a case of developmental dyslexia and dysgraphia

A Case of Developmental Dyslexia and Dysgraphia

Noriko Oishi

Tama Habilitation Clinic

Teiko Sumino

Department of Neurology, Juntendo University

Masamichi Nagahata

Institute of Special Education, University of Tsukuba

ABSTRACT

This paper describes and discusses certain characteristics of a case of developmental dyslexia, H. M., who was f'Lrst examined at the age of six; his development of written and spoken language was kept under observation until he was eleven years of age, as he continued to complain of dyslexia and dysgraphia.

In the written language, he had a difficulty of associating (kana) letters and symbols (numeric and Chinese characters) with their sound values (in the case of hiragana) and pronunciation (in the case of kan/i and numbers). He finally learned to establish the needed associations but through an extra effort of using a keyword or object as a semantic reminder (a "conveyor or bridge," as it were) to connect sound and its written representation (hiragana, kan/i, or numeral).

Even after he had acquired the sound-symbol relationships, he continued to make two specific types of errors when reading and writing hiragana and kan/i: One is of phonemic type which pertains to errors in reading hiragana; the other is of semantic type which occurs when reading kan/i. These types of errors, coupled with evidence from the literature reported by others, suggest that H.M. had in his CNS a weak association between the visual (i.e., conf'~,urative) aspect of symbols (in the case of hiragana) and their phonemic aspect (i.e., the phonetic values conventionally attached to or represented by them), on the one hand, and a good (i.e., intact) association between the visual aspect of symbols (in the case of /can]/) and theiz semantic aspect (i.e., the meaning conventionally established with them), on the other.

In contrast, he manifested a naming difficulW and a paraphasia in picture-naming tasks in the spoken language. Careful observations of his naming difficulties indicate that he made fewer errors in naming tasks when only a single (i.e., auditory-verbal) modality was involved than when two (i.e., visual and auditory-verbal) modalities participated in the tasks.

86 Language Sciences, Volume 7, Number 1 (1985)

These characteristics of his written and spoken language suggest a functional impairment of the association between visual information conveyed through the visual modality and auditory-verbal information transmitted through the auditory- verbal modality. It is further argued that, as a theoretical construct, the written and spoken language deficits of a developmental dyslexic resemble to a great extent the symptoms of alexia with agraphia in adult. Such being the case, the paper concludes that the studies of H.M.'s written and spoken language deficits have now made possible a cogent albeit partial explanation of the nature of impairment that underlies the long-disputed problems of the so-called language disorder syndrome.

PURPOSE AND METHOD

In adult, when a lesion o f the brain has impaired an acquired ability to com-

prehend the written language, several syndromes manifest themselves which have become symptomatologically well established as independent clinical entities, such

as alexia without agraphia, alexia with agraphia, aphasic alexia, and others. And

neuropsychological and neuroanatomical analyses of the syndromes have to a certain

extent reached a general agreement as to the causes o f impairments and the focal

lesions responsible for the syndromes (Benson and Geschwind 1969; H~caen and

Albert 1978: 54).

In contrast, developmental dyslexia was first reported by Morgan in 1896

as congenital word blindness (Morgan 1896). Since then, numerous studies have

been conducted on this topic in neurology, psychology, and education. But

developmental dyslexia, when compared to acquired alexia in adult, can hardly be said to have established an independent clinical entity or entities. Many investi-

gators generally agree that developmental dyslexia is not a unitary disability based

on a single cause but constitutes a variety of syndromes each of which has a different underlying causation. Efforts have been made to classify developmental dyslexia

into subgroups according to the natures of impairments, but most studies along

this line deal only with a number of cognitive defects that come in combination

which appear on the surface level of the child's behavior, not referring to a distinctive

underlying cause of dyslexia. In view of this situation, a case report o f a boy of developmental dyslexia is

presented here to further clarify the nature and specify the characteristics of

developmental dyslexia. The boy visited the authors at age 6 claiming an inability

to learn to read and write. A remedial training for a 5-year-period followed. He

manifested some characteristic features in the process of acquiring reading and

writing hiragana, kan/i, and numbers. He made a specific kind of errors after he

acquired them. Both the process of his acquiring kana letters and errors he made

were totally different from those observed in normal children. He also manifested

some symptoms in his spoken language which could not be construed as due to a

general developmental delay in language.

A Case of Developmental Dyslexia and Dysgraphia 87

Attempts will be given in this article to deal with (1) description and analyses of the processes the boy underwent to acquire reading and writing, (2) analyses of the errors he made in reading and writing, and (3) the analyses of deficits in his spoken language. It is the purpose of this report to investigate an underlying cause of his dyslexia and to find a possible relationship between his dyslexia and his language deficits. The authors believe that the accumulation of case reports such as this will be a necessary step to clarify the neurolinguistic and neuropsychological mechanisms of developmental dyslexia.

DESCRIPTION OF THE CASE

Family History

H.M., an 11 year old boy, was born as a son of healthy parents. He has a sister 9 years older. His father had only an elementary school education but presently owns a constructional firm with success. His mother finished middle school and his sister, high school; neither of them has any difficulty in reading and writing. His father, according to his mother's report, cut the right fingers by an accident before marriage; consequently his mother has been writing for the father who reads newspaper and documents related to his business by himself but seldom reads books.

Case History

H.M. was born on February 1 lth, 1971, two weeks later than expected, with sluggish uterine contraction and Caesarean section (birth weight, 3,705g), without asphyxia. He began to walk at age 1,6 and started to speak at 2;0. At age 1;8, he was found to have a ventricle septum defect; he then had a surgery at age 2;0. By age 3 ~, he had caught up with his slightly slow development, including speech. No problem was noticed while he was attending nursery school. At age 6;4, two months after school enrollment, his school teacher sent him to us claiming that he did not learn reading and writing like his peers.

Neurological Findings

Neurological findings of the initial examination revealed no abnormality in the tonus of the extremities, reflexes, visual field and acuity, and auditory acuity. Soft neurological signs were absent. His EEGs, taken every year since the initial examination, repeatedly showed 9 c/sec alpha waves predominant in the occipital lobe. A small amount of sharp waves were observed simultaneously in the c~ntro- parietal areas of both hemispheres with the right parietal lobe predominant. A computerized tomography was taken at age 10 with no abnormal finding. He was right handed with no history of ambidexterity.

88 IAnguage Sciences, Volume 7, Number 1 (1985)

Neuropsychologicai Findings

Intelligence

The WISC was taken on two occasions (Table I). The results indicate a

consistent inferiority of verbal to performance IQ, the performance IQ being in

the normal IQ range.

Table 1

Results of Intelligence Tests at 6,6 and 8;8

Age

6;6

8;8

Name of Test Verbal IQ Performance IQ

WISC 74 108

WISC 82 109

Among the subtests of the Illinois Test of Psycholinguistic Abilities (Kirk

e t al. 1973) administered at age 6;6, he had his psycholinguistic age almost equal to his chronological age in Visual Association and Visual Reception; in contrast, his psycholinguistic age was almost three years behind in Auditory Association and

Auditory Sequential Memory.

Spoken Language

During the initial examination, he responded to, and answered accurately and promptly, our verbal commands. He spoke fluently. His conversation did not make us doubt of his language impairment until a close examination was administered.

As mentioned earlier, his WlSC verbal IQ was on a borderline range, although his performance IQ was above 100. A vocabulary test revealed his delayed develop-

ment in the acquisition of vocabulary. In naming pictures, he showed paraphasias and a naming difficulty. These points will be discussed later in detail.

His auditory memory span was short. When he was asked to repeat a series of

numbers in an increasing length like '4', ' 2 - 1 ' , ' 3 - 5 - 2 ' , ' 1 - 5 - 3 - 2 ' and so on,

he was able to repeat only up to two items at age 6;6, which was equivalent to a

three-year-old's auditory memory span. He was able to reproduce a series of 4 items of nonsense visual patterns in a correct sequential order in a visual memory

subtest of the ITPA at the same age. His auditory memory span increased to four items at age 9 (equivalent to a 4-year-old's auditory memory span) and five items

at age 11 (equivalent to a 6-year-old).


Discrimination of speech sounds was tested at age 6;6: Fifteen pairs of speech sounds whose initial consonants are dissimilar (/ra/-/da/,/hi/-/ki/, etc.) and 15 pairs consisting of the same speech sounds in each (/ra/-/ra/,/da/-/da/, etc) were given at random, one pair at a time, so as to ask for a same-or-different judgement. The result suggests an unimpaired discriminative ability of the speech sound.

He did not have a difficulty in the syntactic usage of words as far as his spoken language was concerned. No problem was observed in his articulation and prosody of speech.

Visuo-motor and Visual Perceptual Functions

That H.M. has good scores of the WlSC performance tests and visual-perceptual

subtests of ITPA has already been mentioned. For instance, copying of geometric forms, hiragana and kan/i, was done accurately (age 6;6). (See Figure 1). Color

sorting and matching were also done correctly; he chose the right colors in coloring

pictures (age 6;6). The results of these tests suggest that he had no major developmental delay in his visuo-motor and visual perceptual abilities.

~5

• , [ ]

1 2 3

Figure 1. Copying of Geometric Figures (first row), Hiragana (second row), Kan/i (third row), and digits (bottom row) at Age 6;6.


He could describe how to use scissors, a toothbrush, a spoon and chopsticks, when they were presented to him, without touching them (age 8;0). Facial

recognition and spatial orientation were good, too.

Hiragana, KanjL and Numerals

It is of interest to note that at 6~ , five months after school enrollment, he could not read or write any single letters or words in hiragana but his own name. When the individual hiragana letters from his name were shown or dictated in a random order, he was not able to read nor write any of them, although he could recognize them as symbols for his name, saying "This letter appears in my name."

He did not learn how to read or write any single kan]i during the first grade, even though he was supposed to have been taught 70 kanji (Chinese characters). Nor could he read or write any of the digits until age 8 but he could do simple calculations using a calendar. For example, in calculating 2 + 3, he marked numeral 2 first on the calendar; confirming that numeral 3 is the third number from 1, he wrote down the third numeral from 2, i.e., 5, as an answer. He could not give a

verbal answer to this calculation. Copying hiragana, kanfi, and digits was good as far as keeping the configurations

without too much distortion was concerned, even when he was at age 6. (See

Figure 1 .)

Summary based on the Clinical Findings

On the basis of the clinical findings, it may be summarized that H.M. (1) showed

a normal intelligence measured by the performance tests, (2) obtained a relatively low verbal IQ within a borderline range but had functionally sufficient language

skills for daily conversations, (3) displayed no developmental delay in visuo-motor and visual perceptual functions, (4) indicated no emotional problems, and (5) was never deprived of opportunity to learn kana letters. His problem was limited to the inability to learn reading and writing with no developmental delay in other spheres, except for some signs of impairment in his spoken language. He was, therefore, diagnosed as a developmental dyslexic. A remedial program was, thus, prescribed for him from age 6 ~ through age 11.

ANALYSES OF THE DEFICITS IN WRITTEN AND SPOKEN LANGUAGE

Having described the case, we should now proceed to analyze H.M.'s deficits which pertain to two language skills, written and spoken. They will be discussed in connection with the remedial program.

A Case of DevelopmentM Dyslexia and Dysgraphia 91

Written Language

Because of the clinical findings just stated, it was thought that the written

language skill might be easier for H.M., which was then divided into three areas, each being fitted with a set of strategies.

Strategies in Teaching Hiragana, Kanji, and Numerals to ll.M.

Hiragana

It is of interest to note that H.M., when he first came to us, did not know that

a hiragana, for example ~v , possesses the sound value [a/, even though he had

been repeatedly taught about this. This deficit looked as if he were unable to put the sound value as an acoustic property in his memory. Writing hiragana many

times did not help him in remembering their sound values, which is to say that a

kinesthetic approach was ineffective. Thus, a different strategy was pursued as follows: First, each of the 46 hiragana was assigned a particular word (keyword)

which began with the sound value of the hiragana, like 5 • 'horse' for the hiragana ~ and ~ , , - J " 'icecream' for the hiragana ~b • Forty-six cards illustrating a picture of each keyword and 46 individual hiragana cards were prepared. The

first task he was assigned was to match each hiragana card with its keyword picture card, making a visual association between the hiragana configuration and the picture of the keyword (Step 1). (See Figure 2 in the following descriptions of the strategies for learning letters.) He learned to establish 46 associations easily and quickly. It must be mentioned that step 1 was a purely visual task since no verbal response like naming pictures or reading hiragana was required.

Next, he practiced naming keywords on picture cards (Step 2). Although all keywords were selected from his expressive vocabulary, this task was not easy for him. Some pictures could not be named promptly; he deliberately named them after a pause. Some keywords had to be replaced by other words because they consistently caused him a naming difficulty.

Thirdly, he learned to say, by looking at a hiragana card, the name of the picture with which he had learned to associate, and then extracted its initial syllable which

was in fact the sound value of the hiragana he was looking at (Step 3). For example, he was shown the hiragana card 5 , recited the keyword/ tuma/ 'horse' and then said its initial sound [tu[. This step gave him the same degree of difficulty as in

step 2. For writing hiragana, he first practiced writing them from a keyword picture

card (Step 4), since associations between hiragana and the pictures had already been made in step 1. He wrote the hiragana by looking at the picture card of a horse. Then, he learned to write hiragana given the keyword auditorily (Step 5). For instance, he wrote the hiragana ~ when the keyword /tuma[ 'horse' was

9 2 L a n g u a g e Sc iences , V o l u m e 7, N u m b e r 1 ( 1 9 8 5 )

o t "~ t

N Z ~

-,.,.. , . . ~ ~ 0 " ' - C;Z;

o ~' f " - "

N Z ~

r' ~ a

z ~

~ m

° ~

t

VVIq [ 1

f

0

0

~ t >

t

>

O

q )

E E ~ t 0 0 0

' ~ ~1~ 0

._=

ee t,

&


pronounced. Finally, he learned to write hiragana when the initial syllable of each keyword was pronounced (Step 6). For. instance, he wrote the hiragana ~ when /tu / was pronounced.

Step 4, which was purely a visual task like step 1, was easy for him. Steps 5 and 6, which required him to write upon verbal stimuli, took him more time. In step 6, he necessarily recited its keyword first, given the initial sound, and then wrote the hiragana; for example, when / tu / was said, he recited the keyword / tuma/ 'horse', and then wrote the hiragana

It took him a year and four months to learn reading and writing of 46 hiragana. He proceeded to learn the reading and writing of words written in hiragana at age 8 but the progress was very slow. At age 11, he was able to read two- to three- syllable words fairly easily but words longer than four syllables were difficult. Reading sentences was not at all possible. Writing two-word sentences was possible

on dictation at age 10 ;2.

In reading and writing words, he exhibited a remarkable characteristic; he

necessarily referred to a keyword of every hiragana in words before reading and

writing them. In reading the word -9 ( L 'table', for example, he uttered/tsurmiki/ ( 'block', keyword for "~ ) , /ktu ts tu/( ' shoes ' , keyword for () , /eNpitstu/(_ 'pencil ' , keyword for ~_ ) and then . . . / tstu-ktu-e./ That is, it was necessary for him to

recite the keyword of each hiragana first, and then blended the initial sounds of the keywords, as it were, in order to read the target word. No difficulty was observed in blending initial sound and in recognizing the target word as a meaningful word. Referring to keywords was also a necessary step for him when writing words. Reading words was harder for him than writing them since, in reading, the initial sounds of keywords had to be sequentially stored in the memory until he came to recite the keyword of the last letter of each target word.

Kan/i

The same procedure was employed for teaching kan/i as for teaching hiragana. Two sets of cards, kan/i cards and @icture cards describing the meanings of kan/i, were prepared. Matching kan/i cards to picture cards (Step 1), naming picture cards (Step 2), reading kan/i cards (Step 3), writing kan/i from picture cards (Step 4), and writing kan/i on dictation (Step 5) followed. Step 1 was the easiest of all tasks. However, steps 2 and 3 required of him the same amount of effort;naming pictures was as hard a task for him as reading kan/i. Step 4 was easier than step

5; in fact, he sometimes failed to write certain kan/i on dictation but succeeded in writing them when pictures corresponding to them were shown.

He learned to read and write 23 kan/i in a 5-month period, slightly faster than learning hiragana, but no significant difference was observed in easiness of learning

between them. Yet, it can be predicted that the learning of kan/i will progress


faster than hiragana in the future, since he has already shown a good comprehension of kanji in step 1.

Numerals

In teaching numerals, tiles and tile-bars were used in place of picture cards

employed for hiragana and kan]i. He learned to estabfish the association between tiles and numerals (Step 1), tiles and the sound value of numerals (Step 2), and

numerals and their sound values (Step 3). As in hiragana and kanji, Step 1 was the easiest for him. He quickly learned that such a numerical concept as numeral 20 is equivalent to two 10-tile bars or four 5-tile bars but in steps 2 and 3 he

encountered a difficulty since he was now required to verbalize the numerical name of the number of tiles presented, and then, to read its numeral, e.g., '20' as/nij tu/ .

He finally learned to read and write numerals up to 20 by age 9;10.

The Analyses of Errors from Reading and Writing

Hiragana

Two types of errors were observed from the reading of words written in

hiragana. The first was the phonemic type of error in which he read one or two constituents (hiragana) of each word incorrectly: he read ~,~ /i-ntu/ 'dog' as / i -ne/( ~,,~a ), i.e., reading ~ / n t u / i n c o r r e c t l y as f a /ne / , ~',:1,, ~ / ta-i-ko/ 'drum' as /ta-i-ni/ ( t , : x , , ~ ) where r_ /ko/ was read as It- /ni/, ~LA, ry-9 /e-N-pi-tstu/ 'pencil' as /e-no-pi-tstu/ ( ~ © r Y - ' 9 ) where /o /N/ was read as © /no/, etc.

Hiragana which caused this type of error and the substitutions made were fairly consistent, the most frequent errors being between: ~ /ntu/ , f a /ne / , and 26/me/;

9 /r i /and L /fi/; ~/sa/and ~ /ki/; or ~- /ko /and ~ / n i / . More interesting is the second type of error in which a word was arbitrarily

substituted for the target word but in such a way that the two words always have the first syllable in common: For instance, he read -9 < ~ / tstu-ktu-e/ 'table'

as /tstu-ba-me/ 'swallow', ,'- 7a.g /ko-ro-btu/ 'to fall down' as /ko-o-so-ktu-do-

o-ro/ 'highway', ~ I,, ~ O /ka-i-mo-no/ 'shopping' as /ka-i, mo-no-re-e-r tu / ' shel l ' and 'monorail', etc. However, this type of error decreased in frequency, as he made progress in reading skills.

When writing hiragana, he made two types of errors also. The first was

graphemic in that he replaced one or two letters in a word with some other similar

ones without paying much attention to the sound differences. For instance, he wrote ~,,ab /i-me/, a meaningless word, for ~,,~ /i-ntu/ 'dog'; ." t g k 9 /ko-wa-

to-ri/, a meaningless word, for ~ t 9 / - 9 /ni-wa-to-ri/ 'chicken'; ~ r9 5 [o-ra-tu/, another meaningless word, for ~ to 5 /a-ra-tu / ' to wash', etc. Hiragana that caused

this type of error and the substitutions made resemble those in the reading errors


noted above. For instance, the most frequent errors were observed between: /me/ and ~t /n tu/ ; 9 /ri/ and L /fi/; ~-/ko[ and It__ /ni/; ~ / a / and ~ /o/;

/ r tu/ and 79 /ro[, etc. Upon careful observation, however, it is found that

when he produced this type of error, he first recited the correct keyword for the

letter he was to write but then he wrote down a hiragana letter unrelated to the keyword he had just recited. For example, in attempting to write I, , / i / , he recited

the correct keyword /i-stu/ 'chair' for ~,, and then wrote something else like ~.

/ko/, thus producing a discrepancy between the sound he uttered in the keyword

and the letter he wrote. The second type of error when writing hiragana was concerned with a

kinesthetic aspect of writing. That is, after writing one letter repeatedly as in Figure 3, he would suddenly scribble clumsily or change to a different hiragana, usually

resembling in configuration the original one. This type of errors also appeared in writing words on dictation. (See Figure 3.) He usually noticed these errors immediately and tried to correct them but it looked as though his hand worked by itself and he had no control over its movement.

b

Figure3. a. After repeatedly writing the same hiragana, he scribbled them. In the case of ~b , he wrote a different hiragana ~ which resembled the original letter in its configuration (Age 11).

b. When dictating a nonsense word fa7"z-~ , he scribbled the last syllable and corrected it on the left (Age 11).


In order to investigate H.M.'s errors of reading and writing further, he was told to read aloud and write on dictation five times each of 46 single hiragana at age 1 1 in the following way: Forty-six hiragana cards were shown in random order

but as soon as he read one card, the next card was shown. Dictation was administered in the same fashion. However, each time, only five trials were administered,

but on different days within a 3-month period. The results are shown in Table 2. By adding up all errors across 5 trials, 16 kinds were found in reading hiragana aloud and 13 in dictation from among the 46 hiragana letters. Besides reading or writing incorrectly or making no response, he read or wrote some hiragana deliberately, though correctly, after a pause. Ten of the hiragana were found to be frequently causing errors in both reading and writing.

Upon reviewing the errors he made when reading and writing letters as described earlier, the result of which is shown in Table 2, it is found that many of them occurred among hiragana which resemble one another in their configurations or sound values. For instance, the hiragana in each of the following sets ( g a / n t u / ,

~5 /me/, and ~ /ne/; ~-. /he/ and ,( / k tu / ; ~ /o/ and ~b /a/; ~ / r tu / and 79 /to/; ~ , / i / a n d ~_ /ko/; and ~ / sa /and ~ /ki/) are similar in their configura-

tions; but those in each of the next sets ( ~ / j tu / and ~ / t u / ; ~ / f tu / and 5

/ tu / ; 9 /ri/, L /fi/, ~/hi/,and ~. /mi/) are similar in their sound values because the same vowel recurs throughout.

Kanji

Semantic paralexia was also evident in reading kan/i. For instance, he read

~, /mtu-fi/ 'bug' as /k tu -mo/ 'spider'; Jl~ /miz tu / 'water" as /d 3 a-gtu- t f i / 'a tap' ; ~] /o-to-ko/ 'a male' as /ni-N-ge-N/ 'a human being'; and ~, /a-ka/ ' red' as

/ha-na/ 'flower'. But the interesting point is that the "erroneous" output in each

pair is not a nonsense word but a legitimate one which is semantically related to the stimulus word in some significant way: Similar semantic paralexia was observed,

too, in words composed of kanji and hiragana. For instance, he read ~ E ;~ /o-hi-sa-ma/ "the sun' as / ts tu-ki/ ' the moon ' ; ~ 4 ~ /o-ka-ne/ 'money ' a s / d ] ru- e-N/ 'ten yen'. Judging from these errors, it seems that each stimulus kanji, though erroneously read, has a strong semantic association with the meaning of its "erroneous" output, although their phonological shapes have little in common. For instance,

'a male' is semantically related to 'a human being' but they share not even a segment in their phonological make-ups,

On dictation, however, he made fewer errors than in reading. Moreover, those kan/i on which he made semantic paralexia in reading were usually written correctly.

Numerals

In reading and writing numerals, errors were often observed even at age 11.


Table 2. H.M.'s Errors when Reading and Writing Hiragana

97

Reading errors

Hiragana 1st 2nd 3rd

trial trial trial

n m ne ne

g,~ j m m ,.u

~'- he pc km

J: ho j o

L, n fi

~'o me NR

k'~ ke ~e

~b :~ o a

hi

;5 ro rtu

Y j o ho

mi

ni ko

t . f i

-~ k i sa

x c so

.g,- f m

fg na

;It, re

Total number of errors in 7 5 4 each trial

4 th t r ia l

J~ ne

u/

% t f i

se

5t

Writing errors

5th 1st 2nd 3rd 4th

~ia] trial ~ial trial trial

~b me

tu

be

NR NR

NR NR

NR

ntu

< km

NR

5th

trial

NR NR

NR

w

mi hi

J: jo

ts tu

4 4 5 4 2 5

NR

wa

NOTES: Hiragana were presented to H.M. one at a time, so that he could read it aloud. The same hiragana was also dictated to H.M. The Table shows the results of both tasks. For example, H.M. read the hiragana IO as/he/"J~ four times and /me/ ~ once. He wrote nothing on dictation in the first two trials but wTote correctly after the 3rd trial NR means no response• Blank means "correct response'.


He read numeral 7 as /ha- t f i / , meaning 8, and wrote 4 on dictation as 3. Errors in writing numerals were also typically observed in dictation of formulas (additions

and subtractions). For instance, when he was dictated 3+9, he wrote them down

as 4+9, thus getting the answer 13; the answer was wrong, although the calculation

itself was correct. Likewise, he scribbled when writing numerals.

Spoken Language

The spoken language skill, though functionally sufficient, as was mentioned

before, also showed certain deficits two of which are singled out here, viz.,

vocabulary size and naming difficulty.

Small Vocabulary

The receptive vocabulary test (Owada and Nakanishi 1980; Ueno et al. 1978)

administered at age 8;4 revealed his vocabulary age to be that of a four-year-old,

suggesting a delay of 4 years in the development of vocabulary. Among the words

he did not comprehend at this time were < 7"~ ~o 09 'fruit ' , ( -'J" 9 'drug', 5 -J" ~,'

' thin', O' o tg ;5 ' to pull', etc. His vocabulary age increased to six years at age 9;8

and seven years at age 11;3, still showing a consistent delay in the receptive vocabulary development.

A naming test of objects and pictures evidenced his further limited expressive vocabulary. At age 6;9, he claimed not to know the names of 'egg', 'vegetables', 'coins', etc. in a picture. The results of naming at age 6;9, 10;7, and 11 ;5 are shown

in Table 3.

His vocabulary was not only limited in the number of nouns, but also in the

number of words belonging to other parts o f speech. At age 8, he could not choose

the correct pictures of a man polishing shoes and a man picking up grapes, when

stimuli -b.~ { ' to polish' and - 9 ~ ' to pick up' were given verbally. In describing

pictures of a girl wearing shoes and a girl bouncing a ball, he said " ~ A~ t~: © C. ~

( ---o L "( ;5 ," 'A girl doing shoes', and " ~ A, t,c 09,7. ~ • 9 b X7 ;5 ," 'A girl

doing a ball' which are all ungrammatical, because "< -9 U "~ ;5" /k tu tstu f i te r tu /

and " • 9 L ' ~ ;5 " /mari f i t e r t u / are un-Japanese. After 5 months of school

enrollment, he still could not remember his teacher's name: H.M. addressed him as " ~ < © ~ A,-~ t,, ," 'My teacher' instead. He did not recognize the name of

the city he had lived in when it was said to him (age 8).

At age 6;9, in order to see whether there was any difference in the sizes

between his receptive and expressive vocabularies, 21 words were selected which

he had failed in picture-naming tasks to test him. He was asked to point to the

right one among 10 pictures when the name was given verbally (words in the first

column marked with * of Table 3). He chose 18 correctly out of 21 words. The

result indicated that some words he failed in picture-naming tasks belonged to


Table 3

H.M.'s Responses to Pictures Shown at Different Ages

99

Pictures s h o w n Responses Responses Responses at age 6 ; 9 a t a g e 10;7 a t a g e 11 ;5

Sa fe ty p in* N R Tweezers Tweezers

I ron Kn i t t i ng o o

H a m m e r * Tap, t ap N R o

Can* N R o o

Safe* Thief , m o n e y N R o

Fan* N R Propel le r N R

Purse N R o o

D r u m A th ing t h a t b u m p o o

B r o o m * A th ing to sweep o V a c u u m c leaner

Bell* N R o o

Ladde r* A th ing o n wh ich to c l imb up N R o

Pos t ca rd* N R - N R

Hair b r u s h * T o o t h b r u s h N R N R

Bucke t* N R - -

Egg N R - o

Vege tab le* N R - -

Barber N R o o

Rail* Tram o o

T a n k * N R o Bat t le

Soldier* G u n o o

Ski* Ska te Ska te N R

Ki te* N R - -

Peacock* N R - Swan

Eagle* Bird - N R

G o a t * Cow Deer o

Camel* It l ooks l ike a ho r se o o

NOTES: o means 'correct naming'; NR, 'no response'; - , 'not tested'. Words marked with * were also used in a comprehension test at 6;9 in which H.M. was asked to choose the correct one from among 10 pictures, when the name of a picture was given verbally as a stimulus. He chose 18 correct pictures out of 21 stimuli.


his receptive vocabulary. As will be discussed later, he also showed a naming

difficulty and manifested paraphasia in naming tasks.

Naming Errors

Picture-naming tasks elicited further characteristic features of his spoken

language; that is, naming difficulty and paraphasia. Although they became obvious

in naming tasks, they could hardly be detected in his daily conversation.

The naming difficulty showed up in his trouble of retrieving words immediately

after seeing pictures. However, he could name some pictures correctly after a short

pause; others he could not name, at first, although he named them correctly on

another occasion. Among such pictures were 'pencil', 'horse', 'fish', and 'mother ' .

His paraphasia was mostly verbal. For instance, he said /de-N-f a~ ' t ram' for

'rail' and /stu-ke-e-to/ 'skate' for 'skis'. Instead of saying the name of an object,

he sometimes described its usage or shape like "white and square" for 'towel'. In order to analyse his naming errors, the following two experiments were

undertaken at age 11. First, colored picture cards of fifty familiar objects and animals were prepared. He was then told to name the cards one by one consecu- tively. When he did not name a card or gave a wrong answer, neither comment

nor correction was made. Naming of the set of 50 cards was repeated once a month

for a total of five times during a 5-month period. The results are shown in Table 4.

Note that the number of cards he failed to name or gave wrong answers for

varied between two to six from one trial to another. There are also words which

he failed on consistently for more than two trials like ~ / o to_ ~ -~ /seNtaktuki/ 'washing machine', ~" 7, /gastu/ 'gas', L ,t 5 ~ 5 L ~ / fooboofa / 'fire engine'

and ~ k-" A, / t udoN/ 'noodles'; such failures resulted from the fact that either his

responses were paraphasic or there was no response. On the basis of this experi-

ment, it was confirmed that H.M. still had naming difficulty and paraphasia at

age 11.

Second, twenty pictures were selected, for which he manifested naming

difficulty or was paraphasic at age 11 (Table 5, a and b). H.M. was then given

the words of those pictures verbally one by one and told to choose the right picture

from among five. The pictures in each trial were five line drawings of objects which

resembled one another in shape and one of which was a picture he had misnamed

previously (Figure 4). He chose the correct pictures in all 20 trials (Table 5, c).

From the result of this experiment it followed that his comprehension of words

was intact and that there was no visual perceptual disorder as a cause for errors

in picture naming.

Next, two months later, a dictionary-like definition was read to him for each

of the 20 words; he was then asked to supply the word upon hearing its definition.

Examples of such definitions are: 'an appliance used to make ice and cool food '

A C a s e o f D e v e l o p m e n t a l D y s l e x i a a n d D y s g r a p h i a

T a b l e 4.

H.M. 's Responses to P ic tu re -Naming Task at 11 ;0

1 0 1

Response

Pictures shown 1st 2nd 3rd 4th 5th

trial trial trial trial trial

1. Kite 2. Lunch box 3. Refrigerator 4. Mailbox 5. Gold fish 6. Gas 7. Television 8. Giraffe 9. Chopsticks

10. Grape 11. Chair 12. Rocket 13. Leaf 14. Cow 15. Pig 16. Bicycle 17. Spectacles 18. Candy 19. Tea cup 20. Mouth organ 21. Soap 22. Cat 23. Tram 24. Fish 25. Noodle 26. Train 27. Doll 28. Bucket 29. Hen 30. Umbrella 31. Pencil 32. Washing machine 33. Rabbit 34. Duck 3.5. Orange 36. Teaspoon 37. Balloon 38. Strawberry 39. Fire engine 40. Crab 41. Clock 42. Scissor 43. Rice 44. Vacuum 45. Crocodile

46. Glass

47. Horse

48. Coffee 49. Boat 50. Trousers

NR

NR

Chinese noodle

Teddy bear

NR

NR

NR

Strawberry

NR

Chinese noodle

Refrigerator

NR

Halfsplit chopsUcks

Refrigerator

Orange

Chopsticks

Soup

NR

Yacht

Total number of errors in each 6 2 4 .5 3 trial

NOTES: Blanks mean that the objects were named correctly. NR means 'no response'.

Chinese noodle


Table 5

H.M.'s Types of Responses at 11 ;0 to Twenty Words Selected from Picture-Naming Tasks

a. b. c. d.

Target words for H.M. 's e r r o n e o u s A u d i t o r y N a m i n g resul ts f rom

wh ich pic ture- responses to c o m p r e h e n s i o n d ic t ionary- l ike

n a m i n g er rors p ic ture- o f ta rget oral

occur red n a m i n g words de f in i t ions

1. Orange S t r a w b e r r y o o

2. Giraffe N R o o

3. Hen Bird o o

4. aEagle N R o o

5. Peacock Swan o o

6. Socks Shoes o o

7. Hair b rush N R o o

8. B room V a c u u m o N R

9. Gas N R o o

10. Safe ty pin Tweezers o Tweezers

11. Ladder N R o o

12 Ref r igera tor Washing m ach i ne o o

13. Washing m a c h i n e N R o o

14. Fan N R o o

15. Pos tca rd N R o Mail

16. Dice Block o o

17. Ring D i a m o n d o D i a m o n d

18. T h e r m o m e t e r N R o N R

19. Fire engine N R o o

20. Tank Bat t le o Jeep

NOTES: H.M. was given several picture-naming tasks Table 4 was one of them. Twenty target words with which H.M. had naming difficulty or showed paraphasia were selected from those tasks. They are listed under a. The erroneous responses are listed under b. H.M. was given these target words verbally and asked to point to the pictures. The results are shown under c. Then, he was given a dictionary-like definition orally of each target word and asked to name it. The results are shown under d. o means 'correct response'. NR means 'no response'.

A Case of Devdopmenud Dyslexia and Dysgraphia 10 3

~ , - ~ - ~ . ~ _ ~ ~'_~.Z-l~ ~ -

Figure 4. Given the word "peacock" auditorily, he had to choose the right picture out of these five pictures. He had previously named the picture of a peacock 'swan'.

for a refrigerator and 'a bird in a zoo which has unusually large tail feathers that

resemble a fan when spread out ' for a peacock. He gave 14 correct answers out of 20 definitions (Table 5, d). This result suggests that the task administered within a single modality (naming from a verbal definition) was easier for H.M. than the task involving two different modalities (naming pictures).

DISCUSSION

Given the above analyses of H.M.'s deficits in both written and spoken language

skills, some discussions of the results are in order.

Deficits in Written Language

Normal children learn the association of each letter and its sound value without any special effort. However, H.M. had a difficulty in establishing that kind of

association. To accomplish this goal, a special method was used. That is, an intermediary object (a keyword, a picture, or even a tile) was "inserted" between

letter and sound to facilitate the association, because the object served as a meaningful clue for the association. For instance, in reading hiragana, the visual configuration of each letter reminded him of its keyword, thereby triggering the


pronunciation of its initial syllable which is the sound value of the letter, In writing, the process was reversed. A sound first reminded him of its keyword; the keyword then served to elicit the corresponding hiragana configuration. In so doing, he learned the conversion from sound to hiragana configuration. The same method went for the learning of kanji and numerals. But after the acquisition of ortho- graphy, it was found that the errors he made in reading and writing hiragana were mostly of syllabic nature, which suggested a weak association between kana letter and sound, whereas the errors he made in reading kanji were of semantic type which also suggested a weak association of sound and symbol.

From those specific characteristics of his written language, it may be suggested that there exists a functional deficit in H.M. which caused his difficulty in reading and writing, a deficit that is the weak association of visual information and auditory- verbal information. This suggestion may be substantiated in the following way: Recall that in the process of learning hiragana, kanji, and numerals, he consistently showed a tendency of performing the tasks more easily when a single visual modality was involved (Steps 1 and 4 in Figure 2), but he needed much more efforts and longer time in performing the tasks when both visual and auditory-verbal modalities were involved (Steps 2, 3 and 5 in Figure 2).

As an example of reading and writing impairments caused by the dissociation between visual and auditory modalities, alexia with agraphia in adult is often mentioned. Its clinical symptoms are: (1) Defects in reading and writing dominate other defects of the subject; (2) Dictation and spontaneous writing are impaired; (3) Copying may (Benson and Geschwind 1969) or may not (Yamadori 1979) be impaired; (4) Aphasia inevitably coexists but varies in degree of severity; (5) Naming difficulty and paraphasia are frequently exhibited; (6) Repetition is usually good; (7) Reading hiragana is usually more seriously affected than kan/i; and (8) Semantic paralexia appears in reading kan/i (Benson and Geschwind 1969; Yamadori 1979).

Geschwind (1965) suggested that, as a theoretical interpretation of alexia with agraphia in adult, a lesion in the angular gyrus obstructed the association between literal configurative information conveyed through the visual modality and auditory-vocal information through the auditory modality, which caused alexia. On the other hand, Yamadori (1979) analysed the errors made by two Japanese patients of alexia with agraphia in reading hiragana, and postulated as an underlying mechanism of these patients' alexia in hiragana an inability to convert grapheme to phoneme. Moreover, in contrast to the grapheme-phoneme route for the reading of hiragana, he also suggested a grapheme-semantic route through which kanji was read, and explained that the fact that the alexics could read kanji better than hiragana was because the grapheme-phoneme route was impaired while the grapheme- semantic route was preserved.


Yamadori's hypothesis seems sound and could be used to explain developmental dyslexia because H.M. made it possible to convert the visual configurative information (grapheme) into the auditory-vocal information (phoneme) by inserting the semantic information in between. In line with Yamadori's term, it can be said that H.M. utilized the grapheme-semantic route in learning to read hiragana. The functional deficit which was suggested as an underlying mechanism of H.M.'s reading and writing difficulties, therefore, looks similar in nature to that of alexia with agraphia in adult, because, except for poor repetition, H.M. manifested many symptoms of alexia with agraphia in adult.

Alexia with agraphia in adult is further suggested to have a functional dissociation across visual, auditory, motor and tactile modalities (Yamadori 1975; 1982). If so, some of H.M.'s symptoms observed were suggestive of similar functional dissociations across those modalities. He could not utilize the kinesthetic sense in learning to read. This fact suggested that he had a poor association of auditory information and kinesthetic information across two modalities. When writing,

moreover, errors occurred among letters that resembled each other in their configurations. While repeatedly writing the same letter, he suddenly scribbled it. These may suggest that the association between the visual and the kinesthetic sense

has not been fully developed and that, as a result, he made such errors because he

depended heavily on the kinesthetic sense to write letters without sufficient visual

information from the visual sense to the kinesthetic sense. From the clinical point of view, although H.M.'s reading and writing difficulties

certainly resembled the functional impairment of alexia with agraphia in adult,

it is dangerous to assume a focal brain lesion by simply following alexia with agraphia in adult when discussing a biological foundation of such functional deficits in H.M. For instance, it is important to bear in mind that even though he manifested a

paroxysmal activity in the centro-parietal areas on EEG, this did not coincide with the brain lesion suggested for alexia with agraphia in adult. That is to say, deficits of a developmental nature like H.M. and adult deficits owing to the loss of an acquired ability may not have the same biological foundation, even if both may show the same clinical symptoms. At this point, it can only be concluded that H.M.'s reading and writing difficulties are due to a certain deficit or malfunction of the central nervous system, that the functional deficit caused by the dissociation between visual and auditory-verbal modalities may be suggested as the underlying cause of his difficulties, and that such a functional deficit resembles that of alexia

with agraphia in adult.

Deficits in Spoken Language

Recall that naming difficulties and a delayed development of vocabulary were

the main characteristics of H.M.'s spoken language. In his naming difficulties, a


naming task that involved a single modality (the auditory-verbal modality) evoked fewer errors than a task that involved two modalities (visual and auditory-verbal modalities). This indicates that he had a functional deficit of associating visual information with auditory-verbal information even in the expression of the spoken language.

Geschwind (1965) suggested the role of the left angular gyrus in language development, especially in its early stage, where the somesthetic-auditory, visual- auditory, and other cross-modal associations are formed. According to him, the development of object-naming is greatly dependent on the formation of the associations between auditory and other modalities (1965: 274). In this sense, although his pathological background is not known, and whether or not he has a left angular lesion is immaterial, it is insightful to regard a delayed or impaired formation of the associations between auditory and other modalities as the underlying cause of H.M.'s small vocabulary.

It follows that when the two main characteristics of his spoken language are understood to be the results of an impaired or delayed development of the cross- modal associations, it can be said that he had the common underlying mechanism which caused the deficits in both written and spoken language.

H.M. as a Case of Developmental Dyslexia

Mattis e t al. (1975) made a neuropsychological study on children of developmental dyslexia, and found among them a group who typically showed anomia in picture-naming tasks. Although these children had anomia in picture-naming tasks as their primary deficit, they also had the following language deficits" (1) a mild degree of impairment in the comprehension of spoken language, (2) poor repetition, (3) poor auditory discrimination of speech sounds. These children had a performance IQ within the normal range and had no deficits in articulation and visual perceptual functions. Mattis et al. (1975) and Denckla (1977) caUed this type of disorder the language disorder syndrome, a subtype of developmental dyslexia.

H.M. had a naming difficulty and paraphasia, a limited size of receptive and expressive vocabulary, and poor repetition, although he had no problem in auditory discrimination of speech sounds. Accordingly, H.M. can be classified as a case of one of the various types of developmental dyslexia, viz., language disorder syndrome.

It has been suggested by many investigators that reading difficulties of the language disorder syndrome have their underlying cause in the functional deficits of the spoken language (Mattis et al. 1975; Benson 1978; Rapin 1982). But how such language deficits as anomia, poor comprehension, poor repetition, and poor speech sound discrimination cause reading difficulties, or how language deficits and reading difficulties are related, have yet to be investigated.

Nonetheless, it has been indicated that H.M.'s language deficits beginning with


the anomia have as their underlying mechanism the impairment in the association of sensory modalities including that of the auditory and visual modalities. But the same underlying mechanism has also been thought of as the cause for his reading and writing difficulties. Such being the case, it may be concluded that through the studies on H.M.'s written and spoken language deficits a partial explanation of the nature of impairment underlying the language disorder syndrome has now been made available.

REFERENCES

Benson, David F. and Norman Geschwind

1969 "The Alexias," in Handbook of Clinieal Neurology, Vol. 4, pp. 112-40, P.J. Vinken and G.W. Bruyn (eds.), Amsterdam: North Holland Publishing Co.

Benton, Arthur L. 1978 "Some Conclusions about Dyslexia," in Dyslexia, Chapter 22, pp.

451-76, Arthur L. Benton and David Pearl (eds.), New York: Oxford University Press.

Denckla, Martha 1977 "Minimal Brain Dysfunction and Dyslexia: Beyond Diagnosis by

Exclusion," in Topics in Child Neurology, pp. 243-61, Michael E. Blaw, Isabelle Rapin, and Marcel Kinsbourne (eds.), New York: Spectrum Publication, Inc.

Geschwind, Norman 1965 "Disconnection Syndrome in Animals and Man," Brain 88.237-94,

585-644. H6caen, Henry and Martin L. Albert

1978 Human Neuropsychology, New York: John Wiley and Sons.

Kirk, Samuel A., James J. McCarthy, and Winifred D. Kirk 1973 Illinois Test of Psycholinguistic Abilities (Japanese edition), Tokyo:

Nihon Bunka Kagakusha. Mattis, Steven, Joseph H. French, and Isabelle Rapin

1975 "Dyslexia in Children and Young Adults: Three Independent Neuro- psychological Syndromes," Developmental Medicine and Child Neurology 17.150-63.

Morgan, Pringle 1896 "A Case of Congenital Word Blindness," British Medical Journal 2.

1378. Owada, Kenjiro and Asako Nakanishi

1980 "The Vocabulary Test of Picture-Word Identification," Onsei Gengo Igaku 21.217-23 (In Japanese).


Rapin, Isabelle 1982 Children

Neurology, New York: Raven Press. Ueno, Kazuhiko, Tomonobu Nadeo and Kiichiro Iinaga

1978 lh'cture Vocabulary Test (Kaiga Goi Kensa), Tokyo: Kagakusha.

Yamadori, Atsushi 1975 "Ideogram Reading in Alexia," Brain 98.231-8. 1979 1982

with Brain Dysfunction, The International Review of Child

N~on Bunka

"Alexia with Agraphia," Shinkei Naika 10.428-36. (In Japanese). "Alexia with Agraphia and the Angular Gyrus Lesion," Shitsugosho Kenkyu 2.236-42. (In Japanese).

a case of developmental dyslexia and dysgraphia

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