Mr. ROBERTS. The gentlemen from Minnesota.

Mr. NELSEN. I was curious, years ago in Minnesota I think an operation was performed, called lobotomy.

Dr. BRACELAND. Yes.

Mr. NELSEN. Is that still practiced to any degree?

Dr. BRACELAND. No, not to any degree, Mr. Nelsen, because once you cut those fibers in the brain you can't tie them together with pink ribbons.

Now, it happens occasionally in one or two types of illness, but very, very rarely, and we are reluctant to do it.

I may have said this earlier, Mr. Nelsen, but I am getting along in years and as my body gets shorter my anecdotes get longer-I was chairman of that committee of Governor Youngdahl's advisoryMr. NELSEN. I was in the legislature at that time.

Dr. BRACELAND (continuing). And I remember we had a great deal to do about all this.

Mr. NELSEN. Another point I would like to touch on, I think we all recognize, and I think all the committees have recognized, that the main impetus comes from the States.

This bill which is intended to provide that incentive to get things moving, in your judgment, does this protect adequately so that we don't lean too much on the Federal Government in the future, but it starts our States moving, and then we will do a better job?

Do you think there is adequate protection in this bill to guard against the possibility that too much will be expected from the Federal Government on a long-range basis in the future?

Dr. BRACELAND. I think that the committee has it nicely built into the bill.

There is a certain percentage for the construction, and only a certain time allotted for helping with the staffing.

And I think also that it has been proven, because I am afraid to have to tell you, I have been coming down for a number of years looking for funds for the NIMH-this money seeds the States, the States now have come out so much further than we ever thought they would, and the seed money has come from the seed money that has been put in. And I think it is well protected.

Mr. NELSEN. Thank you.

Mr. ROBERTS. Thank you again, Doctor.

Our next witness is Dr. James Tramonti, of the American Optometric Association, Providence, R.I.

STATEMENT OF DR. JAMES TRAMONTI, AMERICAN OPTOMETRIC ASSOCIATION, PROVIDENCE. R.I.

Dr. TRAMONTI. Mr. Chairman, and members of the committee, my name is James Tramonti. I am an optometrist practicing my profession in Providence, R.I., having been licensed in that State in 1949.

My preoptometry education was obtained at the University of Rhode Island and my professional degree in optometry was earned at the Illinois College of Optometry.

I am a member of the Americn Optometric Association; past president and member of the Rhode Island Optometric Association; former

representative of the State of Rhode Island to the New England Council of Optometrists; chairman of the committee on visual problems of children and youth of that council; consultant to the office of Medical Service, Division of Public Assistance, Rhode Island State Department of Social Welfare since 1952; optometric consultant, Meeting Street School, Children's Rehabilitation Center, Providence, R.I.; consultant in preparation of a book by Eric Denhoff, M.D., and Isabel Robinault, Ph. D., "Cerebral Palsy and Related Disorders." Quite a task; it took about 3 or 4 years to turn out, and I have it here today, and it is a book on the developmental approach to dysfunction. I was a staff member, outpatient eye clinic, Rhode Island Hospital, 1955-58; participated in pilot research studies at Meeting Street School, Children's Rehabilitation Center, Providence, R.I., and Bradley Hospital; Children's Neuropsychiatric Hospital, Riverside, R.I.; and am to participate in a research study on reading retardation, Child Study Center, to be conducted by the Ohio State University. You notice I have used the word "habilitation" here rather than the word we have heard so much, "rehabilitation."

Our association is vitally interested in the two bills being considered by this committee: one H.R. 3688 to provide for assistance in the construction and initial operation of community health centers; and the other, H.R. 3689, to assist States in combating mental retardation through construction of research centers and facilities for the mentally retarded.

Our association, which includes optometrists in all 50 States and the District of Columbia, has 3 committees dealing with this area of optometric practice.

One is the committee on visual problems of children and youth, another is the committee on vision care of the aged, and the third is the committee on vision aid to the blind.

It also publishes a monthly journal which contains articles of interest to members of our profession.

The February 1963 issue contains five articles directly bearing on vision and the mentally retarded child. It was my privilege to be the author of one of these articles.

It might serve a useful purpose if these articles were included in the record of the hearings.

Accordingly, I have taken the liberty of obtaining copies of them which I trust the committee will see fit to incorporate in the record. With your permission, sir, I would like to submit these for the record.

(The articles referred to follows:)

VISUAL PERCEPTUAL TRAINING AND THE RETARDED SCHOOL ACHIEVER

(James Tramonti, O.D.)

"Close your eyes. Pretend that you are standing across the street from your house. With your eyes closed pretend you are looking at your house. Can you tell me what your house looks like? Can you describe it to me?"

This is what you may hear in our training room during one of the early visual perceptual training sessions with a nonachieving child. He is learning to learn, and he is learning to see with his eyes closed.

There are a diversity of reasons for low school achievement and failure. The outstanding cause is intellectual subnormality. Visual, hearing, emotional, and environmental problems are some of the many additional contributing factors.

There are a great number of children with normal potential who are not achieving at school. These youngsters are sometimes referred to as "psuedoretarded." They may score as low as 2 years below their chronological age on standardized tests. In contrast to the true retarded which include the trainable with I.Q.'s of 25 to 49 and the educable with 50 to 69 I.Q.'s, these children are capable of average school achievement and often have a potential to perform above the average.

The greater number of referred cases come from pediatricians, pediatric neurologists, pediatric psychiatrists, psychologists, and psychiatrists. The patients have usually been through medical, neurological, electroencephalogram (EEG), and psychological evaluation. The basic reasons for consulting with any of the above professions is parent or school complaints of one or more, and usually more of the following: poor reader or inability to learn to read; poor concentration; low comprehension; inability to sit still; assigned written work never completed; poor or "sloppy" handwriting; "immaturity"; reversals in reading and writing; and inability to handle number facts or arithmetic.

Seldom have we found both reading and numbers to be a severe problem with this type of child patient. Sometimes the only evidence of a problem in the total work-up is a form perception problem; there may be only subtle neurological signs.

The earlier the child is seen, the more complete and positive diagnosis can be made; neurological and other findings do change with maturity. We want to emphasize the importance of knowing the child in order to understand his learning problem. To the inexperienced, the child is physically and mentally normal and he may have excellent verbal ability; but he is a school failure because he is not able to learn.

MEASURING IMPROVEMENT

It is not unusual after a few visual training sessions to learn of drastic improvement in school performance. The only criteria we use for determining a child's school progress resulting from visual perceptual training are school report cards and parent-teacher comments.

Regardless of the patient's advancement in the training room, there is really no progress unless the training is transferred to learning. The child has been referred because of the learning problem and unless the benefits of visual perceptual training affect this end, we have accomplished little.

What about IQ? Is the measurable increase or decrease of IQ after training a reliable means of determining success or failure of training? A longitudinal study, "Mental Growth and Personality Development" by Lester W. Sontoag, and others of the Fel Research Institute of Antioch College, notes that "*** significant changes in intelligence quotients (IQ) do occur among many children who have been documented by data from nearly every research organization using longitudinal techniques *** wide changes in IQ can and do occur in children of various ages * * * not only does the amount of change in IQ differ from individuals to individuals but also the ages that changes occur differ in individual cases * acceleration and deceleration rates of mental growth do not appear to be related to any specific areas of abilities as measured by the differences in performance on different types of items found in the Stanford Binet."

The above study, in one extreme case, found a 57.6 IQ increase in one child from age 3 to age 11 years and in another case a decrease of 32 points from age 3 to age 8 years. All children in this study started with normal IQ's. These observations and findings make two important points: The unreliability of basing prognosis of training on a single intelligence test and an increase in IQ after visual training does not necessarily mean that the visual training increased the child's IQ.

DETECTING BRAIN DYSFUNCTION

If a child's IQ is on the increase at the time of visual training, then, regardless of the training, the child will show an increase on retest. This is called a change factor. Another consideration is that a nonachiever, based on an organic factor, scores low on performance parts of tests. A difference of 10 points or more on the Wechsler intelligence scale for children (WISC) between a higher mean verbal subtest score and a lower mean performance subtest score is particularly helpful in detecting the brain dysfunction profile.

The detection of cerebral dysfunction by means of the formula verbal-higherthan-performance can be extended to younger and younger children. For exam

ple, the 7-year-old child of average mental age can be expected to reproduce a diamond on the Revised Stanford Binet (year VII) correctly. The functionally retarded or immature child draws the diamond more like a square (year V) tilted sideways. The sides are not in the correct proportion for a diamond shape, but there is no evident distortion. By comparison, the brain-injured child draws the diamond with "rabbit ears." He is uncertain of the direction of the lines, and must reverse his direction to complete the figure. This type of performance has been shown to be diagnostic of brain damage (particularly of the occipitalparietal region as confirmed by localized EEG abnormalities) even in children who have no apparent physical disability.

If the performance abilities in these children increase, school performance increases. Clinical experience has shown that if a child is able to compensate for this low performance ability, school performance can increase in spite of the low performance score on tests. Our best reliability, therefore, is actual school achievement. When a parent requests a report on progress during the visual perceptual training period, we do not discuss training progress, instead we discuss school progress.

WORKING WITH WHAT IS AVAILABLE

The true retardate has very limited capacities. From an optometric point, we have found that a high degree of hyperopia is common among the mentally retarded. There are many cases where parents are completely unaware of a retardation problem until the child enters school. Parents sometimes refuse to accept an early diagnosis of mental retardation because at an early age the child's intellect may not be in sharp contrast with other children of the same age. But, as years pass, the gap widens and the child's chronological age goes on while his intellect remains the same or improves little.

Mental retardation may be the result of primary factors such as heredity, genetic, or endogenous, or secondary factors such as organic or exogenous during the perinatal period or later. It is essential that optometrists have competent medical-psychological diagnosis. before starting any type of visual perceptual training on mentally retarded patients. We can only work with what we have: If brain cells are not present or not able to function, we cannot create new cells. Visual perceptual training may be an effective means in helping to improve IQ's and performance levels but it cannot generate brain tissue.

THE AFTER IMAGE PROCEDURE

Optometrists know that there is no one, two, three procedure in visual training. Training begins where the child is able to perform. The following procedures, therefore, are not done in the order presented, with the exception of the first procedure, which we usually do first, if possible.

To begin we try to make the child aware of his visual apparatus by demonstrating its function on a conscious and subconscious level. The child sits a few feet from a screen upon which the Ginger Bread Boy, or any similar picture of the Keystone Familiar Forms slides, is projected. He is instructed to fixate on the nose or on one of the buttons of the Ginger Bread Boy. After a few seconds, the projector is turned off and the child is instructed to continue to look at the same exact spot. We then ask him what he sees.

The important point in the demonstration of after image is to have the child explain how it happens. A common response is "I see it with my eyes." The conversation between the child and the examiner may be something like this: "Do you ever dream?" "Yes." "Are your eyes open when you dream?" "No." "Do you see in your dreams?" "Yes." "How can you see in your dreams if your eyes are closed and you tell me we see with our eyes?" At this point there is generally some hesitation. "Where do the things come from that you see if your eyes are closed?" More hesitation.

We now go on to another train of thought. "Have you ever missed seeing something when your eyes were open and you were looking straight at the object you missed seeing?" "Yes." "How can you miss seeing something if your eyes are open and you were looking at it?" Usually the child has no answer. "Well, then, it seems that sometimes you see when your eyes are closed, like in your dreams, and sometimes you do not see even though your eyes are opened." On the other hand, children who were medically diagnosed as emotionally disturbed or anxious were not classified as having a perceptual problem. In the entire group demonstrating perceptual problems, there were nine with ocular motility problems. In the group demonstrating no perceptual problems, only two

had ocular motility involvements. All the children in the study had learning difficulties.

The neurologically handicapped group had many more ocular motility problems than the nonneurologically handicapped. Clinical observation over the last 8 years has uncovered many more ocular motility problems in children with neurological problems, and the more severe the neurological difficulty the more severe the disturbance in ocular motility. Besides the motility problem there may be sensory disorders of position and feel in hand function.

A technique blending laterality with mental imagery is the tic-tac-toe perception slides of the Keystone series. Practically every child knows the game tic-tac-toe. The No. 1 slide in this group has one circle or a cross in one of the nine spaces of the tic-tac-toe form. The No. 2 slide is so marked with two places and Nos. 3 and 4 have three places.

The child is first asked if he knows the game. We next ask him to tell us how the tic-tac-toe form is made and how many spaces the form makes. In order for the child to reply to these questions correctly, he must first have a mental picture of the form.

If the answers are correct, we make him conscious of the fact that he had to see this in his mind first. It is surprising how many children cannot tell the number of spaces within the form even though they can tell you that the form is made by intersecting two horizontal lines and two vertical lines.

In some instances, the child may know the game but cannot draw the form. We then project one of the forms. The child is orientated to the nine spaces running in groups of three in any direction: right, left, up, down.

Let us say, for instance, that the form projected upon the screen has a cross in the upper left corner. We say to the child "If I were not able to see this at all, would you be able to tell me exactly where the cross is so that I shall know exactly where it is without having to look at it?" The answers usually are like this: "In that one," "in the first square," or "on that side." There is usually no responses as to left or right, etc.

This is a summation as to the type of conversation that takes place with the child. The discussion is often carried over into succeeding training sessions. Most of the time it takes more than one exposure for the child to get the after image; we may have to work with it several times.

We have worked with children with whom after images were impossible. Progress is not good with these patients.

When the after image response and its explanation by the child is satisfactory, it is repeated at least one more time at another session in order to know if the child really understands. We do not proceed to other training procedures until we get a fairly good understanding of eyes/brain/vision concept. It is possible to work this on 5-year-olds. This is perception; without it there is no learning. The first paragraph of this paper includes the type of conversation which takes place during our after image sessions. We may use this technique many ways. We have the child write his name or some letters or numbers on paper with his eyes closed. The tactual-kinesthetic clue will have little meaning without mental imagery.

When a child cannot at first achieve an after image, we try greater light intensity such as with the Beilschowsky after image tester for anomalous correspondence. Most children have experienced an after image from a camera flash bulb, but this is meaningless to him. In training procedures, wherever possible, we stress the "mental picture" or "brain picture"-we endeavor to bring to the child patient what vision is and what it does for him.

With some children the after image is not possible because fixation is so poor; in such cases, it becomes necessary to work in areas of ocular motility and fixation before working with after image.

READING TRAINING TECHNIQUES

Many poor readers do very well in spelling because of rote memory. Good spelling sometimes puzzles parents of nonreaders. If they know how to spell the words, why can't they read them, parents reason. We have seen children who spell every word in a book before they can say it. Many mentally retarded children have excellent memory for events or places but no learning or reasoning ability. We know retarded children who can recall every gift and from whom they received it for the last 3 years. This is not the same memory one uses in learning. Yet, parents ask "If he can remember these things, why can't he remember what he is taught?"