Combined Defect
- Author:
Carleton Williams, M.R.C.S., D.P.H.
These few notes embody the results of personal experience with some of the conditions that complicate the problem of Mental Deficiency. The question has to be faced under various aspects. Sometimes it is a matter of differential diagnosis, as, for example, when we have to decide whether an infant is mentally defective or deaf; on other occasions, the co-existence of the two types of defect rciay be suspected and then, if the presence of the one cannot be eliminated, special methods of examination must be adopted. In this short paper it is obvious that a few only of the most important conditions can be discussed, and these but briefly. The subject matter has been arranged so as to reproduce the various questions that have arisen in actual practice.
Three kinds of disability will be considered :? i. Paralysis. ii. Blindness and Defective Vision. iii. Deafness, Complete and Partial.
Section I.?Paralysis.
The types of paralysis which occasion most difficulty are the Infantile Hemi- plegias and the Diplegias. The physical handicaps due to these conditions make both education and employment difficult, often the paralysis is accompanied by epilepsy; in the Hemiplegias, especially, there are not infrequently emotional disturbances and failures in self-control, amounting sometimes to outbursts of violence which make them a danger to others, and there is often some mental subnormality. Freud, in one of his early works, before he devoted himself to Psychopathology, described how the cerebral paralysis of children may be accom- panied by epilepsy and mental impairment varying greatly in degree, and not necessarily proportionate to the severity of the physical handicaps. A survey of 490 children in Cripple Schools made by the writer gave the following figures :?
Anterior Poliomyelitis
(Infantile Paralysis) Infantile Hemiplegia … Cerebral Diplegia
INTELLIGENCE.
Above Average. 18.1 Average. 48.7 32.4 15.1 Below Average. 25.6 33.9 24.2 Nearly M.D. 7.5 27.9 60.6
Besides these, there are, of course, very many feeble-minded, imbeciles and idiots not admitted to the schools for the Physically Defective. The estimates of mental ability were those given by their teachers, supple- mented by a knowledge of the educational attainments and a few rough mental tests. It will be seen that the figures for the poliomyelitis cases afford a control, for they, like the others, would show the effects of loss of education through absence from school, and the distribution of mental capacity in this group does not differ very much from that of normal children. The Hemiplegias show a considerable lowering of intellectual capacity, while the Cerebral Diplegias show this to a much greater degree. Thus, with these children, the question often arises as to how they shall be educated ; by reason of their physical disability, they are more suited for P.D. than M.D. Schools, but it is not desirable to admit to these schools children who are definitely M.D. Their educability has, therefore, to be ascertained, and to do this the ordinary methods of examination need modification. To begin with, the physical appearances must not be allowed to influence the judgment : even a dribbling child may be normal mentally. Readers of ” David Copperfield ” will remember the warning of Miss Mowcher : ” Try not to associate bodily defects with mental, my good friend, except for a solid reason.” Then, if both hands are affected, some tests may be inapplicable, or their results have to be specially assessed, e.g., the copy of a diamond or other drawing is often a failure according to ordinary standards, but watching the child’s efforts, it can be seen that the failure is due simply to physical disability, correct intentions being frustrated by lack of muscular co-ordination. Or again, speech may be so defective from Dysarthria that the examination has to be taken very slowly ; often the examiner finds it very difficult to understand the answers of the subject, and occasionally this may go so far as to render ordinary verbal tests impossible; and they have to be replaced by performance tests or by questions which can be answered by an affirmative nod or a shake of the head.
When both speech and motor functions are impaired difficulty becomes very great; but even in these cases a rough idea of the mentalitv can be obtained by a study of the type of the reactions, aided by an account of the child’s ordinary behaviour. In certain types of cerebral paralysis, efforts to get out correct replies cause gross, almost violent, involuntary movements. Another difficulty arises from the great fatigability of these children, which renders a strict and prolonged examination unjustifiable, and makes it necessary to take the investiga- tion at two sittings. Then, on the other hand, some of these children have a pleasing appearance and conversation, and are able to repeat little verses brightly, so that there is a tendency to give a favourable prognosis which is not borne out by experience. They may also respond to mental tests in the brief period of an examination and yet be incapable of sustained efforts necessary for school progress.
With paralysed persons who are outside the limits of school age, the diffi- culties of the examination have to be met by similar modifications, the question determine, however, is no longer educability, but the need for institutional treatment and the justification for certifying. Social inefficiency, with perhaps some conduct disturbances, makes these persons a burden to their relatives and to the community, so that institutional care is urgently wished for, yet, if their mentality as shown by examination, is not sub-normal, and reports show that their behaviour in general is quite sensible, certification is not scientifically correct and their confinement in institutions with the feeble-minded a cruelty. In actual practice, however, although their reactions to tests rarely show the all-round lowering found in ordinary primary aments, there is often evidence of marked intellectual failure in several directions, and this, coupled with reports of irresponsible con- duct, should, in my opinion, justify certification.
Section II.?Blindness and Defective Vision.
The mentality of the blind child may be considerably affected; even the dreams of the congenitally blind are unlike those of the seeing children, and there is often an attitude of timidity and distrust. But when this is overcome, the behaviour and reactions of the intelligent child are quite unlike those of the Mentally deficient. Some of the blind, however, have also mental subnormality ln varying degrees, even imbecility or idiocy.
For the purposes of education, it may be necessary to determine whether a blind child who is said to be rather backward is fit for the teaching of a Blind School. Naturally, one wishes to give the child the opportunity, if possible, but ?n the other hand, the mentally defective are unable to make use of Braille and many other appliances, so that it is useless to send them to these schools. If they are imbecile, they can go to institutions under the M.D. Act, a complete Schedule F. being required. For Blind and Feeble-minded children of school age there are few special facilities, but such children must be ascertained and then dealt with in the best manner possible. To determine the mentality of a blind child is a task that needs some patience and adaptability in the examiner; the Binet series of mental tests can be modified, all tests with drawings and pictures, etc., being omitted, and in questions of comparison for wood and glass should be substituted carpet and oilcloth, or paper and cloth. A few special motor and Performance tests can be added, e.g., the Norsworthy form board, the child being told to feel the blocks and spaces and fit them in, and he may also be asked to name objects given him to hold. If greater accuracy is desired, it may be pbtained by the use of the Point Scale for the Blind, described by Drummond 111 the Edinburgh Medical Journal for February, 1920.
Partial blindness (including high myopia) is not infrequently complicated by mental deficiency; if the latter is markedly present, the child is unsuited for Myope School, and unless special accommodation can be found, he must be sent to an M.D. School for oral teaching only. The determination in such cases is considered in the next paragraph.
M.D. School Examinations.
In all examinations for M.D. Schools, it is essential to know whether the vision is normal. If no record exists, it must be specifically tested?for children who do not know their letters the E card can be used ; the writer prefers to give them a Model E. cut out of cardboard to hold. (The card of pictures gives inferior results.) If by this means defective vision is shown to be present, the examiner can make all necessary allowances for failure in learning” to read, and can omit the tests which need good vision for success. Failure to learn to read may be due to a special disability. The rare condition of true Word Blind- ness was described by Dr C. J. Thomas in 1908, in “The Aphasias of Child- hood,” and more recently Miss Fildes has investigated its psychology (British Journal of Psychology for 1921). There are also many non-readers in whom the cause appears to be partly a defect of vision with perhaps eye-strain, and a lack of effort and of interest in the subject. Failure to read is not in itself much evidence of certifiable mental defect.
In the certification of infants under the M.D. Act, the matter becomes more serious. They may be reported not to notice things and the parents are often in doubt as to whether this is due to mental or visual defect; it is, therefore, essential to know if the child sees or not. Some idea of the power of sight can be obtained by getting him to pick up from the floor a small piece of paper, say l/8in. square. Seeing-children of two years and upwards will do this, and failure means either blindness or complete imbecility. The latter is easily excluded by the general behaviour and reactions to the simplest tests, and the child should then be tested on the assumption that he is blind. With the smallest children and those of the lowest mental level, it should first be noticed if a bright light is followed by the eyes, and if this fails, recourse must be had to objective methods, the reaction of the pupil or an ophthalmoscopic examination.
In the certification of adults under the M.D. Act, the common difficulty is to know how far defective vision has been a handicap to social efficiency. Mental Defectives, especially those seen in prison, often make a great deal of a minor defect of vision, alleging that it accounted for their inability to read, for discharge from the Army, and dismissal from occupation. Visual defects are, of course, real handicaps, and if severe might have the effects described, e.g., a feeble- minded youth of high grade and good type did very well in general work, but was repeatedly dismissed from his position as an errand-boy because he could not read the names over shops on account of his bad sight. It is, therefore, essential to have an accurate record of visual acuity. Malingering partial blindness is common among delinquents, but in them it is, as a rule, fairly readily detected, and the examination follows its usual course, the examiner being put on his guard against other forms of trickery.
Section III.?Deafness.
Deafness is a far more troublesome complication than either of those dealt with above, and serious mistakes are more likely to arise. Statements of others are often quite fallacious guides; for parents and even experienced teachers occa- sionally ascribe to mental defect behaviour in children which is, in fact, due to deafness ; or they make the opposite error and think that a child is suitable for a Deaf School who is nearly or quite imbecile. Examination, too, is rendered very difficult by the lack of means of communication. For these reasons there are widely varying estimates of the percentage of the deaf who are mentally detective. From such figures as are available, it would appear to the writer that the real figure is a little less than 10 per cent., and this proportion is in agreement with the opinion of the chief experts on deafness.
Proper education of the deaf, including lip-reading and the acquisition of speech, is of immense importance, and training should begin at the earliest possible age. Excellent results are obtained in the schools for the deaf, but the training demands intelligence and good powers of attention, so that it is useless to attempt it with children who are mentally deficient. For feeble-minded or very subnormal children, the methods of education must be largely manual, and com- munication carried on by the finger alphabet or even by signs, while the imbecile deaf are sent to institutions under the M.D. Act, a complete Schedule F. being necessary. Thus, if there is any doubt about the intelligence of a deaf child, an estimate of its mentality must be obtained. For this purpose, the earlier tests given at the close of this article have been found of use, and apart from success ?r failure with them, much information can be obtained from observation of the child and its attitude to the tasks. The bright deaf child is pathetically eager to do well, and shows a persistent and purposive behaviour, in marked contrast to the inertness or futile actions of the mentally defective. The personal history js also of value, including an account of the powers of communication established in his home, though it must be remembered that even in such matters as the acquisition of correct habits, the deaf child sometimes shows a slight disadvantage.
The right way to deal with partially deaf children is to send them to a Hard of Hearing School; or if the defect is slight, to insist on their being kept in the front row of an Elementary School. If, however, they are in addition really Mentally defective, these methods are unsuccessful, and they must go to the front r?w of an M.D. School. For this, a certificate of mental deficiency is, of course, necessary, and the methods of examination are those described below.
M.D. School Examinations.
On these occasions, anything like complete deafness is rarely met with, but slighter degrees are often found, in fact, no examination for M.D. Schools can be called satisfactory unless the hearing, like the vision, is specifically tested. If the forced whisper can be heard at twenty feet, there is no practical handicap to education present. If, however, there is a history of defective hearing that has been cured, due importance must be attached to it, for a child who has had difficulty in hearing often forms a persistent habit of not listening. Again, there may be at the time of examination, only very slight loss of hearing present, but the condition of the ear and naso-pharynx may be such that the auditary acuity varies much, and may be lowered when catarrh is present. Variable deafness is often associated with adenoids, and is, in the majority of cases, the main reason for the dullness. Observations made by the writer on children in M.D. Schools who had adenoids removed, showed that mental benefit was marked only in those cases where there had been some deafness.
Deatness, whether present, past or intermittent, causes much hindrance to educational progress, and a mental stagnation which is far greater than might be anticipated. Thus, much allowance must be made for it, and the examination itself conducted in a loud, clear voice, and the child should be told to repeat the questions aloud before attempting to answer them.
Here may be noted the interesting- condition of word-deafness, in which the child is able to hear what is said to him but is unable to attach any meaning to the word, and therefore fails to answer questions or to carry out commands. This pathological curiosity is extremely rare in children, and it is simulated by combi- nations of slight deafness, slight mental deficiency and especially repression due to adverse home conditions; for these cases change of environment as in a resi- dential school often works wonders. In general, for children who are M.D. and also slightly deaf, the bestitreatment is M.D. School (Front Row).
M.D. Act Examinations.
Infants.
With little children who are examined for mental deficiency, it is essential to make sure that they are not deaf. The parents’ report is often unreliable, though it is of more Value if they can give practical reasons for their opinions. The examiner must always test the hearing for himself, and if a response is not easily obtained, attempts should be made to elicit one by persistence and by choosing questions or sounds that arouse the child’s interests. If there is no response, the child is either a low-grade imbecile or deaf, or possibly both. The methods of differentiation are largely those described for the disposal of the deaf in schools, but with the youngest children more depends upon the accounts of the child’s ordinary behaviour and the tests used will be the very simplest.
Adults.
Here again, the first thing is to test the hearing. For this purpose the forced whisper test is the best, but it needs special care, for mistakes are remarkably frequent. Malingering deafness is very common in delinquents, and the examiner must be prepared to meet and expose it. On the other hand, real deafness has been unrecognised because the subject had good powers of lip-reading, but this possibility is excluded if the test is always conducted with the subject’s back to the examiner.
If a defect of hearing is present, but not severe, it is merely necessary to make allowances for it and modify the examination accordingly ; but if complete deafness is present, the problem of means of communication has to be faced. There may be good lip-reading and speech also, though the intonation is always characteristic; the possession of these attainments makes the existence of ordinary mental deficiency extremely unlikely. Others can communicate in writing, though the syntax and arrangement of words is peculiar, as it often is even in the normal deaf, and thus such characteristics in the writings of the deaf should not be thought to connote mental deficiency. Others, again, can express themselves with the finger alphabet only, and this fact makes it a little more likely that they are mentally deficient, but it may be due to lack of facilities for instruction by oral methods.
Lastly, there are those whose only language is that of signs, and it is useful for the examiner to know a few of these for the purpose of giving directions; but the examination must consist almost exclusively of the performance and picture tests described below which, indeed, play an important part in all investigations of the mentality of the deaf. With the elder deaf in general, several peculiarities are found. Besides their curious methods of expressing themselves in writing, they have a marked lack of capacity for dealing with abstract questions and with numbers, and they often show ignorance of social conventions and a tendency to temperamental instability, in sharp contrast to good powers of memory and reason- ing, and skilled craftsmanship.
Mental welfare!. yg
When deafness and blindness are combined, the handicap is very great, so that many writers speak of “Imbecility by deprivation,” but how little the intrinsic intelligence may be affected is shown by the famous cases of Helen Keller and Laura Bridgman. The real potentialities can be roughly gauged by watching the general behaviour, and the perlormance with certain tests, particularly the Norsworthy Form Board as described for the Blind.
Non-Verbal Tests.
A. Those given for infants (1 to 2) by Binet in his 1905 series only. 1. Eye follows a light. 2. Objects shown are grasped and handled. 3. A suspended object is grasped. 4. Child offered a sweet and a block of wood chooses a sweet. 5. Child unwraps the paper containing a sweet before attempting to eat it. 6. Child imitates simple movements and obeys simple commands (for the deaf the orders take the form of signs). B. Additional infant tests found useful in practice for ages 2 to 3 :? 1. Fitting together a nest of boxes. 2. Matching the four primary colours by fitting coloured discs into frames similarly coloured. 3. The Norsworthy Form Board, success or failure and method. C. Tests for later ages standardised at a Deaf School to the ages given. 1. Reproduction of two written digits shown for five seconds. (Age 5.) 2. Reproduction of three digits. (Age 7.) 3. Reproduction of four digits. (Age 9.) 4. Copying of a square. (Age 5.) 5. Copying of a diamond. (Age 7.) 6. Counting four objects. (Age 5.) (The number is written, or four fingers shown, and the child is directed to count out four objects such as beads.) 7. Counting thirteen objects, method as above. (Age 6.) 8. Adaptation Board. (Age 7.) (This is a board with four round holes at its corners, one of which will just admit a plug, while the others are a shade too small. The subject is shown which is the right hole; the board is then reversed and he is directed to re-insert the plug. A defective would fail by trying again in the same corner.)
9. ” Patience ” in frame, done in 15 seconds. (Age 5.) (Two wooden triangles have to be fitted into a rectangular frame.) 10. Binet’s design A. (Age 8.) 11. Binet’s design B (the scioll). (Age 9.) (These designs are shown separately for 10 seconds each.) 12. Tying a bow-not. (Age 7.) (The subject is shown a bow tied round a stick; it is undone and he is directed to re-tie it.) 13. The Norsworthy Form Board. (This is of value for many purposes, while a great deal is learnt by merely watching the child’s efforts. It also standardises quite well as to speed for age.) Time in seconds 50.3 46.4 37.5 32.5 29.3 23.7 Age 5 6 7 8 9 10 14. Healy A puzzle. (Age 10.) 15. Healy B puzzle. (Age 12.) 16. Healy picture completion. (This is by far the most valuable test for the older and brighter deaf, and with it mental ages from 9 to 12 can be determined. It is rather expensive and has to be obtained specially from America, Messrs. Stoelting, of Chicago.) 17. Words in order test. (Ages 9 to 11.)
(Each word of a simple sentence, such as ” The cat ran after the mouse and caught it,” is written on a separate card. These cards are then put on the table in a wrong order and the subject is directed to arrange them into the sentence. It is often necessary to show children what is wanted by making them watch the re-arrangement of another set of words. This example with nine simple words, is usually done by the deaf who have a mental age of 11; a sentence of six. words can be done at age 9.)
These tests do not form a complete series, but a selection from them is found to give a fairly accurate estimate of the mental level and an opportunity for observing the type of reaction. In tests Nos. 8, 9, 13, 14 and 15 especially, this qualitative aspect is of more impoi tance than success or failure at a given age.
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