MENTALLY
DEFECTIVE CHILDREN 11ST THE PUBLIC SCHOOLS.
By Walter S.
Cornell,
M.D.
University of Pennsylvania.
of presence in tlie public schools instituin be should whom of mentally defective children, many tions for the feeble-minded, is accounted for by a didactic, nonpractical training of teachers in anatomy, physiology and psycholThe almost
unprotested
?gy, by their disinclination to give precious time to a problem which has had as yet no administrative solution, and by the confusion at present existing as to the meaning of the terms used to
describe mental defect in its various
grades. Happily each of these causative conditions shows signs of speedy improvement. The demonstration of school children's physical defects through the inauguration of general medical inspection, and the problems arising therefrom, will without doubt as it will the necesand functions the structure useful knowledge of an is Clinical psychology expression of the
revolutionize the training of teachers, showing
sity for a more of the human body.
advance in the study of the mind. The demonstration of these defects is likewise inciting educators and physicians to devise measures for their relief, with the natural consequence that standard terms for description and classification will be universally adopted in the near future. In to discuss conditions actually existing in the same
attempting
it is necessary to use some system of classification for the purpose of a common understanding; and the lack of such universal standard, already commented upon, has led me to adopt the following one, which evades
schools of
the
a
large city,
such
as
Philadelphia,
of such terms as "retarded," "defective," "pseudo-backand "exceptional." It may be said that mental defect in school children exists in
use
ward," "atypical" four groups of
cases:?
1. Children in whom defect is only relative. That is to say, children with good intelligence, who have not attained their best development because of poor general health, poor eyesight, or home surroundings. 2. Dull Children. Those who
improper
(75)
are
poor in school work' and
76
the psychological clinic.
slow
mentally, but who appear intelligent in their behavior and ordinary conversation. Sometimes the cause of the poor school work is evident,?physical defect, poor nutrition, poor home, forThese children are numerous and in round per cent of the younger school children. 3. Backward Children. Those who are very deficient intellectually and possess associated traits which mark them as abnormal in their whole mental make-up. Physical defects are frequent in these children, but their removal cannot effect a cure,
eign birth, etc., etc. numbers comprise ten
?only
a
possible improvement.
4. Feeble-minded Children.
All those of lower mentality The two classes merge into each than the backward children. other and the border line cases are definitely classified in one or the other group. The grading of mentality roughly corresponds in each group to a degree of intellectual development, and the latter in its turn may be fairly gauged by the child's school work. In classifying children by this method, however, the associated symptoms are
considered, because the item an erroneous judgment.
also
of
scholarship
alone may
give
rise to
forgotten that lack of mentality is in some simply secondary symptom of some curable physical ailment or the natural result of poor home surroundings, while in others it is the expression of inherent brain defect and therefore primary in character. Thus some young children classified as dull may temporarily be inferior in attainments to others who are backward, but who by reason of organic brain defect or inferior nervous constitution are incapable of great ultimate improvement. Relative Mental Defect. By this is meant the educational It should
cases
never
be
a
the average child on account of poor eyesight, nasal obstruction and other bodily ills. deafness, poor Since the correspondence of mental defect with physical defect is a rule to which there are numerous individual exceptions, statisdiscount suffered
by
nutrition,
tical studies are necessary to demonstrate it beyond controversy. Those have of late years been numerous. In a previous number of Tiie Psychological Clinic/* I reported studies of my own,
covering several hundred cases, showing that eye strain and nasal obstruction definitely lower the scholastic standing of the pupils suffering from them, if these pupils be considered as a class. Recently several other statistical papers have appeared,?notably ?Vol. I, No.
8, January 15, 1908,
p. 231.
77
MENTALLY DEFECTIVE CHILDREN. one
published
the year 1907.
in the
Report
of tlie London
Council for
County
Dull Children. The proportion of mental defectives to the whole school population is at the present time estimated from teachers' reports, which claim recognition rather for conscientious effort than for accuracy. The reasons for this have been already
commented upon. Particularly is error liable to occur in estithe of children who are only slightly defective. number mating The number of dull children is estimated at about 10 per cent of the whole school population, with the majority of the cases in the four lower grades. So far as I know, the first attempt in America to gain accurate information on this point was that of Will S. Monroe, of the Westfield (Mass.) State Normal School, who, in 1893 or there-
stagnating
addressed letters of inquiry to numerous teachers throughState of California. The replies to his circular, covering 10,842 children, showed an average opinion that ten per cent of all school children were mentally dull, and two and one-half per
abouts,
out the
cent
feeble-minded. More recently the Scotch cities of Edinburgh and Aberdeen
made
a
similar
inquiry, classifying
the children
as
excellent, good,
dull and deficient. Although gathered independently, the results were practically the same, and therefore trustworthy.
medium,
Aberdeen.
Edinburgh.
Per cent.
Per cent.
Excellent Good Medium
17.50
)
40.
I
30.33
32
Dull
11-50
9
83
0
Defective
it Passing to the personal examination of these dull children, of them, has been my good fortune to examine physically six classes The fact that last the total 235 year. cases, during numbering they had been officially recognized as below average capacity, precludes the charge that enthusiasm and the personal equation might have led to my selecting at random those dull children, scatteied defects. The through the schools, who possessed evident physical
conclusion to be drawn from the examination of this large number of dull children is that curable physical defects, such as poor in these children in eyesight, deafness and poor nutrition, exist
78
THE PSYCHOLOGICAL CLINIC.
far
than in average children. By inference of much of the dulness, but this cannot be stated as a proven fact until improvement in scholarship following medical treatment has been shown. The classes of dnll children first examined by me were two in number and have been already commented upon in a previous
greater proportion
they
are
the
paper here
cause
quoted:?
"An investigation the existence in the
on
slightly different lines
Claghorn
made
possible by same
gram-
made np at the beginning of the year that the brighter children constituted two classes, and the duller children the other two classes. The latter were smaller, so as to afford more opportunity for individual instruction. A comparison of the physical mar
grade,
which had been
was
School of fonr classes of the
so
condition of the children is instructive: Class 1
"Number of children Normal
was
nose
be about the
Dull
Children
x
7
82%
Class 11 ^u
Children
32
29
20
13
12
16
02.5%
44.8%
made to determine the exact degree of influence of The harmful results of these have been
and throat.
recognized in recent years. In bright and dull children were to
39 32
72%
normal children
"An effort defects of the
50 3G 14
Defective
Percentage of
Class 9
Class 15
Bright Children
same
the
Claghorn
School the four classes of
examined again.
(averaging
5i?,
*L|?,
Their
eyesight proved
*^?} 5^?). Enlarged
tonsils
adenoids, deafness, and nasal catarrh occurred much more frequently, however, among the two classes of duller children. In many the adenoid expression was written only too plainly on their faces. The following table shows the findings: Class 1
Class 15
Bright Children
"Number of children
Class 9
Dull
Children
Class 11 Children
50
39
32
29
G
4
9
9 3
Nose and throat conditions: Number defective
With single
or
combined defects, viz:
Tonsils
3
4
3
Adenoids
2
1
5
6
Deaf
2
..
5
1
.
2
3
Catarrh
Percentage of children with throat defects
.
nose
and
12%
10.2%
28.1%
31%"
MENTALLY DEFECTIVE CHILDREN. Several months subsequent
to tlie
79
examination of these chil-
made in the William McSchool. Here, for the sake of better instruction, a large number of dull children had been grouped by the principal, Miss McKinney, into four so-called "special classes." They practically represented that twenty-five per cent of the school population which stood lowest in school work, the retardation in
dren,
another
along
the
same
lines
was
Kinley Primary
several instances being as much as three years. Although, as I have said, 1hese children were spoken of as belonging to special
simply one of convenience, for none were only a very few really backward. The proportion of physical defect, however, was surprisingly large, particularly the cases of poor eyesight and adenoid nasal obstruction. Thus, in 174 pupils, 188 physical defects (G8 eye-strain, 40 nasal classes,
the term
feeble-minded
was
and
notices to parents, were noted upon defects minor additional and G9 discovered; the registration cards. The distribution of these defects among the 174 children was as follows: One hundred and sixteen children received notices urging the correction of one or more
obstruction,
80
miscellaneous), necessitating
were
defects,
parents' possessed minor defects, a clean physical record.
2G children
muster with
and
only
33
passed
The condition of the children in these four classcs in the McKinley School is shown in the summary on the following page. Experience gained from the systematic examination of about 7,000 children leads me to believe that dulness during school life arises principally from physical defects, poor nutrition, and environmental causes, such as improper home surroundings and frequent change of residence. Instances of these are so numerous in the work of medical that they soon cease to excite
inspection
than passing comment and routine official measures for their relief. To those less familiar with the subject, a few illustrative examples may prove interesting. Lack of space forbids more than the barest comment upon each. All are in attendance in
more
public
schools and
were
examined by
myself quite recently.
Mt. Vernon School.
Girl, aged 13, dull memory. Anaemia, poor nutrition, defective vision, adenoids, stoop shoulders, flat and rachitic chest. 2. Russian girl, dull mentally. Enlarged tonsils, adenoids, nasal 1.
catarrh.
Fleiclier School. 3. Girl, aged 8, dull mentally. Extremely poor nutrition, defective vision, enlarged tonsils, adenoid nasal obstruction.
80
THE PSYCHOLOGICAL CLINIC.
Summary
of
Four Special Classes
in the
William MoKinley School.
II
Number of
pupils
39
Grade
3?
Average 1.
age of
class, in
noteworthy physical
2.
years
Number of children in whom was
45
Hi
III
IV
Total
44
46
174
21 10
11
H 8?
no
defect
2d observec
10
10
33
Children with slight visual defect, or nasal obstruction, not sufficient to justify official recommendation for treatment
3.
26
Children with physical defects which necessitated notices to 29
30
27
29
115
Number of slight defects for which notices were not issued
19
17
16
17
69
Number of defects for which notices were issued
43
50
43
52
188
Poor vision
12
19
18
19
13
11
4
12
4
2
2
3
1
3
2
1
4
5
8
5
1
5
2
5
Round shoulders and flat chest
6
2
4
2
Other defects
2
3
3
5
Total number of defects for which notices were issued
43
50
43
52
Total number of defects, including both slight and serious
62
67
59
69
parents. 2a.
3a.
Nasal
obstruction (adenoid); majority with nasal catarrh and slight deafness
Hypertrophied
tonsils
Marked deafness and discharg-
ing
ears
Poor nutrition
Badly decayed
teeth
.
257
81
MENTALLY DEFECTIVE CHILDREN.
Washington
School.
boy, dull mentally. Poor nutrition and tuber(Mother, brother, two paternal uncles and one consumption.)
4. Italian-American
cular family history. paternal aunt had
BurJc School. 5. Boy, dull mentally. Adenoid obstruction, nasal catarrh ondary conjunctivitis from extension through the nasal ducts.
and
sec-
Miller School. 6. nasal
Girl, aged
obstruction,
10 years and 8 months, dull very defective vision,
mentally. Deaf, adenoid
Nebinger
School. 7 and 8. Two Italian boys, dull mentally, probably backward. Principal cause environmental (poverty and foreign nationality). The smaller one has never had a bath. The older one has been five years in the first grade.
Backward and Feeble-Minded Children.
Bearing
in mind
that the term backward children in the definition here adopted refers to those whose poor intellect is associated with suspicious signs of general mental defect, it is seen at once that this class of children is affiliated more closely with the feeble-minded than with the dull group. As these children are on the borderland between normality above and abnormality below, many assigned be to the group of backward children by one examiner, may designated as by another. To a certain extent it
feeble-minded
compromise class for debatable cases. Many children exist, however, who correspond clearly to the idea expressed in the definiis
a
tion.
tainted children. diagnosis of these cases rests more on psychical than on physical grounds, and the theoretical limits of the class varies slightly with each examiner, the number of backward children in the schools is difficult to determine. Furthermore, the
They
are
Since the
and social condition combine to mental defectives in some communities than in others, and this fact makes the value of statistical studies, based on official reports, rather uncertain. of The sources of information on the proportion
predisposing influences of race produce a larger proportion of following
truly
backward and
any:?? 1. The
feeble-minded children
working
rule
adopted by
are
those
as
trustworthy
as
officially interested,
82
THE PSYCHOLOGICAL CLINIC.
that
one
mind.
of every five hundred of the entire population is of feeble A fair proportion of these find their way into the public
schools. 2. The
Report of a London Commission several years ago, that one stating per cent of the school population is mentally defective. I have often seen this statement, but have not been able to ascertain its trustworthiness. 3. A very painstaking study by Miss Dendy, of Manchester, England,* in which expert examination of 44,000 children showed 2SO (over l/j per cent in the schools) to be of feeble mind. An equal
number of children nominated for examination were diagnosed by the examiners as simply dull
teachers
the back-
by or
ward. 4. The existence in New York classes for
truly
backward
City
special, ungraded
731 children offimedical examiner. These by of the New York pupils schools,
children, containing
cially committed to these classes children do not represent all the the report from which these
a
figures are Superintendent's Report, 1008, page 628)
as
of 41
taken covers
work of the medical examiner in 69 schools. figures we may assume these schools to be the 1200
(New York City only six months' To utilize these
large
ones
in the
which would result
enrollment, poorer districts, averaging in a percentage of 0.9. The backward children contain among their number an appreciable proportion of feeble-minded. 5. The examination by the writer of 63 truly backward and ]2 feeble-minded children in 13 Philadelphia public schools, of 10,100 enrollment. As all of the pupils in eight of these schools examined by me and as the cases were by teachers, the number of backward children is It should be nearer 80, which would give a too small. certainly of 0.8. The 12 feeble-minded children doubtless reppercentage
were not
systematically
referred to
me
resented all of this
class,
so
be 0.1 per cent of the school
that the
proportion population.
in this
case
would
?Of 100.322 children in the public elementary schools of Manchester, in 1808. 44.403 were under the direction of the School Board, and were inspected to ascertain the proportion of those who were mentally defective. The accuracy of these figures is undoubted, since the case reports were all passed upon by Dr. George Shuttleworth, and the children were all personally examined by Dr. Asliby, a leading Manchester physician. Five hundred and twenty-five children with suspected mental defect were noted by the teachers and by Miss Dendy. and 500 of these were examined by Dr. Ashby. Of these latter "214 were dull and backward, 270 were mentally feeble, 4 were deaf mutes and 5 did not appear sufficiently behind hand to (From Report of Conference of Women come under any of these terms." Workers, Edinburgh, 1902, p. 110, paper read by Miss Dendy, of Manches-
ter, England.)
MENTALLY DEFECTIVE CHILDREN. In view of these
that 10 per
cent of
facts,
public
cases
may be
83
it may be asserted with fair accuracy school children are dull, often from
removable causes, 0.5 per cent to 1 per cent and 0.1 per cent actually feeble-minded. A few
-
cited, illustrating
are
the
truly backward,
general
istics of backward and feeble-minded children. They
character-
serve
particu-
emphasize the actual presence in the schools of a class, who not only derive no benefit from the regular school curriculum, but also subtract from the efficiency of teachers and the instruction of normal children.
larly
to
among other special classes, there the Wharton School, Fifth Street and Washington Avenue, organized by Miss Maguire, the school principal, under the direction of District Superintendent Brelsford. This class I examined with the kind assistance of Miss Devereux, its teacher. At the time of examination the class numbered 22 children, mostly of foreign parentage. Practically nil of them presented In
is
Philadelphia schools,
one at
abnormalities
of
physique
or
facial
expression, betraying
more or
less the mental defect existing. Physical examination showed that children possessed three-fourths or less vision, the vision in one case being one-twelfth. These poor vision cases included four
Seven others possessed minor defects of vision. Only four had normal visual acuity. Defects of the nose and throat were as numerous, fourteen of the children suffrom adenoid nasal obstruction of pronounced degree. This cases
of strabismus.
fering
nasal obstruction was associated with enlarged tonsils in one case, with enlarged tonsils and nasal catarrh in two cases, and with There were five cases of nasal catarrh alone in seven others. deafness and discharging ears, all apparently being secondary to nose and throat defects, since all the sufferers were adenoid cases. Very poor nutrition existed in seven children. Miscellaneous de-
fects and disorders of various degrees
were
plentiful.
The mental faculties were judged by the perception, memory, and reasoning power of the children. The perception was fair in five instances, poor in ten, and very poor in seven. The memory The was fair in seven, poor in seven, and very poor in eight. and very poor in reasoning power was fair in eight, poor in ten, four. After three months' instruction by object teaching, paper mat and wood designed to stimulate the motor
work,
cutting,
had undoubtpower, co-ordination, and reason, some improvement of these were Some edly taken place in seven of the children. in the regular first, second, and third of the
working part
grade
classes.
day
84
THE PSYCHOLOGICAL CLINIC.
The Wharton School, from which this class is recruited, is
a
large one, numbering seventeen hundred children. Practically every school, however, has one or more of these backward children in its lower grades. The following instances not only very
serve as
descriptive
cases, but illustrate this fact
as
well:
Fletcher School. 9. C. H., aged 14 years. Mentality "backward." Defective vision. and adenoid nasal obstruction. An undoubted history also of epilepsy or some kindred psycho-motor disturbance. He has
Enlarged tonsils, slowly
worked his way into the fourth grade.
Last year,
through the provided and the resulting improvebehavior always good.
efforts of my colleague, Dr. Smith, eyeglasses were adenoids and tonsils removed, but with no apparent ment in
scholarship.
Temperament placid
and
Mt. Vernon School.
W., aged 12 years. Mentality doubtful (between backward feeble-minded). Height three feet six inches. This child has no perception of number, form, or color, juged by the ordinary tests, but his Italian nationality and the illiteracy of his parents made these incon10. D.
and
clusive. than
I
am
inclined to believe that this
was a
of feeble mind, and fairly trainable. 11. M. H., aged 7 years and 7 months;
backward
case
rather
one
parentage German; is
Inspection showed fair sized boy; nutrition good; exTeeth treme adenoid expression of the face, with mouth wide open. the to determine It was of Hutchinson the impossible type. possibly acuity of vision because of bis low mental development. His nose was in first
grade.
completely obstructed by adenoids, with resulting deafness and catarrh. a condition of nervous instability, shown by a continual restlessness, jumping up and down, and a superficial curiosity regarding objects around him. Facial expression usually lifeless, but animated when interested. Temperament placid, timid, and affectionate, and teacher reports that he is always well behaved. The motor power and the control was good, but co-ordination only fair. He had some difficulty in buttoning his jacket when asked to do so. There was a great variability in his promptness of movement, he was often decidedly slow He betrayed
and occasionally
remarkably
active.
Speech
was
rapid
and
indistinct,
due to inability to form many of the consonant sounds, and his voice loud and high pitched. His words, when understood, were found to be fairly
intelligent.
He has
no
perception
of color, form
or
number,
no
power
of attention, and poor memory. The school work accomplished is practically nothing. Teacher reports that he sits idle all day. During half-
swinging his legs constantly and looking idly around, laughing good-naturedly when spoken to. There is a history hour examination he sat in this in
a
case
of
hospital.
a
fall at five years of
age, for
which he
was
two weeks
MENTALLY DEFECTIVE CHILDREN. Diagnosis:?Feeble mind, due, existence of deafness and adenoids
85
in part at least, to deprivation. The may possibly make this case one of
extreme backwardness only, but this is not probable. 12. S. M., Russian Hebrew, aged 7 years. Mentality, feeble mind. The primary cause here appeared to be poor nutrition. It was impossible to determine the visual acuity, a coincident blepharitis being due The more probably to the constitutional condition that to eye strain. mind of this child appeared almost blank, a condition again due to the general inanition. The best that could be elicited was that 1 and 1 made 2, and the statement of his
own name.
Miller School. 13. K. A., 15 years old, in the first grade. "She makes no progress whatever. She appears to be fairly nourished. She has a slight squint in the right eye. Her mouth is always open, but there appears to be no na8al obstruction. There is no deafness. Her teeth are good but not clean. She is round-shouldered. Her facial expression is heavy, with a dull, foolish smile. Her skin is muddy; temperament placid, generally good-natured, but is sullen when crossed; re-action to commands is
slow;
she is able
poor, gait
to dress herself and says she can sew.
shambling,
her
speech slovenly,
not clear.
Her grip is She does not
recognize colors except black and red; does not know coins; can add 1 and 1, and occasionally 2 and 2. Attention, memory, association and judgment poor." (L. E.) This case is one of high grade imbecility. 14. W. B., aged 9 years 8 months, white; father, a city fireman; mother, stated by the teacher to be peculiar. One brother in school, who is dull and has repeatedly failed of promotion. This brother has defective speech and is stated to be peculiarly obstinate at times. One older sister, now out of school, who is also dull in her studies. Physical condition good, no physical defects of the skull, ears or limbs. Vision one-third normal. Tonsils slightly enlarged. The left nostril entirely obstructed by adenoid growth, the right nostril partly so, with resultant nasal catarrh. The sense of hearing was studied with great difficulty,
owing to the poor attention and mentality of the boy. It was necessary to shout to attract his attention when not looking, and the fact that he observed the movements of the speaker's lips and leaned forward to His teacher, however, states hear that deafness was
pronounoed. proved that he appears at times to hear much better than at others. Whether this was true could not be ascertained. An endeavor to test his hearing did not with a watch was an absolute failure, as he said he heard it, or hear it, as he fancied the form of the question with con The expression of the face was an habitual silly smile, almost with stant twitching of the facial muscles. This was associated His and tempera continuous nervous movements of the hands obstinate. During ment was quiet and good natured, but exceedingly under careful has improved condition the past two years his nervous
demanded.^ fingers.^
THE PSYCHOLOGICAL CLINIC.
86
school discipline. Ilis motor control clumsy, but good enough to allow him
pencil stiffly.
His
half his words
were
a
his
use
lips
grip not
good. intelligible; was
and the tones showed
was
fair, being
very
slow and
to button his clothes and handle
speech was so defective that apparently made no effort to plainly the effects of the nasal
His he
catarrh. An endeavor to test the mental faculties showed
color, seconds,
to concentrate
the attention for
no
perception than
of
few
inability apparent reasoning power, and no ability at number work. His memory, however, was good, and he recognized letters and easy words readily. He has been two years in the first grade, with a probability of continuing there indefinitely. The diagnosis in the case is not possible without preliminary expert examination of the eyes, nose and ears. The deprivation in this case, by reason of the deficient sense organs, makes the diagnosis of imbecility There is no doubt, however, from the family history, a little uncertain. an
the
more
a
no
multiple association of physical defects, and the nervous condition, some degree of true feeble-mindedness exists. 15. J. A., aged 13 years, 8 months; German parentage. Father
that
dead, mother and sisters illiterate. Has attended German-American and parochial schools until seven months ago, when he entered this school. He was placed in the third grade because his size and age made it inadvisable to allow him to associate with the youngest children. He absolutely no progress, and is actually unfit for first grade
has made
Inspection showed a large boy with coarse heavy features, dull expression, slouchy carriage and shambling gait. His forehead is low, owing to a coarse growth of hair, and despite his age he already has a growth of hair on the upper lip. Vision, by the illiterate test card, is apparently normal; hearing normal. Response both in actions and words is very slow. His speech is indistinct, with an inability to pronounce "th." Vocabiilary small, due probably in part to German family. Examination showed his grip to be fair, but not good. He buttoned his clothes very readily. The perception is fair, and attention apparently good. His imitation is also good, as he can readily copy work.
facial
from the blackboard.
Memory
very poor.
Number work
so
poor that
multiply 2 times G. Other school work, such as reading, entirely beyond him. Diagnosis: Feeble mind. This is a typical institution case. he could not
is
DEFECTIVE CHILDREN 11ST THE PUBLIC SCHOOLS.
By Walter S.
Cornell,
M.D.
University of Pennsylvania.
of presence in tlie public schools instituin be should whom of mentally defective children, many tions for the feeble-minded, is accounted for by a didactic, nonpractical training of teachers in anatomy, physiology and psycholThe almost
unprotested
?gy, by their disinclination to give precious time to a problem which has had as yet no administrative solution, and by the confusion at present existing as to the meaning of the terms used to
describe mental defect in its various
grades. Happily each of these causative conditions shows signs of speedy improvement. The demonstration of school children's physical defects through the inauguration of general medical inspection, and the problems arising therefrom, will without doubt as it will the necesand functions the structure useful knowledge of an is Clinical psychology expression of the
revolutionize the training of teachers, showing
sity for a more of the human body.
advance in the study of the mind. The demonstration of these defects is likewise inciting educators and physicians to devise measures for their relief, with the natural consequence that standard terms for description and classification will be universally adopted in the near future. In to discuss conditions actually existing in the same
attempting
it is necessary to use some system of classification for the purpose of a common understanding; and the lack of such universal standard, already commented upon, has led me to adopt the following one, which evades
schools of
the
a
large city,
such
as
Philadelphia,
of such terms as "retarded," "defective," "pseudo-backand "exceptional." It may be said that mental defect in school children exists in
use
ward," "atypical" four groups of
cases:?
1. Children in whom defect is only relative. That is to say, children with good intelligence, who have not attained their best development because of poor general health, poor eyesight, or home surroundings. 2. Dull Children. Those who
improper
(75)
are
poor in school work' and
76
the psychological clinic.
slow
mentally, but who appear intelligent in their behavior and ordinary conversation. Sometimes the cause of the poor school work is evident,?physical defect, poor nutrition, poor home, forThese children are numerous and in round per cent of the younger school children. 3. Backward Children. Those who are very deficient intellectually and possess associated traits which mark them as abnormal in their whole mental make-up. Physical defects are frequent in these children, but their removal cannot effect a cure,
eign birth, etc., etc. numbers comprise ten
?only
a
possible improvement.
4. Feeble-minded Children.
All those of lower mentality The two classes merge into each than the backward children. other and the border line cases are definitely classified in one or the other group. The grading of mentality roughly corresponds in each group to a degree of intellectual development, and the latter in its turn may be fairly gauged by the child's school work. In classifying children by this method, however, the associated symptoms are
considered, because the item an erroneous judgment.
also
of
scholarship
alone may
give
rise to
forgotten that lack of mentality is in some simply secondary symptom of some curable physical ailment or the natural result of poor home surroundings, while in others it is the expression of inherent brain defect and therefore primary in character. Thus some young children classified as dull may temporarily be inferior in attainments to others who are backward, but who by reason of organic brain defect or inferior nervous constitution are incapable of great ultimate improvement. Relative Mental Defect. By this is meant the educational It should
cases
never
be
a
the average child on account of poor eyesight, nasal obstruction and other bodily ills. deafness, poor Since the correspondence of mental defect with physical defect is a rule to which there are numerous individual exceptions, statisdiscount suffered
by
nutrition,
tical studies are necessary to demonstrate it beyond controversy. Those have of late years been numerous. In a previous number of Tiie Psychological Clinic/* I reported studies of my own,
covering several hundred cases, showing that eye strain and nasal obstruction definitely lower the scholastic standing of the pupils suffering from them, if these pupils be considered as a class. Recently several other statistical papers have appeared,?notably ?Vol. I, No.
8, January 15, 1908,
p. 231.
77
MENTALLY DEFECTIVE CHILDREN. one
published
the year 1907.
in the
Report
of tlie London
Council for
County
Dull Children. The proportion of mental defectives to the whole school population is at the present time estimated from teachers' reports, which claim recognition rather for conscientious effort than for accuracy. The reasons for this have been already
commented upon. Particularly is error liable to occur in estithe of children who are only slightly defective. number mating The number of dull children is estimated at about 10 per cent of the whole school population, with the majority of the cases in the four lower grades. So far as I know, the first attempt in America to gain accurate information on this point was that of Will S. Monroe, of the Westfield (Mass.) State Normal School, who, in 1893 or there-
stagnating
addressed letters of inquiry to numerous teachers throughState of California. The replies to his circular, covering 10,842 children, showed an average opinion that ten per cent of all school children were mentally dull, and two and one-half per
abouts,
out the
cent
feeble-minded. More recently the Scotch cities of Edinburgh and Aberdeen
made
a
similar
inquiry, classifying
the children
as
excellent, good,
dull and deficient. Although gathered independently, the results were practically the same, and therefore trustworthy.
medium,
Aberdeen.
Edinburgh.
Per cent.
Per cent.
Excellent Good Medium
17.50
)
40.
I
30.33
32
Dull
11-50
9
83
0
Defective
it Passing to the personal examination of these dull children, of them, has been my good fortune to examine physically six classes The fact that last the total 235 year. cases, during numbering they had been officially recognized as below average capacity, precludes the charge that enthusiasm and the personal equation might have led to my selecting at random those dull children, scatteied defects. The through the schools, who possessed evident physical
conclusion to be drawn from the examination of this large number of dull children is that curable physical defects, such as poor in these children in eyesight, deafness and poor nutrition, exist
78
THE PSYCHOLOGICAL CLINIC.
far
than in average children. By inference of much of the dulness, but this cannot be stated as a proven fact until improvement in scholarship following medical treatment has been shown. The classes of dnll children first examined by me were two in number and have been already commented upon in a previous
greater proportion
they
are
the
paper here
cause
quoted:?
"An investigation the existence in the
on
slightly different lines
Claghorn
made
possible by same
gram-
made np at the beginning of the year that the brighter children constituted two classes, and the duller children the other two classes. The latter were smaller, so as to afford more opportunity for individual instruction. A comparison of the physical mar
grade,
which had been
was
School of fonr classes of the
so
condition of the children is instructive: Class 1
"Number of children Normal
was
nose
be about the
Dull
Children
x
7
82%
Class 11 ^u
Children
32
29
20
13
12
16
02.5%
44.8%
made to determine the exact degree of influence of The harmful results of these have been
and throat.
recognized in recent years. In bright and dull children were to
39 32
72%
normal children
"An effort defects of the
50 3G 14
Defective
Percentage of
Class 9
Class 15
Bright Children
same
the
Claghorn
School the four classes of
examined again.
(averaging
5i?,
*L|?,
Their
eyesight proved
*^?} 5^?). Enlarged
tonsils
adenoids, deafness, and nasal catarrh occurred much more frequently, however, among the two classes of duller children. In many the adenoid expression was written only too plainly on their faces. The following table shows the findings: Class 1
Class 15
Bright Children
"Number of children
Class 9
Dull
Children
Class 11 Children
50
39
32
29
G
4
9
9 3
Nose and throat conditions: Number defective
With single
or
combined defects, viz:
Tonsils
3
4
3
Adenoids
2
1
5
6
Deaf
2
..
5
1
.
2
3
Catarrh
Percentage of children with throat defects
.
nose
and
12%
10.2%
28.1%
31%"
MENTALLY DEFECTIVE CHILDREN. Several months subsequent
to tlie
79
examination of these chil-
made in the William McSchool. Here, for the sake of better instruction, a large number of dull children had been grouped by the principal, Miss McKinney, into four so-called "special classes." They practically represented that twenty-five per cent of the school population which stood lowest in school work, the retardation in
dren,
another
along
the
same
lines
was
Kinley Primary
several instances being as much as three years. Although, as I have said, 1hese children were spoken of as belonging to special
simply one of convenience, for none were only a very few really backward. The proportion of physical defect, however, was surprisingly large, particularly the cases of poor eyesight and adenoid nasal obstruction. Thus, in 174 pupils, 188 physical defects (G8 eye-strain, 40 nasal classes,
the term
feeble-minded
was
and
notices to parents, were noted upon defects minor additional and G9 discovered; the registration cards. The distribution of these defects among the 174 children was as follows: One hundred and sixteen children received notices urging the correction of one or more
obstruction,
80
miscellaneous), necessitating
were
defects,
parents' possessed minor defects, a clean physical record.
2G children
muster with
and
only
33
passed
The condition of the children in these four classcs in the McKinley School is shown in the summary on the following page. Experience gained from the systematic examination of about 7,000 children leads me to believe that dulness during school life arises principally from physical defects, poor nutrition, and environmental causes, such as improper home surroundings and frequent change of residence. Instances of these are so numerous in the work of medical that they soon cease to excite
inspection
than passing comment and routine official measures for their relief. To those less familiar with the subject, a few illustrative examples may prove interesting. Lack of space forbids more than the barest comment upon each. All are in attendance in
more
public
schools and
were
examined by
myself quite recently.
Mt. Vernon School.
Girl, aged 13, dull memory. Anaemia, poor nutrition, defective vision, adenoids, stoop shoulders, flat and rachitic chest. 2. Russian girl, dull mentally. Enlarged tonsils, adenoids, nasal 1.
catarrh.
Fleiclier School. 3. Girl, aged 8, dull mentally. Extremely poor nutrition, defective vision, enlarged tonsils, adenoid nasal obstruction.
80
THE PSYCHOLOGICAL CLINIC.
Summary
of
Four Special Classes
in the
William MoKinley School.
II
Number of
pupils
39
Grade
3?
Average 1.
age of
class, in
noteworthy physical
2.
years
Number of children in whom was
45
Hi
III
IV
Total
44
46
174
21 10
11
H 8?
no
defect
2d observec
10
10
33
Children with slight visual defect, or nasal obstruction, not sufficient to justify official recommendation for treatment
3.
26
Children with physical defects which necessitated notices to 29
30
27
29
115
Number of slight defects for which notices were not issued
19
17
16
17
69
Number of defects for which notices were issued
43
50
43
52
188
Poor vision
12
19
18
19
13
11
4
12
4
2
2
3
1
3
2
1
4
5
8
5
1
5
2
5
Round shoulders and flat chest
6
2
4
2
Other defects
2
3
3
5
Total number of defects for which notices were issued
43
50
43
52
Total number of defects, including both slight and serious
62
67
59
69
parents. 2a.
3a.
Nasal
obstruction (adenoid); majority with nasal catarrh and slight deafness
Hypertrophied
tonsils
Marked deafness and discharg-
ing
ears
Poor nutrition
Badly decayed
teeth
.
257
81
MENTALLY DEFECTIVE CHILDREN.
Washington
School.
boy, dull mentally. Poor nutrition and tuber(Mother, brother, two paternal uncles and one consumption.)
4. Italian-American
cular family history. paternal aunt had
BurJc School. 5. Boy, dull mentally. Adenoid obstruction, nasal catarrh ondary conjunctivitis from extension through the nasal ducts.
and
sec-
Miller School. 6. nasal
Girl, aged
obstruction,
10 years and 8 months, dull very defective vision,
mentally. Deaf, adenoid
Nebinger
School. 7 and 8. Two Italian boys, dull mentally, probably backward. Principal cause environmental (poverty and foreign nationality). The smaller one has never had a bath. The older one has been five years in the first grade.
Backward and Feeble-Minded Children.
Bearing
in mind
that the term backward children in the definition here adopted refers to those whose poor intellect is associated with suspicious signs of general mental defect, it is seen at once that this class of children is affiliated more closely with the feeble-minded than with the dull group. As these children are on the borderland between normality above and abnormality below, many assigned be to the group of backward children by one examiner, may designated as by another. To a certain extent it
feeble-minded
compromise class for debatable cases. Many children exist, however, who correspond clearly to the idea expressed in the definiis
a
tion.
tainted children. diagnosis of these cases rests more on psychical than on physical grounds, and the theoretical limits of the class varies slightly with each examiner, the number of backward children in the schools is difficult to determine. Furthermore, the
They
are
Since the
and social condition combine to mental defectives in some communities than in others, and this fact makes the value of statistical studies, based on official reports, rather uncertain. of The sources of information on the proportion
predisposing influences of race produce a larger proportion of following
truly
backward and
any:?? 1. The
feeble-minded children
working
rule
adopted by
are
those
as
trustworthy
as
officially interested,
82
THE PSYCHOLOGICAL CLINIC.
that
one
mind.
of every five hundred of the entire population is of feeble A fair proportion of these find their way into the public
schools. 2. The
Report of a London Commission several years ago, that one stating per cent of the school population is mentally defective. I have often seen this statement, but have not been able to ascertain its trustworthiness. 3. A very painstaking study by Miss Dendy, of Manchester, England,* in which expert examination of 44,000 children showed 2SO (over l/j per cent in the schools) to be of feeble mind. An equal
number of children nominated for examination were diagnosed by the examiners as simply dull
teachers
the back-
by or
ward. 4. The existence in New York classes for
truly
backward
City
special, ungraded
731 children offimedical examiner. These by of the New York pupils schools,
children, containing
cially committed to these classes children do not represent all the the report from which these
a
figures are Superintendent's Report, 1008, page 628)
as
of 41
taken covers
work of the medical examiner in 69 schools. figures we may assume these schools to be the 1200
(New York City only six months' To utilize these
large
ones
in the
which would result
enrollment, poorer districts, averaging in a percentage of 0.9. The backward children contain among their number an appreciable proportion of feeble-minded. 5. The examination by the writer of 63 truly backward and ]2 feeble-minded children in 13 Philadelphia public schools, of 10,100 enrollment. As all of the pupils in eight of these schools examined by me and as the cases were by teachers, the number of backward children is It should be nearer 80, which would give a too small. certainly of 0.8. The 12 feeble-minded children doubtless reppercentage
were not
systematically
referred to
me
resented all of this
class,
so
be 0.1 per cent of the school
that the
proportion population.
in this
case
would
?Of 100.322 children in the public elementary schools of Manchester, in 1808. 44.403 were under the direction of the School Board, and were inspected to ascertain the proportion of those who were mentally defective. The accuracy of these figures is undoubted, since the case reports were all passed upon by Dr. George Shuttleworth, and the children were all personally examined by Dr. Asliby, a leading Manchester physician. Five hundred and twenty-five children with suspected mental defect were noted by the teachers and by Miss Dendy. and 500 of these were examined by Dr. Ashby. Of these latter "214 were dull and backward, 270 were mentally feeble, 4 were deaf mutes and 5 did not appear sufficiently behind hand to (From Report of Conference of Women come under any of these terms." Workers, Edinburgh, 1902, p. 110, paper read by Miss Dendy, of Manches-
ter, England.)
MENTALLY DEFECTIVE CHILDREN. In view of these
that 10 per
cent of
facts,
public
cases
may be
83
it may be asserted with fair accuracy school children are dull, often from
removable causes, 0.5 per cent to 1 per cent and 0.1 per cent actually feeble-minded. A few
-
cited, illustrating
are
the
truly backward,
general
istics of backward and feeble-minded children. They
character-
serve
particu-
emphasize the actual presence in the schools of a class, who not only derive no benefit from the regular school curriculum, but also subtract from the efficiency of teachers and the instruction of normal children.
larly
to
among other special classes, there the Wharton School, Fifth Street and Washington Avenue, organized by Miss Maguire, the school principal, under the direction of District Superintendent Brelsford. This class I examined with the kind assistance of Miss Devereux, its teacher. At the time of examination the class numbered 22 children, mostly of foreign parentage. Practically nil of them presented In
is
Philadelphia schools,
one at
abnormalities
of
physique
or
facial
expression, betraying
more or
less the mental defect existing. Physical examination showed that children possessed three-fourths or less vision, the vision in one case being one-twelfth. These poor vision cases included four
Seven others possessed minor defects of vision. Only four had normal visual acuity. Defects of the nose and throat were as numerous, fourteen of the children suffrom adenoid nasal obstruction of pronounced degree. This cases
of strabismus.
fering
nasal obstruction was associated with enlarged tonsils in one case, with enlarged tonsils and nasal catarrh in two cases, and with There were five cases of nasal catarrh alone in seven others. deafness and discharging ears, all apparently being secondary to nose and throat defects, since all the sufferers were adenoid cases. Very poor nutrition existed in seven children. Miscellaneous de-
fects and disorders of various degrees
were
plentiful.
The mental faculties were judged by the perception, memory, and reasoning power of the children. The perception was fair in five instances, poor in ten, and very poor in seven. The memory The was fair in seven, poor in seven, and very poor in eight. and very poor in reasoning power was fair in eight, poor in ten, four. After three months' instruction by object teaching, paper mat and wood designed to stimulate the motor
work,
cutting,
had undoubtpower, co-ordination, and reason, some improvement of these were Some edly taken place in seven of the children. in the regular first, second, and third of the
working part
grade
classes.
day
84
THE PSYCHOLOGICAL CLINIC.
The Wharton School, from which this class is recruited, is
a
large one, numbering seventeen hundred children. Practically every school, however, has one or more of these backward children in its lower grades. The following instances not only very
serve as
descriptive
cases, but illustrate this fact
as
well:
Fletcher School. 9. C. H., aged 14 years. Mentality "backward." Defective vision. and adenoid nasal obstruction. An undoubted history also of epilepsy or some kindred psycho-motor disturbance. He has
Enlarged tonsils, slowly
worked his way into the fourth grade.
Last year,
through the provided and the resulting improvebehavior always good.
efforts of my colleague, Dr. Smith, eyeglasses were adenoids and tonsils removed, but with no apparent ment in
scholarship.
Temperament placid
and
Mt. Vernon School.
W., aged 12 years. Mentality doubtful (between backward feeble-minded). Height three feet six inches. This child has no perception of number, form, or color, juged by the ordinary tests, but his Italian nationality and the illiteracy of his parents made these incon10. D.
and
clusive. than
I
am
inclined to believe that this
was a
of feeble mind, and fairly trainable. 11. M. H., aged 7 years and 7 months;
backward
case
rather
one
parentage German; is
Inspection showed fair sized boy; nutrition good; exTeeth treme adenoid expression of the face, with mouth wide open. the to determine It was of Hutchinson the impossible type. possibly acuity of vision because of bis low mental development. His nose was in first
grade.
completely obstructed by adenoids, with resulting deafness and catarrh. a condition of nervous instability, shown by a continual restlessness, jumping up and down, and a superficial curiosity regarding objects around him. Facial expression usually lifeless, but animated when interested. Temperament placid, timid, and affectionate, and teacher reports that he is always well behaved. The motor power and the control was good, but co-ordination only fair. He had some difficulty in buttoning his jacket when asked to do so. There was a great variability in his promptness of movement, he was often decidedly slow He betrayed
and occasionally
remarkably
active.
Speech
was
rapid
and
indistinct,
due to inability to form many of the consonant sounds, and his voice loud and high pitched. His words, when understood, were found to be fairly
intelligent.
He has
no
perception
of color, form
or
number,
no
power
of attention, and poor memory. The school work accomplished is practically nothing. Teacher reports that he sits idle all day. During half-
swinging his legs constantly and looking idly around, laughing good-naturedly when spoken to. There is a history hour examination he sat in this in
a
case
of
hospital.
a
fall at five years of
age, for
which he
was
two weeks
MENTALLY DEFECTIVE CHILDREN. Diagnosis:?Feeble mind, due, existence of deafness and adenoids
85
in part at least, to deprivation. The may possibly make this case one of
extreme backwardness only, but this is not probable. 12. S. M., Russian Hebrew, aged 7 years. Mentality, feeble mind. The primary cause here appeared to be poor nutrition. It was impossible to determine the visual acuity, a coincident blepharitis being due The more probably to the constitutional condition that to eye strain. mind of this child appeared almost blank, a condition again due to the general inanition. The best that could be elicited was that 1 and 1 made 2, and the statement of his
own name.
Miller School. 13. K. A., 15 years old, in the first grade. "She makes no progress whatever. She appears to be fairly nourished. She has a slight squint in the right eye. Her mouth is always open, but there appears to be no na8al obstruction. There is no deafness. Her teeth are good but not clean. She is round-shouldered. Her facial expression is heavy, with a dull, foolish smile. Her skin is muddy; temperament placid, generally good-natured, but is sullen when crossed; re-action to commands is
slow;
she is able
poor, gait
to dress herself and says she can sew.
shambling,
her
speech slovenly,
not clear.
Her grip is She does not
recognize colors except black and red; does not know coins; can add 1 and 1, and occasionally 2 and 2. Attention, memory, association and judgment poor." (L. E.) This case is one of high grade imbecility. 14. W. B., aged 9 years 8 months, white; father, a city fireman; mother, stated by the teacher to be peculiar. One brother in school, who is dull and has repeatedly failed of promotion. This brother has defective speech and is stated to be peculiarly obstinate at times. One older sister, now out of school, who is also dull in her studies. Physical condition good, no physical defects of the skull, ears or limbs. Vision one-third normal. Tonsils slightly enlarged. The left nostril entirely obstructed by adenoid growth, the right nostril partly so, with resultant nasal catarrh. The sense of hearing was studied with great difficulty,
owing to the poor attention and mentality of the boy. It was necessary to shout to attract his attention when not looking, and the fact that he observed the movements of the speaker's lips and leaned forward to His teacher, however, states hear that deafness was
pronounoed. proved that he appears at times to hear much better than at others. Whether this was true could not be ascertained. An endeavor to test his hearing did not with a watch was an absolute failure, as he said he heard it, or hear it, as he fancied the form of the question with con The expression of the face was an habitual silly smile, almost with stant twitching of the facial muscles. This was associated His and tempera continuous nervous movements of the hands obstinate. During ment was quiet and good natured, but exceedingly under careful has improved condition the past two years his nervous
demanded.^ fingers.^
THE PSYCHOLOGICAL CLINIC.
86
school discipline. Ilis motor control clumsy, but good enough to allow him
pencil stiffly.
His
half his words
were
a
his
use
lips
grip not
good. intelligible; was
and the tones showed
was
fair, being
very
slow and
to button his clothes and handle
speech was so defective that apparently made no effort to plainly the effects of the nasal
His he
catarrh. An endeavor to test the mental faculties showed
color, seconds,
to concentrate
the attention for
no
perception than
of
few
inability apparent reasoning power, and no ability at number work. His memory, however, was good, and he recognized letters and easy words readily. He has been two years in the first grade, with a probability of continuing there indefinitely. The diagnosis in the case is not possible without preliminary expert examination of the eyes, nose and ears. The deprivation in this case, by reason of the deficient sense organs, makes the diagnosis of imbecility There is no doubt, however, from the family history, a little uncertain. an
the
more
a
no
multiple association of physical defects, and the nervous condition, some degree of true feeble-mindedness exists. 15. J. A., aged 13 years, 8 months; German parentage. Father
that
dead, mother and sisters illiterate. Has attended German-American and parochial schools until seven months ago, when he entered this school. He was placed in the third grade because his size and age made it inadvisable to allow him to associate with the youngest children. He absolutely no progress, and is actually unfit for first grade
has made
Inspection showed a large boy with coarse heavy features, dull expression, slouchy carriage and shambling gait. His forehead is low, owing to a coarse growth of hair, and despite his age he already has a growth of hair on the upper lip. Vision, by the illiterate test card, is apparently normal; hearing normal. Response both in actions and words is very slow. His speech is indistinct, with an inability to pronounce "th." Vocabiilary small, due probably in part to German family. Examination showed his grip to be fair, but not good. He buttoned his clothes very readily. The perception is fair, and attention apparently good. His imitation is also good, as he can readily copy work.
facial
from the blackboard.
Memory
very poor.
Number work
so
poor that
multiply 2 times G. Other school work, such as reading, entirely beyond him. Diagnosis: Feeble mind. This is a typical institution case. he could not
is
