The Diagnosis of Mental Deficiency
MENTAL WELFARE 21 :Type: Book Reviews & Abstracts :Author: Henry Herd, M.D.(LoncL). Hodder & Stoughton. 1930. pp. x and 272. 8vo. 12/6 net.
This little work is designed to serve as a guide to practitioners, school medical officers atld others in the recognition of those mentally defective individuals who may need to be dealt ^ith under the provisions of the Education or the Mental Deficiency Act, an aim !y ch the author has kept in the foreground hroughout. Starting off from the definition of mental deficiency as a ” condition of arrested or incomplete development of mind,” he in- quires how this is to be estimated; ” clearly,” ((r- Herd states, “we must recognise defectives u by their mental ‘fruits’ their psychological ,, resPonse to stimuli, their reaction to stresses t( ?f environment, as practical diagnosticians f( We are less concerned with the ultimate <i ;?asis of the deficiency, whether that be a (( ,ailure in structural cerebral development or ln endocrine efficiency.” He therefore be- ^ns by a discussion of mental processes as plewf^ in the light of the older and newer sychologies, passing on to a detailed consid- int!?11 men^a^ development of the child sin ? decade ?f life- This is necessary fo CC ^ *S only comparison with the per- anrm.ances of the great majority that those of ofy dividual can be said to indicate the lack p lllaturity or of such reasonably to be ex- ino rectitude as would justify a diagnosis of be 0rn]?le*e mental development. There might ^ a foilure in either of the three generally ces^ ^ divisions into which the mental pro- tiv^ are classified, the cognitive, the affec- ? ?r the conative, but usually the defect is mem1 -iaH~round character. On the tempera- stabK. -s^e ^e subject may be stable or un- em ln the former case the instincts and g00dl0ns may weak or the control relatively ‘ ln ^e latter relatively strong emotions ?V-ercorne a weak control. So far as cog- Sener concerned the fundamental defect is si(je f rather than specific and on the conative a laol- fCt *s ^ue ^ilure of concentration, great”-0 enerSy and purpose. The latter is of Weak ^Portance for, as Dr Herd stresses, a a Uorrn’^ a serious hindrance even in a lndividual, in a defective with a sub- normal intelligence it hinders the growth of even the modicum that is present and the result is a social misfit.
In five chapters mainly devoted to diag- nosis Dr Herd discusses first the history and physical appearances, not as being of prime import but because they are often the first points brought to the notice of the certifying officer while the child is settling down, and then general and specific tests of intelligence and temperament. He draws attention to the value of a wide range of performance tests and to the limitations of the Binet scale. Here it is interesting to note the gradual change of orientation. Tests have always been needed since the days when evidence of defect had to be given for legal procedure and some in com- mon use were equally well-known in Plantag- enet or Tudor times, the difficulty was their lack of standardisation. Tests now found suitable to one of the age of five or six might be given to an adolescent or adult who received undue credit for success, while on another occasion a younger person was deemed to fail when asked something now known to be quite beyond the normal range of powers or know- ledge for his years. Binet’s scale was so well adapted and so successful that for some years it checked all efforts at standardising other lines of testing and led many to think that a simple procedure, a real litmus test of uni- versal applicability, had been found. The scale was the more welcome at the start as it simpli- fied the giving of evidence to courts which are notoriously given to regarding the intellect as the sole property or at least as the predominant of mind. It is doubtful if many certifying officers who had to deal with adults ever took that view and it is well to call a halt and bring the investigation back to a survey of the whole child. Yet care must be taken to keep the pendulum from swinging too far on the other side when attention might be devoted equally exclusively to the affective mechanisms. All tests must be considered in the light of the history, opportunities and interests of the subject and while it must never be forgotten that the certifying officer has no right to assume that the examinee is putting forth his best efforts it must equally be remembered that if a child really tries at all he usually does his best?in this respect he differs to some ex- tent from many adults. Dr Herd gives much wise advice on the technique of examinations from this angle and will generally be held to hold the scales of the balance truly, as he says judgment must be based on the ” ensemble ” ?history, observations, tests, intelligence and educational and social traits. Where there is a backward class he recommends a limited period of observation of a child therein as the best diagnostic measure; advice with which all school medical officers will agree. Where there is no such class, as he says, the certifying officer sits on a very real fence of decision as his subject sits on the imaginary fence between the dull and the defective. He has to decide between the stigma or supposed stigma on the one hand and leaving the child to probable idleness and the growth of inferiority com- plexes and grudges in the ordinary school. He agrees that a backward class may be very suitable as an educational medium for the high-grade defective and that there are grave objections to mixing cases of that type with the lower grades who constitute the majority in the present day special schools, and appears to agree with the Wood Report that the lower grades should be weeded out to occupation centres and come under the purview of the Mental Deficiency Committee even if, for the sake of efficiency, these centres be run by the Education department.
In dealing with moral deficiency Dr Herd falls in line with those who say that the so- called moral defective of the Act is an unstable feebleminded person and that it would have been better if the class were retained at all to have defined the mental defect as being shown by strong vicious and criminal propensities. He gives good descriptions of the type of moral defectives who are characterised by weakness in the social instinct and of altruistic senti- ments but with strong self impulses. He looks forward to a time when the budding moral defective can be fully investigated in a child guidance centre before the powerful action of habit has been added to the difficulties arising from lack of affective and conative balance.
A short legal section sets out the action which has to be taken by school medical officers and certifying officers generally in making suitable provision for defectives who come to their notice and gives hints on the selection of the best modes of action whether by supervision, guardianship, institutional care or special schooling. In one point he makes a rather surprising statement with re- gard to action to be taken in a petty sessional court in a school attendance case. ” It should be noted that no certificate from the parents’ own doctor, and no opinion expressed by any other person regarding thg child’s mentality can be allowed to influence the Court’s decision in a disputed case.” If by this Dr Herd means only that the local education authority might require the parents’ practitioner to be called as a witness this would be in accordance with current practice; if, however, he means that the parent cannot call his own practitioner to give opposing evidence it would seem to be contrary to the general course of law by which all relevant evidence must be placed before a court of justice. Most people would hold the word give means present or you have the position that technical evidence can only be opnosed by a layman.
In a future edition Dr Herd should certainly give a reference to the case on which he bases this statement, which if correct would much facilitate the work or the school medical officer. It is the usual practice, in the south at least, to admit any opposing medical evidence and the case of Rex v. de Grey in the High Court which has usually been taken to indicate the law only determined that in a case in which the evidence of defect was not in dispute the magistrate must accept the statutory certifi- cate of defect and not make an examination for himself of the child before him. It is also the practice in the south for the court to refer a case of doubt to the Board of Education; if the court is not in doubt it would seem there is no right of appeal to the Board in law. This book will be welcomed by school med- ical officers, generally as a useful chart to rather intricate waters.
F.C.S. Mental Aspects of Stammering. By C. S. Bluemel, M.A., M.D., L.R.C.P.(Lond.), M.R.C.S. Bailli?re, Tindall & Cox, 1930. Price 11/6 net.
This book, written by an American phys- ician of some standing, deals with the medical and psychological aspects of stammering. The author has already done much work on this subject and may be said to be a pioneer in a country where there are over a million stam- merers. His methods, as he himself says, are not infallible, but they are designed to help children and, to a certain degree, adults. . In the main the book leaves one with the ^npression of having skimmed the surface of j-he subject only. Dr Bluemel has left the depths untouched. He omits any reference to hereditary influences; devotes a few lines only to the all-important subject of environment, and leads one to suppose that the primary causal factors are those which, in London, are regarded as secondary or determining causes oi stammer.
‘ This capriciousness of stammering is sufficient evidence in itself to show that the lrnPediment does not result from physical dis- ease ?f the speech organs, for no physical defect could appear and vanish in this manner in ?sP?nse to external influences. In reality, ere is no disturbance in the physical mechan- sm of speech; the disturbance lies in the Cental mechanism. Stammering is an impedi- ment of thought.” While agreeing with this atenient one wishes it had been further ?d, orated. It is interesting to find that Dr. thUeme^’ althouSh still holding to his original e?ry ?f transient auditory amnesia as a thUSC stammering, now states that, ” By eve ?Se of synonyms, circumlocutions and asions, the stammerer frequently succeeds concealing his difficulty altogether.” s ? au^or makes some very pertinent ob- ernV?tl0.ns on the psychoneuroses, especially ac P^asizing that the diagnoses should not be pei.Usatory, nor should they be interpreted by t00S0- lacking medical knowledge. I agree stud su^ect ?f spasm deserves further ?eti J’ n?^ only from the point of view of ?8y but also from that of treatment.
illiKt ^a-rt w^ich contains some excellent trainiratl0nsj Dr Bluemel deals with “Thought Here^k ES basis ?f speech correction.” his m author gives a detailed account of an jnoe ^ods. Treatment is regulated through of Ca&fni0US ari*angement of signals by means ” ston Mne*s anc^ clickers, which are used to help fn<? ” start ” the pupil. I cannot ^e ant”1Bering whether, in a nervous patient, crease i1?1^a^on of such a signal may not in- in ” t ls n}uscular tension, rather than result s?metifn^Ul^Z^n8 ^is mind.” Relaxation must Dr Bluoi i ndifficult in such circumstnces; ” a niinC1-riC ^owever, regards relaxation as c?rrecti r anc^ no a mai?r principle of speech adults’’’ Its benefit is largely limited to The kindergarten methods are good; nursery rhymes, sung and recited, story-telling and language games are employed, and ” despite the rigid discipline of thought, the children themselves are not repressed. Spontaneity is allowed, especially when the transition has been made from group work to individual speech. If spontaneity becomes too marked, the class can be tranquilized by a few moments silence. The children can also be quieted by the game of going to sleep. They close their eyes, fold their hands, and droop their heads. In a few moments they are allowed to ‘ wake ‘ and the work proceeds with the class under control.”
The grade school children gradually acquire confidence in reading by various ” group ” methods and by individual reading with the instructor, whose help is gradually withdrawn as the child becomes more self-assured. Silent reading leads step by step to reading aloud; conversational sentences are built up in the same way. Oral games, narratives and dis- cussions are indulged in when spontaneous speech has been established. ” The principles of speech correction are substantially the same with adults as with children. The basis of therapy is thought training. The training co- ordinates the mind, and the mind co-ordinates the speech.” Adult pupils are blindfolded to enable them to concentrate on thought when addressing the group; they practise with tele- phones and dictaphones, and ” with the con- sent of the pupil, a punitive electric shock is given to check careless habits of speech.” Can this be good for the patient’s nervous system ? ” The atmosphere should be one of inform- ality and ease, and no circumstances should weaken the stammerer’s confidence.” ” The instructor’s manner should be tranquil.” “No child was ever cured of stammering by the simple expedient of taking lessons,” and Dr. Bluemel emphasizes the importance of the home influence. He insists that parental help and co-operation are essential, and that the child must be protected from undue excite- ment and fatigue. But, ” With an early case of stammering the treatment should consist solely of bed rest and the administration of sedatives.” Few authorities would agree that Luminal is the sedative of choice for stam- merers, even if drugs were ever needed for their disorder.
In conclusion, ” Much work remains to be done in the field of speech correction.” Re- search into the cause of stammering, its treat- ment, and into the methods already available, are of the highest importance. There is much in this book to interest those who desire know- ledge of one of the most fascinating psycho- logical problems of the day. There is a good index.
A.R. Annual Report of the London County Council for 1929. Part III. Public Health. P. S. King & Son. 2/6 net. This Report, which incorporates that of the School Medical Officer, contains the usual in- teresting statistics which appear annually in the London County Council’s Reports. These Statistics deal chiefly with the incidence of Infectious Diseases, Tuberculosis, and with the administration of the various Acts relating to public health.
The number of cases dealt with by the Council under the Mental Deficiency Acts amounted to 5,560. Of these, 3,191 were in institutions, 74 were under Guardianship, 2,276 were under supervision and 19 were in places of safety awaiting action. Referring to an analysis of these cases the Report points out that it is interesting to note the higher pro- portion of cases of secondary amentia in those of lower mental status. Of the idiots, approx- imately 27% were instances of primary amentia and in 73% the deficiency was due to conditions arising in the course of the pre- or post-natal life of the individual. Dr Shrubsall has analysed the family histories of 1,360 cases and has found that in only 129 cases (that is approximately 9.5%) one or more of the brothers and sisters were also mentally defec- tive. Dr Shrubsall states that ” in one in- stance five brothers and sisters of a defective individual had won scholarships and in another case two brothers had done so; both of these defectives were samples of simple primary amentia.” It is remarkable that the fre- quency with which other children in the family were affected varied inversely with the grade of defect; that is, the feeble-minded had defective siblings in 11.6%, imbeciles in 5.7% and idiots only in 4.3%.
An account is also given in this Report of an investigation carried out by Dr Carleton Williams into the question of the direct trans- mission of defect. The mentality of the parents of 100 children who were admitted to Special (M.D.) Schools was classified under the follow- ing headings:?superior, average, inferior, unstable and mentally defective. The results of his investigation were as follows: ?- superior 15, average 45, inferior 28, unstable 8, mentally defective 4. An independent in- vestigation into 66 families of which a head- mistress of an M.D. School had accurate knowledge gave figures which tallied very closely with those of Dr Carleton Williams. Dr Letitia Fairfield has tabulated the data available as to the after-careers of children who had been deemed ineducable during school age, as recorded by the London Assoc- iation for Mental Welfare. Out of the 1,155 such imbeciles now under supervision, 41 were found to be in more or less regular employ- ment. Fifteen of them earn between 10/- and 30/- weekly in food and wages and thirteen earn 30/- to 35/- or the equivalent. Only a very few are in occupations indicating any in- itiative or intellectual capacity beyond the grade to which they had been allotted and practically all of them had some kind and stable relative in the home to shield them from full adult responsibility in the management of their lives. Dr Fairfield draws attention to one or two interesting points arising from this brief study. It shows the accuracy of prog- nosis in childhood by means of tests and school observation, for of those certified im- beciles 97% were not fit for industrial occupa- tion of any kind. “It may further be suggested that the exclusion of the really low-grade im- becile from special schools is no hardship and operates equitably. Children of this grade have more to gain from the ‘ socialising training of an Occupation Centre type than by any more formal education. Experience tends to confirm the opinion expressed in the Wood Report that an intelligence quotient of should, generally speaking, be the lower lim^ for the special school child and that those below that level should be relegated to occupa- tion centres in their own interests and in that of the higher grade child.”
The Health of the School Child. Annual Report of the Chief Medical Officer of the Board of Education for the Year 1929. H-^* Stationery Office. 1930. 2/- net.
The form of this Report is somewhat dif?e1’ ent from that which has been adopted in the Past. The four main Chapters deal with a general survey of the principal branches of |ne School Medical Service and statistical ables and a series of Chapters dealing with special subjects are relegated to the Appendix. n this form the Report is, perhaps, more ^tractive to the casual reader.
Special effort has been made in the past ur?e l?cal authorities, school medical officers and teachers to provide school children With adequate instruction in personal hygiene. r George Newman is of the opinion that three hings are needed in this respect; first the re.c?gnition that health education is something ider than elementary physiology and should embrace the life of the citizen at home and at ^?rk; secondly the acceptance of health educa- ]?n as a fundamental and integral part of the cUrriculum, and thirdly the working-out of a?y? adapted to suit the curriculum, type 1. circumstances of each school. Informa- i?n gained from 3,133 returns from schools ? as shown that at the moment health teaching very unevenly given.
is ? secti?n on Exceptional Children it Qf Pointed out that the complete ascertainment of children depends on the co-operation do school teacher, the school attendance Partment, health visitors, school nurses and others ?f voluntary committees with the r ?ol Medical Officer. The number of child- fed ascertained in 1929 as mentally defective m^ca.ble)_amounted to 32,775, and the accom- to iff cl0n Special Schools for these children or fl 6; Inall> 28,598 were attending schools ic ? institutions. Reports of School Med- the 1? rs indicate that the publication of Comport of the Joint Mental Deficiency lem ^as stimulated interest in the prob- for making special educational provision tions efretar(lecl child. “The recommenda- criti’0-?: i ^e. Committee were discussed and In with discrimination in many areas. rai.n areas an attempt to make provision may C es recommended by the Committee A n?er^e as time and circumstances allow.” subie , aPter of the Appendix is devoted to the iritere t ^ursery Schools in which keen year s has been displayed during the past orty such schools have now received recognition and plans have been approved for an additional 12 schools. The cost of building, equipment, etc., must naturally vary with a number of factors involved, but an average cost per place may be said to be about ?30. The most successful method of staffing such schools is found to be the appointment of one or two qualified teachers (according to the numbers of children in attendance) assisted by less highly qualified assistants, as certain parts of nursery school management can usefully be performed by students who wish to increase their experience in the care of children. Amongst the chapters in the Appendix there is an interesting review of the history of the development of the School Medical Service since its inauguration in 1907.
Psychopathology. By J. Ernest Nicole, L.M.S.S.A., D.P.M. With a Foreword by W. H. B. Stoddart, M.D., B.S., F.R.C.P. Bailliere Tindall and Cox. 1930. 10/6. Dr Nicole has in this book attempted a brief summary of the principal schools of psycho- pathology as they are known by translated works and otherwise in this country, and has, on the whole, succeeded well. The chapter on Freud’s theories and the subsequent chapter principally on the Freudian conception of the ego are specially good for the condensation of a difficult subject. Clearly the author hasnotonly read about Freud but has also discussed his views at length with others. The Chapters on Adler and Jung are also neatly condensed and these chapters form the most useful part of the book. Not many persons would regard Kempf and Berman’s views as worthy of a chapter to themselves besides these others. Watson’s real contribution to psychology (his methods of ex- periment and observation) is missed and the account of The ” Biochemical approaches ” does not profess to be more than a summary. As a purely literary and uncritical symposium of such modern views as are available to the English reader the book is useful, and the chapters on the most popular schools are well done. R.D.G.
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