Lecture
Delayed mental development (abbr. DMD) — a disturbance of the normal tempo of mental development, in which individual mental functions (memory, attention, thinking, the emotional-volitional sphere) lag in their development behind the accepted psychological norms for the given age. As a psychological and pedagogical category, DMD is used only in the preschool and primary-school years; if by the end of this period signs of underdevelopment of mental functions persist, one then speaks of constitutional infantilism or uses other terms appropriate to the situation.
The very concept of "delayed mental development," widely used in Soviet psychological, pedagogical, and medical literature until the 1990s, had become outdated by the end of that period. In 1997 it was definitively withdrawn from use as a medical (psychiatric) diagnosis by Order No. 170 of the Ministry of Health , by which the International Classification of Diseases, 10th revision (ICD-10) was brought into force throughout the territory of the Russian Federation. In ICD-10 the category "DMD" was replaced by categories that are better grounded from a scientific and medical standpoint and oriented toward evidence-based psychiatric practice, relating to "disorders of psychological (mental) development" (ICD-10: F80—F89; Eng.: "disorders of psychological development") and, to a lesser extent, to "emotional and behavioural disorders with onset usually occurring in childhood and adolescence" (ICD-10: F90—F98; Eng.: "behavioural and emotional disorders with onset usually occurring in childhood and adolescence"). From that time on, the formulation "delayed mental development" cannot be used as a medical diagnosis and formally cannot be contrasted with mental disorders, including mental retardation, hyperkinetic disorders, disorders of psychological development, and others.
Having lost its significance as a medical diagnosis, the concept of DMD continues to be used in Russian-language (predominantly Russian) psychological and pedagogical literature to denote tempo characteristics of development without regard to their etiology, pathogenesis, or the prognosis for the effectiveness of treatment. In 2015 the Adapted Basic General Education Program of Primary General Education for Students with Delayed Mental Development was included in the group of documents of the Special Basic General Education Programs of Primary General Education of the Federal State Educational Standard. This program began to be implemented on 1 September 2016 in schools of the Russian Federation within the framework of inclusive education.
Let us dwell on the history of the problem connected with the concept of "delayed mental development" and with the division of this amorphous group into fundamentally different types of development. Its roots go back to the 1950s — to the work of G. E. Sukhareva and other Russian psychologists and psychiatrists. In its classic form the term "delayed mental development" was articulated and proposed by the classic figures of Russian defectology T. A. Vlasova and M. S. Pevzner in the 1960s and 1970s. In those works the term was quite justly formulated as "temporary delay of mental development." This declared the fact that after some definite period this delay would be compensated, the child would catch up with his peers, and his development would enter the normative "channel." The introduction of this approach determined for many years the main path of diagnosis and correction for a vast "stratum" of the child population. Delayed mental development was understood asa slowing of the tempo of mental development.
This approach was subsequently developed further in the likewise classic works of V. I. Lubovsky, K. S. and V. V. Lebedinsky, U. V. Ulyenkova, and others. At the Institute of Defectology (now the Institute of Corrective Pedagogy of the Russian Academy of Education) separate units were established devoted to the psychological study and instruction of this category of children. The substantive characteristics of the concept were deepened and refined. The main variants of delayed mental development were systematized in the works of G. E. Sukhareva, T. A. Vlasova, and M. S. Pevzner.
Fig. Classification of mental dysontogenesis by V. V. Lebedinsky
The works of Klara Samoylovna and Viktor Vasilyevich Lebedinsky [1, 19] are based on the etiological principle, which makes it possible to distinguish four variants of such development:
In this form the general taxonomy of DMD still exists today. By now, however, more detailed approaches have been developed to differentiating the variants of delayed development, especially those cases assigned to "DMD of cerebral-organic origin," which in themselves constitute the group that is most difficult in differential-diagnostic terms.
To sum up, it may be noted that across the various classifications of DMD the common radical is an a priori understanding of the term "delay" as a temporary phenomenon: it is assumed that in time the tempo of the child's development will undergo positive changes (with or without corrective work) and that the child will catch up with his peers in development. At the same time, the practice of working with children whose condition is characterized as DMD shows that things are not so simple. "A pillow for a lazy head" — such, according to G. E. Sukhareva's contemporaries, was her remark about this "label."
Indeed, already in the course of diagnostic and, all the more, developmental-corrective work, serious doubts arise as to whether fundamentally heterogeneous groups of children can be designated by a single concept. Thus, with some children the traditional approaches are quite effective and help the child overcome his developmental lag. With others (and there are far more such children) these methods prove insufficiently effective and cannot fully promote compensation of the existing impairments. Many contemporary practitioners note that the developmental and corrective work carried out with such children not only fails to promote compensation of the problems but in some of the most difficult cases worsens the child's condition over time. Moreover, assessing the condition of some children as "delayed mental development" does not reflect the actual state of affairs at all. The reasons for this phenomenon should be sought in an insufficiently precise (oversimplified) understanding of the psychological structure of development in this category of children.
In our view, all the variants of forms of delayed mental development described by various authors belong, following D. N. Isaev [11] and V. V. Kovalev [13], to the group of "insufficient development" (underdevelopment). The psychological characterization of this group is presented most clearly in the work of V. V. Lebedinsky [19]. At the same time, we consider it possible to propose our own, refined psychological typology, one that answers to the specifics of the development of the child population at the present stage.
Thus, within the group of "insufficient development," in addition to "total underdevelopment," we propose to distinguish the subgroups "delayed development" and "partial underdevelopment of higher mental functions." In this way the category of children traditionally assigned to the group of "delayed mental development" is divided into two fundamentally different subgroups.
The subgroup "delayed development" includes the variants of genuinely delayed development, which are characterized precisely by a slowing of the tempo at which various characteristics of the cognitive and emotional-personality spheres are formed, including the regulatory mechanisms of activity. To this subgroup we assign such types of deviant development as the "tempo-delayed type of development" (harmonious infantilism) and the "unevenly delayed type of development" (disharmonious infantilism).
In our understanding of the developmental features of these categories of children we are in accord with the conception of "delayed mental development" held by the classic figures of Russian psychology and defectology, namely that the tempo of the child's development will gradually increase (on its own or with the help of corrective measures) and that by the threshold of 9 to 11 years the child will genuinely catch up with his peers in development and his condition may be characterized as "conventionally normative."
A typical child with the tempo-delayed type of development (harmonious infantilism) looks younger than his chronological age; he is lively and spontaneous, and "...an infantile body type with childlike plasticity of facial expression and motor behavior often corresponds to the infantility of the psyche." "The emotional (and cognitive — auth.) sphere of these children is, as it were, at an earlier stage of development, corresponding to the mental makeup of a younger child: with vividness and liveliness of emotions, a predominance of emotional reactions in behavior, play interests, suggestibility, and insufficient independence" (Lebedinsky V. V. Disturbances of Mental Development in Children. — Moscow: Moscow State University, 1985, p. 55). At school age they are tireless in play and at the same time have low working capacity, quickly become satiated with intellectual load, and the immaturity of their regulatory functions and motivational-volitional sphere also hampers their social adaptation, by virtue of which they are unable to follow established rules of behavior. Indicators of intellectual development, as a rule, correspond to the level of the actual psychophysical age at which the child is functioning.
Let us consider the specifics of the basic components of mental development. The practice of diagnostic work shows that the formation of the basic components of mental development in children with harmonious infantilism corresponds to the course of normal ontogenesis, i.e., it does not change its proportions but simply proceeds more slowly. Moreover, the levels of development of the basic components themselves are harmoniously related to one another, apparently determining the harmonious character of the delayed development of both the regulatory functions and the emotional and cognitive spheres, and on the whole they correspond to the general program of the child's mental development. It is precisely this aspect that is the sense-forming one in the typology we propose.
Clearly, with such an understanding of development one cannot speak of corrective work in the literal sense of the term, but it should be borne in mind that this must be developmental work specific to the age that the child is displaying. It is of course also necessary to form the functions of programming, control, and regulation of one's own activity, mainly through the play component and taking account of the leading type of motivation. If necessary, a speech therapist may be brought in "in parallel" (as a rule, to correct sound pronunciation). Observation by a pediatrician is needed insofar as the child requires general tonic support, vitamin therapy, and the like. Left-handedness occurs in this variant of development no more often than the population average and is usually genuine, that is, it does not further complicate the course of the child's development. Signs of neurological or somatic problems are either absent or are well compensated as early as the first year of life, which can apparently be explained by adequate compensatory and adaptive capacities that are "innate."
The developmental prognosis should be assessed as good, especially when the child begins regular schooling not in accordance with his chronological age but according to actual readiness (the maturation, to the extent required for the start of schooling, of the regulatory functions proper and of the emotional-personality and cognitive spheres). As a rule, this occurs by the age of 7.5–8.5 years.
If, however, the child's developmental features are not taken into account and he begins schooling "by age," or if the parents on the contrary believe that school is precisely what will "knock some sense into him," then the actual impossibility not only of normally mastering the material but also emotional and behavioral inadequacy to the conditions of schooling may contribute to the formation of disharmonious personality traits, behavioral disturbances, and school maladaptation as a whole.
Specialists in related fields usually make the diagnosis of "infantilism" or "constitutional delay of mental development," while the speech therapist's diagnoses are "functional dyslalia" or "mildly expressed general underdevelopment of speech."
Unlike harmonious infantilism, the unevenly delayed type of development (disharmonious infantilism) is characterized primarily by a greater level of maturity (formedness) of the cognitive link of higher mental functions compared with the level of development of voluntary regulation of one's own activity and of the motivational-volitional and emotional-personality spheres. The child's appearance and behavior likewise bear the marks characteristic of a younger age, but chronic somatic illnesses, visual impairments (of varying severity), or simply somatic weakness are often noted as well. Signs of atypical development (left-handedness, unestablished lateralization, etc.) occur among this category of children more often than the population average, that is, they are specific, which in turn complicates the course of development as a whole.
The presence of somatic problems reduces the child's working capacity still further and makes him emotionally labile, often with elements of demonstrativeness. Children may be capricious and stubborn. This is entirely understandable, since intellectual competence is present but the child is "not ready" for the demands made of him in accordance with it. The child may be quite adequate but insufficiently critical of the results of his own activity; self-esteem may be either inflated or, conversely, lowered. In communicating with peers he often fails to find common ground, is too emotional, and can rarely "hold" a role. Compensatory emotional reactions may be of either the intrapunitive or the extrapunitive type (see below); a mixed type of response is often possible. On the whole, indicators of criticality and adequacy correspond to the actual psychophysiological age, while learning capacity for new types of activity may even be high, that is, correspond to the actual chronological age.
A certain disproportion is also observed in the formation of the basic components of mental development. But their formation proceeds with the essential difference that in this type of development one may rather speak of an advance in the formation of spatial representations and their correspondence to age (the consequence being a corresponding level of development of the cognitive sphere). The age-appropriate, conventionally normative development of spatial representations is combined with development that is delayed in its dynamics in the other basic components (the voluntariness of mental activity and the basal system of affective regulation). Moreover, in analyzing the level system of affective regulation, one may conclude that the regulating influence of the 4th level (the level of affective control) on all the other, lower-lying levels is insufficient (compared with the conventional age norm). At the same time, the level of affective expansion (the 3rd level) may be in either hypofunction or hyperfunction (see Appendix 4). This is specific to the group with the tempo-delayed type of development. At the same time, what is common and fundamentally important for both types of delayed development is that in both cases the formation of all the basic prerequisites (components) passes successively through (without skipping or jumping over) all the levels of its development (the structure of the basic prerequisites or components is described in detail in section 1.3).
In the system of developmental and corrective work with this category of children, priority is given to programs for harmonizing the level system of affective regulation (after O. S. Nikolskaya). In addition to purely psychotherapeutic assistance, a program for forming voluntary regulation (in its developmental variant) is effective, as is motor correction based on a neuropsychological approach. In a number of cases parent-child psychotherapy (individual and/or group) is indicated. In the case of somatic illnesses, observation by the appropriate specialist physician is of course necessary.
In analyzing the prognosis for children with the unevenly delayed type of development, its ambivalence is evident: with respect to the formation of the so-called cognitive link of higher mental functions it is quite favorable, whereas from the standpoint of motivational-volitional, emotional, or personality development as a whole there is a high probability of the formation of variants of disharmonious personality development (deviations); and where somatic problems are more or less pronounced, of a variant of intrapunitive disharmonious development of the child along the psychosomatic type (see below).
Among the diagnoses given by other specialists: "MCD" (minimal cerebral dysfunction), "delayed mental development of somatogenic or constitutional origin," "affective instability," "children at risk for impaired formation of scholastic skills" - sometimes a speech-therapy diagnosis is also present: "functional dyslalia."
The term "dysontogenesis" (from the Greek "dys," a prefix denoting deviation from the norm, "ontos" – being, entity, "genesis" – development) was first used by Schwalbe in 1927 to denote deviation of the intrauterine formation of the body's structures from the normal course of development. In Russian defectology these conditions are grouped together as developmental disturbances (deviations).
The main types of mental dysontogenesis are regression, disintegration, retardation, and asynchrony of mental development.
Regression (regress) – the return of functions to an earlier age level, either of a temporary, functional nature (temporary regression) or of a persistent nature associated with damage to the function (persistent regression). Thus, for example, even a somatic illness in the first years of life can lead to a temporary loss of walking and toileting skills. An example of persistent regression may be a return to autonomous speech as a result of the loss of communicative needs observed in early childhood autism. A tendency toward regression is more characteristic of a less mature function. At the same time, regression may affect not only functions that are in a sensitive period, but also functions that have already been sufficiently consolidated, which is observed under more severe pathological influences: in cases of shock psychic trauma, or at the acute onset of a schizophrenic process.
The phenomena of regression are differentiated from the phenomena of disintegration, in which there is no return of a function to an earlier age level, but rather its gross disorganization or loss. The more severe the lesion of the nervous system, the more persistent the regression and the more probable the disintegration.
Retardation – the delay or arrest of mental development. A distinction is made between general (total) and partial mental retardation. In the latter case, what is meant is a delay or arrest in the development of individual mental functions or individual personality traits.
Asynchrony, as distorted, disproportionate, disharmonious mental development, is characterized by a marked advance in the development of some mental functions and properties of the developing personality and a significant lag in the rate and timing of maturation of other functions and properties, which becomes the basis of a disharmonious structure of the personality and psyche as a whole. Asynchrony of development, both quantitatively and qualitatively, differs from the physiological heterochrony of development, that is, the non-simultaneous maturation of cerebral structures and functions. The principal manifestations of asynchronous development, in accordance with the conceptions of physiology and psychology, arise in the form of new qualities as a result of the restructuring of intrasystemic relations. Restructuring and increasing complexity proceed in a definite chronological sequence determined by the law of heterochrony – the non-simultaneous formation of various functions with the advanced development of some in relation to others. Each of the mental functions has its own "chronological formula," its own cycle of development. There are sensitive periods of more rapid, sometimes abrupt, development of a function and periods of relative slowing of its formation.
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