IMPAIRED MENTAL FUNCTION
(CLINICAL AND NEUROPSYCHOLOGICAL DIAGNOSIS)
Published according to the publication: Mental retardation (clinical and neuropsychological diagnostics). M., 1993. part II. – pp. 149-176
METHOD OF NEUROPSYCHOLOGICAL STUDY OF CHILDREN WITH ANOMALIES OF MENTAL DEVELOPMENT
1. Tasks and criteria for qualitative and quantitative analysis of higher cortical functions, interpretation of the results of the study.
Systematic analysis of higher cortical functions (HCF) is increasingly used in childhood psychiatry and defectology in various types of mental dysontogenesis: oligophrenia, intellectual retardation, including states of mental infantilism, specific delay in the development of school skills (dyslexia, dysgraphia, dyscalculia), specific speech disorders and others. As is known, these types of mental development anomalies are usually associated with organic brain damage in the early stages of ontogenesis and secondary underdevelopment of brain structures that form in the postnatal period (L. S. Vygotsky, G. E. Sukhareva, S. S. Mnukhin , M. S. Pevzner and others).
According to many domestic and foreign researchers, it is advisable to use neuropsychological methods in the complex of clinical and psychological study of abnormal children, since the data obtained in this way make it possible to assess the state of visual and auditory perception, praxis, speech, memory – those functions that provide opportunities for mastering elementary school skills (reading, writing, counting, solving arithmetic problems). (A. R. Luria, 1963; Yu. G. Demyanov, 1971; Yu. I. Daulenskene, 1973; V. I. Lubovsky, 1976; K. S. Lebedinskaya, 1980; L. T. Zhurba, E. M. Mastyukova, 1981; AL Benton, 1962; A. Lefford, 1963; H. Spionek, 1975 and others).
In addition to partial disorders of the modal-specific mental functions listed above, the difficulties in teaching children may be due to general non-specific disorders of brain activity, reflecting the discoordination of cortical-subcortical functional relationships.
At the same time, in some cases, disorders of general neurodynamics come to the fore, manifested in increased exhaustion, impaired pace and mobility of mental processes, and asthenic type of performance.
In other clinical variants of mental dysontogenesis, violations of the arbitrariness and purposefulness of cognitive activity are more significant: the absence or instability of the attitude (motivation) for cognitive activity, difficulties in planning a given mental operation, instability of voluntary attention and control. These higher forms of regulation of volitional conscious activity, as is known, are provided, first of all, by the work of the frontal cerebral systems (A.R. Luria, M.S. Pevzner, E.D. Khomskaya, V.V. Lebedinskaya, etc.).
As follows from the foregoing, the data of a neuropsychological study of an abnormal child make it possible to clarify the structure of cognitive impairment, which is extremely important in solving problems of prognosis and individualization of psychological and pedagogical correction.
Already the very first studies showed differences in HCF disorders in children with residual organic cerebral insufficiency from the neuropsychological symptoms observed in the clinic of focal brain lesions: the severity of disorders, the lack of a clear outline of the neuropsychological syndrome. It is the non-roughness of HCF disorders in children with residual cerebral insufficiency that excludes the possibility of only stating the fact of completing or not completing the task and requires a more differentiated assessment of the nature of the difficulties that arise, the mode of action, and the analysis of the types of assistance that help overcome or reduce these difficulties.
A qualitative-quantitative diagnostic technique, successfully used in the clinic of adult patients, serves to determine the current level of the subject’s capabilities (L.I. Wasserman, S.A. Dorofeeva, Ya.M. Meyerson, 1977). Based on the provisions of L.S. Vygotsky about the “zone of proximal development”, such an approach in the study of children cannot be productive, since it makes it impossible to observe the qualitative originality and dynamics of activity, does not reveal the child’s susceptibility to help, and therefore does not create conditions for assessing his potential.
Starting to develop a new modification of the neuropsychological technique (A.R. Luria et al., 1973), adapted for the study of children with symptoms of residual cerebral insufficiency, we set ourselves the following tasks:
1) highlight the main criteria for a qualitative assessment of the state of higher cortical functions;
2) to determine the criteria for a qualitative and quantitative assessment of the state of the HCF to determine the degree of their violations, to be able to compare the results of repeated studies of the same child in the process of corrective work with him, as well as to compare the neuropsychological characteristics of children of the same age of homogeneous or heterogeneous clinical groups.
In a qualitative analysis of the state of the VKF, we assume the identification of the leading factor that makes it difficult to carry out a given psychological operation:
1) neurodynamic disorders;
2) violations of higher forms of regulation;
3) partial impairment of modal-specific cortical functions.
When determining the criterion for a qualitative-quantitative assessment, we proceed from a different degree of severity of the above-mentioned qualitative indicators of HCF violations. For this purpose, a five-point rating scale was developed.
First, we will give an interpretation of the qualitative-quantitative assessment of neurodynamic disorders.
5 points – neurodynamic disorders are absent.
4 points – there are neurodynamic disorders of mild severity, which manifest themselves at a slower rate of task completion (with the structure of the psychological operation being studied being completely preserved ).
3 points – neurodynamic disorders of moderate severity reflect a greater degree of exhaustion of the tested function, instability of mental tone, manifested in a slight deautomatization of a motor or other skill, the presence of unstable and non -specific errors; (the change in the structure of the psychological operation under study is secondary).
2 points – gross neurodynamic disorders, manifested in perseverative phenomena, the presence of primary structural disorders of a given operation (the severity of which still reflects the relationship with the severity of the exhaustion of general neurodynamics), errors specific in nature.
1 point – persistent gross violations of neurodynamics, persistent primary violations of the structure of a given operation (lack of connection with the phenomena of exhaustion of general neurodynamics); the practical impossibility of completing the task. In the qualitative-quantitative assessment of violations of higher forms of regulation , we focused not only on the nature of violations of voluntary control, programming, and initiation, but also on the child’s susceptibility to help from the experimenter. Thus, the scoring will reflect both the severity of violations and the content and effectiveness of supportive measures.
5 points – no violations. 4 points – the child is quite purposeful, if there are difficulties, he independently finds ways to overcome them (slows down the pace when completing the task, circles the images with his finger, accompanies the action with pronunciation, etc.).
3 points – at first the task is performed with interest and correctly, but due to the lability and increased exhaustibility of the mental tone, the instability of control in the process of practical implementation, a simplification or distortion of the program of the given operation occurs again ; the optimal measure of help is to organize attention and emotional stimulation; There are no refusals from work, the help is effective.
2 points – primary violations of programming come to the fore: simplification or distortion of the content side of the program, slipping onto the program of the previous task; the child needs special organized detailed assistance, consisting in the phased formation of the action: the division of the program into its constituent elements, the development of the program in speech terms, the inclusion of speech commands in the process of practical implementation of the learned program; help provides the ability to reproduce the tasks of the program, but its effect is unstable; secondly, the child may refuse to complete tasks.
1 point – the extreme severity of the phenomena described in the characteristic score “2”; help is not effective, the task is not performed.
Based on the results of a qualitative and quantitative analysis of the state of the VCF, it can be said that scores “2” and “1” indicate the presence of partial disorders of higher cortical functions of a modal-specific nature. The same scores allow us to assume pronounced, general non-specific violations of the processes of regulation by arbitrary forms of mental activity. However, the final conclusion about such gross violations of the brain organization of the VCF as a whole is possible only at the end of a complete systematic analysis of the results of neuropsychological research.
Experience with the proposed modification of the neuropsychological methodology has shown that general neurodynamic disorders in the form of lability and exhaustion correspond to dysfunction of the frontal systems in the control link, and more severe disorders of neurodynamics in the form of perseveration, inertia are more often combined with partial impairments of cortical functions and the resulting secondary disorganization of the programming of integral systems. actions. In this connection, we believe it is possible and most convenient to combine the characteristics of neurodynamic and regulatory disorders when describing the content of each point of the five-point rating scale developed by us.
Thus, a more generalized characteristic of each score is presented as follows: 5 points – the task is performed correctly; 4 points – the task is performed correctly, but slowly, the child independently finds means of correction; 3 points – the task is performed correctly at first, but at exhaustion unstable errors occur, which are overcome by organizing attention, as well as by emotional reinforcement; i points – the presence of severe disorders (perseveration, persistent echopraxia, loss of the action program), the phenomena of dyslexia, dysgraphia, dyscalculia; obligatory massive assistance (step-by-step formation of the action) leads to unstable error correction. 1 point – the task is not available, the help is not effective.
Interpretation of the data of neuropsychological research is carried out on the basis of the analysis of protocol records, the construction of an individual “profile” of the state of mental functions (see Fig. 12–15).
To assess the potential abilities of a child, the following questions should be answered:
1) what is the intensity (severity) and extensiveness (prevalence) of mental disorders?
2) what is the leading factor hindering the performance of tasks?
3) what is the child’s receptivity to the help offered during the experiment?
The experimenter can answer the first two questions by analyzing the so-called individual “profile of neuropsychological characteristics, identifying the most typical (frequently repeated) score, highlighting deficient functions that make it difficult to form one or another school skill.
The possibility of answering the third question was originally provided by a special organization of neuropsychological research – most of the tasks included in the study are presented in 2 versions. In the first case, the instruction does not differ from that used in the practice of adult research. If the task is performed incorrectly, it is given in a game situation that provides not only emotional stimulation, but also the inclusion of verbal and semantic mediation of actions (for example: “You are the commander, and your fingers are soldiers, command: one, two …”, etc. .). After such an organization of activities, the results of the task, as a rule, improve, the score increases (Fig. 9-11). This result is recorded in the study protocol and, accordingly, marked on the graph of the individual “profile”. Thus, the effectiveness of assistance and, most importantly, its types become important data for assessing the potential of a child.
2. Recommendations for the study and description of tasks.
Neuropsychological research should be preceded by a clinical study of the child, a conversation with parents, teachers and educators, acquaintance with the history of the child’s development and the characteristics of a speech therapist and educators of a preschool institution. Prior to the start of the study, the neuropsychologist (or the doctor who has mastered the technique) must look through the child’s notebooks in order to first find out which skill is most difficult to learn, which mistakes are most typical. It is useful to get acquainted with the visual activity of the child: drawings, crafts, etc.
The proposed modification of the neuropsychological study includes a set of 70 tasks. Of these, 21 were selected for qualitative and quantitative analysis, which seem to us the most informative and convenient for scoring (see Table 22).
For the uniformity of the approach in the qualitative-quantitative assessment, we offer a detailed description of the set of 70 tasks that we have tested.