From the very first time she came to my office, Aurore’s clear blue eyes fascinated me. A melodic murmuring of linked vowels accompanied a circular movement of the eyes which swept around the room. She was quite tense and stopped, then a very light finger fluttered around the room as if detached from her body.

It was impossible to assess her language since she did not utter a single word during this first session. But I was able to evaluate her verbal comprehension of single words, albeit not without triggering a huge temper tantrum. She hit the set of pictures with a stiff and violent arm. I was nevertheless able to measure her receptive vocabulary, which was at a three year-old level. Communication was totally non verbal, yet full of nuances which I was progressively to discover.

We organized speech and language therapy around symbolic play. One day, after many weeks of therapy, she stuck her head through the frame of a puppet theatre and uttered one powerful and isolated sound, " O ", with her hands cupped around her mouth. She then laughed heartily with a mischievous look on her face!

Hadn’t she just loudly declaimed her first name, Aurore?

Christiane was also over the age of 5 when she came to see me for the first time. She was in her last year of preschool. Her mother, who was worried about her ability to handle the first year of primary school the following year, had requested this consultation.

The gaze of this child was just as intense as that of Aurore, but she remained totally still, waiting like a statue of salt.

She seemed to be quite present and attentive, but did not initiate any activity. Her drawings were tangled lines with no recognizable shape. She physically clung to her mother. She did use play material as props for communication, typically staring at those objects she wanted to take. Later during the session, a non verbal exchange took place: she would bat her eyelashes or nod her head softly in answer to my questions, but she did not utter a single " yes " nor make a single movement, as she was immobilized by tension.

It was only after many weeks, first in the presence of her mother then without her, that a faint smile signalled her acceptance of my presence.

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It took many months to progressively establish communication and language with these two girls. Their parents gave them a lot of support, and even tended to spoil them. One of the fathers was a physician, the other one a warehouseman. These girls were both adequately stimulated. Yet, the " word deficit", which bordered on a total absence of language, was associated with particular and atypical behaviours.

How could we develop a better understanding of these behaviours and use this knowledge to foster language development? Was it possible to conduct therapy without taking into account both the child’s attitude and her language disorder?

The aim of this presentation is not to provide practitioners with a finished product from personal experience, but rather to raise questions for consideration by other practitioners regarding the possible relationships between the development of the dysphasic child and his (her) inability to use language for thinking through and resolving normal childhood conflicts.

My first experience in speech and language therapy was as a private practitioner; I later joined a multi-disciplinary team in child psychiatry. In this centre, children and adolescents are treated on an outpatient basis and those with language disorders are generally referred to the speech and language therapist. Requests for therapy can be made directly by the child’s family, or by the child’s teacher, or the school psychologist, the family physician or pediatrician. In agreement with the referral source, additional E.N.T. or neuro-pediatric tests can be prescribed, but will not necessarily be systematically conducted. The medical history of our dysphasic patients generally reveals no premature delivery, or severe physical trauma, or serious illnesses during early childhood.

Tests of intellectual performance are administered to each child as soon as his (her) behaviour and language permit it: IQ scores are in the 90 to 110 range, with a distribution of verbal vs. performance scores which is always to the benefit of non verbal functioning.

Their level of intellectual functioning clearly indicates that their language deficit is not due to a delay in intellectual development. In terms of psycho-emotional and communicative functioning, some vulnerabilities are observed in both the child and his (her) family, without reaching the severity of what Professor Bernardi calls a " psychiatric disaster " or of neurotic pathology. All these children belong to supportive family environments which adequately meet their academic, therapeutic and medical needs, thus maintaining continuity in what may be a long and costly therapeutic process.

From a theoretical standpoint, the language deficits displayed by these children find support in descriptive, linguistic, and more recently neuro-psychological theories. In private practice, it is not unusual to obtain comprehensive results from neurological tests. [meaning??]

Results from E.E.G. tests are generally normal and do not encourage hospital services to consider further testing through topscan or magnetic resonance imagery.

Within this framework, an operational definition such as that suggested by Ch. L. Gérard can serve as a starting point when a verbal deficit is clearly present.

According to this author, " dysphasia can be defined in terms of a long-term deficit in verbal performance which is significant in comparison with established same-age norms. This condition is not due to an auditory deficit, a structural impairment of the phonatory system, limited intellectual skills, brain damage acquired during childhood, a pervasive developmental disorder, or emotional or educational deprivation " . All children treated for dysphasia in our centre meet these criteria.

Cognitive models, such as those proposed by I. Rapin and Ch. L. Gérard, help us refine the knowledge we have of these children’s language profiles. They clarify our understanding of their verbal functioning, which in turn contributes to developing the most appropriate treatment plan.

Which type of tools should be selected or developed to best reveal the child’s language skills without engaging him (her) in lengthy and burdensome testing?

Pr. Alegria would say this endeavour resembles Sherlock Holmes’ detective work of step by step searching for indices, treatment being in itself a revealing process.

Our objective is to build on intact language skills and select the most appropriate complementary approaches.

We will now describe the evolution of dysphasic children’s language skills over the course of therapy by presenting two clinical cases of boys treated for dysphasia.

We will then address the concept of verbal thought disorder in these children. Our purpose is to establish links between developmental verbal deficits and those tools which the thinking subject needs for communicating beyond produced or understood words. Language is also needed to develop representations of the outside world, to adapt to it, to metabolize affect and go beyond the static " here and now " in order to think, react and anticipate.

Born on August 2nd, 1991, J.G. was 4 years 3 months when he was referred to us by the pediatrician of a large clinic located in Brabant Wallon. At that time, the child lived in a conflictual home environment due to a difficult, sometimes violent, process of parental separation. According to the mother, this had been going on since she was pregnant with J.G. Two audiological tests performed by two different physicians yielded normal results.

J.G. was born four years after his brother who had displayed slight speech problems; pregnancy and delivery were normal. There were no feeding problems during infancy although he tended to suck more at night than during the day. He babbled a lot and was an active baby. According to his mother, he started to walk at the age of 11 months. He was always on the go and showed good balance. He was an expressive toddler who readily used sounds, gestures and mimicry to express himself.

He was very attached to his older brother, but when they fought, he expressed his anger in very intense and physical ways. Several au pair girls, sometimes of foreign origin, took care of him while his mother worked.

He started school at the age of 3 and his teacher described him as stubborn, driven in his activities, yet often in his own world and somewhat isolated from his peers.

His domineering character hampered social integration; in addition, his low level of language development prevented him from following his peers’ verbal interactions. Interventions geared to developing social skills were initiated within the school system. He often went beyond established limits and frequently had to be reminded of social rules.

Before he was referred to our Child Psychiatry Centre, he went through five months of training with the Tomatis method. The report described him as " a lively child, seemingly bright and observant. Quite free and harmonious in his movements, he communicates his wants through onomatopoeias; but when talked to, he seems to ignore the speaker, perhaps out of frustration from not being able to express himself better. Yet, he is lively and active when he communicates with adults ".

He was between 3 ½ and 4 years old during this period of training which resulted in no apparent changes in his language skills. Upon meeting him, we requested a neuro-pediatric consultation which did not indicate the need for further neurological tests.

In comparison with other areas of functioning, verbal development was the most disturbed. Praxic skills of construction and neuro-motor integration were weak, as well as object praxis (prehension).

Psychomotor training and speech and language therapy were both prescribed and initiated and have continued on an ongoing basis, up to the present.

Our first language evaluation, which involved the mother as well, started in January 1996, at the age of 4 years and 4 months. He clearly sought to be understood, but his language was difficult to understand out of context.

He expressed himself through numerous gestures and onomatopoeias inflected in the imperative mode, and gave orders where identified " no "s were much more spontaneous than " yes "s. Using a fortified castle as symbolic play material and relying on this context, it was possible to identify simple but almost unintelligible sentences: " Ye, I...ha one; is bro " (Yes, I also have a(n) (indian?) feather; its broken). These rare utterances were drowned in an ocean of unintelligible vocalizations. Only two receptive tasks could be administered, demonstrating significant delay. On the receptive part of the TVAP test (an expressive and receptive vocabulary test), he obtained a score of 43 (SD = - 1), which placed him at an age level of 3 to 3 ½ years, suggesting a one year delay in receptive vocabulary, while word production was almost non-existent.

On the Khomsi-O52 test, his score of 14 was slightly below his chronological age level. He understood affirmative and negative lexical phrases, but concepts of time, singular vs. plural articles, names and verbs were not mastered. Interrogative and passive forms were not understood.

The family, the physician, the school psychologist, the psychomotor specialist and speech and language therapist agreed on a course of therapy. These conjoint sessions were co-directed by the school psychologist and speech and language therapist. This was the only time both parents had a chance to meet...although they would never look at each other. For us, these meetings were crucial in fostering role complementarity and a better understanding of the child. We based our therapeutic project on our own convictions regarding the best approach to use for language to emerge. These convictions were reinforced when we came across the observation by Mrs. Juarez-Sanchez and Mr. Monfort:

" One does not teach a child how to talk, rather one places the child in a context which allows him(her) to develop oral language ".

It is in such a context that various alternative and strengthening resources can be mobilized for the development of language: intonation, mimicry, gestures, and other supportive props which increase intelligibility. J.G. was a domineering child who rejected all technique-related injunctions.

Symbolic play was thus used as the centre of therapy. During the first year of therapy, this particular context was the only one which allowed communication to take place. Symbolic play fostered the dialogic and morpho-syntactic dimensions of language, while visual and auditory games fostered its lexical and phonological dimensions. Memory games, which focused on specific phoneme oppositions, helped him distinguish speech sounds. With regard to the family, it was the mother who initially requested help, but we made every effort to bring the father to the centre of our meetings. To do so, we initially went as far as accepting a non payment of fees on his part, until he finally adjusted to the consultation process in a positive manner.

After a year of therapy, receptive language skills had improved at different phonological, lexical and syntactic levels. Our hypothesis was that the child’s dysphasia was of the dyspraxic type (Rapin) or of the phonological production type (Gérard).

The next phase of therapy preceded by several months the child’s entry into primary school, a transition which encouraged us to modify our approach. While oral language skills primarily follow a contextual development, written language skills (another sign system) involve more awareness of those links which exist between the written word and the oral word.

In this respect, Mrs. Borel’s action-oriented method offers the double advantage of clarifying speech as well as anchoring it through mimicry, gestures and drawings. The book " Read well and enjoy reading " by S. de Sacy was very helpful for this purpose. With the help of the family who provided us with feedback on the child and gave us some family pictures of the children, we successfully anticipated letter recognition. J.G. was bursting with joy and pride when he deciphered words on his own for the first time, and this success helped him accept failure when trying to read more complex words. His expressive vocabulary improved and he accepted the praxia-gnosia test

In September 1997, he began his first year of primary school. He was slow entering the world of written language. Each new grapheme-phoneme pair was progressively introduced. The process of merging written syllables suffered numerous inversions and automatic written skills were slow to develop. By January 1998, his gnostic and syntactic skills had improved.

In 1999, J.G. repeated the second year of primary school. In spite of significant progress, his development continued to be marked by his dysphasia, but not to the extent of hindering social integration or preventing him from asking appropriate questions.

With regard to his learning skills, J.G. never had difficulty mastering maths concepts. In December 1999, a language re-assessment showed adequate progress in reading and spelling skills which placed him at a solid end of first-year level (he was repeating his second year). The teacher observed significant improvement in his handwriting and stressed the fact that he had no difficulties understanding a text, provided he was able to decipher it.

J.G. thus progressed enough in his speech production and lexical, syntactic and written language skills to overcome the most deficient aspects of his language, but other difficulties remained.

In school, although his social skills had improved, he still displayed social integration problems. He continued to be rejected, sometimes even ostracized, by his peers because of behaviours which implicitly or explicitly remained dominating. At this stage of development, such behaviours were a real source of concern. His teacher complained he could not follow any of the basic classroom rules. For instance, he would put away his sports wear wherever he pleased in spite of the fact there was a special place for it which every child knew about.

During therapy sessions, he also continued to resist rules, refused planned activities and distracted us from work by his extravagant discourse. These avoidance techniques were not directly confrontational but consisted primarily in endless talk which prevented dialogue and made us feel powerless. He would drag behind, both coming into the office and leaving it. He managed to find logical justifications for all his behaviours and often fooled us. These relationship difficulties encouraged us to think about the possible interactions between J.G.’s language disorder and his socio-emotional adjustment. We will address this issue again in the conclusion of this presentation.

M.B. was 8 years old when I met him for the first time, in November 1997. At the time, he was beginning his third year in primary school. His teacher had referred him because of very delayed reading achievement which made her suspect dyslexia.

During the first meeting, the mother, Mrs. R., was extremely talkative, and all I could do was listen to her and learn that the family had recently moved from the Brussels area to Brabant Wallon. According to her, his former school had reported no particular problem during the first two years of primary school, but she noted his language development had been slower than that of his sisters. Previous speech and language therapists could not really help him as he had a difficult time tolerating the demands of the therapeutic setting. I learned much later from the school psychologist that Mrs. R. had interrupted therapy several times. She was frequently in disagreement, and sometimes aggressive, with the therapists.

I rapidly understood that the family history was not a " standard " one. Mrs. R., a Jewish woman of Belgian nationality, and her Franco-Tunisian ex-husband had had three children, our patient and two girls who were three and four years older than M.B. The boy’s early childhood was marked by a succession of au pair girls who spoke different languages such as Yiddish, French or English. M.B.’s sisters had also displayed some learning difficulties, particularly in French, but these spontaneously resolved over the years without requiring professional help or grade repetition. During his childhood years, family life was quite tumultuous. At the age of 4 months, his parents separated in a climate of violence due to father’s accumulating gambling debts, according to mother. Out of rage, the father illegally took the children with him. This kidnapping did not last very long, but the result was that they were kept shut in their mother’s home for a long period after this incident. Since that time, M.B. was never allowed to go to school or to his therapy sessions by himself, although both places were close to his home. The father moved to the United States and this act of abandonment made it possible for the mother to obtain a change of last name for the child, from the father’s to her own. With this information in mind, I asked the mother about her own views regarding the child’s school difficulties and the best therapeutic course to follow. She remained vague about previous therapeutic interventions, while implying that she had not been satisfied with the speech and language therapists who had treated her son so far.

With the help of the school psychologist and the teacher, I first defined a framework for the medical, psychological and speech and language evaluations. Upon my first contact with M.B. in the waiting room, the boy looked at me sideways, slid from the armchair and slowly stood up while inviting his mother with a rapid glance to accompany him to my office. She rapidly got up and we started the evaluation in her presence. The ENT and neuro-pediatric tests were completed: the former gave normal results while the latter did not reveal any significant findings aside from some difficulties in construction and digital praxic skills. The EEG test was normal.

An assessment of his intellectual functioning based on the WISC confirmed our clinical impressions of a boy of solid intelligence (full scale IQ of 106), his performance (non verbal) IQ being significantly higher than the verbal one (112 vs. 99). On the performance scale, a low score on the block design subtest contrasted with an excellent score on the arithmetic subtest.

Academically, M.B. demonstrated excellent mathematical skills for a third-year pupil.

The speech and language evaluation initially addressed questions raised by the school and focused on written language skills. The mother was surprised to learn that M.B. had cooperated with the test and had been attentive and persistent. The discrepancy between his production of already acquired written words and that of new words, which necessarily relied on phoneme/grapheme conversion, was striking. For words such as " carrot " written as " ota " and " chocolate " written as " oaoa ", production was extremely deficient for an 8 year-old child. Handwriting was consistently clumsy.

Partial administration of the Belec test battery showed a significant discrepancy between his production of words and of letter sounds, and between syllable and phoneme segmentation. He had not mastered the notion and technique of grapheme-phoneme correspondence. In contrast, visual memory for a written text was above average. Spelling skills were quite adequate, after reading a text only twice.

An oral language evaluation was clearly needed as well. It was easy to assess his verbal delay as ranging between one and four years, depending on the variables involved. Sentence comprehension (O52) was age appropriate whereas active syntactic skills were the most impaired, with an age equivalence of 3 years 9 months for a chronological age of 8 years 3 months.

In situations of spontaneous or partially induced language, his articulation reflected adequate distinction of phonemes except for sibilants (s, ch, z, j) which were poorly distinguished; in contrast, syntagmatic phoneme sequencing was more fragile. Speech was slow and slurred and his voice was toneless. Intelligibility was poor because of articulatory praxic difficulties. Based on Rapin and Gérard’s definition, we hypothesized a diagnosis of language disorder, phonological-syntactic type.

Which type of therapeutic project should we consider on the basis of this information? In agreement with the mother, physicians and psychologists, we decided to give priority to the development of learning skills. We surmised that this bright child had the ability to progress if appropriately encouraged and supported by the therapeutic team. Mrs. R., the school psychologist, the teachers and speech and language therapist conjointly agreed to discuss progress at key moments during the school year. Our initial objective focused on the development of more precise phoneme-grapheme correspondence without which his expressive written language skills could not improve. We selected techniques and games which appropriately fostered the development of phoneme-grapheme conversion, while drawing upon his acquired meta-syllabic skills.

We also used Mrs. Borel’s action-oriented method as a prop during this first stage of therapy. The intelligibility of his speech productions improved, phoneme-grapheme correspondences started to be established, use of " letter sounds " and " metaphonology " also improved. A reassessment of his language skills continued to reflect significant impairment, but the beginning of progress could also be noted.

In school, improvement in both written language skills and intelligibility was evident. Although progress was not sufficient for him to be promoted to the next grade level, it was significant enough to ensure better academic integration the following year. Therapy could be built upon easier, more free-flowing reading skills in order to work on units of meaning and syntactic skills. Reading and spelling skills when working on new unprepared texts also improved consistently.

He also continued to progress in language areas which represented strengths for him. Results on the oral-E.CO.SS.E. test (a test of syntactic-semantic comprehension) indicated a high level of functioning. His weakest area, expressive syntactic skills, was still adequate, at a 7 ½ year-old level.

On the L.M.C. reading test (a test of word reading and comprehension), his comprehension skills were high for a chronological age level of 7 to 9 years, and he was able to correctly identify 15 pseudo-logatoms. His rate of reading continued to be slow on the Regul-Belec reading test, with a score slightly below a second year level for both regular and irregular words.

In contrast, on the RUP dictation test (test of Rules, Usage and Phonetics; Gossens), his spelling skills (usage and grammar) were quite adequate for his current fourth-year level placement. He could use a dictionary actively and with perseverance and his academic achievement confirmed these acquisitions. At the present time, oral and written syntactic productions are his most impaired area of functioning. He has no linguistic intuition for sentence structure and use of verb tenses remains limited. He readily memorizes meta-syntactic relays which are presented visually or in the form of games dealing with oral and written word morphology. But these strategies do not improve his oral verbal syntactic skills and thus essentially remain " palliative " strategies. He is still a slow reader whose comprehension is hindered by words of infrequent usage and by complex sentence structures. His speech production is just as slow as his reading and writing. This slowness, along with slack bodily postures and psychological functioning which raised some questions, will be addressed next in therapy.

We were immediately struck by the mother’s extreme volubility and her numerous and never completed daily activities. At the age of 10, M.B. was still not allowed to go places on his own.

Each child in the family was caught up in a wind of activities, an atmosphere which obviously aggravated M.B.’s difficulty in making decisions and hindered the development of his autonomy. In the classroom, he had a hard time participating in verbal exchanges and also in preserving his own space. He would ask his mother to buy candy for him, which he then would systematically give away to his peers. He would do the same thing with his video games, and this did not go unnoticed by the teachers. He clearly worked hard at being accepted by others.

His bodily postures, neglected way of dressing (shoelaces and bottons undone), and slack gait did not improve much in spite of group psychomotor training. He seemed hypotonic to us but on the contrary, the psychomotor specialist felt he was very tense when at rest.

We asked for the help of a child psychiatrist but meetings with my colleague were either forgotten or cancelled by the family.

School meetings continued to take place with all participants involved, including the mother and the child psychiatrist (with mother’s consent). All meetings were beneficial as they encouraged useful discussions on the child’s behavioural, social and academic functioning.

We drew upon these interdisciplinary meetings to begin more direct work on pragmatic aspects of communication.

We had observed that M.B. took very little initiative in different social contexts, that his expression of emotions was either limited or indirect (through a gaze or a smile) and that his use of words did not really reveal his inner life. I proposed play people and animals as material for making up a story. I would write down his story.

His stories expressed themes of cruelty and death, endlessly and without limits. They sometimes continued with the narration of a recent nightmare, where his fear of being choked to death was intensely expressed.

Our observations of M.B.’s and J.G.’s difficulties and progress seem to throw a new light on these children’s problems and this is what we will attempt to describe during the following discussion.

Within a cognitive framework, Baron-Cohen, Leslie and Frith suggest the presence of a specific cognitive deficit which, as is the case for autism, would explain the association of three types of disorders in these children: poor socialization, disturbed verbal and non verbal communication, and restriction of activities and interests. One area of this cognitive module may involve the " mind theory ", i.e., the ability to identify one’s own thoughts and of attributing mental states to other persons. The above authors believe this cognitive module is innate and is the necessary foundation for the development of meta-representations.

A prototypical example is the " make believe " game which involves two simulated representations of the situation. The primary representation of reality and the secondary representation, a meta-representation reflecting the simulated situation.

Within this theoretical framework, several successive developmental levels may participate either in the ability to attribute a thought to a person regarding an objective event, or in the ability to attribute a thought to a person according to what another person thinks of this same objective event.

According to the above-mentioned authors, this cognitive ability reaches maturity between the ages of 7 and 9 years.

Results from research by these same authors demonstrated that this capacity is delayed in dysphasic children, as is their notion of conservation of matter (Piaget). As a result, they encourage us to take into account the " theory of mind " which " has a serious impact on communication disorders, since the basic motivation to communicate is grounded in a desire to share intentions, thoughts and emotions with other persons ".

These conclusions should reinforce our efforts to develop meta-cognitive evaluations as well as specific therapeutic strategies, such as symbolic play, geared to the development of meta-cognitive abilities and, more generally, of the pragmatic aspect of language.

Using a psychopathological perspective, M. Bernardi’s and J. Uzé’s work points to the presence of highly disturbed representational processes in severe dysphasia.

Their investigations underscore the importance of an inter-disciplinary approach to these problems. For these clinicians and medical specialists in psychopathology, it is inappropriate to view severe dysphasia within the framework of psychotic or neurotic personality profiles, or even of other personality disorders.

Pr. Bernardi suggests yet another alternative, worded as a question: " ...do the developmental language disturbances displayed by children with severe dysphasia represent a specific style of adjustment to primary emotional-relational problems which are yet to be understood, or do they drastically modify the child’s relationships with the world, rendering them complex and obscure, thus generating personality styles whose complexity is difficult to grasp with standard clinical tools? "

As a clinician, the author proposes an interactional perspective in the treatment and education of the dysphasic child.

These conclusions clearly stress that it is not only essential for the dysphasic child to develop the highest possible language abilities, but also to reach the cognitive level of " word representation ".

As we understand it, it reflects the ability to use words so as to express needs and wants within a relationship with another person. Speech and language therapists can foster the development of such an internal tool of reflection, allowing the child to resolve daily conflicts without constantly acting out or being completely passive.

If life circumstances and level of language development permit, the child can begin " reflecting " at the age of 7 or 8, i.e., be able to stop and think before deciding on the path he wants to take.

At that point in development, language can be used to build a representation of the other person, of his (her) desires and point of view, thus building the concept of " otherness ". The development of this internal psychological space requires representational abilities which are best provided by words in the context of human communication.

Dr. Uzé stresses the importance of encouraging these dysphasic children to also use non verbal means of communication. It is not enough to rely on their existing visual and imitation skills, as this could reduce the communication process to a simple act of transmission of information, but it is also important to rely on all their different communicational modalities (visual skills, gestures, melody, mimicry), so as to progress toward a level of language which is much more developed.

The aim of therapy and education goes well beyond the fostering of communication skills; the objective is to foster the development of the thought-language function through a different language system. For Uzé, it is a way of moving beyond the " here and now " and beyond concrete reality: as a complementary semiotic system, he suggests using pictograms which are adapted to the needs of the child.

We believe this concept of complementary semiotic system is already addressed by Juarez and Monfort through the use of strategies of reinforced stimulation, active communicational situations, functional activities and augmentative systems. Nevertheless, we must pay attention to the representational quality of these devices, so as to foster good socio-emotional adjustment in these children. Through research in the cognitive sciences and use of theoretical frameworks such as psychoanalysis, researchers and practitioners will help these children progress, but they also need to keep in mind their well-being as social human beings. We hope these recent investigations and reflections will open up new therapeutic avenues for those speech and language therapists who want to help dysphasic children and their families.

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