Early Detection: Blessing or Curse

Reuven Feuerstein, Ph.D.

Being introduced to an audience is often a way of learning about oneself, by getting some exogenous sources of information. I feel that what is being described is not so much me as it is about my part in affecting certain attitudes, approaches and programs related to children in need. And I must begin by saying that as I am here and lecturing before you, I have to overcome some difficulties. Yesterday I became accustomed to being a listener and avid learner. I thank Professor Greenspan and Serena Wieder, and all those whom I have had contact with at this wonderful conference. I do not often have an opportunity to sit avidly and listen to each word said. I have certainly learned a great deal, as has my staff whom I invited to come from Jerusalem. However, the passage from learner to listening to presenting speaker is not an easy one. Secondly, I have been strongly intimidated by the descriptions of the biological bases and the neurophysiological determinants of the behavior in the autistic child and other disabilities. to the point where I asked myself, What can I possibly contribute here? Then I heard one of the presenters say that "this is the condition where education must start from. If we give medications, this will make the child accessible to your educational interventions. Dont think of us as changing the child. The ultimate point of changing the child will be the educational act. I felt much once I grasped that this is the attitude of some of my prospective audience. My third difficulty is that while it is challenging to speak in front of specialists like you, I am somewhat intimidatedhappily soby the presence of parents. It is the parents, in large measure, to whom I address myself in my remarks today and in the body of my work, so this makes me extremely responsibly engaged. Will I be able to convey to you what I feel you need, what you feel you need, what you so deeply desire to hear, without creating false expectations? This is a very serious conflict for me since one of the major goals of our work is to make our contribution meaningful and realistic. I want you to know that from time to time I have been labeled as a pathological optimist and this has not been a complimentary description from some specialists in the field. I will try to make up for whatever has given me this reputation, and I will start my presentation by addressing the issues related to the topic I have chosen, then give you the basic theoretical assumptions that underlie our work, and outline the various applied systems that are derived from the theory. Finally, we will see to what extent and in what ways the applied systems confirm the expectations produced by the theoretical framework we have developed.
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Before I begin I would like to tell you where we are coming from. I am the founder and director of the International Center for the Enhancement of Learning Potential and the Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997 253

HadassahWIZO-Canada Research Institute. We are located in Jerusalem, and I also serve as a Professor at Bar-Ilan University in Ramat Gan. At the Center and Institute our activities involve three major components: research and development, training, and service. These three elements are constantly combined. We do not deal with research without service, we do not train without theory, and we do not theorize without daily encounters with children. This combination gives us a very important advantage over pure academia. We learn daily from the children with whom we are working, and from the parents, communities, and schools involved. We generate working hypotheses, we adapt whatever we are doing according to our findings, in whatever areas as we succeed or fail, and learn how to create the dynamics of change in ourselvesin our theories as well as our practices. In this context, one of the problems which we became confronted with is the issue of early detection. The Dilemma of Early Detection: Blessing or Curse? The concept of early detection is a very important step in the development of preventive strategies, within the medical model. The basic tenet of this approach is that the detection of the first signs of a given condition can be considered as predictive of a more fully developed pathological condition in the organism. This model, when applied to conditions such as cancer, cardiopulmonary distress, or cerebral conditions, etc., has as its major goal the prevention of the full development of the condition, by responding proactively to the early detected signs. A most important element in early detection is marked by the fact that the preventive steps to be taken may have iatrogenic effects, but compared to what might happen as the full fledged condition comes to expression, it can be considered a risk well worth taking, and to have a meaningful priority of action. Furthermore, early detection based on the medical model has very little implication or attention focused on the social life of the person so detected. In particular, it does not affect the nature of the relationship between the individual and the affective environmentthe emotional bonding with the significant people in the interactive world. However, the circumscribed focus on the problem of concern, in appropriate applications of early detection activities, helps to increase emotional engagement and a sense of positive responding. In this usage, early detection can represent a true blessing. Of course, there may be cases where early detection, even in the medical model, may present a danger. It can represent an over interpretation of the seriousness of the condition, or a misinterpretation of the condition. Representation of a trauma may be painful, but it may not be indicative of a more pervasive condition. In spite of this, its value is that it may mobilize the participantsthe parents, the caregivers, professionalsto be more adaptive and responsive than they might have bene were not such a severe condition diagnosed and predicted. However, the extension of the early detection model to areas related to the psychological, mental and developmental conditions of the individual creates a large number of questions as to the nature of the effects that early detection may have. There are two types of risk present in early detection. In the first type, produced by the use of minimal signs in order to form a diagnosis, the potential is there to over-attribute the meaning of certain signs as representing types of syndromes which are totally encompassing, affecting areas of behavior and personality. Early is meant here not in the sense of early appearance, but rather in the sense of an early interpretation. Too early interpretation creates overextensions 254Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997

of certain syndromes, by using a strategy of pars pro toto (part as whole). A second type of risk in early detection is in using certain signs, developmental milestones, appearing at early stages, or in a delayed or inadequate way in the individual, and deciding on the basis of them as to the developmental curves (on a normative basis) extrapolated over the individuals lifespan. This approach predicts the nature of the curve. The early detection of developmental signs, delayed or insufficiently apparent, etc., are related to the existence of norms to which individuals can be compared, in terms of times of development, or the use of stages of development in the sense of Piaget. Such phases consider the appearance of certain cognitive functions as occurring in a given order, or in a specific configuration, and acting as preconditions for subsequent appearances at further given levels. These norms are considered predictive of development, in particular those related to mental age, IQ, and stages of development. This is the concept of developmental milestones. Such approaches create conditions for interpreting certain deviations of these norms as signs which indicate the developmental curve of the individual or the individuals rank order, in relating to the developmental norm. In this regard, some syndromes themselves incorporate developmental norms as part of their configuration, and early detection can set a series of predictions in place based on the nature of the conceptualized syndrome. The attempt, therefore, to apply the medical model to the cognitive, mental, behavioral development of human beings potentially represents great risks. The medical model is a legitimate approach to prevention. But one must be careful. In the case of the mental processes, or those conditions in which certain types of behavior are anchored in the medical model, but represent the product of social, cultural, emotional, behavioral environments, early detection can become of questionable value if not an outright source of danger. So the issue of whether early detecting is a curse or blessing must be considered in the context and outcomes where early detection occurs, to what it leads, what kinds of interventions it elicits, and how it will affect the interaction of the child with the environment. There are a number of conditions under which early detection in the mental, behavioral, and emotional field may become really dangerous. The first and foremost are in the dealing with problems related to areas which are strongly affected by cultural elements. We consider the ideas of Rom Harre, a student of Vygotsky, and other social scientists, who have described the double ontogeny of the human being as being very important here. Notably, the biological nature of the human being, which represents the human organism as a community of cells, which is ipso facto individualized in its existence, and the social ontogeny which makes the individual strongly affected by the cultural context in which he/she exists. When we deal with the socio-cultural dimension, and we use criterion from behavioral/mental aspects, and try to give them the value of a sign which predicts the future, we expose ourselves to a very serious dilemma. To what extent can we consider elements which are so diverse in different cultures, as reflecting types of developments which are biological. In other words, to what extent shall we ascribe an attribute as having biological value when it reflects a mental, social, or cultural phenomena. For example, it is known that Navaho children start to walk at the age of 6 to 7 months. At the age of one year, they dance the war dances of their parents with an agility that is incredible, and not observed in children from other, different cultural experiences. The Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997 255

Navaho people will tell us that a child who doesnt walk at 6 months, and does not dance at one year, is considered deviant. Why? Because the culture encourages, imposes, does everything to guarantee that the child will be able to walk and dance on time. There is a strong imposition from the culture on the biological system. A child who doesnt do it because of a lack of teaching is considered deviant. The early detected sign is ascribed not only to the child, but to the culture. This illustrates the importance of linking the early detecting of certain mental, behavioral, emotional manifestations with their cultural context. Let us use the child with Downs syndrome as a model for the potential dangers of early detection. What is the great danger in ascribing to the child with Downs syndrome certain mental characteristics? It is obvious that a child with Downs syndrom will be early detected, due to the immediately perceived physical characteristics at birth. The child with Downs syndrome produces in parents a feeling of a cataclysm in their lives, often followed by a state of marasma, a state of mourning, producing a state of alienation. The parents ask themselves, Is this our child? He doesnt resemble any one of us. The condition thus shows us how early detection pervasively affects the life of this child. For many years, the early detected Downs syndrome child, because of his/her appearance, became the object of rejection, abandonment, or in the best cases, totally passive acceptance and, therefore, not offered any kind of stimulation needed in order to grow and develop, and undo the meaning of the signs which have been detected. The child, because of the slowness of responding and developing inherent to the biological system needing much more, in terms of intensity, amplitude, and repetition of stimulation presented, to outgrow the difficulties inherent in the conditiongets less because of the early detection. In this instance, we see the early detection as a curse. In this particular case, early detection was for a very long time coupled with the contention that there is nothing to be done because it is a chromosomal disorder which, by itself, cannot be affected by intervention. Therefore, early detection becomes a source of lack of development due to stimuli deprivation, of alienation, which is often compensated for by a reaction formation on the part of the parents. They may start to love the child in a totally unconditioned way, and do not attempt to make any kinds of changes in the course of the childs life, which may ultimately result in the placement of the child in custodial care programs, foster homes, or in leaving him/her in the hospital. This consequence, although not as strong, may be true for many other types of conditions, which are often detected too early in the two senses described abovein the amount and nature of the observed signs and/or in the sense of timing. There is a tendency to extend the meaning of a particular sign, in a very pervasive way, which will then, in turn, become a source of treatments, placements, reduced expectations, and eventually determine a very low quality of life. It is our contention that many of the signs which are considered as representing the existence of mental retardation related to such conditions as deficiencies in cognitive functions, specifically on the receptive and expressive levels, and the like, even if they really manifest in the repertoire of the individual, do not take away the possibilities which can prevent these conditions from fully developing. Therefore, early detection, rather than mobilizing the efforts to prevent the onset of the total picture, which has been signaled by the early signs, may create the tendency to become passive and accept the condition as such. This is true in the educational history of many children referred to as mentally 256 Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997

retarded on diverse levels. The approach in the environment of these children was marked by a passive acceptance, since their condition was considered as immutable and fixed. At later stages of development they are given types of treatments which, instead of developing higher levels of functioning stimulating them further, give them a status quo experience, meant to address the levels at which they presently function and presumed to be able to respond. This results, invariably, in creating conditions which make the individual become what he or she has been predicted to be. This is prophesy which fulfills itself We do all that is needed to materialize that which has been even minimally detected. We act to fulfill the prophesy by piacing the child in situations where there will not be the opportunity to learn anything se we speak in a way that prevents learning from new situations we dont give stimuli which are considered to be beyond the level of manifest responses. This is true for a variety of conditions. Two different difficulties thus emerge. one, that a detected sign is overextended and considered as a pervasive phenomena, and second, that a regimen of treatment is provided and conditons, perspectives, and prognoses are produced which are meant to materialize the prophesy which was offered by the early detection. Children with Downs syndrome, Fragile X, and among these, even the autistic child, have become victims of this early detection phenomenon. Herein is the potential for the overgeneralization of the meaning of signs, and of conceptions that once the sign is detected nothing can be done to modify the course of life other than some minimal alleviation of the symptoms. In this scenario, the basic conditions responsible for its presence are not addressed. The search after such signs, in order to detect them, does not lead to any strategies of change or of prevention. As a matter of fact, in the case of the autistic child, it leads toward an exacerbation of the symptom, which may have been transient, making it a pervasive phenomenon, when it may have been initially a simple, singular, or isolated behavior. The fact that the child doesnt establish eye contact, or does not respond to certain auditory stimuli, is all too often interpreted as a sign of a pervasive affective disorder. One often neglects to explore alternative explanations. For example, there might be some sensorial deficiencies of the child that affect responses to the environment, perhaps to the mothers voice, or other phenomena. and may thus be responsible for a lack of an orienting reflex to the voice and eyes of the mother. Many other reasons may not be fully explored. Other examples are cases of children who did not speak because they did not hear well. Other children may not respond because of heightened thresholds for attention to stimuli. The diagnosis of PDD is an all to frequent example of the tendency to turn single, insufficiently explored signs into indications of a pervasive disorder. The early detection and the generalization of the detected signs as representative of the future developments of the individual thus becomes a real source of deleterious effects on the organism thus diagnosed. But, under what conditions can early detection become a source of blessing? This will be the case if we do not deny the meanings of the signs, but we deny the interpretation given to them, and the passive acceptance approach which may be elicited by such signs. But under certain conditions, knowing that a child may become delayed in development due to pre-, para-, or postnatal conditions, or that the child has had certain other medical or developmental conditions, or predispositions due to certain genetic or Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997 259

chromosomal conditionsall these are very valuable signs to know, to detect, and to consider, if they are not viewed as leading to a condition of immutability. (Later in this presentation, we address the concept of distal and proximal determinants of cognitive development.) If one considers these signs as reasons for mobilizing certain preventive conditions, certain increased and amplified types of interventions, which we define and describe as mediated learning experience, and specifically focusing on the needs that the child presents. then early detection may become a blessing. What are these conditions? The first is the belief that the immutability of conditions produced by genetic, chromosomal, hereditary, or by acquired disability should be substituted by the concept of modifiability. The modifiability of cognitive processes and emotional conditions does not deny the existence of certain biophysical determinants of behavior. We recognize the effects of certain configurations in the individual, as well as the meaning of intrauterine and post-natal conditions of the child, but by the same token we believe that these conditions can become affected by modes of interaction with the environment, and in particular by mediated learning experience (MLE). Under such conditions, early detection of all types may become a source of great blessing. The theory of structural cognitive modifiability, which is elaborated in the rest of this paper, is an attempt to provide the educational system with an optimistic model for the adequate use of open approaches to changing the human organism, and maximizes the positive meaning of early detection.
Structural Cognitive Modifiability as a Belief System

We often refer to the basic tenets or postulates of our theory as a belief system. I am aware that it is not very acceptable for a scientist to use the term belief system, but the reason why we do so will become clear as we describe our theory. The theory we have developed is basically a set of postulates responding to a very strongly experienced and felt need. We focus upon the individual in our care, the target of our intervention. We want to see that individual develop, reach out to higher levels of functioning, become involved in a higher quality of life. It is a need which we have as parents, educators, and caregivers. This need creates a beliefif we need something, we believe that it can be made possible. Once the belief system becomes generated by a need, persistence, ingenuity, and a readiness to persistently pursue success even when resistance is encountered becomes part of the repertoire of intervention. One who is animated by such a need does not stop at the first experiences of resistance, but will find alternative ways to succeed. Of course, it is still necessary to combine this need with other necessary qualities to find ways to materialize the need system, to learn how to act on the beliefs, but one must start with a belief system. We believe that human beings have the unique conditions and options of becoming modifiable, as able to modify themselves, not necessarily and not restrictively through living under certain conditions or in ecosystems, even though changes may be experienced at this level. The individual can modify him/herself by an act of will, and can create conditions for self change. The concept of modifiability is very different from the concept of modification. In our view, these are very different, although not necessarily mutually exclusive concepts. We differentiate them within our definition of the term structural modifiability. Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997 259

Structural Changes in the Organism We define modifiability as certain changes which the organism undergoes, such as an increase or decrease in the quantity, quality, or intensity of certain behaviors, or in the adding through learning a certain type of behavior to the existent repertoire. We speak, instead, of modifiability as reflected in structural changes. This implies that the individual becomes involved in the process of generating new structures, which will enable learning. Put in simpler terms, the individual is modified by learning processes and the structural changes provide a way to learn how to learn and to modify oneself through the learning process. The concept of modifiability is not just adding a certain amount of skills, or new information or even more complex information. It is the very process of learning how to build the tools for further learning. In this sense, the concept of structural change based on Piagetian concepts of structure offers a constructivist approach which involves three major characteristics: 1. If the child is changed by changing cognitive structures, each time a certain part of behavior or skills is changed so, too, will be the total universe of behaviors to which the part belongs. It will not be limited or restricted to what the individual has just learned. But once this has been mastered in a structural way, the whole to which this part belongs will become changed in the individual. 2. Structural changes are marked by transformability. This means that the process of change itself undergoes transformations in its rhythm, rapidity, amplitude, and other to its manifestations. A change has occurred in one area. It will affect more and more general areas, and will not be restricted to one particular category or one particular whole. It will change the nature and efficiency of the elements that are acquired, but the most important characteristic of the structural change (and this is what we look for when we initiate an intervention) is what are the processes necessary to induce the changes produced in the individual; what is the nature of the intervention that produced the change. 3. The individual has been changed, and once modified as a result of the intervention, a process of self-perpetuation is generated, whereby the individual continues to modify him or herself, and thus projects into the future the acquired changes. This is well illustrated in the various research studies on Instrumental Enrichment that show the presence of divergent effectsgains that continue well after the experimental condition has been terminated. So when we speak of structural modifiability; we refer to a characteristic of the organism which is able to generate new structures within, and not limited to those concepts which have been modified through the external source of intervention. We add another term to the concept when we speak of structural cognitive modifiability. We consider the cognitive dimension as being the basis for change in the individual, and in addition to the intellective areas, as having an influence on the affective, energetic, emotional, and motivational elements. We consider cognition as the magma of our mental and behavioral states. Cognitive functions are the generators of our behavior, including certain affective and emotional conditions, articulating emotional responses, Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997 259

coloring our perceptions and bringing them into the larger cognitive processes. Cognition enables the establishment of relationships between the perceived experiences, as well as the possibility of generating new information from existent sources, and brings in the affectivemotivational dimensions, which generate, as well as are generated, by the integration of the structural/cognitive with the energetic/emotional. Role of Cognition in the Production of Structural Change I will not go through the whole list of elements which I consider necessary for a consideration of cognitive functions and processes. We consider cognition as the key element in our theory and practice. We use cognitive processes to make children able to use whatever encounters they have with stimuli to enrich their repertoire of thinking, of modes of interaction with stimuli, of bringing stimuli together and grouping them, of changing them. We consider that this cognitive processing will also meaningfully affect the affectiveenergetic elements. Piaget has helped us in this regard by making the connection between cognition and affect. According to Piaget, cognition and affect are two sides of the same coin. Cognition tells you what to do, where to do it, how and when to do it, and with whom (these are questions depicting the structural nature of behavior), the affective element asks the questions of what for?", why must I do it?, what is the purpose of my behavior? To strengthen the inter-connectiveness between the two dimensions of our life, I have added to Piagets metaphor of the two-sided coin the notion that the coin is transparent. That is, one cannot do something without being animated by an objective determinant, that the what and the why are intimately connected even in the most elementary behavior. If we look deeply into it, one sees that affect adds purpose, driving the individual to perform. And the cognitive processes structure behavior so that its purpose, set by the affective-emotional element, will be efficient, adequate, and able to reach out to the goals established (or internalized) for the learner. From our point of view, cognitive processes are very important, in particular for children with special needs, to endow and equip them to generate new emotional elements, more articulate ones, and especially to create in the child the realness of these emotional elements and needs so that one will be able, through them, to generate new behaviors of a purposeful, self-initiated and meaningful nature. Structural cognitive modifiability thus creates an option that exists for each individual. We believe that each Individual can increase his/her cognitive processes, articulate them, enrich them, create new structures and be able to dominate and master new tasks, new areas of functioning. We call it an option because the individual, at given moments and experiences of life must materialize it, but such materialization of the option may not happen. Overcoming Barriers to Change As an option, structural cognitive change can be attributed to each individual irrespective of three barriers usually considered as limiting the individuals propensity to develop and increase ones capacity: Etiology, the critical period, and the severity of the condition.

264 Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997

Etiology The etiological condition of the individual may be more or less difficult and more or less resistant to change. With barriers such as organicity or chromosomal conditions, or the biological determinants of certain behaviors such as in autism or the autisto-form manifestation, one asks oneself what can one do? How can one change? This has been one of our major questions. As we dealt with the large masses of culturally different and social disadvantaged children, we are able to show that they are able to become modified, that they have gone much beyond their manifest levels of functioning at a given point in their development, without being limited by the causes of their condition. Furthermore, we have examined thousands of children who, in addition to their coming from socially disadvantaged and dysfunctional environments, had genetic or organic conditions as the etiology of their low levels of functioning. Again, the questions raised concerning these children are will these children be able to make it in a normal environment? In normal schools? Or are they doomed to go on to special education, and to low, menial types of activities for the remainder of their lives? Consider the Downs syndrome child. When we started, there was a great movement against our telling the parents about the potentiality of these children. It was said, Be careful. Feuerstein is going to impose on your children things that they are not able to do. But today, we are at a point, as the successes of children with Downs syndrome makes possible, to bring parents who have been shocked by the early detection of the condition of their child to an understanding that much can be done to further the development of their child and creates in them the willingness to undertake positive actions. We have shown that individuals with Downs syndrome are highly modifiable. We do not consider the chromosomal barrier as immutable, and now after several decades of such work, we have children with Downs syndrome finishing high school, participating in normal schools, writing poetry, painting, performing on the stage. One of our artists has his works in the Israel Museum, and has had three of his paintings turned into stamps by the government postal service. An interesting issue for the point of early and active intervention occurred when we proposed glosectomia (partial reduction of the tongue) for Downs syndrome children. We were first attacked: What for? Why do they have to speak better? What will they have to say if they speak better? And I must say that it is difficult to maintain ones optimistic orientation in the face of such negative attitudes. And yet, when the child experiences this surgery and no longer has the tongue protruding, stops drooling, and can speak clearly, breathe clearly, eat more comfortably, and see him or herself as physically altered, the changes in function and self-perception clearly vindicate the value and meaningfulness of this approach. You may wish to read moving accounts of this in the case studies of several children in our newly revised book, Dont Accept Me As JAm. So, for the parents of children with severe developmental disorders, such as Down s syndrome, or other equally pervasive conditions, who, in the past have tended to go into states of depression to the point that they didnt want to take the child home from the hospital, often leaving the child there for months (some of them dying in the hospital, some placed into institutions or foster homes). As our efforts to overcome these effects have become more widely known in Europe, our approach was described by a French reporter in the publication
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264 Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997

Le Monde under the headline For Feuerstein, the Chromosomes Do Not Have the Last Word (C. Bert). The chromosomes exist, they act and they change, and they create certain conditions that make adjustment and adaptation through learning difficult. But must they have the last word? Is there a way to over come the effects and create meaningful changes? We will describe a case below where our fight against the pessimism and the actual effects of the endogenous and organic condition justifies the question of whether the frequently expressed pessimistic view is justified. We believe that human beings are modifiable, irrespective of the distal etiologies which have made them the way they are. The Critical Period The second barrier is that of the critical period. Even if one is very optimistic about the effects of experience on the individuals capacities, on its propensities to become involved in change, are there not limits which are imposed on our organism by certain processes of maturation and development which have their time, their rhythm? And if your interventions are concerted, and not at the time when these processes mature (in our brain), then one might be forced to conclude that the option for change is lost (or at least severely limited) for the individual. The response given by the theory of structural cognitive modifiability is that the critical period for meaningful intervention is the lifespan In our view, lifespan psychology has most explicitly and convincingly stated the issue of lifespan development as an option of modifiability extended over the whole life of the individual. Unfortunately, after a wonderful beginning, it has not continued its sudies and its conclusions that mental development need not be limited to the growth of the bones or stages of development have not been further elaborated. There is a great deal of research done by Warner Schaye, Baltes Datan and others who have shown that humans are modifiable to the utmost of their age. Modifiability has been seen to occur all along the lifespan, and there is no reason to link the course of mental and cognitive development with the concept of critical period, which has its known validity in the embryological realities. For example, it has been discovered that the earlier research that described deteriorating intelligence with advancing age contained serious methodological errors. We need to return to a view of the human being, irrespective of age, as an open system, accessible to meaningful intervention and resulting in structural modifiability. Unfortunately, as a consequence, a generation of lifespan research has convinced many behavioral and developmental scientists of the misleading view of deterioration with age, and by accepting this view we indeed deteriorate by our own acts. We believe, on the other hand, that modifiability exists as an option to the individual irrespective of age, and the great question is what are the differential needs and conditions of each individual at different ages. Of course there are differential elements to be considered. However, certain types of interventions can change the order of the stages, and many of these barriers to change become less formidable. Our experience with the case of Alex will illustrate the potential to overcome the barriers of etiology and critical periods. Alex presents an extreme condition of organicityhe is living with only the right half of his brain. Alex had convulsive disorders throughout his early life due to Sturge-Weber syndrome. The severity of this condition, in the early years of his life, caused him not to 264 Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997

speak, and to have an IQ of about 35. At the age of nine, it was decided to remove the atrophied left hemisphere of his brain and to stop the heavy autoconvulsive treatment. After this he began to speak, contrary to the predictions made by the neurologist and neuropsychologist. His IQ, which was 35 prior to the surgery. raised to 50. Yet no one believed he could go further, not even the established experts whom the parents consulted in the major medical facilities in the country in which he lived Although he had spoken language, he was not considered able to learn to read, write or do the most simple arithmetic so he did not learn to read or write, and indeed at the age of 1 6.6 he had hot. His parents were told that while his speaking was an unexplained miracle, they should not expect further miracles to happen. He came to us five and a half years after his surgery. When we examined him with the LPAD, we saw types of behavior emerge which were conducive for meaningful changes in those areas in which he was said to be unable to show any achievement. At the outset he presented us with the paradigmatic mediational dilemmadoes one accept the condition set by the brain or does one have to impose on the brain the conditions of mediational intervention? Will the mediational intervention be able to overcome both the organic etiology and the critical period with its limitations? Alex has been with us now for about 8 months and he has learned to read. We began by teaching him Hebrew, making him acquire the basic lexic functions in about three months, after which he began to read in English. (By the time this paper appears it will have been two years since that first intervention.) And at the present time he is reading in English at approximately a sixth grade level. Similarly, his writing is developing (he became left-handed after surgery), with beautiful form and without spelling errors He is also calculating in mathematics. He is working hardhe must make major efforts, and so too must the efforts of his teachers be focused and dedicated. His abstract thinking has developed, and he is doing analogies in three modalitiesspatial, numerical, and verbal. As a test, we gave him 200 verbal analogies, very difficult ones which he solved and understood. In short, he is now responding to mediation in cognitive and academic areas, succeeding with the kinds of tasks that are often associated with individuals who present with IQ's in the 120 range And most importantly, he is a cooperative, motivated learner who has internalized his capacity to learn, and who sees himself as able to go beyond his limitations, which have been imposed by his condition, his history, and the diagnoses of his intellectual capacity. The possibility of this development was and is still denied by those who consider the absence of the left hemisphere and the prolonged exposure to anti-convulsant medications that affected the right brain to make the developments we describe above as impossible. Denying the possibility affects those who would intervene, and the whole environment. The fact is that Alex was treated for five years in special education systems, without producing signs of reading or other cognitive propensities. In The American Scientist, a paper summing up Alexs case and development suggested that at most he would be able (and we paraphrase here) to navigate a supermarket and make decisions about what kind of breakfast cereal he wished to eat. By the same token, the various specialists involved in assessing and following up Alexs development have questioned the possibility of the kinds of achievements we have experienced with himtheir meaning, their durability, their significance. The results we have been able to bring into evidence, and are continuing to achieve makes such questions, to our 264 Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997

mind, irrelevant, and reveals a regrettable degree of cynicism in the established and respected community of specialists. Alexs modifiability brings ample evidence of such processes despite the barriers of etiology (hemispherectomy) and despite the critical period at which speaking and reading functions started. Severity of Condition The third barrier is the severity of the condition. If you have a multiply handicapped individual you may well feel helpless and unable to make a breakthrough. The severity of the condition can appear to be a serious impediment to change. it took me a long time to see that even this barrier can be meaningfully overcome. The case of Ravital will help me to convey this condition. (I am using her real name because her mother insists that her experience be a public example of modifiability.) Ravital was brought to me by her mother. She had a very peculiar face (a condition of ornithocephally)probably some kind of syndrome that has yet to be identifiedwith a small chin, long nose, and bulging eyes. She was totally aphonic, unable to bring out any voice, emitting only a shrieking noise of ahhhh! Upon observing, one might be tempted to call this kind of lonesomeness which made her turn to the wall, look at the wall, and do nothing, not responding except to make twisting motions with the fingers of her right hand, autistic. All this she did as self stimulating behavior. I saw her with her mother, and I tried to have her respond. I gave her a piece of plasticine and made her roll it. As long as my hand was on hers she would roll it. The moment 1 removed my hand she stopped. A case of aboulia. As I recall the case, I must admit that I made a mistake. I spoke to the mother very openly about my disbelief that I could be of any help to Ravital. The mother began to cry and said, Well, teach me how to help her! I will do it. I will not accept that my child stays as a profoundly retarded imbecile idiot [she named. it all], and I am happy saying this in front of her! (She, too, didnt think it made any difference.) I saw the mother several times a year, teaching her, giving her new instruments and orientations to help the child, cues as to what to do. A little more than three years later she brought Ravital back and told me that she was reading. I thought, Well, wishful thinking from a well-intentioned mother. But the mother took out a plate with magnetic letters and Ravital began constructing words, with her exophthalmic bulging eyes going around and around, very slowly, until she found the letters she wanted. It took her a lot of time. She was also able to identify sentences read to her and she made some calculations. I must tell you I felt very badlyI felt as though I had received a slap on my face. Because of the massive difficulties the child experienced, I had kept back from helping her to develop. From that point we engaged in a massive effort with herwe put her on a computer, and she learned to write on the computer. Her bulging eyes made it difficult, but nonetheless she began to write. In the course of time she wrote a beautiful autobiography. We did wonder whether her accomplishments were due to the assistance of the mother, controlling her right hand, perhaps in a way similar to the case of Clever Hans. But we could detect nothing; she was doing it by herself At one point we said, Ravital, you are such a clever girl, why do you need your mothers assistance? And she responded, Dear Professor Feuerstein (and I felt her pointed criticism in the quotation marks), If you, dear professor Feuerstein, very honorable Professor Feuerstein, would have been like me, told by 264 Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997

everybody that you would be an idiot and you would not be able to do this, and the only one who believed in me was my mother, you also, dear honorable Professor Feuerstein, will not give up on your mother. For me, this is the real meaning of what is called need. The need of the mother, which generated a belief against all odds, against all science and realities. She believed, and expressed her belief very clearly: I am not accepting this reality. And she found ways to change what all of us deemed as the unchangeable. Implications for Autistic Children Let me now address the issue of the child referred to as autistic, as having behaviors within the autistoform spectrum or with pervasive developmental disorders. It is often said that 75% of the total population labeled as autistic or in the autistic-spectrum are considered as mentally retarded to various degrees. From what I have already conveyed about the very limited meaning one may attribute to these diagnoses, considering the great barriers to assess and evaluate the individual, and considering the fact that the assessment is of necessity based on the manifest level of function which is severely restricted, my question is To what extent do we have the right to consider this population as retarded and unmodifiable? Yes, they are dysfunctional. However, should this be considered as an end condition, as a condition that cannot be modified? Do we give up too early because of what we see as the manifest level of functioning, because we confound the manifest level of functioning with the propensity of the individual to become modified? Or shall we better refer to the dysfunctioning as reflecting a state in which the organism finds itself at a given point of its existence and still have the option to become modifiable. The three barriers exist (etiology, critical period, and severity of the manifestation), and they impose a kind of reality on parents, educators and other helping professionals, and on our theories. But these barriers can be bypassed, and the question is What are the differential modes of intervention needed to overcome these diverse barriers? Defining Intelligence and Other Modal Functions as States Rather Than as Traits Here, we come to the concept of propensity as an attribute of the human organism. We are not using the term potential or capacity because these qualities, if they exist, are thought to exist in a given quantity and therefore fixed and immutable. The word propensity is more consonant with our dynamic theory of intelligence. We define intelligence as the propensity of the organism to modify itself in order to be able to respond in an adaptive way to changes in the conditions of the stimuli, and to its particular needs. We conceive of intelligence not as a trait, which has a fixed nature, appearing each time in the same way, stable and relatively immutable. We propose, instead, the term state The state of autism certainly exists. One has a state of being isolated, of being alone and cut off from social contact, inaccessible to types of mediational interactions offered by the environment. But a state is a dynamic condition that modifies itself and can be modified, can be changed. It is transient. If nothing happens it may stay and may even appear permanent, with time becoming resistant to change. However, if a condition exists which may affect the state, such as a particular event or intervention, we may witness a more or less significant change in the state. One of the most powerful forces of intervention is that of mediated learning experience, to be 276 Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997

described immediately below. Applying Mediated Learning Experience (MLE) We consider the human being as experiencing and maintaining a variety of states, which can become modified. In a sense, this is like having a blank check, with the availability of modification. We just must act. We can do so by using our theory to describe ways by which the modifiability of the human organism can be increased and materialized, irrespective of the biological condition, irrespective of previous experiencesall of which determine functioning but are not the end point and do not: put an end to the propensity to be changed. As we encounter the human being in this way, in the contact with stimuli, in confrontation with the individuals need system, there are two modalities of interaction. The option of modifiability attributed to the human being in a large variety of cognitive, emotional and behavioral functions is, according to our theoretical stance, due to the MILE to which the human organism is exposed. The animal world is exposed in a direct way to a multitude of stimuli, out of which experiences are registered and responded to only to the extent to which they address a particular and, in most cases, highly relevant and immediate need. Once this need is satisfied, the relevance of stimuli is reduced or absent, following which the registration and experience is reduced as well, to be revocated only when the need is renewed, in a process of circularity. As in the animal world, humans, too, have this modality, as the most pervasive form of interaction with the world, notably the direct interaction with stimuli ands experiences. Any exposure to the world affects us. We learn from the effects of what we observe, what we have seen, and what we have done in a direct way. This learning through direct experience is certainly the greatest source of changes in our organism, contributing to our psychological make-up, to our capacity to handle the demands of tomorrow in ways different than were responded to today. This direct learning experience is indicated in the 5 and the R of the behaviorists conception of the learning process. However, we consider the S-R formula as insufficient to explain human developmentthe formulation requires additional elements.

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~ ~ ~~ ~~ ~ ~ ~~ ~ ~ ~~ ~~~ ~ ~ ~~ ~~ ~ ~ ~ ~ ~ ~~ ~ ~~ ~ ~ ~ ~ ~ ~~~~~ ~~ ~~~ ~~ ~~~ ~~ ~ ~~ ~ ~~ ~~

Piaget introduced the 0 into the equation. The organism is affected by what it perceives, what it engages in, its interactions with what it experiences, and the way it experiences. However, what is experienced and the way it is experienced is heavily determined by some of 276 Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997

~ ~~ ~~ ~~~ ~~ ~ ~~ ~~ ~ ~ ~~ ~ ~~ ~ ~~ ~~~ ~~ ~ ~ ~~ ~ ~ ~~ ~ ~ ~~ ~~~ ~ ~ ~

Figure 1. Mediated Learning Experience Model. (Note: S = stimulus, H = human mediator, 0 = organism, R =response)

the characteristics of the organismthe state of development, previous experiences, the nature of perceptual processes, and existing schemata. According to Piaget, the organism determines the nature of our experience. The equation requires that it is not just S and R, but that the characteristics of the organism (the 0) be taken into consideration in order to understand the specific process of learning and development of the individual. This is the way Piaget defines the interaction generating the development of cognitive processes leading to the hierarchy of higher mental operations. Thus, both behaviorists and structural developmentalists (such as Piaget) claim that the S-R or the S-O-R are enough to explain the development of intelligence and the increased capacity of the organism to adapt itself. They contend that one doesnt need more. If you are exposed to stimuli and you are mature enough to interact with them, then you experience and are modified by them, leading to the enlargement of schemata that you bring into the world, shaping your development. We accept the view of direct exposure to stimuli as affecting the individual. Yet, there are many people who are exposed to stimulation constantly and do not benefit from it. We know that there are great differences as to the capacity of individuals to benefit from the exposure to stimuli. Some people are constantly exposed and they are not modifiedeach time they see the same thing they are seeing it as though for the first time, as if no trace is left behind. Consider the child who is repeatedly exposed to certain words or letters, or certain knowledge and information, but is not modified by the exposure. Our question here must be why are certain children and even adults not affected by repeated and intensive exposure to stimuli, events, and experiences? We consider this due to the lack of experience of MLE that there is a second modality of interaction between the organism and the environment which may not have been present, or present in an insufficient quantity or quality. The second modality occurs when, between the world of stimulation and the organism and between the organism and its responses, a human organism, a mediator, interposes him or herself When examining the model, one sees the lines going through the H from the 5 to the 0 and from the 0 to the R, causing a transformation before entering the system. The mediator intensifies, filters, chooses, schedules the stimuli and events, both at the level of exposure (input) and at the level of responding (output). The mediator creates conditions of awareness, makes the individual use modalities of search, perception, types of instruments and tasks, look for relationships in what has been observed or responded to, creating a plasticity and flexibility which enables modification, and enables the learner to benefit from further exposure to stimuli. The mediator has a very crucial role in the development of this flexibility of the human being. Mediated learning experience requires the interaction of an animated and intentioned adult, an adult who has a particular interest in making the child aware of certain stimuli being received, to which exposure is experienced. The mediator will affect the childs level of awareness, create a consciousness of the observed experience, and then create an explicit awareness about itof the relationship between what is seen, what has been seen, what may be anticipated at a later point, of looking forward and looking for causal relationships, of looking for conditions by which certain changes in the stimuli can be produced. The mediator, who interposes him or herself between the organism who received the stimuli and produces 276 Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997

responses will shape the types of responses that will be most adaptable, most purposeful and by this create a kind of loop between the perceived and the response. Mediated learning is typically human, although research with primates, such as that of Peterson who taught Koko (a gorilla) American Sign Language, helps us to analyze the effects of interspecies mediational interactions. By the way, the ability of the primates who learned ASL to tell jokes, to lie, and to curse expands the parameters of our understanding not only of mediation, but also of the role of language structures to facilitate thinking. What then is mediated learning experience (MLE)? At its simplest level, it is the way by which all of the experience of generations, of millenias of human life, are transmitted through the mediator to the human organism, creating an endless richness of needs, of articulations, or modalities of interaction which would not be available without MLE. The first to emphasize the role of the human mediator in the learning process was Vygotsky, although there were others such as Durkheim. Vygotsky is the one who described the strong relationship between the type of social interaction in the development of human intelligence, conceptual and abstract thinking. Interestingly, our development of the MLE concept occurred in the early 1950's, before we were cognizant of Vygotskys work, which later became a source of stimulation for our theoretical formulations. What is the nature of this interaction? What are the qualities of the interaction between mediator and mediatee? And most importantly, what is the relationship of this interaction to the phenomena of modifiability of the human being, turning him/her into an open system for change? Mediated Learning Experience: Criteria and Categories of Interaction This approach is a brief blueprint of the encoding of MILE interactions according to their meditative meaning. It represents a shortened version of suggested categories for didactical purposes. As such, it is not to be considered as either exhaustive or definitive. I. Criteria of Mediated Learning Interactions 1 Intentionality and reciprocity 2 Transcendence 3 Mediation of meaning 4 Mediation of feelings of competence 5 Mediation of regulation and control of behavior 6 Mediation of sharing behavior 7 Mediation of individuation and psychological differentiation 8 Mediation of goal-seeking, goal-setting, goal-planning and goal-achieving behavior 9 Mediation of challenge: the search of novelty and complexity 10 Mediation of an awareness of the human being as a changing entity 11 Mediation of an optimistic alternative II Categorization of Mediated Interactions 1 Mediated focusing 2 Mediated selection of stimuli 3 Me3diated scheduling 276 Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997

4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47

Provoking (requesting) mediation Mediation of positive anticipation Mediated act substitute Mediated imitation Mediated repetition Mediated reinforcement and reward Mediated verbal stimulation Mediated inhibition and control Mediated provision of stimuli Mediated recall-short term Mediated recall-long term Mediated transmission of past Mediated representation of future Mediated identification and description-verbal Mediated identification and description non-verbal Positive verbal response to mediation Positive nonverbal response to mediation Mediation of assuming responsibility Mediation of shared responsibility Mediation of cause-and-effect relationship Mediated response - verbal Mediated response- motor Mediated discrimination and sequencing Mediation of spatial orientation Mediation of temporal orientation Mediation of comparative behavior Mediated fostering of a sense of completion Mediation of directing attention Mediated association and application Mediated critical interpretation Mediated deductive reasoning Mediated inductive reasoning Mediation of developing inferential thinking Mediation of problem solving strategies Mediated transmission of values Mediation of need of precision at input levels Mediation of need of precision at output levels Mediation of need for logical evidence at input levels Mediation of need fo logical evidence at output levels Mediation of systematic exploration Mediated confrontation of reality Mediated organization of stimuli Mediation of cognitive operation - verbal Mediation of cognitive operation - motor

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48 Mediation of perception of feeling - verbal 49 Mediation of perception of feeling - nonverbal 50 Mediation of reciprocity [Based on R. Feuerstein and others, 1980. Instrumental Enrichment, Chap. 2, Baltimore: University Park Press.] Parameters of Mediated Learning Experience One of the first elements is that the mediator is animated by an intention, not just to offer the child an opportunity to see or interact with something, but the intention to mediate to the child. We say to the child, I want you to see it here (focusing). The mediator brings in concepts of time and space that accompany the particular intention so that the child learns the very important crossroads of perception and experience. I want you to see it after, not before. I want you to consider it, and link it to something else. As the child recognizes the mediators intention, and the conveyance of the great importance of the focusing and selecting, of the experiencing, a reciprocity is created. I want you to know why I do it, why I impose on you this particular schedule or rhythm of responding. I have an intention and it is important for you (the learner) to recognize my intention. Reciprocity makes us impose on children not just the particular stimuli, but also a need for the child to discover in the mediator subjective qualities of interaction (moving toward the mediation of meaning). This is one of the important things that we want to see happen for children on the autistic spectrum: to recognize in the mediator and in the self a set of reasons, a set of needs: Why do I cry? Why do I scream? Why am I happy? Why do I smile at you now? Intentionality and reciprocity are thus the most important characteristics of MLE. This gives the interaction a very special quality, well beyond direct exposure types of interactions. In direct exposure, stimuli come when they want, there is little possibility of predicting when a particular stimuli will be seen. In mediated interactions, the mediator makes sure that the child will perceive the stimuli that are deemed important for further development or responding. There is certainly a kind of intention in the behavior of other animals. The mother cat, for example, takes her kittens to the garden and delays her elimination process so as to model for her young ones, to make sure that they see her and see what she does. But there are limits on the flexibility and adaptiveness of such mediation, which can be posed for most other animal species (notwithstanding what we are learning from the primate studies mentioned above). The mediator must be able to shape stimuli so that they will be able to penetrate the system, often in spite of the barriers. There have been many presentations at this conference suggesting that many have developed ingenious ways of changing the childs functioning by adapting types of interactions. For example, if you have the intention to have the child see something, you do not just put it on the table. You take the thing, you repeatedly point to it, you make it intensive, you change attributes of it to direct attention (the color, the orientation, etc.), you amplify it, you put in a central place in the childs perception of ityou do not rely on the chance that it may or may not be perceived. Intentionality changes the three partners of the interactionthe mediator, the mediatee, and the stimuli (task). First, if you intend the child to see something you will modify the thing you want him 276 Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997

to see. You will modify the childif there is a state of low level of awareness, you make the child more alert to the particular stimuli to which you want him or her to attend. By the same token, the mediator undergoes very meaningful changes. We have an intention to mediate the child because we want the child to change, we do our best to be the preferred and effective mediator. We will do all of the things that constitute the potential richness of the repertoire of MLE, creatively and intuitively. The mediators intention is to create a need in the child, to make the child ready to accept what is being pointed out, and help the child derive benefit. MILE represents the qualities of interaction manifesting itself in the parameters of intentionality and reciprocity which imposes on the direct exposure to stimuli. The stimuli have no intentions and no ways of changing the child, except by its direct exposure. The mediator is the agent of change, animated by the quality of intentionality. A second element of importance to MLE, and which adds to the humanizing influence of the interaction, is that of transcendence. One doesnt limit the mediational interaction to the particular cause, goal, or event being experienced. One looks for a way to turn this particular experience into a source of changes in a variety of other areas, reaching out to more remote purposes, to more remote interactions. Transcendence is the way by which human beings are mediated to enlarge their need systems, going beyond the immediacy of the state or the need (as, for example, hunger) to respond to new needs transmitted through the larger cultural experience (the desire to eat a particular variety or type of food), and the generations of repertoires contained within it. Would we know about Mozart without a mediator to bring the music to our awareness? What would we know about a variety of other elements which are not accessible to us, but by means of a mediator who takes us beyond the immediacy of the experience and gives us what we need to go beyond. The next criteria for MLE represents the energetic factor, the mediation of meaning. When one works with children, the conveying of the meaning of what one does, what one is being asked to do, the making of this meaning in the search for reasons and values is that which mobilizes the energy needed to perform. Again, the goal is to broaden the need system. Thus, the affective-motivational and emotional elements generate the reasons for doing something, the purposefulness of behavior. The cognitive elements that mediate intentionality/reciprocity and transcendence are responsible for the structure of behavior, whereas the mediation of meaning represents the affective component reflected in the answers to the questions, Why am I doing it? Why is it important to be done? Penetrating the Learners Need System If the individuals need system has not been penetrated and the mediation has not been experienced, the modality of shaping the interaction according to the particular needs will not have taken place. One must find the particular pace, from which the organism becomes accessible to the stimuli and becomes changed through the interaction. When it does not occur (as, for example, when parents say I told them, I showed them, I made them, I did it with them, but it didnt work), our response to this is that one did not find the proper way to penetrate the system, and that the mediation did not close the loop. The loop is closed only when the stimuli, the mediator, and the mediatee have interacted in a relevant and meaningful way. 276 Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997

SELECTED AND ENHANCED STIMULI

MEDIATOR

MEDIATEE Figure 2. The Mediational Loop Why Do Some People Not Benefit from MLE? I now turn to the reasons why certain people do not benefit from or have sufficient MLE. There are two categories of reasons. One reason is that mediation is not offered. The parents do not mediate the child. The culture doesnt mediate the child. The reasons are manypoverty, social disruption, and the stresses of everyday life. Parents focus on dimensions of basic existencetheyre catering to the lifesaving needs. But poverty is not necessarily a source for lack of mediation. Many poor people will take a piece of bread from their mouths to give education to their child. I will never forget Professor Jim Comers remark to me that by teaching me to clean the corners of the house, my mother mediated to me all that I do now. (Professor Comers mother did menial domestic work during his childhood and developmental years.) So it is not poverty alone, but the impact that poverty has on the parents sense of the ability to give to their childtheir intentionality, transcendence, and meaningfulness. To some extent, the human being is the only organism that mediates to its progeny because of the awareness of the limits of ones biological existence and the need to see oneself continued through ones children. We project ourselves into the future by mediating to our offspring. It may not be explicit, but it is certainly one of the very strong motives for human interest and desire to see themselves continued in the qualities of lives of their children. Yet some people give up on their children. They dont want to see themselves continued, and this affects the child bitterly. There are others who say, Why should I impose 276 Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997

on my child? Am I qualified to impose on him or her? Why shouldnt I give him the right to exist totally as an individual without my imposition? They do not now that by depriving the child in this way they miss the opportunity to develop modifiabilitythe most important human characteristicwhich is produced by mediation. There is another category of reasons for the lack of MILE Rather than a failure of the environment to mediate, there may be various conditions which exist in the individual that make mediation difficult and inefficient. If you have a hyperactive child, and you try to mediate something, the hyperactivity may prevent the mediation from getting through. When you try to interpose yourself between the child and the stimuli, the short attention span or the distractive behavior may prevent an interaction from occurring. It is very difficult, discouraging, it takes a lot of time, you may not have the patience for it, or the child may have serious resistances to being mediated. The autistic child presents a good paradigm for this kind of lack of mediated learning experience.
Heredity/ Genetic Factors Neurophysiological factors Emotional Balance of Child and of Parents Cultural Difference

Organicity

Early Onset

Severe Disturbance of Social Relatedness

Severe Abnormalities of Language Development

Elaborate Repetitive Routines

Mental Retardation

Perceptual and Sensory Disorders

Mediated Learning Experience

Lack of Mediated Learning Experience

ADEQUATE COGNITIVE AFFECTIVE AND SOCIAL DEVELOPMENT ENHANCED MODIFIABILITY

INADEQUATE DEVELOPMENT AUTISTIC AND P.D.D. SYNDROME REDUCED MODIFIABILITY

Figure 3. Distal, Intermediate and Proximal Determinants of Autistic and Normative Development. In the child with autistoform conditions that include a lack of relatedness, the lack of readiness to accept mediation is a source of great difficulties. Penetrating the system, and bringing the type of stimuli to which you want the child to attend, encouraging the child to see relationships, will require massive and masterful interventions. Here, we have two types of determinants the distal determinants of development, which can affect both cognitive and emotional development insofar as they prevent the adequate provision of MILE, which can be seer as the proximal determinant. There are heredity, genetic, and organicity factors that determine the nature of development. But they do not determine their effects unavoidably, they can be overcome. Put in another way, they are not necessary and not sufficient conditions, although they certainly will have a determinant effect on behavior and functioning. In the case of the child with behavior in the autistic spectrum, there may be an 276 Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997

intermediate factor. This is where the concept of early onset fits: the child may not have had accessability to certain kinds of stimulation, mediation, and interactions. Severe conditions of lack of social relatedness, severe abnormalities of language development, elaborate repetitive behaviors, rigidity, otherwise retarded performance in various systems, sensory or perceptual disorders may become intermediate factors, and as such may create barriers to the attempted MLE. When this happens, the individual does not get mediation, and this will result unavoidably in inadequate development, and a reinforcement of the autistic behavioral syndrome, with reduced social and emotional contact with others. With reduced MLE the individual becomes much less modifiable for the simple reason that any attempt to produce a new element (new ways of thinking, perceiving) will founder against the resistance to these new, intermediate elements or barriers. If, on the other hand, one has a way to bypass the barriers that create resistance, one eventually may go beyond the present functions and initiate meaningful new forms of functioning. It means that one considers MLE as the proximal determinant of human modifiability. People who have had MLE will be able to modify themselves, will be able to benefit from their encounter with new stimuli, will be able to elaborate whatever they have experienced and will be able to use whatever comes into their system in order to enlarge their need systems and their repertoires of adaptive behavior. MLE thus assumes the role of facilitating human development and the development of flexibility, plasticity and hence the modifiability of cognitive processes, as well as the development of a more rich and articulate emotional affective system. Lack of MLE creates in the individual a condition which we have referred to as culturally deprived, inasmuch as the failure to mediate results in a lack of transmission of ones own culture. MLE and Cultural Deprivation For whatever reasons (see above), MILE was either not accepted, or not offered, and created an individual who is marked by a lack of modifiability. Our basic contention is that MILE can increase the modifiability of all individuals, across the life span, irrespective of previous performance and the reasons for its absence. The provision of MILE enhances and creates the conditions of modifiabilitylearning how to learn, of using whatever direct exposure to stimuli is offered. Both inside and outside of the self mediation enables the individual to grow, develop, be modified, and adapt to situations of various types of complexity and conditions. In this regard this is what it means to be culturally connected and adapted. If we want to see the child become able to benefit from experiences to which he/she is exposed, we will have to prepare for the appropriate use of mediation, according to the condition of the individual and the diversity of his/her needs. We have developed an extensive list of mediational interactions which can be adapted to the condition of the individual. The Case of Elchanan An Application and Summary When our grandchild Elchanan was born (he is now eight years old) with Down s syndrome we knew that we were confronted with a number of significant barriers. He was very hypotonic and slow. He barely engaged in eye contact, and manifested a number of other conditions, which represented developmental risk factors. 276 Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997

Figure 4. Professor Feuerstein and Elchanan working together. Note the proximity of Professor Feuersteins and Elchanans faces, the progression of eye contact and focus, and the sought-after result, the imitative lip formation and vocalization.

We started to provide MILE, from the first weeks of life. The whole peribucal area was extremely weak and hypotonic, and we knew that this could cause great difficulties in later development -the protruding tongue and lack of capacity to mobilize his lips. So we started out by making Elchanan imitate, but not just as a chance encounter with certain models of behavior. We would hold his head close to ours, maintaining eye contact, and offer repeating amplifying sounds that would cause him to form his lips and imitate with his tongue. The minute he averted his eyes, I ran after him to establish contact. And he learned, step-by-step, to keep a steady eye contact with me, and to begin to form his mouth and lips in anticipating of our modeling. I was not the only one to do thishis mother and others did it continuously. We did not leave anything to a chance encounter. We created conditions under which Elchanan was exposed to modified types of stimuli, by creating appropriate degrees of amplitude and repetition. As a mediator, I impose. My imposition, however, creates the conditions for him to overcome his difficulties, and then to do things which are possible by the prior overcoming.

As Elchanan has grown, we have continued to mediate him in a variety of other areas, which will best affect him in his academic and social environments. Today he is eight years old, is in the second grade in a regular school, along with a younger brother. He has a very strong personality, he knows what he wants, and he has not been at all negatively affected by conforming to our impositions. MLE is a meaningful way to affect childrens conditions, in spite of the distal or intermediate factors present in their functioning, the outcome will be an increase in modifiability the enhancing of an individuals option for becoming involved in positive change. It is necessary to analyze the specific deficiencies that may appear, and consider these deficiencies as the target of our attack. We have developed an extensive list of cognitive functions which serve as the focus of potential deficient functioning, and guide us in the mediational shaping of our particular intervention programs, so that the individual will be responded to and shaped by the interaction.

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Reuven Feuerstein, Ph.D. Applying Systems of Mediated Learning Experience To reiterate, we believe that all humans have an option to become modified, irrespective of the three barriers to change: etiology, age, and severity of condition. We therefore must do away with the emphasis on the manifest behavior of the individual as a basis for predicting future development. If individuals are indeed modifiable, we must meet the needs in an ongoing way, stimulating further development even after the initial levels of change. Any attempt to create conditions for prediction are seen by us as a source of limitation and restriction for the development of the individual. Can we predict which child will make it and which will not? Happily, human beings are not very predictable, despite the existence of elegant statistical systems. We cannot predict which child will develop and who will not. This has led us to the development of new ways of assessing individualsnot to measure, as is done in psychometric practices, but to evaluate, observe, elicit activity and produce samples of change which will help us establish a profile of modifiability and types of mediational intervention needed for the materialization of the focused options. This has further led us to the development of applied systems to help the individual overcome resistance and become meaningfully modified. Our assessment methodology is called the Learning Propensity Assessment Device (LPAD). Its major goal is to create certain samples of change and create profiles of modifiability. The LPAD is one of the most important ways to avoid that type of prediction that becomes self-fulfilling, by actually producing the condition for their materialization. While the LPAD uses specially designed instruments for assessment, the general dynamic approach can be used in a more informal, observational manner. This is particularly useful when applied to a wide variety of conditions, including those of the autistic and autistic-spectrum child, and the PDD child who is not always accessible to formal assessment. Professor Steven Gross has organized and conceptualized a process of multi-disciplinary clinical intervention using our applied systems with children presenting a variety of special needs, including an increasing number of children who come with diagnoses placing them in the autistic spectrum Our psychologist who specializes in play therapy, Dr. Shoshana Levin, works with such children, who are not testable using the more formal LPAD procedures, but whose modifiability can nonetheless be evaluated by producing samples of changes in their behavior that help to modify them in ways most appropriate to their needs. The task is to interpret their changes in order to plan further therapeutic interventions. Dr. Levins approach is directed primarily at three to seven year old children. The process involves a mediated interactive engagement with the child. She adapts her presentation of stimuli to the childs needs. She observes, describes, and looks for points of change in the childs reactions, using the framework of the cognitive map and the deficient cognitive functions. Changes are elicited using a variety of modes of mediation, and this is demonstrated to the parent (who is often encouraged to interact with the child and the therapist). As with all other aspects of the mediational learning experience approach, it is the process rather than the product that we look for and much less at what the child is able to do. As with all other aspects of the dynamic approach, we distinguish between the manifest level of functioning and potential, and this can be observed in the free and structured play environment we create. As we have the 276 Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997

Reuven Feuerstein, Ph.D. parents involved in the assessment process, we use it to teach them initial mediational responses. We teach them the principles of MLE as they watch us work with their children. Dr. Levin has worked with over 200 children in the last several years, almost all of whom have come with the diagnoses of autistic spectrum, autistic features, or PDD. Of that number, after the kind of dynamic observation and assessment described above, she estimates that approximately only a very small number could be considered to be actually conforming to the formal autistic diagnosis. The remainder are more accurately viewed as having a variety of developmental and communication problems which need specific intervention, but which really should never have been labeled as autistic, with all of the burdens that the label entails. To give a child such a label takes the energy and motivation away from the parent at the time when the child needs it most. Furthermore, placing the child in a homogeneous environment with children manifesting the same difficulties is to offer a subnormal culture as a source of learning and stimulation. A second applied system that we have developed is lnstrumental Enrichment (IE). IE is a program designed to increase the modifiability of the individual that was evidenced during assessment. Once having discovered the childs potential, or propensity to be changed, we may find it exists in a very limited quantity, that there are great gaps in the cognitive structure and many deficient cognitive functions, and that they are modifiable. We will then respond to each sign of change as presenting us with possibilities which are not seen in the manifest functioning. The IE program is thus a set of activities which create powerful conditionsof stimuli, experiences, eventsmaking the individual able to learn, to produce strategies to learn, to help the student apply learning to a broader scale and variety of life experiences. The third applied system, which represents our most newly developing area of intervention, is that of shaping modifying environments (SME). The goal here is to turn the environment into a powerful modifier of the individual. If we assess the individual, and we show the present existence of the propensity for modifiability, and then we amplify this propensive modifiability by offering a program which strongly affects cognitive structures, is it enough? What will happen if the child so affected is placed in an environment which will not require exposing the child to these kinds of variations of speech that addresses the propensity to imitate and learn from this exposure that determines the nature of the imitative processes that will be established. Once the child has learned to imitate in a distinguishable way, there will be an increase in sensitivity to the spoken environment and the verbal stimuli within it, and there will be increase the learning process through a more direct exposure to verbal stimuli. Many parents have used this method in a natural, spontaneous way, and have spoken to their children in what has been referred to as infantile language. They understood that such a way of imitation was necessary to expose the child to models of imitation. In the child with special developmental, communicational disorders this method becomes a necessary and explicit approach. A Last Brief Word These applications not only convey the heart and flavor of our approach, but illustrate the adaptive and dynamic nature of our work, with children from all spectrums of need. We emphasize an awareness of the existence of people who can be helped. and the need to reject the passive acceptant approachthe position that is so often adopted, which says accept them the way they are, dont attempt to change them, dont attempt to go beyond that which exists. We 276 Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997

Reuven Feuerstein, Ph.D. consider our way as requiring and permitting a real, meaningful, active modification of the child. We know some children will not make it. We cannot promise for each childsince we are speaking about options, and the possibility of materializing the option that can and must be offered to the individual by all possible means. We have to be creative, to be ingenious, to be inventive. And most importantly, to believe that it is indeed possible. And finally, not only to preach it, but to do it. It is only under such conditions of beliefbelief leading to practice-that early detection becomes the desired blessing. Wherever early detection is accompanied by a sense of lack of options for change, therefore leading to a feeling of futility and helplessness, early detection becomes a curse. Let us choose the blessing!

276 Proceedings: Approaches to Developmental and Learning DisordersTheory and Practice 1997