articles

DEVELOPMENTAL
WITH

THERAPEUTIC

APHASIA:

A SPECULATIVE

VIEW

IMPLICATIONS

Jon Eisenson
Stan[ord University School of Medicine
Palo Alto, California

DEVELOPMENTAL APHASIA:
An aphasic child is one with central
nervous system dysfunction. This dysfunction, which presumably is caused
either by a failure or lag in cerebral
maturation or because of cerebral damage, produces perceptual impairment
that is associated with severe difficulty
in the normal acquisition of language.
T h e aphasic child presents linguistic
and behavioral manifestations that distinguish him from other children (both

A DIFFERENTIAL

DEFINITION

the normal and verbally deviant)

ways that include the following:

in

1. Developmentally, the aphasic child usually manifests:

a. Perceptual dysfunction in one or more
sensory modalities
b. Auditory inefficiency over and above
what may be expected from audiometrically determined hearing loss
c. Intellectual inefficiency over and
above any "objectively" assessed intellectual limitation

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JOURNAL OF SPEECH A N D HEARING DISORDERS

2. Linguistically, the aphasic child shows

severe retardation for both the reception
(comprehension) and the production of
language. That language which the child
achieves is likely to be characterized by
an absence of conventional grammar, by
a deviation from developmental language
norms (size of vocabulary, sentence
length), and by a disproportion of the
expected comprehension-production language ratio. As the child grows older, his
language output is not likely to reveal
the expected increments, the correlative
abilities, or the "ordered pattern" that
characterize language achievement for
most normal children.
5. Behaviorally, other than in language, the
aphasic child is likely to manifest perseveration, inconsistency of response,
emotional lability and frequently, but
not always, general hyperactivity. Occasionally the child may become hypoactive to a degree so severe as to make
him appear to be withdrawn from his
environment.
T h e aphasic child is distinguished
from other nonverbal children by the
likelihood that the behavioral manifestations just cited, as well as inefficiency in sensory, perceptual, and
intellectual functions, are usually more
evident in verbal situations than in
nonverbal ones. These manifestations
are also likely to increase as the child
confronts a verbal-symbol situation and
he realizes that a verbal-symbol response
is expected of him.
This rather lengthy characterizationdefinition of the congenitally aphasic
child sums up my impressions following
many years of evaluating and supervising the language training of nonverbal
children. Relatively few of the nonverbal children I have seen and evaluated "qualify" as truly aphasic according to the characteristics just indicated.
The great majority, with or without
clearly determined central nervous sys-

--

XXXlll, 1

tem involvements, are more likely to be

basically mentally retarded and lacking
in the capacity for the development of
language function except for a limited
identification vocabulary. Some children present definite indications of
central nervous system involvement
manifest in multiple perceptual dysfunctions. Such children, as Benton
(1964) observes, show such pervasive impairment in all aspects of intellectual
functioning that they are appropriately
considered mentally retarded. These
children have little or no language because of their multiple incapacities for
the development of this function. We
need, however, to be on guard to distinguish the children with multiple and
pervasive perceptual dysfunctions from
others with specific perceptual dysfunction which may impair language
development and result in difficulties in
adjustment. A child may "act out" or
he may withdraw into himself because
he cannot "speak out." This is the kind
of child who may be the one with developmental aphasia.
When we use the term developmendesignate a child with
severe language retardation, we imply
that he lacks the capacity, at the time
we make the designation, for the perception and so for the production of
spoken language. We also imply that it
is entirely possible that if the child
could be left unimpressed, unimposed
upon, and undisturbed by environmental influences so that he does not try to
achieve what he is incapable of achieving at a given developmental age and
stage, he might in time learn to speak.
It is probably unfortunate for the
children we designate as developmentally aphasic that most other children

tally aphasic to

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EISENSON: DEVELOPMENTAL APHASIA

begin to speak by 18 months, and that

by 36 months they have larger comprehension vocabularies than we have been
able to date to assess and approximate
with accuracy or confidence. Beyond
this, children who are normal in language development are able to understand the significance of sentences and
of verbal formulations they have never
heard before. Such comprehension
ability cannot be explained solely on
the basis of their comprehension of

THE

CHILD

WITH

individual words. In addition to the

sizable production vocabularies that
most children achieve at 36 months,
they can usually verbalize in a manner
consistent with the syntax or rules for
stringing words according to the linguistic system of the adults in their
environment. It is of interest to note
that syntactic proficiency is achieved by
most children at about half the age at
which they achieve stable articulatory
proficiency.

DEVELOPMENTAL

With rare exception, developmentally aphasic children are essentially

those who have auditory perceptual involvements. The child with auditory
aphasia is one who may give the impression of being a severely hard-of-hearing
or deaf child, or a mentally retarded
deaf child. In fact, he is quite likely to
have a mild or moderate hearing loss
which may be determined by objective
audiometry. His hearing disability,
however, tends to vary with conditions
not directly related to the state of the
child's physical health or with the intensity or frequency range of the auditory events to which he is exposed. We
may then begin to characterize this nonverbal child as one who may have some
degree of difficulty in the physical reception of sound, but considerably more
functional and practical difficulty in his
ability to deal with the sounds-the
streams of utterance-which are received. Restating the observation, we
may say that the child's functional or
practical hearing is considerably more
impaired than audiometric findings per
se would imply for most other children.

(AUDITORY)

APHASIA

A majority of the children we regard

as developmentally aphasic present
neurological findings, EEG and otherwise, that implicate the left cerebral
hemisphere. To be sure, sometimes the
only clear finding is that the child has
some degree of hearing loss, and considerable hearing imperception that
goes beyond the expectation of the audiometric findings. We accept this as an
implication that the central system is
involved and that the child is not capable of processing speech signals. Yet we
know from the child's behavior that he
is able to deal with nonlinguistic signals, with mechanical and even animal
noises in appropriate ways. We also
know from investigations in our own
Institute I that the aphasic child is able
to discriminate between isolated speech
sounds. He has, however, considerable
difficulty in discriminating between
contexts of two or three phonemes
when the phonemes are incorporated
into nonsense syllables even though he
qnstitute for Childhood Aphasia,
University School of Medicine.

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Stanford

JOURNAL OF SPEECH AND HEARING DISORDERS

may be a b l e to identify any of these

phonemes in isolation.
W h a t are some underlying causes of
this impairment? Following are some
speculations supported in part by clinical observations and research findings.
1. THE CHILD'S STORAGE SYSTEM FOR
SPEECH SIGNALS MAY BE DEFECTIVE.

Thus, even though the child may be

able to make a correct matching of signals on the basis of immediate recall,
his storage system is defective for these
signals. T h e child does not retain what
he hears. If the child cannot store auditory linguistic events even for a brief
time, he may appear to be both deaf as
well as mute. If he can store them only
briefly, he will not be able to speak,
though he may be able to imitate
speech signals if there is no delay period
for imitation.
W h a t is suggested is that the nature
of the signals, the characteristics of
those auditory events that constitute
speech, call for different control and
storage than do other auditory events. 2
2. IMPAIRMENT OF DISCRIMINATION
AND PERCEPTION OF PHONEMICS IN CON-

TEXT. T h e child may be able to discriminate between isolated phonemes, even

when they are much alike as /s/ and
/z/, or / t / a n d / d / , o r / u / a n d / i / , but
cannot make the discriminations and
the perceptions when the phonemes are
incorporated into phonetic contexts. At
the risk of being obvious, I will point
out that t h e / t / in ten is not quite the
same as t h e / t / i n its, or in plenty, or in
omit. Further, in the word twenty we
have allophones of / t / that are produced somewhat differently by speakers
of American-English and by those who
2See Lieberman et al. (1967), 443-444, for a
discussion of this point.

--

XXXIII, 1

speak English-English. Perhaps what

our aphasic child lacks is a capacity to
generalize sounds into phoneme categories. Sounds may be stored as discrete
entities. W h a t the child stores may not
permit him to make matchings to a
broad enough category to be useful in
language processing. He may be a victim of a narrow and premature rigidity
of his categories.
3. DIFFICULTY

IN

RECEIVING

AND

PROCESSING AUDITORY SIGNALS WITHIN

THE RANGE OF RATE AT WHICH SUCH
SIGNALS ARE

NORMALLY

PROCESSED.

T h e aphasic child may not be able to

listen as fast as do children who learn to
speak. T o understand speech we must
learn to become fast listeners, to make
quick matchings between ongoing auditory events and those events, or images
of the events, which are stored somewhere in our nervous systems. A corelated impairment may be a difficulty
in determining the order of presented
events. Unless it is possible for the child
to identify the auditory signals, and to
keep the order of signals in mind,
speech perception cannot be established.
How rapidly must we be able to
listen to understand speech? This rather
simply worded question calls for very
complex and sophisticated answers. A
flow of utterance sounds like a torrential outpouring to an inexperienced
listener. B y inexperienced, I mean for
the moment an individual who has had
little or no exposure to a particular
linguistic system. T h a t is why foreigners
seem to be fast speakers on first exposure. On repeated exposure, they
seem to slow down. Even though as
listeners we still may not know what
they are saying, with experience we can
at least, or at best, attach a label to the

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EISENSON: DEVELOPMENTAL APHASIA

language used by the speaker. Interestingly, we find that the time interval
between successive stimuli--the minim u m time needed to make judgments
as to whether we are exposed to one or
two sound bursts, or light flashes, as well
as to the temporal order of the e v e n t s is considerably reduced with experience
for these nonverbal events.
Perhaps we are not yet ready to
answer the question of how rapidly we
must learn to listen in order to understand speech. T o arrive at the answer,
we need to do considerable more experimentation with speech than we
have done to date. We do, however,
have some information as to minimal time for sound discriminations for
normal listeners, and some information
as to differences between normal and
brain-damaged respondents.
Hirsh (1967) summing up the findings
on the m i n i m u m time interval for
awareness of succession of stimuli (resolution of one or two events), reports a
figure as small as 2 msecs. Fay (1966), in
his survey on temporal sequencing, reports that for sound clicks, successiveness can be perceived within a range
of 2-10 msecs. This is, indeed, fast
listening. A longer interval is required
when the listener has to decide the
order of sequence of presented stimuli.
Hirsh and Sherrick (1961) found that
an experienced subject required an
interval of 20 msecs to report correctly
(75% of the time) the correct sequence
of events when two e v e n t s - a light and
a sound s i g n a l - a r e presented repeatedly
in the same order. T h e time interval is
about the same for sounds, light flashes,
and tactile events, or when two different
sensory stimuli are involved. Hirsh and
Fraisse (1965) found that naive observers required about 60 msecs for the

same accuracy of performance when

the discriminating-sequencing situation
was a single rather than repeated presentation of light and sound. 3
W h a t is the effect of brain damage
on the ability to make correct judgments as to the serial order of different
sounds? Some information is available
on investigations of adults. Efron (1963)
compared inexperienced neurologically
normal adults with a population of
aphasic adults who had incurred left
temporal lobe lesions. His findings for
the normal adults were essentially the
same as those in the Hirsh and Fraisse
study cited above. Approximately 50-60
msecs were required for correct judgments to be made as to the order of two
10-msec sound pulses markedly different in frequency. In sharp contrast,
most of the aphasic patients required
considerably more time, some as much
as a full second interval between sound
pulses before a correct judgment was
made. In commenting on this finding,
Efron (1967) said about the aphasic
subjects:
We can, of course, show that their pitch
discrimination was normal by routine
audiometry. When the intervals between
two sounds are made sufficiently long,
these aphasic subjects achieve I00%
correct score, proving that they understand the instructions and performed
reliably. However, as the interval between stimuli was reduced, they failed
miserably and their reports of the correct
sequence of sounds became random.
Efron's investigation and findings
have been replicated by several other investigators, including Edwards and
aSee also Broadbent, P. E., anti Ladefoged, P.,
Auditory perception of temporal order, J.
acoust. Soc. Amer., 31, II, 1539 0959) for information on differences in time-order perception between untrained
and
trained
listeners.

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JOURNAL OF SPEECH AND HEARING DISORDERS

Auger (1965) who worked with adult

subjects and Lowe and Campbell (1965)
who worked with children.
Lowe and Campbell employed eight
normal and eight aphasoid children
ranging in age from 7 to 14 years as
subjects. T h e experimental serial order
task called for the subject to indicate
the order of two 15-msec pulses, one at
2220 Hz and one at 400 Hz. T h e range
of interval time for the normal subject
was from 15 to 80 msecs, with a mean
of 36.1 and a median of 30 msecs. T h e
range for the aphasoid children was
from 55 to 700 msecs, with a mean of
357 and a median of 350 msecs (difference between the groups was significant
at the 0.005 level).
T h e ability to recognize the serial
order of sound pulses is a far cry from
the ability to sequence complex speech
sounds. Because of this we must still
exercise caution in generalizing from
reported findings. Nevertheless, to
quote Efron (1967) again as to the
implication of sequencing impairment
in adult aphasics:
We can thus consider it to be definitely
established that aphasics as a group do
suffer from a profound defect of auditory sequencing. What is not established
is the relationship of this clearly defined
defect of auditory function to the understanding of spoken language. We now
know that there is an association between
aphasia and this type of sequencing
defect. It has not been proved that the
defect in temporal sequencing is the
primary cause of the inability to understand speech.
Since we are engaged in conjecture,
we need not be limited to the implications of available findings on sequencing studies which for the most part
concern adults. We need not even be

- -

XXXIII, 1

disturbed by Efron's observation that

some aphasics with fairly good understanding of speech did very poorly on
sequencing, while others who had severe
impairment in speech comprehension
were close to normal in the sequencing
function. We do know that most aphasic
adults are severely impaired in sequencing function. Why some are not so impaired certainly deserves study. We
should also keep in m i n d that the Hirsh
and Sherrick type of experiment deals
with the presentation of discrete stimuli. In speech our signals, except at
pauses, are not discrete. We speak a
stream of sounds that do not have sharp
edges or regular distinct pauses to help
us in our discriminations. So, our aphasic children may be much like the tourist with one year of high school French
trying to understand and keep up with
what is going on in an argument between a French gendarme and a taxi
driver on the Champs s
at 5:00
p.m. on a weekday.
4. CLINICAL OBSERVATIONS OF IMPAIRMENT IN SEQUENCING. C l i n i c a l observat i o n and psychodiagnostic test findings

(Stark, 1967) support the impression

that aphasic children are certainly impaired in their capacity for sequencing
auditory events and that many may
have a more general impairment for
sequencing. We consider this tendency
to be generally true, though occasionally we find an aphasic child who has
normal or superior ability for visual
sequencing as measured by items such
as the Knox Cube T a p p i n g Test and
those on the I T P A and the Leiter
International. In a recent study, Furth
and Pufall (1966) found that young
aphasic children (ages 6-7) were poorer
than deaf children in auditory sequencing when the stimuli were white

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EISENSON: DEVELOPMENTAL APHASIA

noise and a complex noise. These auditory events, we might point out, are
considerably more distinctive than sequences of speech sounds.
McReynolds (1964, 1966), in her doctoral study found that children who can
discriminate isolated speech sounds had
considerable difficulty in identifying
sequences of sounds. Whether this diffi-

SEQUENCING

AND

culty was a result of contextual imbedding or because of sequencing, or a

combination of both, needs to be determined. In any event, we are impressed that sequencing ability is a
critical factor in differentiating the
aphasic child from the deaf and the
mentally retarded.

PERCEPTION

All linguistic events, regardless of the

principal intake modality, are temporal
and spatial. That is, they occur in an
order that occupies time and/or space.
To understand language we must somehow manage to deal with present or
occurring linguistic events on the basis
of responses to past linguistic events
and in anticipation of events in the immediate and not so immediate future.
Every response made to language involves the responding individual in a
situation in which he is required to
guess the probabilities of what is about
to happen in regard to a given lexical
content. Linguists, psychologists, and
others who look at language processes
from the point of view of information
theory, take the position that the elements of the input signal--that is, what
is received--are sequentially chained by
the influence of lexical conditions that
determine or linguistic probabilities.
In the related processes of reception
and perception, the individual is required to take into account new evidence related to the information provided by the signal or signals to which
he has already made responses. As he
continues to receive information, the
responding individual narrows the
mathematical possibilities as to the

RELATED

TO LANGUAGE

nature of the succeeding signal. At some

point he determines that he will commit
himself about the likelihood of a given
signal-auditory or visual, a phoneme
or grapheme, or a sequence of phonemes or graphemes. The commitment
he makes is essentially that the signal
is in fact what he anticipated it should
be and predicted that it was. If his guess
is confirmed by the linguistic events
that follow, he continues his involvement in the language game. 4
Nonverbal children in general, and
aphasic children in particular, are impaired in their ability to deal with
linguistic sequences. They are poor at
the guessing and gambling which are inherent and are required for becoming
proficient in verbal behavior. The developmentally aphasic child is so poor,
so apt to be a born loser, that he may
become apprehensive about exposing
himself to situations that require him to
be involved in continued tries and trials
to understand and produce conventional language. His negative attitude
toward language may be maintained
even when his nervous system and his

*See Fay (1966), pp. 16-21, for a survey and

position.

discussion of this

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10

JOURNAL OF SPEECH A N D HEARING DISORDERS

potential for improved perceptual functioning may have matured sufficiently

so that the odds, and the likelihood,

PRODUCTIVE

The child with apparent productive

or expressive aphasia probably has such
impairment because of his primary
recepti-~e-perceptive involvement. T h e
child who produces jargon may well
hear speech as jargon. The child who
transposes may do so because he is not
able to keep the order of sounds in
mind. Even the child who seems to have
word finding difficulty may simply be
one who was late in acquiring language;
in storing words to be retrieved according to need. He has not had ample time
and opportunity to practice word evocation. He still falters and fumbles, not
only with individual words but even
more so with strings of words. Much
like the adult aphasic, he may be able
to recognize the appropriate word when
it is presented to him though he is not
readily able to produce the word at will.
Unless, therefore, there is clear evidence
to suspect an underlying dysarthria or
oral apraxia, expressive manifestations
in the child may be considered just another aspect of auditory aphasia. If

A UNITARY

EXPLANATION

PRODUCTION

--

XXXlll, 1

that he can become involved in the

language game and develop verbal behavior may finally be in his favor.

IMPAIRMENTS

there is reason to believe that a child

may be suffering from dysarthric i n volvement, if there is substantial evidence that the child cannot imitate
nonsense sound sequences at a rate and
of a complexity in which sounds occur
in speech utterances, we may still
postulate that auditory processing is
impaired. If articulatory products are
not correctly, reliably, and consistently
produced, the child cannot store units
of language for retrieval and production
according to the demands of a linguistic
situation. What the child produces may
not be understood, and so not reinforced by a listener. The young child
who says pasghetti for spaghetti and
says so consistently, is likely to be understood and for many months his oral
product may be accepted and even enjoyed. If, however, he produces pasghetti on one occasion and sapghetti on
another, and tasgheppi on still another,
he may fail to be understood and his
product rejected.

F OR C O M P R E H E N S I O N

I M P A I R M E N T S ON T H E

AND

BASIS

OF L E F T C E R E B R A L L O B E P A T H O L O G Y

Now it is time to try to return to the

notion that both the comprehension
and production difficulties of the child
with developmental aphasia may be

explained on a unitary basis. We accept

the failure of the deaf child to learn to
speak "naturally and spontaneously" on
the basis of his inability for the normal

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EiSENSON: DEVELOPMENTAL APHASIA

reception of auditory symbols. In the

case of the aphasic child, the capacity
to listen, to process what is physically
received, is impaired. The point has
already been made that late maturation
may be associated with inadequate storage of speech signals, and with limited
opportunity for the practice of articulatory patterns. The close relationship
between articulation and audition in
the normal development of speech is
emphasized by Luria (1966) in his text
from which the following quotations
are taken:
The development of the ability to perceive sounds and to hear speech requires
the closest participation of the articulatory apparatus and assumes its final
character only in the process of active
articulatory experience.
The active articulatory experience is
overt and readily apparent in the young
child. As the child develops proficiency
as a listener and a speaker, the participation of the articulators in the process
of auditory-articulatory analysis becomes less apparent and "recedes into
the background." Electromyographic
studies indicate, however, that the suppression of articulatory activity is a
gradual process and is likely to continue
to some degree until the child is of
school age.
However, if the child is told a word with
a complicated sound or, still more, asked
to write it, the articulatory apparatus
will again be brought into visible use
to aid in the perception and recognition
of the precise sound structure of the
word.
Luria argues that
The articulation of the sounds of speech,
like the process of perception of these

11

sounds by ear, thus obeys the laws of

analysis and integration.
In this manner the child learns to identify and produce the essential or phonemic signs of speech and to inhibit
responses to the unessential signs.
Which signs are essential, distinctive,
and phonemic are determined by the
given linguistic system to which the
child is exposed. "Their character is
complex, generalized, and social in origin." So, according to Luria,
It is clear . . . that the perception of
speech by hearing requires not merely
delicate, but also systematized hearing.
When this selection of the essential phonemic signs is no longer possible, phonemic hearing is disturbed. This is why
the boundary between hearing speech
and understanding it loses its sharp distinction.
If we accept Luria's position we may explain auditory aphasia as a breakdown
in the individual's ability to analyze
the flow of spoken utterance. If the
aphasia is acquired, the individual is
impaired or is no longer capable of phonemic hearing. Presumably, also, the
child with developmental aphasia is
initially lacking in the necessary capacity for subtle phonemic analysis and
so he does not learn to understand
speech.
The functions involved in phonemic
analysis are carried on by the secondary
divisions of the auditory cortex of the
left cerebral hemisphere. These areas,
Luria points out, "are closely associated
with the cortical apparatuses of kinesthetic (articulatory) analysis."
The work of these divisions consists
of the analysis and integration of the
sound flow by identification of the
phonemic signs of the objective system

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12

JOURNAL OF SPEECH AND HEARING DISORDERS

of the language. This work must be

carried out with the very close participation of articulatory acts, which, like the
singing activity of the vocal cords for the
hearing of music, constitute the efferent
link for the perception of the sounds of
speech. It consists of differentiating the
significant, phonemic signs of the spoken
sounds, inhibiting the unessential, nonphonemic signs, and comparing the perceived sound complexes on this phonemic basis. It refracts the newly arriving
sounds through a system of dynamic
stereotypes formed while the language
was being learned and thus carries out
its task on the basis of objective, historically established systems of connections. This deciphering of sound signals
in accordance with historically established codes of spoken speech and the
organization of auditory experience into
new systems constitute the basic activity
of the speech areas of the auditory
cortex.
Luria's postulations, supplemented
by the implications of the findings previously cited of the studies by Hirsh,

PERCEPTUAL

DEFENSES

One point that might have been

slighted in the early part of this paper
has to do with imperceptions that are
maintained by the child in the form of
perceptual defenses. These defenses may
well arise because the child is confronted with tasks which are beyond his
coping ability at a given stage in his
development. He may generalize his
perceptual defenses against the speech
signals which are meaningless to him
to speech signals in general and to the
makers of the signals and possibly to all
environmental sounds. A child who has
developed such defenses needs to be
enticed back to exposure to speech and

--

XXXlll, 1

Efron, Lowe and Campbell, and others,

on serial order judgments round out
my speculations as to the nature of
developmental aphasia. It is clear that
most adults with left cerebral lobe
damage require considerably more time
to make judgments as to the correct
order of sound impulses than do normal
persons. Comparable results were found
with aphasic children. It is my belief
that a child who cannot sequence
sounds is impaired in a capacity that is
essential for learning to understand
language and so, of course, to speak.
Thus, we may characterize the child
with developmental aphasia as one who
has a basic impairment in the necessary
capacity for the analysis of speech
signals and for the sequencing of
temporal events, especially for those
events which are received through the
ear and require not only discrimination
and identification but, in addition,
auditory processing.

AND

COUNTER

DEFENSES

to his involvement with speech and with

speakers. We have found operant conditioning and incremental teaching
(programmed instruction) to be promising techniques for enticement and
initial stage involvement. This does not
mean that we plan to replace the human being by a machine, or that all
communicative teaching needs to be machine programmed, or that clinicians
need to program themselves and the
objects of their efforts in machine fashion. It does suggest that we can make
human use of the machine as well as of
the human being in clinical teaching
approaches which may be broadly char-

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EISENSON: DEVELOPMENTAL APHASIA

acterized as operant conditioning. In

the long run, however, we might well
keep in mind the observation of de
Hirsch (1967) to the effect that: " T h e
way a child copes with his handicap
depends, of course, largely on the manner in which significant people in his
environment respond to his deficit."

13

A child's ego and his ego defenses

require consideration and treatment
that presently cannot be provided by
machines or machine-like programs.
Significant persons in a child's environment must provide a h u m a n basis for
h u m a n language usage.

ACKNOWLEDGMENT

This article is based on a paper presented at the 1966 Convention of the

American Speech and Hearing Association in Washington, D.C.

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