Our Formative Years 1900-1945
Among the earliest American books on speech disorders was one written by Samuel Potter (Potter, 1882). Potter was a medical doctor in America who stuttered. In his book he reviewed the European literature speech disorders, focusing specifically on terminology and treatments. Included in his general classification of disorders are alalia (language and motor speech disorders arising from cerebral lesions or motor paralysis), paralalia (articulation disorders), and dyslalia (stuttering). He recommended careful speech training for alalia, offering no further details.
For paralalia Potter recommended that "the patient should be carefully and regularly exercised on the offending sounds by reading aloud, repeating the alphabet, or other exercises in pronunciation (pps. 35-36). He also recommended phonetic placement suggesting that "the various organs of articulation should be explained to him, and he should be required to place them in their proper positions before enunciating the sounds" p. 36). For rhotacism, or difficulty with the r sound, Potter suggesting selecting "tr" blends and substituting a "d' for an "r" and "exercising thereon, until by degrees the rapid combinations of the sounds td, produce the lingual "r" (p. 36). Finally Potter recommended that breathing be regulated throughout the reading practice by requiring the patient to inspire at the punctuation marks (p. 36).
Potter devoted most attention to treatments for dyslalia, or stuttering. He recommended two to three hours of daily work involving education of the will and reeducation of the faculty of speech. The reeducation should involve exercises regulating respiration, and vowel-consonant practice (pp. 98-102). He also warns against the use of tricks, mechanical contrivances, and tyrannical practices prescribed by "fools" (p. 11).
Thirty years following the publication of Potter's book Edward Wheeler Scripture published a book Stuttering and Lisping (Scripture, 1912), which he republished 11 years later under the new title Stuttering, Lisping, and the Speech of the Deaf (Scripture, 1923). Scripture's methods and terminology in the two editions of his book were drawn from his knowledge of the late nineteenth century "speech doctors" in Germany (Weiner, 1986). The term "lisping" in the title was Scripture's term for articulation problems. He divided lisping into four subtypes: negligent lisping, organic lisping, neurotic lisping, and cluttering.
The first, negligent lisping, Scripture said was due to "mental carelessness" where "the child is careless or negligent in his observation of the speech of other people or himself" and thus "fails to produce the sounds properly." His remedy was to place the articulators in the correct position, sometimes using devices such as a tongue depressor, a rod for pushing the tongue, a velar hook for elevating the velum, and an instrument for measuring "air current." Once the correct articulatory position is learned for the defective sound, the therapy proceeds to "careful drill in pronouncing words and sentences... in connection with reading exercises."
Scripture's organic lisping category included articulatory problems caused by physical defects. He saw some organic problems as hopeless and others as curable through the same articulatory placement and drill methods used for negligent lisping.
Neurotic lisping differed from negligent lisping in Scripture's system in that the neurotic lisper is "not careless about her speech but overanxious" (Scripture, 1923). Neurotic lisping, according to Scripture "appears in nervous persons and not in phlegmatic or dull ones, and that the muscular movements are cramplike instead of careless (p.185)." His treatments for neurotic lisping was borrowed from the physicians of the day who used them to cure hysteria and other psychologically caused disorders:
General hygiene, mode of life (school profession), moral habits, eyestrain, nose and throat conditions, etc., must be considered. Arsenic, quinine, strychnine, and other tonics, cold rubs, lukewarm or cold half baths, sprays, moist packs electrotherapy, massage, change of climate, and sea baths may be tried. open?air exercise is always admirable. Hypnotism and other forms of psychotherapy are often most efficient.
Scripture added a "speech treatment" to the medical regimen for neurotic lisping:
The special speech treatment consists in explaining the trouble to the patient and then having him repeat sentences, answer questions, and talk in a relaxed way. The relaxation may be brought about voluntarily or by suggestion. An efficacious method of suggesting relaxation is to have the patient recline on a couch and gradually fall into a semidoze while repeating sentences or conversing (p. 185?6).
Also regarded by Scripture as a type of nervous disease was cluttering. The symptoms of cluttering, according to Scripture and those who preceded him (Klencke, 1842, cited in Rieber & Froeschels, 1966) were rapid speech and indistinct enunciation. His therapy for cluttering entailed:
... tongue gymnastics, of exercises in enunciating words single and in combination, and in speaking slowly and distinctly. If the clutterer is forced to enunciate certain sounds such as the explosives or "s" very distinctly, he is obliged to speak slowly, and can thus learn to enunciate all sounds better. The breath indicator can be used. In severe cases the treatment may begin with singing. The nervousness may be combated by proper hygiene, tonics, rest cures, hypnotics, or psychoanalysis.
So, as early as 1912, Scripture offered a variety of ways to remediate speech problems, ways that varied depending upon the type of speech problem and its presumed cause. For problems caused by carelessness or those of physical origin, the treatment involved what was later to be called a phonetic placement approach, where articulators were placed in the desired position. Once clients were able to form the sound, Scripture had them practice the correct sound by using drill activities or having them read aloud.
For lisping caused by anxiety, the treatment was to use the methods used in Europe and America for curing hysteria?medicinal prescriptions of arsenic, quinine and tonics or the newly discovered medical therapies of electrotherapy, psychotherapy, and rest cures. Along with the medical treatments Scripture suggested a relaxation approach where anxious or rapid speakers were taught to "talk in a relaxed way." And for cluttering, which Scripture saw as a type of hypertense nervous disease, he recommended careful enunciation, and tongue gymnastics.
Scripture's diagnostic as well as therapy focus was on the motor production side of speech. He differentiated muscular laxness from tenseness, and distinguished patients who did not know how to say sounds from those who said them too fast. He also subscribed to the notion that practice in the form of exercise and drill or relaxation was the procedure to be used for bringing about changes patients' speech production.
In 1920, Margaret Gray Blanton and Smiley Blanton published a book directed to parents and teachers of normal and speech disordered children (Blanton & Blanton, 1920). The book had a double focus. First it outlined ways parents and teachers of speech should encourage good speech in normal children, and then it outlined the incidence, nature, and therapy methods for treating children who stutter, and children with monotonous voices, with letter substitutions (articulation disorders), idioglossia, and a lack of speech. The Blantons recommended speech training for all children, as part of the everyday school program. They recommended that parents desist from frequent admonitions such as "Do not talk so loud," or Do not talk so much" and to give up the "pernicious doctrine" that "children should be seen and not heard" (p.18). For teachers they recommended that not too much emphasis be placed in class on the "correction or pronunciation and grammatical construction." Nor did they recommend that teachers engage young children in "direct work for letter position" (p. 2l). Rather than correcting the child during the day or working on speech directly, they recommended a fifteen minute daily drill period which would include high interest activities such as "reading rhymes" or "playing games and reading or acting stories" (p. 20).
In their discussion of speech disorders, Blanton and Blanton hypothesized about causality and recommended therapy accordingly. For example they forwarded the following reasons why children may lack speech: mental deficiency, brain injury, digestive disorders, or because of rearing problems. The rearing problems were of two sorts: one of caretakers' anticipating the child's "slightest whim" thereby reducing the child's motivation to talk, and the second of caretakers' over protectiveness. The lack of speech in the case of over protectiveness is a secondary result.
Blanton and Blanton (1920) explain:
A second very handicapping fault in the rearing is too great an anxiety on the part of the parent to preserve the child from possible falls and blows. This results in the child not being permitted to crawl and walk freely, and as a result, the fundamental coordination of the muscles does not develop. Allied to this is the handicap of being reared in a house of slick floors and being made to wear still?soled shoes, under which conditions the acquiring of walking and running is delayed, with a subsequent delay of the development of speech (p128-9).
For intelligent children who lack speech, the authors recommend that the child be "required to make an attempt at repeating the names of things before they are given to them" (p128).
In 1928 Sara Stinchfield, the first person in America to receive a Ph.D. degree in speech pathology, published her book entitled The Psychology of Speech (Stinchfield, 1928). She followed it a few years later by a second, called Speech Disorders (Stinchfield, 1933). She co-authored her third book five years later, Children with Delayed or Defective Speech, (Stinchfield & Young, 1938) with Edna Hill Young, and published a fourth in 1950 on Speech Therapy for the Physically Handicapped (Stinchfield-Hawk, 1950). Her fifth and last book was published in 1955, again with Edna Hill Young on Moto-kinesthetic Speech Training (Young & Stinchfield, 1955). It was an updating of the 1938 book, focusing more on the therapies and less on the science of speech production.
Stinchfield-Hawk differed from Scripture in that she did not attempt to fit specific therapies to different types of speech problems. Her primary focus in her second book was to present a taxonomy of diagnostic categories, designed to differentiate speech disorders from one another. For example, she listed six general problem types, 42 disorders under those, and 106 subtypes under the 42 categories. Thus dyslalia (articulation disorder) is seen as a general type, alalia (mutism) as a subtype under that, and delayed speech as a subtype of alalia. Stinchfield-Hawk selected some of the more common disorders for discussion, and devoted a section to defining them, giving a brief symptom description of each, and, for a few disorders offered a paragraph or so of therapy suggestions. Her therapies usually involved general muscle exercises and drill on isolated speech sounds. She recommended change in the psychological environment, more rest, and changes in diet for speech problems caused by nervous disturbances. Her most elaborated therapy recommendation was for articulation (dyslalia) where she advocated organizing therapy around five speech learning habits outlined by Palmer in 1921 (Palmer, 1921).
Stinchfield's five speech habits included sound bombardment, sound imitation, and sound and word sequencing. They also included the notion that clients must learn to associate words, phrases, and sentences with their meanings. This focus Palmer called semanticizing. Finally, Stinchfield followed Palmer's recommendation for teaching grammar, using drills involving different grammatical patterns.
The Stinchfield-Hawk's approach to teaching sounds was like Scripture's, where the clinician is advised to teach sounds by rote practice procedures of drill and reading aloud. Stinchfield-Hawk, emphasized auditory aspects of speech rather than on motor production. Also, following the linguistic emphasis of Palmer, Stinchfield-Hawk included grammar in her approach, rather than presuming, as did Scripture, that speech consists solely of sounds.
The motor-kinesthetic approach advocated by Stinchfield-Hawk in her 1938 book with Edna Hill Young, was an elaborate and intrusive version of phonetic placement in which the articulators were directly manipulated by the clinician (Stinchfield & Young, 1938). Edna Hill Young had a severe malocclusion resulting in an open bite as a child. She moved her jaw to the right when she talked and used her tongue against her teeth achieve frication for s and z sounds. She studied her own speech production in relation to others, had dental work done, and developed a phonetic placement method for sounds production that was later called the moto-kinaesthetic method. Although reminiscent of the phonetic placement techniques described in Scripture, Young offered much more detail about how to manipulate the child's articulators to produce each of the sounds of English. The approach was designed to remediate a variety of speech problems, including cleft palate, articulation, aphasia in adults, and delayed speech and primary stuttering in children. This suggests that Young viewed all speech disorders as originating in a lack of motor skill or competing motor skills, a view which is, interestingly, directly counter to that presented by Stinchfield-Hawk in her earlier book which argued for multiple etiologies. Young's approach also runs counter to Stinchfield's in that it attends solely to motor production and does not include techniques for auditory or linguistic training.
In 1931, Lee Edward Travis published a book called Speech Pathology in which he outlined the neurophysiological bases and clinical subtypes for stuttering, articulation problems, phonation problems, and aphasia (Travis, 1931). His discussion of the disorders presumed that the speech sound is the basic unit of speech. Articulation therapy is covered in one paragraph with an accompanying appendix containing word lists organized by sounds in the initial, medial, and final position. The lists were intended to be used to practice drills on particular speech sounds. This book appeared in several later versions and was to become a classic in the field and referred to as "the Travis handbook."
Close on the heels of the first edition of the Travis' handbook was another classic by West, Kennedy, and Carr entitled The Rehabilitation of Speech (West, Kennedy, & Carr, 1937). Robert West wrote the first section, covering the neurophysiology and neuropathology of speech, psychogenic disorders, stuttering, misarticulations caused by mouth deformities and hearing loss, and nasalized speech. The second half of the book, on remedial procedures and case studies offered specific suggestions for muscle relaxation, exercising the articulators and for remediating particular disorders. The emphasis was motor, with phonetic placement, exercise and drill being the means for teaching correct speech.
One chapter in the West, Kennedy and Carr book stands out as unusual in several respects: it is three pages long, it refers to language in its title (linguistic disturbances) and it recommends the whole-word approach for working with dysphasic children:
In training these cases of retarded speech, the clinician should use the same devices a mother uses in teaching a young child to speak: give the child objects to see and feel; say the name of the object over and over; encourage the child to look at you as you say the word and to attempt to say the word himself.
This chapter was omitted in the 1947 edition of the book (West, Kennedy, Carr, & Backus, 1947).
Another significant book appeared on the scene in 1937 that was destined to have a long life. It was written by Samuel T. Orton and entitled Reading, Writing and Speech Problems in Children (Orton, 1937). Orton drew heavily on the work of late nineteenth century European scholars researching adult aphasia. For example, he borrowed the term "word deafness" from the British neurologist Bastian (Bastian, 1869) and German physician Kussmaul (Kussmaul, 1877). Orton, as did his predecessors, used the term word deafness to mean a "loss of the ability to understand the spoken word." Orton described children with word deafness as inattentive and hyperactive, as having word confusions, delayed speech, echolalia, and grammatical problems; and as omitting syllables and committing other pronunciation errors. He presumed that the origin of the word deafness is in "the recall of sounds in proper temporal sequence" (p.148). His therapy prescription was to have the child engage in sound blending exercises, a method he called phonetic synthesis.
Two years later in 1939, Mildred McGinnis wrote her masters' thesis on aphasia in children, distinguishing it from deafness and devising a therapy similar to Orton's sound blending (McGinnis, 1939). McGinnis differed from Orton in that her blending training also involved blending in written form, and her method continued beyond individual word pronunciations to work on grammar both in oral and written form. McGinnis' thesis was the first version of what was to become her well known "association method" for working with aphasic children (McGinnis, 1963)
McGinnis called her technique the association method "because through its application there is a close association of the essential processes of learning, i.e., attention, retention, and recall" (McGinnis, 1963, p.59). The method begins its first unit of instruction with sound production, teaching the aphasic child to produce individual sounds and to associate them with phonetic symbols taken from the Northhampton Charts used in working with deaf children (Yale, 1938). Next the child produces sound sequences in response to the written form, and then writes and says the sounds at the same time. Later the sound sequences are revealed to the child as meaningful words through picture association. The child is asked to name an object from memory and once he can pronounce the words from memory he proceeds to the second unit, whose focus was on grammar. In this unit the child learns to write and say short sentences (e.g., I see a _), to answer and ask questions (What is this _?), to describe pictures, and to use prepositions, the -ing form of verbs, and comparative adjectives. The last unit of instruction includes work on past and future tense and subjunctions, and recommends that children build stories from their own experiences.
In 1939 Charles Van Riper published the first edition of what was later to become a classic in the field--the well-known Speech Correction: Principles and Methods (Van Riper, 1939). The book was unique for its time in that it acknowledged the importance of the social context on the life of the handicapped speaker. His cultural-social attuneness is capsulized in his definition of defective speech:
Speech is defective when it deviates so far from the speech of other people in the group that it calls attention to itself, interferes with communication, or causes its possessor to be maladjusted to his environment (p.51).
In his first chapter, Van Riper further expressed this social view by showing how societies can reject and ridicule their handicapped. Even in his discussion of personality and behavior problems, Van Riper remained faithful to his social view and recommends that clinicians ask the following three questions:
1. What marked differences of physical appearance, behavior or environment distinguish the person from his associates?
2. Which of the differences were approved, which were penalized, and by whom?
3. How did this person react to this disapproval or penalty?
In Van Riper's discussion of these three questions, he elaborated on the importance of how the acquaintances of the handicapped person interpret the handicap. He also emphasized the importance of the social interpretation made by the handicapped person himself. The social emphasis is revealed in these following statements:
"The difference in itself was not so important as its interpretation by the speech defective's associates" (p.66); "Personality is not merely individuality but evaluated individuality" (p. 67); "If a speech defective honestly admits his difference, the group will accept it unemotionally" (p.75).
Van Riper's sensitivities to the importance of social interaction extended to his chapter entitled: "The Speech Correctionist and General Procedures in Treatment." Rather than discuss techniques for conducting therapy or keeping records, Van
Riper offered suggestions for how the speech correctionist can work with classroom teachers and parents in carrying out their therapy goals.
Finally, Van Riper recommended that speech correctionists in training assume the perspective of their clients by deliberately stuttering, lisping, or speaking as a cleft palate speaker would. These assignments for the clinicians-to-be were intended to create in them a sensitivity for what it must feel like to have a speech problem.
Van Riper's first book revolved around the following disorders: delayed speech, articulatory disorders, voice disorders, stuttering, cleft palate speech, and foreign dialect. Delayed speech, which is the category closest to our current category of language disorder, included nonverbal children as well as those who were unintelligible. Van Riper mentioned childhood aphasia as a possible cause for delayed speech, and discussed it in one short paragraph:
Under the disorders of symbolic formulation and expression we have that disorder of the linguistic aspect of speech known as aphasia, which is characterized by the inability to comprehend, formulate, or express certain ideas through speech. It is usually due to injury to or disease of the central nervous system, and is seldom found in most school systems (p. 53).
Van Riper's therapy techniques, which have been handed down through generations of students were fully elaborated in his 1939 text. Departing from the social perspective, he recommended that clinicians focus therapy on the child's problems. He begins therapy by convincing the child or adult of the problem. Van Riper justified this direct approach as a need to build motivation for making change. He argued: "a vague, generalized feeling that something is wrong with the speech will not provide sufficient motivation for the type of retraining that is necessary" (p.210).
Once the person became convinced that he or she had a problem, Van Riper proceeded to ear training, whatever the symptoms, be they voice problems, articulation problems, or delayed speech. In the case of the nonverbal child, the sounds identified and discriminated were those which would be put into key words later in therapy. For children with misarticulations, the sounds to be identified and discriminated were the error sounds from the correct sound. Once the child had a firm "auditory impression" of the sound being taught, Van Riper recommended working on "the concept of sequence." He gave an example of how he might go about training the concept of sequence as follows:
Three different dolls were named "wa," "ba," and "ma." After the child learned their names, the teacher pretended that the dolls were going to school, and as they entered the door the child was to say their names. Sometimes, two entered the door in a hurry, and so the child had to say "ma" and "ba" in swift sequence. By varying this situation in many ways, the child soon learned to point out the dolls in their proper sequence and to give their names in proper order (Van Riper, 1939, p.196-7).
After the child progressed through the ear training program, he was taught to produce the correct sound through auditory stimulation (e.g., say sssss), phonetic placement (e.g., put your tongue behind your teeth), modifying similar sounds (e.g., put your tongue up for a /t/ then hold on to the sound), vocal play (having the child babble in order to come upon the sound randomly), or negative practice (creating the error sound on purpose).
This examination of Van Riper's first edition reveals that he subscribed to a social view of speech disorders when talking about handicap in general, and switched to an atomistic, peripheralist, sensory-based view when presenting treatment techniques.
Besides Van Riper's 1939 book, the 1930s also witnessed the emergence of exercise books and clinical manuals containing practice materials such as word lists, rhymes, stories, and techniques and activities for carrying out their speech lessons (Fairbanks, 1940; Nemoy & Davis, 1937; Robbins & Robbins, 1937; Twitmeyer & Nathanson, 1932)
The early 1940s echoed the 1920s and 1930s. Van Riper's second edition of Speech Correction was similar to his first, with some additional clinical examples and suggestions, a new section on the prevention of speech problems, and a new short chapter on hearing problems (Van Riper, 1947).
In 1943 Mildred Berry and Jon Eisenson published a rival text to Van Ripers' (Berry & Eisenson, 1942). The chapter headings in this book entitled The Defective in Speech, were comparable to Van Riper's 1939 edition with the addition of a chapter on the hard of hearing, the blind, and the mentally deficient. Unlike Van Riper, whose focus was on the auditory, Berry and Eisenson concentrated heavily on the motor aspect of speech production. They recommended the moto-kinesthetic method for sound production and recommend regular work on general muscle exercises and muscle relaxation. They also differed from Van Riper in that they emphasized auditory memory span training as a regular part of therapy and de-emphasized ear training, tucking it into the various motor training regimens. Like Van Riper, they took an atomistic view, beginning therapy with isolated sound production.
Notably absent from the Berry and Eisenson text are any references to the social context, and notably present for the first time in American texts were discussions of the process by which children learn language. The Berry and Eisenson language learning model was taken from (Allport, 1924) and was associationist as well as mentalist in its theoretical design. It depicted the acquisition of first words, what they called the "learning process in speech," as an associative, imitative process, where stimuli become connected with responses apart from any influence of meaning or intent. Berry and Eisenson said it this way:
Speech learning from its very inception is a process of stimulus and response and a strengthening of responses, a process in which associations are formed which are at first unintentional random and meaningless, but which later become selective intentional and meaningful (p. 7).
Berry and Eisenson described children's language in linguistic terms. They saw first words as really sentences "in that they express complete thoughts" and most often nouns. They went on to describe the mental intent behind the child's use of first words:
These noun word?sentences are usually spoken with wish-fulfilling import. The small child is much more interested in letting persons around him know how he feels or what he wishes of them, or of objects near him or them, than in indicating merely that he has mastered a name for a person or an object (p.11).
Berry and Eisenson also gave some consideration to language comprehension in their depiction of early language learning:
it might also be pointed out that not only does the small child use isolated words as sentences, but what he understands of adult sentences is determined by his ability to recognize an isolated word he knows (p.11).
Other indications that Berry and Eisenson were thinking about language as a linguistic system can be found in various places in their 1942 text. In one instance, they described delayed speech as occurring "when the manner or content of the child's language usage is significantly below the norm for children of his age" (p.271). In another section on language development of blind children, they report the findings from a study by Maxfield that blind children used more questions and proper names than their normal counterparts, and that they spoke in incomplete sentences (Maxfield, 1936).
While Berry and Eisenson seemed to be emphasizing language in their background sections, their clinical techniques did not reflect their awareness of language. Judging from the therapy suggestions, they considered speech and language disorders to be a motor problem and speech training for sounds in isolation as the way children can come to learn their native language.
In summary, the approaches to speech and language therapy during this formative period took three paths. One was biological/medical where the emphasis was on eliminating causes and prescribing physical remedies such as arsenic and physical rest. A second was atomistic, peripheralist and either sensory or motor in focus. It began by teaching sounds either through auditory training (auditory stimulation, discrimination, and sequencing) or motor training (motor placement, tongue exercise). A third presaged later conceptual and linguistic approaches to therapy in that they taught semantic meaning of single words and included grammar training.
There was sometimes a disjuncture between the theoretical emphasis used by authors to describe disorders and their therapy approaches. Van Riper, for example, recognized the importance of social context yet did not include social training in his therapy. Orton described the condition of "word deafness" as a loss of comprehension for spoken words, but his training consisted of sound sequencing. Berry and Eisenson's theoretical focus was mentalist and linguistic, yet their therapy methods focused on teaching speech sounds and phonetic placement. These pioneers in the field were exhibiting what was to become a familiar trait in our professional development, the theory?therapy gap.
A second identifiable gap was between research findings and therapy practices. For example, research in the developmental psychology was readily available to speech pathologists. Studies of normal children were being conducted by G. Stanley Hall, an American psychologist and student of William James. Hall was instrumental in organizing and publishing journals on various aspects of child development. His student, Arnold Gesell, established a laboratory at Yale where he conducted child development studies. Those studies, beginning in the 1920's resulted in his books on developmental ages and stages for specific skills (Gesell, 1925, 1928, 1929). His norms were later incorporated a development tests and used by many to diagnose childhood abnormalities (Gesell, 1949).
The widespread interest in studying normal children led to the emergence of many centers of institutes particularly devoted to supporting research on children. The best known to us were two: the Iowa institute which published the well know series of monographs "University of Iowa Studies in Child Welfare" and the Minnesota institute which supported and published studies from their "Institute of Child Welfare." Researchers affiliated with this movement during the 1920's and 1930's accumulated knowledge about what ages normal children acquired different competencies, and language was given its rightful place in the list of competencies. The notables among the early language researchers were Madorah Smith at Iowa and Dorothea McCarthy at Minnesota. Smith's first study in 1926, her dissertation, involved collecting language samples from children of different ages and analyzing them for mean sentence length (Smith, 1926) McCarthy a few years later (McCarthy, 1930) elaborated on Smith's language sample technique and examined sentence structure by examining their complexity (simple, complex) and the proportion of different parts of speech (nouns, verbs, adjectives). McCarthy's analyses were to become the methodology for a number of studies in language development to follow, and became known as "The McCarthy Method" (Davis, 1932). But it was not until the development of standardized tests that the language research of those in the child study movement began to be used by speech-language pathologists.