Partial immaturity of the higher mental functions

Another subgroup of “insufficient development”, designated “partial immaturity of the higher mental functions”, has a number of fundamental differences compared with the subgroup described in the previous section.

From the outset it should be acknowledged that many psychologists and psychiatrists widely use the term “partiality” to characterise the unevenness of development of one or another aspect of mental activity. These questions are set out most thoroughly in the work of D.N. Isaev.

In our interpretation of this concept we, following many researchers, emphasise the mosaic character, the “partiality”, of the immaturity of individual aspects of the child’s mental development. The most fundamental, principal difference between children of this subgroup and children with various types of delayed development lies in the fact that in this case one cannot in any way speak merely of a delay in development. Many years of practice show that the development of children in this category proceeds along a fundamentally different path than the development of children with a true delay of mental development.

Diverging as early as infancy, the developmental paths of these two groups of children continue to diverge throughout preschool childhood, and if serious specific measures of assistance are not taken, this divergence will continue into the primary school years as well. These children do not “catch up” with their peers either by the age of 9-11 or even later. Subsequently, the signs of immaturity of the cognitive component of the higher mental functions are “masked” by features of emotional and personal development, which are later classified as other variants of dysontogenesis (for example, various types of disharmony or, in the most severe cases, as total underdevelopment).

The direction of development of this group of children is characterised not only by indicators quantitatively different from those of a true delay, which is noted by some researchers working exclusively in the field of phenomenological assessment, but also by a qualitatively different structure of the features of the components of the child’s mental activity. In most cases the development of this category of children proceeds without converging with or intersecting the “general line of development”.

The qualitative differences concern first and foremost the maturity of the basic components (prerequisites) of mental activity. Sometimes, even in a situation of massive corrective intervention involving the most varied specialists and medication support, one can as a rule speak only of a certain degree of compensation in the development of the higher mental functions, of the child’s development “approaching” the “socio-psychological norm”. Therefore, from our point of view, this variant of deviant development cannot be assigned to “delayed development”, since it does not meet the main criteria of the concept of a “temporary tempo delay of mental development”.

One of the main important diagnostic conclusions in such an approach is the need, with the help of parental interviewing (collection of the psychological history), observation of the child and appropriate diagnostic procedures, to determine at which age stage the “failure” of the developmental programme most probably occurred. This is one of the starting points determining the construction of adequate corrective programmes in accordance with the principle of substitutive development (substitutive ontogenesis — after A.V. Semenovich).

In turn, the subgroup “partial immaturity of the higher mental functions” can be divided into the following types:

- with predominant immaturity of the regulatory component;

- with predominant immaturity of the verbal and verbal-logical component;

- with immaturity of the mixed type.

From both diagnostic and corrective standpoints, such a “separation” reflects the specific nature of the children’s problems and determines the priority direction of one or another type of psychological corrective work and the participation of other specialists in helping the child.

Partial immaturity of the higher mental functions predominantly of the regulatory component is characterised first and foremost by impulsivity in behaviour, more often by motor and speech disinhibition than by lethargy. At the same time, the physical parameters of development generally correspond to the child’s age. Besides impulsivity in any kind of activity, including play, it should be noted that at times the child’s behaviour becomes unmanageable and not regulable by an adult. Pronounced play interests predominate, although even in play such children are most often conflict-prone and insufficiently self-critical.

A distinctive feature of the development of the cognitive sphere is the immaturity precisely of the voluntary regulation of the higher mental functions: not so much of the elementary ones (perception, memory, attention) as of the “higher” ones (programming and control), that is, of the regulatory processes proper. Given sufficient external organisation of activity and strict control of it, the children are capable of performing cognitive tasks appropriate to their age. In cases of “lethargy” of mental manifestations, a general loss of interest is noted, along with the need to create vivid play motivation in order to achieve positive results of activity. These features must be taken into account not only in developmental or corrective work, but also when conducting a diagnostic examination.

As with some other identified types of deviant development, the presence of signs of atypical development (the specific formation of both cortical-subcortical processes and the individual profile of functional asymmetry) is an aggravating factor, often determining not only the prognosis of the child’s further development but also the sequence of introduction and the specific nature of the various corrective measures.

The overall structure (profile) and proportions of the immaturity of individual basic components are uneven; among the latter, one should note first and foremost the immaturity of voluntary regulation of mental activity, beginning with difficulties in maintaining a motor programme (a rigidly specified sequence of motor acts), and often also with the voluntary regulation of the strength of muscle tone (see section 1.3.1).

The formation of spatial representations is impaired predominantly at the level of verbal representations, which entails, among other things, difficulties in understanding certain spatial, spatio-temporal and quasi-spatial speech constructions.

As regards the level-based affective organisation as one of the basic components, in this type of dysontogenesis one observes, as a rule, a distortion of the proportions of the basal system at the expense of the 3rd level of affective organisation (more often of the hyperfunction type, less often hypofunction is observed). It should be emphasised that this disproportion is significantly less pronounced than in the case of total underdevelopment.

Developmental and corrective work with this category of children should first and foremost be aimed at forming voluntary regulation of activity and the functions of programming and control. Moreover, the work should be carried out drawing initially on motor methods and later (if time permits) or in parallel (depending on the child’s age) on cognitive methods based on the neuropsychological approach. In some cases the environment itself may prove to be “programming” (in the event that it is specially structured), which creates the possibility for constant external control.

It is assumed that the child needs to be monitored by a neurologist and, in markedly pronounced cases, by a child psychiatrist as well, with the dynamics of development tracked by a neuropsychologist (with a mandatory preliminary analysis of the features of cortical-subcortical interactions and the nature of lateralisation). Speech therapy corrective work at the initial stages of helping the child may be considered inexpedient, both because of its extremely low effectiveness owing to the pronounced regulatory immaturity and because of the specific features of the functional organisation of brain activity. It is precisely the latter factor that also explains the need for an extremely cautious approach to the prescription of medication.

The prognosis of development is the more favourable the earlier specific corrective work is begun. In neglected cases, or when the work is begun after the age of 8-9 years, a deviation of development towards the group of asynchronous development (disharmonious development of the extrapunitive type) is possible. In these cases great importance attaches to the presence and severity of such factors aggravating the child’s development as atypicality of development, an unfavourable socio-pedagogical situation of development and inadequate corrective work (for example, only massive psychotherapy without medication support, etc.).

The main diagnoses are: “organic infantilism”, “attention deficit hyperactivity disorder”, “minimal brain dysfunction”, “hyperkinetic disorders” — (F90) (ICD-10). Specific forms of speech disorders may also be observed, such as an increased rate of speech — “tachylalia” (in ICD-10 “cluttering” — F98.6).

The lead specialist for this type of deviant development should be a psychologist with a knowledge of neuropsychology or with a neuropsychological specialization. In cases of pronounced neurological impairment, the lead specialist may be a neurologist or a psychiatrist.

The category of children with partial underdevelopment of higher mental functions predominantly involving the verbal and verbal-logical component is the most widely represented in the work of an educational psychologist. As a rule, the reason for referral is not difficulty in organizing the child's behavior in preschool or school educational settings or at home, but difficulty in mastering the corresponding curriculum material.

Most often these children already attract attention in the preschool years with a so-called "delay in speech development" and are very likely to come under the observation of a speech therapist or to be referred to specialized speech-therapy kindergartens (groups). In a certain proportion of children, however, the speech underdevelopment remains uncompensated.

As a rule, these children display low verbal activity, accompanied by distinctive features of development, primarily of gross motor skills. They are clumsy and awkward. The tempo of activity is often low, and against a background of fatigue the goal-directedness of activity declines. Among the features of cognitive development, it should be noted that they perform nonverbal tasks significantly more successfully (at times exceeding average age norms) than verbal and verbal-logical tasks. Comprehension of complex speech constructions is impaired, as are all forms of word formation; the active vocabulary is small, and searching for superordinate (categorical) words is difficult.

Semantic substitutions (verbal paraphasias) frequently occur in their speech, and comprehension of complex spatial, spatiotemporal, and cause-and-effect linguistic constructions is impaired. Children may exhibit self-doubt and anxiety, apparently compensatory in nature and conditioned by an entrenched pattern of failure. It is precisely these children who often display neurotic signs (tics, enuresis, stuttering, etc.). With respect to the specific profile of functional asymmetry, this variant of deviant development is most often accompanied by mixed or unestablished lateralization, that is, by signs of atypical development.

In somatic terms, children of this category are also fairly compromised: their history often includes allergic reactions, intestinal dysbacteriosis, manifestations of respiratory allergosis (in particular, bronchial asthma), as well as a markedly idiosyncratic sequence in the development of motor skills during the first year of life, usually of neurological origin.

With regard to the specific formation of the basic prerequisites (components) of mental development, the type described here is characterized primarily by pronounced underdevelopment of spatial representations. Moreover, whereas in the case of partial underdevelopment of higher mental functions predominantly involving the regulatory component of activity (the type described previously) we also spoke of underdevelopment of the verbal link, in children of the present category, despite the sometimes seemingly similar picture of speech problems, one observes a failure to master even the simplest levels of space. In some cases one can speak of underdevelopment of the body and face schema even in the vertical plane: at the level of "higher — lower" (see section 3.3.3.), to say nothing of difficulties in analyzing the spatial relationships of objects external to the body in both the vertical and the horizontal plane.

That is, one may say that metric and coordinate representations are unformed. It is clear that all subsequent levels of spatial representations turn out to be "deficient," incompletely formed. As we have already said, this may most probably be closely connected with a shift in timing and a disrupted sequence of early motor development in ontogenesis, resulting from impaired neurobiological functioning of the central nervous system.

At the same time, the levels of basal affective regulation of emotions and the formation of voluntary mechanisms of activity may lag in time, may fail to coincide with the ontogenetic program of development as a whole, and may show one or another mildly expressed peculiarity. An example of the development of these basic components is the above-described difficulty in regulating one's own behavior against a background of fatigue or in a stressful situation. Features of affective-emotional development (timidity, fearfulness, lack of confidence in difficult situations) may indicate a mild hypofunction of the 3rd and 4th levels.

It follows from the foregoing that the principal direction of developmental or corrective work should be the formation of spatial representations in accordance with the principle of substitutive ontogenesis, that is, the building up of spatial representations starting from the most elementary levels of work with the body. Such children are undoubtedly also indicated for motor correction based on a neuropsychological approach (and, accordingly, for monitoring of the dynamics of this work by a specialist with a neuropsychological specialization).

Only once a certain developmental progress has been achieved is it recommended that speech-therapy work proper be added (Such a sequence of corrective measures is possible only when working with children of early preschool age, when there is a sufficient reserve of time. When working with older children, one must speak of conducting psychological and speech-therapy corrective sessions in parallel). In addition, work on harmonizing the levels of affective regulation is envisaged, mainly within the framework of a specially designed program of group (play) psychotherapy.

The considerable representation in this group of children with specific features of the functional organization of brain activity itself (unestablished or mixed lateralization, familial or latent left-handedness, other signs of atypical development) calls for an extremely cautious approach to the use of pharmaceuticals and to drug therapy in general.

The developmental prognosis appears favorable when the "scenario" of the work is properly constructed (an appropriate sequence in which specialists are brought into work with the child) and the work itself begins relatively early, that is, when a solid foundation is created for mastering the corresponding educational programs. A very important factor is undoubtedly the general emotional climate.

Under an unfavorable combination of circumstances, developmental deviation is possible along two lines:

1. An increase with age in problems associated with insufficiency of the operational side of mental (thinking) activity, of gnostic functions — especially phonemic perception — and of mnestic functions. The situation is aggravated by the inadequate formation, relative to conventionally normative age indicators, of voluntary regulation of one's own activity. All of this brings about an ever greater discrepancy between conventionally normative age parameters and the indicators of development of the child's higher forms of logical thinking, that is, it effectively entails a worsening of the condition to partial underdevelopment of the mixed type, and in some cases further deviation of the condition toward socially conditioned forms of total underdevelopment — an oligophrenia-like syndrome — is possible.

2. Deviation of the condition toward the group of asynchronous development (various variants of disharmonious development), that is, an escalation of behavioral reactions up to pathocharacterological reactions, which are initially compensatory in nature but at an older age lead to pathological formation of the personality as a whole.

The principal ones are: first and foremost, a speech-therapy diagnosis (predominantly "general underdevelopment of speech" of varying degrees of severity); and a medical diagnosis — "delay of psycho-speech development against a residual-organic background." At school age these children are given such diagnoses as "dysgraphia and/or dyslexia against a background of uncompensated general underdevelopment of speech." In addition, neurologists often diagnose a neurosis-like syndrome (its asthenic or astheno-neurotic variants). In accordance with the current classification of mental disorders of childhood (ICD-10), such diagnoses (without further specification) may be made as "specific developmental disorders of speech and language" — (F80), "specific developmental disorders of scholastic skills" — (F81).

The designation of the lead specialist depends on the child's age and the severity of the speech impairments. Accordingly, the lead specialist may be either a speech therapist or (at the first stage of corrective work) a psychologist (neuropsychologist). Often both of these specialists may be regarded as leading.

Partial underdevelopment of the mixed type often represents an intermediate variant of development (borderline between partial underdevelopment of higher mental functions and total underdevelopment). This is the most difficult category of children in differential-diagnostic terms. Both in the tabular description of this type of development (Appendix 1) and in the present section we have sought to draw on all the accumulated experience of diagnostic work and on observational data from more than 20 years of our own diagnostic practice.

Children whom we assign to this type of development are characterized by a fairly low level of adaptive capacity and a general decline in activity and in orienting reactions. At the same time, the presence of signs of atypical development is nonspecific, although it does aggravate the child's problems, while pronounced consequences of organic damage to the central nervous system adversely affect both the indicators of the tempo of activity and the characteristics of working capacity. Often, against a background of fatigue (even mild), impulsivity appears both in the general pattern of behavior and in the performance of the tasks presented.

In the assessment situation these children are usually behaviorally adequate, but they tire quickly and lose interest; criticality toward the results of their own activity may be reduced, and the process of learning new types of activity and transferring them to analogous material is slowed. Because of this, toward the end of a lengthy assessment they may begin to display phenomena that are as alike as two peas in a pod to the features of children with total underdevelopment. This imposes particular limitations both on the duration of the diagnostic assessment of such children and on the methodological apparatus used.

Among the features of cognitive development, one should note first of all the insufficiency of the operational side of mental (thinking) activity (including the parameters of attention). Insufficiency of individual links of higher mental functions is also observed: gnostic functions, especially phonemic perception; mnestic functions; and speech-thinking activity. Underdevelopment of spatial representations and difficulties in understanding relatively complex speech constructions are also noted.

All of this brings about the underdevelopment of even simple forms of logical thinking, which results in difficulties in working with nonverbal material, including at the visual-active level. It should be noted, moreover, that the children's state (the level of mental activity as a whole) may fluctuate depending on meteorological changes, the phases of the moon, and so on, which may not only worsen task performance but at times even improve it. Such fluctuations in state indicate the instability of neurodynamic characteristics.

At school age children grow accustomed to failure, and they begin to form compensatory personality and behavioral reactions in the form of lowered self-esteem, anxiety, and oppositional forms of behavior.

If we consider the features of voluntary mental activity as one of the basic components of mental activity as a whole, we may say that what is characteristic of this type is that the voluntariness of higher mental functions and the voluntary emotional regulation of behavior are not so much pronouncedly immature as unstable, against a background of relatively well-formed voluntary regulation at the motor level.

This type of development also includes those mixed variants in which underdevelopment of a regulatory nature and inadequate mastery of spatial representations are noted to an equal degree.

Spatial representations, as has already been said, are insufficiently formed (often at the level of analysis "from the body"), or they are unstable and there are difficulties in actualizing the representations that are present. Only the simplest prepositions are present in speech; there are marked difficulties in understanding even relatively simple spatial and spatiotemporal and, consequently, cause-and-effect relations, which indicates insufficient development of the 3rd and 4th levels (the verbal and the quasi-spatial — linguistic) of the formation of spatial representations.

Analysis of basic affective regulation shows a relative proportionality in the development of all levels of the basal system of emotional regulation against a background of general weakness of neurodynamic characteristics. In severe cases both hypofunction and hyperfunction of the 3rd and 4th levels and a general disproportionality of the entire level system of emotional regulation are observed.

Turning to the specifics of conducting corrective measures, particular attention should be paid to work on raising the general level of activity and of productive working capacity, which should precede the start of psychological and pedagogical correction proper. Here it is most often necessary to have the help not only of a neurologist but also of a pediatrician and a homeopath, together with the prescription of nonspecific vitamin therapy, general tonic and regimen measures, sensible dosing of loads, and so on. It is hard to imagine that, without these measures, merely by loading the child with additional corrective sessions — even in a play or motor format — we could help him overcome his existing difficulties (especially given these children's personal attitude toward their own failure). Of the types of special assistance indicated (Appendix 1), not one can be considered superfluous.

Such a "corrective load" on the child is possible only in a situation where the work of all the specialists is coordinated. In most cases it makes sense to speak of an integrated version of corrective work that also includes psychotherapeutic elements, since sessions in all the various "directions" with different specialists often prove excessively "burdensome."

If all the observations concerning the specifics of providing assistance to this group of children are taken into account, and if the work itself is begun no later than the age of 7.5–8 years, then one may expect, on the one hand, a low rate of the child's overall developmental progress and, on the other, a prognosis for further development that can be assessed as fairly favorable. Otherwise (with late referral to specialists), deviation of development toward total underdevelopment, often complicated by personality disharmony and behavioral disturbances, is entirely possible. In that case, in addition to mounting learning problems, the child's sphere of interests will narrow sharply and emotional reactions will flatten.

The social situation of development may introduce both positive and negative "corrections" into the child's development. Under unfavorable conditions (a single-parent or low-income family, parental alcoholism, low social level of the family, etc.) one often has to note with regret that a child who could have been "pulled through" with early intervention (at the age of 5–7) has to be given a diagnosis such as "socially conditioned total underdevelopment."

Diagnoses by other specialists: "delay of psycho-speech development," "delayed mental development of cerebral-organic origin," "specific delays in development" - (315.0-315.9) (ICD-9), "neurosis-like (asthenic) syndrome," "specific developmental disorders of scholastic skills" - (F81) (ICD-10), "dysgraphia," "dyslexia," and so on. Often such children are already mistakenly given the diagnosis of "mild mental retardation" - (F70) (ICD-10) at preschool age, which determines the entire life course of the child and his family. At the same time, at an age over 9–10 years, especially in cases of pronounced social "disadvantage" in development, the diagnosis of "oligophrenia-like syndrome" may quite legitimately be made.