The Prevalence of Visual and Aural Defects Among the Public-School Children of St. Louis County, Mo
The Psychological Clinic Vol. III. !N”o. 6. November 15, 1909. :Author: Albert E. Taussig, M.D. St. Louis, Mo.
The following investigation, the funds for which were generously supplied by Mr. B. Greensfelder of Clayton, Mo., was undertaken under the auspices of the St. Louis School of Philanthropy, at the suggestion of its director, Prof. Thomas J. Riley. The measurements were made by Drs. J. G. Calhoun and C. A. Vosburgh of St. Louis, under the general direction of the writer. The prevalence of physical defects among city children has been thoroughly investigated at many places both in this country and abroad and there can be no longer any difference of opinion as to the necessity for thorough medical inspection in city schools. Much less is known as to the prevalence of such defects among the school children in suburban and rural communities, and yet such information is indispensable to enable the state authorities to form a just opinion as to the advisability of inaugurating a state-wide medical inspection of all school children.
It seemed worth while to undertake such a study of the school children of St. Louis County for the purpose of adding to our knowledge in this matter. The present investigation was limited to the prevalence of impaired vision, defective hearing and well marked adenoids. Some two thousand children were examined in the public schools of Wellston, Clayton, Webster and Tuxedo, suburban communities in the neighborhood of St. Louis. The eyes were tested by means of Snellen’s charts hung in a good light at a distance of twenty feet, each eye being tested separately. Such an examination, however, fails to reveal the presence of hyperopia, a frequent cause of eye-strain in younger children, and our figures for impaired vision among the youngest children are therefore probably somewhat too low. It seemed best to omit the tests for hyperopia not only on account of the added labor involved, but also to facilitate a comparison of our results with those obtained elsewhere by examinations limited to the use of Snellen’s charts. .
The hearing was tested by means of a standard whisper, audible to normal ears at a distance of fifteen to twenty feet, each ear again being tested separately. Adenoids were recorded as present only where they clearly interfered with nasal respiration and thus represented an actual handicap to the child. Records were kept on cards arranged as follows:
Age at Name G. Q.1 Nearest Birthday Left Eye v = 20/ Right Eye v. = 20/ Spectacles ? Yes. No. Date School Right Ear, Whisper Heard Ft. Left Ear, Whisper Heard Adenoids ? Yes. No. Examiner
1. The Total Percentage of Visual and Aural Defects. Of the two thousand children examined some 30.6 per cent had vision that was below normal in one or both eyes. In about half of these children, however, this defect was not sufficiently grave to signify a real handicap. A little over 14 per cent had vision that was less than two-thirds of the normal in both eyes. This is a serious defect and such eyes urgently demand proper glasses. The extreme cases of visual impairment were rather rare, the children with vision less than half the normal in both eyes being a little less than 3 per cent of the total number examined. These findings about correspond to the observations made elsewhere, as illustrated by the following table: *G. Q. stand for Grade and Quarter.
VISUAL AND AURAL DEFECTS 151 VISUAL, DEFECTS IN PUBLIC SCHOOLS.
Per Cent Heidelberg, Germany (1870)2 35 Edinburgh, Scotland (1904)3 43.2 Dunfermline, Scotland (1907)3 17 Cleveland, well-to-do district (1907)3 32.4 Cleveland, congested district (1907)3 71.7 Massachusetts, except Boston and environment (1907)3.. . 19.9 Boston and environment (1907)3 30.7 Boston (1908)4 23 New York City (1906)3 31.3 ISTew York City, Borough of Manhattan (1908)5 10.2 Chicago (1909)6 19.4 Jefferson City, Mo., either eye (1908)7 36.5 Jefferson City, Mo., both eyes (1908)7 22.7 St. Louis County, Mo., either eye less than 20/20 (1909). 30.6 St. Louis County, Mo., both eyes less than 20/30 (1909) . 14.3 St. Louis County, Mo., both eyes less than 20/40 (1909). 2.8 All of these figures are probably a little too small, since they do not include cases of hyperopia or of moderate degrees of astigmatism. Their most striking feature is their lack of uniformity. For this several factors are probably responsible. In the first place, there is no agreement as to what constitutes defective vision. In some cities everything less than perfect vision for each eye is reported as defective. Elsewhere vision by both eyes must be less than perfect or must even be less than 20/30. The last would seem a rational criterion since it alone involves a real handicap. It would seem, too, that in congested districts visual defects are more prevalent than elsewhere, as is shown by a comparison of the figures for Edinburgh and Dunfermline, between the two portions of Cleveland and between Boston and the rest of Massachusetts. Finally the drop in the percentage of visual defects 2A. Colsman, Die iiberhandnehmende Kurzsichtigkeit unter der deutschen Jugend, etc., p. 10. Barmen, 1877. SL. *H. Gulick and L. P. Ayres, Medical Inspection of Schools, p. 83. New York, 1908.
Calculated from table, p. 43, Report on Dept. of School Hygiene, Boston, 1908. “Personal communication from Dr S. J. Baker, Chief of Division of Child Hygiene. “Bulletin Chicago School of Sanitary Instruction, April 3, 1909. 7C. M. Sneed and G. M. Whipple, The Psychological Clinic, Vol. II, No. 8, January, 1909, p. 236. 152 THE PSYCHOLOGICAL CLINIC in Boston between 1907 and 1908 and in New York City between 1906 and 1908 may, at least in part, be due to the beneficial effect of systematic school inspection. A similar divergence is seen in the figures for defective hearing. Among our children over 7 per cent were found defective in either ear, whereas the number able to hear the standard whisper with neither ear, at a distance of over ten feet, was only a little over 2 per cent. This corresponds fairly with results obtained elsewhere:
DEFECTIVE HEARING IN PUBLIC SCHOOLS.8 Per Cent Edinburgh, Scotland (1904) 12.2 Dunfermline, Scotland (1907) 4. Cleveland, well-to-do district (1907) 5.2 Cleveland, congested district (1907) 1.8 Massachusetts, except Boston and environment (1907) … 5.8 Boston and environment (1907) 7.7 Boston (1908) 7.6 New York City (1906) 2. New York City, Borough of Manhattan (1908) 1. Chicago (1909) 2.7 Jefferson City, Mo., either ear defective (1908) 7.7 Jefferson City, Mo., both ears defective (1908) 1.3 St. Louis County, Mo., either ear defective (1909) 7.3 St. Louis County, Mo., both ears seriously defective (1909) 2.2 Here, too, our figures suggest that the variation in the results obtained elsewhere may, at least in part, be due to the fact that in some places any departure from the normal is recorded whereas in others only a serious defect is counted. Adenoids sufficiently well marked to interfere seriously with nasal respiration were found in less than 1 per cent of our children. This is distinctly less than the findings elsewhere. New York City (1908) 16.4 per cent * Boston (1908) 4.7 ” Chicago (1909) 3.7 ” St. Louis County 0.9 ” “See references for previous table. “See references for first table. VISUAL AND AURAL DEFECTS 153 The low percentage of adenoids among our children is probably partly due to the fact that we included only well marked cases. It is also doubtless influenced by the probability that in an intelligent suburban population an unusually large proportion of the children suffering from adenoids receive proper surgical attention. It is of interest to note that, without exception, every one of our cases of adenoids had markedly defective hearing. 2. Influence of Sex Upon Vision and Hearing. On the whole it would seem that defective vision was a little more prevalent among girls than among boys, whereas the reverse is true for defective hearing. Gulick and Ayres have made the same observations in New York in regard to visual defects. INFLUENCE OF SEX UPON VISUAL AND AUDITORY DEFECTS. Per cent Boys Girls
New York City (1908), defective vision10 15.7 20.8 St. Louis County (1909), defective vision 29.1 31.1 St. Louis County (1909), seriously defective vision 13.5 15.1 St. Louis County (1909), defective hearing 8.7 6.0 These differences as found in St. Louis County are probably too small to have any definite significance. 3. The Influence of Age Upon the Frequency of Physical Defects. In their careful study of New York City school children published last year, Gulick and Ayres made the very interesting observation that the frequency of defects tends steadily to decrease as the children grow older. This furnishes them with an explanation for their finding that in each grade the over-age children on the average have fewer physical defects than those of normal age. In our schools the same observation was made, as is shown by the following table. Our figures are uniformly lower than those of Gulick and Ayres since their records included a large variety of defects, while ours were limited to vision, hearing, and adenoids.
10Gulick and Ayres, p. 199. 154 THE PSYCHOLOGICAL CLINIC INFLUENCE OF AGE UPON PREVALENCE OF DEFECTS. PER CENT OF CHILDREN WITH DEFECTS Age Guliek & Ayres” St. Louis Co. 6 82.9 40.4 7 . 86.5 47.8 8 85.8 51.8 9 81.8 41.6 10 77.8 38.1 11 73.8 35.4 12 69.9 35.4 13 68.0 34.3 14 68.1 27.4 15 63.1 27.3 Over 15 23.9
A closer study of the data, however, discloses a very curious divergence on the part of our observations from those previously made. Gulick and Ayres, while they found a steady decrease in the prevalence of physical defects as the children grow older, noted that the frequency of impaired vision seemed, on the other hand, to increase with age. Observations made in Germany12 show this fact even more strikingly, the percentage of shortsighted children increasing from a small per cent in the lowest grades to nearly 100 per cent in the highest. In our schools, on the other hand, a contrary tendency showed itself. With the exception of the first two years the frequency of short-sightedness seemed steadily to diminish with increasing age. This is most striking if we tabulate only the unrecognized visual defects, i.e. if we count as normal those whose defective vision is perfectly corrected by glasses. The phenomenon appears, however, hardly less clearly if we count as defective even those wearing correct glasses. The following table contrasts the observations of Gulick and Ayres with ours:
“Gulick and Ayres, op. cit., p. 195. 12A. Colsman, loc. cit. VISUAL AND AURAL DEFECTS 155 INFLUENCE OF AGE UPON PREVALENCE OF VISUAL DEFECTS. PER CENT OF CHILDREN WITH PER CENT DEFECTIVE VISION WEARING GLASSES Gulick & Ayres’3 st. Louis Co. St. Louis Co. Age Uncorrected14 Totalis 6 7 8 9 10 11 12 13 14 15 Over 15 29.4 29.4 0 41.0 41.0 0 17.5 42.5 44.1 2.1 20.2 32.5 32.9 0.4 25.0 32.3 . . 34.1 3.4 23.9 28.3 32.7 6.6 26.5 28.8 32.3 5.2 23.7 27.2 28.7 2.5 27.7 21.7 22.3 1.7 25.6 20.9 22.7 2.7 17.7 22.1 8.0
About 3 per cent of all the children wore glasses of which two-thirds were approximately correct while one-third were definitely incorrect.16 The explanation of the divergence of our results from those obtained by others is not readily apparent. Why should the eyes of our children improve with age when those of city children tend to deteriorate ? It is not due to any greater care on the part of parents, for the percentage of unrecognized and uncorrected visual defects is as great in St. Louis County as elsewhere and the percentage of visual defects corrected by glasses does not increase with the age of the children. Perhaps the smaller classes of suburban schools enable the teachers to give their .pupils more individual attention and so to prevent undue eye-strain. Or it may be that the favorable hygienic surroundings of suburban children make it possible for visual defects spontaneously to correct themselves. The graver visual defects tend to become fewer with advancing age quite as definitely as the slighter ones, as shown by the following table. The greater irregularity of the fluctuations in the subdivisions of the visual defects is probably due to the fact that we are dealing with smaller figures.
“Gulick and Ayres, p. 195. “”Uncorrected” includes all children whose defective vision has not been fully corrected by glasses. “”Total” includes all children with defective vision, whether corrected by glasses or not. “The chief cause of this deplorable condition is probably the fact that glasses are often prescribed by opticians rather than by oculists. 156 THE PSYCHOLOGICAL CLINIC INFLUENCE OF AGE UPON SLIGHT AND GRAVE VISUAL DEFECTS. PERCENTAGE OF CHILDREN WITH VISUAL DEFECTS Age All Visual Slight Visual Serious Visual Grave Visual Defects Defects Defects (Vision Defects (Vision of both eyes of both eyes less than 20/ 30) less than 16/30) 16.7 12.7 0.9 20.8 20.2 2.8 16.6 25.9 2.6 6 7 8 9 10 11 12 13 14 15 Over 15 29.4 41.0 42.5 32.5 32.2 28.3 28.8 27.2 21.7 20.9 17.7 18.2 14.3 1.7 19.0 13.2 3.9 19.0 9.3 3.2 14.0 14.8 4.4 14.6 12.5 4.0 11.7 10.0 2.3 10.0 10.9 1.8 7.1 10.6 2.7
The gravest lesions alone show an irregular increase up to twelve years, but thereafter diminish. Such an increase is to be expected, since it is well known that short-sightedness tends to grow worse under the influence of school work. The surprising feature of these observations is that this increase it not seen in any but the gravest defects and even here not after the age of twelve.
Defects of hearing are not definitely influenced by age, as may be seen by the following table. I have not been able to find other observations for comparison.
INFLUENCE OF AGE UPON DEFECTIVE HEARING. ^ PERCENTAGE OF CHILDREN WITH DEFECTIVE HEARING Age -Age 6 11.0 ? 12 6.6 7 6.8 13 7.1 8 9.3 14 5.7 9 9.1 15 6.4 10 5.9 Over 15 6.2 11 7.1
The extreme cases of adenoids were too few in number to render a classification by ages trustworthy. So far as our figures went, however, they indicated an increase in frequency up to 2.5 per cent at. the age of ten years and thereafter a diminution. Gulick and Ayres17 with their larger material found a steady decrease in frequency from six to fifteen years.
“Gulick and Ayres, p. 195. VISUAL AND AURAL DEFECTS 157 4. Have Physical Defects an Important Bearing on School Progress?18
This problem has apparently never been properly approached. Gulick and Ayres19 divided the children in each grade into those of normal age and those over age. The latter are those who for one reason or another have been retarded in their school progress. They found, nearly constantly, a greater frequency of physical defects in each grade among the children of normal age than in those above the normal age. At first sight this might seem to show that physical defects are conducive to school progress. As they point out, however, it is clear that since the frequency of physical defects tends to decrease as the children grow older, children in each grade who are above the normal age will have fewer defects than those of normal age, just because they are older. This method can therefore not lead to any solution of the problem. It is better to approach the question from the other side. If for each age we determine the average grade of all the children of that age, such an average grade can be calculated for normal and for defective children. If at each age the normal children will, on the average, be found to have attained a more advanced grade than the physically defective ones, we may fairly conclude that these defects have proved a handicap to school progress, and the difference between the average grades will be an approximate measure of this handicap. The word “grade” is here used in the technical school sense, signifying a stage of scholastic progress. In our schools the children begin with the first grade, advancing annually, on the average, one grade up to the eighth. For purposes of comparison I have called the high school the ninth grade. When we tabulate our data according to this method we obtain the following table. It will be seen that, on the whole, the children with visual or aural defects make slower progress at school than their normal mates. The difference is not, however, nearly so great nor so constant as we might a priori expect; indeed, about half the time this difference is practically negligible. Moreover, the children with grave visual defects have apparently not at all lagged behind those with slighter visual impairment.
18It must be remembered that in this discussion the term “school progress” is used to indicate the rate at which the children advance from one grade to another. It has nothing to do directly with the quality of the school work or the rate at which they acquire knowledge. In the ideal school, “school progress” will depend directly upon the quality of the work done by the children; practically, however, as appears below, this is apparently not the case. “Gulick and Ayres, p. 191 ff.
AVERAGE GRADES OF NOKMAL AND DEFECTIVE CHILDREN. Age Normal Children with Children with Children with children visual de- serious vis- impaired fects ual defects hearing (both eyes less than 20/30) 6” 7 8 9 10 11 12 13 14 15 Over 15 1.1 1.3 2.2 3.0 3.7 4.0 5.0 6.2 7.0 7.8 8.7 1.1 1.6 2.1 2.8 3.3 4.0 4.9 5.9 7.0 7.6 8.4 1.1 1.7 2.1 2.6 3.2 3.7 5.2 5.7 7.4 7.7 7.8 1.1 1.7 1.7 3.0 3.8 4.0 4.5 5.9 6.3 6.9 8.3
The question naturally arises: “Why do not these physical defects cause a greater and more. constant retardation in the children’s school progress ?” There are apparently no data at hand upon which to base a reply. Perhaps physical defects have actually but little bearing upon school progress though this seems inherently improbable. A possible explanation has been suggested by a number of teachers who followed our work with interest. They ascribe our findings to the undue prevalence of the so-called “lock-step.” At the end of each preordained period, practically all the children are promoted to the next higher grades, irrespective of whether they have done their work well or ill. The dullards ore pushed along with their brighter fellow students and the latter are held back to allow the former to keep pace with them. An exception is made only occasionally, when the pupil is extremely quick or extremely deficient. Under these circumstances the school work of the children with defective vision or hearing might be seriously hampered without their school progress, as shown by a table like the above, being definitely retarded. Conclusions.
The following conclusions may fairly be drawn from our data:
1. Unrecognized or at least untreated defects of vision and hearing are nearly as common in our suburban communities as in large cities. Both call urgently for systematic medical inspection. 2. Unrecognized adenoids, so extreme as to cause serious interference with normal respiration, were not found to be very common. In nearly one per cent of the children, however, the adenoids imperatively demanded operation. The condition was apparently not realized by the parents and here, too, adequate medical inspection might be of great service to the children so affected. It is probable that the marked deafness, present in every one of the children with adenoids, would disappear promptly after operation.
3. Defective vision seems a little commoner among girls and defective hearing among boys. The difference it not, however, very great. 4. In other communities a progressive increase in the prevalence of impaired vision was noted as the children grew older, whereas in St. Louis County the reverse was found to be true both as regards slight and grave defects. The explanation of this fact is not readily apparent. It does not, however, furnish an argument against inspection, since at the best these defects are common enough. The fact that one-third of the children with spectacles wore unsuitable glasses is also suggestive in this respect. 5. Our data show that to a certain, though not very great extent, the children with impaired vision or hearing progress more slowly in their school work than their normal fellow students. The evil effects of unrecognized physical defects may, however, go far deeper than this. If it is true that, to a great extent, children are promoted from one grade to the next irrespective of the quality of their school work, the brighter children are necessarily held back to a pace that can be followed by the dullards. It is clear that the latter class will in part consist of children mentally normal but handicapped by impaired hearing or vision or by other remediable defects. Adequate medical school inspection would lead to the recognition and, to a great extent, to the correction of such defects. Such children would then not only themselves be able to do better work, but by ceasing to act as a drag upon the normal children would enable the latter to progress more rapidly. The efficiency of school inspection, in this respect, is shown by the fact that in cities in which this measure has been in operation for some years, a considerable diminution in the prevalence of physical defects has been noted.
6. The marked divergence between the data obtained in different cities, or in the same city by different investigators, indicates the need for greater uniformity in methods of tabulating these statistics. Thus children with slightly impaired vision in one eye would by some examiners be classed as normal, by others as defective. For statistical purposes it is important for the investigator to state just where he draws the line between defective and normal. As regards vision, hearing, and adenoids, a division into slight and serious defects is to be recommended. Appendix.
It is probable that in future investigations, the bearing of physical defects upon school progress can best be estimated by calculating the average grade for each age in normal and in defective children. The problem, arithmetically, is an interesting variation of the method of determining the point of equilibrium! of a straight lever. The number of children in each grade is multiplied by the number of the grade. The sum of these products divided by the total number of children gives -the average grade. Example: Normal children aged eight years are divided among the first four grades as follows, the total number of normal children of this age being 94: Grade Number of Children Product 1 x 17 = 17 2 x 50 = 100 3 x 26 == 78 4 x 1 = 4 94 199 199 2.16, the average grade of normal children aged eight years. 94
If we regard as a unit of work done, the passing through one grade of one child, then towards the end of the school year, the 17 children in grade 1 will have done 17 units of work. The 50 children in grade 2 will, during their school life, have done 100 units of work, the 26 in grade 3 will have done 78 units, etc. Thus the 94 normal children aged eight will have done 199 units of work and the average child will have done 2.16 units. The last will therefore represent the grade of the average typical child of this group. It is clear that unless artificially held back, the more fit a group of children is, the greater the number of units of work it will accomplish and the higher its average grade will be. Thus, in the absence of the so-called “lock-step,” the difference between the average grade, at each age, of normal children and those with any special defect will be a measure of the influence exerted by this defect upon school work. Or, on the other hand, assuming that such defect should seriously influence school work, the absence of such a difference indicates the prevalence of the “lock-step”.
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