Exceptional Children

Introduction

Exceptional children differ from the norm, either above or below, in physical attributes or learning ability to such an extent that they need specialized educational services or physical accommodations to benefit fully from schooling (Heward, 2012). The term is more often used in the special education community than by medical and psychological professionals, and includes children whose performance is superior and who require enrichment of curriculum and more challenging instruction in order to achieve their maximum potential, as well as those with learning difficulties, physical or sensory impairments or behavior problems that require modification of the education regimen in order to help them learn. The “exceptional” rubric is preferred to terms involving disabilities, impairments or handicaps because it includes gifted and especially talented children. The disabilities or impairments of exceptional children are subsumed by psychiatry and psychology under the category of Neurodevelopmental Disorders in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013).

Handicap, Impairment, Disability, and Disorder

The term “handicap” came to be applied to a physical or mental disability during the 20th century. The word appears to have originated in the 16th century, and may refer to the 1504 decree by King Henry VII that permitted maimed war veterans to beg in the streets of England; this was usually done with a cap in the hand. An alternative explanation involves “hand-in-cap”, a 17th-century lottery game in which 2 players offered up objects in return for a monetary prize and the presenter of the less valuable item had to make up the difference in value. The term came to be applied to an attempt to make a contest more equal by imposing a burden on one contestant. The first practical application of this was in racing, where the stronger horse had to carry extra weight to make the race more equal. The process was applied numerically in golf, and came during the 19th century to signify the act of equalization itself. The term came by the end of the century to be applied to persons who were “mentally or physically defective” (Anderson, 2013).

Impairment refers to reduction or loss of function or ability, and can be produced by multiple causes ranging from amputation to intoxication. When an impairment limits an individual’s ability to perform a particular function as normal individuals do, such as the effect of paralysis on walking or running, a disability is considered to exist. When an impairment or disability prevents or hampers the individual’s interaction with the environment, the individual may be considered to be handicapped. An impairment or disability may not constitute a handicap if it can be overcome by effort or accommodation: an amputee can walk with a prosthetic limb, and there are numerous examples, ranging from Milton to Beethoven to Stephen Hawking, of great achievement despite severe disability. An impairment or disability can also be handicapping in some circumstances but not in others: a blind individual can walk and read, for example, but cannot drive. Historically, many of the handicaps imposed by impairment or disability have been the result of the beliefs and reactions of others. Children who may experience developmental problems at a later time because of the circumstances of their birth or environment are termed “at risk”. The categories of exceptionality generally recognized in special education include: gifted or talented, multiple disabilities, medical disorders, traumatic brain injury, visual or hearing impairment, communication disorders, autistim and related disorders, emotional and behavioral disorders, learning disabilities and mental retardation or developmental disorders.

Learning Disabilities

About 6.5 million children are identified as exceptional in our educational system. Learning disabilities are the most prevalent exceptional condition, and affect up to 10 per cent of the population.This was not always the case, and through most of history those with learning disability were either not specifically identified or wrongly considered to be lazy or of low intelligence. German internist Adolph Kussmaul is memorialized in 6 medical eponyms and introduced endoscopy, gastric lavage and thoracentesis; his contribution to neuropsychiatry came in 1877 with the recognition of “word blindness”, an inability to learn to read despite intact vision and speech and normal intellect.Ten years later, Rudolf Berlin observed individuals unable to read because they could not decipher written or printed symbols, and termed this “dyslexia”. Hinshelwood and Morgan in Britain and W.E. Bruner in the United States studied children with apparent congenital inability to learn to read between 1895 and 1905. Samuel Orton began the systematic study of learning disability at the University of Iowa in 1919, and first postulated that reading disability arose because the appropriate cerebral organization to connect the spoken and visual forms of words had not been established. The term “learning disability” was introduced by Samuel Kirk in 1963. Magnetic Resonance Imaging and Functional MRI studies after 1996 have established that learning disabilities are associated with thalamocortical and arcuate fasciculus volume loss (Anand, 2006), and at least 9 candidate genes on the X chromosome and one specific mutation on chromosome 6 have been associated with learning disability (Kovas & Plomin, 2007).

Children with learning disabilities represent 46 per cent of students receiving special educational assistance. Learning disability is characterized by difficulty learning despite intelligence at or above normal levels, and is manifested in the classroom by a discrepancy between measured intelligence and documented achievement. Language, reading and writing, mathematical learning or information processing may be individually affected or involved in combinations, and the causes are multiple and both familial and environmental; inherited learning deficiency, prematurity and birth injury and toxic exposure are the chief causes (Sonoma State University, 2014).

Communication Disorders

The diagnosis and treatment of disorders of communication grew from the discipline of speech and language pathology, which in turn arose from elocution and “speech correction” in the 19th century. Alexander Melville Bell and his son, the better-known Alexander Graham Bell, were practitioners of speech correction and teachers of elocution who developed in the 1870s a symbolic code that indicated the position of the tongue, throat and lips in the production of speech sounds. This “visible speech” became the basis for a technique of teaching speech to those who had difficulty forming the proper sound . The younger Bell’s interest in a means of transmitting speech for diagnostic and teaching purposes led him to invent the telephone. Two organizations developed to study and treat speech disorders: one consisted of speech correctionists who were or had been schoolteachers, and became the National Society for the Study and Correction of Speech Disorders in 1918, while another group more closely affiliated with the medical profession started in 1925 and became the American Speech-Language-Hearing Association. Samuel Orton was active in this field as well, and suggested in the 1920s, along with Lee Edward Travis, that speech disorders generally and stuttering in particular were analogous to dyslexia, and resulted from failure to establish cerebral hemispheric dominance. This theory was extended but never conclusively proven by Wendell Johnson and Charles van Riper in the 1930s, and the latter suggested in 1939 that the social implications of communication were as important as the linguistic ones, which led in turn to the development of psycholinguistics by George Miller and others, which was one of the foundations of cognitive psychology (Prutting, 1982).

Communication disorders account for about 18 per cent of the educational services received by children. These can involve expressive language, language comprehension, the physical production of speech or social communication, the interpretation of and appropriate response to verbal and nonverbal language in social contexts.

Mental Retardation

Intellectual disability or mental retardation is one of the most common disabilities, and has been recognized for longer than the other forms of modern exceptionality. Intellectual subnormality was discussed in an Egyptian papyrus from about 1552 BCE. The Greeks generally regarded mental retardation as a sign of the gods’ displeasure and advocated infanticide: exposure was mandatory in Sparta, where children belonged to the state and not the parents, but Plato and Aristotle urged that the practice be adopted in Athens as well, in the interest of what would later be called eugenics. Hippocrates felt around 370 BCE that the behavioral abnormalities and seizures that often attended retardation were due to brain disease rather than supernatural causes, but it was not until the 1st century BCE that Soranus of Ephesus founded a hospital for mental disorders where the retarded were also housed. The Romans often allowed brain-injured children to die of exposure, but the retarded children of the wealthy had property rights and were generally entrusted to guardians (Harris, 2006). In the Middle Ages and Renaissance, church and public institutions cared for the developmentally handicapped, and they were often allowed to speak more freely than others and sometimes felt capable of divine inspiration (Beirne-Smith, Patton & Kim, 2006).

The first special education for intellectual disability was attempted in 1799 by Jean-Marc Itard, who undertook the training of Victor the Wild Boy, a probably retarded feral child; an earlier Wild Boy named Peter had been found in Germany and brought to the court of George I in London, but he was a source of amusement and was not trained. Victor acquired only a few words of language but learned social rudiments and lived equably with a family until his death in 1828. Inspired by this case, Edouard Seguin established an educational program at the Hôpital Salpetrière, where developmentally handicapped women were housed along with the insane, and there introduced concepts such as individualized instruction plans and behavior modification that are in use today. Seguin continued these efforts in America and in 1856 published an influential book, Idiocy and its Treatments by Physiological Methods. A similar institution, Abendberg, was established in Switzerland by Johann Guggenbühl, but this ended badly because the institution was not sufficiently staffed or supervised.

Dorothea Dix, Hervey Wilbur and Samuel Gridley Howe established institutions for rehabilitation and training of the retarded, first in Massachusetts and then in other states, but disillusionment set in when retarded residents could be taught simple skills but could not achieve normality.As it became clear that “idiocy” could not be “treated” in the medical sense, many institutions became custodial and conditions deteriorated because of insufficient staffing or funding. In addition, the increasing and often inappropriate use of IQ testing led to the identification of large numbers of people, particularly immigrants, as mentally deficient. The growing concern that “feeblemindedness” was inherited and associated with crime, violence and other social pathologies, and widespread interest in eugenic limitation of breeding by the unfit, led to an increasing focus on institutionalization and sterilization of the mentally subnormal in the United States and even more markedly in Europe (Bachrach, 2004).

Multiple etiologies for mental retardation rather than a unitary hereditary disorder were established by studies in the 1920s and 1930s, and Abraham Myerson established through extensive family studies at the Boston and Taunton State Hospitals that “feeblemindedness” was not more common among the lower classes and the hereditary component to intellectual disability was minor. Special educational arrangements for children with intellectual disability was introduced in Rhode Island in 1896 and New Jersey in 1911, and were available in 46 of 48 states by mid-century, when the National Association of Parents and Friends of Mentally Retarded Children, now known as the Arc, was founded. The subsequent half-century has brought a focus on deinstitutionalization, habilitation in society, elucidation of prenatal and perinatal causes for developmental disability and better medical and psychological management of associated symptoms (Beadle-Brown, Mansell & Kozma, 2007).

Children with intellectual disability currently make up about 10 per cent of service recipients, equally divided between genetic, environmental and obscure causes. The pejorative classifications such as idiot, imbecile and moron have been replaced by mild (85 per cent of the identified population, IQ 50-70), moderate (10 per cent, IQ 35-55), severe (3-4 per cent, IQ 20-40) and profound (1-2 per cent, IQ below 20) mental retardation. An etiology, usually acquired, can be established in 60 to 75 per cent of severe MR cases but in only 40 to 50 per cent of mild retardation; a genetic basis is evident in 25 to 50 per cent, mainly hereditary syndromes of which mental retardation is but one feature. Inherited nonspecific or monosyndromal mental retardation has been linked to several mutations, mostly on the X chromosome (Inlow & Restifo, 2004).

Attention Deficit Hyperactivity Disorder

Attention Deficit Hyperactivity Disorder (ADHD) was recognized in ancient times, and may first have been described not by a neurologist or psychiatrist, but by a playwright – Molière depicted a disorganized and inattentive “scatterbrain” (ètourdi) on the stage in 1653. Melchior Adam Weikart in 1775 and Sir Alexander Crichton in 1798 provided the first clinical observations of attention deficit , and Heinrich Hoffmann associated this with motor restlessness in the 1840s. Sir Charles Still in 1902 added the concepts of impulsivity and low frustration tolerance, and noted the marked male predominance that is still seen, although many of his patients had other behavior and neurological problems and may have been examples of the minimal brain damage or dysfunction that has often been conflated with ADHD. One of the first institutions for exceptional children, Bradley Hospital in Rhode Island, was the site of trials of stimulants for ADHD, which has led both to improvement of the educational and social situations of those with ADHD and concern about the escalating rate of diagnosis and drug treatment (Lange, Reichl, Lange, Tucha, Lara & Tucha, 2010).

ADHD currently affects about 3.5 per cent of the population, with a male preponderance of 6:1. Contributing factors include genetics, prenatal toxic exposure, single-parent upbringing, a chaotic home environment and insufficient social support. The diagnosis in children is based on at least 6 months of inattentive, hyperactive or impulsive behavior in several different settings. The childhood syndrome is generally responsive to medical and psychoeducational treatment, but it is now clear that the disorder does not remit but continues into adulthood with often different manifestations.

Emotional and Behavioral Disorders

The study and treatment of emotional and behavioral disorders in children is a relatively new discipline. The psychiatric nosologies and taxonomies of the 19th century were focused on adults, and the disorders of children were generally the purview of pediatricians. The first school for children with psychiatric problems was founded near Jena in 1892, and the first text on child psychiatry was published in France in 1899. The first child psychiatry journal (Zeitschrift für Kinderpsychiatrie) was established in 1934. The first child guidance clinic, the Juvenile Psychopathic Institute, was founded in Chicago by Jane Addams in 1909, and Leo Kanner, later of autism fame, established the first academic Child Psychiatry department at Johns Hopkins in 1930. The separate treatment of childhood mental disorders in Britain began at the Maudsley Hospital in 1923. A specialty organization, the American Academy of Child Psychiatry, now Adolescent also, was founded in 1953 and board certification was started in 1959 (Kanner, 1960).

Children with these psychiatric conditions are only 1 or 2 per cent of the special education population. They manifest external (misconduct and defiance) or internal (anxiety and depression) symptoms, and may have both. Temperament, family history of psychiatric disorder and neurologic disorders or deficits are biological contributing factors. Adaptive or maladaptive parenting strategies, school situations and peer group influences are predominant environmental factors.

Autistic Spectrum

Autism was first described in 1908, but has been alleged in many historical figures. Michelangelo, Sir Isaac Newton, Wolfgang Amadeus Mozart, Charles Darwin, Nikola Tesla and a host of famous and near-famous moderns have been thought to be autistic. Martin Luther told of a parishioner with behavioral abnormalities consistent with autism, whom Luther felt to be possessed and should be put to death. A 1747 court case in Scotland involved autistic behaviors, with the marriage of Hugh Blair of Borgue being annulled and his inheritance redistributed to his brothers. Some commentators have suggested that Peter and Victor, the wild boys discussed earlier, may have been autistic rather than retarded.

Bleuler first used the term “autistic psychopaths” in 1908 for the self-absorbed aloofness characteristic of many schizophrenic patients. Leo Kanner applied the name “infantile autism” in 1943 to children with “a powerful desire for aloneness and sameness”. In the following year, Hans Asperger described as “autistic” children with odd use of language, physical clumsiness, limited empathy with peers and poor nonverbal language skills, a syndrome which was named for him after his death in 1980. A third “autistic” disorder, with severe regression of language skills and interaction, had been described by Theodor Heller in 1908, and Andreas Rett reported in 1966 on a predominantly female disorder with autistic-like behavior, seizures, dysmorphism and developmental regression that was for a time placed in the autistic spectrum.

Kanner observed that the parents of his patients were often reserved and the children’s upbringing cold, although he considered the disorder to be innate. The refrigeration analogy was continued by Bruno Bettelheim, who in the 1950s ascribed the disorder to the harmful parenting of “refrigerator mothers”. This theory was strongly attacked by Bernard Rimlin, himself the parent of an autistic child, in 1964, and was largely discredited after Bettelheim’s death. A proposed relationship between autism and vaccination has also been shown to be unsubstantiated and in fact fabricated. The current consensus is that autism and related disorders are organic in origin and involve several co-occurring abnormalities of neuronal migration, synapse formation and brain growth, that are probably under the control of several different genes and may be influenced by a number of external factors. Controlled trials have shown that atypical antipsychotics are helpful for the behavioral aberrations of autism, and the internet has permitted many autistic individuals to work, study and interact with greater ease (Volkmar, 2007). Rett syndrome has been found to have a specific causative gene mutation and is not related to autism. The 3 autistic disorders (infantile, Asperger’s and disintegrative) and pervasive developmental disorder (not otherwise specified), which has in fact been the most common diagnosis, have been combined into a single autistic spectrum disorder in the DSM-5 (American Psychiatric Association, 2013).

About 1 in 110 children are currently diagnosed with an autistic spectrum disorder. The chief symptoms involve behavior (repetitive movements and obsessive adherence to routines), social interaction (poor eye contact and lack of interactive behavior) and communication (delayed language, lack of symbolism and impaired conversation).

Gifted and Talented

The term “savant” was introduced in 1978 to describe individuals with exceptional skill in a single field of learning, such as music or mathematics, in association with other features of mental disability, particularly autism spectrum disorder (Treffert, 2009). “Twice-exceptional” students have intellectual gifts and learning strengths, usually less prodigious but more broadly distributed, as well as learning disabilities or behavior problems, such that they need both remediation and enhancement (Kronchak & Ryan, 2007). These individuals are often characterized by extensive vocabulary but difficulty with written expression, the ability to understand complex ideas and wide-ranging interests, sensitivity and easy frustration, creativity, humor and curiosity but stubbornness and fixed opinions. These conditions are not recognized in psychiatric diagnosis, but may benefit from counseling and therapy as well as educational intervention.

References

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Anand, R. (2006). Neuropsychiatry of learning disabilities. Int J Neurology, 6: 1.

Anderson, K. (2013). A History of the word, “Handicapped”. London, Academia.

Beadle-Brown, J., Mansell, J. & Kozma, A. (2007). Deinstitutionalization in intellectual disabilities. Curr Opin Psychiat, 20(5): 437-442.

Beirne-Smith, M, Patton, J.R. & Kim, S.H. (2006). Mental Retardation: An Introduction to Intellectual Disabilities, ed. 7. Upper Saddle River, NJ, Pearson Merrill Prentice Hall.

Harris, J.C. (2006). Intellectual Disability: Understanding its Development, Causes, Classification, Evaluation and Treatment. New York, Oxford University Press.

Heward, W.L. (2012). Exceptional Children: An Introduction to Special Education, ed. 10. New York, Pearson.

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Lange, Klaus W., Reichl, S., Lange, Katharina M., Tucha, Lara & Tucha, Oliver (2010). The history of attention deficit disorder. ADHD, 2(4): 241-255.

Prutting, C. (1982). Scientific inquiry and communicative disorders: An emerging paradigm across six decades. In, Gallagher, T. & pruting, C. (eds). Pragmatic assessment and intervention issues in language. San Diego, College-Hill Press.

Sonoma State University, School of Education, Department of Educational Leadership and Special Education (2014). Exceptional Children. Rohnert Park, CA.

Treffert, D.A. (2009). The savant syndrome: An extraordinary condition. A synopsis: past, present, future. Philos Trans Royal Soc B: Biol Sci, 364(1522): 1351-1357.

Volkmar, F.R. (2007). Autism and Pervasive Developmental Disorders, ed. 2. New York, Cambridge University Press.

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