The Nervous Disorders of School Children
The Psychological Clinic Vol. IV. IsTo. 3. May 15, 1910. :Author: Walter S. Cornell, M.D.
The practical purpose of this article limits it to a brief exposition of the conditions existing in a disordered nervous system, the causes of these conditions and the symptoms arising therefrom. ^To attempt has been made to discuss child psychology, adolescence, mentally deficient children, difficult children and kindred subjects. The study of nervous disorders is greatly simplified by reason ?f the fact that many apparently diverse affections are really expressions in different degree by different parts of the nervous system of the same faults. This is true particularly of general nervousness, neurasthenia, chorea, habit-spasm, migraine, epilepsy, hysteria, and neuralgia.
The following propositions may almost be taken as axioms lrx the study of neurology. 1. Heredity influences the nervous system more than any other tissue. Original stability on the one hand, or an inherent weakness and tendency to exhaustion on the other, largely predetermine the existence of nervous health or disease in childhood. 2. The principal exciting causes of nervous disorders are anaemia, reflex irritation, intoxication of the system, and injury of the brain and spinal cord. 3. Increased sensibility and irritability, rapid fatigue, and lack of emotional control are the three fundamental conditions underlying the various nervous disorders named in the next paragraph, and existing in these disorders singly or in combination. 4. Ordinary nervousness, neurasthenia, hysteria, epilepsy, migraine, habit spasm, chorea and neuralgia are expressions of the three conditions just mentioned, manifested singly or in combination. The more severe of these, epilepsy, hysteria, and migraine, are frequently found in persons of the same family, The causes of the nervous disorders of children are both predisposing and exciting. The predisposing causes are?1. An inherent weakness and irritability of the nervous system,?the so called neurotic constitution. 2. Poor general health. 3. Improper social habits. 4. Dissipation.
1. The neurotic constitution. Heredity is the most powerful and the most common cause of inherent nervous weakness. In such cases low physical, nervous, mental or social standards exist in the parents. Thus, one or both may have been insane, hysterical, illiterate, intemperate, or broken down from overwork. Lack of vigor and of nervous stability if present, are manifested early in life. Indigestion will produce convulsions in one baby and not affect another. A healthy school girl will endure without apparent effect a shock or fright which produces an emotional outbreak in her classmate. Adolescence is a period during which these morbid tendencies are particularly manifest, owing to the profound disturbance incidental to the evolution of many of the glandular structures and nerve centers. Occurring as it does coincidently with school life, irreparable damage is often inflicted on neurotic children by the double strain thus imposed upon them.
2. Poor general health. This may be the expression of numerous influences, particularly poor nutrition, anaemia, organic heart and kidney disease, or the depressing poisons of some recent infectious disease, such as typhoid fever or diphtheria. The explanation of the relation between lowered general health and nervous disorder is a very simple one. The nervous system suffers from starvation or intoxication in common with the other parts of the body, but its delicate and complex character makes it extraordinarily liable to injury and difficult to repair. 3. Improper social habits, such as late hours, loss of sleep, overwork, uncongenial work, unhappy home life, and the general depressing effects of poverty, all lower the vitality of the nervous organization and predispose it to exhaustion.
4. Vicious personal habits, including intemperance, are among the most powerful of influences contributing to this same end, and if indulged in at the critical adolescent period, when rapid development and internal readjustment are disturbing the nervous balance, they may be considered as actually exciting rather than predisposing causes. Unfortunately, the victims are of the very type destined to suffer most from any depressing influence. Their vivid imaginations, weak will power, and emotional nature make them an easy prey to such attractions as dissipation may offer. The principal exciting causes of nervous disorder are (1) the overstimulation of the nervous system, and (2) intoxication. 1. Overstimulation may be due to reflex irritation resulting from eye-strain, post-nasal adenoid growth, indigestion, intestinal worms, and menstrual disorders. Particularly do nervous symptoms arise from astigmatic eyes,1 and from nasal obstruction.2 Exhaustion may also be the result of continued mental irritation from friction at home or at school. Particularly is a high strung school teacher an unfortunate guardian for a nervous child, since two such emotional, poorly controlled natures react badly on one another to the misery of both. A nervous, poorly disciplined mother is a still worse influence on the child than an unsuitable teacher, and unfortunately in the class of children under discussion she usually exists.
Overstimulation may occur as a single severe shock. Thus emotional disturbance, particularly fright, is causative of general nervousness and of such special nervous symptoms as hysterical attacks, epilepsy, enuresis, disturbed sleep and chorea. Contrariwise the most narrow escapes from dangerous physical accidents usually make but little impression. Healthy children are repeatedly mentioned in the daily press as half-drowned, or rescued from burning buildings, but resulting nervous disorders are actually rare because danger is not appreciated until the imaginative faculty is developed. The average boy will carelessly risk life and limb stealing rides on street cars and wagons and climbing poles and roofs, but will be fretful for hours if scolded by his teacher, and paralyzed with terror if suddenly seized by a policeman for throwing a snow-ball. The viewpoint of the child is far different from that of the adult, a fact which cannot be too strongly emphasized. 1In astigmatism, the strain on the ciliary muscle of the eye, from its constant contractions while endeavoring to obtain a focus, frequently results in the most violent headaches and occasionally in irritability of temper, emotional outbreaks, nausea, and lassitude from nervous exhaustion.
‘Notwithstanding the exploitation of late, in the daily press, of adenoid growtns, as the cause of nervous defect and disorder, thereby creating a very imperfect conception of a complex subject, there is no doubt that they constitute the most powerful of any single influence. Medical and other scientific journals frequently present communications calling attention to mental deficiency, stupidity, lack of mental concentration and of memory, headache, dyspnoea, incontinence of urine, renex cough, chorea, habit spasm, night terrors, iritability of disposition, and epileptic convulsions, as the result of this condition.
2. Intoxication of the nervous system may be caused by numerous agencies such as kidney disease, gout, alcoholism, constipation and drugs, but fortunately only one of these, constipation (and indigestion), need be considered in the study of children. Indigestion and constipation are one of the principal causes of epilepsy, of acute rheumatism, chorea and headache. Probably a condition of faulty metabolism, akin to gout, exists in many children with resulting nervous manifestations, but too little is known at the present time to warrant more than this passing mention. Manifestations of Nervous Disorders. The essentials of a healthy condition of the nervous system are power and endurance in muscular movement, a sufficient but not excessive degree of sensibility, and a reasonable control over the emotions. Conversely the most prominent symptoms of a weak nervous constitution are (1) motor weakness, (2) over-sensitiveness and (3) lack of emotional control. Individuals so constituted are said to be neurotic. They form a numerous and easily recognizable class in every walk of life. (1) Motor weakness:?Children in whom this condition exists are often so listless and adverse to activity that their lack of animation readily distinguishes them. A more frequent condition and therefore even more characteristic is rapid fatigue. The children of this numerous latter group start the day refreshed by the night’s sleep and in the morning may display exuberant vigor and spirits. The nerve centers rapidly tire upon mental or physical effort, however, and a degree of exhaustion ensues which is in striking contrast to the apparent healthy condition of the period a few hours previous.
A poor control of muscular movement (poor coordination), if present, signifies that the motor centers are not acting in harmony owing to weakness in them or to lack of development of the association nerve tracts connecting them. A lowered tone of the sympathetic system may result in a general poor circulation with cold hands and feet, to excessive perspiration on slight exertion, and attacks of palpitation of the heart.
(2) Over-sensitiveness:?(1) Annoyance by loud sounds and bright light are symptoms due to hypersensitiveness of the auditory nerve or of the retina. (2) Hypersensitiveness to heat? cold NERVOUS DISORDERS OF CHILDREN. 69 and pain may be manifested by the general nervous system. (3) Hyperirritability of the sympathetic system is shown by too ready flushing, often to an uncomfortable degree. (4) Irritability of the motor centers leads to involuntary movement. This may merely be a condition of restlessness or fidgets, or may be severe enough to be classed as chorea or as habit spasm. In quiet children this condition may be betrayed only by a tense expression of the face, or by involuntary movements of the muscles of the forehead or jaw, or perhaps by general restlessness.
Excitement on slight provocation is evidence of brain irritability, and the gesticulations frequently accompanying excited speech furnish a common instance of the increased irritability of neighboring brain centers which ordinarily in health are not affected. This condition may be observed in the shrill tones unconsciously acquired by earnest speakers, especially when under the nerve strain incident to difficult work. The pitch of the voice constantly rises as the excitement increases, so that in extreme cases of nervousness it becomes very marked.
It would be a grave error, although one scarcely possible of occurrence, to mistake an excess of energy in a healthy child for irritability due to weakness. A vigorous boy, full of animal spirits, does not exhibit the drooping figure, rapid fatigue and emotional temperament of the neurotic child.
(3) Lack of emotional control:?This is evidenced by weeping, laughing, or outbreaks of anger on slight provocation. Other symptoms more or less related are great sensitiveness to criticism, weak will power, craving for sympathy, a vivid imagination, and a tendency to magnify real or imaginary misfortunes. The signs of nervous exhaustion and their significance once understood, the recognition of the various nervous symptoms displayed by school children becomes a comparatively simple matter. A list of those most commonly occurring is given below, both for its practical help, and as a demonstration of the applicability of the scientific truths just stated.
These nerve signs of fatigue are most marked at times when the child is tired, worried, or excited. Approaching examinations and entertainments are therefore particularly favorable seasons for the observation. The depression of spirits incident to the low atmospheric pressure existing before a rain storm produces a condition of nervousness well recognized by teachers.
1. General Nervousness.?”Nervous Children.” By far the greater number of these children cannot be classified more accurately than by the general appellation “nervous,” owing to the large number of possible symptoms and their numerous combinations. The general characteristic of weakness and irritability in body and mind is present in all, and this is best seen in those parts of the body possessing the most delicate nervous organization, namely, the face, the hands, and the general speech apparatus. For this reason trembling or tensely held hands, quivering lips, husky voice, and feeble or jerky articular speech are the most peculiar signs of nervousness in a child. The following may be noted by the teacher:
By observation:?? Face. Great mobility of expression. Wandering of the eyes. Twitching of the muscles of the eyes and mouth. Grinding of the teeth. Extremities. Twitching of the fingers. Peculiar and jerky handwriting. Shuffling of feet. Body. General restlessness. Frequent movement and changes of position, either spontaneously or Lowered nerve tone / on trifling cause. with irritability. Abnormally quick reaction or response to stimulus. Associated purposeless movements, upon emotional disturbance or excitement, such as involuntary winking, protruding of the tongue, laughing, waving the hands, etc. A shrill voice. Rapid stuttering or stammering speech. Irritability of temper. Outbursts of passion. Emotional outbreaks. Ready laughing or crying on slight cause. with exhaustion. NERVOUS DISORDERS OF CHILDREN. 71 ‘ !iii! Face. Toneless apathetic expression. Eyes dull. Extremities. Nerveless drooping position of the hands and arms when extended forward. Slouching gait. T , / Body. Drooping shoulders. -Lowered nerve tone < ?> Poor station and balance when standing. Inattention. Mental dulness and stupidity. Poor memory. Sighing and yawning from poor circulation. (2) By test:? Test vigor by asking class to sit up straight. Test control by asking class to sit perfectly quiet for five minutes. Test motor power by asking child to place fingers on desk, and then tap desk rapidly with the forefinger. Examination periods, those devoted to such occupations as sewing, or drawing, and also the recess hour, are especially favorable times for observation. (3) By statement of the child:?Fatigue, headaches, morbid fears and apprehensions. (4) Frequently associated conditions:? Physical defects (eye strain, adenoids, indigestion) which act by reflex irritation.
Poor nutrition and anaemia, which starve the nervous system as well as the other parts of the body. Mental dulness, which if not due to evident physical cause, signifies defect in the entire nervous system. Certain groups of symptoms occur frequently enough to admit of classification as definite nervous disorders. The most common of these are chorea, habit spasm, hysteria, epilepsy, and headache. | : - ;i Chorea (St. Vitus’s Dance). This is the most frequent of the nervous disorders of childhood and is characterized by jerky irregular contractions of muscles. Associated conditions not suf72 THE PSYCHOLOGICAL CLINIC. ficiently emphasized in many books describing the disease, are mental irritability, and frequent temporary weakness of the muscles affected. The causes of chorea are those already given for the group of nervous diseases now under consideration, but especially rheumatism (probably one-half of all cases), and poor nutrition, or other cause of nervous exhaustion. As might be expected, nervous fatigue or excitement makes the condition worse, and so chorea is particularly seen in the springtime, a season associated with tired nerves. One author has remarked that chorea is “a school made disease.” The great majority of cases of chorea occur in children between the ages of five and fifteen years. The symptoms of chorea1 are chiefly motor and psychic. Motor. In the mild cases, restlessness and inability to sit still are the only visible signs of inability to control the muscles. Jerking of the head, grinding of the teeth, spasmodic twitching of the face, and shuffling of the feet are common. In the more severe and well defined cases, involuntary, irregular jerking movements of the limbs are present. These take the child out of school and may become so severe that the child is not able to dress, to hold anything in the hand or even to talk. A well defined case of chorea tossing in bed with jerking movements of the hands and arms never ceasing while awake, can never be forgotten. Psychic symptoms. The association of these with the muscular movements should always be borne in mind. Irritability of temper is very characteristic, and emotional outbreaks during the day and bad dreams at night result.
The recognition of chorea is important for three reasons: (1) That it may be treated early in its course. (2) Because its existence signifies something wrong?the existence of rheumatism, or nerve exhaustion, or poor nutrition. (3) Because it absolves the unfortunate victim from the charge of malicious intent in making grimaces at the teacher, being noisy, restless and troublesome, and of dropping articles with apparent carelessness. This is most important from practical as well as humane considerations, since punishment only makes the symptoms worse.
The treatment of chorea is the medical treatment of the underlying cause, and the avoidance of overwork by too many studies and insufficient relaxation. The teacher should guard these cases carefully, as nervous disorders particularly demand her cooperation Huntingdon’s chorea and chorea insaniensis are not here considered. in the treatment of the case. Without doubt all these children are best treated by a return to care-free country life, but this is of course usually impracticable.
Habit spasm (‘Habit chorea) :?This resembles chorea and may possibly be a variety of it. Habit spasm is observed among children in the lower grades, and consists in the habitual sudden contraction of certain muscles. The regions of the eyes, mouth, neck and shoulders are the most commonly affected. The spasm may be quick, almost instantaneous, or may last for one or two seconds while the face is distorted by the tense muscles. Shrugging of the shoulders is a fairly frequent symptom, and I have frequently noticed in overworked college students a spasmodic clenching of the jaws occurring every few seconds. When the eyelids are blinked forcibly and frequently, the condition is termed blepharo-spasm; and it is usually significant of eye strain in a nervous person.
Facial habit spasm is frequently associated with frequent sniffing of the nose. So many of these cases arise from adenoids and nasal catarrh that the quick nervous character of the movement rather than its simple occurrence is necessary to make this sign a suspicious one.
The chief features which help to differentiate habit spasm from chorea are the usual existence of a local rather than a general cause (i. e. eye strain rather than rheumatism or nervous shock), the limitation of the affection to the face, neck and shoulders, and the repetition of the same muscular movement more or less rhythmically. The contraction of the muscles is spasmodic and powerful, and quite different from the wild jerky and irregular movements of chorea.
Habit spasm is a hint both of a nervous constitution and of local physical defect. The treatment should therefore consider both. Most cases recover, some lasting only a few months. Rarely it becomes chronic and incurable.
A few days previous to this writing I examined a boy of ten years, at the Miller school, who was suffering from habit spasm. He frequently drew down his lower lip in a spasmodic manner showing the lower teeth conspicuously. His eyes, nose and throat proved to be normal, but he was poorly nourished and nervous. The knowledge that he was being observed made the facial grimace particularly noticeable. He had a bruise upon the forehead, and the principal asked its source. “My father kicked me there,” “Why, Joe, I thought your sister hit you there with a flat iron.” “That was here,” he replied, and exhibited another wound behind the left ear.
Epilepsy:?Epilepsy is a habitual disposition to, and an occasional occurrence of convulsions which are accompanied by loss of consciousness.
The tendency of medical writers is to look upon persons suffering from epilepsy as divisible into three classes according to the nature of the cause of the attack:?1. Individuals possessing an exceedingly unstable nervous system, who require very little disturbance to precipitate an attack. 2. Those with mora or less instability of the nervous system, but with some evident exciting cause, such as eye-strain, intestinal indigestion, post-nasal adenoid growths, etc. 3.’ Those persons possessing an originally sound and healthy nervous system, but afflicted by some overwhelming poison, as in Bright’s disease, or by the pressure of a tumor, or by an injury.
The convulsions of babies are not considered as epileptic in character unless the habit becomes established. The symptoms may be here very briefly described, to relieve the inexperienced teacher of alarm and uncertainty, and to call attention to the occurrence and sinister significance of the minor form, and the psychic form of the disease.
Major epilepsy constitutes the ordinary epileptic convulsion. Its onset may be instantaneous, but usually the brain disturbance causes very various premonitory symptoms, such as numbness and tingling in one of the extremities, or flashes of light or color before the eyes. The actual convulsion frequently begins with an inarticulate cry on the part of the sufferer, who falls regardless of disastrous results. The muscles of the entire body are at first rigidly contracted, causing inability to breathe and an apparently alarming congestion and blueness of the face for some time less than a minute. The rigidity ceases soon because of the exhaustion of the nerve force and probably by reason of the partial asphyxia, the contractions continue but become jerky and intermittent in character with a beginning of return to a more natural color. Frothy saliva, possibly bloody from a bitten tongue, shows at the mouth. This stage lasts two or three minutes (rarely considerably more), and is succeeded by a third stage of stupor due to nervous exhaustion, from which the patient can soon be aroused if necessary. Such persons usually suffer for several liours from headache and fatigue, a few appear to be scarcely affected, while others may be incapacitated for a day or two.
The treatment of the attack is conducted with the assurance, born of experience, that the patient will speedily recover if not injured accidentally by the fall. The clothing should be loosened at the neck to allow of free respiration, and an endeavor made to secure privacy for the sufferer, and safe custody for his personal property. A handkerchief should be inserted between the teeth to prevent injury to the tongue.
Minor epilepsy. This may be defined as habitual, or at least occasional periods of lost nervous control. The attack presents a great variety of symptoms in different subjects, and is diagnosed by its periodical occurrence, by the fairly constant character of the symptoms in each person affected, and by the (almost) certain occurrence of loss of consciousness, though this is so transient that it may not be noticed, unless a dish is dropped from the nerveless hand, or conversation stopped in the middle of a sentence, with more or less subsequent mental confusion. Peculiar automatic actions and a few irrational words may betray the condition. P arents are frequently cognizant of such attacks of minor epilepsy, but fail to realize their true significance, and carelessly speak of them as “spells,”?a medical waste-basket for uncertain diagnosis. Psychic epilepsy. This, like minor epilepsy, must rest its claim for existence in each case upon the fact that it is either of habitual occurrence, or that the patient suffers also from one of the other forms of epilepsy. Psychic epilepsy exhibits a loss of control (inhibition) and action results rather than inaction, as in typical minor epilepsy. The attack usually consists of sudden maniacal excitement, aptly described as a brain storm, often accompanied by violent automatic movements. In the mentally irresponsible state existing, articles may be recklessly destroyed, or an assault committed. The ensuing mental calm is in striking contrast to the emotional outbreak.
A knowledge of epilepsy is valuable to the teacher as well as the physician, since the former possesses facilities for observation second only to those of the family and is often much more discerning. First it should be realized that children suffering from convulsions are frequently curable if only the cause is found, and removed before the fit habit is established. The unthinking doctor doses his patients with bromides, until a pimply complexion, dyspepsia, and a deadened intellect all attest the vigor of his treatment. The convulsions become less severe and less frequent and this is considered a fair equivalent for the practical invaliding of the sufferer. This is a necessary procedure of last resort in severe and proven incurable cases; but the scientific and proper treatment of epilepsy is based on the theory of the removal of the cause if such procedure be possible. For this reason, the causes of nervous disorder already mentioned should be considered carefully one by one, with especial attention devoted to the examination of the stomach and the bowels, the eyes, and the naso-pharynx.
Another most important point is the recognition of the true character of minor and psychic epilepsy, both theoretically and practically when actually seen. The former because the minor forms have all the potential significance of the major and may develop into it if not checked. The latter because of the paramount importance of recognizing psychic epilepsy, or kindred emotional disturbances occurring in ill balanced children, in order that the child may be shielded from exciting shocks, and terrifying punishments, otherwise very liable to fall to him. Needless to say that an ordinary fit of bad temper should not be taken as a case of psychic epilepsy, or an absent minded movement construed as an attack of minor epilepsy. The repeated occurrence of these, however, should give rise to a suspicion that abnormal conditions exist, and cause a quiet inquiry into the child’s home life, the nervous health of the family, and the existence of physical defects of the character already discussed. The diagnosis of such cases carries with it such heavy purport that it should be only tentatively made by any one not a physician.
Headache:?While the causes of headache systematically considered are numerous and practically correspond to those of other functional nervous disorders such as epilepsy and chorea, it may be said definitely that eye strain is the basis of at least four-fifths of the habitual headaches occurring in school children. The remainder arise from adenoid growths and obstructive nasal catarrh, and from constipation. A few cases may be ascribed to coffee combined with lack of proper nourishment. Single accidental headaches result from injuries, indigestion or beginning acute illness.
The headaches of eye strain are localized over the eyes, are accompanied as a rule by discomfort in the eyes after their use, and by more or less imperfect vision. Astigmatism is particularly a cause of headache, and the minor degrees of error with little or no diminution in vision by the ordinary type-test, may cause much distress. It is my custom when children are referred to me in this connection to first ask whether the headache occurs frequently. If it does further inquiry is made as to tiring of the eyes after reading, which usually elicits an affirmative answer. The vision should then be tested with the ordinary type-card and the diagnosis established.
The evident presence of adenoids, a question or two as to the character of the breakfast (cinnamon bun and coffee), and the statement of constipation explain the remaining causes. As to accidental cases, I have had a considerable number of children referred to me by teachers in whom the headache was the first one ever experienced, and due to a blow on the head a few minutes previously. A hasty assumption of eye strain by the teacher dependent on her own judgment would lead to a diagnosis easily susceptible of disproof and as mortifying as it is ridiculous., Hysteria:?True hysteria presenting profound preversions of mind, sensation, and motion rarely occurs before the age of puberty. Throughout school life, however, there are encountered numerous nervous, emotional children who can hardly be described by any other term than hysterical, and who in their later years are prone actually to develop the disease by reason of the neurotic constitution thus early manifested. Our thought therefore in the study of these cases should center on the presence of the predisposition rather than the existence of the full-fledged disorder. The traits of children particularly indicative of hysterical tendency are:? 1. Emotional temperament. There is a lack of control resulting in frequent exhibitions of joy or temper, or grief. Particularly occurring in shop and factory girls but occasionally seen in older school children are severe nervous attacks due to menstrual disturbance. There may be simply a semi-collapse accompanied by a nervous chill, or there may take place a demonstrative outburst with sobbing and screaming.
2. Weah will power and weak moral sense. This causes a craving for sympathy and mental support, so that every mishap is loudly lamented over, rather than resolutely faced. The vivid imaginations possessed by these children cause exaggerations in their tales of misfortune experienced and the most startling falsehoods may be told. Teachers are accused of barbarous punishments or of improper conduct, classmates of assault, and all with a plausibility that goes far toward convicting the one falsely accused. It may be noted in this connection that an absolute rule in the conduct of medical inspection should be to avoid examining girls unless in the presence of teacher or classmates. The ordinary tests of vision and hearing conducted in school will be reported to the parents at home with added imaginary acts and conversation to attract interest. The request to exhibit a vaccination mark has often been quietly complied with, but resulted subsequently in a parent’s complaint that a request had been made to undress. Curiously enough these false accusations are from the most unexpected sources, so that, aa I have remarked, the presence of a third person in a room when one is a girl should be absolutely insisted upon.
The same perverted traits lead to a remarkable faculty of imitation either of the peculiarities of others or of diseases accidentally read of in newspapers. A patent medicine advertisement describing a lame back or the symptoms of consumption may produce like symptoms in the hysterical child. In continental Europe whole classes have been simultaneously affected. Thus Schoedel reports (Jahrbuck fur Kinderh., Volume LXIV, ISTo. 4) an epidemic of imitation, in which the children shook their hands and arms continually so that writing was impossible. Twenty-one out of thirty-five were affected. The cause was a newspaper account of a similar nervous epidemic in a neighboring town, and cure was accomplished by the dismissal and dispersion of the class for several days. The London School Report for 1907 (Report of the London County Council) mentions four cases of temporary paralysis in the left arm occurring among the children of one school class, because of the admission of a girl into the class who possessed a true paralysis in that limb. The children affected were not English, but Poles and Italians.
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