o n s p r o d u c i n g an a p h a s i a was s i m i l a r t o t h a t observed i n a d u l t s . S i m i l a r a s s y m e t r i e s have been d i s c l o s e d i n animal e x p e r i m e n t a t i o n . N e u r o s c i e n t i s t s have d i s c o v e r e d b e h a v i o u r a l and a n a t o m i c a l a s s y m e t r i e s i n the b r a i n s of apes and monkeys as e l l as of b i r d s and r a t s . Nottebohm (1979) found l e f t - b r a i n c e n t e r s i n c a n a r i e s which he showed to be r e s p o n s i b l e f o r the development of song. S e c t i o n i n g of the l e f t hemisphere l e d to the l o s s of most song components. When damage o c c u r s b e f o r e song i s d e v e l o p e d , c e n t e r s on the r i g h t s i d e can take o v e r . T h i s p l a s t i c i t y i s a p p a r e n t l y hormone-dependant. Kinsbourne and H i s c o c k (1977) found no i n c r e a s e i n l a t e r a l i t y w i t h age on d i c h o t i c l i s t e n i n g t a s k s . M o l f e s e (1971) observed l a t e r a l i z e d r e s p o n s e s i n newborns i n t h e i r p e r c e p t i o n of speech 8 sounds. Furthermore Dennis (1980) found r i g h t - l e f t d i f f e r e n c e s i n h e m i d e c o r t i c a t e d c h i l d r e n , b e f o r e a c q u i s i t i o n of language. More s p e c i f i c a l l y the r i g h t hemisphere was more competent i n p e r c e p t u a l s k i l l s and the two hemispheres used d i f f e r e n t v e r b a l s t r a t e g i e s t o encode and decode language. B e s i d e s b e h a v i o u r a l d a t a , e v i d e n c e f o r e a r l y l a t e r a l i z a t i o n comes from s t r u c t u r a l a s s y m e t r i e s between the hemispheres. ( G a l a b u r d a e t a l . , 1978; Geschwind & L e v i t s k y , 1968; LeMay & C u l e b r a s , 1972). G a l a b u r d a e t a l . found s t r u c t u r a l d i f f e r e n c e s i n the a u d i t o r y r e g i o n s and the S y l v i a n F i s s u r e even i n the f o e t u s . From t h e i r d a t a they a l s o s u g g ested t h a t " a s s y m e t r i e s seem to be d i s t r i b u t e d a l o n g a continuum, t h a t i s , the r e g i o n which i s l a r g e r on one s i d e may vary from b e i n g o n l y s l i g h t l y l a r g e r t o , a t t i m e s , b e i n g many times l a r g e r . " As a consequence such d i f f e r e n c e s i n assymetry may account f o r i n d i v i d u a l d i f f e r e n c e s i n r e c o v e r y ; when two s i d e s are l e s s l a t e r a l i z e d , r e c o v e r y i s b e t t e r . However, C o r b a l l i s & Beale (1983) p o i n t out t h a t measured d i f f e r e n c e s i n assymetry do not c o r r e s p o n d t o p r o p o r t i o n s of i n d i v i d u a l s w i t h language r e p r e s e n t e d on the l e f t , b i l a t e r a l l y , or on the r i g h t . They su s p e c t "the d i s c r e p a n c y p r o b a b l y has to do w i t h the n a t u r e of the measurements" (P.141). N o n e t h e l e s s , b r a i n s w i t h o u t a p a r t i c u l a r a s symetry are more common i n l e f t handers (Rasmussen and M i l n e r , 1977), w h i l e assymetry f o r v e r b a l f u n c t i o n s may be more c o n s i s t e n t l y e s t a b l i s h e d i n males (McGlone, 1978). V a r i a t i o n s on the " e q u i p o t e n t i a l i t y p o s i t i o n " have been 9 p o s t u l a t e d i n an attempt to e x p l a i n d i f f e r e n c e s i n l a t e r a l i z a t i o n . Rasmussen and M i l n e r (1977) d i s c u s s e d the p o s s i b i l i t y of p a r t i a l use of e i t h e r hemisphere depending on the s i t e of l e s i o n . They used Sodium Amytal to t e s t f o r c e r e b r a l a ssymetry i n b o t h brain-damaged and c o n t r o l s u b j e c t s . R e s u l t s i n d i c a t e d t h a t the l o c u s of the l e s i o n was c r i t i c a l i n d e t e r m i n i n g l a t e r a l i z a t i o n of speech f u n c t i o n s a f t e r e a r l y l e f t -b r a i n i n j u r y . F o r example one s u b j e c t , a 16;0 year o l d g i r l had i n c u r r e d an i n j u r y a t 2;5 y e a r s , but language was adequate and r e p r e s e n t e d i n the r i g h t hemisphere a t t e s t i n g . They s p e c u l a t e d t h a t damage to the p a r i e t o - t e m p o r a l r e g i o n l e d to the development of speech r e p r e s e n t a t i o n i n the c o r r e s p o n d i n g r e g i o n of the r i g h t hemisphere. The s i t e of l e s i o n , a c c o r d i n g to t h i s s t u d y , i s the c r i t i c a l f a c t o r i n d i s p l a c e m e n t of f u n c t i o n a l r e p r e s e n t a t i o n . Other v a r i a t i o n s which have been d i s c u s s e d i n c l u d e i n t r a h e m i s p h e r i c r e o r g a n i z a t i o n of the hemisphere s u b s e r v i n g lanaguage, (Hecaen, 1976), and r e c o v e r y of language f u n c t i o n s i n the l e f t hemisphere a t the expense of nonlanguage f u n c t i o n s i n the r i g h t hemisphere. (Woods and Teuber, 1978). In summary, a p h a s i a i s not r a r e i n c h i l d r e n , but i t i s more prominent i n damage t o the dominant l e f t hemisphere. T h i s e v i d e n c e c o n t r a d i c t s the e q u i p o t e n t i a l i t y h y p o t h e s i s , on the b a s i s of which o t h e r v a r i a t i o n s c o n c e r n i n g c e r e b r a l assymetry have been s u g g e s t e d . B e s i d e s b e h a v i o u r a l d a t a , t h e r e i s 10 s t r u c t u r a l e v i d e n c e f o r e a r l y l a t e r a l i z a t i o n . T h i s l a t e r a l i z a t i o n d i f f e r s i n i n d i v i d u a l s and may not be comparable i n f u n c t i o n t o the a d u l t . 2^3_PREINJURY_STATUS: The h e a d - i n j u r e d p o p u l a t i o n does not , i n many c a s e s , t y p i f y the normal c h i l d p o p u l a t i o n . V a r i o u s s o c i a l or academic problems may make the c h i l d more s u s c e p t i b l e t o a head i n j u r y . K l o n o f f e t a l . (1977) i n t h e i r d e velopmental f o l l o w - u p of head-i n j u r e d c h i l d r e n , found t h a t p r e i n j u r y l e a r n i n g d i s a b i l i t i e s and o t h e r "developmental a n o m a l i e s " were common i n boys. Jennet (1974) examined the p s y c h o l o g i c a l sequelae of head-i n j u r e d c h i l d r e n and c o n c l u d e d t h a t few h e a d - i n j u r e d c h i l d r e n have b e h a v i o u r a l d i s o r d e r s ; those who do prove t o have been m a l a d j u s t e d b e f o r e the i n j u r y . F u l d & F i s h e r (1977) conducted one of the few s t u d i e s which i n c l u d e s d e t a i l e d p r e i n j u r y d a t a on a l l s u b j e c t s . In t h e i r sample of seven c h i l d r e n o n l y one was d e s c r i b e d as b r i g h t and one as normal b e f o r e the a c c i d e n t . The o t h e r 5 had l e a r n i n g d i s a b i l i t i e s , m i l d mental r e t a r d a t i o n , and m i l d r e a d i n g problems. F u l d and F i s h e r s t a t e t h a t i n t h e i r c l i n i c a l e x p e r i e n c e they " o n l y saw t h r e e who c o u l d be d e s c r i b e d as a c a d e m i c a l l y and s o c i a l l y normal b e f o r e t h e i r a c c i d e n t . " 2 ..^SYMPTOMATOLOGY: S i m i l a r i t i e s A c r o s s S t u d i e s : I t i s d i f f i c u l t to make comparisons a c r o s s s t u d i e s c o n c e r n i n g 11 symptomatology; t h i s l a c k of comparison i s due t o : f a i l u r e to c o n t r o l language measures, inadequate d e s c r i p t i o n of the s t a t u s of the b r a i n damage, r e c o v e r y p e r i o d s i n v o l v e d , and e x p e r i e n t i a l v a r i a b l e s . A l l these f a c t o r s c o n t r i b u t e to b r a i n damage r e c o v e r y measures. However, one can d e r i v e from the l i t e r a t u r e two almost d i s t i n c t hypotheses c o n c e r n i n g language of the h e a d - i n j u r e d c h i l d . One p o s i t s t h a t the c h i l d r e c o v e r s f a s t e r the e a r l i e r the damage i s s u s t a i n e d and t h a t g i v e n time he w i l l r e c o v e r c o m p l e t e l y ( B a s s e r , 1962). The o t h e r s u g g e s t s t h a t r e c o v e r y of language i s not so complete and l i n g u i s t i c d e f i c i t s may be a p o t e n t i a l cause of academic and s o c i a l problems ( R a n k i n e t . a l . , 1981; Woods and Carey, 1979 ). S i m i l a r i t i e s a c r o s s s t u d i e s c o n c e r n i n g language of the head-i n j u r e d c h i l d do e x i s t i n the l i t e r a t u r e . A l a j o u a n i n e and L h e r m i t t e (1965) conducted a study of 32 c h i l d r e n r a n g i n g from 6-15 ye a r s a t time of trauma. The st u d y i s comprehensive i n t h a t the c h i l d r e n were f o l l o w e d over a p e r i o d of one to twelve y e a r s . At t h r e e months t e s t i n g the symptomatologies i n c l u d e d a r e d u c t i o n i n o r a l and w r i t t e n e x p r e s s i o n , s y n t a c t i c s i m p l i f i c a t i o n , absence of l o g o r r h o e a and p e r s e v e r a t i o n . The a u t h o r s suggest t h a t absence of a u t o m a t i z e d sequences such as l o g o r r h o e a and p e r s e v e r a t i o n i s due to the nervous c i r c u i t s which are " l e s s d e e p l y e s t a b l i s h e d " i n the c h i l d . R e c e p t i v e d i s o r d e r s were noted t o be r a r e , and r e a d i n g problems were d e s c r i b e d as d i f f e r e n t from those i n a d u l t s . I n s t e a d of h a v i n g a problem w i t h l e t t e r s l i k e a d u l t s , most problems were 12 e n c o u n t e r e d on words as wholes. A f t e r one year many of the symptoms were r e p o r t e d to have d i s a p p e a r e d ; some d i f f i c u l t i e s were s t i l l n o t e d i n c o n s t r u c t i o n of sentences and word d e f i n i t i o n s i n 14 c h i l d r e n . W r i t i n g d i s t u r b a n c e s a l s o tended to p e r s i s t . Hecaen (1976) c o n f i r m e d these f i n d i n g s i n h i s s t u d y of 26 c h i l d r e n w i t h a c q u i r e d a p h a s i a ( a g e s 3.5-15*0). The e t i o l o g i e s i n these c h i l d r e n were mixed and i n c l u d e d trauma, hematomas, tumors and a b s e s s e s . From an e x a m i n a t i o n of the language of these c h i l d r e n he r e p o r t e d 15/17 l e f t - l e s i o n e d and 2/6 r i g h t -l e s i o n e d to have language d i s o r d e r s . I t s h o u l d be noted t h a t t h i s d e f i n i t i o n of language d i s o r d e r v a r i e d g r e a t l y depending on the i n d i v i d u a l . I t i n c l u d e d d e f i c i t s as m i l d as a t r a n s i t o r y a r t i c u l a t i o n problem or as severe as a 6 year w r i t i n g d i s o r d e r . L i k e A l a j o u a n i n e and L h e r m i t t e , he r e p o r t s a f r e q u e n c y of i n i t i a l mutism, and r a r i t y of p a r a p h a s i a s and l o g o r r h o e a . D i s o r d e r s of r e a d i n g were a l s o noted i n the acute stage but they tended to d i s a p p e a r r a p i d l y . D i s o r d e r s of w r i t i n g and naming were most f r e q u e n t and tend to p e r s i s t l o n g e s t . Hecaen r e p o r t e d few a u d i t o r y comprehension problems, which was c o n s i s t e n t w i t h the f i n d i n g s of A l a j o u a n i n e and L h e r m i t t e . With r e s p e c t to r e c o v e r y , he found s i z e and b i l a t e r a l i t y of l e s i o n to be two of the most important f a c t o r s , but found no c o r r e l a t i o n between coma and s e v e r i t y of de f i c i t . F u l d & F i s h e r (1977) conducted a s t u d y of seven c h i l d r e n w i t h 13 c l o s e d head i n j u r y . Age a t i n j u r y v a r i e d from 1 to 15 y e a r s . Of these c h i l d r e n o n l y 2 c o u l d be c o n s i d e r e d to be normal p r i o r to the i n j u r y ; problems i n c l u d e d m i l d mental r e a t a r d a t i o n , l e a r n i n g d i s a b i l i t i e s and m i l d r e a d i n g problems. They p r e s e n t e d an overview of a l l c h i l d r e n i n a d d i t i o n to d e t a i l e d case s t u d i e s of two of the c h i l d r e n . T e s t i n g was performed a few months a f t e r the i n j u r y as w e l l as 6 months and 1 year l a t e r . B e h a v i o u r problems were marked i n two c h i l d r e n , and a t t e n t i o n problems were noted i n f o u r . T a k i n g i n t o c o n s i d e r a t i o n premorbid s t a t u s , they i d e n t i f i e d i n t e l l e c t u a l impairment l o n g a f t e r EEG's and n e u r o l o g i c a l exams had r e t u r n e d to normal. Comprehension d e f i c i t s were r e v e a l e d i n two cases a cou p l e of months a f t e r i n j u r y but they d i s a p p e a r e d 6 months l a t e r . In one c a s e , r e a d i n g problems were d e s c r i b e d , which p e r s i s t e d f o r a t l e a s t 6 months. Byers & Mclean (1962) r e p o r t 11 c a s e s of h e m i p l e g i a accompagnied by a p h a s i a . T h i s study was v e r y comprehensive i n t h a t i t p r e s e n t e d the c l i n i c a l r e c o v e r y c o u r s e f o r each of the c h i l d r e n as w e l l as a f o l l o w - u p 3 t o 7 ye a r s l a t e r . D i s t u r b a n c e s of a l l forms of e x p r e s s i v e language i n c l u d i n g i n i t i a l mutism were d e s c r i b e d as a common symptom i n the acute s t a g e . These language d i f f i c u l t i e s were i n a l l i n s t a n c e s combined w i t h v i s u a l d i f f i c u l t i e s which c o n t r i b u t e d to r e a d i n g problems. R e v e r s a l s were noted both i n o r d e r of l e t t e r s and i n t h e i r f o r m a t i o n . Recovery proceeded a t d i f f e r e n t speeds i n a l l c a s e s , but a l l c h i l d r e n g a i n e d spontaneous speech . Four 14 appeared to be f u n c t i o n i n g a d e q u a t e l y a f t e r a few y e a r s , w h i l e a l l the o t h e r s showed p e r s i s t i n g p s y c h o l o g i c a l problems. A concensus can be a r r i v e d a t from these s t u d i e s (and o t h e r s ) r e g a r d i n g the symptomatology of the h e a d - i n j u r e d c h i l d . I t appears t h a t i n i t i a l mutism and absence of p a r a p h a s i a s i s a common symptom. A u d i t o r y comprehension problems are found i n some ca s e s but d i s a p p e a r q u i c k l y . W r i t i n g and r e a d i n g d i s t u r b a n c e s are common and o f t e n p e r s i s t . 2_.5_SYMPTOMATOLOGY: D i f f e r e n c e s A c r o s s S t u d i e s -D e s p i t e these s i m i l a r i t i e s , d i f f e r e n c e s i n the language d e f i c i t s of h e a d - i n j u r e d c h i l d r e n s t i l l e x i s t . R e s e a r c h e r s who have a n a l y z e d language a t an acute stage have r e c o g n i z e d the freque n c y of p a r a p h a s i a s . F u l d & F i s h e r (1977) r e p o r t e d a g i r l w i t h o c c a s i o n a l p a r a p h a s i a s one year a f t e r her i n j u r y . V i s h -B r i n k and Van de Sandt-Koenderman (1984) a n a l y z e d the spontaneous speech of 14 c h i l d r e n w i t h a c q u i r e d a p h a s i a , v a r y i n g i n age from 5;0 to 12,0 y e a r s . They showed t h a t the term " r a r e " has been i n a p p r o p r i a t e l y a p p l i e d t o p a r a p h a s i a s . More than h a l f of the c h i l d r e n they s t u d i e d produced p a r a p h a s i a s , and the number of p a r a p h a s i a s u t t e r e d by a s i n g l e c h i l d c o u l d be q u i t e l a r g e . Furthermore they found t h a t a l l the c h i l d r e n , a t an e a r l y s t a g e , produced more th a n one p a r a p h a s i a a minute, a fr e q u e n c y s i m i l a r to t h a t found i n a d u l t a p h a s i c s (Goodglass & K a p l a n , 1972). " N o n - f l u e n t " a term borrowed from a d u l t a p h a s i o l o g y ,has been 15 used, by consensus, to d e s c r i b e the i n i t i a l p r o f i l e of a head i n j u r e d c h i l d (Hecaen, 1983; B a s s e r , 1962; Guttmann, 1942). Cases of f l u e n t a p h a s i a have now been r e p o r t e d by a number of r e s e a r c h e r s ( V i s c h - B r i n k and Van De Sandt-Koenderman, 1984; Woods and Teuber, 1978; F u l d & F i s h e r , 1977). V i s c h - B r i n k and Van De Sandt-Koenderman were a b l e t o c l a s s i f y t h e i r s u b j e c t s , as e i t h e r f l u e n t or n o n f l u e n t on the b a s i s of tempo and mean l e n g t h of u t t e r a n c e . Woods and Teuber (1978) p o i n t out t h a t t h e r e can be e x c e p t i o n s to n o n f l u e n c y , such as a 5 year o l d j a r g o n a p h a s i c , whom they s t u d i e d . They i n d i c a t e t h a t p r e v i o u s l y "Our o b s e r v a t i o n s of p r i m a r i l y n o n f l u e n t a p h a s i a a f t e r e a r l y l e s i o n s may have been i n f l u e n c e d by our r e l i a n c e on h e m i p a r e s i s as the n e u r o l o g i c a l c r i t e r i o n f o r i n c l u s i o n i n the sample." The r a r i t y of r e p o r t s of a u d i t o r y comprehension d e f i c i t s i n the l i t e r a t u r e may a l s o be e x p l a i n e d by the r e l i a n c e on h e m i p a r e s i s f o r i n c l u s i o n i n a sample. That i s , a u d i t o r y comprehension d e f i c i t s have been a s s o c i a t e d w i t h temporal lobe l e s i o n s i n a d u l t s , whereas h e m i p a r e s i s i s g e n e r a l l y a s s o c i a t e d w i t h f r o n t a l lobe l e s i o n s . Hecaen (1976) found a r e l a t i o n between d i s o r d e r s of a u d i t o r y comprehension and l e s i o n l o c a l i z a t i o n i n h i s s t u d y ; they were found o n l y w i t h temporal l e s i o n s . These l o c a l i z a t i o n f e a t u r e s were found i n both the younger and o l d e r groups. Hecaen (1983) has suggested t h a t a l l a s p e c t s of language 16 i n c l u d i n g a u d i t o r y comprehension, are a f f e c t e d more by a n t e r i o r than temporal lobe damage. He f u r t h e r suggested t h a t the f r o n t o - r o l a n d i c a r e a of the b r a i n i s engaged i n more d i v e r s e language f u n c t i o n s than i n a d u l t s . However, the m a j o r i t y of comprehension problems i n h i s st u d y were m i l d o r t r a n s i t o r y and no o b j e c t i v e measures were used f o r t e s t i n g such d e f i c i t s . A u d i t o r y comprehension d e f i c i t s are not as apparent as p r o d u c t i o n problems, but appear to be more f r e q u e n t than once tho u g h t , when o b j e c t i v e measures are employed i n t e s t i n g . A l a j o u a n i n e and L h e r m i t t e (1965) found d e f i c i t s of t h i s n a t u r e i n many of t h e i r s u b j e c t s . The st u d y by Aram e t . a l (1981) i s one of the few which i n c l u d e s i n f o r m a t i o n about l e s i o n s i t e . They s t u d i e d c h i l d r e n (6-8 y e a r s ) who had i n c u r r e d b r a i n damage d u r i n g the p r e n a t a l or p e r i n a t a l p e r i o d . The a r e a of damage i n the l e f t - h e m i s p h e r e of these s u b j e c t s i n c l u d e d the temporal and p a r i e t a l lobe i n two, and the f r o n t a l and p a r i e t a l l o b e s i n a n o t h e r . I n t e l l i g e n c e measures i n d i c a t e d comparable s c o r e s a c r o s s s u b j e c t s . Through an e x t e n s i v e b a t t e r y of e x p r e s s i v e and r e c e p t i v e language t e s t s they i d e n t i f i e d comprehension d e f i c i t s as w e l l as s y n t a c t i c and v o c a b u l a r y d e f i c i t s i n these c h i l d r e n . C h i l d r e n w i t h l e f t hemisphere damage performed s i g n i f i c a n t l y below the normal mean on both the Token Test ( r e c c e p t i v e lnaguage) and the N o r t h w e s t e r n Syntax S c r e e n i n g Test ( r e c e p t i v e s y n t a x ) . R a n k i n e t a l . (1985) t e s t e d 16 c h i l d r e n w i t h u n i l a t e r a l l e s i o n s 1 to 4 years a f t e r onset of damage. E x t e n s i v e 17 d a t a was a v a i l a b l e on l e s i o n s i t e , and e x t e n s i v e language t e s t i n g was c o n d ucted. The l e s i o n s i t e was f o r the most p a r t i n the pre and r e t r o r o l a n d i c a r e a w i t h or w i t h o u t b a s a l g a n g l i a i n v o l v e m e n t . In a l l c h i l d r e n , t h e r e was documented ev i d e n c e of normal n e u r o l o g i c a l s t a t u s and development, p r i o r to l e s i o n i n g . Test r e s u l t s i n d i c a t e d r e c e p t i v e d e f i c i t s i n 3/8 of the l e f t l e s i o n e d s u b j e c t s , w h i l e a l l but one performed a t or above the 50th p e r c e n t i l e . No s i g n i f i c a n t r e c e p t i v e d e f i c i t s were found i n the r i g h t - l e s i o n e d s u b j e c t s . The weakness i n t h i s s t u d y l i e s i n i t s g e n e r a l i z a b i l i t y to o t h e r c h i l d r e n w i t h u n i l a t e r a l l e s i o n s s i n c e the m a j o r i t y of l e s i o n s r e p o r t e d were i n c u r r e d b e f o r e language a c q u i s i t i o n . The i s s u e p r e s e n t e d i n t h i s study i s how w e l l these c h i l d r e n can a c q u i r e language r a t h e r than how w e l l they r e l e a r n " o l d " s k i l l s . T h i s d i s c r e p a n c y c o n c e r n i n g symptomatology i n language may be more apparent than r e a l , r e f l e c t i n g the heterogeneous e t i o l o g i e s , l e s i o n s and l i n g u i s t i c m a t u r i t y of the c h i l d h o o d samples s t u d i e d . With r e s p e c t to l i n g u i s t i c m a t u r i t y , some r e s e a r c h e r s suggest t h a t h e a d - i n j u r e d c h i l d r e n may be a b l e to r e a t t a i n p r e m o r b i d l e v e l s of f u n c t i o n i n g but have d i f f i c u l t y a c q u i r i n g new s k i l l s ( A l a j o u a n i n e and L h e r m i t t e , 19S5). Those s t u d i e s which i n c l u d e h e a d - i n j u r e d c h i l d r e n w i t h l e s i o n s d a t i n g back to p r e n a t a l or p e r i n a t a l p e r i o d s s h o u l d be s e p a r a t e d out from those i n c u r r e d a f t e r language a c q u i s i t i o n . Annett (1972) i n c l u d e d m a i n l y p e r i n a t a l l e s i o n s i n her s t u d y , 18 and noted t h a t developmental d e l a y , r a t h e r than d i s t i n c t i v e or s p e c i f i c problems. Aram e t a l . (1981) a l s o i n d i c a t e d a d e l a y i n language development a f t e r p e r i n a t a l l e s i o n s , p a r t i c u l a r i 1 y i n the l e f t l e s i o n e d group. Thus i n t e r p r e t a t i o n of r e s u l t s as e i t h e r a d e l a y or an a p h a s i c d i s o r d e r , may depend on time of l e s i on. E t i o l o g y i s a n o t h e r v a r i a b l e which has not been a d e q u a t e l y c o n t r o l l e d and may l e a d to m i s l e a d i n g r e s u l t s . Hecaen (1976), and A l a j o u a n i n e and L h e r m i t t e (1965 ) i n c l u d e d trauma, tumor, m e n i n g i t i s , and hematomas i n c a l c u l a t i n g t h e i r p e r c e n t a g e s of l a n g u a g e - d i s o r d e r e d c h i l d r e n . The e t i o l o g y of l e s i o n and i t s secondary e f f e c t s have been shown to be s i g n i f i c a n t i n p r e d i c t i n g l o n g - t e r m r e c o v e r y of language i n c h i l d h o o d a p h a s i a . (Van Dongen & Loonen, 1977) . Woods and Teuber (1978) conducted a s t u d y of 65 c h i l d r e n w i t h u n i l a t e r a l l e s i o n s i n c u r r e d between 2-14 y e a r s . The e t i o l o g y of these l e s i o n s were d i v e r s e and may have l e d to h i s i n t e r p r e t a t i o n of r e s u l t s . They o n l y i n c l u d e d c ases i n which t h e r e was c l i n i c a l e v i d e n c e of a s i n g l e f i x e d l e s i o n . Note however, t h a t e v i d e n c e was based on b r a i n s c a n s , "whenever p o s s i b l e " . More than h a l f of the s u b j e c t s ' d a t a were from c h a r t r e v i e w s o n l y , t h e r e f o r e o b j e c t i v e measurements of a p h a s i a c o u l d not be performed. From i d e n t i f i c a t i o n of a p h a s i a i n t h e i r s u b j e c t s they p o s i t t h a t r e c o v e r y was b e t t e r and more l i k e l y b e f o r e 8;0. E t i o l o g y may a l s o be a f a c t o r i n t h e i r f i n d i n g s ; a l l but 2 trauma cases were i n the under 8;0 group. 19 S i n c e c h i l d r e n have been shown to r e c o v e r f a s t e r f o l l o w i n g trauma t h a n they do f o l l o w i n g c e r e b r o v a s c u l a r a c c i d e n t s , these p a r t i c u l a r s u b j e c t s c o u l d have i n f l u e n c e d r e s u l t s i n f a v o u r of the younger group. D i f f e r e n c e s i n the l i n g u i s t i c f e a t u r e s of a p h a s i c speech have, f o r many years been a s o c i a t e d w i t h v a r i o u s l o c a l i z a t i o n s i t e s . In terms of f l u e n c y , Benson (1967) found a c o r r e l a t i o n between f l u e n t and n o n f l u e n t types of a p h a s i a w i t h a n t e r i o r and p o s t e r i o r l e s i o n s r e s p e c t i v e l y . V i s c h and Van De Sandt Koenderman (1984) r e p o r t an i n f a n t case i n which a s i m i l a r r e l a t i o n i s found; a p o s t e r i o r l e s i o n w i t h a f l u e n t a p h a s i a . Hecaen (1976) r e p o r t e d the i n c i d e n c e of mutism and a r t i c u l a t o r y d i s o r d e r s to be a s s o c i a t e d w i t h a n t e r i o r l e s i o n s , and a u d i t o r y comprehension to be a s s o c i a t e d w i t h temporal l e s i o n s . Other r e a s o n s f o r d i f f e r e n c e s i n symptomatology c o u l d i n c l u d e : language measures employed i n the s t u d y , and the time p o s t -onset a t which they were a d m i n i s t e r e d . Many s t u d i e s have employed vague measures of language, and use such phrases as "normal" or " s p e a k i n g p o o r l y . " In o t h e r c ases IQ measures are used which r e l y on s e m a n t i c a l l y based i n f o r m a t i o n or m e t a l i n g u i s t i c s k i l l s r a t h e r than a c t u a l language a b i l i t i e s . I t has been shown t h a t i t i s syntax which i s most a f f e c t e d i n b r a i n trauma (Dennis 1980). When more o b j e c t i v e measures of language are used then the d e f i c i t s not r e a d i l y a p p a r e n t , are r e c o g n i z e d i n these c h i l d r e n . 20 2 iG_C0URSE_0F_REC0VERY: L i k e symptomatology, r e c o v e r y p a t t e r n s are v a r i e d and documented i n v a r i o u s f o r m a t s , making comparisons a c r o s s s t u d i e s somewhat d i f f i c u l t . The time course of r e c o v e r y i s by no means i n v a r i a n t . Some s t u d i e s r e p o r t f u l l r e s t o r a t i o n of language w i t h i n one year (Lenneberg, 1967; Guttman, 1942) and o t h e r s r e p o r t d e f i c i t s p e r s i s t i n g up to f i v e y ears ( K l o n o f f & C l a r k , 1977). Recovery e f f e c t s have been r e p o r t e d t o c o n t i n u e f o r l o n g e r p e r i o d s of time i n younger c h i l d r e n . K l o n o f f & C l a r k (1977) s t u d i e d r e c o v e r y i n a young group (mean age 5 y e a r s ) and i n an o l d group (mean age 11 y e a r s ) . R e s u l t s i n d i c a t e d t h a t "the o l d e r group s t a b i l i s e d t h r e e y e a r s a f t e r trauma w h i l e improvement was s t i l l e v i d e n t i n the younger group 5 years a f t e r trauma". S i m i l a r d i f f e r e n c e s have been noted between c h i l d r e n and a d u l t s ( S t . James-Roberts, 1980). S t . James-Roberts (1981) performed a c r i t i c a l e x a m i n a t i o n of hemispherectomy d a t a , and noted h e t e r o g e n e i t y of r e c o v e r y w i t h i n i n f a n c y t o be f a r g r e a t e r than had been t r a d i t i o n a l l y supposed. Comparisons were made of speech p r o d u c t i o n and i n t e l l i g e n c e measures w i t h i n and between age groups. S t a t i s t i c a l a n a l y s e s were a p p l i e d t o i n t e l l i g e n c e measures f o r s u b j e c t s w i t h r e c o v e r y p e r i o d s g r e a t e r than one y e a r . F i n d i n g s i n d i c a t e d t h a t n e i t h e r age, hemisphere damaged, nor sex, i n f l u e n c e d r e c o v e r y s c o r e s c o n s i s t e n t l y . The problem w i t h 21 these a n a l y s e s i s t h a t a s t a t i s t i c a l b i a s e x i s t e d f o r l e f t -damaged a d u l t c a s e s ; many had d i e d due to tumor r e c u r r e n c e . A l s o l e f t - d a m a g e d c h i l d r e n a c h i e v e d h i g h e r v e r b a l IQ s c o r e s but s i n c e they were a s t a t i s t i c a l l y s m a l l p a r t of the p o p u l a t i o n , r e s u l t s d i d not r e a c h s i g n i f i c a n c e . The imp o r t a n t o b s e r v a t i o n s r e g a r d i n g r e c o v e r y made by S t . James-Roberts a r e : 1) Recovery h e t e r o g e n e i t y e x i s t s w i t h i n the c h i l d and a d u l t h e a d - i n j u r e d p o p u l a t i o n . 2. ) Recovery p e r i o d s appear to d i f f e r between a d u l t s and c h i l d r e n p a r t i c u l a r i l y i n hemispherectomy c a s e s . A d u l t s moreso than c h i l d r e n , tend t o s t a b i l i z e f a s t e r or d i e from tumor r e c u r r e n c e . 3. ) Secondary damage d i f f e r s i n a d u l t s and c h i l d r e n and may acoount f o r , a l o n g w i t h e x p e r i e n t a l f a c t o r s , d i f f e r e n c e s i n r e c o v e r y p a t t e r n s . B a s s e r (19S2) r e p o r t e d two t r e n d s observed d u r i n g r e c o v e r y ; e i t h e r r e c o v e r y o c c u r s very q u i c k l y once speech r e a p p e a r s , or i t o c c u r s s l o w l y encompassing a l l the l i n g u i s t i c s t a g e s of development. These p a t t e r n s of r e c o v e r y were not r e l a t e d to s e v e r i t y of h e m i p a r e s i s . Byers & Mclean (1962) conducted a st u d y of 11 a p h a s i c c h i l d r e n , i n which outcomes were v a r i e d . C o n s i s t e n t w i t h B a s s e r ' s f i n d i n g s , some i n d i v i d u a l s r e c o v e r e d v e r y q u i c k l y w h i l e o t h e r s p r o g r e s s e d s l o w l y through the developmental s t a g e s of language a c q u i s i t i o n . The r e c o v e r y of e x p r e s s i v e language proceeded through the f o l l o w i n g s t a g e s : 1) a few s i n g l e words 2) a u t o m a t i c sequences such as days of the week, the a l p h a b e t and n u r s e r y rhymes 3) spontaneous language 4) spontaneous d e s c r i p t i o n of t h i n g s or e v e n t s . Those p a t i e n t s 22 t h a t r e c o v e r e d q u i c k l y s k i p p e d some s t a g e s and, a c c o r d i n g to Byers and Mclean were noted to be suddenly r e a d i n g . Teuber & Rudel (1962) s t u d i e d the b e h a v i o u r a l e f f e c t s of c e r e b r a l l e s i o n s i n c h i l d r e n and i n a d u l t s . They employed t a s k s which i n c l u d e d v a r i o u s v i s u a l and p e r c p t u a l t e s t s , f o r which heterogeneous e f f e c t s were e v i d e n t a c c o r d i n g to age and t a s k . On the f i r s t , a l o c a l i z a t i o n e x p e r i m e n t , the e f f e c t s of e a r l y i n j u r y were not apparent u n t i l the age of 11 y e a r s , and become i n c r e a s i n g l y e v i d e n t t h e r e a f t e r . On the second, a d e f i c i t was found a c r o s s age groups, and on the t h i r d no d e f i c i t s were found a f t e r 11 y e a r s . They c o n c l u d e d t h a t the r e s i l i e n c y of the i n f a n t b r a i n and the e f f e c t s of such r e s i l i e n c i e s on r e c o v e r y , may depend on the t a s k employed and the age a t which the c h i l d i s t e s t e d . In summary, the time c o u r s e of r e c o v e r y appears to be heterogeneous i n h e a d - i n j u r e d c h i l d r e n . R a p i d r e c o v e r y i s s t i l l r e p o r t e d but such r e p o r t s are i n c o n f l i c t w i t h a number of case r e p o r t s a t t e s t i n g to p e r s i s t i n g d e f i c i t s . I t i s p o s s i b l e t h a t a l o n g e r p e r i o d of c o n t i n u i n g r e c o v e r y i n a c h i l d may p a r t i a l l y account f o r the b e t t e r r e c o v e r y noted when c h i l d r e n are compared w i t h a d u l t s . 2 i7_FACT0RS_PREDICTING_RE Length of Coma: Many i n v e s t i g a t o r s have observed t h a t l e n g t h of coma i s i n v e r s e l y r e l a t e d to q u a l i t y of r e c o v e r y i n c h i l d r e n . 23 ( G i l c h r i s t & W i l k i n s o n , 1979; Heiskanen & K a s t e , 1974). Heiskanen & Kaste (1974) examined c h i l d r e n w i t h h e a d - i n j u r i e s d u r i n g a ten year p e r i o d , p o s t - t r a u m a . They c o n c l u d e d t h a t any p e r i o d of u n c o n s c i o u s n e s s l o n g e r than two weeks i s l i k e l y to r e s u l t i n l i t t l e chance of normal s c h o o l p r o g r e s s , once r e c o v e r y i s t a k i n g p l a c e . In c o n t r a s t , Hecaen (1976) found no r e l a t i o n s h i p between d u r a t i o n of coma and p e r s i s t e n c e and s e v e r i t y of d e f i c i t . Age : Age has been s t u d i e d i n r e l a t i o n to the time course of r e c o v e r y . Sugar s t a t e d , ( P e r l s t e i n & Sugar, 1954) " i f the speech c e n t e r i s damaged b e f o r e the age of t e n , the c h i l d w i l l r e c o v e r h i s speech." A c c o r d i n g to Woods and Carey (1979) any c h i l d over l ; 0 who r e c e i v e d an a p h a s i a p r o d u c i n g l e s i o n i n the l e f t hemisphere i s l e s s l i k e l y to have normal language r e c o v e r y . C h i l d r e n who have been r e p o r t e d to have i n c u r r e d l e s i o n s b e f o r e 1;0 however, d i d so e i t h e r p e r i n a t a l l y or p r e n a t a l l y . T h i s type of damage would be d i f f e r e n t from damage i n c u r r e d w i t h head i n j u r i e s i n o l d e r c h i l d r e n . S t u d i e s which a t t e s t t h a t r e c o v e r y i s b e t t e r i n younger c h i l d r e n base t h i s a s s e s s i o n on the acute stage of r e c o v e r y . I f one examines f o l l o w - u p s t u d i e s of l o n g - t e r m r e c o v e r y , they p r o v i d e e x c e p t i o n s to the t h e o r y t h a t e a r l y l e s i o n s r e s u l t i n b e t t e r . For example, Van Doongen & Loonen (1977) f o l l o w e d 15 a p h a s i c c h i l d r e n f o r p e r i o d s r a n g i n g from one to t h r e e y e a r s . They c o n c l u d e d t h a t age i s not an important c o n s i d e r a t i o n i n 24 p r o g n o s i s . Mantovani & Landau (1980) r e p o r t e d a 4;0 year o l d g i r l who was unable to speak a f t e r minor head trauma. L e f t -s i d e d s e i z u r e s were not e d . I t took t h r e e to f o u r y e a r s of i n t e n s i v e s p e c i a l e d u c a t i o n f o r her to r e c o v e r her a b i l i t y to communicate. In Woods and Teuber's s t u d y (1978) the c h i l d who took the l o n g e s t to r e c o v e r (2.5 y e a r s ) was o n l y 5 years 1 month a t the time of the CVA. Annett (1972) found younger c h i l d r e n who had i n c u r r e d an i n t r i n s i c l e s i o n to be more s e v e r e l y a f f e c t e d than o l d e r c h i l d r e n who had i n c u r r e d s i m i l a r l e s i o n s . EEG Shoumaker, B e n n e t t , Bray, and C u r l e s s (1974) c o n c l u d e d t h a t degree of a p h a s i a and EEG a b n o r m a l i t y p a r a l l e l each o t h e r . In c o n t r a d i c t i o n , B a c c h i (1980) r e p o r t e d t h a t EEG's are not r e l i a b l e p r e d i c t o r s of r e c o v e r y i n h e a d - i n j u r e d c h i l d r e n , p a r t i c u l a r i 1 y those EEG's o b t a i n e d i n the acute stage of r e c o v e r y . Rose (1969) r e p o r t e d t h a t r e c o v e r y of speech and language s k i l l s may l a g b e h i n d EEG improvement by as much as s i x months. S i m i l a r i l y , Worster Drought (1971) and F u l d & F i s h e r (1977) have r e p o r t e d p e r s i s t e n t speech and language problems l o n g a f t e r normal EEG's have been o b t a i n e d . Et i o l o g y Trauma, when compared w i t h c e r e b r o v a s c u l a r a c c i d e n t as source of l e s i o n i n g , has been r e p o r t e d to be a f a v o u r a b l e p r o g n o s t i c 25 i n d i c a t o r , (Hecaen, 1983; Van Doongen & Loonen, 1977) a l t h o u g h t h i s r e l a t i o n s h i p does not always h o l d . F u l d & F i s h e r (1977) s t u d i e d o n l y trauma cases and found p e r s i s t i n g l i n g u i s t i c d e f i c i t s i n a l l c h i l d r e n . Byers & Mclean (1962) s t u d i e d c h i l d r e n w i t h v a r i e d e t i o l o g i e s ; no c o r r e l a t i o n was found between trauma v i c t i m s and q u a l i t y of r e c o v e r y . Our purpose i n t h i s s t u d y i s to examine the d a t a f o r : 1) D i f f e r e n c e s between the language d e f i c i t s of h e a d - i n j u r e d c h i l d r e n and h e a d - I n j u r e d a d u l t s . 2) C o r r e l a t i o n between s e v e r i t y of l i n g u i s t i c d e f i c i t and EEG, age, and/or l e n g t h of coma. 3) D i f f e r e n c e s between the e x t e n t of r e c o v e r y i n the c h i l d when compared w i t h the h e a d - i n j u r e d a d u l t . 26 CHAPTER THREE 3___1 _Sub j_ects: H e a d - i n j u r e d p a t i e n t s were drawn from S u n n y h i l l H o s p i t a l f o r C h i l d r e n and the S u r r e y S c h o o l Board . Ages ranged from 6;0-17;0 y e a r s . A l l had s u f f e r e d e x t e r n a l head i n j u r y . None of the p a t i e n t s had s i g n i f i c a n t d y s a r t h r i c symptoms and e x p r e s s i v e language was r e q u i r e d t o be " f l u e n t " a t the spontaneous l e v e l . P s y c h o l o g i c a l t e s t i n g p r i o r to the a c c i d e n t i n d i c a t e d t h a t i n t e l l e c t u a l f u n c t i o n i n g was w i t h i n normal l i m i t s . Two s u b j e c t s had to be e x c l u d e d from the d a t a a n a l y s i s due to evi d e n c e of pre m o r b i d developmental d e l a y s . 3_.2_CONTROLS: Each h e a d - i n j u r e d s u b j e c t was matched w i t h one c o n t r o l s u b j e c t a c c o r d i n g to age and gender. P a r e n t a l and t e a c h e r r e p o r t s ( i f a v a i l a b l e ) were used as g r o s s e s t i m a t e s of pre m o r b i d d e v e l o p m e n t a l l e v e l s ( d e l a y e d v s . normal development). _ L 3_DATA_MEASURES: A l l c h i l d r e n were a d m i n i s t e r e d a b a t t e r y of e x p r e s s i v e and r e c e p t i v e language t e s t s . S t a n d a r d i z e d language measures i n c l u d e d the Peabody P i c t u r e V o c a b u l a r y Test (Dunn, 1965) which e s t i m a t e s r e c e p t i v e v o c a b u l a r y , the Token t e s t ( D i S i m o n i , 1978) which e s t i m a t e s r e t e n t i o n of d e t a i l i n sequence, The A u d i t o r y comprehension t e s t f o r Sentences (Shewan, 1984) and The C l i n i c a l E v a l u a t i o n of Language F u n c t i o n s (Wigg and Semel, 1980) - P r o d u c t i o n s u b t e s t s . 27 Other measures are o u t l i n e d as f o l l o w s ; 1. ) £20verstion_ was c a s u a l and i n t e n d e d t o r e l i e v e any a n x i e t i e s . The t o p i c s i n c l u d e d f r i e n d s , f a m i l y and T.V. shows. 2. ) E i c t u r e De s c r j_£t j_on_: The c h i l d was p r e s e n t e d w i t h 3 p i c t u r e s d e p i c t i n g d i f f e r e n t scenes. He was asked q u e s t i o n s about them and i n g e n e r a l asked to d e s c r i b e "What i s happen i n g ? " Both of the 2 t a s k s above were a n a l y z e d f o r : a. p a r a p h a s i a s - % and type b. M.L U. c. 14 Grammatical morphemes d. S y n t a c t i c C o m p l e x i t y one word u t t e r a n c e - 1 p o i n t s i m p l e NP VP (X) - 3 p o i n t s s u b o r d i n a t e c l a u s e - 5 p o i n t s > 1 subord. c l a u s e - 6 or 7 p o i n t s . 3. ) Token_Test_-Only s u b t e s t s 3,4,5, were a d m i n i s t e r e d due to time c o n s t r a i n t s . For warm-up,sample commands from s u b t e s t 1 and 2 were a d m i n i s t e r e d . 4. ) Word_Retrj,eval_-a) A u d i t o r y Sentence Co m p l e t i o n A sentence was re a d t o the s u b j e c t w i t h one word m i s s i n g a t the end. The grammatical c a t e g o r i e s of noun, and verb were examined f o r r e c a l l i n t h i s t a s k , and i n the f o l l o w i n g two t a s k s . e.g. To f i n d out what to eat i n a r e s t a u r a n t you loo k a t the b. A u d i t o r y D e s c r i p t i o n An o b j e c t , or verb i s d e s c r i b e d i n a q u e s t i o n r e q u e s t i n g i t s name. S u b j e c t was r e q u i r e d t o answer the q u e s t i o n w i t h the word b e i n g d e s c r i b e d . e.g. What i s the name f o r a moving s t a i r c a s e ? c. P i c t u r e Naming The s u b j e c t was r e q u i r e d t o name a p i c t u r e . The p i c t u r e s became p r o g r e s s i v e l y d i f f i c u l t . ( l e s s f r e q u e n t i n the E n g l i s h Language,Thorndike and Lorge 1944). A l l of the 3 s u b t e s t s l i s t e d above were timed i n o r d e r to measure l a t e n c y of re s p o n s e . 5 . ) Comprehens j_on_o f _Sy_ntax 28 S u b j e c t was r e q u i r e d to p o i n t to p i c t u r e which matches the sentence r e a d by the e x p e r i m e n t e r . A u d i t o r y Comprehension Test f o r Sentences ( C i n d y Shewan) 6 . CI i n i c a l _ E v a l u a t i o n _ o f _Languacje2_Product_i on a) Sentence I m i t a t i o n Taperecorded sentences of v a r i e d s y n t a c t i c c o m p l e x i t y were p r e s e n t e d t o s u b j e c t . S u b j e c t was r e q u i r e d to r e p e a t v e r b a t i m the sentence h e a r d . b) C o n f r o n t a t i o n Naming c) F o r m u l a t e d Sentences 7.) Sentence_Order_Task The s u b j e c t was p r o v i d e d w i t h the c o n s t i t u e n t s of a sentence i n the form of words p r i n t e d on s e p a r a t e c a r d s . The task i s to arra n g e the scramble d c a r d s i n l i n e a r o r d e r t o produce a w e l l -formed s e n t e n c e . The e x p e r i m e n t e r p r i o r t o t e s t i n g has the s u b j e c t r e a d out each i n d i v i d u a l word. 3.4 PROCEDURES: A l l s u b j e c t s were t e s t e d i n d i v i d u a l l y by the i n v e s t i g a t o r i n the home. One to two s e s s i o n s were r e q u i r e d t o t a l l i n g 2 hours of t e s t i n g t i m e . A l l spontaneous language and e x p r e s s i v e language t e s t s were tape r e c o r d e d to p e r m i t l a t e r t r a n s c r i p t i o n and a n a l y s i s . 3^5_DATA_ANAL,YSI_S: The d a t a c o l l e c t e d f o r each c h i l d was a n a l y z e d and compared t o t h a t of a matched c o n t r o l s u b j e c t . The s c o r e s from the s t a n d a r d i z e d t e s t s were o b j e c t i v e l y l a i d out i n t a b l e form. Types of e r r o r s were s u b j e c t i v e l y examined i n the f o l l o w i n g t e s t s ; Token T e s t , Sentence I m i t a t i o n , and P i c t u r e Naming. 29 CHAPTER FOUR Case H i s t o r i e s £ASE#i_PATIENTzJB Pre j_n j_ur y_: B i r t h h i s t o r y was unremarkable and developmental m i l e s t o n e s were r e p o r t e d t o be w i t h i n normal l i m i t s . S c h o o l p r o g r e s s was c o n s i d e r e d t o be f a i r but o n l y because he f r e q u e n t l y s k i p p e d out of c l a s s e s . P s y c h o l o g i c a l t e s t i n g b e f o r e the a c c i d e n t i n d i c a t e d o v e r a l l i n t e l l e c t u a l f u n c t i o n i n g t o be above average. JjT.j.ury.1 JB s u s t a i n e d a severe head i n j u r y w h i l e r i d i n g a m o t o r c y c l e . He was thrown o f f w h i l e t a k i n g a sharp t u r n and h i t h i s head a g a i n s t the c u r b . He was found u n c o n s c i o u s and d u r i n g h i s t r a n s f e r by ambulance he had some r e s p i r a t o r y d i s t r e s s . On a d m i s s i o n a CT Scan r e v e a l e d no f r a c t u r e s , but s o f t t i s s u e s w e l l i n g i n the r i g h t o c c i p i t a l r e g i o n , and b r a i n stem i n j u r y were o b s e r v e d . He was r e s p o n s i v e t o p a i n but was assuming d e c e r e b r a t e p o s i t i o n i n g . He had some t w i t c h i n g a l o n g the l e f t s i d e of h i s face which was presumed to be s e i z u r e a c t i v i t y . Recovery: H i s l e v e l of u n c o n s c i o u s n e s s l i g h t e n e d by the 4th day and he began to open h i s eyes by 8 days p o s t - i n j u r y . EEG was r e p o r t e d to be normal. By the 19th day p o s t - i n j u r y he was l o o k i n g around, and had spontaneous eye movement. A l l l i m b s were 30 n o t a b l y s p a s t i c . Q_t£_!_2_i_:_5_E2_it2onse t : He was more o r i e n t a t e d . He responded to h i s name and f o l l o w e d s i m p l e commands. At t h i s time he began r e c e i v i n g speech t h e r a p y . Two months E2£_iZ£!__>e t : JB began s p e a k i n g words i n a s o f t v o i c e which became l o u d e r e v e r y day. H i s use of language was s o c i a l l y i n a p p r o p r i a t e , and he e x p e r i e n c e d severe w o r d - f i n d i n g d i f f i c u l t i e s . H i s comprehension i n c r e a s e d r a p i d l y and was almost a t age l e v e l a t t h r e e months p o s t - i n j u r y . Three months E2_i tz2!__L_._:: Sentences were becoming l o n g e r and more a p p r o p r i a t e i n c o n t e n t . Speech was m i l d y d y s a r t h r i c , and slow. W r i t i n g had improved but l e g i b i l i t y was poor due to h e m i p a r e s i s i n h i s r i g h t hand. Reading was v e r y good. He c o u l d o n l y take a few s t e p s a t t h i s t i m e ; g a i t was a t a x i c and s p a s t i c . D i a g n o s i s i n d i c a t e d a double s p a s t i c a t a x i c h e m i p l e g i a w i t h g r e a t e r involvement of the l e f t s i d e . An i n t e n t i o n tremor was e v i d e n t i n the r i g h t hand, and i m p a i r e d f i n e f i n g e r c o o r d i n a t i o n was e v i d e n t i n both hands. He has s u b s e q u e n t l y been p l a c e d i n a s p e c i a l c l a s s f o r c h i l d r e n w i t h l e a r n i n g problems. P r o g r e s s i s encouraged a t a s l o w e r r a t e . Teacher r e p o r t s i n d i c a t e p r o g r e s s i s adequate a l t h o u g h he has d i f f i c u l t y i n w o r d - f i n d i n g . £_iSE_#2_PATIENT-PB Pre J_n__ury_: B i r t h h i s t o r y was unremarkable and developmental m i l e s t o n e s were r e p o r t e d to be w i t h i n normal l i m i t s . P r i o r to i n j u r y PB was e n r o l l e d i n a r e g u l a r Grade 9 c l a s s . He had performed a t an average to above average l e v e l w i t h l i t t l e problem. F a v o r i t e a c t i v i t i e s i n c l u d e d s p o r t s and drama. He had no h i s t o r y of h e a r i n g problems. In j_ury_i PB s u s t a i n e d a head i n j u r y when he was h i t by a c a r w h i l e 31 r i d i n g h i s b i k e . On a d m i s s i o n t o the h o s p i t a l he was i n a comatose s t a t e w i t h b i l a t e r a l d e c e r e b r a t e p o s t u r i n g . D i a g n o s i s i n d i c a t e d a severe head i n j u r y . A CT scan a t time of a d m i s s i o n r e v e a l e d a hematoma i n the l e f t f r o n t a l r e g i o n w i t h c o m p r e s s i o n of the l e f t l a t e r a l v e n t r i c l e . There was some evi d e n c e of c o n t u s i o n i n the l e f t p a r i e t a l lobe i n c l o s e r e l a t i o n s h i p t o a l i n e a r s k u l l f r a c t u r e , and an a s s o c i a t e d c o n t u s i o n i n the r i g h t f r o n t a l p a r i e t a l a r e a . H i s c o u r s e of r e c o v e r y was c o m p l i c a t e d by pneumonia and a t r a c h e a l a s p i r a t e growing s t a p h o l a c o c c a l i n f e c t i o n . He had no apparent s e i z u r e s but was s a i d t o be tremulous and s h i v e r y f o r which he was t r e a t e d w i t h V a l i u m . Recovery: PB was i n a comatose s t a t e f o r two weeks. Up to the 5 t h day p o s t - i n j u r y h i s Glasgow Coma S c a l e Score was 5. A l t h o u g h t h e r e was no eye-opening i n response to p a i n , l i m b f l e x i o n was noted i n bo t h l i m b s . By the 11th day p o s t - i n j u r y he opened h i s eyes to v o i c e , but d i d not obey commands. On the 19th day p o s t - i n j u r y he attempted to a r t i c u l a t e and feed h i m s e l f . He responded to s i m p l e commands. He s t a r t e d v e r b a l i z i n g a t 23 days p o s t - i n j u r y . At t h i s time c o n v e r s a t i o n was i n a p p r o p r i a t e ; he t a l k e d i n l o n g r a m b l i n g s e n t e n c e s . He tended to p e r s e v e r a t e , t a l k c o m p u l s i v e l y , and "have d i f f i c u l t y f i n d i n g the words f o r what he wanted to say". 32 One _Mo n^h_Po s t-ir__Li__ZZ • P a r a p h a s i a s were noted i n e x p r e s s i v e language. i . e . " K i l l i p " f o r " P h i l l i p " . l 2 2 _ M 2 S i b S _ P o s t -1 nj,ury: Empty speech- i . e . when asked to p o i n t to g r e y , he responded, "Grey, watch the Bismark, I ' l l g i v e you grey now, the grey squ i r r e 1 . " Many l i t e r a l and v e r b a l p a r a p h a s i a s - i . e . "You're s n o r i n g my breath",when he t i r e d of the t a s k . Reduced a u d i t o r y comprehension, f a i r naming, and good r e p e t i t i o n s k i l l s . Word r e a d i n g adequate but problems w i t h sentence r e a d i n g . W r i t i n g was moderately i m p a i r e d . Thre e _Mon t hs_Po s t ~Xn j.ury_: W o r d - f i n d i n g problems were s t i l l p r e s e n t . He c o n t i n u e d to produce l i t e r a l and v e r b a l p a r a p h a s i a s . A u d i t o r y comprehension was s t i l l r e d u c e d , p a r t i c u l a r i 1 y p r o c e s s i n g l i n g u i s t i c c o n c e p t s . S h o r t term memory was weak, but r e a d i n g and w r i t i n g had improved. At s i x months p o s t - i n j u r y he i s i n Grade 9 and r e c e i v e s L e a r n i n g A s s i s t a n c e i n a l l s u b j e c t s . Academic s k i l l s are r e p o r t e d to be w e l l below those b e f o r e the a c c i d e n t . Comprehension i s adequate and p a r a p h a s i a s are reduced. Word f i n d i n g and p r o c e s s i n g of a b s t r a c t i n f o r m a t i o n are s t i l l s i g n i f i c a n t problems. Case_#3_PATIEWT z_SK Pre_i n__ury: SK had e a r l y language t r a i n i n g i n A u s t r i a (1974-1976) i n the German language. Upon r e t u r n to Canada, he e n r o l l e d i n K i n d e r g a r t e n and a d j u s t e d v e r y w e l l . D u r i n g h i s e a r l y s c h o o l years h i s comprehension and e x p r e s s i o n of language was average to above avera g e . H i s motor development was a l s o average f o r 33 h i s age. SK was i n v o l v e d i n a m o t o r v e h i c l e a c c i d e n t , i n which he i n c u r r e d a severe b r a i n trauma. The a c c i d e n t l e f t h i s comatosed f o r a p p r o x i m a t e l y one month, and h o s p i t a l i z e d f o r s i x months f o l l o w i n g t h i s s t a t e . Recovery.: SK was g r a d u a l l y i n t e g r a t e d i n t o the s c h o o l system. He c o n t i n u e s to r e q u i r e s p e c i a l c l a s s placement. £ASE_#4_PATIEMT-_JA Pre j_nj_ury_: JA was d e s c r i b e d as a good s t u d e n t p r i o r t o the a c c i d e n t . He had no d i f f i c u l t y i n s c h o o l and performed a t an average l e v e l . He was l e f t - h a n d e d p r i o r t o , and a f t e r , the a c c i d e n t . H e a r i n g was r e p o r t e d t o be w i t h i n normal l i m i t s . X s j u r y : JA s u s t a i n e d a head i n j u r y when he was d r i v i n g a m o t o r c y c l e on which he was i n a head-on c o l l i s i o n w i t h a t r u c k . He was wear i n g a helmet, which came o f f i n the a c c i d e n t . The a c c i d e n t l e f t him i n a deep un c o n s c i o u s s t a t e . On a d m i s s i o n t o h o s p i t a l he was d i a g n o s e d as h a v i n g a severe head i n j u r y w i t h no f r a c t u r e s or observed c o n v u l s i o n s . A r i g h t angiogram was performed which showed n o t h i n g abnormal; 34 the l e f t angiogram f a i l e d . A CT Scan r e v e a l e d a l e f t f r o n t a l p a r i e t a l s u b - d u r a l hematoma w i t h no s h i f t of m i d l i n e s t r u c t u r e s . He had i n c r e a s e d i n t r a c r a n i a l p r e s s u r e which was t r e a t e d w i t h h y p o v e n t i l a t i o n . He was a l s o r e p o r t e d to have a r i g h t comminuted f r a c t u r e of the r i g h t femur. Recovery: There was l i t t l e change i n JA's deep u n c o n s c i o u s s t a t e f o r 3 weeks d u r i n g which time no s e i z u r e s were no t e d . On day 5 p o s t -i n j u r y h i s GCS was r e p o r t e d to be 5. H i s c o n d i t i o n l i g h t e n e d a f t e r 3 weeks but i t wasn't u n t i l 45 days post i n j u r y t h a t he showed c o n s c i o u s r e s p o n s i t i v i t y . At t h a t time he s t a r t e d o r a l feed i n g . Two months E2. s t _onse t : he began i n d i c a t i n g "yes" and "no" w i t h h i s f i n g e r s but was s t i l l unable to t a l k . Two §i!_d_a_haif _months_po s t_onse t : he was s t a r t i n g to s e l f - f e e d , w h i s p e r words and c o u l d s t a n d w i t h a s s i s t a n c e . He p r o g r e s s e d from u s i n g s i n g l e word r e s p o n s e s to t a l k i n g i n complete s e n t e n c e s over a 2 week p e r i o d . D u r i n g t h i s stage JA r e c e i v e d speech t h e r a p y 3 times weekly. Three months E2_>iz£SS_l_i: he was t a l k i n g w e l l w i t h a low v o i c e , and s e 1 f - f e e d i n g . Four months E2_i t ^ onse t : Test r e s u l t s i n d i c a t e d d i f f i c u l t y comprehending l o n g e r and more complex demands. Language age f o r a l l a u d i t o r y comprehension t a s k s was 3 years below age l e v e l . E x p r e s s i v e language s k i l l s were i n e x c e s s of r e c e p t i v e s k i l l s by 18 months. Reading s k i l l s were very good. He had d i f f i c u l t y i n w r i t i n g down h i s t h o u g h t s and sentence s t r u c t u r e was poor. F_i ve months p o s t - o n s e t : V o c a l i z a t i o n was s t i l l a t a low i n t e n s i t y l e v e l . He had severe problems i n r e c a l l and p r o c e s s i n g of a u d i t o r y cues and i n w o r d - f i n d i n g . A b i l i t y to o r g a n i z e t h o u g h t s was m i l d l y i m p a i r e d . Sj.x months E_i_> t^onse t : H i s c o g n i t i v e a b i l i t i e s c o n t i n u e d to improve. A b i l i t y to r e a d and comprehend was a t age l e v e l . Math was s t i l l somewhat d e l a y e d (6 months). 35 E i g h t months E 2 s t - o n s e t : He s t a r t e d to a t t e n d some r e g u l a r c l a s s e s . He s t i l l had a r i g h t - s i d e d weakness and r i g h t h e m i p a r e s i s i n h i s hand. T h i n k i n g was s t i l l s l o w , and s h o r t term memory was s t i l l poor. W o r d - f i n d i n g was s t i l l a problem, p a r t i c u l a r i 1 y i n a t e s t i n g s i t u a t i o n . O v e r a l l i n t e l l e c t u a l f u n c t i o n i n g was r e p o r t e d t o be i n the average range. Nme months_Post-onset: A s c h o o l r e p o r t i n d i c a t e d t h a t w h i l e JA was r e g a i n i n g o l d v e r b a l c o g n i t i v e s k i l l s a t a r e a s o n a b l e r a t e , the l e a r n i n g and r e t e n t i o n of new v e r b a l m a t e r i a l was mod e r a t e l y to s e v e r e l y i m p a i r e d . L e a r n i n g a s s i s t a n c e was r e q u i r e d i n the s c h o o l program. £ASE_#5_PATIENT Z_KP Pre j_nj_ury_: B i r t h h i s t o r y was r e p o r t e d t o be normal. Development m i l e s t o n e s were w i t h i n normal l i m i t s . There i s no h i s t o r y of h e a r i n g problems. P r i o r t o the a c c i d e n t he was s a i d t o do w e l l b o th i n s c h o o l and s o c i a l l y ; academic s t a n d i n g was average. S c h o o l r e p o r t i n d i c a t e s "K has m a i n t a i n e d an achievement l e v e l t h a t i s above average as w e l l as p a r t i c i p a t i n g i n many e x t r a -c u r r i c u l a r a c t i v i t i e s " . Xnj_ury: KP s u s t a i n e d a severe head i n j u r y i n a h i g h speed m o t o r v e h i c l e a c c i d e n t . He was unconsious immediately and had m u l t i p l e s m a l l l a c e r a t i o n s t o the a n t e r i o r r i g h t f o r e h e a d . He was found to have a f r a c t u r e of the r i g h t f r o n t a l and p a r i e t a l s k u l l e x t e n d i n g t o the base of the s k u l l a t the l e v e l of the o r b i t a l r o o f . I n i t i a l CT scan r e v e a l e d b r a i n s h i f t from m i d l i n e to the l e f t i n v o l v i n g the r i g h t l a t e r a l v e n t r i c l e s . M i l d d i l a t i o n of the l e f t l a t e r a l v e n t r i c l e and hematoma i n r i g h t f r o n t a l 3 6 p a r i e t a l a r e a were a l s o i n d i c a t e d . Recovery: KP remained i n an u n c o n s c i o u s s t a t e f o r 10 days, a t which time he s t a r t e d to obey s i m p l e commands. He was not t a l k i n g but d i d t r y t o mouth some words. He a l s o wrote h i s name. R e f l e x e s were i n t a c t however an o v e r a l l l e f t - s i d e d weakness was ev i d e n t . Two Weeks £osiziHiury: he was nodding h i s head f o r "yes" and p o i n t i n g when he wanted something. Comprehension was i m p r o v i n g rap i d l y . Three weeks E2_>tziQiury: He was s p e a k i n g words,but a t low i n t e n s i t y , and a n s w e r i n g s i m p l e q u e s t i o n s . One month E2_>t-injury: He began u s i n g one and two word sen t e n c e s w i t h a very s o f t v o i c e . Speech r a p i d l y began to improve. He s t a r t e d to use sentences more o f t e n ; most were incomplete or p e r s e v e r a t i v e . i . e . "Me get b e t t e r f a s t " . A t t e n t i o n span and p e r c e p t u a l a b i l i t e s were l i m i t e d . S h o r t term memory was p a r t i c u l a r i 1 y weak. He was a b l e to w r i t e words and s e n t e n c e s . lH2_3 _ ° . ! _ J _ ! _ S . _ E Ost-_injury,: KP s t i l l had w o r d - f i n d i n g d i f f i c u l t i e s . Language t e s t s r e v e a l e d a b i l i t i e s c l o s e to p r e m o r b i d l e v e l s . I n t e l l e c t u a l a b i l i t e s were a t age l e v e l , a l t h o u g h he was s t i l l e x p r e s s i n g d i f f i c u l t y on h i g h e r l e v e l f u n c t i o n s . At two months he began a t t e n d i n g some r e g u l a r c l a s s e s a t s c h o o l . Three months E2§_izi2i_l_IZ: On t e s t i n g , r e c e p t i v e language a b i l i t i e s were w i t h i n normal 1 i m i t s . E x p r e s s i v e language was c i r c u m l o c u t o r y and o f t e n s o c i a l l y i n a p p r o p r i a t e . Word f i n d i n g problems were e v i d e n t i n c o n v e r s a t i o n a l s i t u a t i o n s . At 7 months p o s t - i n j u r y KP i s a t t e n d i n g a r e g u l a r c l a s s . He has r e c e i v e d i n d i v i d u a l t u t o r i n g a t home i n a l l s u b j e c t s up to t h i s t i m e . He i s p r o g r e s s i n g a d e q u a t e l y a l t h o u g h memory l a p s e s are s t i l l a p p a r e n t . 37 CASE_#6_PATIENT-CG i n j u r y . : C l i n t was i n v o l v e d i n a m o t o r v e h i c l e a c c i d e n t , i n which he i n c u r r e d a severe head i n j u r y . He was s t r u c k on the r i g h t s i d e of h i s head, and was l e f t u n c o n s c i o u s . A f t e r the a c c i d e n t he remained i n i n t e n s i v e care f o r f o r t y days. Recovery: C l i n t was i n i t i a l l y mute, and c o n f u s e d . He had problems r e c o g n i z i n g and remembering f r i e n d s and f a m i l y . A f t e r one month he began a c q u i r i n g s i n g l e words, and then g r a d u a l l y he combined them i n t o s h o r t s e n t e n c e s . I t wasn't u n t i l a p p r o x i m a t e l y two months p o s t - i n j u r y t h a t he began c o n v e r s i n g i n s i m p l e s e n t e n c e s . Memory c o n t i n u e s to be i m p a i r e d . C l i n t began r e c e i v i n g speech t h e r a p y , i n a d d i t i o n to o c c u p a t i o n a l and p h y s i o t h e r a p y s h o r t l y a f t e r the a c c i d e n t . H i s g a i t i s i m p a i r e d due to muscle damage, and hence he c o n t i n u e s to need p h y s i o t h e r a p y . £ASE_#7_PATIENT-CY Premj.ury_: Developmental m i l e s t o n e s were r e p o r t e d to be normal; he s t a r t e d t a l k i n g a t 0;18 months. H i s p r o g r e s s i n s c h o o l was r e p o r t e d to be above average f o r a l l s k i l l s . I_n j.ury: 38 CY was i n v o l v e d i n a m o t o r v e h i c l e a c c i d e n t which l e f t him i n a comatose s t a t e f o r two weeks. A CT Scan r e v e a l e d a f r a c t u r e on the l e f t s i d e . Secondary to t h i s f r a c t u r e , he had a weakness on the r i g h t s i d e of h i s body. Recovery: He had to l e a r n t o walk a g a i n d u r i n g the f i r s t few months p o s t -i n j u r y . He was i n i t i a l l y mute, but s t a r t e d p r o d u c i n g speech sounds G weeks p o s t - o n s e t . Recovery of speech was p r o l o n g e d b e g i n n i n g w i t h sounds , f o l l o w e d by g r a d u a l a c q u i s i t i o n of words and f i n a l l y s e n t e n c e s . He r e c e i v e d speech t h e r a p y f o r two years p o s t - o n s e t . S h o r t term memory was p a r t i c u 1 a r i 1 y weak. He was r i g h t handed p r i o r t o i n j u r y but s w i t c h e d t o the l e f t -hand because of a r i g h t s i d e weakness. P r o g r e s s i n s c h o o l has been slow, and he has en c o u n t e r e d much d i f f i c u l t y a t 2 y r s . -5 mths, p o s t - i n j u r y . H i s performance i s average a l t h o u g h he r e c e i v e s e x t r a a s s i s t a n c e a t home. Reading has improved but i s not a t p r e - i n j u r y l e v e l . £ASE_#8_PATIENT-_LD Pre j_n j_ury: B i r t h h i s t o r y was unremarkable; her developmental m i l e s t o n e s were r e p o r t e d to be normal. By 2;0 years she i s r e p o r t e d to have spoken 2 word u t t e r a n c e s . LD was competant i n p r e -academic s k i l l s i n c l u d i n g c o l o r s , c o u n t i n g , and p r i n t i n g her 39 name . i n j u r y . : LD s u s t a i n e d a m i l d head i n j u r y a f t e r f a l l i n g from a f o u r t h f l o o r window. There was a p p r o x i m a t e l y one minute l o s s of c o n s i o u s n e s s , and m u l t i p l e s e i z u r e s ( R t . s i d e ) . No c e r e b r a l edema was noted on medical e x a m i n a t i o n , but p a s s i v e venous c o n g e s t i o n was mentioned secondary t o m e d i c a t i o n . No s k u l l f r a c t u r e s were found. Recovery: LD was i n t i a l l y mute a f t e r the i n j u r y . One day p o s t - i n j u r y she was o r i e n t a t e d and made a few v e r b a l r e s p o n s e s . At t h i s time GCS was s c o r e d a t 10: 4(eye) 2 ( V e r b a l ) 4<Motor). Two days p o s t - i n j u r y she was a l e r t and c o o p e r a t i v e and GCS was 13. F i v e days p o s t - i n j u r y c o n v e r s a t i o n was c o n f u s e d . She s k i p p e d around from t o p i c to t o p i c i n r a m b l i n g s e n t e n c e s . She appeared to be o r i e n t a t e d and asked t o go home. At the time of w r i t i n g 10 months p o s t - i n j u r y ) , she i s p l a c e d i n a m o d i f i e d K i n d e r g a r t e n - G r a d e 1 c l a s s . K i n d e r g a r t e n r e p o r t s t a t e s t h a t L.D. i s "slow i n l e a r n i n g " , and i s below average i n u n d e r s t a n d i n g a b s t r a c t c o n c e p t s . Immediate and l o n g term memory are weak. P s y c h o l o g i c a l t e s t i n g i n d i c a t e d g e n e r a l i n t e l l e c t u a l f u n c t i o n i n g t o be i n the average range. 40 TABLE 1 DESCRIPTION OF SUBJECTS P r e s e n t Time S u b j e c t / S e x Age Post-Onset E t i o l o g y Area of Damage 1.JB CM) 17;8 2;9 M/C A (1) R i g h t o c c i p . s w e l l i n g B r a i n stem i n j u r y 2.PB (M) 15;3 0,6 M/V A (2) L f t . F r o n t a l Hematoma L f t . S u b g a l i a l Hematoma Rt. F r o n t a l C o n c u s s i o n L f t . P a r i e t a l F r a c t u r e L f t . T i b i a l F r a c t u r e 3.SK (M) 13;2 7;5 M/V A D i f f u s e c e r e b r a l damage 4. JA CM) 12; 1 1 2;10 M/C A L f t . f r o n t a l p a r i e t a l hematoma 5. KP (M) 12;6 0;7 M/V A Rt. p a r i e t . f r t . f r a c t . R t . c o n t u s i o n , hematoma L f t . d i l a t i o n V e n t r i c l e 6. CG (M) 10;0 4;0 M/V A D i f f u s e c e r e b r a l damage 7. CY CM) 6 ; l 2;5 M/V A L f t . f r a c t u r e 8. LD (F) 6;10 0;10 F a l l Venous c o n g e s t i o n Rt. s i d e s e i z u r e s (1) M/C A =motorcycle a c c i d e n t (2) M/V A =mo t o r v e h i c l e a c c i d e n t 41 TABLE 2 SUBJECTS' PERFORMANCE ON RECEPTIVE LANGUAGE TASKS 1. P.P.V.T.(Raw S c o r e ) 2. TOKEN TEST<Total 41) Subj e c t s l . J B 125* C o n t r o l s 1 48 136 129 127 124 107 81 80 Subj e c t s 37* 35* CNT 38 37 24* 31 23* C o n t r o l s 40 38 38 38 35 32 32 2 PB 3.SK 4. JA 5. KP 6. CG 7. CY 8. LD 128 92* 123 131 95 91 48* 3 • A • 0 • T • S • S u b j e c t s C o n t r o l s 1. JB 17* 20 2. PB 18 20 3.SK 12* 19 4. JA 16 18 5. KP 19 18 6. CG 15 16 7. CY 10 12 8. LD 6 11 42 TABLE 3 SUBJECTS* PERFORMANCE ON SENTENCE FORMULATION TASK (Mean L a t e n c y - sees.) SUBJECTS CONTROLS 1. JB 19.3 10.5 2. PB 31.2 33.5 3.SK 31.1 21.0 4. JA 9.1 2 3.0 5. KP 1 0 1 . 1 * 14.8 6. CG 48.G 27.0 7. CY CNT 8. LD CNT 43 TABLE 4 SUBJECTS' PERFORMANCE ON WORD-FINDING TASKS WORD FLUENCY SUBJECTS CONTROLS PIC NAMING SUBJECTS 1. JB 29* 2. PB 31* 3.SK 14* 4. JA 27* 5. KP 40 6. CG" 16* 7. CY 21 8. LD 14 63 52 42 38 51 34 31 16 Word-Finding W o r d - F i n d i n g , A r t i c u l a t i o n Word-F i n d i n g Word-Finding Word-F i n d i n g Word-F i n d i n g 44 TABLE 5 SUBJECTS PERFORMANCE ON C.E.L.F.-PRODUCTION Sentence R e p e t i t i o n Sentence F o r m u l a t i o n SUBJECTS CONTROLS SUBJECTS CONTROLS 1. JB 42 50 47 45 2. PB 36 50 58 59 3.SK 28* 46 CNT 4. JA 42 45 46 45 5. KP 48 52 55 51 6. CG 34 37 51 48 7. CY 32 38 40 38 8. LD 41 38 CNT Test R e s u l t s : 5.1 RESULTS: 45 CHAPTER FIVE R e c e p t i v e language a b i l i t i e s were m i l d l y reduced i n t h r e e (*) s u b j e c t s (Table 2 ) . E x p r e s s i v e language a b i l i t i e s , however were adequate a c r o s s a l l s u b j e c t s (Table 5 ) . Sentence F o r m u l a t i o n proved to be d i f f i c u l t f o r o n l y one s u b j e c t ( K P ) . V i s u a l - p e r c e p t u a l problems c o u l d have c o n t r i b u t e d t o lowered performance f o r t h i s s u b j e c t . F i n a l l y , w o r d - f i n d i n g d i f f i c u l t i e s p e r s i s t e d a c r o s s most s u b j e c t s (Table 4 ) . 5j.2_TOKEN_TESTj.TABLE_2 The Token Test (TT) r e s u l t s , c o n s i s t e n t w i t h r e s u l t s on the P.P.V.T. ( r e c e p t i v e v o c a b u l a r y ) , i n d i c a t e reduced r e c e p t i v e a b i l i t i e s i n t h r e e s u b j e c t s . A l l s u b j e c t s made more e r r o r s on P a r t 4 and 5 of the TT, i n which t h e r e are i n c r e a s e d demands f o r r e t e n t i o n of d e t a i l . G r e a t e r d i f f i c u l t y was en c o u n t e r e d on P a r t 5, ( r e l a t i v e to P a r t 4) which t e s t s p r i m a r i l y s y n t a c t i c comprehens i on. An item a n a l y s i s was conducted f o r the t h r e e s u b j e c t s who performed below the l e v e l of normal c h i l d r e n . A l l t h r e e f a i l e d t o respond c o r r e c t l y t o the f o l l o w i n g commands: 2. Put the white square behmd the y e l l o w c i r c l e . 2.( S u b j e c t s p l a c e d the square under the c i r c l e ) . 6 . P i c k up the bl u e c i r c l e or the r e d square. 6 . ( S u b j e c t s performed both a c t i o n s ) . 2 1 • B e f o r e _ t o u c h i n g the y e l l o w c i r c l e , p i c k up the r e d square. 21.( S u b j e c t s r e v e r s e d the o r d e r , i n d i c a t i n g a seq u e n c i n g p r o b l e m ) . 46 Two of these commands (2,21) are among the e i g h t missed by a p h a s i c c h i l d r e n as r e p o r t e d by Rankin e t a l . , ( 1981). F o r commands 2, 6,and 21 r e t e n t i o n of two s e p a r a t e e v e n t s i s r e q u i r e d i n a d d i t i o n t o comprehension of a l i n g u i s t i c concept ("behind", " o r " , " b e f o r e " ) . They performed c o r r e c t l y on those commands which r e q u i r e d two s i m i l a r a c t i o n s , u n l i k e the above which r e q u i r e two d i s t i n c t ones. P e r s e v e r a t i o n and s u b - v o c a l i z a t i o n were two common s t r a t e g i e s used by f o u r s u b j e c t s . The s u b j e c t s ( J . B . C.Y. P.B. and L.D.) used s u b - v o c a l i z a t i o n d u r i n g a response presumably i n an attempt to r e t a i n d e t a i l i n s h o r t term memory. P e r s e v e r a t i o n from t e s t item to t e s t item ( i . e . c o l o r , shape) was observed i n the same s u b j e c t s . (1) JB p o i n t e d t o both green and r e d tokens i n c o r r e c t l y d u r i n g a command which had been preceded by a command i n which these c o l o u r s were i n c l u d e d . (2) CY had d i f f i c u l t y r e t a i n i n g more than two c r i t i c a l items one command. H i s p e r s e v e r a t i o n s were of the type i n which he r e p e a t e d the same two items i n c o r r e c t l y i n one command. For example f o r item 9 "Touch the s m a l l r e d square and the s m a l l y e l l o w c i r c l e " , he touched the s m a l l r e d square and the l a r g e r e d s q u are. For item 10 "Touch the s m a l l white square and the l a r g e r e d square",he touched the s m a l l white square and the l a r g e white square. 5.3 WORD FINDING: Table 4 47 The Word F l u e n c y S u b t e s t r e v e a l e d w o r d - f i n d i n g problems i n thre e s u b j e c t s , c o n s i s t e n t w i t h the P i c t u r e Naming T e s t . F i r s t , the t o t a l number of a t t r i b u t e s named w i t h i n a c e r t a i n c a t e g o r y (Food, A n i m a l s ) i n one minute was lower than t h a t of the c o n t r o l s . Second, the s t r a t e g y used by each of these s u b j e c t s was d i f f e r e n t from t h a t used by the c o n t r o l s . S u b j e c t s d i d not c o n s i s t e n t l y name from a semantic s u b c l a s s but i n s t e a d moved randomly from s u b c l a s s t o s u b c l a s s . ( e . g . from v e g e t a b l e s to meats, to s t a p l e s ) . P i c t u r e Naming was more s u c c e s s f u l i n r e v e a l i n g w o r d - f i n d i n g problems, s i n c e o n l y one answer was c o n s i d e r e d c o r r e c t . The r e s u l t s i n d i c a t e d moderate problems i n two s u b j e c t s ( JB and PB) and m i l d problems i n t h r e e o t h e r s (CY,JA, and KP). One i n s i g h t i n t o t h i s problem comes from f r e q u e n t comments of the type "I know the word but I c a n ' t t h i n k of i t " . Some i n d i c a t i o n of the s t r a t e g i e s b e i n g employed to a c c e s s the c o r r e c t item i n c l u d e d the use of s e m a n t i c a l l y o r p h o n e m i c a l l y s i m i l a r words, and/or the use of a c t i o n s to " d e s c r i b e " the use of the p i c t u r e d word. We s h a l l r e f e r t o t h i s l a t e r . S u b j e c t JB made e r r o r s i n the P i c t u r e Naming Test i n d i c a t i v e of w o r d - f i n d i n g problems; i n s t e a d of naming the p i c t u r e c o r r e c t l y he d e s c r i b e d and g e s t u r e d i t s a c t i o n . These words were named c o r r e c t l y g i v e n a phonemic cue. ( F i r s t two segments of the word). Comments such as " I know the word, but I can ' t t h i n k of i t " were common. Some e r r o r s i n c l u d e d : 48 1. "squeeze-box" ( a c c o r d i o n ) g e s t u r e d i n f r u s t r a t i o n . 2. " H o r s e - p u l l e r t h i n g " (wagon) 3. "Egypt" (sphynx) 4. "Camers-stander" ( t r i p o d ) 5. "Penc i1-Drawer" (Compass) S u b j e c t PB produced both a r t i c u l a t i o n e r r o r s and w o r d - f i n d i n g e r r o r s d u r i n g the p i c t u r e - n a m i n g t e s t . He a l s o made such comments as " I know i t , but I c a n ' t remember i t . " H i s word-f i n d i n g e r r o r s can be grouped i n t o two t y p e s ; 1. w o r d - r e t r i e v a l and a r t i c u l a t i o n e r r o r s - s h o r t l a t e n c y . 2. w o r d - r e t r i e v a l - d e s c r i p t o r s of a c t i o n , l o n g e r l a t e n c y . i . Word R e t r i e v a l w i t h a r t i c u l a t i o n e r r o r s ; s h o r t l a t e n c y . 6. " s t e f i s c o p e " ( s t e t h o c o p e ) 7. "dinominoes" (dominoes) 8. "wreaf" (wreath) 9. " s p i n x " ( s p h i n x ) These words were r e t r i e v e d q u i t e r a p i d l y w i t h a mean l a t e n c y 1.14 seconds. i i . Word R e t r i e v a l : D e s c r i p t i o n of a c t i o n s , l o n g e r l a t e n c y . 10. " i c e - b r e a k e r s " ( t o n g s ) 11. "moving s t a i r c a s e " ( e s c a l a t o r ) 12. "door l o c k e r " ( b o l t ) Semantic cues e.g. "you r i d e on i t " were not h e l p f u l i n at t e m p t s t o r e t r i e v e these words, however g i v i n g the s u b j e c t the f i r s t two segments was s u f f i c i e n t t o enable him/her to c o r r e c t l y name the item. e.g."to" f o r tongs. 49 Some e r r o r s i n d i c a t i v e of w o r d - f i n d i n g problems were a l s o found on t e s t i n g KP and CY. For example, KP made the f o l l o w i n g e r r o r s : 13. " t h i n g a m i j i g y " ( a c c o r d i o n ) 14. "hang-man rope" (noose) Gi v e n a phonemic cue i . e . " a c c " f o r " a c c o r d i o n " , he was a b l e t o name th e s e s p i c t u r e s c o r r e c t l y . G e s t u r e s accompanied h i s att e m p t s t o name " a c c o r d i o n " . C.Y. made the f o l l o w i n g e r r o r s : 15. "so you won"t b i t e p e o p l e " (muzzle) 16. " p e n c i l h o l d e r " (compass) 5_.4_SENTENCE_REPETITI0N: In t h i s t e s t , t h e r e were t h r e e common typ e s of e r r o r s : i . S equencing E r r o r s i i . Ommisssion of segments. i i i . C o n v e r s i o n of s e m a n t i c a l l y anomalous sentences i n t o s e m a n t i c a l l y a p p r o p r i a t e s e n t e n c e s . Four s u b j e c t s ( J B , PB, CY and KP) had common sequ e n c i n g e r r o r s . F o r example, they i n c o r r e c t l y sequenced the a d j e c t i v e s when r e p e a t i n g the f o l l o w i n g s e n t e n c e s ; 1. The woman has r e a d the twe l v e b i g heavy brown books.(#25) 2. The b i g twelve brown heavy packages have c a r r i e d the man.(#29) S u b j e c t s (CY, PB and LD) c o n v e r t e d s e m a n t i c a l l y anomalous se n t e n c e s i n t o s e m a n t i c a l l y a p p r o p r i a t e s e n t e n c e s , i n d i c a t i n g 50 reduced e x p r e s s i v e s y n t a x . For example, the f o l l o w i n g c o n v e r s i o n s o c c u r r e d : 3. The p i c t u r e t h a t p a i n t e d the pers o n was very kind.(#16) > "The p e r s o n who p a i n t e d the p i c t u r e was very k i n d . " 4. Were d e l i v e r e d the f l o w e r s by the messenger? (#2) > "Were the f l o w e r s d e l i v e r e d by the messenger?" These e r r o r s i n sentence r e p e t i t i o n are most c r i t i c a l f o r s u b j e c t s JB and PB. Both of these s u b j e c t w s are o l d e r and th e r e f o r e m o r e advanced s y n t a x i s e x p e c t e d from them, r e l a t i v e to the r e s t of the s u b j e c t sample. I t s h o u l d be noted t h a t ommission e r r o r s f o r a l l s u b j e c t s mig be the r e s u l t of memory c o n s t r a i n t s . T h i s d i d not appear to a major f a c t o r i n the r e s u l t s s i n c e , a l t h o u g h they sequenced words i n c o r r e c t l y , they d i d appear to remember most of them. 5^5_SUMMARY_OF_INDIVIDUAL_SU S u b j e c t s JB and PB who s u f f e r from d i f f u s e b r a i n trauma, have s i m i l a r language d e f i c i t s . T h e i r e x p r e s s i v e language i s adequate f o r t h e i r age l e v e l when c o n s i d e r e d i n terms of s y n t a c t i c c o m p l e x i t y . I t i s a p p a r e n t , however, t h a t they both have w o r d - f i n d i n g problems and reduced r e c e p t i v e v o c a b u l a r y . Measures of a u d i t o r y comprehension show r e d u c t i o n i n the r e t e n t i o n of l i n g u i s t i c d e t a i l , which may be a t t r i b u t e d t o memory c o n s t r a i n t s . S u b j e c t s SK and CG, who bo t h i n c u r r e d d i f f u s e c e r e b r a l damage and concommitant p h y s i c a l d i s a b i l l i t y had s i m i l a r language problems. E x p r e s s i v e language i n terms of sy n t a x and 51 l i n g u i s t i c c o m p l e x i t y was adequate f o r age l e v e l . Comprehension, was moderately i m p a i r e d , however t h i s reduced a b i l i t y was p r o b a b l y due p a r t l y to l i m i t e d memory . Word-f i n d i n g problems were pronounced i n b o t h these s u b j e c t s ; they were e x e m p l i f i e d i n both p i c t u r e naming and word f l u e n c y t a s k s . S u b j e c t JA e x e m p l i f i e d the most c l e a r case of l e x i c a l d i s t u r b a n c e accompagnied by o t h e r w i s e normal language a b i l i t i e s . Both comprehension and e x p r e s s i o n of language were w e l l i n t a c t . Problems were e v i d e n t on p i c t u r e naming and word f l u e n c y t a s k s . S u b j e c t KP who s u s t a i n e d a r i g h t - s i d e d l e s i o n performed a t age-a p p r o p r i a t e l e v e l s i n both r e c e p t i v e and e x p r e s s i v e language e s t s . Some w o r d - f i n d i n g problems were e v i d e n t i n p i c t u r e naming but not i n a c o n v e r s t i o n a l s e t t i n g . S u b j e c t CY who i n c u r r e d a l e f t - s i d e d f r a c t u r e performed a t low average l e v e l s on most t e s t s ; p r i o r t o i n j u r y language s k i l l s were above aver a g e . R e c e p t i v e l y and e x p r e s s i v e l y h i s language a b i l i t e s were c o n s i d e r e d adequate. There was evi d e n c e of reduced r e t e n t i o n of d e t a i l i n s h o r t term memory. S u b j e c t LD who r e v e a l e d r i g h t s e i z u r e s a t i n j u r y p r e s e n t e d w i t h a m i l d p r o c e s s i n g problem of d e t a i l i n o r a l l y p r e s e n t e d i n f o r m a t i o n . Her l i m i t e d v o c a b u l a r y a l s o c o n t r i b u t e d to t h i s d i f f i c u l t y i n u n d e r s t a n d i n g language. Sentences are of a p p r o p r i a t e l e n g t h f o r her age and are c o n s i d e r e d to be of 52 a p p r o p r i a t e s y n t a c t i c c o m p l e x i t y . 53 CHAPTER SIX DISCUSSION S_.i_PEQBLEM_#i: There i s no d i f f e r e n c e between the language d e f i c i t s of head-i n j u r e d c h i l d when compared w i t h the h e a d - i n j u r e d a d u l t . From the r e s u l t s o b t a i n e d i t appears t h a t the prominent l i n g u i s t i c d e f i c i t s i n the h e a d - i n j u r e d c h i l d are s i m i l a r to those of the h e a d - i n j u r e d a d u l t . The d e f i c i t s o bserved i n t h i s s t u d y are c o n s i s t e n t w i t h those found by Sarno (1980) i n s t u d y i n g a p h a s i c a d u l t s w i t h c l o s e d head i n j u r y . She r e p o r t e d naming and Token Test performance to be most a f f e c t e d i n a p h a s i c a d u l t s , f o l l o w e d by word f l u e n c y and sentence r e p e t i t i on. In t h i s s t u d y , w o r d - r e t r i e v a l ( l e x i c a l a c c e s s ) was s e v e r e l y a f f e c t e d i n f o u r s u b j e c t s (JB PB CY SK ) and m i l d y i m p a i r e d i n t h r e e (CY KP J A ) . A u d i t o r y comprehension was m i l d l y i m p a i r e d i n f o u r s u b j e c t s (JB PB LD CG SK); p e r s e v e r a t i o n and weak r e t e n t i o n of d e t a i l appeared to c o n t r i b u t e t o lowered comprehension d u r i n g t e s t i n g . P e r s e v e r a t i o n , i n a d d i t i o n to se q u e n c i n g problems, was observed i n sentence r e p e t i t i o n by t h r e e s u b j e c t s (KP PB SK). As i n the h e a d - i n j u r e d a d u l t , the synt a x remains i n t a c t i n our sample of h e a d - i n j u r e d c h i l d r e n ; no word-order i n v e r s i o n s or gr a m m a t i c a l e r r o r s were observed i n the e x p r e s s i v e language of these s u b j e c t s . We suggest t h a t what i s b e i n g observed i s a l e x i c a l l y m o t i v a t e d , r a t h e r than a s y n t a c t i c a l l y m o t i v a t e d language d i s o r d e r . 54 2_WQRD-F I ND I NG : Our f i n d i n g s of a s p e c i f i c l i n g u i s t i c d i s t u r b a n c e a s s o c i a t e d w i t h the l e x i c o n (naming), are i n a c c o r d w i t h s t u d i e s of a d u l t a p h a s i a a f t e r c l o s e d head trauma (Heilman e t a l . , 1971; L e v i n e t a l . , 1976; L e v i n e t a l . , 1981; Najenson e t a l . , 1978; Sarno, 1980). L e v i n e t a l . (1976) a s s e s s e d f i f t y a d u l t s w i t h c l o s e d head i n j u r y and r e s u l t s d i s c l o s e d t h a t word f i n d i n g d i f f i c u l t y was a prominent d e f i c i t ; h a l f of t h e i r s u b j e c t s t e s t e d had reduced s c o r e s on naming and/or word a s s o c i a t i o n . The p s y c h o l o g i c a l framework of w o r d - r e t r i e v a l has been c o n s i d e r e d by i n v e s t i g a t o r s s i n c e the t u r n of the c e n t u r y . The e a r l i e s t r e s e a r c h e r s , l i k e W ernicke, b e l i e v e d t h a t naming d i s t u r b a n c e s were the r e s u l t of d e f i c i t memory. In 1888 C a r l Freund r e f u t e d Wernicke's memory h y p o t h e s i s when he d e s c r i b e d a p a t i e n t who o n l y e x h i b i t e d w o r d - r e t r i e v a l problems o n l y when asked t o name v i s u a l l y p r e s e n t e d m a t e r i a l . L a t e r r e s e a r c h e r s f o c u s e d on the c o n c e p t u a l a s p e c t s of naming and i n d i c a t e d the need t o i n c l u d e some p r o c e s s which c o n c e p t u a l i z e s the " i d e a " of a word. T h i s a t t i t u d e i s b e s t e x e m p l i f i e d by Go l d s t e i n , ; " I n p o i n t of f a c t , the p a t i e n t has not l o s t the words but h i s words appear to have l o s t to him the p e c u l a r i t y r e q u i s i t e f o r use i n a c a t e g o r i c a l sense t o be employed as symbols. I t may indeed be thought t h a t the words have become f o r the p a t i e n t empty sounds, which may b e l o n g to a d e f i n i t e o b j e c t as t h i s o b j e c t ' s p r o p e r t y , but which can no l o n g e r serve as a symbol f o r an i d e a , i . e . cannot be used as a g e n e r i c name", (p.307) Opposing t h i s c o n c e p t u a l l y based h y p o t h e s i s Lotmar (1919) 55 s u g g e sted an e x p l a n a t i o n f o r the d e f i c i t based on word f r e q u e n c y ; thus the more f r e q u e n t a word i s i n the language, the f a s t e r i t i s r e t r i e v e d . He a l s o p o s i t e d a p r e l e x i c a l c l a s s i f i c a t i o n which i n c l u d e s a sound ( p h o n o l o g i c a l ) and a meaning ( s e m a n t i c ) component f o r d i r e c t i n g r e t r i e v a l . R o c h f o r d and W i l l i a m s (1962,1963,1965) a l s o emphasized the e f f e c t of word fr e q u e n c y on word r e t r i e v a l . They showed t h a t names f i r s t l e a r n e d by c h i l d r e n were l e a s t or l a s t l o s t by a p h a s i c a d u l t s . They a l s o found t h a t word r e t r i e v a l i n younger c h i l d r e n seemed be s t cued by p h o n o l o g i c a l prompts, r a t h e r than s e m a n t i c a s s o c i a t i o n s . Wolf (1982) p r e s e n t e d a model of word r e t r i e v a l based on i n v e s t i g a t i o n s up to 1980. In t h i s model t h e r e are f o u r components w i t h the f o l l o w i n g f u n c t i o n s : 1. The u_§i component s o r t s and i d e n t i f i e s s t i m u l i on the b a s i s of a) p e r c e p t u a l f e a t u r e s ,b) s t i m u l u s f a m i l i a r i t y and c) r a t e of p r e s e n t a t i o n . 2. The Conce.gt.ion_ o p e r a t i o n f u n c t i o n s to p r o v i d e a s e m a n t i c s e t and connect p e r c e p t u a l i n f o r m a t i o n w i t h a c o n c e p t . 3. The L e x i c o n has two a s p e c t s ; a p h o n o l o g i c a l and s e mantic one . 4. The l a s t component, the Motor_s_stem i n v o l v e s the e x e c u t i o n of motor commands to the a r t i c u l a t o r s . S t u d i e s of l e x i c a l c a t e g o r i z a t i o n have broadened the n o t i o n of the l e x i c o n . I n v e s t i g a t o r s have p o i n t e d to the p h o n o l o g i c a l form of the l e x i c o n as the r o o t of w o r d - r e t r i e v a l problems. For example, Pease and Goodglass (1978) showed t h a t the most s u c c e s s f u l c u e i n g i n a d u l t s and a p h a s i c s on p i c t u r e - n a m i n g 56 t e s t s i s p h o n o l o g i c a l . S i m i l a r i l y , R o c h f o r d and W i l l i a m ' s f i n d i n g s (1962) suggest t h a t normal young c h i l d r e n r e l y more on a p h o n o l o g i c a l system of o r g a n i z a t i o n than a s e mantic system. Wolf (1982) showed t h a t w o r d - r e t r i e v a l and poor r e a d i n g was c l o s e l y c o r r e l a t e d i n c h i l d r e n ; poor r e a d e r s were d e f i c i e n t i n measures of p h o n o l o g i c a l f l u e n c y . Other i n v e s t i g a t o r s have emphasized the s e mantic b a s i s of the l e x i c o n as the i n f l u e n t i a l f a c t o r i n w o r d - r e t r i e v a l . For example, Goodglass and Baker (1977) i n a s t u d y of s e mantic f i e l d s and word a s s o c i a t i o n s found t h a t the words named most e a s i l y were a l s o the ones w i t h the most i n t a c t a s s o c i a t i o n networks. They c o n c l u d e d t h a t a b i l i t y to name i s i n f l u e n c e d by an e l a b o r a t e d s e mantic f i e l d . In summary, from the s t u d i e s p r e s e n t e d (and o t h e r s ) one can p o s i t f i r s t a m o d a l i t y - d i f f e r e n t i a t e d component which s o r t s the incoming p e r c e p t u a l s t i m u l i . The concept of a word r e f e r r e d to by G o l d s t e i n as "empty sounds " i s then c l a s s i f i e d p h o n o l o g i c a l 1 y and s e m a n t i c a l l y i n the l e x i c o n . F i n a l l y the motor system e x e c u t e s the spoken word. §Z3_£E_T_RE_AS___FACIL G e s t u r e s have been r e c o g n i z e d as s u c c e s s f u l i n f a c i l i t a t i n g language i n a p h a s i c a d u l t s . T h i s f a c i l i t a t o r y e f f e c t i s i n a c c o r d w i t h G o o d g l a s s ' C u m u l a t i v e - M o d a l i t y h y p o t h e s i s ; the s t i m u l a t i o n of d i f f e r e n t m o d a l i t i e s summate to a i d i n the a r o u s a l of p e r c e p t u a l p r o c e s s e s . 57 Helm & Benson (1978) have s t u d i e d the use of g e s t u r e i n a program c a l l e d V i s u a l A c t i o n Therapy. T h i s program i s a r r a n g e d i n t o s t e p s which are aimed a t s h a p i n g p a t i e n t s i n t o p r o d u c i n g s y m b o l i c g e s t u r e s f o r p i c t u r e s . They showed t h a t u s i n g t h i s method, a l l p a t i e n t s improved i n a u d i t o r y comprehension and pantomine. Improvement was a l s o noted i n naming and w r i t i n g among i n d i v i d u a l s . Other i n v e s t i g a t o r s who view d e f i c i t s i n w o r d - r e t r i e v a l as f a u l t y r e t r i e v a l mechanisms, have a t t e s t e d to the f a c i l i t a t o r y e f f e c t s of g e s t u r e . F o r example, Weisenberg & McBride (1935) r e p o r t e d t h a t a p a t i e n t was a b l e to say " s c i s s o r s " a f t e r w i g g l i n g h i s f i n g e r s back and f o r t h as i n c u t t i n g . O l d f i e l d (1966) observed t h a t anomic p a t i e n t s may show t h a t they know what an o b j e c t i s by r e f e r r i n g t o the f u n c i t o n of o b j e c t s d u r i n g speech. 6^4_THE_RELAT£QNSHIP_BE : The r e s u l t s r e p o r t e d here are c o n s i s t e n t w i t h some of the a v a i l a b l e d a t a c o n c e r n i n g w o r d - r e t r i e v a l . Word freq u e n c y was c l e a r l y a f a c t o r i n f l u e n c i n g performance on the P i c t u r e - N a m i n g t a s k . As words became l e s s f r e q u e n t i n the l e x i c o n e r r o r s i n c r e a s e . P h o n o l o g i c a l cues d e f i n i t e l y a s s i s t e d i n r e t r i e v a l of t a r g e t words whereas s e m a n t i c cues d i d n o t . These f i n d i n g s i . e . the e f f e c t i v e n e s s of p h o n o l o g i c a l prompts, are c o n s i s t e n t w i t h those of Pease & Goodglass (1978) and R o c h f o r d & W i l l i a m s (1962) and suggest a p h o n o l o g i c a l 1 y based l e x i c o n i n the 58 r e t r i e v a l of words. The f a c t t h a t s u b j e c t s c o u l d r e t r i e v e words g i v e n these p h o n o l o g i c a l c u e s , and t h e i r comments t h a t they "knew the word", suggest a c o n c l u s i o n s i m i l a r t o t h a t of i . e . G o l d s t e i n ; " t h a t the words have become empty sounds which may be l o n g t o a d e f i n i t e o b j e c t as t h i s o b j e c t ' s p r o p e r t y " . That i s , the words are not l o s t from the l e x i c o n but a f a u l t y r e t r i e v a l system p r e v e n t s an a c c u r a t e match between the phonology and the motor programme f o r these sounds. G e s t u r e s and " f u n c t i o n d e s c r i p t i o n s " i n a c c o r d w i t h O l d f i e l d (1966) are f a c i l a t o r y mechanisms, which s u b s t i t u t e f o r the t a r g e t word. These two s t r a t e g i e s ; g e s t u r a l a c c e s s and a r t i c u l a t o r y a c c e s s may be p r o c e s s e d through a l t e r n a t e , l e s s d i s r u p t i b l e r o u t e s than those t h rough which the word i s e x e c u t e d . F i n a l l y , the e x t e n t of the semantic f i e l d , c o n s i s t e n t w i t h Goodglass and Baker (1977) c o u l d be an i n f l u e n t i a l f a c t o r i n the speed or percentage c o r r e c t . R e s u l t s on the Word F l u e n c y Test i n d i c a t e a c l e a r s e mantic d i s o r g a n i z a t i o n , when these r e s u l t s are compared w i t h s t r a t e g i e s used by normal c h i l d r e n ; t h a t i s , s u b j e c t s randomly named from v a r i o u s s e mantic c a t e g o r i e s . F i g u r e 1 o u t l i n e s a proposed model f o r w o r d - r e t r i e v a l , based on p r e s e n t r e s u l t s . The s e n s o r y i n p u t i s m o d a l i t y s p e c i f i c and i s c a t e g o r i z e d i n t o a concept a c c o r d i n g l y . T h i s f i r s t concept 59 Sensory Input . V i s u a l » , , Au d i t o r y - - J - - > - | l . CONCEPT .Tact i l e ,01 f a c t o r y 3.ACCESS 2.LEXICON .Phonolog i c a l Semant i c > MOTOR SYSTEM GESTURE FIGURE 1. MODEL OF WORD RETRIEVAL 60 component s o r t s incoming s t i m u l i i n t o semantic s e t s , and c o g n i t i v e l y s o r t s out the g e n e r i c a t t r i b u t e s . I f d i s o r g a n i z a t i o n does e x i s t a t t h i s l e v e l , s o r t i n g would d e l a y r e t r i e v a l t i m e . The second component, the l e x i c o n i s d i v i d e d i n t o a p h o n o l o g i c a l form and a s e mantic form. At l e v e l t h r e e d i s r u p t i o n i s presumed to be most c r i t i c a l a f t e r h e a d - i n j u r y . The a c c e s s i n g a t t h i s l e v e l depends on the matching of a p h o n o l o g i c a l form to i t s motor program ( a r t i c u l a t o r y ) form. At the f o u r t h l e v e l , the motor system, the word i s e x e c u t e d . The s e m a n t i c component of the l e x i c o n , which i n c l u d e s the f u n c t i o n and i n h e r e n t p r o p e r t i e s of the word e n t e r s an a l t e r n a t e r o u t e . T h i s s e mantic form i s a c c e s s e d t h rough e i t h e r g e s t u r e or the motor system by an a s s o c i a t i v e or f u n c t i o n word. 6^5_PERSEVERATION: P e r s e v e r a t i o n has been viewed as "the c o n t i n u a t i o n or r e c u r r e n c e of an e x p e r i e n c e w i t h o u t the a p p r o p r i a t e e x c i t i n g s t i m u l u s " ( M c N a l t y , 1961). Hudson (1968) and L u r i a (1966) argue t h a t p e r s e v e r a t i o n o c c u r s i n d i f f e r e n t forms and may be r e l a t e d t o the s e v e r i t y of i n j u r y . Helmick & Berg (1976) s t u d i e d p e r s e v e r a t i o n i n b r a i n - i n j u r e d a d u l t s on a number of e x p e r i m e n t a l t a s k s . They found t h a t s i g n i f i c a n t l y more p e r s e v e r a t i o n was observed i n the b r a i n -i n j u r e d a d u l t than was noted i n the normal s u b j e c t s . There was 61 no r e l a t i o n s h i p between the amount of p e r s e v e r a t i o n on a t a s k and e i t h e r age or e d u c a t i o n a l l e v e l of the brain-damaged s u b j e c t s . R e s u l t s d i d i n d i c a t e t h a t most p e r s e v e r a t i v e b e h a v i o u r o c c u r r e d on naming and r e v e r s i n g a s e r i e s . The a u t h o r s suggest t h a t t a s k s t h a t are " l e a s t a u t o m a t i c " i . e . r e v e r s i n g a s e r i e s , drawing d e s i g n s from memory, are most e f f e c t i v e a t e l i c i t i n g p e r s e v e r a t i o n . From our t e s t r e s u l t s , we found p e r s e v e r a t i o n to be a r e p e t i t i o n of a sequence of words or a c t i o n s , w i t h o u t the a p p r o p r i a t e s t i m u l u s . The t a s k s most e f f e c t i v e a t e l i c i t i n g p e r s e v e r a t i o n were the Token Test and Sentence I m i t a t i o n . In b o th t a s k s , a s e r i e s of s i m i l a r a c t i o n s must be r e p e a t e d or performed i n o r d e r to c o r r e c t l y complete a t a s k . I t seems t h a t from our r e s u l t s , s t i m u l i which are most s i m i l a r i n n a t u r e w i l l cause the most p e r s e v e r a t i v e b e h a v i o u r . F u r t h e r m o r e , when the h e a d - i n j u r e d s u b j e c t has w o r d - r e t r i e v a l problems i n the l e x i c o n , he may use the p e r s e v e r a t i v e response as a s u b s t i t u t e f o r those words which are more d i f f i c u l t to r e t r i e v e . 6_6_PR0BLE__#2_REC0VERY: There i s no d i f f e r e n c e between the e x t e n t of r e c o v e r y i n the h e a d - i n j u r e d c h i l d when compared w i t h the h e a d - i n j u r e d a d u l t . From our d a t a on r e c o v e r y from and l o n g term l i n g u i s t i c consequences of head i n j u r y i t seems t h a t r e c o v e r y i s f a s t e r i n c h i l d r e n i . e . 1 month when compared t o a d u l t s f o r whom spontaneous r e c o v e r y i s g e n e r a l l y s e t a t 6 months. The e x t e n t 62 of l i n g u i s t i c r e c o v e r y a f t e r head i n j u r y i s s i m i l a r however i n b o th the c h i l d and a d u l t . Comprehension i s f i r s t to r e c o v e r , and g i v e n a l i n g u i s t i c d i s t u r b a n c e i t i s more l i k e l y to i n v o l v e the l e x i c o n r a t h e r than phonology or s y n t a x . S i m i l a r to our f i n d i n g s i n c h i l d r e n , w o r d - f i n d i n g problems have been noted to p e r s i s t i n h e a d - i n j u r e d a d u l t s . In the p a s t the h e a d - i n j u r e d c h i l d has more commonly been d e s c r i b e d as r e c o v e r i n g q u i c k l y and c o m p l e t e l y a f t e r a spontaneous r e c o v e r y p e r i o d . T h i s i s not t r u e a c c o r d i n g to our sample of h e a d - i n j u r e d c h i l d r e n and a d o l e s c e n t s . In our sample of c h i l d r e n complete r e c o v e r y of language a b i l i t i e s was not e v i d e n t up to f o u r years p o s t - i n j u r y . As i n the a d u l t p e r s i s t e n t d e f i c i t s were p a r t i c u l a r i 1 y s t r i k i n g i n word-r e t r i e v a l . 6 i7_SCH00L_PERFQRMANCE: Long term f o l l o w - u p of performance i n h e a d - i n j u r e d c h i l d r e n i s i n most ca s e s l i m i t e d to d e s c r i p t i o n s of s c h o o l performance. In most c a s e s , c h i l d r e n who have s u f f e r e d head i n j u r y r e q u i r e e x t r a a s s i s t a n c e or s p e c i a l c l a s s placement. A l a j o u a n i n e & L h e r m i t t e (1965) r e p o r t e d s i x c h i l d r e n who a f t e r h e a d - i n j u r y , r e g a i n e d p r e v i o u s a c q u i r e d academic s k i l l s but were unable to advance f u r t h e r , and e v e n t u a l l y dropped out of s c h o o l . A l l of the c h i l d r e n they t e s t e d f a i l e d to f o l l o w a normal p r o g r e s s i o n i n s c h o o o l . F u l d & F i s h e r (1977) s i m i l a r i l y r e p o r t e d t h a t s e v e r a l of the c h i l d r e n they s t u d i e d r e q u i r e d s p e c i a l c l a s s placement s e v e r a l years a f t e r t h e i r i n j u r y . 63 The r e s u l t s of t h i s s t u d y (and o t h e r s ) suggest t h a t r e g a r d l e s s of c h r o n o l o g i c a l age, c h i l d r e n who s u f f e r head i n j u r y may r e q u i r e s i g n i f i c a n t time t o a d j u s t t o t h e i r a l t e r e d s t a t e b e f o r e b e i n g p l a c e d back i n the s c h o o l system, and t h a t , i n a d d i t i o n , r e c o v e r y t o p r e - i n j u r y performance l e v e l s appears never to o c c u r . C o n t i n u i n g inadequate performance i n s c h o o l i s p r o b a b l y r e l a t e d not o n l y t o a c o n t i n u i n g d i s r u p t i o n of the l e x i c o n but a l s o to b e h a v i o u r a l and a t t e n t i o n a l sequelae r e l a t e d t o the i n j u r y , which may themselvews be r e s p o n s i b l e f o r l e x i c a l d i s r u p t i o n . B l a c k e t A l . (1969) observed t h a t i m p a i r e d a t t e n t i o n , p a r t i c u l a r i l y i n boys, was a common c o n t i n u i n g problem f o l l o w i n g head i n j u r y . I t would appear r e a s o n a b l e t o suppose t h a t t h i s a t t e n t i o n d e f i c i t , i n a d d i t i o n to a g g r e s s i o n and f r u s t r a t i o n c o u l d i n i t i a l l y p r e v e n t the c h i l d from f u n c t i o n i n g s a t i s f a c t o r i l y . I f a t the same time too many demands are p l a c e d on the c h i l d when he/she i s not ready to cope, a v i s c i o u s c i r c l e of s c h o o l f a i l u r e and d i s c o n t i n u e d i n t e r e s t would be a n a t u r a l r e s u l t . Thus, slow and c a r e f u l i n t e g r a t i o n i s p r o b a b l y v i t a l i f the h e a d - i n j u r e d c h i l d i s to b e n e f i t from r e t u r n to a r e g u l a r s c h o o l program. On the b a s i s of p r e s e n t (and p a s t ) r e s u l t s c o n t i n u a l m o n i t o r i n g and a s s i s t a n c e are n e c e s s a r y i f p r o g r e s s i s to c o n t i n u e . 6_8_C0_CLUSIQ_S: l.The s y m p t o m a t o l o g i c a l d e f i c i t s of language are s i m i l a r i n the h e a d - i n j u r e d c h i l d and a d u l t . They i n c l u d e reduced a u d i t o r y comprehension . p e r s e v e r a t i o n , w o r d - f i n d i n g ,and sequ e n c i n g problems. 64 2.If any l e v e l of language i s seen to be c o n t i n u a l l y d i s t u r b e d r e g a r d l e s s of age, i t i s the l e x i c o n , which continues to be a f f e c t e d even a f t e r spontaneoous recov e r y . 3. Despite a q u i c k e r recovery in c h i l d r e n , complete recovery of a l l language a b i l i t i e s i s not evident i n t h i s sample of c h i l d r e n up to 4 years p o s t - i n j u r y . 4. There appears to be no r e l a t i o n s h i p between length of coma and s e v e r i t y of l i n g u i s t i c d e f i c i t s . 5. There appears to be no r e l a t i o n s h i p between age and s e v e r i t y of l i n g u i s t i c d e f i c i t s . 6r T h e S u b j e c t s With dSSOCJated p h / s i c & l handicaps i . e . s p a s t i c i t y and s e i z u r e s , d i s p l a y e d the most d e f i c i e n t language s k i l l s . These r e s u l t s present us with a r a t h e r i n t e r e s t i n g view of language. I t would appear that the grammar (syntax) i s a robust phenomena which i s h i g h l y r e s i s t a n t to d i s r u p t i o n , thus l e a d i n g MS to suggest ( s p e c u l a t i v e l y ) that i t has c e r t a i n innate p r o p e r t i e s . On the other hand, the l e x i c o n which i s ac q u i r e d by many d i f f e r e n t means, i . e . by one or more of the sensory systems, i s seen as f r a g i l e and most s u s c e p t i b l e to d i s r u p t i o n when pa r t of the a s s o c i a t i v e network f o r naming, i s d i s r u p ted. It i s t h e r e f o r e , f o r us not s u r p r i s i n g , that the language e f f e c t s of traumatic head i n j u r y are s i m i l a r f o r both young and o l d , when i n j u r y occurs a f t e r the grammatical system has been a c q u i r e d i . e . around 2;5-3;0 years. The long term e f f e c t s of h e a d - i n j u r y give us some very i n t e r e s t i n g i n s i g h t s into the s e p a r a t i o n between syntax and the l e x i c o n , and t h e r e f o r e f o r c e us to r e c o n s i d e r in a new l i g h t G5 the " e a r l y means b e t t e r and f a s t e r r ecovery" h y p o t h e s i s . 66 REFERENCES A l a j o u a n i n e , T.H.,& L h e r m i t t e , F. 1965. A c q u i r e d A p h a s i a i n C h i l d r e n . B r a i n , 88, 653-662. A n n e t t , M., 1973. L a t e r a l i t y of c h i l d h o o d h e m i p l e g i a and the growth of speech and i n t e l l i g e n c e . C o r t e x , 9, 4-33. B a s s e r , L.S. 1962. H e m i p l e g i a of e a r l y onset and the f a c u l t y of speech w i t h s p e c i a l r e f e r e n c e t o the e f f e c t s of hemispherectomy. B r a i n , 85, 427-460. B e r g , C. & Hel m i c k , J.W. 1976. P e r s e v e r a t i o n i n B r a i n - I n j u r e d A d u l t s . Journal__o f _ C o m m u n i c a _ i o n _ _ i s o r d e r s , 9, 143-156. B o r k o w s k i , J.G. Benton, A.L. & Spreen, D. 1967. Word F l u e n c y and B r a i n Damage. N e u r o _ s _ c h o l o g i a , 5, 135-140. Bruce D.A., & Sc h u t , L. The Value of Cat Sc a n n i n g f o l l o w i n g P e d i a t r i c Head I n j u r i e s . C _ i _ i _ _ _ P _ e d i _ t _ i c s , 19, 719-725. Bruce D.A. Sc h u t , L. Wood, J.H. and S u t t o n , L.N. 1978. Outcome f o l l o w i n g severe head i n j u r i e s i n c h i l d r e n . J o u r n a l of Ne u r o s u r g e r y , 48, 679-688. B y e r s , R.K., & Mclean, W.T. 1962. E t i o l o g y and course of c e r t a i n h e m i p l e g i a s w i t h a p h a s i a i n c h i l d h o o d . P e d i a t r i c s , 29, 376-383. C r a f t , A. 1974. C h i l d r e n w i t h Head I n j u r i e s . S_ec_Educ_Forward Trends, 1 ( 3 ) , 11-13. De n n i s , M. 1980. C a p a c i t y and S t r a t e g y f o r S y n t a c t i c Comprehension a f t e r L e f t or R i g h t H e m i d e c o r t i c a t i o n . B r a i _ _ _ Language, 10, 287-317. Den n i s , M. 1980b. S t r o k e s i n C h i l d h o o d I : Communication i n t e n t , e x p r e s s i o n , and comprehension a f t e r l e f t hemisphere a r t e r i o p a t h y i n a r i g h t - h a n d e d n i n e - y e a r - o l d . I n R.W. R i e b e r ( E d ) , Language_Dev_io__e_t_and (pp. 45-67). New York: Academic P r e s s . D e n n i s , M. & Kohn B. 1975. Comprehension of Syntax i n I n f a n t i l e H e m i p l e g i a a f t e r C e r e b r a l H e m i d e c o r t i c a t i o n ; Left-Hemisphere S u p e r i o r i t y . B r _ i n _ _ _ L a n g u a g e , 2, 472-482. D i S i m o n i , F.G. 1978. T h e _ T o k e n _ T e s t _ f o r _ C h i l d r e n New York: T e a c h i n g Resources C o r p o r a t i o n . Dunn, L.M. 1969. Expanded Manuai f o r the Peabody P i c t u r e Y ^ S l S - I i E - - ! - ! - - * C i r c l e P i n e s , MN: American Guidance S e r v i c e . E i b e n , C F . e t a l . 1984. F u n c t i o n a l Outcome of C l o s e d Head I n j u r y i n C h i l d r e n and Young A d u l t s . A r c h i v e s _ P h y _ M e d _ R e h a b i i 65, 168-170. 67 G a l a b u r a d a , A.M., LeMay, M., Kemper,T.L., & Geschwind, N. 1978. R i g h t - L e f t A s s y m e t r i e s i n the b r a i n . S c i e n c e , 199, 852-856. Geschwind, N. & L e v i t s k y , W. 1968. Human b r a i n : L e f t - r i g h t a s s y m e t r i e s i n temporal speech r e g i o n . S c i e n c e , 161, 186-187. G i l c h r i s t , E., M.D., W i l k i n s o n , M. 1979. Some F a c t o r s D e t e r m i n i n g P r o g n o s i s i n Young People With Severe Head I n j u r i e s . A r c h i v e s_Ne urology., 36, 355-359. G l o n i n g K.& H i f t E. 1970. Aphasie im V o o r s c h u l a l t . K e r y e n h e i l k u n d e , 28, 20-28. G o l d , A.P. & C a r t e r S. 1976. Acute H e m i p l e g i a of I n f a n c y and C h i l d h o o d . P a e d i a t r i c _ C i i n i c s _ o f _ N o r t h _ A m e r i c a , 23, No. 3. G o l d s t e i n , K. 1936. The problem of the meaning of words based upon o b s e r v a t i o n of a p h a s i e p a t i e n t s . J o u r n a ^ o f P s y c h o l o g y , 2, 306-316. Hecaen, H. 1976. A c q u i r e d A p h a s i a i n C h i l d r e n and the Ont o g e n e s i s of F u n c t i o n a l S p e c i a l i z a t i o n . Bra m_&_Languacje, 3, 114-134. Hecaen, H. 1983. A c q u i r e d A p h a s i a i n C h i l d r e n : R e v i s i t e d . Ne u r o Qs%ch ol_ og_ia, 21, No. 6, 581-587. Heilman, K.M. & S a f r a n , A. & Geshwind, N. 1971. C l o s e d Head Trauma and A p h a s i a . J^Neurol_ A_Neuosurg J L_PsychXa , 34, 265-269 . Heiskanen 0. & K a s t e , M. 1974. Lat e P r o g n o s i s of Severe B r a i n I n j u r y ; i n C h i l d r e n . Deve 1 ogmental,_Med^_Chlld_Ne , 16. 11-14. Hudson, A . J . 1968. P e r s e v e r a t i o n . B r a i n , 91, 571-582. K e r t e s z , A. & McCabe,P. 1977. Recovery P a t t e r n s and P r o g n o s i s i n A p h a s i a . B r a i n , 100,1-18. K l o n o f f , H. Low, M.D. & C l a r k C. 1977. Head I n j u r i e s i n C h i l d r e n , a P r o s p e c t i v e F i v e Year F o l l o w - u p . J_.of _5§.ii_I2i22X_ _}§._L£2._L_l_12_!._l_C^  _<_P_>Y._;h_ia1:ry, 40, 1211-12 19. Krashen, S.D. 1972. Language and the l e f t hemisphere. UCLA W o r k i n g _ P a p e r s _ i n _ P h o n e t i c s , 2 4, 1-72. L a n g f i t t T.W. 1978. Measuring the Outcome from Head I n j u r i e s . J J.0 f _Ne ur o u rge ry_, 48, 673-678. Lenneberg, E.H. 1967. B i o l o g i c a l _ F o u n d a t i o n s _ o f . . L a n g u a g e New York: W i l e y . 68 L e s s e r , R. 1976. V e r b a l and Non-Verbal Memory Components of the Token T e s t . N e u r o g s y c h o l o g i a , 14, 79-85. L e v a t t , A. e t a l . 1982. P r o g n o s i s of Severe Head I n j u r i e s . J o u r n a _ _ o f _ N e u r o s u r g e r y , 57, 770-78 3. L e v i n , H.S. Grossman, R.G. and K e l l y P . J. 1976. A p h a s i e D i s o r d e r i n P a t i e n t s w i t h C l o s e d Head I n j u r y . J o _ r n a _ _ o f Ne urol_ogy.j5._Ne uros urge r x A _ a n d _ P s y c M a t r y , 39, 106 2-1070. L e v i n , H.S. e t a l . 1981. L i n g u i s t i c Recovery a f t e r C l o s e d Head I n j u r y . Bra_n_&_Lan_ua_e, 12, 360-374. L e v i n e , D.N. 1981. A c q u i r e d L e a r n i n g D i s a b i l i t y f o r r e a d i n g a f t e r l e f t temporal lobe damage i n C h i l d h o o d . N e u r o l o g y , 31, 257-264. Lotmar, F. 1919. Sur K e n n t n i s der e r s c h w e r t e n W o r t f i n d u n g und i h r e Bedeutung f u r das Denken der A p h a s i s c h e n . Schwe j_zer_Arch j_y f M _ _ N e u r o i o g _ e _ u n d _ P s y c h X a t r i e , 5, 206-239. Man t o v a n i , J.F. & Landau, W.M. 1980. A c q u i r e d A p h a s i a w i t h C o n v u l s i v e D i s o r d e r : Course and P r o g n o s i s . N e u r o l o g y , 30, 524-529 . McFie, J . 1961. I n t e l l e c t u a l impairment i n c h i l d r e n w i t h l o c a l i z e d p o s t - i n f a n t i l e c e r e b r a l l e s i o n s . J o u r n a _ _ o f Neuro_ogy__Neurosurgery_^ , 361-365. N e l s o n , K.E. & B o n v i l l i a n , J.D. E x c e p t i o n a l Cases of Language A c q u i s i t i o n . Ch__dren_s_Language volume 3. O e s c h l a g e r , M.L.& Scarborough J . 1976. T r a u m a t i c A p h a s i a i n C h i l d r e n A Case Study. J_of_Commun_cat_on_D_sorders, 9, 281-88. Ojemann, George A. 1982. I n t e r r e l a t i o n s h i p s i n the L o c a l i z a t i o n of Language, Memory, and Motor Mechnisms i n Human Cor t e x and Thalamus. i n (Eds.) R.A. Thompson and J.R. Green. New E££s_ect_yes__n_Cerebra__Loca__zat_on New York:Raven P r e s s . Pease, D.M. & Goodgalss, H. 1978. The e f f e c t s of c u e i n g on p i c t u r e naming i n a p h a s i a . C o r t e x , 14, 178-189. P e r l s t e i n M.A., Sugar,0. 1954. Hemispherectomy i n i n f a n t i l e h e m i p l e g i a . Arch_yes_of_Neuro_ogj,ca__Psych 72, 256-259. R a n k i n , M.J. Aram, D.M. & H o r w i t z S.J. 1981. Language A b i l i t y i n R i g h t and L e f t H e m i p l e g i c C h i l d r e n . Bra_n___Language, 14, 292-306. Rasmussen, T., & M i l n e r , B. 1977. The r o l e of e a r l y l e f t - b r a i n i n j u r y i n d e t e r m i n i n g l a t e r a l i z a t i o n of c e r e b r a l speech 69 f u n c t i o n s . In S . J . Dimond & D.A. B l i z a r d ( E d s ) E _ o _ u t _ o n _ a n d _ I__ e .__Ii____on o f __e_b_aj,n__Anna_s_o f _th____w_Yo_k__cademy__o f S c i e n c e s , New Y o r k : Academic P r e s s . R o c h f o r d , G. & W i l l i a m s , M. 1962. S t u d i e s i n the d e v e l o p m e n t and breakdown o f the use o f names. P a r t s 1 & 2. J o u r n a i _ o f _ N e u r o i o 2 _ _ _ N e u r o s u r _ e r _ _ _ _ _ P s _ 25, 222-233. R o c h f o r d , G. & W i l l i a m s , M. 1965. S t u d i e s i n the d e v e l o p m e n t and breakdown o f t h e use o f names. P a r t 4: The e f f e c t s o f word f r e q u e n c y . J o u r n a i _ o f _ N e u r o i o g y _ N e u r o s u r _ e r _ _ _ & _ P s y _ c h i a t r y , 28, 407-413. R u d e l , R.G.,Teuber, H.L.& T w i t c h e l l , T.E. 1974. L e v e l s o f i m p a i r m e n t o f s e n s o r i m o t o r f u n c t i o n s i n c h i l d r e n w i t h e a r l y b r a i n damage. N e u r o g s y c h o l o g i a , 12, 95-108. S a r n o , M.T.,1980. The N a t u r e o f V e r b a l Impairment a f t e r C l o s e d Head I n j u r y . J o u r n a l o f N e r v o u s and M e n t a l D i s e a s e . 168. 685 = 692. S a t z , P. and C. B u i l a r d - B a t e s 1981. A c q u i r e d A p h a s i a i n C h i l d r e n , i n M.T. S a r n o (Ed) _i£guired_Aphasia, New Y o r k : A c a d e m i c P r e s s . S h a p i r o , K. 1983. P e d i a t r i c _ H e a d _ T r a u m a , Mount K i s c o , NY: F u t u r a P u b l i s h i n g Company. S t o v e r , Samuel L. and Evan Z e i g e r J r . 1976. Head I n j u r y i n C h i l d r e n and T e e n a g e r s : F u n c t i o n a l R e c o v e r y C o r r e l a t e d w i t h the D u r a t i o n o f Coma. A r c h i v e s _ o f _ P h y i g i c a l _ M e d i c i n e _ a n d _ B _ _ _ _ i _ _ _ i _ _ i o n , 57, 201-205. T e u b e r , H.L., and R u d e l , R.G.1962. B e h a v i o u r a f t e r c e r e b r a l l e s i o n s i n c h i l r e n and a d u l t s . D e v e i o _ _ M e d _ C h i i d _ N e u r o i , 4:3. T s v e t k o v a , L.S. 1967. The Naming P r o c e s s and I t s Impairment, i n L e n n e b e r g , E.H. ( e d . ) l i o i o g i c a i _ F o u n d a t i o n s _ o f _ L a n g u a g e , New Y o r k : W i l e y . Van Dongen, H.R. & Loonen, M.C.B. 1977. F a c t o r s R e l a t e d t o the P r o g n o s i s o f A c q u i r e d A p h a s i a i n C h i l d r e n . C o r t e x , 13, 131-136 . V i s c h - B r i n k , E.G. & Van de Sandt-Koenderman M. 1984. The O c c u r r e n c e o f P a r a p h a s i a s i n the S p o n t a n e o u s S p e e c h o f C h i l d r e n w i t h an A c q u i r e d A p h a s i a . B r a i n _ _ _ L a n g u a g e , 23, 258-271. W a l l e c k , C. 1980. Head Trauma i n C h i l d r e n . N u r s i n g _ Q i i n i c s _ o f _ N o r t h_Amer_ca, 15, N o . l , 115-127. W i i g , E.H. and B e c k e r - C a p l a n , L . 1984. L i n g u i s t i c R e t r i e v a l S t r a t e g i e s and w o r d - f i n d i n g d i f f i c u l t i e s among c h i l d r e n w i t h l a n g u a g e d i s a b i l i t i e s . J o £ i c s _ i n _ L a n g u a _ e _ _ i s o r d e r s , Dec. 70 W i i g , E.H. & Semel E.M. 1980. C l i n i c a l E v a l u a t i o n of Language F u n c t i o n s , Columbus, Ohio: B e l l and Howell Company. Wolf, Maryanne. 1982. Word F i n d i n g and Reading D i s o r d e r s i n £i_iI_i r._____Language V o l . 3, N e l s o n (Ed.) Woods, B.T. and Carey, S. 1979. Language D e f i c i t s a f t e r Apparent C l i n i c a l Recovery from C h i l d h o o d A p h a s i a . An_§I_>_of Neu r o l o g y , 405-409. Woods, B.T., & Teuber, H.L. 1978. Changing p a t t e r n s of c h i l d h o o d a p h a s i a . A__a_s_of_Neuro_og_, 3, 272-280. Worster-Drought, C. 1971. An Unusual Form of a c q u i r e d a p h a s i a i n c h i l d r e n . Developmental M e d i c i n e a n d _ C h _ l d _ _ e _ _ o l o g _ , 13, 563-571. 7 1 APPENDIX 72 PATIENT PROFILE NAME: ADDRESS: PHONE: D.O.B. HANDEDNESS: DATE OF TRAUMA: DATE OF TESTING:1) 2) DIAGNOSIS:-- :  LENGTH OF COMA: *************************************** TEST_RESULTSi l.P.P.V.T 2.TOKEN TEST Noun Verb Adv . Ad j . 3.SYNTACTIC STRUCTURES 4. WORD FINDING A. P i c t u r e Naming B. Word F l u e n c y C. Sentence C o m p l e t i o n D. Aud. D e s c r i p t i o n 5. SENTENCE ORDER TASK 6.SENTENCE IMITATION-A. Omm i ss ions B. Rearrangements 7.M.L.U. SYNTACTIC COMPLEXITY % PARAPHS. TTR 73 NAME: DATE : Raw S c o r e : AyDITQRY_SENTENCE__QMPLE RESPONSE LATENCY: 1. You hang l a u n d r y out to d r y on a 2. To f i n d out what to eat i n a r e s t a u r a n t you loo k a t the 3. You buy stamps from a p l a c e c a l l e d the 4. I f you are a r r e s t e d they w i l l put you i n 5. The d o c t o r measures your h e a r t b e a t w i t h a 6. To pound a n a i l i n wood you use a 7. A pers o n who has j u s t been born i s c a l l e d a AUDI TORY_DESC_IPTig__ 1. What i s the name f o r a moving s t a i r c a s e ? 2. What do you use to shave w i t h ? 3. What i s a t o o l f o r d i g g i n g a h o l e i n the ground. 4. What i s the name f o r the t h i n g one s i t s on? 5. What do you use to c u t paper w i t h ? 6. What do you put a l e t t e r i n b e f o r e you m a i l i t ? 7. What i s the o b j e c t used f o r l i g h t i n g a f i r e ? 74 Name : Date : S c o r e : Word F i n d i n g — V e r b s AUDITORY_D_SCRI_TIQNi 1 What do you do when your h a i r i s messy? 2. What do you do when someone t i c k l e s you? 3. What do you do when you are s i c k ? 4. What do you do w i t h soap? 5. What do you do on a m o t o r c y c y l e ? -AyD^__E_TE_CE__g_PLETig_i 1. When I go to bed I 2. A boy runs and an o l d man 3. I open the book and s t a r t t o 4. When I am ve r y unhappy I 5. When something f a l l s i n t o p i e c e s i t 75 P a r e _ t a _ _ _ e _ o _ t B e f o r e the a c c i d e n t : 1. When d i d your c h i l d s t a r t a) w a l k i n g b) t o i l e t t r a i n e d c ) s a y i n g words d) s a y i n g s e n t e n c e s 2. D i d he p e r f o r m i n h i s s c h o o l s t u d i e s -a. below average b. average c. above average 3. D i d he/she need any s p e c i a l h e l p a t s c h o o l , and i f so what k i n d of h e l p ? £__E£esent_ 1. What s c h o o l i s your c h i l d now a t t e n d i n g ? - -2. What Grade and type of c l a s s i s he/she in? 3. I s he/she h a v i n g any p a r t i c u l a r problems a t s c h o o l s i n c e the acc i d e n t ? 4. Does he/she r e c e i v e L e a r n i n g a s s i s t a n c e or • speech t h e r a p y ? 5 . Any n o t i c e a b l e changes i n b e h a v i o u r s i n c e the a c c i d e n t ? 6 . Doe s she/he have any problems r e l a t i n g t o h i s / h e r f r i e n d s ? 7. Does he/she have any problems remembering ? 8. Has your c h i l d had any o t h e r s e r i o u s i l l n e s s e s i n the p a s t ? 76 Name : La t e n c y Response Ph. Cues 31 — 77 M e d i c a l Data Name BD Date of Trauma A. Cause of A c c i d e n t B. I n i t i a l H o s p i t a l i z a t i o n S t a t e : ParalysIs Co iii3.= GCS Cat S c a n - B r a i n Damage S i t e Speech/Lang. C. Recovery walk i n g Behav i o u r - -78 SENTENCE ORDER TASK Name : Date : 1. the door was not c l o s e d by him L1V1S3 2. The f e l i n e p erched on the t r o u g h L1V3S2 3. T h i s box c o n t a i n s some p r e s e n t s L1V1S1 4. The eggs were bought by mother L1V1S2 5. The g i r l i s w r i t i n g a note L1V1S1 6. The m i l k was not drunk by her L1V1S3 Length L2V1S1 L3V1S1 V o c a b u l a r y L1V2S1 L1V3S1 Syntax L1V1S2 L1V1S3 

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