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DOCUMENT RESUME ED 285 332 EC 200 269 AUTHOR Stockman, Ida J. TITLE New Directions in the Treatment of Severe Developmental Disability: St. Gallen, Switzerland's Model of Guided Movement Therapy. Fellowship Report. INSTITUTION World Rehabilitation Fund, Inc., New York, NY. SPONS AGENCY National Inst. of Handicapped Research (ED), Washington, D.C. PUB DATE 15 Jun 86 GRANT G008103982 NOTE 57p. PUB TYPE Reports - Descriptive (141) EDRS PRICE MF01/PC03 Plus Postage. DESCRIPTORS Cognitive Development; Developmental Disabilities; *Educational Methods; Elementary Secondary Education; Foreign Countries; Kinesthetic Perception; Language Handicaps; *Learning Disabilities; Learning Processes; *Movement Education; Multisensory Learning; *Perceptual Motor Learning; *Problem Solving; Teaching Methods; Theories IDENTIFIERS *Switzerland (Saint Gallen) ABSTRACT The paper describes an innovative treatment approach to severe learning disabilities in use in St. Gallen, Switzerland. The multisensory approach is based on the assumption that learning disabled children have perceptual cognitive deficits. Reality based problem-solvng events __tea with tactilia-kinesthetic input become the primary foci of treatment. Guided movement during daily "life problem-solving activities allows the child to learn in naturalistic contexts. A 1-month fellowship visit to St. Gallen lends greater understanding to a description of the four main theoretical principles: the importance of perception to learning; the complexity of the situation as a factor in learning; the primary role of tactile-kinesthetic sensory input in achieving adequate perceptual/cognitive organization; and the common root of verbal and nonverbal skills. A second section discusses application of the theories in assessment, work with families, and treatment strategies. Implementation is reviewed in an educational and rehabilitation hospital setting. The final section considers application of the theories to the United States, noting that a perceptual hypothesis about language impairment requires broader definition than the auditory modality. To encourage further learning, a working relationship with the St. Gallen team has been initiated. (CL) *********************************************************************** Reproductions supplied by EDRS are the best that can be made from the original document. ***********************************************************************

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DOCUMENT RESUME

ED 285 332 EC 200 269

AUTHOR Stockman, Ida J.TITLE New Directions in the Treatment of Severe

Developmental Disability: St. Gallen, Switzerland'sModel of Guided Movement Therapy. FellowshipReport.

INSTITUTION World Rehabilitation Fund, Inc., New York, NY.SPONS AGENCY National Inst. of Handicapped Research (ED),

Washington, D.C.PUB DATE 15 Jun 86GRANT G008103982NOTE 57p.PUB TYPE Reports - Descriptive (141)

EDRS PRICE MF01/PC03 Plus Postage.DESCRIPTORS Cognitive Development; Developmental Disabilities;

*Educational Methods; Elementary Secondary Education;Foreign Countries; Kinesthetic Perception; LanguageHandicaps; *Learning Disabilities; LearningProcesses; *Movement Education; MultisensoryLearning; *Perceptual Motor Learning; *ProblemSolving; Teaching Methods; Theories

IDENTIFIERS *Switzerland (Saint Gallen)

ABSTRACTThe paper describes an innovative treatment approach

to severe learning disabilities in use in St. Gallen, Switzerland.The multisensory approach is based on the assumption that learningdisabled children have perceptual cognitive deficits. Reality basedproblem-solvng events __tea with tactilia-kinesthetic input becomethe primary foci of treatment. Guided movement during daily "lifeproblem-solving activities allows the child to learn in naturalisticcontexts. A 1-month fellowship visit to St. Gallen lends greaterunderstanding to a description of the four main theoreticalprinciples: the importance of perception to learning; the complexityof the situation as a factor in learning; the primary role oftactile-kinesthetic sensory input in achieving adequateperceptual/cognitive organization; and the common root of verbal andnonverbal skills. A second section discusses application of thetheories in assessment, work with families, and treatment strategies.Implementation is reviewed in an educational and rehabilitationhospital setting. The final section considers application of thetheories to the United States, noting that a perceptual hypothesisabout language impairment requires broader definition than theauditory modality. To encourage further learning, a workingrelationship with the St. Gallen team has been initiated. (CL)

***********************************************************************

Reproductions supplied by EDRS are the best that can be madefrom the original document.

***********************************************************************

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U.S. DEPARTMENT OF EDUCATIONOftce of Educational Research and Improvement

EDUCATIONAL RESOURCES INFORMATIONCENTER (ERIC>

/Ns document has been reproduced asreceived from the person Or organizationoriginating

r Minor cnanges have been made to imprOvereproduction quality

Points of view Or Opinions Stated in this document do not necessarily represent officialOEIRl position or oolicy

FELLOWSHIP REPORT

NEW DIRECTIONS IN THE TREATMENT OF SEVERE DEVELOPMENTAL DISABILITY:

ST. GALLEN, SWITZERLAND'S MODEL OF GUIDED MOVEMENT THERAPY

This investigation was supported (in part) by a

fellowship from the

National Institute of Handicapped Research

U,S- Department of Education

Washington, D.C. 20201

World Rehabilitation Fund

Grant *G008 103982

"PERMISSION TO REPRODUCE THISMATER) L HAS BEEN GRANTED BY

TO THE EDUCATION . RESOU CESINFORMAPON C N 1 to (C:RICI

2

Ida J. Stockman, Ph.D.Associate Professor

Michigan State UniversityJune 15, 1386

Fellowship period:June 21-July 19, 1985

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Table of Contents

INTRODUCTION 1

MOTIVATION FOR FELLOWSHIP VISIT 1

GOALS OF THE FELLOWSHIP VISIT 5

GENERAL ACTIVITIES OF FELLOWSHIP VISIT 6

I_ TREATMENT FRAMEWORK 8

FOUR BASIC THEORETICAL PRINCIPLES 8

The Importance of Perception to Learning 8

Implications for Language Impairment and Treatment 11

The Complexity of the Situtation as a Factor in Learning 12

Implications for Language Impairment and Treatment 14

The Primary Role of Tactile-Kinesthetic Sensory Input in

Achieving Adequate Perceptual/Cognitive Organization 15

Implications for Language Impairment and Treatment 17

Verbal and Nonverbal Skills Evolve from the Same Root 17

Implications for Language Impairment and Treatment 20

II_ IMPLEMENTATION OF TREATMENT FRAMEWORK. 22

IMPLEMENTATION AT THE CENTER FOR PERCEPTUAL DISTURBANCES. 22

The Nature 6 perceptual Impairment 22

Assessment of Perceptual Impairment 25

Orienting the Family to the Treatment Strategies 28

Treatment Goal 29

Treatment Strategies: The Technique of Guided Movement 30

The Role of Daily Life Problem-Solving Activity i3

Working on Language 34

Evaluating Patient Response to Therapy 36

Treatment Efficacy 38

IMPLEMENTATION IN AN EDUCATIONAL SETTING 39

IMPLEMENTATION WITH BRAIN INJURED ADULTS IN A REHABILITATION HOSPITAL SETTING. . 41

III_ APPLICATION TO THE U S A 43

REFERENCES CITED 51

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Ih4TRODUCTIOhl

MOTIVATION FOR FELLOWSHIP VISIT

This report is the outcome of a one monthfellowship visit to the Center for PerceptualDisturbances in St. Gallen, Switzerland where an

innovative approach is being developed for remediating

the verbal/nonverbal performances of children 'with

severe developmental disability. This work has

significant implications for rehabilitation disciplines

in the U.S. that focus on children whose deficits

cannot be explained by the well known etiologies of

blindness, hearing loss or mental retardation. Such

children have been viewed broadly as learning disabled.

The proliferation of 4iagnostic labels for this

clinical group undoubtedly reflects its ?iverse

symptomatology. These labels include dyslexia,

aphasia, autism, specific language disability,attention disorder, etc. Although definition of

learning disability continues to be debated (cf. Ames,

1983; Keogh, 1983; Ysseldyke & Algozzine, 1983), the

literature suggests that these children, unlike the

mentally retarded, present uneven skill development and

perform lower than their judged potential to learn.

Despite the broad spectrum of behavioral difficulties

presented by the learning disabled, the difficulty of

acquiring one or more language modalities stands out as

a unifying theme.' It is estimated that at least 3% to

5% of U.S, children are learning disabled (see review

of prevalence and incidence data in Mercer, 1903).

Over the past two decades, the strides made in

characterizing learning disorders have not been matched

equally by strides in treatment. Longitudinal follow-

up studies (e.g. Rhea & Cohen, 1984; see also

summaries in Maxwell & Wallach, 1984) show that

learning disabled children do not catch up with their

age peers even with intervention and that their

performances appear wore depressed as they get older.

The prognosis for achieving a functional level of

adaptive behavior is particularly bleak for children

who present 'severe' learning disorders. Here

reference is made to those who are nonverbal several

'Throughout the text, language refers to a conventional

system of spoken, written or signed symbols. It is

used synonymously with verbal in contradistinction to

nonverbal behavior which may or may not hove semiotic

value.

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years after expected age of language onset and who, inaddition, exhibit apparent difficulty on a nonverballevel in the daily life activities of self care, playand social interactions. Current rehabilitationapproaches in the U.S. offer little hope of achievingeven minimal adaptive functioning with an autisticchild who still is nonverbal at 5 or 6 years of age.

The passage of handicapped legislation has sharplyfocused the need for more adeqlate treatment approachesfor the severely learning disabled in the U.S. Forexample, Public Law #94-142 mandates equal educationalaccess to handicapped children under the leastrestrictive conditions. its implementation,undoubtedly, has caused fewer children to be placed inresidential institutions. The assumption ofresponsibility for the child by the home, communityschools and health care agencies has elevatedsensitivity to treatment efficacy since servicedelivery is more glaringly accountable to publicscrutiny.

There currently is no consensus about the best wayto manage severe learning disability. The lack ofconsensus is particularly apparent for languagehabilitation which is widely viewed as a necessary goalof any treatment program. The diminishing theoreticaland practical appeal of behaviorist models of ]earninghas ushered in an era of electicism in clinicalnractices. A basic criticism of the behaviorist&pproach to treatment is that its highly structuredtasks are contextually isolated from real life events.Language becomes words or phrases on paper or labelsfor pictures or objects on a table. The child must sitat attention and deliver set types of clinicianprescribed and reinforced responses. Learning ismeasured by counting the number of responses emittedunder specific stimulus conditions. While the relative`straightforwardness' of such an approach has obviouspractical appeal to the day-to-day reality of clinicalwork, repetitive skill routines may not be functionalin natural situations. Guess, Keogh and Sailor (1978)comment on this problem below:

"There is unanimity among language practitioners,however that a problem frequently faced inlanguage programming is the generalization ofwhat is taught in the classroom or laboratory tospontaneous use in a less constrained nontrainingenvironment...It appears easier to establish arudimentary language repertoire in languagedeficient children than it is to teach the

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spontaneous use of the skill in nontrainingsituations." (p. 375)

The shift away from a strict behaviorist frameworkhas been activated further by expanding knowledge aboutthe complexity of language and its acquisitionalprocesses. In the last decade, research has led us toappreciate the influence of semantic and pragmaticknowledge on the learning of phonologic and morpho-syntactic forms. In addition, it has exposed thepossible prerequisite and co-occurring influence ofcognitive and social factors on language acquisition.This expanding knowledge base has pointed to the needfor dynamic, integrative treatment models thatencourage the teaching of language forms in contextshaving semantic and pragmatic relevance to the realworld.

Emerging U.S. treatment alternatives to a strictbehaviorist approach have attempted to increase thenaturalness of therapy by making it more child centeredand pragmatically interactive (see reviews by Seibert &Oiler, 1981; Yoder & Calculator, 1981; Fay, 1986).This trend has translated into therapy methods such asfacilitative play (Hubbell, 1981), pragmatic games(Conant, Budoff, Hecht, & Morse, 1984) and focusedstimulation (Leonard, et al., 1982). However, suchapproaches, while laying the groundwork for movingbeyond the restrictions of behaviorism, do not appearto be appropriate for every child. Given their verbalfoci, pragmatically motivated stiategies zeem mosteffective for the child who is already at a cognitivelevel for language discovery or the child who canrespond to verbal input in socially interactivecontexts.

On the other hand, a verbally oriented focus,albeit in more naturalistic contexts, is not likely tohelp the nonverbal child (i.e. one who has not reachedthe stage of semiotic function, and therefore has nosymbolic means to externalize thought). Neither is itlikely to help the child who functions on such a lowlevel that he/she does not play or interact withpeoz.le. In fact, Conant, et al. (1984) reported thatthe pragmatic game approach was not effective withseverely impaired children. Fay (1986) argues furtherthat it is counterintuitive to advocate naturalisticapproaches which merely replicate the dynamism of theenvironment since the child has already shown thatlanguage cannot be learned in this way. This argumentseems particularly relevant to the severely disabledchildren. Yet, if communication is to be appliedoutside of therapy, attention must be given to

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naturalistic events. The notion of naturalisticcontext poses an unresolved dilemma for currentstrategies.

There is another limitation of currentstrategies. Like the behaviorist approach,klragmatically focused strategies do not take intoaccount the fact that low functioning children presentmaladaptive nonverbal behavior on a semiotic andnonsemiotic level. For example, one may observedifficulty in recognizing or arawing pictures,structuring play, completing a puzzle, getting dressed,retrieving a ball from a hole. Although all suchobservations point to cognitive limitations, currentlanguage treatment approaches, are not designed tobuild the cognitive base needed to remedy thesebehaviors nor to help the nonverbal child discoverlanguage except in an incidental way.

It is surprising that tieatment modeling has notmoved closer to a cognitive mode given the evidence forat least a weak language/cognition link (Rice & Kemper,1984). In fact, the results of just one study (Steckol& Leonard, 1981) led rather quickly to the conclusionthat working on a nonverbal cognitive task such asmeans/end does not facilitate language progress. Theview that the cognitive aspects associated withnonverbal behaviors have no place in language therapysuggests that language impairment, both written andoral, evolves from a different root than do coexistingnonverbal deficits. The re6ulting fragmented treatmentperspective is reinforced by professional turfdom thatallocates written language skills to the specialeducation teacher, oral language skills to thespeech/language pathologist and nonverbal behaviors tocounseling psychologists, physical and occupationaltherapists.

However, Ma :well & Wallach (1984) suggest that newtreatment models must move toward a more integrativeperspective.

"Recent advances in the study of languageacquisition suggest that the theoretical andclinical model for the 1980's must be dynamic,interactive...Furthermore, a system of symbolssuch as verbal language, cannot be understoodindependent of development in other behavioraldomains which coincide with it..." (p. 32)

Such an integrative perspective is offered by yetanother treatment alternative to behavior modificationtherapy, which is being developed in St. Gallen,

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Switzerland. Although Affolter and Stricker calledattention to this approach in their 1980 Englishpublication, Perceptual Processes as Prerequisites forComplex Human Behavior, it is not well known in theU.S. .Their brief desc:iption introduced a radicallydifferent treatment approach that was the focus of thefellowship visit.

The treatment is based on the assumption thatlearning disabled childrer have perceptual-cognitivedeficits. While this is not a new notion,complementary theoretical aspects of informationprocessing and developmental cognition converge toshape broader definition of perceptual impairment thanthe auditory processing hypothesis that historicallyhas dominated attention in the U.S. St. Gallen'smuitisensory treatment model not only goes beyond anauditory processing hypothesis, but it regards realitybased problem-solving events connected with tactile-kinesthetic input as she primary focus of impairmentand remediation of verbal and nonverbal behavior.Guided movement during daily life problem-solvingactivities offers augmented sensory input that ellowsthe child to learn in naturalistic contexts. Bothverbal and nonverbal behaviors are expected to improvesimultaneously by focusing on the organization ofunderlying perceptual-cognitive processes.

A process oriented treatment strategy that evolvesfrom a well motivated hypothesis about an underlyingconnecting root between different behavioral domainsoffers a potentially powerful approach to treatingseverely impaired children who oftea have multipledeficits. In principle, therapy can achieve moreefficiently a wide range of behavioral changes b:freeing its focus on specific skills that merely aresymptomatic of a shared underlying difficulty. Guidedmovement as the principal source of input for learning,means that the clinician can directly facilitatelearning by imposing the child's movements on theenvironment, thereby inducing contact with it. Onecannot, on the other hand, induce a child to look orlisten. The shift away from a strictly verbal learningapproach should lead one to expect progress even whenworking with a nonverbal child.

GOALS OF THE FELLOWSHIP ViSIT

The St. Gallen approach raises new questions aboutthe nature and treatment of developmental disabilitythat encourage further exploration. The primarypurpose of the fellowship visit to St. Gallen was to

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obtain more specific information about the principlesof this treatment model and how it translates intoactual treatment practices. A secondary goal was toexplore the possibility of establishing a collaborativeresearch/clinical relationship between the St. Gallenteam and a Language Sciences Laboratory that currentlyis being developed at Michigan Slate University.

GENERAL ACTIVITIES DURING THE FELLOWSHIP VISIT

This report incorporates information gathered fromseveral activities during the intensive one monthfellowship visit, which extended from June 21 to July19, 1985. A global impression of the treatmentframework was formed during my participation in theculminating week of a two year course offered by theSt. Gallen team to about 25 persons that includedparents, speech/language pathologists and specialeducation teachers. Throughout the week, lectures wereinterwoven with participant selfexperience in guidedmovement and case demonstrations. The casedemonstrations focused on two severely learningdisabled children who presented different clinicalprofiles. The participants were responsible for makingthe initial evaluation of the children as well asplanning and executing therapy sessions for each child.Each participant had the opportunity to guide one orboth children while being videotaped. The videotapeswere replayed for analysis and feedback about theadequacy of patient contact. The week offered manyopportunities to discuss the treatment framework withpersons who use or desire to use the St. Gallentreatment model.

Information obtained in the course wassupplemented i...5, three weeks of video and liveobservation of patients at three sites: (1) the Centerfor Perceptual Disturbances in St. Gallen, (2) theSchool for the Perceptually Handicapped in St. Gallenand (3) the Rehabilitation Hospital at Bad Ragaz. Ateach site, I discussed my observations withprofessionals who were directly involved in applyingthe St. Gallen model to their treatment practices.

This report of my observations is presented inthree sections. The first section describes the maintheoretical principles of the treatment framework,whereas the second section attempts to paint & pictureof how the treatment is implemented in three Swissrehabilitation settings. The third section considersapplication of the St. Gallen model in the U.S. Thereport necessarily suffers from the oversimplification

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that results when complex concepts are treated in a fewpages and have been grasped within a few weeks ofobservation.

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I. TREATMENT FRAMEWORK

St. Gallen's treatment framework has evolved frommore than a decade of clinical and researchobservations by Dr. Felicia Affolter and amultidisciplinary team of clinical psychologists,speech-language pathologists, audiologists, teachers ofthe deaf and the blind. The team is currently based inSt. Gallen, Switzerland at the Center for ierceptualDisturbances, which it founded in 1976 along with a

pilot school for the perceptually handicapped (TheSonderschule).

The team's work has been shaped by the broadtheoretical perspective of Dr. Affolter, a clinicalpsychologist, who al3o is trained as a speech/languagepathologist and teacher of the deaf. Faving studiedpsychology at the University of Geneva, Dr. Affolter'sorientation to learning theory has been influencedstrongly by the work of Jean Piaget. But, thePiagetian framework has been integrated into a largerpicture of learning theory that incorporates theinformation processing focus growing out of her studyin communication sciences and more current versions ofcognitive theory in psychology.

FOUR BASIC THEORETICAL PRINCIPLES

The Importance of Perception to Learning

The St. Gallen team's view of language impairmentand treatment evolves from theoretical assumptionsabout the nature of learning complex behavior. Withinits framework, perception plays a critical rile.According to Affolter and Stricker (1980),

"...perception includes all mechanisms used inprocessing the stimuli of an actual situation,including the different sensory modalities,supramodal organization levels, respectivestorage systems, and recognition performances..."(p. 12)

The definition points to perception as a complexprocess involving more than the stimulus detection andprocessing of sensory data; it also involves comparisonof sensory data in an actual situation with storedexperience, thereby enabling one to judge theirfamiliarity. Perception occurs when the stimulusevents are recognized as having been experiencedbefore.

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Recognition activity is a requirement for learningand development. Rec'Jgnition that a situation isfamiliar means that the presenting stimulus events areassimilable to existing knowledge, and therefore can betreated in the same way as previously experiencedevents of the same kind. Failure to recognize asituation should elicit new responses that adapt to thenew stimulus events, and as a result, expand theexisting knowledge base for responding to subsequentsituations. One quickly recognizes that the basicpremise of the treatment model is tied to Piagetiantheory in which "learning" is viewed as the adaptiveeffect of the complementary relationship betweenprocesses of "assimilation" and "accommodation".

To discuss further on a more concrete level, theSt. Gallen treatment model assumes that tworequirements must be met in order for learning tooccur. First, the environment must present newsituations in the sense that they offer problems to besolved. A problem is created when one's existingresponse repertoire is inadequate to achieve a goal inan actual situation. For example, a child, who isaccustomed to getting the lid off a cup by only pullingup on it, suddenly is faced with a problem when ascrew-on lid cannot be detached in the same way.Similarly, a child is faced with a language structureproblem when exposed to an utterance whose syntacticstructure is perceived to contradict an existing rule.During the course of development, the naturalenvironment offers many daily life problems for thechild to solve: Can I put this stick in the tiny hole,take the top off the cup to drink, climb the tree toget my ball, how do I tell Mom I've wet my pants, whatis th. name of this object, or the meaning of thisword, and so on.

Having potential problem situations available forlearning is not enough. The amount and type ofinformation that the child can extract, compare andstore in relation to existing knowledge are equallyimportant. Th.3 child first, must have enoughinformation to perceive the situation as having anunfamiliar aspect, and therefore presenting a problemto be solved. Failure to recognize a problem resultsin the use of the existing response repertoire.Consequently, the behavior appears maladaptive when theexisting repertoire does not meet the requirements ofthe situation. In the above hypothetical example, thechild would repeatedly apply the familiar 'pull up'action used for a pop-on can lid if she/he fails tonotice that the screw-on lid is different.

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Having recognized an existing problem, the childmust then explore the situation to solve the problem-imposing first one action and then another on thesituation in accord with hypotheses or plans arisingfrom stored exper',ences. In the above example, let'sassume that the child perceives that there is a problemgetting the screw-on lid off the cup. The pob3em isdetected either (1) by making pre-inferences about thelid from just looking at it and noticing its unfamiliarappearance relative to pop-on lids handled in the pastor (2) by quickly observing that the lid does not comeoff when the familiar pulling action is applied. Amongthe alternative actions that can be taken, the childmay now adjust his movements so that he/she pullsharder on the lid if past experience has shown thatthis action can change an object's state. Perceptualactivity is again important to the exploratoryactivity.

Sensory feedback provides a check on responseexecution and informs about goal achievement. in orderto judge the effect of the "pulling harder" action(i.e. whether it achieves the goal of getting the lidoff the cup), the child relies on tactile-kinestheticand visual feedback. For example, lifting the lid offthe cup will be experienced as a change in resistanceto movement. Such tactile-kinesthetic information maybe complemented by visually observing the lid'L.;separation from the cup. When the child perceives thatthe goal is not achieved with a given action, one canpredict continued attention to the task if storedexperiences are rich e ugh to offer new actionpossibilities or hypotheses to be tried. A normal babywith little experience may quickly move on to anotherobject after trying one or two unsuccessful actionstrategies. Something new is learned though .,hen aproblem is solved (i.e. goal reached' by applying andadapting a new combination of actIonb. This newlearning experience now expands the mental schema forperceiving and responding in subsequent situations.

To summarize, learning results from the child'sinteractions with the environment. The perceptual-cognitive schemes that guide one's response to theenvironment are not innate, but acquired as aconsequence of the child's continual exploration of theenvironment in response to countless daily life problemsituations. The normal baby, observes the St. Gallenteam, is continually active--trying to stick a fingerthrough a hole, nulling off an earring, putting it onagain, pulling pots and pans from the cabinet, etc. Achild who deliberately gets through rather than around

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a water puddle shows how new experiences or problemsare sought out. In fact, it is taken as axiomatic thatell huttan beings want to be active. When there are noproblems to solve, even the adult reports boredom.Perceptual activity is required to detect and solveproblems.

From all sensory input associated with successfulproblem-solving activity comes knowledge atlut theworld--the functional properties of objects and theirrelationships, how to plan events, change andreconstruct them, and finally, what aspects of eventsare encoded through language. Hence, problem-solvingexploratory activity is viewed as the developmentalroot for verbal and nonverbal behavior.

Implications for Language Impairment andTreatment. The St. Gallen learning model implies thatunderstanding the basis for learning disorders mustevolve from assumptions about how the child interactswith or explores the environment. The St. Gallen teamargues that developmental problems for many childrencan be traced to their inability to explore theenvironment adequately for learning because ofperceptual handicaps. If the amount or type of sensoryinput and/or its organization are inadequate, then thechild will not be able to detect problems to be solved.Consequently, maladaptive stereotypic behavior will beobserved because the child applies the same responserepertoire to situations that are perceived as familiarbut which, in reality, have unfamiliar aspects thathe/she does not detect. No new learning occurs if thesame response repertoire is applied all the time todifferent situations. Reduced learning experiencerestricts the range of existing knowledge and the typesof hypotheses that can be generated to solve problemseven when detected.

Learning also will not occur even for thosechildren who get enough information to detect problems,but fa:1.1 to explore the situation adequately to solvethe pv.ablem. The lack of adequate 'nformation canprevent the child from detecting if a problem is solvedor goal reached by a particular response. For example,a child, who applies a turning strategy to getting offa screw-on cup lid, w:11 not be able to judge Cueeffect of the action if he/she cannot feel changingresistance as a result of the turning movement. If thelid does not come off right away, the child is likelyto conclude that the turning st, t-egy does not solvethe problem or achieve the goal. Such a child may moveon to strategy after strategy without success--givingthe appearance of hyperactivity and/or frustration

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intolerance. Naturally, no new learning occurs in theabsence of success.

Therapy for such children must provide situationsthat offer problem-solvin/ exploratory activity inconnection with language. Moreover, deliberate stepsmust be taken to increase the aaequacy of sensory inputso that problems can be detected and successexperienced in solving them.

The Complexity of the Situation as a Factor in Learning

The requirements of adequate problem-solvingexploratory activity vary with the complexity ofstimuli in the actual situation as determined, forinstance, by their number, order and modality ofpresentation. Situation complexity introduces thenotions of attention and ch,lanel capacity as importantaspects of learning given limitations on the amount ofinformation that can be processed at one tine (Miller,1956). Intuitively, one can assume that the morecomplex the stimuli are in terms of informationprocessing load, the longer will be the developmentalperiod required to extract the relevant information.

The St. Gallen team argues that language, likemany nonverbal skills, offers very complex stimuli forlearning because of its multisensory and sequentialnature. 'o illustrate, it is known that languagetypically is presented to children in the presence ofsome event that is being experienc,'. An utterancesuch as "the dog is jumping off tip chair" offersauditory information about the phonologic and morpho-syntactc forms of the language. Visual informationalso is offered about linguistic form and about thecontent of the corresponding event which involves achanging relationship between the dog and chair. Inaddition, tactile-kinesthetic information is offered ifthe child, at the same time, is poking the dog to getit off the chair. In such a situation, several sensorychannels are stimulated simultaneously. The highlysequential nature of language is reflected by theconcatenation of basic units (i.e. phonemes, graphemesor manual movements) into larger syntactic units, notto mention linkages across utterances from the same ordifferent speakers during discourse. Similarly, anonverbal act such as making a sandwich, which some mayregard as a simple activity, involves several sensorymodalities and connected action sequences.

In order to detect and explore such complex verbaland nonverbal stimuli, the child must bring to thelearning task, a capacity to extract, store and

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perceive information from more than one sensorymodality and to sequence such multisensory stimuli intime and space. Just how such a large amount ofinformation is organized by the nervous system becomesan important theoretical issue.

The St. Gallen team capitalizes on the early workof information processing theorists (e.g. Broadbent,1958) and psychophysicists (e.g. Hirsh & Sherrick,1961) who argue for a two stage model of sensory-perceptual organization. The first stage registersmodality specific information about stimulus properties(e.g. color in vision, tonicity in audition andpressure in touch). But, the acquisition of manyaspects of verbal and nonverbal skills, including theirsequential properties, depend especially on the secondstage, which organizes sensory data across modalities.A supramodal organization requires a nervous systemthat first can connect information from differentmodalities and then extract the properties that arecommon to them. Hence, the two hierarchicallydependent stages of perceptual oragnization include (1)an elementary modality specific stage and (2) a morecomplex supramodal stage with intermodal and serial-sequential sub-levels.

Cross-modal perceptual organization means that onelearns about sequential properties of language not onlyfrom audition, which is exclusively temporal, but alsofrom vision and taction-kinesthesis, which aretemporally and spatially based. This reasoning led tc,the hypotheses that (1) verbal and nonverbal deficitsare associated with sequential deficits that reflectreduced multimodal perceptual organization, and (2)reduced multimodal organization can occur whenperipheral sensory input from one or more modalities isabsent or reduced or when at a central level, one hasdifficulty connecting sensory data across modalities orextracting the sequential features of such connectedinput.

To test these hypotheses, the St. Gallen team(Affolter & Stricker, 1980) compared the performancesof various clinical groups on a sequential patterndiscrimination task. The task offered analogousstimuli in the auditory, visual and vibrotactilemodalities, and incorporated four levels of stimuluscomplexity. The simplest stimulus set requiredsubjects to judge if two successive stimuli were thesame or not. Stimulus contrasts varied along twolevels of intensity and quality. The remaining threestimulus sets required comparisons of patterns havingtwo, three and four stimulus elements. The tasks were

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normed on nonlanguage impaired children at 5-14 years.They were given to congenitally deaf children and blindchildren and to severely learning disordered childrenwith verbal and nonverbal dysfunction. The lattergroup included three subgroups whose clinical profileswere derived from longitudinal observation. Onesubgroup had been judged to have tactile-kinestheticsensory deficits while the second and third groups werejudged to have intermodal and sequential difficulties,respectively. (Refer to pp. 23 and 24 of this reportfor brief clinical descriptions of these subgroups.)In addition to these three subgroups, the sequentialtasks were given to dyslexic children and to right andleft brain damaged adults. All groups exhibited severedevelopmental or acquired lancaage deficits.

Two striking observations were made. First, allclinical groups exhibited difficulty in processingsequential stimuli relative to normal controls.Performances became more depressed with increased taskcomplexity. On tasks requiring the comparison ofpatterns with three and four stimuli, performancesplummeted for the deaf and the blind even in thenondeprived modalities. This meant, for example, thatdeaf children's sensory deprivation reduced the amountof sequential organization that could be achieved andexpressed in vision and vibrotaction.

The second observation was that sequentialperformances for all clinical groups were depressed inevery modality and not just in the auditory modality.Score depression was present in every modalityirrespective of age.

The pattern of sequential deficits observedsupported the expectation that language impairment isassociated with reduced multimodal perceptualorganization created by dysfunction at a variety oflevels.

Implications for Language Impairment andTreatment. The more complex the verbal or nonverballearning situation is particularly with respect to itssequential and multisensory features, the more likelywill perceptually handicapped children experiencedifficulty. Perceptual difficulty with sequentialinformation is not restricted to a particular subgroupof the language impaired with auditory processingproblems. Sequential processing problems are common tomany different clinical groups that show deficits inboth verbal and nonverbal function. Treatment for theperceptually handicapped must take steps to reduce thecomplexity of learning situation in certain ways while

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at the same time preserving the opportunity formultisensory input and organization to occur.

The Primary Role of Tactile-Kinesthetic Sensory Inputin Achieving Adequate Perceptual/Cognitive Organization

A third major finding from St. Gallen'saforementioned sequential pattern research suggestedthat all sensory modalities do not contribute equallyto the multisensory organization underlying complexperformances. Although all clinical groups scoredlower than normal children on sequential patterns, thedeaf and the blind scored higher than children whoappeared to exhibit tactile-kinesthetic deprivation.In fact, children in the tactile-kinesthetic groupscored just as poorly or poorer than those withpresumably more central difficulties in connecting andsequencing information from more than one modality.The difficulty of all three latter subgroups wasexpressed on the simplest vibrotactile task thatrequired the comparison of just two stimulus events.On the same 'simple task, the deaf and the blindperformed successfully--their scores surpassing thoseof some normal children possibly due to a compensationeffect. Of course, their vibrotactile scores also wereconsiderably lower than normal children's on complexsequential tasks.

These differences between the deaf or blind andother clinical groups were made especially cbvious inthe comparative study of their tactile form recognitionperformances (Affolter & Stricker, 1980). Moreover,the clinical observation of group differences inoverall Functioning were consistent with the well-knownclaims that deafness or blindness per se does notpreclude adaptive learning. The deaf with noassociated impairments, for example, develop manyadequate nonverbal skills and easily acquire nonauralverbal forms as well. On the other hand, children withtactile-kinesthetic difficulties, and those with morecentral perceptual difficulty can see and hear, butfail to develop adequately on a nonverbal and a verballevel. The verbal deficit is basic in that meaning isimpaired, in addition to linguistic form.

It was reasoned that tactile-kinestheticdeprivation and its lack of central integration withother sensory systems has a more adverse impact on thelearning of complex skills than do visual or auditorydeprivation. Affolter and Stricker (1980) acknowledgedthat little is known about this relatively unexploredsensory channel, but it seems to offer differentinformation about the environment than do audition and

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vision (Gibson, 1966).

St. Gallen's theoretical assumptions about thecritical role of tactile-kinesthetic input in learningare shaped further by arguments for a strong linkaction (in the sense of movement) and cognitivedevelopment. Casual observations reveal how difficultit is for a normal child to sit quietly in places whereadults look and listen or to keep from touching objectsthat are off limits in a new situation. Although thechild also can look and listen in such situations,neither seems to be an adequate substitute for beingactive by moving, i.e. touching, handling or eventalking or singing out loud. When one considers thephysical properties of movement, tactile-kinestheticsensory input becomes important to learning.

Within the Piagetian framework (Piaget, 1960),goal directed movement is a dominant feature of theexploratory sensorimo'cor activity leading to complexintelligent behavior. During the sensorimotor stage,the child's movements with its accompanying tactile-kinesthetic feedback are important to constructingreality. The child discovers early on that sometLingelse exists besides his own body by encounteringchanges in resistance to body movement as a result ofcontact with different objects. For example, poking ahole in thin tissue paper offers different resistanceto movement than poking a hole through cardboard.Tactile-kinesthetic sensory feedback about changes inresistances connect with input from other modalities.Associated visual feedback is obtained by inspecting ifa hole is created or tot. Connections between movementand its effect on object states leads to knowledgeabout cause-effect relationships (e.g. the child hits aball, and it rolls; the child pushes a pencil throughthe paper, and a hole results; the child drops abottle, and the mother picks it up; or the child makesa vocal sound, and the mother responds with a vocalsound or another visible reaction). These cause/effectrelationships between actions and changing states ofobjects become the basis for perceptual inferences-i.e. the ability to predict or anticipate changes instates of objects before an action occurs or to make ajudgment about a probable prior action based on thevisua' state of the object. Such pre-inferencesinitiate plans for action in a situation.

More current versions of action theory fill insome of the gaps of Piaget's theory by showing how thephysical or 'cinematic' features of movement and itssensory systems provide evidence for perceptualcognitive inferences. For example, Mounoud and Hauert

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(1982) used arm swing amplitude during grasping tomeasure adaptive movement changes in response tohandling objects of different weights. By 12 months,babies could already regulate lift/grasp patterns inrelation to anticipated weight changes based on thevisual appearance of object size. Such perceptualinferences reflect the child's ability to store motorplans that incorporate cross-modal connections betweentactile-kinesthetic and other sensory inputs.

From handling objects (opening, closing, reachingand mouthing them), the child discovers a lot about thefunctional properties of objects. These functionalrelations become c.i'rdinated into longer and longersequences of cause-effect action events that areconnected to a goal. For example, dressing one's selfis a very complex event involving differentcombinations of object relations and movement routines.Just putting on a shoe involves several movementsequences--reaching for shoe, making contact betweenfoot and shoe, mcving into shoe, and lacing or bucklingit, etc. The St. Gallen team holds that suchorganization of movement has multisensoryrepresentation with tactile-kinesthetic input as itsbase. It is the tactile-kinesthetic system whichoffers the dynamic transfo_4ng aspect ofperceptual/cognitive organization. According toAffolter and Stricker (1980, p. 115), one cannot changeor create real events by merely looking or listening.But rarely can one touch the environment withoutchanging it.

Implications for Language Impairment andTreatment. Given what is known about the functioningof the blind and the deaf, one must look beyondaudition and vision to account for severe learningdisability among other clinical groups. The St. Gallenteam argues that the perceptual handicaps thatinterfere with verbal and nonverbal learning are rootedin tactile-kinesthetic deprivation and/or thedisconnection of tactile-kinesthetic input from othersensory inputs. For treatment then, tactile-kinesthetic input associated with problem-solvingaction sequences becomes obligatory if the child isexpected to experience direct interaction with theenvironment.

Verbal and Nonverbal Skills Evolve from the Same Root

According to the St. Gallen team, problem-solvingexploratory activity involving multisensory, sequentialevents, is the developmental root of both verbal andnonverbal skills. Multisensory schema, rich in

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tactile-kinesthetic representation, become the basisfor recognizing and planning nonverbal behavior. Suchschema also motivate the meaningful learning oflinguistic forms. The predominance of action contentin children's early utterances is well documented.

A common root hypothesis leads to the expectationthat verbal and nonverbal skills emerge simultaneouslyand not in hierarchical dependency. It is true thatchildren, typically do not say their first words untila year after they have begun cognicively to organizenonverbal behavior. However, there is now considerableevidence that during the first year when the baby isorganizing nonverbal behavior, it also is learningattributes of speech sounds and aspects ofcommunicative interaction that are continuous with thelater onset of linguistic skill. See for example, theresearch on babbling drift (e.g. 011er, 1978) anduother-child interactions (e.g. Snow, 1977). Morespecific evidence for a nonlinear developmentaldependence of verbal and nonverbal skills was providedby St. Gallen's longitudinal study of preverbalchildren (Affolter & Stricker, 1980, pp. 82-104). Theyobserve that some children began to produce languagebefore they could imitate directly. Others couldproduce language before they could produce a sequenceof actions leading to a goal (event production). In

fact, event recognition was the only nonverbal skillthat was concurrent with or prior to languagecomprehension. These findings are consistent withthose that support a homologous developmentalrelationship between language and nonlinguisticcognitive skills (e.g. Bates, 1979).

The St. Gallen team argues that the lateremergence of some skills (e.g., spontaneous speechproduction) relative to others (e.g. means-end eventproduction) does not occur because the earlier skillcontains the prerequisite requirements for the laterone. Rather, the developmental order reflectsdifferent complexity levels in underlying perceptual-cognitive organization. The more complex a task is interms of its information processing load, the moreproblem-solving exploratory experience needed toextract all the relevant features given limitations onhuman attention and the amount of information that canbe handled by the nervous system at any one time. Theresult is a longer developmental period, the sorecomplex the skill. For the child who has difficultyprocessing sequential information, direct verbalimitation may be a mere difficult task than spontaneousspeech because it requires attention to the exactdetails of the model input. Consequently, the later

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development relative to spontaneous speech reflects thechild's need to achieve a higher le "el of underlyingperceptual-cognitive organization in order to reduceinformation load during an imitative task. The moreknowledge the child brings to the task, the more likelycan some details be ignored, or regrouped with others.For example, precise recall of a digit sequence, 121416is easier if digits are regrouped and stored as three(12 14 16) rather than six bits of information.

The earlier appearance of complex nonverbal actionskill relative to language in early life also can beexplained in terms of information load. Meaningfullanguage is more complex because it incorporatesinformation about both the action events plus thelinguistic code for representing the action. Prior tolanguage, the child's nonlinguistic vocal output can beregarded as less complex in its information 'toadbecause it can be guided by just oral tactile-kinesthetic and/or auditory information that isdisconnected from action events. On the other hand,meaningful vocal output increases information load.Auditory/oral tactile-kinesthetic information now mustbe linked to information arising from action events,which include whole body tactile-kinesthesis, visionand possibly other sensory channels (e.g. smell,taste, etc.). Considering the amount of informationthat competes for the child's attention, it is easy toappreciate why the St. Gallen team stresses thecomplexity of meaningful language. In fact, so such isgoing on during a spoken language event that one shouldnot be surprised that the normal baby extracts justsome of the features at any one time...possiblyfocusing just on the auditory form during onelinguistic event and just on action in another event.Language discovery may occur when there has been enoughexperience in each domain that attention can focus onboth the form and action event at the same time in asituation.

Language discovery means that the child is awarethat a particular auditory form (or in the case of thedeaf, visual (manual) form) is associated with someaspect of an object or action in a situation. Evenafter language emerges, it is known that the normalchild is able to connect just some of the features ofits form with some aspect of an event. At first, justsingle words are connected to an event and not all thefeatures of this word are extracted. For example,early word pronunciations are simplified by omittingsome segments. The literature hints further at thepossibility that in learning language, the young childmay not focus on its form, content and use at the same

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time, e.g. Blake's (1984) dissertation showed that whenchildren expanded their form, :; e. mean length ofutterance (MLU), no new changes occurred in semanticrelations or pragmatic functions. Conversely,expansion in semantic and pragmatic content were notcoincident with shifts in utterance length.

The linguistic features extracted are determinedby attention to stimulus saliency n relation to theprior knowledge that sets boundaries on what one mightattend or expect in a situation. The work ofHuttenlocher, Smiley, and Charney (1983) suggests thatin observing an action event, children may focus firston those actions that they have already donethemselves. The early linguistic coding of actionevents is well documented.

Further development is the consequence ofexploring and extracting more and more information fromactual situations about actions, linguistic form andconnections between the two. According to the St.Gallen model, a relatively long period of languageexperience connected with actual situations precedesthe child's ability to use language in a true symbolicsense in that it can refer to events that are absent.

The process of extracting new features is not apaseive one. The new learning results fromcontradictions between hypotheses or expectanciesimposed on the situation from prior knowledge and thekind of information actually experienced in the newsituation. The problem-solving nature of languagelearning has been discussed by Menn (1976) in phonologyand Miller (1984) for syntax.

Imr,lications for Language Impairment and Treatment

The St. Gallen team holds the position thatperceptual handicaps involving the tactile-kin,astheticsystem result from inadequate problem-solving activityin actual situations that imract on both verbal andnonverbal skills.

If verbal and non ,erbal skills both are productsof problem-solving exploratory activity, then itfollows that such activity must be the focus of therapyand not the acquisition of specific skills. This meansthat one should focus on providing more and more inputexperiences that offer problem-solving opportunity tolearn about the language in relation to eventsexperienced. This does not mean that linguistic formsare referenced against a picture or object which areremoved from direct experience. Rather, the clhild must

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actually be engaged in a reality type problem-solvingexperience and efforts made to represent this actionthrough language. Problem-solving activity in actualsituations should yield improvement in both verbal andnonverbal behavior.

However, one 4ay to reduce stimulus complexity isto explore problem situations first without the verbalinput. By working on a nonverbal action level, thetreatment not only reduces the potential forinformation overload, but it provides the opportunityfor the child to learn something from the situationthat can build the content base onto which languageforms can be subsequently mapped even in the sametherapy session. It is assumed that language forms(words and grammatical patterns) will be acquired andretrieved'most easily when they relate to some aspectof the situation that is familiar to the child'sexperiences.

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II- IMPLEMENTATION OF TREATMENT FRAMEWORK

IMPLEMENTATION AT THE CENTER FORPERCEPTUAL DISTURBANCES

The Center for Perceptual Disturbences is aprivately financed non-profit clinic located atFlorastrasse 14, in St. Gallen, Switzerland, a cantonalcapitol city. The approximately 4500 square footfacility provides an audiometric testing suite, typicaloffice and work space plus two kitchens fully equippedfor storing, cooking and eating food. I was struck bythe simplicity of the work environment, particularlythe absence of special toys and materials thatfrequently adorn cabinets and tables in U.S. clinicalenvironments. The large number of videotapes and filmsmaintained on patients, in addition to the usualclinical records, equally focused my attention.

The significant rehabilitative role played by theCenter is underscored by the fact that it thrives in arelatively small city of about 100,000 persons thatglso supports two other major clinical facilitiesserving children with developmental disability: theKantonsspital St. Gallen (Cantonal Hospital) and theChildren's Hospital. However, patients of all ages arereferred to the Center from all over Switzerland andbordering European countries. They come with varyingdiagnoses including deafness, dyslexia, autism,aphasia, schizophrenia, mental retardation andemotional disturbance. The Center enjoys a reputationof helping children who do not respond to establishedtreatment approaches. Children are most often referredin the age range of 4-10 years though a patient asyoung as 15 months has been seen.

The staff of about seven clinicians devotes timenot only to diagnosis and treatment of developmentaldisability, but also to clinical research and theteaching Jf courses on the therapy method to parentsand professionals who serve learning disabled children.

The Nature of Perceptual Impairment

The St. Gallen model views a perceptuallyhandicapped child as one who does not explore theenvironment adequately for learning because of eitherreduced peripheral sensory input or abnormal centralorganization of such input. Strictly speaking, thisgroup includes the deaf and the blind whose peripheral

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sensory deprivation leads to perceptual deficits forspecific tasks. But, since their sensory deprivationeffects do not prevent general adaptive learning, theyare not regarded as learning disabled and for thisreason, are treated less often than other groups at theCenter. Among learning disabled children I observedthree clinical subgroups.

One subgroup appears to present perceptualdeficits due to reduced tactile and/or kinestheticacuity. Children in this group show immature objectgrasp, release and manipulative patterns. They graspwith one hand and/or use just two fingers as opposed tothe whole hand. Objects may be touched but notactively handled. Walking and climbing movements areawkward, and maximum tactile-kinesthetic support isrequired'to execute movement or to alter body positionduring movement. Otherwise, the child may show panic.Some children refuse to touch objects--appearingtactile defensive and inactive. They create theimpression of being mentally retarded or lacking inmotivation. However, such children appear tounderstand more than they can do whenever the task canbe performed on the basis of visual information. Forexample, such a child may quickly learn to visuallymatch and sort pictures or objects or to associate anauditory form with a pictu,-1. Yet, the same child canshow tremendous difficulty pouring water from a pitcherinto different size glasses because the movements haveto be referenced from the tactile-kinesthetic system.Although the child may observe visually that the actionresulted in water on the table instead of the glasses,he/she is not able to solve this problem given failureto perceive kinesthetic sensory feedback aboutmovement. The same child will have difficultyarticulating speech sounds or adapting his/her walkingmoy...ments to an unfamiliar situation. These childrenwill also fail complex cross-modal and sequential tasksinvolving just vi..ion or audition given that ta,:tilt,-kinesthetic deprivation reduces the multisens)ryorganization on which they depend. The tactile-kinesthetic subgroup is the largest and most frequentlyseen group.

Still other children are skilled in theirmovements, but present stereotypic, unconnected anddisorganized movement sequences. They lack eye contactand appear socially detached. They do not always lookat what they are doing, and some give the impression ofbeing hyperactive. Such children's difficultiesincrease whenever the task requires connections betweentactile-kinesthetic information and other sensory data.These children, labeled as the intermodal subgroup to

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reflect their difficulty in making cross-modalconnections, are often referred to the St. Gallen teamwith the label of autism. Bryson (1972) is among thosein the U.S. who have called attention to the cross-modal difficulty of autistic children. Intermodalchildren may quickly learn tasks that can be done byusing sensory feedback within a single modality.Visual matching may be done successfully. An inlaidwooden puzzle also can be done if the child can detectwhen the puzzle form fits in the designated space byfeeling a change in resistance, and does not have tolook. However, since most human behavior depends oncross-modal connections, one can appreciate whyintermodal children can exhibit such low levels offunctioning. For example, the lack of cross-modalconnections prevents the child from discovering thatsomething heard is something that can be seen.Consequently, the child does not turn its head in thedirection of a sound source. Yet, normal babies showanditory localization behavior as early as threemonths. Intermodal difficulty can account for some ofthe bizarre behaviors described in the autismliterature. The lack of mother recognition and socialinteraction can be explained by the failure to linktactile-kinesthetic information obtained during feedingand body contact with the visual features of mother.Compulsive maintenance of the same objects in a givenarrangement could result from an effort to create orderfrom strong dependency on crystalized visual schema.Only by connecting visual information with tactile-kinesthetic information arising from object handlingcan the child discover that objects do not have astatic visual configuration. Naturally, these childrenexhibit sequential difficulties inasmuch as sequentialskills are assumed to rely on an integratedmultisensory store of experience.

Children in a third clinical subgroup, labeled asserially impaired, appear similar to those labeled asdevelopmentally asphasic in the U.S. It is notsurprising that this group is least often seen by theSt. Gallen Team. This group has no sensory deprivationand experiences adequately connected sensory input, butfails tasks once they involve a certain level ofsequential complexity. Consequently, it appears thatmany develop enough skill to function in conventionalspecial programs. However, these children are said tobe easily frustrated probably because they can oftentake the first steps towa.d solving a problem but failbecause of difficulty connecting sequences. of actionsor linguistic form. Difficulty is seen in allmodalities, especially the vibrotactile one. Like theaforementioned groups, visual tasks are the easiest

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possibly because vision offers greater simultaneity ofsensory data compared to audition andtaction/kinesthesis.

In summary, children in all three clinicalsubgroups present normal physical appearance. They allshow general difficulty with comprehension andproduction of verbal tasks and with planning orexecuting actions on nonverbal tasks. However, allshow uneven skill development in both areas, withvisual tasks yielding the best performance. Somechildren presented symptoms characteristic of more thanone subgroup.

Assessment of Perceptual Impairments

The assessment of perceptual handicap at theCenter, naturally relies on checklists to guideiLformal observations since many children are unable torespond to structured tasks at the onset of therapy.In addition, the staff relies on responses to threeperceptual/cognitive tasks that they developed andnormed, These structured tasks permit responses to beobserved under different sensory modality and stimuluscomplexity conditions. The classic Piagetian seriationand haptic recognition te.sk are offered in the visual,tactile and visual-tactile conditions at three levelsof stimulus complexity. Analogous successive patterndiscrimination tasks are offered in the auditory,visual and viorotactile conditions at four levels ofstimulus complexity. Although case history report andmedical records are obtained, the team relies heavilyon its own observations of what the child is doing inan actual situation. Videotapes are frequently made ofthe child's behavior for purposes of reliable anddetailed analyses. From observation, I inferred thatthe diagnostic process is designed to answer threequestions:

1. What is the status of the child's verbal andnonverbal skills? The goal is to determine presence orabsence of age appropriate skills. That is, does thechild comprehend and produce spoken or manual languageforms? Does the child recognize or draw pictures,exhibit symbolic play? On the social level, does thechild initiate interaction with other people, recognizeparents, show affection, smile socially, maintain eyecontact or show fear of strangers? On a cognitivelevel, does the child recognize self in a mirror,identify common objects, adapt movements to unfamiliarsituations, recognize and/or produce functional objectrelationships or daily life events requiring planningand execution of action goals? It should be pointed

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out that the team not only determines presence orabsence of various skills, but the specific conditionsunder which they are present or absent. Informationabout behavioral conditions is used to determine if' andhow behavior is influenced by the type of sensoryinformation offered in a particular situation; e.g.does performance break down whenever the child has toplan a sequence of actions leading to a goal as opposedto executing a well practiced routine, or doesperformance break down (e.g. panic reaction) wheneverthe child has to perform an action without maximumsupport or use tactile-kinesthetic feedback to monitormovements as opposed to other forms of sensoryfeedback?

2. What kind of sensory information is the childgetting? Auditory and visual peripheral functions areassessed using familiar formal and informal techniques.Much time is devoted to evaluating movement in order toinfer tactile-kinesthetic input. In spontaneousinformal situations, o1servations are made about howthe child touches, grasps and handles objects, walks,negotiates stairs, etc. On a more formal structuredlevel, I observed th_t the tactile conditions of thehaptic and seriation tasks are used to obtainsystematic data on how the child moves when solving aproblem using just tactile- kinesthetic information.The haptic task requires the child to match forms ofvarying shapes and complexity whereas the seriationtask requires the child to order wooden bars by size.Since these tasks have been normed, performances can bequantified against some standard.

3. How does the child respond to changes ininformation? Logging the situations under which ageappropriate skills are present or absent issupplemented by observing if the child focusesattention during'guided movement. The St. Gallen tammaintains that a child who knows how to solve a nroblemwill resist guiding and that even a normal child willpermit guiding if he/she does not know how to act onthe environment in a particular problem-solvingsituation. During my visit to Bad Ragaz, I observedthat even the brain injured adult did not resistguiding. One can also observe how the child performswith added sequential complexity or added visualinformation, and so forth. The information in thelatter category is important to revealing ifperformance success is uneven relative to the kind ofinformation that must be perceived in an actualsituation.

The answers to the above three questions over time

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allow the therapists to determ_ne if perceptualimpairment is probable, and the type of perceptualdeficit exhibited. However, I observed no magicconstellation of skills or a test score that leads tothe interpretatior that a child is perceptuallyimpaired. Many groups of childrenlincluding thementally retardedIfail to obtain the same score as thenormative group on perceptual tasks. It seemed to methat the presence of perceptual impairment is judgedprimarily by the child's uneven performances indifferent situations. The child is likely to beperceptually impaired if successful performance issituation dependent, i.e. can be explained by theamount and type of information load. A mentallyretarded child would not be expected to perform in suchan uneven manner.

A more promising approach to diagnosis is likelyto evolve from the St. Gallen team's current researchon the different clinical profiles shown on seriationand form recognition problem-solving tasks (Affolter,forthcoming). The problem-solving model developed byRuth Fitt and Mattie Janse-Brouwer at the University ofMinnesota is being used to analyze detailed behavioralobservations. For example, on the seriation task, suchobservations include the following: the child measureswith twc pieces, touches or looks at the display,measures top line resistance, etc. Using thePitt/Janse-Brouwer Model, Dr. Affolter has been able tocategorize behaviors according to the evidence theyoffered for various aspects of the problem-solvingprocess such as making an hypothesis about how to solvethe problem, evaluating feedback, etc. Preliminaryresults-from the seriation analysis point to differentclinical profiles for the mentally retarded andlearning disordered children who fail the task. Forexample, the mentally retarded fail to generatehypotheses for solving the problem, i.e. one or twostrategies are tried before concluding the task.Learning disabled children, on the other hand, generatemany hypotheses but fail to solve the problem becausethey presumably do not get enough information to judgethe adequacy of the strategy. Other features areemerging to distinguish the tactile-kinesthetic andintermodal clinical subgroups as well.

But, differential diagnosis is not important forthe therapy process since all perceptually disturbedgroups get the same therapy. However, differentialdiagnostic information is useful for predicting andexplaining the child's response to learning situations.To illustrate, intermodal patients (those havingdifficulty connecting sensory information across

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modalities) may differ from tactile-kinestheticpatients (those having difficulty extracting sensoryinformation from movement) in the kind of feedback cuesthat can be used. Consider the task of matching puzzlepieces to their corresponding inlaid patterns on a two-dimensional puzzle board. The intermodal child mayhave difficulty knowing when the puzzle piece is a fitbecause vision also must be used to check on themovement. On the other hand, the tactile-kinestheticgroup can use the visual information to solve theproblem because there is no intermodal problem. Addingdepth to the puzzle board increases the possibility forthe inter-modal child to just use tactile-kinestheticfeedback to monitor correctness of puzzle placement,i.e. the puzzle piece is inlaid correctly when it fitssnugly against the inside of the board, and visualinformation, therefore, is not needed to verify goalattainment. The tactile-kinesthetic child, however,may not be able to use this new tactile-kinestheticinformation, and consequently will continue to solveproblems on the basis of feedback about what the puzzlelooks like. To the extent that visual information,alone, is insufficient, task failure will also beobserved for the tactile-kinesthetic subgroup.

Orienting the Family to the Treatment Strategies

Once the child is diagnosed as perceptuallyimpaired and a candidate for guided movement therapy,the child's caretakers are trained to do the therapy.Conducting the therapy in the home is required sinceit provides the !,realest opportunity for experiencingrelevant daily life events. If therapists are hired bythe family to work with the child in the home, theyalso are included in the training. Training has twogoals.

The first goal is to develop skill at guidedmovement. This is accomplished by having familymembers experience guided movement by guiding eachother and then the patient under supervision.Videotapes are made of guiding for feedback anddiscussion.

A second goal is to increase the family'ssensitivity to the nature of the patient's problem. I

found the use of self experience exercises to be arather interesting approach to sensitizing thecaretaker to the frustrations of the child. During myvisit, for example, each member of one familyparticipated In a writing exercise during which visualfeedback was deliberately distorted to inducefrustration. Afterwards, discussion of the family's

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frustrations on the task was used as a basis fororienting it to the child's problems.

The family orientation can last a week or more forfamilies who travel from other countries. The child isthen returned to the center at periodic intervals formonitoring and evaluation. Some patients may be seenat the center once or twice per week whereas others maybe seen every six months depending on the family'slocation and needs. The Center's staff clinicians alsomake field visits to patients' homes to monitorprogress when needed.

Treatment Goal

Therapy strategies are consistent with the viewthat language and nonlaaguage delay are due toperceptual-cognitive deficits. The goal of the therapyis to offer problem-solving exploratory experiencesthat can make perceptual-cognitive activity moreadequate for interacting with the environment. Giventhe theoretical framework described above, two aspectsof the treatment focus stand out as different from mostU.S approaches.

First, the therapy is geared mainly towardcomprehension rather than production performances.Consequently, the child is not required to emitparticular responses, especially at the early stages.This treatment practice follows from the theoreticalassumption that all patterned, adaptive behavioraloutput is guided by some kind of prior establishedmental schema or principle. For example, the act ofgetting a drink of water will be guided by alreadyinternalized rules for moving in the environment toaccomplish the goal. A meaningful verbal response tothe same event (e.g. I want a drink) will reflectstored grammatical rules and articulo-motor nrogramsconnected with stored tactile-kinesthetic experiencesof drinking. If observable behavior is the product ofalready formed schemes, it follows that the way tochange the output is not by working on the output, butby altering input experiences that can change theexisting schema for acting.

A second feeture that stands in contrast to U.-.approaches, is the lack of focus on specific skills.That is, the treatment is not structured to teachcc.lors, picture recognition or grammaticalconstructions if such skills are lacking. Neither doesthe treatment attempt to teach nonverbal skills such asobject permanency or means-e,:d relations. lather,treatment focuses on facilitating perceptual-cognitive

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representation through problem-solving experience thatis assumed to be at the root of a wide variety ofcomplex skills. Hence, the treatment is processoriented.

Treatment Strategies: The Technique of Guided Movement

The goal of stimulating perceptual-cognitivelearning is achieved through guided movement. Thismeans that the therapist takes the child's hands orbody and guides their movements during activities. Theassumption is that the same sensory feedback isexperienced whether the child moves on his own or ismoved by someone else.

The clinician's hands are positioned on those ofthe child such that input to the whole hand includingthe fingertips can be experienced. TypicellyIthetherapist guides from a standing or sitting positionbehind the child. The body movements of the child andthe clinician are synchronized and naturally paced (nottoo slow or to fast) with smooth positionaltransitions. The therapist moves with the child in thesame way that he/she might move naturally in theactivity. This means that the therapist does notprestructure the precise movements to be made whensolving a problem, although the materials ought to befamiliar to the therapist. In fact, the therapistshould expect and welcome problems that may arisenaturally in trying to solve a problem. For example,if the instrument used to cut the apple or an applepiece falls to the floor, the therapist guides thechild's movements to pick up the object. Such detoursare part of natural events and create a new problemwith its own cause-effect sequence of actionsubroutines embedded in the larger problem context ofcutting the apple. Similarly, if the object needed tocomplete the task is not on the table, the child ivguided to the cupboard to get it. Consequently, thewhole body, and not just the hands, are involved inpurposeful guided movement.

The movements involve both hands. Routinized orstereorpic patterns are minimized by varying themovemen#1 on different objects or on the same object.For example, when cutting apples, one does notstructure the movement to cut every apple in the sameway. A large apple may be managed most easily bycutting it in half before preparing smaller pieceswhile small pieces may be cut from the whole of anotherapple. The variation in movement encourages adaptivelearning.

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The therapist does not verbally announce whatmovements are going to be made. In fact, the therapistdoes not talk during the problem-sOving activity so asnot to overload the child with too much information.During my own attempts at guiding someone, I noticedhow difficult it is for the therapist to talk and focuson the guiding at the same time.

Guided movement is structured so that the childexperiences maximum tactile-kinesthetic feedback aboutmovement. This is achieved by executing the guidedmovement such that the child experiences maximumchanges in resistance created by the opposition betweenmovement and no movement. Recall that this sensoryfeedback is important to evaluating when av action goalis reached, and consequently, establishing a causalrelationihip between one's movements and their effectson the environment. When slicing an apple, to use St.Gallen team's frequent example, the knife's verticalmovement through the fruit continues until it reachesthe stable support of the table at which point,movement is met with maximum resistance. Since themovement cannot continue, the child can use the inputof information to judge the completion of an act or theattainment of a goal. On the other hand, it is moredifficult to judge the completion of a movement whenslicing the apple by moving the knife horizontally suchthat the movement never makes contact with the table.Much less resistance is offered to movement in thelatter than in the former situation. At the extremeend of the continuum, spreading butter or jam on breadoffers hardly any resistance to movement that can beused to judge the completion of an act. In amazement,I observed even adult brain damaged patients continuetheir spreading movements indefinitely after the breadhad been covered visually. The movement was stoppedonly when the therapist intervened. Such patients withseverely reduced tactile-kinesthetic representationcould not even use the available visual information tomonitor act completion or goal attainment. Just thissmall clinical observation adds support to the St.Gallen team's claim that visual perception is supportedby the prior perceptual organization of tactile-kinesthetic input.

To provide maximum change in resistance, thepatient must have stable body support from beneath andalong the side since any change of stimulus informationis perceived relative to some reference point. Astable support anchors the body in order that tactile-kinesthetic feedback associated with a particularmovement can stand out. Tactile-kinesthetic feedbackin the form of felt resistance is experienced ap a

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change in the relationship between the support andone's body and/or object. For example, if the bodymoves around continually, then aay new movementsuperimposed on this general movement is difficult, todetect--under ordinary conditions--i.e. unless itpresents extraordinary contrast with the ongoingmovement. Simply put, the movements of one's arm isaccentuated when the body is in a resting position. Itis also difficult to detect the arm movement if onecannot feel where the body is in space.

Consequently, guiding is not done with hands orfeet up in the air. All movement is guided along astable support so that the patient knows where the bodyis at all times. Maximum changes in resistance alsoare facilitated by choosing stimulus material thatoffers instant rather than gradual opposition tomovement (cf. apple and peach), and those that maintainfrom consistency (cf. sand vs. paper).

A child who tries to take over the movement andperform the task without help, is allowed to do so, butnot at the expense of reinforcing maladaptive responsehabits. During my visit, I observed one child who hada rich repertoire of habit responses based on visualpatterns. During a dish washing task, the childresisted guided movement. However, his habitualmovements were nonadaptive in that each dish,regardless of size or debris, was put into the tub,stroked once with a dish cloth and taken out. Itappeared that th,-... child had visually extracted theproper sequence of activity without connected tactile-kinesthetic representation. Consequently, once thechild's hand was in the water, the therapist imposedguided movement in order to create a more adaptiveresponse to the task.

Strategies also are used to connect tactile-kinesthetic effects of action with feedback from othersensory systems (e.g. visuai, gustatory). I observedthat a child often was guided to taste food after amovement goal had been reached (e.g. after cutting anapple piece) or the child was encouraged to touchand/or look at the changed state of the apple followingeach slicing attempt. Establishing such intersensoryfeedback connections allows the child on subsequentoccasions to view a cut apple and make inferences abouthow the apple got in its state or to see an apple andjudge what kind of actions could be imposed on itwithout first having to act on the apple. It should heclear that this is the kind of knowledge that supportsthe search for linguistic forms, for asking questions,and commenting on the states of objects, and their

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cause-effect relations, both probable and real.

The Role of Daily Life Problem-Solving Activity

The guided movement always occurs in the contextof reality based problem-solving events. A problem-solving event involves a sequence of actions leading tosome goal in a situation having an unfamiliar aspect.Such daily life events may occur in preparing a snack,eating, dressing, constructing objects that havefunctional usebeads or hat to wear, a present formother--washing, and retrieving a toy from a shelf forplay, etc. Thus, the therapy setting is the naturalenvironment.

At the C-.;nter, I observed that the kitchen was afreqnent 'setting for therapy. It is one of the fewsettings that offers so many natural problem-solvingevent3 in a restricted clinic environment. Every mealor snack, for example, provides different sensoryinformation and sequences of everts leading to a goal.Cutting an apple offers a different problem thancutting a slice of bread. Even the cutting of an appleoffers different problems depending on its size or thetype of countertop or instrument used, etc. It shouldbe clear that the goal is not to teach the childspecific cooking skills, but to offer the possibilityto experience different types of reality-based problem-solving activities involving cause-effectrelationships. But, the bulk of therapy takes place inthe child's home which provides a much broader contextfor natural problem-solving activity. The child'scaretakers are inst...ucted to do with the child justwhat other people are doing in the home.

Care is taken to select daily life problems thatallow the child to function at his/her performanceceiling. The ceiling 3s most likely to be reached whenthe situation includes familiar features to the childwith some novelty to create a new situation. Forexample, putting on shoes becomes a new problem whenthey are new and have an unfamiliar buckle that must behandled in order to get the shoes on. The child isassumed to be functioning at performance ceiling whenhe/she attends the task--i.e. does not talk or focus onother stimuli in the sensory field. In structuring theactivity, the therapist can exert further control overtha stimuli in the situation to encourage success. Forexample, some or all items can be presented in theperceptual field to facilitate recognition (pre-inferences) about how to solve the task. In suchcases, objects also communicate the activity goal tothe child.

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Choosing daily life problem-solving events offersthree necessary features for development that can bemissed by contrived or artificially created tasks.First, they are dynamic--always changing. The stimulusproperties of real situations are never the same evenwhen one experiences the same events. For example, thetype and sequence of movements associated with gettingdressed change depending on the number and types ofclothing used, the rate at which one has to act, etc.These changes in the natural .situation offer problemsthat force the child to adapt his movements and thusstimulate further development. At the same time,events stimulate perceptual-cognitive organization atmodality specific as well as cross- medal and sequentiallevels of integration.

Second, reality events are rich in their sensoryinputs offering the possibility to connect movement todifferent kinds of associated sensory inputs (e.g.auditory, visual, etc.) that co-occur with the movementand offer additional channels of feedback about theeffect of movement.

Finally, daily life events that reoccur--eating,preparing food, dressing, etc., offer some regularityof experience that cuts across the specific variationsin the specific stimulus events. This regularityoffers the opportunity to initiate the learning ofresponse. patterns having meaningful consequences.

Working on Language

An assumption of the St. Gallen treatment model isthat talking to the child is not the essential basisfor organizing adaptive cognitive behavior. Meaningfuluse of symbolic forms externalize what is known aboutthe world al,eady. Consequently, the teaching oflanguage forms is always done in relation to guidedmovement experience. Thus, the therapy is especiallytuned to the semantic base of language. Prior tolanguage discovery, no attempt is made to relate verbalforms to guided movement events. The focus is onestablishing e content base for linguistic form. Thisdoes not mean that no talking occurs during e therapysession. Even though a child does not understandlanguage, talking does occur, but simply as part ofnatural social interaction with the child before andafter guided movement. From these spoken languageevents and countless others in the environment, thechildren presumably detect whatever rudimentaryauditory features of linguistic form that they can,provided that no hearing loss exists. In some cases,

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recognizable words and phrases may be learned by thechild though they are not used meaningfully. Aftersome critical level of action representation occurs inresponse to guided movement, children begin to connee:on their own, particular features of linguistic form tosome aspect of an object or action in a real situation,i.e. they discover language. Language discovery meansthat the child connects a verbal form with a present orpast action event.

Once language emerges, therapy helps the child tomap symbolic forms onto the guided experiences offeredin a treatment session. However, during the guidedactivity, the clinician does not speak in order thatfull attention is focused on movement events. As soonas possible after the problem-solving activity, theclinician may draw pictures to represent some aspect ofthe child's activity during the guided movement. Laterpictures are combined with written or spoken words, andat still a later stage, words alone are used. Itshould be noted that symbolic mapping can take placeafter each movement goal is reached in an activity andneed not be postponed until the very end of thesession. For example, if the child's task is to cut upan apple, symbolic mapping can occur after each pieceis cut.

The verbal patterns and the particular aspect ofthe guided event are drawn, written or spoken by theclinician at the early stages when the child is workingmainly on comprehension. At least two principles arefollowed in selecting verbal stimuli. First, it isassumed that symbol properties are more likely to belearned and used if they represent the most salientaspects of the guided experience, i.e. those whichaccentuate movement or object attributes that areperceptible to touch and feeling. For example, aftercutting an apple, grammatical constructions such as "Icut the apple," "the apple is hard," are moreappropriate than constructions such as "the apple isred."

A second consideration takes into account the formof the construction. The clinician uses verbal stimulithat reflect an action event as opposed to singlewords. This practice is supported by theoreticalarguments that the normal child's use of single wordsare intended to convey an underlying relationship amongobjects (e.g. Greenfield & Smith, 1976). The practicegains further support from studies, which suggest thatlanguage is tied to the dynamic aspects of s.asorimotorintelligLuce; e.g. event knowledge or means-endactivity as opposed to the more static notions of

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object permanency. Kernel sentences are constructedthat include the basic grammatical constituentsrepresenting the object relations involved in an actionevent. Constructions such as "john cuts the apple,""John eats the apple," are more appropriate thanphrases such as "eating apple," "the big, red apple,"etc. Naturally, the fully formed constructions arekept simple.

As the child's language production increases, thechild also selects verbal responses to represent theguided experience. Therapy encourages drawing as wellas writing and speaking. Clinician responses to thechild's productions serve the goal of social-pragmaticinteraction rather than specific skill reinforcement.As the child's stored experience becomes more complex,comprehension and production of symbolicrepresentations are expected to increase in complexity.Naturally, speech articulation is not a primary goal.

Evaluating Patient Response to Therapy

There are both short and long term measures of achild's respGnse to therapy. Short term gains arejudged by a child's response to a given therapysession. The clinician examines the frequency andduration of focused attention during guided movement.The child is judged to be at attention when the eyesare focused on the task or give the appearance of ablank unfocused stare, and the child is quiet on thechair or floor; i.e. does not talk or cry, nor move thebody aimlessly.

Changes in muscle tone from the beginning to theend of the guided activity is another measure of input;i.e. muscle tone is increased for patients who areflaccid initially, and it decreases for those whoinitially are hypertonic. These changes in state aretaken as evidence of adaptive response to stimulusinput that becomes more familiar.

The clinician also looks for signs of beginningrepresentation or recognition of stimulus events duringthe guiding by noticing, for example, if the patienttakes over some of the movement steps leading to a goalor the patient's eye gaze tracks or precedes a guidedmovement in anticipation of the next step. Moreover,the clinician can observe if the the patient initiatesthe first steps toward solving a problem on his own orif the patient is willing to touch unfamiliar materialused during treatment.

With exception of changes in muscle tone (only

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detectable by the clinician who is guiding), all thesechanges were observed across child and adult patientsduring my visit. It was fascinating to observehyperactive children maintain attention for indefinitetime periods during guided movement.

The fellowship visit was not long enough for me toobserve long term gains for any patient. From thecourse and various d4.scussions, I learned that longterm gains are measured in several ways. First, oneexamines whether or not the number and types ofspecific verbal and nonverbal skills increase after aperiod of therapy. However, clinicians specify theconditions under which the skill initially was notperformed earlier and look for change in skill withrespect to a particular set of conditions. Forexample, a child at a prior time may not be able to cutobjects (e.g. apple) except when maximum feedbacksupport is provided. After a period of time, the childcuts this object and others without such support--thusmoving the behavior closer to normal. With respect tolanguage, attention is given to whether the childconstructs utterances that refer to action relations asopposed to loosely organized phrases.

Second, they look for changes in the frequency ofspontaneous exploratory activity. The child begins tonotice or become more aware of the environment, willapproach objects on his/her own and attempt toincorporate them in a spontaneous problem-solvingactivity. In other words, the child becomes an activelearner on his/her own.

Equally important, progress is measured by changesin the level of planning a sequence of action stepslading to a goal. Six planning levels have beenidentified (see Affolter & Stricker, 1980); e.g. thechild may begin at a level where recognition of theaction steps required in a situation occurs only whenall stimuli needed to solve the problem are present.On higher levels, recognition is still possible evenwhen some or all stimuli connected with the problem-solving event are absent. For example, in one therapysession, I observed a child functioning on the higherlevel. He was simply told that he and the clinicianwould prepare some tea for me, as a guest. None of thematerial for making the tea was present in the therapyroom. The boy walked to the kitchen and brought backmuch of what was needed to make the tea and also k,...tw agreat deal about the steps required to make the tea butrequired partial guided movement. Another boy on thesame morning needed some of the items already presentbefore he comprehended what was to be done, and did not

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have a good idea about how to proceed with the teamaking. For example, in trying to make teas he put theteapot on the hot plate without water and seemed not tounderstand why this act was inappropriate. However,both childrn had language forms.

Treatment Efficacy

The problems invo''ed in determining efficacy ofrewediating complex psychological functions also applyto the St. Gallen treatment approach. Schery (1984) ina cogent review of U.S. efforts at determining efficacyof language therapy, noted that, "Extremely few studies:lave examined the effectiveness of educational orclinical programs specifically for language-disorderedchildren" (p. 3S:)). She goes on to suggest ways ofovercoming some of the obstacles involved indetermining treatment efficacy. The problemsassociated with predicting the type and timing oftreatment outcomes become exaggerated for long termtreatment of severe patients who make up the bulk ofthe clinical population served by the St. Gallen model,

The St. Gallen team has judged treatment efficacyby individual patient gains over time as opposed tocontrolled group experiments. This means that achild's progress is measured against his/her ownperformance baseline and not in relation to a criterionor norm referenced standard. The Center for PercepualDisturbances maintains copious written and videotapeclinical records that document progress in nonverbaland verbal performances. The amount and rate ofprogress vary with severity, age at treatment onset andfamily's skill in implementing the guided movementtherapy. Naturally, the clinic has less control overthe therapy conducted at home than in the clinic. Theamount of patient progress also has been influenced bychanges in the treatment protocol over the past 10years.

The most dramatic ..vidence of treatment efficacy( sts for preverbal children (4-6 years or older) whobegin to talk while receiving the therapy. The St.Gallen team reports that nonverbal behavior progressesas well. Children 'ecome more aware of the environmentand begin to explore it spontaneously. They begin tosolve problems independently, even when no languageexists. I was told how one boy, who I observed, wasable to prepare something to eat for himself when leftalone on one occasion. There is also evidence ofphenomenal changes in severely brain damaged adults wholose verbal and nonverbal function.

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While progress in language reportedly occurr., thespecific changes that occur after its onset are lessclear. No time nas been yet allocated tosystematically collating clinical data to determine iftherapy, for example, favors changes in the semantic asopposed to the structural features of language. Forchildren who attend the School for PerceptualDisturbances, there is more control over the types ofguided movement experiences that are obtained. It canbe predicted now that on the average, severelydisordered children will make enough progress in allareas of functioning after about three years at theschool such that they can follow an existing special orpartially mainstreamed normal school program. Theyounger the child, the better is the prognosticoutlook. There are anecdotal reports that children whoenter other programs following guided movement therapyrespond more adaptively than do children whosetreatment has emphasized specific skills.

IMPLEMENTATION IN AN EDUCATIONAL SETTING

The Center for Perceptual Disturbances is closelyaffiliated with the School for Perceptually HandicappedChildren (The Sonderschule fur Wahrenehmungsgestorte),which is located at MuhlenStrasse 3 in St. Gallen.Like the Center, the school was founded by Dr.Affolter and the clinical team in 1976. Headed by Frl.Doris Clausen, it is a state approved and financedpilot school, and the first of its kind in Switzerland.All 'Thildrea admitted to the school are evaluated firstat the center. Admission is reserved for just thosewhose functioning is too low to meet placement criteriain an existing special program.

As a day facility, the school follows the calendarof regular schools in the St. Gallen canton. A maximumof 30 children are enrolled at one time. Thechildren's ages range from 5;0 years to about 17;0years, and their grade placements span kindergartenthrough high school. The physical space of the threestory facility provides for typical staff wcrkingquarters, classrooms, a gymnasium and onekitchen/dining area on each floor. The staff of 30people includes the classroom teachers, speech-languagepathologists, classroom aides, cooks and a volunteerparent corps. Professional staff credentials andcurricular content must conform to state guidelines,but an unconventional instructional mode is used. Thechoice of specific activities and stimuli used to teachcontent is influenced strongly by the kind of tactile-kinesthetic input they offer for learning. As an

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example, for physical education classes, a ball havinga hard textured surface may be chosen over one which issoft and smooth. During my visit, three additionalinstructional features stood out as unconventional.

First the 1:1 student/staff ratio makes guidedmovement possible for every child at some time duringeach day. Some children require almost total guidedmovement throughout the day whereas others do not.Instructional groups of three to five children areformed according to level of function. Any child isgiven guided movement if he/she experiences difficultywith a task. The children are guided for the totalrange of activities including those related to selfcare, eating, dressing, etc.

SecOnd, the curricular content is tied tonaturally occurring Lily life events. I noticed thatthe children participated in many aspects of runningand maintaining the school. For example, they preparedall snacks and lunches. They also helped to clean upthe kitchen afterwards. Instructional groups on eachfloor are assigned one or more tasks for the lunch ratheir respective floors. Depending on level offunction in planning events, a child may be responsiblefor cutting one carrot or all the carrots needed forthe lunch on his/her floor. Some children may have thetask of cutting or washing vegetables, others mayprepare an entire dish depending on the level offunctioning. The task is completed in the classroomusing total guidance or even no guidance if the childalready functions on a production planning level.Other chidren at higher levels help to shop for foodand use this as a focus for more formal arithmetic,reading and writing lessons. During my week ofobservation, one or more instructional groups went intothe town every day.

Third, everybody is trained to do guided movement,even the cooks. Each staff type does the guiding withhis/her content in mind. In addition, every childreceives one or two hours of weekly therapy from thespeech /language pathologist ...:Ao monitors overallresponse to guiding and the language skills in relationto nonverbal problem-solving events.

The children's daily behaviors are loggedroutinely into standard notebooks kept by classroomteachers and their aides. These written observationsare used to track and evaluate students' progress everysix months. After about three years at the school, atleast 75 percent typically can qualify for a moretraditional special program or a partially mainstreamed

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normal program.

IMPLEMENTATION WITH BRAIN INJURED ADULTS IN AREhABILITATION HOSPITAL SETTING

The Affolter treatment model is applied to adultswith brain injury secondary to stroke and head trauma.The St. Gallen team's clinical observations revealedthat some brain injured adults have problems inplanning and executing daily life activities inaddition to language problems. Their research(Affolter & Stricken, 1980, pp. 70-81) has shownfurther that both left brain damaged aphasic adults andright brain damaged nonaphasic adults score lower thanadults without brain damage on sequential patternrecognition tasks in all sensory modalities,particularly the vibrotactile modality. Guidedmovement therapy is expected to facilitate retrievaland reorganization of existing function by recruitingthe action patterns that presumably represent the baseor 'root' of stored experiences related to adaptivebehavior.

Mach of work with adult patients is donethrough the center's coasulting affiliation with theRehabilitation ninic a: 7311 Valens, and theRehabilitation Hospital at 7310 Bad Ragaz inSwitzerland. I accompanied Dr. Affolter and theleading clini ,1 psychologist from the center on one oftheir two day ,6nsulting visits to Bad Ragaz. At therehabilitation hospital, I was told that only the mostbaffling patients are referred to the St. Gallen team.Some patients show global loss of function and do notprogress with conventional therapy while other patientshave retained some functions but perform at a lowerlevel than their neuromotor status predicts. Thelatter group often is judged to lack motivation oremotional health because they cat alone and do notbecome involved in daily life activity.

During the evaluation, Dr. Affolter and her staffdetermine the types of maladaptive behavior exhibited,and equally important, the specific conditions underwhich it occurs and varies. Information about contextallows them to determine if the behavior can beexplained in terms of the amount and type of sensoryinput offered and the planning demands of thesituation. Behavioral variation as a function of thesituation offers an important cue about the probablepresence of perceptual difficulties.

InformaLiou is gathered by observing patientresponses to a problem-solving task with and without

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guided movement during a therapy session. It also isgathered by talking to the floor nurses and otherpersons who have contact with the patient, and directlyobserving the patient while he/she eras, gets dressedfor the day, sits in the lounge, etc.

All therapies (physical, occupational,recreational, logopedic) implement the recommendationfor guided movement therapy within the context of dailylife activities that relate to their respective foci.For example, physical therapists may focus on "walking"in the context of going to the lounge to watchtelevision or the dining room to eet--all the time,drawing on cognitive activity associated with thespatial relocation of one's body in reaching an actiongoal. Similarly, the occupational therapist appliesguided movement to relevant problemsolving goalsinvolving manual control. Although all therapists maywork on language, the speech/language pathologistspecifically monitors language input in relation toguided movement involving the same kinds of daily lifeproblemsolving activities focused on by othertherapists.

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III. APPLICATION TO THE U.S.A.

The Center for Perceptual Disturbances offers analternative to current U.S. treatment approaches thatcan be applied to severely learning disabled childrenand adults, particularly those who are nonverbal and donot respond to conventional strategies. WidespreadU.S. application of the St. Gallen treatment, however,will depend (1) on further research which documents theefficacy of guided movement as a therapeutic strategyand (2) the availability of instruction on thetreatment approach. The treatment model is likely tohave the most immediate U.S. impact in the area ofresearch.' It encourages research along several lines.

Although patient gains in response to guidedmovement therapy have been documented clinically,efficacy studies need to be conducted. The focus ofthe St. Gallen treatment on underlying process ratherthan specific skills, makes it difficult to link co-existing performance changes directly to the therapy.Thus, group comparative research, though frequentlymessy to do, would provide the most convincing efficacydata. Such research would aim to show if children oradults who receive guided movement therapy show greaterverbal and/or nonverbal gains than a comparable groupthat receives a conventional skills approach.

With respect to language, efficacy studies areneeded to document the types of specific changes thatco-occur with therapy. While guided movement appearsto be effective in facilitating language emergence forthe preverbal child, it is not clear what specificlanguage changes occur after language onset. Thelatter issue becomes critical in the context of recentfindings that support an indirect rather than a directlink between emerging cognitive competency and thetypes of grammatical constructions acquired (see areview of these issues in Rice -A Kemper, 1984). Forexample, it has been argued that the mastery ofalternative forms for expressing the same content (e.g.the opposition between pronominal/nominal andpassive/active reference) cannot be motivated entirelyby cognitive concepts. Hence, the claim that cognitionmay account less for the structural than the semanticfeatures of language.

The efficacy of guided movement therapy will bedetermined further by basic research that is relevantto testing its theoretical claims. Decades have passed

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since Piaget proposed action as a critical link tounderstanding the development of intelligent behavior,but still little is known about the functioning of thetactile-kinesthetic system as a channel for learning.Despite the difficulty of studying tactile-kinestheticsensory input relative to audition and vision, researchbearing on its role in normal and clinical children'slearning is critical to understanding how and why itmight be useful to habilitation.

Fortunately, the emerging body of research on thecognitively related action patterns of normal childrenoffers a beginning point for expanding the focus ontactile-kinesthetic systems of developmentally disabledchildren beyond the traditional study of oral andmanual stereognosis and two point-tactilediscrimination. To my knowledge, the kind of`cinematic' features of normal children's actionpatterns that are described in Forman (1982) have neverbeen applied, systematically to a study of clinicalchildren. Yet, the comparative study of normal andclinical children using, e.g. Mounoud and Hauert's(1982) arm drop amplitude measure of adaptive grasp,could be very instructive. Children who are thought tohave tactile-kinesthetic deficits would be expected todiffer from normal children and other clinical childrenin the rate of grasp adaptation to objects of varyingsizes and weights. Group differences also would oeexpected in the extent to which grasp is altered inanticipation of weight changes based on visualappearance of size since this type of perceptual pre-inferencing depends on cross-modal organization ofsensory input. Moreover, with respect to articulatoryfunction, adaptation to altered tactile-kinestheticfeedback might be less complete among children judgedto have tactile-kinesthetic deficits than among thosewho do not display this difficulty. For example,comparative studies involving the external impositionof artificial loads on the tongue surface may show thatimpaired children do not recover customary function atthe same rate as those who are normal.

Equally promising for understanding the nature oflanguage impairment in an action context, is the St.Gallen team's current research focus on the movementrules that clinical children use in solving classicform recognition and seriation problems (Affolter,forthcoming). Preliminary results suggest that, unlikethe mentally retarded, perceptually handicappedchildren show profiles that suggest a search forinformation.

Although guided movement therapy was developed in

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the context of treating severely learning disabledchildren and adults, it offers a framework for askingnew questions about the nature of language impairmentamong children who perform at the less severe end ofthe continuum. Here reference is made to the ratherlarge group of U.S. children who are labeled asspecifically language impaired. It is known that someof these children who receive spoken language therapyin the preschool years show up later with problems inreading, writing and calculation and may present a hostof other maladaptive areas of functioning subsumedunder the learning disabilities category. YcL, theunderlying basis for the problem is not known.

We have come full circle in our speculation aboutthe underlying basis for the problem. Since the shiftfrom auditory processing to a cognitive representationhypothesis has not yielded entirely defensible answers,a perceptual hypothesis is being entertained once again(see Rice & Kemper, 1984, p. 46). However, the recentarguments for innate perceptual processing mechanismssuggest a lack of clear direction about how to framesuch an hypothesis--if auditory mechanisms are not theanswer.

The St. Gallen treatment model expands ourthinking and research directions in several criticalways. First, it suggests that perceptual hypothesesshould not be framed in isolation of cognitiverepresentation. This notion raises questions about thetheoretical claims tnat have evolved from U.S. researchthat focused on revealing either an auditory processingor a cognitive representation deficit. Researchtypically has not considered both aspects whenobserving the same children. To the extent thatperception and cognition interact, future studies mayshow that deficits in both areas are exhibited by thesame language impaired child. Such an outcome wouldpoint to the need to conceptualize broader and moredynamic perceptual hypotheses than those which havebeen generated so far.

Second, the St. Gallen model suggests that aperceptual hypothesis about language impairmentrequires broader definition than the auditory modality.For example, meaningful comprehension of a constructionsuch as "John hits the ball" draws on knowledge aboutmovement and action effects on objects that is notgained essentially through the auditory channel. Theneed to move beyond a strictly auditory input becomeseven more critical if the perceptual hypothesis also isto account fot deficits in nonverbal problem-solvingp -rformances such as preparing a sandwich, putting a

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puzzle together or locating an object.

St. Gallen's learning model encourages observationof the language impaired performances in allmodalities. While a few attempts at comparing auditoryand visual performances have been made in the U.S.(e.g. Tallal, et al., 1981), the tactile-kinestheticchannel has been virtually ignored. Yet, according tothe St. Gallen model, tactile-kinesthetic sensory inputoffers the dynamic and reality transforming aspects ofone's cognitive store of experiences. In fact, thetactile-kinesthetic clinical subgroup, which has beenidentified in St. Gallen, looks suspiciously like somechildren with specific language impairment that aretreated in the U.S. The children of focus here arethose who present general language delay andarticulatbry difficulty. At the risk of being overlysimplistic, it appears that tactile-kinestheticdifficulty could explain a number of the problemsobserved. Obviously, a tactile-kinesthetic deficitcould account partly for severe articulo-phonologicproblems. But, the broad role of tactile-kinestheticrepresentation in the development of action createsin_:iguing possibilities for explaining delay of otherlanguage features as well. If children normallyacquire language by mapping linguistic forms onto whatthey do, or experience in a situation, then atremendous amount of information involving the tactile-kinesthetic system must be detected and coordinatedwith information from other sense modalities. Theinformation load may be too great for the child who hasdifficulty acting on the environment because oftactile-kinesthetic problems. Such a child would missmore of the information offered in an actual situationthan a normal child. If the child reduces informationload by focusing just on actions of the event or juston linguistic form, then it is clear that form-contentcorrespondences will be difficult to make very quickly;i.e. more experiences would be required to get therelevant input. Consequently, a longer and delayeddevelopment will be observed.

This line of reasoning leads to a number ofquestions. Do language impaired children talk at thesame time as they are acting on the environment? Dothey focus more often on action aspects of the event orits linguistic forms? What are they doing all day longin their natural environments? How do they approachproblems and explore the environment in daily lifeactivity? In typical therapy sessions, do we offer toomuch information to the child by always presentingverbal information simultaneously with some event? Dowe offer the right input when we assume that language

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is learned from just verbal input? The answers to someof these questions will not be obtained by con'. uingto give language impaired children structuredelicitation tasks or taking a spontaneous languagesample at a single time point under semilaboratoryconditions. The same kind of longitudinal naturalisticobservation strategies that have been used to unravelsome of the mysteries of the normal child's developmentneed to be applied to the language impaired child infuture research.

Fortunately, we have begun to call attention tothe issue of problem-solving among the languageimpaired. But, there is a need to expand the currentfocus to include attention to the way language impairedchildren solve problems in relation to the kind ofsensory perceptual information offered in the situationincluding the tactile-kinesthetic information. To theextent that the base of cognitive development is tiedto action, tactile-kinesthetic deficits may explain whysome language impaired score poorer than normal on somecognitive tasks and yet pass visually orientedintelligence tests such as the Leiter InternationalScale (Leiter, 1979). It is noteworthy that of the sixnonlinguistic cognitive tasks on which Kamhi (1981)compared normal and clinical children, just the haptictask which is dependent on tactile-kinesthetic sensoryinput, yielded noticeable differences between normalchildren and language impaired children who score inthe normal range on the Leiter scale. Moreover, giventhe St. Gallea team's claim that sequential knowledgeis derived from multi-sensory input, observed auditorysequential de. may not express a primary deficitof the auditory system as we have always assumed.Rather, auditory deficits may co-exist as a secondaryeffect of sequential difficulty arising from tactile-kinesthetic problems. This interpretation isconsistent with observations that the deaf and theblind show reduced sequential processing performancesin their respective nondeprived modalities. Futureresearch is needed to test these hypotheses.

The research aimed at framing perceptualhypotheses about language impairment also needs to befocused broadly enough to deal with the notion ofconnecting roots among different behavioral domains.One issue is whether or not verbal and nonverbalbehaviors constitute a different problem space. Thisissue can be addressed partly by determining ifdifferences exist in the problem-solving strategiesthat are used to approach verbal and nonverbal tasks.

Another issue pertains to the connections among

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different verbal skills (e.g. spoken or zistned vs.written). St. Gallen's research indicates that somedyslexic children, present the same performance profileson sequential tasks as those with spoken languageimpairmert. Ironically, dyslexics' sores wereobserved to be better in vision than in audition orvibrotaction. In the U.S., there is theoreticalsentiment for the notion that a general linguisticdeficit underlies reading disability. See, forexample, Siegel & Ryan (1984). However, a "commonroot" hypothesis must explain why reading disabilityco-exists with what seems to be normal spoken language.

Again, the St. Gallen model encourages a searchfor the explanation by considering the perceptual-cognitive regnirements of the situation. It is clearthat the 'child must bring to a reading activityinternalized information about action events sincepictures, if they are used, already are an abstractionof actual situations. Spoken language carries the samedemand only when it references events that are i3otpresent. However, since one's spoken language often istied to actual situations, it could appear more normalthan it actually is at older ages. One may wonderthen, if reading impaired children would show the samelevel of spoken language skills as non....mpaired childrenwere more sophisticated observations of their spokenlanguage made; i.e. observations that go beyond ruledescriptions of phonologic and morptJsyntactic form toinclude performance aspects that reflect differentdei:ands for information processing anC situationdet!ndent cognitive representation; e.g. how well doesa reading disabled child track spoken lecture ordiscussion? Does the understanding of spoken languagebreak down in the absence of actual situation or withthe use of long syntactic constructions?

Unfortunately, we do not have much of this kind ofinformation available even for the older normal childbecause research has focused on early languagedevelopment. The spoken language of the older normalchild needs further study. In addition, to comparativeresearch on older normal and clinical children, thesearch for common performance trends among clinicalpopulations that present different skill def'nedimpairments also may be instructive. The latter pointcalls attention to the possibility of revealing moreabout the specifically language impaired when they arestudied not just in relation to normal children, bucalso in relation to the dyslexic, mentally retarded andother clinical groups.

A serious response to the kind of questions and

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issues, which the St. Gallen approach raises aboutlanguage impairment and learning disability, requiresmultidisciplinary-multiperson effort. The universityresearch laboratory provides a recognized vehicle formounting such an effort. The laboratory space atMichigan State University has been expanded torepresent the language sciences. A language scienceslaboratory is being designed to meet research, teachingand service delivery goals within the context of basicand applied issues that relate to language impairment.For example, some aspects of guided movement therapyhave been used with encouraging success to treat aseverely delayed child at the MSU Speech and HearingClinic, We are in the process of evaluating thetreatment effect and identifying problems inadministering the treatment. Research on the semanticfeatures'of impaired language is also underway sincethe semantic aspect of language is assumed to have theclosest link to one's cognitive representation ofexperience. It is speculated that the failure of priorstudies to reveal real semantic differences betweenclinical and normal children occurred because globaldescriptive frameworks were used. Consequently, thelaboratory is in the process of comparing clinical andnormal children using the kind of fine grained analysisof semantic-syntactic categories that have grown out ofdetailed analyses of global categories such as action(Huttenlocher, Smiley & Charney 1983), and location(Stockman & Vaughn-Cooke, forthcoming).

Michigan State University houses several resourcesthat could be tapped by the Language SciencesLaboratory to bring a multidisciplinary force to bearon the research issues raised by the St. Gallenapproach. Among these resources are several servicefacilities for learning disabled children that include(a) the Speech and Hearing Clinic, (b) the LearningCenter and (c) the Motor Skills Clinic. In addition toits service programs, the university maintains amagnetic resonance imaging facility at its ClinicalCenter. This facility offers the most advancedtechnology for conducting brain studies and for thefirst time, makes it almost routinely possible to studythe anatomical features of brains without known risks.The technique is particularly advantageous because itallows one to obtain brain scans during consciousstates, while talking or reading. The current searchfor ways to measure neurochemical features of brainactivity holds the promise of unlocking knowledgebarriers about brain function during learning. Forexample, this kind of technology may lead tounderstanding of the neural correlates of "attention"during learning.

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A multidisciplinary team of professionals isexpected to exist for the purposes of asking researchquestions that bear on the focal area, and generatingresources to address the questions posed. Suchresources ms,, include shared grant writing activity,lectures, seminars and student focused research.

In keeping with the second goal of the fellowshipvisit, a working relationship has been initiated withthe St. Gallen team. As a first step toward developinga collaborative effort, arrangementc were made for Dr.Affolter and another team member, Mr. WalterBischofberger, to conduct a workshop and lecture ontheir method at Michigan State University during theirrecent U.S. trip. In addition to the workshop, Dr.Affolter'observed the child who currently is beingtreated at the university clinic using the St. Gallenapproach.

Further discussion with the St. Gallen team isexpected along the lines of shared research goals andresponsibility. Since the Center for PerceptualDisturbances currently has the least amount of resourcefor research, it may be possible to channel some of itsresearch projects through the MSU Language SciencesLaboratory. The laboratory also will be involved inefforts to disseminate information about the St. Gallenapproach. Discussion already is underway regarding myparticipation in the preparation of an Englishtranslation of Dr. Affolter's forthcoming book,Perception, Reality, and Language, to be publishedlater this year in German by Neckar-Verlag. TheEnglish publication of this new book should stimulate atopical graduate seminar at the University.

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