The Clinical Examination and Diagnostic Teaching of Cases at the Psychological Clinic of the University of Pennsylvania.

The

Psychological

Copyright, 1930, by Lightner Witmer, Editor

Vol. XIX, No. 6

Clinic November,

1930

the clinical examination and diagnostic teaching of cases at the psychological CLINIC OF THE UNIVERSITY OF PENNSYLVANIA By Arthur

Phillips, Ph.D. Executive Officer of the Psychological Clinic, University of Pennsylvania PART I. CLASSIFICATION OF CLINIC CASES IN THE SUMMER SESSION OF 1930 the Summer School, 1930, Dr. Lightner Witmer conmental clinic on Monday, Tuesday and Wednesday mornings from ten to twelve. In the examination of cases he was assisted by Dr. Miles Murphy, Dr. C. L. Altmaier and Dr. Arthur Phillips. Seventy-two cases were examined. Of these, five were

During

ducted

a

demonstration

cases previously examined in the Psychological three of whom were children who are receiving orthogenic treatment. The other two, superior children, were used for demonstration in Psychology 1 C. In the case of two, diagnosis was deferred pending further examination. The remaining sixty-five may be grouped as follows: (1) Superior, 19, 29.2%, (2) Modal group, (middle 60%), 19, 29.2%, (3) Inferior, 27, 41.6%. Of the superior group, five were diagnosed as being in the group of 1% superior to 99%; 10 were in the group of 10% superior to 90% and 4 were in a group of 10% superior to 80%, according to the Witmer standards. The inferior group may be further subdivided as follows: Normal

Clinic,

mentality, intellectually deficient, 16; Borderline, 5; Feebleminded, 6. Of the feebleminded three

were

Idio-Imbeciles. The I.Q. distribution ranged

Low Grade Imbeciles and three

from 32 to 170. In the case of For the 62 reno I.Q. was obtainable. maining cases the average I.Q. was 96.97; standard deviation, 27.70 probable error of the average, .84.

three of the feebleminded

170

THE PSYCHOLOGICAL CLINIC

Of the seventy-two cases fifty-five were diagnosed as being mentally normal. Seventeen were diagnosed as borderline, ten as feebleminded. The percentage of feebleminded in this group of cases was, therefore, 15.3%. The percentage of feebleminded in the population at large is variously estimated as being from .4 to 6.1%. This wide range is due to difference of opinion as to what constitutes feeblemindedness. The medical point of view which is dominantly sociological in its implications is responsible for the low estimates and the psychological point of view, based on objective intelligence tests, is responsible for the larger estimates. As the standard for the determination of feeblemindedness in this Clinic is based on social considerations, due to the practical clinical problems that arise in the placement of children in institutions where the problem of social competency is to the fore, it will be seen at once that the number of clinical cases is extremely weighted at the lower end of the curve of distribution of mental traits. In this Clinic on the score of social competency cases are divided into two main classes: (a) Normal mentality, (b) Feebleminded. The feebleminded or mentally defective are "those who have so many and such severe mental defects that they are unable to overcome these defects as a result of expert training, and must therefore reach adult age arrested in mental and moral development, industrially incapable of earning even a modest livelihood and socially a menace oftentimes to themselves and their families, and always to society, either by virtue of their own behavior or their retained capacity to reproduce their kind."1 In the article cited above, written in 1913, Dr. Witmer urged the substitution of the term socially unfit or socially defective on the ground that the implication of the definition of mentally defective children is not that they are mentally defective but that they are so mentally defective as to be socially unfit. Some children who would be diagnosed as feebleminded on the quantitative score, whether of mental age or Intelligence Quotient or on a percentile basis, would therefore fall within the class of the mentally normal or socially competent. This distinction has been recognized by Pintner and Patterson who recommended a mathematical percentage definition of feeblemindedness. Pintner says, "Many who could be diagnosed by this method as feebleminded or psychopathic would be socially compe1 Witmer, Lightner "Children with Mental Defects Distinguished from Mentally Defective Children," The Psychological Clinic vol. 7, pp. 173-181, 1913.

CLINICAL EXAMINATION AND DIAGNOSIS

171

simple environment."2 Terman makes practically the distinction between intelligence as indicated by the Intelli-

tent in same

a

and endowment "in other mental traits" so that an I.Q. as low as 70 may manage as adults to get in a simple environment while children with an well along fairly as 80 as I.Q. may have to be classed as feebleminded.3 high Normal mentality or social competency is defined by ability to meet minimum requirements. If a child has enough ability to

gence

Quotient

individuals with

discriminate between right and wrong as understood by society in general and conforms to this standard sufficiently to keep him from becoming either a nuisance or a menace to other people, if in addition there is a reasonable probability that he will be able to support himself independently of external aid, he would fall in the group which is described as normal, though he may be deficient intellectu-

ally. The normal group of these cases examined in the summer session of the Psychological Clinic may be subdivided, therefore, into three general classes: (1) Superior, (2) Modal, (3) Inferior on the intellectual scale. It is the purpose of this article to present in each of these groups as well as in the group of borderline and feebleminded a number of typical cases. The object is to show the variety of cases that come to the Psychological Clinic for orthogenic guidance and treatment and consequently become cases for study for those enrolled in the courses in clinical psychology and diagnostic education conducted by Dr. Witmer and his assistants. The Superior Group The Intelligence Quotients of the nineteen children in this group range from 117 to 170. Competency in general is an aggregate of many component abilities. In the child of superior competency we expect to find alertness, speed in performance, ability to acquire and use knowledge with efficiency in the solution of original problems, whether in social life or in the school curriculum. The chief reason why the children under consideration were brought to the Psychological Clinic as given by the parents, though variously phrased, amounts to interest in the examination for the purpose of determining the mental status of their children and to 2

Pintner,

R.

Intelligence Testing, New York Henry Holt and Co.

1925. 3 Terman, L. The Measurement of Intelligence, New York: Houghton Mifflin Co. 1916, pp. 87-88.

172


obtain expert educational advice. Of these nineteen children of superior competency, fourteen fall in this category. In the other five cases there was some specific cause. These causes are: inferior work and poor conduct in school despite an Intelligence Quotient of 143; anti-social behavior, maladjustment in school, home and on the playground, and lying and stealing. Case No. 8767, girl, C.A. 7-3; M.A. 12-4; I.Q. 170; attention span, auditory 6, visual 6, reverse 4. The father is a newspaper editor. She displayed superior intelligence and efficiency in the psychomotor tests. Her performance on the Dearborn formboard was in the upper fertile of ten year old children. Throughout the examination the child was alert, (cooperative, entirely at her ease. She displayed self-confidence. Her vocabulary score was 50?the fourteen year level. Her definitions were superior. She attends a private school and does third grade work in all subjects except arithmetic for which she shows a distaste. She or does manuscript writing beautifully, spells phonically. She read from Terman's "Measurement of Intelligence" working out for herself phonically such words as "individually," "environment," and other polysyllables. Her favorite reading books are "Alice in Wonderland," and "The Five Little Peppers." She told of taking a course in Aesop's fables which toward the end became monotonous to her. She is studying French and music. She prefers to play with older children because children her own age tend to boss her. She is diagnosed as having a general competency of 1% superior to 99%, specific language talent.

prints

Case No. 8768, boy, C.A. 3-9; M.A. 5-4; I.Q. 142; brother of former case. Attention span, auditory 5. He showed some of the distractibility of the small child. He refused to undergo examination and for a time did nothing but scream. Temper tantrums are a part of the picture of this child. He is distinctly spoiled. The usual method employed to get him out of a tantrum is bribery. He is self-willed and hard to manage. His behavior is that of a child who is allowed to have his own way. Had he been cooperative his I.Q. would probably have been higher. His general competency is estimated as being that of 1% superior to 99%. Case No. 8813, boy, C.A. 6-0; M.A. 8-6; I.Q. 142; Attention auditory 6, visual 6, reverse 3. He is the only child. The father and mother are college graduates, the father a Doctor of Philosophy, the mother a Master of Science. Both have taken their degrees in chemistry. According to the history he learned the alphaspan,


173

bet

at 20 months, knew all the printed letters at 30 months and could read time on the clock at 42 months. He now reads from the newspapers, knows his multiplication tables, types his own correspondence. In the Clinic his conversation was beyond his years in many respects. He proved resourceful in amusing himself during the interval of waiting. He is socially well adjusted. In the psychomotor tests he showed good motor control, discrimination and distribution of attention. He read the fourth reader with ease and Rood expression; showed 3A proficiency in spelling and 2A proficiency in arithmetic, though never having gone to school.

Case No. 8818, girl, C.A. 3-9; M.A. 5-2;' I.Q. 140; attention sPan, auditory 4. Father and mother are graduates of the University of Pennsylvania. In height and weight she is the median for 5 years, active, vivacious, determined. She is most happy in the presence of adults. She was cooperative throughout the clinical examination, talked continuously. If anyone entered the examining room the child informed the newcomer that she was working and did not care to be disturbed. She was well poised and displayed

Rood powers of observation and attention. She described a fly as an insect and herself as a human being The mother is disturbed because of her antisocial tendency; she will not play with children her own age. She will not defend herself and is easily imposed upon. The child will be enrolled in the pre-school group of superior children conducted by the Department of Diagnostic Education for further study and socialization. Case No. 8788, boy, C.A. 2-9; M.A. 3-9; I.Q. 136; attention span, auditory 3. He is the only child of Russian Jewish parents. 1'he father is a salesman for a fruit store. The boy does not like to play with other children and is not interested in toys but enjoys

Working with tools and mechanical objects. He has a bad habit of screaming when strangers come into the house; he seems to get real

delight

in this sort of behavior. He is a great pal with his father who fosters the boy's mechanical proclivities at times. The boy helps the mother with the house work in simple duties like drjring the dishes and holding the dust bin for her when she sweeps. In the Clinic he showed some stubbornness and obstinacy of an infantile character at the beginning of the examination. He was disarmed by placing in his hands the parts of a lock and a screwdriver. Im-

mediately he set to work to put the lock together. In the examination the responses which involved some sort of action were executed more promptly than those calling for language responses. He is

174


frequently uses both hands. In the psychomotor good discrimination, excellent comprehension and persistence. He performed the Witmer formboard with a score that put him in the superior one per cent of boys his age. He matched lefthanded but

tests he showed

colors. He became restless and bored when he lost interest. The second performance on the formboard was inferior to the first. For the present he lacks efficiency. Motivation is good. His disposition is equable and in the main his behavior well-conformed. He was diagnosed as being in a group of 5% superior to 95%. Case No. 8776, girl, C.A. 9-7; M.A. 14-6; I.Q. 120; attention auditory 5, visual 7, reverse 4. She is the youngest of three children, the second child having died before she was born, and the oldest, a boy now 23 years old, works with his father, a prosperous merchant. The family are Friends and live in a community where the Friends have a very close social and school life. The child attended the Friends school. Her height is above the median for a twelve year old girl. She is well built, attractive, alert. She was brought to the Clinic because of lying and stealing.

span,

Her mother is of an emotional type, cries easily in discussing the child about whose welfare she entertains great doubts. From time to time the girl has been guilty of petty theft from her mother's pocketbook and occasionally she stole articles from children in school. Her lying is usually connected with the thefts. She has been punished by her father but she has not responded to the punishment. She is highly imaginative. As her mother puts its, she knows how to make a story sound good. Another item of distress to the mother is that she has been unable to make the child see the distinction between mine and thine in the home. From early childhood she has been in the habit of ransacking drawers and trunks, dressing up in her mother's old clothes, pretending that she is grownup. She appears to live in a world all of her own. Recently she purloined a compact which she found in her brother's drawer, the property of one of the young man's lady friends. The child is very frank in saying that she knew that the compact was neither hers nor her brother's and that she took it because she wanted it. She came home from school one day with a nice pocketbook which proved to be the property of another child. When she was taken in the fault, without hesitation or embarrassment she took it back to the child.

Upon investigation it proved that this child, born into a family of adults at the time when the hearts of the parents were tender over the loss of their second child, was allowed to grow up much as

CLINICAL EXAMINATION AND DIAGNOSIS she

175

without much restraint. Her

investigating habits which younger have now become vexatious especially to the older brother who desires to have his things let alone. Information obtained from a competent source in the community seems to indicate that the child is living an isolated life in a family of adults with no close friends of her own age. The family spends much time in the summer in a camp where she associates with girls who are much older than she. When our Social Worker made a visit to the family, the information given above was confirmed. She is regarded as a baby and treated so by the three adult members of the family. Her home is dominated by the spirit of thrift and extreme caution in spending money for what pleased,

were not interfered with when she

was

they regard

as unessential to the child. The most recent theft is that of a dollar from her mother's Pocketbook on the 4th of July which she spent for candy, etc. She stoutly denied this theft but admitted it to the clinical examiner. More recently she was accused of the theft of fifteen dollars from

her aunt in whose charge she was when her parents were away. She maintained her innocence, which was later proved. This incident is characteristic of the treatment which the child has received

also in the school which she attended. When there is a theft of any article, suspicion naturally falls on her. The teachers with whom the child has been in the school are all women in middle life with the strong bias of their religious persuasion toward high ethical conduct. The mother is deeply affected by the disgrace that has come upon the family in the community of Friends, the child being looked upon as of marked deviation from the orderly life that solid Quaker

people prize. The

is

of maladjustment in the home?a orientation much beyond her years and who displays maturity in her conversation and in her attitude to life in general. The situation has been unduly exaggerated by the strict moral principles of a sect that is noted for its discount of dogma and favor of conduct of its own peculiar pattern. Undoubtedly the child finds satisfaction in the stealing. This is her way ?f expressing a feeling of independence and of her ability to do just as she pleases. Too much effort has also been exerted in trying to bring out the emotional reaction of conventional repentance in the child but she is not a sin-sick soul and the probability is that there is no likelihood of her becoming so. She has become immune to ethical instruction and de-sensitized to threats of dire consequences to ensue. case

one

child of less than

primarily

ten with

an


176

The case is still under treatment and the prognosis is uncertain. She has been removed from the school where her reputation is bad and where she has received social ostracism and has been placed in another school under the direct supervision of a tactful, intelligent woman who is deeply interested in the development of the child and who has had experience in connection with this Clinic in

handling difficult moral

cases.

The Modal Group In the modal group

were

19 of the 62 cases, their

Intelligence

Quotients ranging from 91 to 113. All of them fall median mode according to the Witmer standards.

within the 60% Terman places modal at 91 and the of his lower limit the group I.Q. upper limit at 110. All of our cases, therefore, fall within Terman's modal group with the exception of a boy of seven years with an I.Q. of 113. According to the Witmer standards, based on examination of five hundred school children in the first grade of Philadelphia public schools, the upper limit of the modal group is 117.5. The lower limit is 90.4. The modal child is the child of average expectation. A priori, would judge that the cases who are examined in the Psychological Clinic would come largely from the upper and lower quintile and that there should be few cases from the median mode. However, in this summer school session nearly 30% of our cases came from this group.

one

The problems presented by the children in this group are largely problems that fall under the category of motivation. Among the reasons listed for bringing these children to the Clinic are: nervousness, emotional instability, maladjustment in home or school, fear obsessions, lying and stealing, temper tantrums, non-conformed behavior. Two were cases of retardation in school duo primarily to physical causes. One was a reading problem in which motivation

played

an

important part. Another

was

brought because of failure study is too limited

in arithmetic. While the number of cases in this

for general deduction, it would appear, however, that the modal child is not as a rule found among the cases of the Psychological Clinic unless there is disordered or unconformed behavior of some sort involved. Case No. 8806, boy, C.A. 7-1; M.A. 8; I.Q. 113; attention span, auditory 4, visual 5, reverse 3. He was brought to the Clinic because of emotional instability. This boy is a scion of an old Quaker


177

His father and mother are college graduates, the father a sales engineer and the mother described as very musical. Two aunts of the mother have become insane; one became so depressed that she committed suicide and the other is at present in a sana-

family.

torium. school at the age of six. He made his grade the second grade. His conduct in school was, however, very poor. He was constantly pinching, pushing or hurting other children, and seemed to enjoy doing so. Neighbors reported him to be "terrible" and not amenable to discipline. He Was troublesome while in the Clinic and had to be watched or he would have destroyed anything he laid his hands on. He attempted to tear some mail that was lying on the desk. The recorder described him as having a mean and destructive streak. In addition to this, at home he has been guilty of taking money from members of the family. His father seems to be the only one who has any control over him. To the wishes, requests and commands of others he pays practically no attention whatever. As the father is away The

and

was

boy entered promoted to

great part of the time he is subject to almost no discipline. He picture of a child whose non-conformed behavior may be traced to neglect of proper discipline. He is a case of a child sacrificed on the altar of business and "society."

a

presents the

Case No. 8832, boy, C.A. 16-10; M.A. 17-6; I.Q. 109; attention span, auditory 7, visual 8, reverse 6. Pie was brought because ?f desire for advice as to his future schooling. He is the third son. The older boys gave no trouble. Upon investigation, behind the reason given was discovered a maladjustment at home as well as at school. He shows no affection for his parents or his brothers. He shows discontent with his home and his lot, resists parental authority, is insubordinate and insolent to his mother. He has communistic ideas obtained from reading a popular current magazine. One of

his ideas

is that the present social structure based upon the

is

family

children should be taken from their parents and state in groups. The world is not right for this He has some very definite ideas as to how it should

incorrect; that educated by the young

man.

he fixed up. His education has been conducted in private schools for some He is content years. He is working at sub-maximal efficiency. hard. His chief no for He sees reason to merely trying "get by." interest is in science, especially chemistry and biology. He has not attempted to study either seriously, his interest taking the

178

THE PSYCHOLOGICAL CLINIC of

lot after school." He personal appearance; appeared at the Clinic with unshaved, dirty nails and ears; even his clothes were dirty. his family he says that whenever he advances about Questioned of his family become silent and seem to laugh his ideas home at any to themselves. He can offer no suggestions on any topic without fear of ridicule. "They think of me as a baby but I think a lot about life." He is not close to his older brothers; he appears to have little interest in them. Asked about his father he remarked: "He knows his stuff; he doesn't know me; he is not a pal to me; all he does is to scold me instead of giving me some encouragement." The mother volunteered the information that after he had expressed his communistic ideas on the family that his father punished him by refusing to take him along when the family went to the movies saying, "He doesn't like us; why should he go along with us?" His mother and the housekeeper have pampered him. The housekeeper has been with the family since the boy was a baby. He says his mother thinks of him still in terms of a ten year old. He has an aversion to all women.

shape

"hanging

around the

laboratory

a

is careless about his

Here is a boy who wants to be a man among men. He idolizes his father and wants to be his companion, to talk things over with him man to man, but all he gets for his all too blundering and confused ideas of things is ridicule and scorn. The kindness of his mother and old nurse, well intentioned as it is, has palled upon him. He has come to feel like an Ishmaelite, every man's hand is against him. Unless this condition can be remedied, it is safe to predict that his hand will be against every man. The school attitude is but an outgrowth of the home situation. Nothing appears to him to be worth while. Instead of discouraging this boy's independence of thought he should be encouraged. Case No. 8764, girl, C.A. 12-4; M.A. 12-1; I.Q. 98; attention span, auditory 5, visual 7, reverse 4. Brought to the Clinic because of reading difficulty. She is the youngest of seven children, daughter of a clergyman. She is in the 8th grade in school and proved to have

only 4th grade proficiency in reading. She was referred to the Clinic Teaching Department; received two months of individual instruction, her teacher being a graduate student enrolled in Dr. Witmer's course in Orthogenics. Her reading difficulty was due partly to bad eyesight, partly to short perception span. She showed much improvement after two weeks' instruction. Investigation of the case brought out the fact that her motivation for reading was very poor. The


179

correction of her eyesight and the prescription of a method of reading, the analytico-synthetic method, would still leave unchanged this problem of motivation. She was very self-conscious and sensitive toward her defect. Her deficiency was in striking contrast to the fact that the other members of her family were all good and fast readers. Too much emphasis in the home had been placed upon her defect. She had probably been subjected to some scorn and ridicule for being so slow in reading. Further, her motivation had been killed off by her constant sense of failure. She had lost interest in reading. The prognosis in this case is exceedingly favorable, inasmuch as the family is intelligent and cooperative and did not resent criticism of the attitude toward the child within the home and inasmuch as the Clinic Teaching Department had discovered the method by means of which she was already making rapid improvement in the pro-

duction of reading. Normal Mentality

and

Intellectually Deficient

In the next three groups there are 27 cases or 41.6% of the cases of the entire group. All these cases fall in the lowest 20%. The first normal mentally, intellectually deficient, reach as far the 20th centile and as low as the 5th centile. The I.Q.'s of the cases in this group range from 70.5 to 90. Of the sixteen cases, ten Were referred to the Clinic because of school retardation, two because of interest in mental status, one for nonconformed sexual behavior, one for lying. All were pedagogically retarded. The characteristic thing about this group is that those who fall within it are not able to make ordinary school progress, that is to complete eight grades in eight years. They constitute the dull or backward group. Socially they display sufficient competency to be classed as mentally normal. Rarely would they be classed as feebleminded and recommended for institutional or custodial care. As is commonly expressed by the parents, outside of school they are all right. As in every group considered so far, the cases fall into two classes: good and bad or conformed and nonconformed in behavior. In a simple environment many of them would have no difficulty in managing their affairs and with proper training can be prepared to contribute productively in

sub-group,

up

as

the social and economic world. Some of them show in their intellectual deficiency a good and occasionally mechanical ability. Case No. 8831,

span, auditory

boy,

5, visual 6,

contrast to a

superior

C.A. 10-0; M.A. 8-9; I.Q. 88; attention 3. He was referred by a physician

reverse

180


because of school retardation and nervousness. He is one of six children of whom none is retarded but the oldest girl who is 1G years of age and in the 9th grade and our subject who is ten years of age and in grade 3B. He shows a nervous, almost hysterical, condition. He does not sleep well at night, tosses around in bed, bangs his head the pillow until his forehead is bruised. He loses his temper very holds his mouth wide open. Tonsils and adenoids have been removed. He masturbates. His weight is about median for a twelve year old, his height median for an eleven year old. on

easily. Usually

He is fairly well adjusted at home, gets along with his brothers and sisters with only an occasional quarrel. Outside the school he has many friends with whom he gets along well. He helps his father in the summer on the huckster wagon selling fruits and vegetables. For his wages he receives a dollar a week which he is saving to buy a bicycle. He is hyperactive, never seems to tire. He is always looking for something to do. His chief interest is in mechanical toys. His retardation was first noted when he entered school. Up until this time his mother described him as bright. Recently he has the sniflles; nose

running constantly.

psychomotor tests this boy showed good comprehension of the problem involved in the Witmer cylinders, good form discrimination. He corrected his errors as he made them. The same remarks hold for the Dearborn formboard. He showed intelligence, discernment and some degree of efficiency in his first trials. His In the

were not superior quantitatively as his discharge of slow, but qualitatively they were excellent. On the second trial he showed superior trainability?ability to profit by experience. These performances are classed as quantitatively in the upper quintile. The contrast here, then, is between the intellectual performances that are in the lowest quintile and the mechanical performances that are in the upper quintile. On the intellectual scale he may be ranked as a High Grade Imbecile, Barr classification.

performances energy

was

under most favorable circumstances he will not go beyond the sixth grade in school. It has taken him five years to acquire 3A proficiency in reading and spelling and 2B proficiency in arithmetic. The recommendations in this case were that the boy be placed in a special class in school and that he be given manual and mechanical training in order to fit him for a useful place in life. A complete

Probably

medical and neurological examination was also advised. Case No. 8795, boy, C.A. 8-6, M.A. 7-0; I.Q. 82; attention span, auditory 5, visual 8, reverse 3, syllables 15. The youngest of nine


children,

ages

ranging from

30 to 8-6.

His father is

an

181

insurance

undersized, being about the median for seven. His weight is good enough for his height. Headgirth is 19.5 inches, which is inferior to 75% of five year olds. He is having trouble with his teeth; they are coming in irregularly. On the left jawbone there is a hard lump either due to infection or a new tooth. His tonsils are large and inflamed. His circulation is poor. His hands show cyanosis, cold and clammy. A well behaved boy he cooperated in the tests agent.

He is

he was able but showed no great interest. The school has no complaint of his conduct. He plays with children his own age; shows ability to take his own part in childhood's disputes; goes on errands, brings back three or four things without a note. He was slightly infantile in the Clinic where he was confronted with a new situation. He cried and showed fear because he thought his mother had left him. His general orientation is good. In reading and spelling his proficiency is not 1A though he has been to school two years. He knows his letters but has no idea what their sounds are. His writing is good third grade. He is almost as as

far

as

good with his left hand

as with his right. His arithmetic proficiency IB. He did some examples in 2A though he had never been in this grade. Performances on the formboards were inferior on both first and second trials. With the Witmer formboard and cylinders quantitatively he is in the lowest decile. This was largely due to his slow discharge of energy. He is lacking in intelligence and in comprehension of the problem. With a minimum of instruction his performance rapidly improved. In the cylinders he changed from a trial and error to an analytical method and displayed good analytic discrimination. The Dearborn he comprehended immediately. The approach was analytical. Second trial was quantitatively and qualitatively a great improvement over the first. Recommendations were: thorough medical examination with special reference to tonsils and teeth and a period of clinic teaching to complete the diagnosis. Case No. 8809, boy, C. A. 14-11; M.A. 12-10; I.Q. 75; attention span, auditory 5, visual 8, reverse 4. The mother has been in the Philadelphia General Hospital for five years with a nervous disease. His home is in charge of a housekeeper who also serves the father as a mistress. This condition is known to the boy. The general health of the boy is only fair. He is tall for his age being in the upper 25% of sixteen year olds and his weight is the median for fifteen. He lacks initiative, is slow in his responses. Performances on the Witmer cylinders and Dearborn formboard were fair. His trainability, however, was better than average.

was


182

He started school at the age of six and repeated the 5th and 7th He is ready to enter the eighth grade. His work in school is poor and his conduct bad. He does not like school. His school proficiency in reading and spelling is 5B, arithmetic 6A. The boy's antipathy to school is largely due to the fact that he is accelerated, attempting to do work beyond acquired proficiencies. He is one of that too numerous class who are promoted on size. Naturally, he has no interest in work which he cannot do. This with the bad home situation has apparently precipitated nonconformed behavior. He desires to leave school and work.

grades.

His uncle

runs a

truck to

neighboring

trips with his uncle. In fact, he likes

cities.

The

boy enjoys

to travel and has done

so on

of these excursions he his own account. to Prevent was picked up by the Society Cruelty to Children. This of his occasion immediate was the being sent to the Psychological Clinic for examination. Diagnosis was: normal mentality, intellectually dull. Recommendations were: that he have a physical examination, leave school and be put to work. While in New York

on one

Borderline Mentality The second sub-group of the lowest quintile is the borderline. The I.Q.'s of the cases diagnosed as belonging to this group run from 57 to 80. They all fall in the lowest decile, according to the Witmer The characteristic of this group is intellectual deficiency norms. plus a mental deficiency that makes it doubtful whether they will ever be able to reach social competency, that is be able to look out for themselves without supervision. In a simple environment they might be able under favorable circumstances to succeed at simple

occupations. Intellectually they may be classed as lying between the Middle Grade and High Grade Imbecile. Morally they are often a risk. They constitute membership in that social group that is often exploited for criminal purposes by the more intelligent. The girls are particularly likely, if they are at all attractive, to become

sexually a-moral. In complex situations and environment they are likely to degenerate rapidly and therefore need a most favorable

to] keep them from deterioration. Excitement, illness over-stimulation would make their defects highly noticeable. In fact, in these cases either the emotional, moral or physical condition of the individual seems to render normal social life doubtful.

environment or

Case No. 5148, boy, C.A. 14-2; M.A. 11-7; I.Q. 80; attention span, auditory 5, visual 6, reverse 4. Brought to the Clinic by his


183

mother because of desire for educational advice. This boy was examined in the Psychological Clinic in 1923. His I.Q. at that time was 107, attention span, auditory 4, visual 4. An I.Q. taken by the Department of Special Education, Philadelphia, about the same time was 100. He has lost from 20 to 27 points in I.Q. in the last seven years. He is an adopted child, parentage unknown. His school history shows that he repeated the third and fourth grades. At the time of the examination he was in the 7A. His school proficiency, however, is 4A in spelling and 6A in arithmetic, which accounts for his failure to be promoted from the 7A grade. His work at school was poor, his conduct fair, the only complaint being lack of concen-

tration. There is a history of the usual children's diseases and an automobile accident when he was five years of age. The boy is blind in one eye due to a congenital cataract. Socially he does not cooperate well in group games. He failed to adjust himself in a camp for boys. He enjoys doing mechanical things but does not succeed at them.

Examination

in the

psychomotor

tests ranks him in the Witmer

cylinders and Dearborn formboard as belonging in the lowest decile. His second performance on the cylinders was inferior to the first; the second on the Dearborn was superior to the median performance. His analytic discrimination in these tests was poor. He has reached his educational limit. His ambition is to go to

by way of the Schoolship Annapolis but this is obviously beyond his ability. The picture then is one of borderline mental deficiency as proved by his inability to adjust himself in social groups at his own level and an intellectual deficiency as demonstrated by his I.Q. and school proficiency. It was recommended that he return to the Clinic for vocational guidance. Case No. 8789, girl, C.A. 9-7; M.A. 5?G; I.Q. 57; attention span, auditory 4, visual 4, reverse 2. She showed good comprehension and fair discrimination in her performance on the Witmer formboard. Her performance on the cylinders was that of the sea

median six year old child. She is the oldest of two children. Father is an automobile salesman. Birth of the child was preceded by thirty-six hours of difficult and painful labor. The child has a scar over her right eye caused by the pressure of the instruments. There was no history of retardation in walking or talking or habits of cleanness. At three and a half she had an injury to the left eye which threatened the sight of that eye. Her vision, however, has now been pronounced normal. Her general health is good. Her father says


184

she was bright up until the time of the accident. At four and a half she began stammering. Although her retardation may be due partly to the injury at birth, and the accident to her eye, her entire appearShe has some ance is suggestive of lack of development in utero. in her conformed Mongoloid features. She is behavior, gets along well with other children but displays some emotional instability. Her orientation is not that of a ten year old child. In school she repeated the first grade and is about to repeat the third. In three years of schooling she has acquired a IB proficiency in reading and spelling, and second grade competency in these subjects, that is to say, she has done one year's work in three. The prognosis is that she will not advance beyond the third grade. Her pleasing personality and desire to cooperate, the interest of the family and their economic background are factors that favor a social adjustment. However, it is questionable whether she will attain to a measure of self-support. Feebleminded In this group there were six cases. In two cases no I.Q. was obtainable. The other I.Q.'s ranged from 32 to 66. Three were diagnosed as Low Grade Imbeciles and three as Idio-Imbeciles, on the Barr classification. The types represented were microcephaly, one case;

Mongolian, two; post-encephalitis, two; physical degenerate,

one.

Case No. 8817, girl, C.A. 8-6; M.A. 2-9; I.Q. 32, attention She performed the simpler Seguin formboards but failed the Witmer. She could not match colors. Her height as median for 8 year olds, weight median for 9 year olds. Headgirth, 18 inches. The youngest of ten children in an Italian family. Parents come from the region of the Apennines, good sturdy stock. Nine children are well and normal. She was accompanied by a married sister who is an intelligent, high type woman. The child was born when the mother was forty-seven years of age. Pregnancy was not diagnosed until span, 2.

The child weighed three pounds at birth. She is a typical Mongolian child?round bullet head, slanting eyes, indetermiate mouth from which her cross fissured tongue protrudes. The body below the neck was quite normal except for some excess growth of hair, sloping shoulders, and square stubby hands and fingers. She

late.

makes

typical Mongolian gestures

such

as

putting her finger

to her

and eye, pointing and calling out objects and people. She bathes herself every day, is clean, feeds herself, goes to store for one thing at a time, helps a little about the house. She is non-edu-

nose

CLINICAL EXAMINATION AND DIAGNOSIS cable and non-trainable except in

a

few simple directions.

185 She

was

diagnosed as an Idio-Imbecile. Case No. 8766, boy, C.A. 13-1; no I.Q. or attention span Could not match colors; had no form discrimination. The third of six children of Polish ancestors. The father is a coal miner in northeastern Pennsylvania. At 15 months he had double pneumonia which was later diagnosed as encephalitis. He entered the first grade at the age of nine and has made no progress whatsoever. The boy is slightly negativistic. Diagnosis: Idio-Imbecile

obtainable.

Recommendation:

institutional placement. PART II SIX CASES OF DYSLEXIA

The classification of clinical varieties of

reading problems

is

difficult task. A study of twenty-five reading problems referred

a

to

the Department of Diagnostic Education of the Psychological Clinic of the University of Pennsylvania by clinical examiners, under the

direction of Dr. Lightner Witmer, for the purpose of diagnosing their reading difficulty, revealed the fact that rarely in an individual case can any single factor be assigned as the sole cause for the deficiency. Efficiency in learning to read as efficiency in learning in general is always a matter of the establishment of certain habits. In this process there are a multiplicity of factors that serve as determinants in the production of the goods we call reading. These factors or determinants may be catalogued readily. Such a classification, however, breaks down when the effort is made to pigeonhole a particular case which may be filed under more than one, often under several of our chosen categories. In any instance, it may be possible to select

predominating defect as basic, but generally the complicated by the operating presence of other defects. Each case presents, not a clear cut picture of the working of a single factor, but a complex or syndrome of factors working together in the some

situation is

production of

a

reading difficulty.

An exception to such a statement, even with its limiting qualifications, may be taken at once in the case of congenital alexia. Where the visual memory for words and letters is lacking or strikingly deficient, it is useless to look for further causes for non-reading.

Hinshelwood restricts the term of localized defect only where

congenital we

have

word blindness "to

one

definite cerebral

cases area

186


affected in

otherwise undamaged and normal brain."1 Cases of in the visual word center of the brain or of variation physiological some slight defective development of this center, causing varying defects in the ease and rapidity of learning to read, are not regarded as pathological. For such cases he reserves the name dyslexia. Of the twenty-five cases under review, there is only one, case 6?Delia, that approaches in purity and gravity of type Hinshelwood's description of word blindness. In this case there was an undoubted difficulty in storing up and in retaining the visual memory of words. This was the only evidence of defect in any of the categories or factors to be enumerated that this young lady showed. an

She was otherwise a most intelligent child, functioning at a high level of intellectual achievement for her age and grade, possessing excellent auditory and kinaesthetic imagery. The ordinary methods of instruction in reading in an excellent private school failed to produce results. The six weeks of special training, however, were sufficient for her cure. There is more than a suspicion, however, that in her case also, there was a contributing cause?inadequate and poorly adapted methods of instruction which produced bad reading habits. In this case it would be precarious to diagnose congenital word blindness. The indication points rather to some congenital biological variation in the development of the visual word center. The other twenty-four cases are very decidedly cases of dyslexia in which several factors cooperated in making it difficult to establish proper reading habits. Classification I. are

Primary

Causes.

No attempt is made to give a complete list of the causes which basic to failure to learn to read. The classification represents the

more common

types.

A. Sensory defects. Fundamental to the learning process or the formation of new habits are normal sense organs. The commonest physical cause for failure to learn to read is an ocular defect. A diseased condition of the eye, a refractive error, a failure in coordination of the muscles which control eye movement, are frequent causes of failure to read. The eye examinations conducted by the Medical Department of public school systems have undoubtedly reduced the percentage of cases that may be attributed to this cause. It is no 1 Hinshelwood, James. Lewis & Co., 1917. p. 81.

Congenital Word Blindness.

London: H. K.


187

reflection

upon the school eye examination to say that there are still many cases that appear at the Psychological Clinic that can be traced either to a failure to discover defective vision or the failure to have it corrected on the part of the parents. Indeed this is so common among clinic cases that it is a wise practice before attempting diagnostic teaching or any remedial work to have the eyes of the

subject

examined by an expert. B. The second primary cause is a deficit in imagination and memory due to central causes, i.e. non-development of the visual memory for letters and words. Here may be listed congenital and acquired word blindness, congenital and acquired dyslexia. Cases of alexia may be described as due to non-development of the visual memory center for letters and words or to the loss of visual memory through disease or trauma while congenital dyslexia may be described as due to a physiological variation in the development of the area and acquired dyslexia to a similar condition induced by disease

or

ability the

one

dividing line between alexia and dyslexia degree. The diagnosis rests primarily upon the

The

trauma.

proves to be

of

to have correct visual

ability

images of words and letters and upon images. The ease and rapidity

to retain and recall such

with which learning to read may be accomplished is a function of the accuracy and retentivity of visual images, for letters and words. Failure to discriminate small differences in the form of letters may be due to either the inaccuracy of the images or failure to recall correct images. Another defect of memory that conditions the learning Process in reading is the lack of trainability or the capacity for improvement. It is measured by the number of repetitions that are necessary in order to retain a given quantum of material. C. The third primary cause is a limited capacity for associability. It is measured by the co-discernment or attention span, the number of units which an individual is able to recognize as discrete and hold together as a unit in one single moment of attention. A limited attention span is basic to many failures to learn to read and conditions the rapidity with which the process may go forward.

Especially

in learning to spell is the limitation of attention span A child with a limited attention span, e.g. three, would have difficulty in both spelling and recognizing four or five lettered words. A deficit in associability is also shown in another direction. Frequently non-readers show difficulty in associating images of different sense modalities, e.g. the sound of a letter with the written symbol of the letter, or in synthesizing the sounds of letters to form syllables 01 the sound of syllables to form words.

noted.

188


D. The fourth primary cause is found in the field of attention. Two general attention types may be described. The first type has a restricted range and a high degree of concentration of attention. This type is commonly called the "fixating type." The second type has an extended range and a low degree of concentration of attention. This type is commonly called the " fluctuating type." It is the "fluctuating type" that is most commonly met with in reading problem cases. An excessive distribution of attention accompanied by feeble powers of concentration furnishes that distractibility which is often the despair of the clinic teacher and is a primary cause of failure to learn to read. II. Contributing Cause. A. Motivation. Motivation is an affair of desire and desire an affair of energy. Its roots reach back to a physical basis in the amount of energy that is available in the individual for the production of desirable effects in any field of operation. It involves the question of vitality or the ability to resist and recover from fatigue. It determines the speed or the rate of work and is defined by the presence or absence of mental alertness, promptness to decide and to execute. It bears also upon the ability to concentrate, determining the readiness with which the individual can summon and marshall his powers to the task and keep them at it. In a sense the matter of energy is fundamental to all efficiency in establishing new habits or in learning new material. Motivation is listed as a contributing cause, not because its importance is underestimated, but because its nature is not specific to the reading problem but pertains to all learning, all thinking, all doing. It determines not only the strength of desire but the attitude of the learner and especially his ability to carry through any given operation to successful completion.

Secondary Factors. Under secondary factors may be listed: It is well recognized that the A. Inadequate instruction. "look and say" or the word and sentence method is not adapted to children whose visual memory center for letters and words is poorly developed. Such children do not learn to read in groups where the presentation of the material is largely visual. Many of these children have excellent auditory and kinaesthetic imagery and may be taught to read by the old fashioned alphabet method combined with phonetics. B. Faulty reading habits. Non-readers pick up many habits III.


181)

that

are a detriment to further progress in reading such as guessing word from the first syllable and sometimes from the last, or the failure to differentiate small words whose general appearance is similar. Much of the tedious drill work connected with remedial reading consists in the stamping out of these old bad habits and the stamping in of good habits.

at

a

C. An

acquired

constant failure.

deavor, problems

aversion to

reading

induced

by

the

sense

of

in any line of enmust be set before the child in which there is the In order to

acquire efficiency

probability of his succeeding most of the time. A sense of failure produces discouragement and cuts the nerve of endeavor. A child cannot be expected to be interested in anything in which he has no sense of victory nor any confidence in his ability to win out. Sometimes the child receives for his failure to learn to read ridicule which effectually dam up the wells of desire.

censure

and

The way in which these various factors are combined in learning to read is illustrated in the following cases. It is to be noted that

these six cases occur at almost any level of achievement. The I.Q.'s of the children considered are in the order of their presentation 90,

99, 101, 111, 124,

138. Reading problems are thus found throughout the entire range of distribution of I.Q.'s. Two of these cases have as their primary cause defective vision, two have limited associability as indicated by a deficit in attention span, and two a non-development of the cerebral visual memorial area for letters and words.

Richard

Richard, age eight years, five months, was brought to the Psychological Clinic by an elementary supervisor of schools in a district suburban to Philadelphia because of inability to make progress in school. He had entered the first grade at the age of six years and three months, repeated the first grade, and was in the second grade at the time of the examination. His work in academic subjects was described as poor and his handwork good. His conduct was described as variable, at times poor, at other times very good. Dr. Witmer diagnosed him as of normal mentality with the general competency of a group of 20 percent superior to 40 percent and inferior to 40 percent of boys his age. His Intelligence Quotient was 90. His auditory attention span was 5 and his reverse span 2. On performance tests he worked in a planful, intelligent manner and displayed very good concentration of attention. Dr. Witmer advised an eye examination immediately by a competent oculist and a period of diagnostic

190


in order to determine the cause of his deficiency in reading. At the time of this examination Richard did not have first grade proficiency in reading.

teaching

The eye examination revealed "No need nor indication for glasses; no indication for training of the fusion sense." The oculist reported his belief that Richard did not know all of his letters as he skipped certain letters even on the larger types whereas he read all the numbers very easily. Richard reported for clinic teaching on October 15, 1929. He under observation two hours per week for twelve weeks. At the beginning of his clinic teaching, his attention span was taken again. There was no change in the audito-vocal span but the reverse was 3, showing an increase of 1, and a tendency toward a 4. Richard had learned the trick of reversing digits. He memorized the series forward, using kinaesthetic imagery, and then after memorizing, reversed the series. Richard's chronological age is now nine years, six months. Sixty percent of eight year olds in the third grade have a forward attention span of 6 and 40 percent have a reverse attention span of 4. In co-discernment span therefore, Richard is inferior to 60 percent of boys his age. was

The type of reading errors that Richard made indicate a deficit of visual discrimination. He had difficulty in discriminating between the words very, every and ever. He read how?who, saw?was, from? for. His deficit in discrimination extended also to letters, so that when he was told to write o, he wrote a. However when words were placed before him and he was asked to note the differences, his discrimination functioned. Therefore combined with slowness in visual discrimination, there was a deficit in attention evidenced by the fact that when he was compelled to attend and to note differences visually, he was able to do so. His retention is also below average. He was not however lacking in motivation and showed considerable interest in learning to read which compensated somewhat for his deficiency in attention and retention. As he had learned inattention, to find differences in letters and words he had to be taught attention. He was taught by the alphabet method because his limited attention span made it difficult for him to construct words. Phonic analysis was also employed and Richard showed considerable ability after training to synthesize the sounds of letters and syllables to make larger units provided the units were not too many for his limited attention span. At the close of his clinic teaching period he was reading the fourth reader, very slowly indeed, but with few mistakes,


working

out difficult words such

phonic analysis with little

or no

as

191

conversation and explain by The prognosis is good

assistance.

provided this method is continued. Joseph

Joseph, age ten years, ten months, referred to the Psychological Clinic by the Principal of a suburban public school because of retardation in school work, was examined by Dr. Miles Murphy May 8, 1929 and diagnosed as of normal mentality, intellectually backward. At the time of his examination he was in the fifth grade. He had never repeated a grade but was doing very poor work in reading, writing and arithmetic. He obtained an I.Q. of 99. His attention span was, audito-vocal reverse 3. The auditory forward span was adequate but the reverse span indicated a definite deficit in ability to

forward 6, visual 8,

re-organize his perceptions. Clinic teaching began October 14, 1929. He received twentyfive hours of clinic teaching. His attention span was taken again. His forward span was unchanged. His reverse span was found to be 5, 2 more than on the initial examination, thus duplicating the performance of Richard. He, too, had hit upon the plan of learning the series forward and then reversing them one by one. The type of imagery used was audito-kinaesthetic. His school proficiency taken by the clinic teacher gave him an inferior rating to that obtained at his first examination. He received 2B proficiency in spelling and reading instead of fourth grade proficiency. His proficiency in arithmetic remained unchanged?3B. He spelled like?lick, and automobile?otanonbeal. He was also made?mad, wreck?reck, found to be incapable of reciting the multiplication tables. He did not know the answers to such simple problems as 3 times 9 and 6 times 4. He was at this time repeating the fifth grade. At the conclusion of his period of clinic teaching he had advanced to 4A proficiency in addition, multiplication and division, but not in fractions and problems. This was as a result of intensive work in mechanizing the elementary processes. In his reading, by his confusion of letters, we were led to suspect defect. Upon examination it proved he had a marked strabismus of the right eye apparently due to a weakness of the internal rectus muscle for he was unable to focus his eyes on a single point for many seconds. Only by effort can he make the convergence necesary for fixation. When he confused a letter, if his attention an eye


192

called to it, he could by effort succeed in focusing and discriminating the letter. He complained frequently that his eyes hurt him. There is not much doubt but that his retardation in both reading and arithmetic was largely due to this eye defect. On inquiry it was found that his eyes had been refracted and glasses recommended which he wore occasionally. When he wore them, his work was considerably improved. The correction of his eyes by the use of glasses however did not remove the careless reading habits which Joseph had acquired. It had been easier for him to guess at a word than to undergo the strain of focusing. Some of these bad reading habits were corrected during his period of clinic teaching. He read

was

lowly

but his work showed great improvement.

His comprehension of what he read was good. His school reports showed that during his period of clinic teaching he had advanced in reading, geography and history. The conclusion, then, with reference to Joseph is that his retardation in reading is due to defective vision which produced a poor visual discrimination for letters. While not of an intellectual type, Joseph works better with his mind than with his hands. His codiscernment span is entirely adequate for the work he was supposed to have been doing in the fifth and sixth grades, certainly above the median in this respect as the re-examination of his span showed. In general comprehension he is above the average. His trainability is good. His motivation and persistence were all that could be expected from one who had failed so consistently to learn to read. His school

of his

behaviour, that he exceedingly friendly

wasted time. and cooperative. It was scarcely any surprise that his attention wandered in the school room for he was attempting to do work for which he was not prepared and in which he could not succeed nor develop interest. It is to be regretted that this boy who was not physically strong and shows some symptoms of nervousness, did not receive earlier the kind of medical attention that his case requires. In this case the home is to blame. He is the oldest of two children of an Italian barber. The boy has not received good home training and it is surprising that he is as amenable to discipline as he proved to be. An earlier correction of his visual defect backed up by proper home influence would have made it possible for this boy to have advanced at least through the grades. Without individual instruction there is no possibility of his advancing beyond the fifth grade in which he In

our

now

complained

contact with him he

was

is and for the work of which he is

absolutely unprepared.


193

Thomas

Thomas, age eleven years, ten months, brought to the Psychological Clinic because of backwardness in reading, spelling and writing, was examined by Dr. Murphy July 10, 1929. Thomas entered first grade at six years and now is in the fifth grade of school. He repeated third grade and was repeating fifth

a

parochial

at the time

His school proficiency taken here in the Clinic was not first grade in either reading or spelling and that in arithmetic he had fourth grade proficiency. of his examination.

showed that he

His I.Q. was 101. His attention span was auditory G, visual 0, reverse 4. On the formboards he showed good analytical discriminacoordination and trainability, ranking in the upper quintile. The diagnosis was normal mentality, general competency in a group of 20 percent superior to 50 percent and inferior to 30 percent. The

tion,

recommendations were an eye examination and orthogenic treatspelling and reading. On October 15, 1929 Thomas reported for clinic teaching. He has received fourteen hours of instruction. His eyes were refracted and glasses were provided. A part of his difficulty was due to this eye defect. It could be very plainly seen that when Thomas attempted to read without his glasses, he made very foolish errors in discrimination and after only fourteen hours of instruction he made considerable advance in reading. His attention span was taken by the clinic teacher during his period of clinic teaching. He showed an audito-vocal span of 5 forward, 6 on the fifth trial. His reverse span was 3, 4 on the third trial. Thomas has a very definite deficit in associability. Pie falls below the 30th centile in co-discernment of children in the fifth grade in the public schools of Philadelphia. His deficiency in associability is borne out by the difficulty that he had even after breaking a word up into syllables, in synthesizing the parts to make a single word unit. Thomas also has dyslalia. His speech shows a slight thickness, a lack of clearness in enunciation. This deficit is not however as deleterious as his eye defect because Thomas in his ment in

failure

images of words had compensated by his audito-kinaesthetic imagery. A word that he could not recognize or even sound out, he could spell out and know. Another factor in Thomas' case is social, the unwise treatment accorded the boy at home. His father calls him stupid when he cannot read while his mother coddles him. The boy fears and obeys his father but disobeys his mother. On the whole, he seemed to be to

depending

get

on

correct visual

194

THE

PSYCHOLOGICAL CLINIC

boy who had been greatly repressed both at home and in school and who had been drawn in on himself by the criticism that had been made to his face. He was very quiet and retiring?seemed to lack confidence. It was some time before he mustered up courage to ask his clinic teacher questions. His motivation was good. He was anxious to learn to read. His persistence was on the whole fair. Probably from lack of interest or from a sense of failure, he was distractible. a

With these factors operating, it is not surprising that this boy had little proficiency in reading. His sole method in reading was spelling out the letters. This was necessarily slow. One of the results was that his reading was expressionless. He read in a dull monotone and paid no attention to punctuation. His reading was simply the "sad mechanic exercise" of spelling out word after word. He was taught by the phonetic method and received considerable drilling on the sound of letters and their synthesis into syllables. Syllabification was resorted to to make up for his deficient attention span. Under individual instruction he improved greatly and the prognosis favorable for his being able with further individual instruction to acquire enough reading ability to make him comfortable in a world where reading is a social requirement. His retardation is due to dyslalia, defective eyesight and deficient associability. Secondary factors are the bad habits acquired before his eyes were refracted and the acquired aversion to reading brought on by unwise ridicule. The department recommended that he be dismissed from the Clinic Teaching Department because the diagnosis was complete, and that the boy receive training suitable to his personal talent which is in the mechanical rather than the academic field. William age eight years, six months, was brought to the PsyClinic by his father and mother because of his inability to chological read and spell. He was examined by Dr. Miles Murphy on October

William,

5, 1929. His home background

is excellent. His father is a prosperbusiness man. His mother graduated from college before she had reached her twentieth birthday. His two sisters will graduate from high school at sixteen. Then comes William presenting a problem in reading and spelling.

ous

William entered the first grade at five years, apparently getting off to a good start. He is now in the third grade of a progressive


195

suburban school. He carries the work of his grade in arithmetic and writing efficiently. Our proficiency tests confirmed this. They also revealed that he had no proficiency in reading and spelling. Three years schooling had brought him next to nothing. His eyes were refracted and found to be all

right.

which places him above the median for boys his age. An analytical study of his Binet-Simon responses showed that he had good imageability in the field of form, powers of abstraction and generalization beyond his years, at least equal to the median for ten year old boys in the fifth grade of Philiadelphia public schools. His attention span was, audito-vocal 5, visual 7, reHis

I.Q.

was 111

verse 3. His performances on the formboards were qualitatively above the median though quantitatively slow. His performance on the Dearborn was both quantitatively and qualitatively good.

The diagnosis

normal mentality, general competency superior boys of his own age. He was referred to the Clinic Department for futher analysis of his reading deficiency. was

to the median of

Teaching

William received October 9, 1929. hours of instruction. His associability was again tested. His audito-vocal attention span proved to be 7 which is an increase of 2 over his first examination. He gave 8 digits on the sixth repetition. His reverse was 4, an increase of 1. His span therefore must be judged adequate as he is above the median of boys his age, superior probably to 60 percent. Clinic

teaching began

twenty-two

In reading he resorted to the familiar device of children who have been taught by the context method and failed to profit by it. He studied the pictures at the top of the page and proceeded to guess at the meaning of words. His guesses were good, showing good comprehension. He read wings instead of fly, dove instead of -pigeon, happy instead of glad. He gave back the meaning of the story without the loss of a single detail. His analytical discrimination for letters was poor. This defect is basic to his reading disability. Pie spelled girl?grle and plays?plas. By the use of the analyticosynthetic method, William made excellent progress and at the end of his period of clinic teaching he had a 2B proficiency in spelling and frequently received 100 for a spelling lesson. His reading was a good second grade. He read the third reader with some degree of proficiency. These results are remarkable considering that at the time of the examination he had no proficiency in reading and

spelling. As

a

help

to

diagnosis

he

was

given work

in arithmetic. He had

190


difficulty with problems in his grade, nor in applying the mechanics which he had well learned to new problems. His intelligence in this field is good. He showed no lack of discrimination between no

one was

number and another and established the fact that his defect of a very specific character and limited to letters and words.

Another interesting contrast was his ability to make discriminations between the parts of machines simply by looking at the pictures. His reading disability had led him to develop an interest in another direction for which as judged by his formboard performance he has only an average ability. The Popular Mechanics Magazine interests him. From the pictures he can explain the workings of a machine. His interest showed further development in his planning buildings, railroad terminals, etc. which he constructed with his toys. This is a beautiful illustration of disability in one field leading to a development of ability in another. In addition to his deficit of analytical discrimination, the problem of raising his proficiency in reading was complicated by his utter lack of motivation. He was two boys, one during the reading lesson, and another during the arithmetic lesson. In the reading In the arithmetic lesson he was lesson his attention wandered. absorbed. He frankly confessed that the reasons for his desire to learn to read are because his failure to learn to read makes the other pupils look down on him, causes his teacher to fret and makes his parents unhappy. Here in this intensive social urge was found the force that was exploited in the attack on his problem. It was pointed out to him that while reading plays very little part in his life now and while at present he was able to compensate for it by his interest in other fields, that his further progress depends upon his success in securing the tool called reading. He was intelligent enough to see and grasp this point, and under the spur of this hope of being able to take his part in the world in line with the educational traditions of his family, he buckled down to work.

The third factor that conditioned William's progress in reading his health. He had been examined by several child specialists who had given a negative report. Our observations of him in the Clinic seem to indicate that he was not manufacturing enough energy. His vitality was not that of a normal eight year old boy. First this appeared as a ruse to avoid work. Further observation showed that it was a condition of lowered vitality. Even when he was unobserved, he would lay his head on the desk as though he was very tired. Consequently he was sent to Dr. Max Trumper,

was


197

Bio-chemist of the Psychological

Clinic for examination. The examination showed he had a deficit of hemoglobin. The red cell count was low indicating a moderate degree of secondary anaemia. Our conclusions therefore in this

case are

that William is

con-

formed?that his abilities are conforming to expectation in all ways except in reading and spelling. His intelligence, comprehension

and analytical discrimination are superior to the median in every field except reading and spelling. His auditory and kinaesthetic imagery are good. His visual memory is good in every field except that of letters and words. His specific defect in reading and spelling is probably due to a functional variation in the cerebral mechanism for language. He was discharged from the Clinic Teaching Department with these recommendations?first, that he receive medical attention to put him in as good condition physically as is possible; second, that he be given private instruction until his reading pro-

ficiency is brought

up to

grade. Bert

Bert, born February 14, 1921, age eight years, three months, brought to the Clinic by his mother because of difficulty in reading. He was examined by Dr. Miles Murphy. Bert's father Was

school principal and his mother before her marriage was a of backward children. The significant thing in his medical is history that his birth was Caesarian, the operation being performed after three daj^s of hard labor. His head was so badly bruised by the instruments that an operation was necessary when he was one week old, following which he had a series of abscesses. At three years he had whooping cough and pneumonia. His development was not retarded. He walked at thirteen months and talked a few words at ten months. His head as a result of damage done at birth is misshapen. The malformation is especially noticeable when his facial muscles are in action as in smiling. was a

teacher

Bert

was

first examined in this Clinic when he

was

two years,

three months old. He obtained an I.Q. of 144. He returned to the Clinic May 18, 1929. He was then in the 3A grade in school and the best student in the class in all subjects except reading. His I.Q.

Was 124 which is inferior to about 5 percent of ten year old boys in the fifth grade of the public schools of Philadelphia. His attention span, audito-vocal is 8, visual 8, reverse 4. His forward span correlates closely with his I.Q., placing him superior to 98 percent of ten year olds. On the formboards his performances were not super-

198


ior either

His second performance On the Dearborn, the examiner remarked that he showed more analysis than efficiency and trainability, and suggested that he was more educable than trainable. During the entire examination he exhibited considerable restlessness which increased as he became tired. He fatigued easily. He was diagnosed as superior to 80 percent. He was rated low in the category of efficiency. He was referred to the Clinic Teaching Department for a further analysis of his reading difficulty. on

the

quantitatively or qualitatively. cylinders was inferior to the first.

He began his clinic teaching October 23, 1929 and received His eyes had been refracted but sixteen hours of instruction. many of the bad reading habits accumulated prior to treatment of his eyes survived. On his first lesson he did not have his glasses. His reading was poor. He skipped lines. He made the same mistakes in the primer as he did in the fourth reader. He took one look at a word and then guessed what it might be. Did was read done or does. Cottage was read cabin. In the one case he guessed by the looks of the word and in the other by the context. His spelling was equally poor. He spelled were-where, and where he spelled war. They, their and there were hopelessly confused. However he showed excellent motivation and a desire to become a good reader. In contrast to his failure with small words was his ability to read big words. The large words he analyzed out phonetically and synthesized. Owing to his necessity of working out each word as it appeared, he read slowly. The same contrast was noted in his spelling. He had no difficulty in spelling words like parcel, portion, least, summit, enemy, immediate, volunteer, assistance, and regulation, but he spelled cross-cress and they-thay. On December 16 he was making the same type of mistakes?left for fell and for for to. Invariably when his attention was called to errors in small words, he corrected his errors. His comprehension was excellent. He was interested in knowing the meaning and application of each new word. His errors suggested bad habits that could be traced to defective vision and that had not been stamped out by individual instruction which the boy needed. His failure in discrimination was due to carelessness and inattention rather than to any inability to discriminate the forms of letters and words. There was no suspicion of any cerebral injury to the visual memorial area. At the end of his teaching period he read accurately though slowly. The mistakes that he made were usually at the end of the lesson when he was fatigued On December 4 Bert had an audito-vocal attention span of 9, 10 on


three repetitions, showing good trainability. This of 1

1929. His

was an

199 increase

his performance May definitely 5. The diagnosis in this case as far as his reading difficulty is concerned is that it is due to defective vision, a secondary factor being bad reading habits. He showed no intellectual deficiency of any sort. His specific talent is in the field of the abstract rather than the concrete. He is of the scholarly type. The only complicating factor in the situation is fatigue. With continued individual instruction such as the boy fortunately may obtain in his own home, he will in

over

completely

master his bad

reading

reverse span was now

habits.

Della

Delia, age nine years, nine months, was brought to the Psychological Clinic because of difficulty with reading. She was examined by Dr. Miles Murphy December 12, 1929. The home background

in this

the case of Bert is excellent. Her father is an attorney, graduate of this University, and formerly an instructor in one of its schools. Her I.Q. was 138 which places her superior to 99 percent of ten year old children in the fifth grade of the public schools of Philadelphia. Her attention span is, audito-vocal, 9, visual 9, reverse 5 which correlates with her I.Q. The diagnosis was normal case as in a

that of a group of 5 percent superior to 95 percent. She was referred to the Clinic Teaching Department for diagnostic teaching in order to determine the cause for her

mentality, general competency

retardation in reading. Delia received twelve hours of clinic teaching. At her first appearance she seemed excited, a bit apprehensive. At times she manifested a quickened breathing, almost a gasping for breath. In her reading the usual bad habits of the non-reader were discovered. She guessed blindly when she did not know words and put in and left out words according to her idea of what the meaning required. She failed to discriminate one group of letters from another of similar character. She displayed no failure to discriminate between letter and letter, but she was unable to carry the

image of a word after being directed to observe it on a printed page long enough to be able to transcribe it on the board. Her spelling good enough if spelled ache-ake, afraid-afrade, already-alredy, cheese-chese, journey-journay, legendWas all done phonetically and would have been the mother tongue were spelled phonetically. She

200


legand.

Evidently

spelled as she pronounced. She sounded University and Pennsylvania, syllable by necessary synthesis, pronouncing the words,

she

out for herself the words

syllable and made the merely misplacing the accent. Pennsylvania on the board, she

When asked to spell the word did it, merely substituting i for y and y for i. Her auditory imagery is excellent. She met the word ground in the text, failed to recognize it by sight, spelled it out and pronounced it. The indications were therefore for a method of

teaching that was primarily audito-kinaesthetic. By strenuous drill method, her bad reading habits were gradually stamped out. By resorting to oral instead of silent reading and insistence on the of voco-motor imagery, Delia advanced to the third reader. She showed excellent comprehension of the content, formed excellent sentences, using the new words she had learned, and displayed a competency in this direction that was distinctly superior. use

Her failure to learn to read by the visual method is readily Her visual imagery of letters is correct but of a larger conformation like words is defective. Her imagery for words is not only incorrect but lacking in retentivity as tested by immediate recall. To compensate for this however, she has excellent kinaesthetic and auditory imagery and excellent retentivity in these fields. Her progress in twelve periods of clinic teaching was so marked that there was no hesitancy in making a favorable prognosis in her case provided that (1) she do oral instead of silent reading and (2) that her auditory and kinaesthetic imagery be exploited in the When discharged from the Clinic Teaching learning process. read new material from the fourth reader she Department accurately with and excellent expression. slowly, though

explained.

is due to one cause and one only?a deficit in for words. She is a clear cut case of congenital visual memory to due functional variation in the cerebral probably dyslexia mechanism for language. Interestingly enough she is left-handed. Her case is similar to that of William, case #4, but in Delia's case

Delia's

difficulty

other

contributing factors except the nervousness desire to overcome her difficulty and succeed eager Delia is a strong as she was succeeding in all others. a good deal of initiative and qualities of shows and personality leadership among playmates of her own age. She has artistic and dramatic ability and intellectually she can function at a much higher level than the grade in which she is in school now that the barrier to academic progress has been removed.

there were induced by in this task

no

an

The Incidence of Feeblemindedness among Cases Examined in the Psychological Clinic of the University of Pennsylvania.

Clinical Field Work in Social Service as Presented in the Psychological Clinic at the University of Pennsylvania by E. B. Twitmyer, Ph.D.

Diagnostic Problems in Educational Guidance at the Observation School, University of Pennsylvania.

The Attempt to Teach: A Diagnostic Method Illustrated by the Clinic Teaching of Typical Cases.

[Academic teaching at the department of ophthalmology of the University Clinic of Saarland (UKS) : The Homburg "Ophthalmo-Week"].

Hospital of the University of Pennsylvania.

Permanent circulatory support systems at the Pennsylvania State University.

Tumors of the heart. Experiences at the Giessen University Clinic.

Van der Woude syndrome: a review of 11 cases seen at the Lagos University Teaching Hospital.

Inclusion of sex and gender in biomedical research: survey of clinical research proposed at the University of Pennsylvania.

Four Cases of Diagnostic Teaching.

Courses in Psychology at the Summer School of the University of Pennsylvania.

The teaching of medical ethics at Southampton University Medical School.

Seroprevalence and determinants of toxoplasmosis in pregnant women attending antenatal clinic at the university teaching hospital, Lusaka, Zambia.

Uveal coloboma: about 3 cases at the University Teaching Hospital, Yaounde, Cameroon.

Hysteroscopic diagnosis of endometrial carcinoma. A report of fifty-three cases examined at the Women's Clinic of Kyoto University Hospital.

Testis tumors: review of 125 cases at the Cleveland Clinic.

The Physical Status of the Special Class for Bright Children at the University of Pennsylvania, Summer Session of 1912.

The use of the objective structured clinical examination as an audit of teaching and student performance.

The teaching of rheumatology at the University. The journey from teacher based to student-centered learning.

The Physical Condition of the School Children of the School of Observation, University of Pennsylvania.

Cut throat injuries at a university teaching hospital in northwestern Tanzania: a review of 98 cases.

Clinical characteristics and outcome of management of Fournier's gangrene at the Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria.

Awareness and Knowledge of Glaucoma Among Adult Patients at the Eye Clinic of a Teaching Hospital.