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