A Clinical Examination Blank for Backward Children in the Public Schools III
- Author:
Heilman,
University of Pennsylvania.
On page 260 is given a sample blank as it was filled, out in the examination of one of a thousand cases of retarded children. I gave a reproduction of this blank, partially filled out, in the last number of Tiie Psychological Clinic. In this third article I propose to consider the items of the blank which I have not as yet discussed.
I turn first to school history (Rcl). A largo number of children are retarded because of frequent changes from one school system to another. This usually involves an initiation into a new course of study and the use of unfamiliar text books, with a consequent loss of time. Even the transfer from one school to another -of the same system is frequently productive of the loss of a grade in the child’s progress. The families of some of the children whom I examined had changed their residence at least half a dozen times during the school life of the children. In some cases this change of residence is made by the family, and even by the children alone, to escape the enforcement of compulsory school attendance. A brief summary of the school history of the child is therefore of importance if we are to estimate tho influenco of this factor in producing retardation. The symbol (Rel) is introduced chiefly to remind tho investigator to enter a record of attendance in the parochial schools in the case of boys who are members of the Roman Catholic Church. The curriculum of parochial schools, as well as of other church schools, is very poorly articulated with that of the public schools. For this reason children who have attended parochial schools in tho early years arc apt to be retarded when they subsequently enter the public schools. Moreover, many children spend a year in the parochial school, at about the age of twelve, in order to receive religious instruction. These children lose a whole year of the public school work, and in some cases have lost step with their fellow pupils of the public schools to such an extent that they are scarcely able to begin again where they had left off.
A child may bo deficient in all his school branches, or he may show himself deficient in but one. If in certain grades this one subject happens to be arithmetic, it may prevent his making normal progress; in other grades it is language that is a great obstacle to progress. For this reason the items most deficient in and best in are recorded. Statistics obtained from large numbers of children will also throw some light on the question whether mentally deficient children commonly manifest ability and memory for some single line of thought or activity like music, drawing or manual work. It is a common belief, although not supported by sufficient evidence, that the public school system does not appeal to the capabilities of children who are exceptionally gifted in one line and possessed of counterbalancing deficiencies in other lines. The child whose blank we have taken as an illustration had been only one year in school, and the absence of any record in the appropriate space leads us to believe that his deficiency in progress was manifested in all the work of the school.
Certain habits of life are found to exist among school children, which seriously interfere with their progress. Among these are the use of tobacco and injurious beverages, like tea and coffee and even beer and whiskey. Under habits I also recorded the amount and kind of food eaten at one or more meals, but especially at breakfast. Immoral practices are also to be recorded in this connection, but these should not be inquired into in every case. It seemed the better part of discretion to record facts of this kind only when brought to my attention by teacher or principal in those cases where such practices were notorious.
The family life may retard the progress of a child in school, in so far as it affects his health, nutrition, support, his care and discipline. The relation of these factors to retardation was discussed in my last article. In addition to these, a few other items concerning the family appear of sufficient importance to warrant the making of a record. If the child has lost one or both of his parents, the probability is that there has been a reduction in care, nutrition and health, for parents must be presumed to take a deeper interest in the welfare of their children than do relatives or friends. In the case of the father’s death the children are often neglected because the mother is’unable to bear the burden of support. Many mothers leave home early in the morning to go to work and return late in the evening; the children are left all day
No. X Name ^3^/yOJ ^/VVxV^O Grade Class ^ 190 Address r> Grade Class ij 190 “f Address SO’K V XOtwL School s 190 Teachef School \T/<0(/VUaJl> ^ 190 T Teacher Progress E G F D Date of birth <bjOO Age 1 Conduct E G F D Age on entering school (o No. years In school | Attendance vR l I vl A School history (Rel) (c> mom; ?)3 fiA-swJc Most deficient in Q Habits . -W-> +” JWlOjcL & fk. O^XbK) ^.T”jooJ . 1 ‘ 5 4 3 2 1 5 4 3 2 1 Father li^img dead Normal vG G M SI D Deficient BlwIHIM II Id Mother liVuig dead Health vG G F P^P Home Care vG G P Ij/vP^ Step-father, Steja-mother Nutrition P G M V St ” Culture vG G F P vP Nationality F.( ftxAufcAuVvO Support R W M VVp ” Discipline vG G P P v| ~ a M.I Occupation of provider h p A A K ) Birthplace 9/^uJLol- ? fchlld works at Lives with 0/<xhJL/viA^ Anormality Asymmetry Home Land. V>ldMJtOTr?nK G&UV C/mJtockdb Older brothers HvingQdeadQArms tr sisters ” 0 ” OLegs Younger brothers ” ^ ” O Hands ? sisters ” 0 ” 0 Feet Eye, R. ) ^ Cranium Eye, L. } ^ Forehead Defects Face Disease Ears Ear, R. 10 Eyes O ) ?rh Ear, L. tT j ‘ U Nose Defects Lips Disease . Palate Co-ordiryition 5 4*21 Tonsils vB Bffld Norm Shy vS Naso-ph’nx Am Resp Paks Sull Sur Mth Breathg Sto In A1 No*/ vN Teeth vR Red NcVm Imp vl Tongue (j Stu Wilf Firm Flex Voice Stammer (inf) 5 4 3 2 1 Speech Stutter 5 4 3 2 1 Diseases . Pilled in by . Ac.KD H Date .. .(LaaAJJ.1!. <vwjJ3j huA. AAOsAxtxi. ^ Laboratory of Psychology, University of Pcnnsylvanii(Tho J7 Lewis Crozcr Fund. *
with no one to provide for their wants or to oversee them excepting when at school. The children of many mothers, who are the support of the family, find it difficult to obtain even one good meal a day. When such children are questioned they usually report tea and bread for breakfast and the same for dinner; some children go to school without breakfast. The loss of the mother is also very unfavorable to good home conditions. Tier place may be taken by a step-mother, but the phrase “a step-mother’s care” has lived long enough in the language of the race to persuade us of its significance. The loss of either father or mother is also an indication of the severity of the struggle for existence on the part of the immediate progenitors of the child, or it may point out a possible lowered resistance to disease.
The blank, therefore, provides for recording whether the child’s father and mother are living or dead and whether the child has a step-father or step-mother. There is also a space provided in which to record with whom the child lives. A child may be living with relatives, guardians or acquaintances, who provide it with a home life distinct from that of its own father and mother. Abnormal home conditions are sometimes brought to light which are significant. If the child is asked whether he lives with his parents he will invariably respond in the affirmative, even though he may be living with only one of them. If he is asked, “Do you live with your father and mother?” he will invariably answer, “With my father,” or “With my mother,” if he is living with but one of them. A record which shows a living father must not be taken to demonstrate the fact that the father is the support of the child or even that the child is living with the father. The blood relations of the child are often in no wise responsible for the child’s support and home care.
The language of the child’s home may be an important factor in producing retardation in school progress. Some children of foreign parentage are retarded for several years because they are not equipped with a knowledge of the language of the school and many school systems fail to provide for proper instruction in the English vocabulary. Every large city has some sections where the children, even at play, speak a foreign language. The necessary information to estimate the importance of this factor in an individual case is given in connection with the items nationality F and nationality M, which provide for the record of the nationality of the father and mother, and with birthplace and home language. When a child is foreign born I found it convenient to inquire as to its age at the time of immigration and I sometimes recorded this in connection with the item birthplace. Even English-speaking children who come to this country at eleven or more years of age lose at least a year on account of the difference in the curriculum. The remaining items with which we have to deal are concerned with the child’s physical condition.. We obtain some indication of the child’s physical vigor, vitality and viability when we know the number of brothers and sisters living and dead. It is very difficult to ask a child or even an adult the necessary questions in such a manner as to elicit exact information of the character we desire. The blank records data in a way that appears to present the question in the best possible form for answer. A numeral records the number of older brothers living and dead, the number of older sisters living and dead, the number of younger brothers living and dead and the number of younger sisters living and dead. The boy whose blank we have taken as an illustration has two younger brothers, both of whom are living. The information obtained from these items is very meagre. Wo know only that he is the first child. According to some authorities, the first child is more apt to suffer from accidents of birth than later children. A physician interested primarily in the child’s physical history would want to know very much more in this connection than is provided for by the blank. For example, he would require a history of miscarriages. No matter how valuable such data may be, it would be undesirable to make an effort to obtain them. It is only when children are brought for examination to a clinic by father or mother that such facts can be ascertained. Discretion as well as the limitation of time render it necessary to omit many other items, for example, the birthplace and condition of the grandparents. The blank probably provides for as many items in this connection as it is wise and convenient to endeavor to obtain.
The purposes of the blank must be borne in mind when we examine the remaining items which deal with the physical condition of the child. Space is provided for an entry of the results of a brief examination of eyesight and hearing and for the record of marked anormalities or asymmetries of the trunk, arms, legs, hands, feet, cranium, forehead, face, ears, eyes, nose and lips. Space is also provided for a record of anormalities that arc often associated with naso-pharyngeal obstruction,?leading in some cases to a diagnosis of adenoids. Thus, the condition of the palate is to be observed, the tonsils, the naso-pharynx, tho teeth, the tongue. If mouth breathing exists, it is to bo recorded; the voice is to be observed for symptoms of adenoids and the quality of speech is to be recorded for the same purpose. Finally, a brief record is to be made of the diseases from which the child has suffered during infancy and childhood. The examination from which this record will be filled out is superficial and is directed only to the ascertainment of striking defects. Time is wanting, nor is it practicable to subject a child to an extensive physical examination. A. child ought not to be touched nor can many instruments be used to facilitate the work of the examination. A medical inspector may perhaps use a tongue depresser, but experience in some cities has shown that even they had better employ some such common article as a spoon for the purpose. The tests which I employed excited no criticism, excepting in the case of one child who refused to take part in the test of hearing, for which I employed an instrument. I feel that I went as far as it is wise for any one, excepting a medical man, to go, and that even the medical inspector could not take much more advanced measures without awakening a storm of criticism. From the standpoint of medical inspection, such results as I obtained with this blank must necessarily be unsatisfactory, but this same criticism holds good also of much of the medical inspection that is made in the schools to-day, excepting in so far as it relates to the discovery of contagious diseases and parasites. From the nature of my investigation it was impossible to make anything like a thorough examination of sight and hearing.
The limitations of time and the lack of proper rooms and instruments practically confined my work to a hasty test of the child’s ability to see and hear. To examine eyesight, I employed Snellen’s test cards, both the alphabet and illiterate types, the latter for children who did not know the alphabet. “Where the child’s familiarity with the alphabet was in doubt, a brief preliminary drill was employed to determine whether the inability to read the line was due to ignorance or defective vision. None of the children examined by me were under ten years of age, and I seldom was compelled to resort to the illiterate card.
On account of the dimensions of most of the rooms in which I tested the eyesight of the children, I was obliged to make use of the ten-foot line. In making my tests, I placed the cards so that the ten-foot line was about level with the eyes and squarely in front of the child. I placed it so’ as to be in a good light and to avoid strong reflections. If the child wore glasses, I tested him with and without them. Both eyes were tested together and each separately. During the test I always looked at the child to be certain that when one eye was tested the other was covered and to observe excessive hesitation and signs of eye-strain. In cases of strain and marked hesitation, the child was asked to move toward the cards until the letters on the line were read easily. Before beginning the test, I laid off a ten-foot range, which I subdivided into feet. When, therefore, the child moved from a distance of ten feet to a shorter distance I was able at once to note the distance in feet at which he read the line. The blank on page 2G0 shows that John Smith read the ten-foot lino at a distance of seven feet with both eyes, and the ditto marks opposite eye R and eye L show that with each eye separately he read the line at the same distance. His sight is therefore sufficiently defective to justify the recommendation that his eyes be examined by an oculist.
Various tests are employed to measure the acuity of hearing. All of these fall into one or the other of two classes; the first is a speech test, and the second is a test with mechanical sounds. The speech may be either whispered or conversational. Undoubtedly tho test which employs conversational speech is of the greatest value, for. it tests tho child’s ability to hear conversation, upon which depends his apprehension of oral instruction in tho school room. A conversation test, however, is objectionable because it requires a very large room. To avoid this difficulty tho whisper test is usually employed as a substitute. Both speech tests are open to the practical objection that the intensity of tho sound cannot be kept constant. Moreover, much time is required to carry out the tests satisfactorily, and tho results vary with tho acoustic properties of different rooms, depending upon their sizo and shape and upon convection currents duo to tho unequal heating of the air. Similar objections may bo offered to tho employment of mechanical sounds for testing hearing. Tho watch, tho Politzer acoumeter, tuning forks, and specially constructed audiometers, aro the instruments usually employed. No instrument has yet been devised which furnishes a constant and accurately measured standard of sound intensity. In my tests I employed an audiometer which is to l>e recommended, not as an instrument of precision, but as a convenience for rapid testing.
This audiometer consists of a box, six inches by seven inches by eleven inches, divided by a partition into two parts. In ono compartment of the box is placed a small clock as the sourco of sound. Tho other compartment contains a specially contrived stop-cock connected with a metal tube, which at one end divides into two branches for conducting tlic sound impulses to eacli of the two ears. These two branches project about an inch beyond the box. To these, when the instrument is to be used, rubber tubes are attached, which connect with the ear-piece of a binaural stethoscope. The stop-cock which regulates the size of the opening through which the sound is allowed to pass, is connected with an index finger moving over a graduated disk, arbitrarily divided into one hundred divisions. When the index finger points to the zero mark, the tube is open to its fullest extent. When it points to one hundred, it is entirely closed. The least audible sound for most normal ears is obtained with the index finger at the mark 92. The instrument is provided with two other stop-cocks, one on each of the two branches of the tube. These are to shut off the sound instantaneously from one of the two ears and without the subject’s knowledge. The advantages of this audiometer are found in the convenient variation of the intensity of the sound and its measurement with some accuracy on an arbitrary scale, and in the ease with which the sound can be shut off from one or both ears so as to test the reliability of the subject’s responses. With this instrument the child whose hearing capacity is measured by 70 for the right ear and by G5 for the left ear (see blank on page 260) has subnormal hearing in both ears, the left being slightly more defective than the right. This record, especially when taken in connection with facts which give rise to the suspicion of adenoids, is sufficient to warrant his being referred to the medical inspector or to a medical clinic for the nose, ear and throat, for examination and treatment. Spaces are provided for the record of disease and defects of the organs of sight and hearing. It is intended that only those diseases and defects shall be recorded which attract attention on superficial examination. These include sore and inflamed eyes, strabismus, nystagmus, certain readily observed defects of pupil and iris, a running ear or a perforated ear drum.
Ample space is provided to record marked anonnalities and asymmetries of bodily members and their functions. It is impossible in this article to attempt a statement of the various physical anormalities and asymmetries that may be reported under this heading. Defects may be recorded for their own sake or because they have diagnostic value as symptoms or stigmata of degeneration and arrested development. The reader must be referred to the copious literature on this subject for information as to the particular defects which may be considered worthy of being recorded. What will be recorded will depend very largely upon the extent of the information possessed by the investigator, on the purposes of the investigation, and on the interest which the investigator may take in the association of physical defects with retardation. I made no attempt at a thorough examination or record of minute deviations of different parts of the body from the normal type, whether in structure or function. My record of the boy whose card I have taken for an illustration shows the cranium and forehead to be smaller on the right side than on the left. It is also reported that the ears are large and outstanding. All the other items recorded have a significance in connection with the diagnosis of naso-pharyngeal obstruction. The chest is reported to be contracted, the tonsils enlarged, the voice muffled, and the speech nasal. He is also reported to have badly decayed teeth, which are frequently found associated with enlarged tonsils and adenoids.
The last item on the blank to be considered is diseases. These include measles, chicken pox, mumps, scarlet fever, diphtheria, whooping cough, meningitis, and convulsions. On the card reported above, no diseases are recorded. This was the case with very many cards. It does not mean, necessarily, freedom from disease during infancy, but perhaps only lack of information. It is difficult, if not impossible, to extract satisfactory information from the child, and I believe that physicians encounter the same difficulty in obtaining accurate information even from the parents. It must be borne in mind that an investigation such as I conducted can only endeavor to obtain the fullest and most exact information possible under the circumstances. We are now prepared from examination of the record of Jonh Smith to make a tentative statement of the causes of his very deficient progress in school work. lie is seven years of age and has been in attendance at school one year. There is no evidence to be had from the blank that deficient progress is due to inefficient instruction, nor can it bo ascribed to delay in entering school, or to irregularity in attendance. He is the child of Russian ?Tews who speak Yiddish at home. This may bo responsible to some extent for his inability to progress at school, but it must bo remembered that the child was born in this country, and other Kussian Jewish children under similar circumstances are pr?” grossing normally in school work. Ifc is rather to the naso-pharyngeal obstruction, the result of poor nutrition, due to insufficient support at home and deficient home care, that I would attribute his retardation in school work. The nasal speech, the muffled voice, the enlarged tonsils, the contracted chest, the subnormal acuity of hearing, his nervousness, and even his vacillating will, are a group of phenomena which suggest adenoids. Adenoids are merely an enlargement or hypertrophy of lymphatic tissue in the naso-pharynx. They may be due to the very decayed teeth, which act as a source of infection to the tonsils and adenoid tissues. The naso-pharyngeal obstruction and the decayed teeth may both result from the insufficient nutrition, the presence of which is attested by the customary breakfast of coffee, bread and cake.
The remedies to be suggested in this case are partly medical and partly social. He should be referred to the medical inspector and taken by his parents or a school nurse to a clinic for nose and throat diseases for examination and treatment. The insufficient nutrition may be due to the impoverished condition of his parents, or to ignorance. The solution and treatment of this problem must be left to the various social and philanthropic agencies, which in our large cities are beginning to attack the problem with determination and scientific insight.
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