Clinical Records
The Psychological Clinic Copyright, 1915, by Lightner Witmer, Editor. Vol. IX, No. 1. March 15, 1915 :Author: Lightner Witmer, Ph.D.,
Director of the Psychological Clinic, University of Pennsylvania. J When asked for specimens of the record blanks which are used by the Psychological Clinic, my invariable answer is that we have none. I am often asked for a list of the tests which we employ at the Psychological Clinic. I do not furnish such lists, because I am in doubt whether there is a single test which I can recommend to be employed with every-case which comes to the Clinic for examination. The formula to be used in the clinical examination must necessarily vary with the type of case that is brought to me. For example, I may see one afternoon a child six years old, who comes because he cannot talk. This case I may diagnose on sight as he walks into the examination room. He is a mongolian imbecile of not higher mental grade than a low-grade imbecile. An examination with tests only serves to fix his mental status with greater certainty. The next child who appears is a girl fourteen years old who also does not talk, and the social worker who brings her thinks that she must be feebleminded. Her physiognomy, her expression, and a few simple exploratory tests, scarcely indeed to be called tests, demonstrate to my satisfaction that the child is almost totally deaf, and this physical defect accounts for her supposed feeblemindedness and lack of speech. The third case is a six-year-old boy who has never been to school, but who does in his head second grade problems in arithmetic. The social worker wants to know whether his mathematical ability is abnormal and how it may be cultivated if I should approve of this procedure. Another case is a boy in the high school, normal enough looking, with well set up parents who are financially able to provide for his orthogenic development. Their complaint is that he has no ambition. Careful testing shows that he is not able to do problems in arithmetic with the efficiency of the average boy in the fourth grade. While deficiencies in school accomplishments are adequately revealed, a three hour probe of the boy’s pedagogical and physical history, combined with a painstaking mental examination, does not disclose sufficient mental inferiority to explain his inability to succeed in high school subjects. An additional observation involving the effort to teach him something, combined with a medical examination, for which he is sent to a competent neurologist, will be necessary before I shall be able to determine whether the boy is mentally incapable of attaining the social efficiency of a high school graduate. My very early experience with cases at the Psychological Clinic revealed the necessity for keeping the examination in a fluid state. I acquired a fear of the formalism of a blank, especially a blank filled in by some more or less adequately trained assistant. Experience also led me to believe in the inefficacy of the quantified result of a test, as for example the Binet test. If some one reports to me that a fifteen-year-old child has a Binet age of twelve, I do not consider this fact as having by itself diagnostic value. It is an interesting statement, which however I would not risk making anything of, until I had further examined the child. I do not know of any single test on which I can rely for diagnostic purposes. Doubtless the report handed to me by a competent examiner that a fifteen-year-old child had a Binet age of six, would safely lead to the diagnosis of feeblemindedness, but usually in such cases an experienced examiner could make the diagnosis of feeblemindedness on sight. Why spend many minutes of valuable time with the Binet test or other elaborate mental tests to find out what one already knows?
We receive for purposes of examination at the Psychological Clinic, children who are by classification idiots, others who are imbeciles, cretins perhaps sixteen years of age with the height of a child of eight and the other symptoms of cretinism, others who are pronounced mongolians of all grades of mentality, or paralytic children who show in body and face the brain defect which is the cause of their mental inferiority. We see also children who appear physically and mentally normal, who lie or steal or are brought to us for sexual immorality. We see children who stammer or stutter, some of them profound cases of speech defect, some with nothing more than an infantile stammer in consequence of adenoids. We see also normal and supposedly extra-bright children, some of them brought to us to assist the parents in finding out what they are most fitted for in life, some of them brought to us as by the parent who said, “Yes, I know that my children are bright, but I have come to you to find out how to keep them bright.”
I confess I do not know how to prepare a single formula of examination which will fit these diverse types of children, nor have I as yet studied these cases long enough to prepare different formulas to fit the classifications which it will some day be necessary to make. Moreover, life is short and we do not have time at the Psychological Clinic to do more than make an exploratory examination for the purpose of classifying the child, ascertaining his major defects and his capabilities, for the parent or teacher is waiting at the door of the Clinic to obtain from us some suggestions as to treatment. We have always held before us as an object of our work, the primary necessity of doing something for the child, and for those who are responsible for his welfare. Let us keep in mind the distinctive purpose of the Psychological Clinic. It is not, in my opinion, to study feebleminded or otherwise defective children. There are already experts in this field, and those connected with institutions for the various classes of defective children have presumably the best opportunities for their study. At least 50 per cent of the cases which have been brought to us are feebleminded children, but in my opinion these children are not our main concern. I am interested in the child who has a handicap, preferably a removable handicap. I believe that the clinical psychologist in conducting his examination must proceed directly to the work in hand. I want to know who brings or sends the child to the Clinic. Why is he brought? What do his parents or teachers complain of? I then proceed to find out whether the complaint is justified. If as usually happens I find that the complaint is well grounded (very rarely is a child brought to the Clinic except for some good reason), my immediate task is then to find out what has caused the child to give occasion for this complaint. For this purpose I inquire into the school history. If this does not adequately explain the situation, I find out from his parents what the child’s life has been from birth. If I suspect that the cause is resident in the child, I seek to discover whether this cause was congenital, of uterine origin, or hereditary. Now one question, now another, will serve to make the situation clear, and give me material for a prognosis and the recommendation of treatment. Frequently when I find a proximate cause I do not search with great diligence for a more remote cause. If from the child’s appearance I am led to ask the mother as to her condition during pregnancy, and I discover either that she had some disease like diabetes, or typhoid fever, or that she attempted to bring on a miscarriage, I do not inquire with the same minuteness into the father’s and mother’s history, for the purpose of discovering possible hereditary taint. Let every specialist stick to his own specialty. The psychologist’s is certainly not the ascertainment of the physical causes of physical defects. He may go into these questions for his own enlightenment, or as a means of checking his own opinions, but his distinctive field of research is in my opinion the mental process, its normal unfolding, and the modifications which environmental influences may produce.
In every case, we are compelled to leave unsolved some problems of interest, many of them extremely important. For example, take syphilis as an etiological factor. In many borderline cases the Wasserman test will positively demonstrate the presence of what is called congenital syphilis. If we are leaving no stone unturned to improve the child, I should always have a Wasserman test made, and I am glad when the result is positive, because there is then one definite line of treatment which may be carried out with a hope of amelioration. If a child is a low grade imbecile, and syphilis is found to be present, the treatment may improve the child somewhat, but in most cases it will not make him normal. We have neither time nor money, nor has anybody else sufficient time or money, to have the Wasserman test made on every case. I therefore use my own judgment, based upon my findings and my experience, as to whether it is worth while for somebody to go to the trouble and expense of making this test. In my opinion exactly the same conditions prevail with respect to nearly every item which may be in a formula of examination, including the mental tests. Why spend or waste our time on tests which perhaps tell us no more than we knew before, or which may tell us something which will be of no help to us in treating the child? Let us have many questions in our formula, let us employ many tests, all the way from the simple sense tests to the Courtis tests, but do not let us become slaves to the items of our formula.
Of course there are questions which arise by the way, which could only be satisfactorily answered if the same formulary were applied to all children. For instance, I believe that syphilis is a cause of feeblemindedness in a certain percentage of cases, but I do not know in what percentage of cases. We are frequently asked,? In what percentage of cases is syphilis a cause of feeblemindedness? I can tell in what percentage of cases we have found syphilis, but this is not a scientific answer to the question. At one time, out of all the children whom I sent to a physician for a Wasserman test, one-third gave a positive reaction, but this only meant that one-third of the children whom I thought it worth while to send for this examination were proved to have syphilis. For the purpose of getting some light on this question, a number of consecutive cases were sent for the Wasserman test. It was then found that the percentage of syphilis in all these cases was no greater than the percentage of syphilis in the community. I had gone out of my way to make a statistical inquiry in an approved scientific fashion, and obtained a negative result so far as demonstrating the etiological significance of syphilis in cases of feeblemindedness. Nevertheless I think we have sufficiently clear evidence that it is a causal factor in some cases, and a clinical examiner must hold in the background of his mind the thought that it may be responsible in any case which he may happen to have under examination. If the Binet test, or the memory-span test, or the formboard test were applied in every case, doubtless we should get data of great statistical value, but this would be turning the Psychological Clinic into a bureau of statistical inquiry, and probably it would lack the means to perform this work well.
Some men of science, and more pseudo-scientific men, fail to criticize the fundamental bases of statistical data. For example, I saw a boy recently, one of nine children. The other eight children were normal, but at sixteen years of age he was stealing and would not work either at school or in industrial employment. I learned that the father of this child had been for a time a hard drinking man, and from the mother’s statement had been at one time in a hospital for treatment for some condition due primarily to drinking. If I had found that his drinking had been at a maximum just before the birth of this child, I might have set this fact down as one bit of evidence of the effect of alcohol in producing degeneracy. As a matter of fact, this boy was the third child, while the father only began to drink after the birth of the fourth child, and his drinking was at a maximum at the birth of the eighth and ninth children. The five children born after he began to drink to excess are all reported to be normal. Here therefore are five cases demonstrating that normal children may be born of an alcoholic father. If we are to gather satisfactory statistics as to the influence of alcohol upon offspring, we must find out the alcoholic proclivities of the fathers of normal children. I do not know any scientific procedure by which we can gather statistics at the Psychological Clinic which will furnish satisfactory evidence on this point, excepting as I may produce now and then a well studied case in which every other possible cause of the child’s degeneracy has been eliminated excepting the alcoholism of the father. I doubt the ability of any agency to do more than this by the statistical method and I look with skepticism on family and social statistics reported by physicians or gathered by eugenicists.* Several times I have had the experience of going with the greatest detail into the family history, and into the history of the mother during pregnancy, and have That parental alcoholism is a cause of degeneracy in the offspring can be positively demonstrated only from experiments on the lower animals. That it is the cause of the feeblemindedness of a particular child can be stated only with some degree of probability, usually a very low degree of probability and combined with other causes having an equal degree of probability. In what percentage of cases it is the determining factor can never be ascertained from data collected by methods in common employment today. perhaps discovered some abnormality in the family of the father or mother. I have then had the mother when alone with me and in a confidential moment say, “I might as well tell you that when I said the other day that I had not tried to produce a miscarriage, I did not tell you the truth. I did try, and almost succeeded.” This fact of course does not prove that there may not have been a hereditary taint in the family, but it suffices to show that if the hereditary taint was responsible for the child’s condition, there was no proof of the fact, because the attempt at miscarriage as a proximate cause was adequate to explain the child’s condition. We do not ask in every case whether the mother attempted to bring on a miscarriage. We ask it often, but only when we think the fact would directly assist us in understanding the case. If I put this question in a formulary and have an assistant ask it, I am simply wasting paper, ink, and my assistant’s time, besides producing statistics which may be misused, as so many statistics of heredity are misused today, to uphold unsound contentions and to urge legislation of doubtful social value. All this for the purpose of introducing the following statistical treatment of the data of forty clinical records. This report was prepared for me by the Social Service Department of the Psychological Clinic. The department consists of a head social worker, an assistant social worker, and a recorder. The recorder who is also a stenographer, is present at all examinations, takes down such matters as may be dictated to her by the clinical examiner, and briefs all the conversations in the shape of questions and answers which may be had between the examiner and the parents or others who bring the child. The recorder is also enjoined not only to put down the results of tests, but to make observations of the child’s behavior. When these are important, the examiner specially indicates those which he wishes to make sure will be recorded. In addition the record usually contains reports of visits to the home and school. I consider this part of the history of equal importance with the examination made at the Clinic. The following report, however, concerns itself chiefly with the data obtained at the examination, and for the most part only at the first examination. This report was prepared in the first instance for the information of clinical examiners, to find out what was actually contained in the records and if possible to serve as a basis for standardizing the records. The report has confirmed my opinion that this standardization would be undesirable. Year by year a change is manifest in the clientele of the Clinic. *Dr Louise Stevens Bryant, Head Social Worker; Miaa May Ayrcs, Acting Head Social Worker; Miss Cyrena Martin, Assistant Social Worker, and Miss Marguerite Lazard, Recorder, at the time the report was prepared. Miss Ayres compiled and wrote the report. We are seeing fewer feebleminded children, and more whom we diagnose as normal. Recently the Psychological Clinic has been examining cases with a view to vocational guidance. I consider that this gradual improvement in the mental quality of our cases is a most hopeful sign, because it is with these cases that a psychological diagnosis can be made most helpful. We are therefore justified, I think, in reducing the time which we give to the diagnosis of feebleminded children to a minimum, so as to spend more time on the cases we can help. I feel also that we have in the larger proportion of normal children who are now being brought to us, a demonstration of the appreciation of the work which we are trying to do, namely, to keep our attention firmly fastened upon helping the child. We cannot help feebleminded children much, excepting as through our social service department we may assist parents in placing these children in institutions, but we can help greatly children of normal grade, who are handicapped in school or in the struggle for existence. The forty records are of children who were diagnosed as follows:
Diagnosis Number. Per cent. Normal 11 27.5 Physically defective 1 2.5 “Speech” 2 5.0 Borderland 1 2.5 Moral delinquent 3 7.5 Feebleminded, all grades 14 35.0 Deferred 6 15.0 Not stated 2 5.0 In view of the wide range of intelligence shown by the forty cases, the figures in the following report can have little or no significance. You can calculate the average weight of eleven elephants and fourteen mosquitoes, but your average will not mean much. Moreover, the forty cases were chosen at random from 1000 cases, and the statistical results might be supposed to represent the thousand cases. As a matter of fact, the forty cases are too few to give quantified data for the entire series,?at the most they indicate the items of examination which we are ready to enter on our records if the case appears to justify the making of a permanent record of such items. I publish this report because it may prove helpful to some as an indication of what we have found gets recorded when cases are examined and records kept under limitation of time and of professional and clerical assistance. The report is published in the main as written by Miss Ayres. Some changes have been made, for which Miss Ayres is not responsible, but some opinions and conclusions remain with which I am not in agreement. 8 THE PSYCHOLOGICAL CLINIC. A. GENERAL EXAMINATION One thousand cases were taken as a basis, and a cross section made of them by pulling from the files every twenty-fifth case from 300 to 1300. These cases covered a period of nearly three and a half years?from October, 1910, to February, 1914. Where the case in question presented unusual conditions the next higher or lower was chosen?for example, cases 1075, 1076, and 1077 were from an institution and nothing could be learned about their family histories. Therefore case 1078 was chosen as more representative of regular clinical work. The selection of cases was made without reference to mental examination, as it was assumed that equal opportunity existed for giving mental examinations in every case.* The forty cases chosen in this way included twelve girls and twenty-eight boys?the normal proportion as found by Dr Bryant in an earlier report. These forty cases were analyzed to find out what information our records give under each of three separate heads, the first of which is the General Examination. In selecting the facts to be tabulated in the General Examination, questions were omitted which would apply only to a limited number of the cases, for example the question as to whether or not a child was a truant, was omitted because in many cases the child could not be a truant. The tabulation has been made under eleven heads:
A-l Name, age, address, by whom sent, and by whom brought. A-2 Diagnosis. A-3 Recommendations. A-4 Preliminary report. A-5 School history. A-6 Medical history. A-7 Babyhood. A-8 Birth. A-9 Family history. A-10 Mother’s history. A-ll Father’s history. The analysis attempted no more than to discover what information was secured and how it was recorded. It was an endeavor to ascertain what the points were which the different clinic examiners regard as most significant, and which tests they feel are of the greatest value. Is there any body of questions asked alike by all the examiners? Is there any uniformity of opinion on their part as to the value of different data?
The General Examination is usually made by the psychologist, although when he is busy with other cases the social service workers may make it for him. It consists of the eleven parts noted. Much of the information is gathered from the parent or guardian at the time of the child’s first visit. Some of it is secured by visits to the home and school. Information is frequently added by correspondence, or on subsequent visits to the Clinic. The results of the General Examinations are recorded under these eleven main heads. Tabulation has been made of the presence or absence of information under each of sixty-one sub-topics considered as of general applicability to all cases. Since the analysis covers forty records, there should be forty times sixty* Theoretically this assumption may be justified, but practically many diverse conditions modify this equal opportunity to make a mental examination in a given case.?L. W. one items of information, or a total of 2440 items, if the record were entirely complete in every case. How nearly the existing records approximate this impossible ideal is shown in the following summary tabulation: Information asked. No. of answers. Information asked. No. of answers. 1. Name 40 9. Family history Age 40 Children living 40 Address 39 Children dead 25 Brought by 39 Miscarriages 12 Sent by 29 Ages 25 2. Diagnosis 34 Which is this 31 3. Recommendations Others backward 19 Physical made 24 Others healthy 16 Physical followed 9 10. Mother’s history Other made 30 Mother living 37 Other followed 16 Abnormal 10 4. Preliminary report Health now 21 Why brought 37 Health pregnant 19 Playmates 9 Age at child’s birth 8 Nervous 16 Works 11 Disposition 19 Drinks 5 Enuresis 9 Nationality 7 Masturbation 7 Married before 3 Dresses self 13 Relatives healthy 26 Recreation 11 Relatives abnormal 14 5. School 11. Father’s history Grade 33 Father living 36 Started 29 Abnormal 9 Progress 33 Healthy 26 6. Medical Nationality 6 Health 36 Works 14 Convulsions 13 Drinks 7 Sores 8 Relatives healthy 17 Accidents 14 Relatives abnormal 10 7. Babyhood Married before 6 Walk 26 Talk 27 Total answers 1171 First Tooth 13 Total possible answers 2440 8. Birth Natural 21 Per cent of possible 48.0 Full time 13 Weight 5 Blue baby 6 Health 9 Different 4 During the three and a half years covered by the cases examined we find that in general less complete records were kept during the first year. After the slight increase at the end of the first year the rate remains the same during the two and a half years following.
The sixty-one questions tabulated were supposed to apply equally to all children brought to the Clinic. Of these three have received attention and been recorded in every case: The name of the child has been given; the age of the child has been given; the question has been raised as to whether the child has brothers or sisters.
Section 1 of the General Examination consists of five points?name, age, address, brought by, sent by.
This section is by far the most complete of all in our tabulation. The psychologists have all agreed on the importance of the five topics. Under the heading “sent by” there are a good many omissions, probably due to the fact that many children are brought to the Clinic by the same people who sent them, and no need has been felt of repeating the name in the second case. Section 2 of the General Examination shows whether or not a diagnosis has been made. In six of the cases examined there is no record of any diagnosis. In five, diagnosis has been “deferred.” This topic is treated more at length under the text relative to mental examination.
Section 3, Recommendations.
In four out of forty cases no recommendations of any kind have been made. In twenty-two, physical recommendations have been made, but they are recorded as having been carried out in only nine. Other recommendations are recorded as having been made in thirty, and carried out in sixteen cases. The discrepancy between the percentages of recommendations made and recommendations carried out is probably due to two factors?(a) a large proportion of our cases are brought to us by outside agents upon whom devolves the responsibility of carrying out recommendations which we have made. It is usually difficult to secure complete “follow-up” histories of these cases. (b) The Social Service department should have as part of its files a “follow-up” system. This work would be of real scientific value. Its need is evident; but the labor entailed is such that the system cannot be installed until a larger number of trained assistants are available.
Section 4, Preliminary Report.
A preliminary report is usually secured at the time of the child’s first examination at the Clinic. In general it answers the question “Why is this child a Special problem?” In very nearly all cases the definite question “Why was he brought?” is asked. In less than one-half of the cases the examiner goes more into detail and asks “What is his general disposition, and is he easy to get along with? Is he nervous? Can he dress himself? What does he do to amuse himself?” In less than one-fourth of the cases the questions are asked, “Does the child have enuresis? Is he a masturbator? Does he like to play with other children, and are they older or younger than himself?” In only one of the cases analyzed is the preliminary report entirely absent.
Many other questions are asked in this preliminary examination. In tabulating an effort was made to record only those questions which were of general application. In looking over the files we find the questions ” Does he steal? Does he run away? Does he lie? Does he show other immoral tendencies?”
These questions are important, but apply to only a limited number of cases. It might be of value to make a more detailed study of high grade imbecile and borderline cases among adolescent boys and girls in order to determine what further questions should be added to the regular examination of these cases.
Section 5, Pedagogical History.
Information with regard to pedagogical history is usually secured from the parent, although corroborative details may be obtained by visits to the school. In general the school records are very full. In over three-fourths of the cases information is given as to the child’s grade and the progress he has made in school. In over half of the cases a record is also given as to the child’s age when he started school. There is but one case where no questions of any kind appear to have been asked. Where the child never attended school, and a statement has appeared on record to that effect, the case has been tabulated as giving positive information.
Section 6, Medical History.
Fairly careful investigation has been made of the child’s general health. In only three out of the forty cases tabulated have no questions been asked. Much less attention has been paid to whether the child ever suffered from convulsions, whether wounds heal easily, and whether the child has had falls or accidents.
Section 7, Babyhood.
The report on babyhood has been rather meagre. In a third of the cases there is no record of any questions having been asked. From one-half to threefourths of the cases show some record of the time when the baby first walked, and when he first talked. Record as to the first tooth occurs in less than half the cases.
Section 8, Birth.
There are many cases in which no questions have been asked concerning the birth of the child. In seventeen of the forty cases no records are shown. The questions most frequently asked, “Was the birth natural?” “Was it full time?” are recorded in only a little over one-fourth of the cases. Other questions as to weight, “Was he a blue baby? Was he healthy? Was he different from the other children?” have been asked and recorded in less than one-fourth of the cases.
Section 9, Family History
Careful efforts appear tohave been made to secure full family histories. In every case examined there is some record. In two of the cases the only record given is in answer to the question, “Are there other children living?” The next question most frequently asked is: “Which is this child?” In over a half of the cases attempt has been made to ascertain the ages of the other children, and whether any children in the family have died. Questions as to miscarriages, the health of other children, and whether the other children are peculiar in any way, occur in from one-fourth to one-half of the cases.
Section 10, Mother’s History.
There are two cases where nothing has been asked about the mother, and in three there is no record as to whether or not the mother is living. The questions most frequently asked are, ” What is the mother’s health now, and are her relatives healthy?” In from one-fourth to one-half the cases the questions were asked, “Has the mother any peculiarities? Was she healthy when she was carrying the child? Does she work? Are any of her relatives peculiar?” Data as to mother’s age when the child was born; whether mother uses intoxicants; whether she was married before; and her nationality, are asked for and recorded in less than onefourth of the cases. Section 11, Father’s History. In two cases nothing is said of the father’s history. In four cases no note is made as to whether he is now living. Next in frequency is the question as to his health at the present time. In less than half of the cases is there mention of whether he works, whether his relatives are healthy, or whether there are abnormalities among his relatives; and in less than one-fourth of the cases examined is there record as to whether the father is peculiar in any way; whether he uses intoxicants; whether he has been married before; and his nationality.
PHYSICAL EXAMINATION.
Twenty-five points were tabulated under the heading Physical Examination. Several of these points are likely to be regarded by clinicians as unimportant. They have been recorded only once or twice in cases examined. Report has been made on these topics not because a criticism is implied if they are not tabulated as having been noted, but because these points all appear on the physical examination sheet which has been freely used as Clinic record. The following is a list of physical points noted in the order of their frequency. Number of cases in
Point noted. which point is noted. Anthropometric measurements 26 Eyes 24 Hair 23 Forehead 19 Teeth 19 Nose 18 Throat 18 General appearance 17 Ears 16 Trunk, limbs 15 Heart 15 Lungs 14 Palate 13 Shoulder blades 13 Hands 12 Head 11 Tongue 9 Glands 9 Blood test 9 Genitals 6 Protuberances 6 Rachitic 4 Jaws.. 2 Pelvis 1 Arches 1 Total 323 Total possible 1000 Per cent of possible 32.3
The first record studied comes in October, 1910. The following year, October, 1911, to October, 1912, records are a little over one and one-half times as full as in the years before and after. From May, 1913, through February 1914, physical examinations are less full than they have ever been before.* * At the present time physical examinations are still less oomplcte, becauso the mental grade of the cases is higher and the mental examination is crowding out the physical examination. The Physical Examination contains twenty-five points which were selected because they appear on the Physical Examination blank which has been used freely in record making.
In three of the forty cases tabulated no physical examination has been made. In six either no examination has been made or there is simply a record of a blood test. Under the heading “anthropometric measurements” records have been marked as giving positive information which gave even one measure, such as weight; although the general caption would include height, weight, chest girth, and head girth. The points most commonly noted in the physical examination are one or more of the anthropometric measurements, the hair, and the eyes.
MENTAL TESTS.
In tabulating this portion of the records, only those tests were included which were recorded in at least two of the cases. There were thirty-three of these tests if we include in that number the Binet tests as one, and general observations as another. In the descending order of the number of records in which they appear, they are as follows: Test. Casea. Form board 20 Binet-Simon test (complete) 18 Arithmetic 17 Copy with pencil or crayon 15 Color discrimination 15 Color naming 15 General observations 14 Writing 14 Reading 9 Memory span for digits, auditory 9 Spelling 8 Definitions 7 Memory span for letters and digits, visual 6 Reproduction of passage read 5 Opposites 4 Count blocks 4 Make change 4 Compare weights 4 Recognize absurdities 3 Interchange clock hands 3 Count backward 3 Describe pictures 3 Picture form board 3 Association test 3 Attempt to teach 2 Rhyme (Binet-Simon) 2 Reconstruct sentence 2 Three words in sentence 2 Sixty words in minute (Binet-Simon) 2 Give value of stamps ( ” ) 2 Name days of week, months of year, give date, etc 2 Tell time 2
Design blocks 2 224 Although there are records of 224 tests having been given to the forty children, this does not mean that each child was given five or six tests. An analysis of the data shows that they do not cluster around any central tendency. When the cases are listed in the order of the number of tests given, it is found that at one extreme are six cases where no formal mental tests were given, while at the other extreme there is one child who was given twenty separate tests. The frequency distribution of the number of children receiving each specified number of tests is as follows:
No. of teats. Cases. 0 6 1 5 2 3 3 2 4 3 5 3 6 3 7 4 8 1 9 2 10 1 11 1 12 2 13 2 17 1 20 1 224 40
Since it would be unfair to assume that in these cases a truly complete record would be one showing that the child had been given every test, it is impossible to make a comparison between the possible number of items of information and the number actually found.
The record frequently shows much less than the psychologist has ascertained. Often the psychologist has in mind facts which may form an adequate basis for a diagnosis but if he does not dictate these facts to the recorder and if the recorder is not aware of them herself, no evidence appears in the record which would seem to justify the diagnosis given. Often tests are used and no record made?for example, the pegging board is frequently employed as a test, yet only once in the cases examined is it mentioned.
It would seem necessary for clinicians to consider this question of recording at some length, in order to decide what should invariably be dictated by the examiner, and what should be left to the discretion of the recorder. If no such definite understanding exists between the recorder and all the examiners, an unfair burden of responsibility will rest upon her; for she will either be obliged to act as an assistant clinical psychologist, making judgment as to the child’s responses, or else she will be guilty of omitting from the records information of importance which would be desirable at a later time if the accuracy of the diagnosis were called into question.
Only those mental teste were considered which were noted in at least two of the cases examined. Had every test given once been included there would have been a total of forty instead of the thirty-three headings. Diagnosis. Six of the cases were undiagnosed. Four had a diagnosis given which was not a diagnosis; for example?”speech” is not properly a statement of mental grade, but has been used several times as a diagnosis.* Section 13, Binet Test.
The Binet test ranges next to the form board in popularity, since it is used in nearly one-half of the cases. In general, definite statements are given as to the mental age, and not infrequently one or more quotations are included. Where quotations are given they are usually entered upon the scoring sheet. In only three cases has the Binet test been given by the same person who conducted the rest of the mental examination.
Section 14, General Observation.
Sections 14 and 15 have been placed first among the mental tests, because they are essentially different in character from the others. Section 14 is the record of statements made by the psychologist of conditions under which the examination was made, or of the child’s reactions and general attitude during the test. Where such statements have been given, they are generally specific in nature. In twenty-six of the forty cases they have been omitted altogether.
Section 15, Attempt to Teach.
There are very few records of any attempt having been made to teach the child during the examination. It is not improbable that such efforts have been made, but that they have been recorded in such a way as to indicate the child’s fund of knowledge rather than his ability to learn. In only two of the cases examined has any attempt to teach been recorded as such.
Section 16, Form Board.
The form board is the most popular of all mental tests. It occurs in fifty per cent of the cases. In one-half of the trials the time is recorded, and in onehalf a specific statement as to the child’s performance is given. Section 17, Mental Tests with Samples or Quotations. The remaining mental tests have been divided into two parts?Section 17, tests where quotations or samples of the work might be secured; Section 18, other mental tests. The tabulation under the heading “copy” should properly be considered in connection with the Binet test, for in most, though not in all cases, the entry under “copy” means the drawing of a diamond or other Binet figure. Not infrequently, however, the child is asked to draw the square or diamond, although * “Speech” means a case we would take on as a training case at our speech clinio?must be mentally normal. It is therefore a satisfactory diagnosis for our purpose.?L. W. t In many cases, the “attempt to teach” plays an important part in the examination and is recorded at great length. In fact I consider the psychological diagnosis as distinguished from the “diagnosis of classification” incomplete without the results of an “attempt to teach.” It happens that the selection of the forty cases provided only a few of those in which an attempt to teach was possible or worth while,?L. W. he has not been given the regular Binet tests, and for this reason “copy” was made a separate heading.
Of 361 entries under Section 17 eleven per cent consist of samples or quotations without comment; three per cent of samples or quotations with comment. Section 18, Other Mental Tests. One of the most popular tests, occurring in fifteen cases, is that for color naming and discrimination, the only test under Section 18 which is used in more than one-fourth of the cases.
Pedagogical Tests.
Sections 17 and 18 contain together several headings which may properly be grouped under the title “pedagogical tests.” Here we find arithmetic and writing are tested in between one-fourth and one-half of the cases, and spelling and reading in less than one-fourth. Arithmetic ranks next to the Binet test in popularity. It is recorded in seventeen of the records examined. Writing is recorded in fifteen cases; reading in nine cases; and spelling in eight cases.
GENERAL SUMMARY.
As stated at the outset, the object of this analysis was to discover through an intensive study of a small number of cases chosen by random selection, what information is secured about each case and how it is recorded. It was an endeavor to ascertain which items of information the different examiners regard as most significant; and if possible which tests they find most frequently applicable. The study has yielded only moderately definite answers to the questions, for the reason that it has brought to light a great variability in the amount and kind of information recorded, and but slight consensus of practice in the manner of making the records.
In the portion of the records devoted to general information, it is found that among sixty-one items the number of answers recorded in the forty cases ranges from forty down to three. The average number is nineteen; and the total number of items recorded is 48 per cent of what it would be if all of the information were recorded for every child. The records are scattered over the past three and one half years, and the study shows that the number of items of information in the general examination was nearly as large at the beginning of the period as at the latter end.
The results of physical examinations are recorded under twenty-five heads, and if they were noted in every case there would be forty entries under each head to cover the forty cases. In point of fact the number of answers ranges from twenty-six down to one; the average is thirteen. The total number of items of information is 32 per cent of the total possible number. Here it appears that the records were distinctly more complete three years ago than they are now. The records of the mental tests are far more scattered than those of the general and physical examinations. Among the forty cases there are records of thirty-three different tests having been used. The most frequent of these was used twenty times, while the least frequent was used only twice. The average number of tests per child was between five and six, but an individual tabulation shows no tests at all recorded in six cases, while in one case there are records of twenty tests having been given to one child. The other cases are scattered between these two extremes. The number of mental tests given appears to have increased during the early part of the period studied, and subsequently remained nearly stationary.
One of the reasons for undertaking this study of 1000 clinical records was to secure a list of questions and tests upon which clinicians were so generally agreed, that it might be used as a minimum standard for all examinations. It seemed that a fair model examination blank could be compiled by selecting those questions which had been asked in at least three-fourths of the records examined. When we summarize the results of the tabulation we find that the study has been fruitless so far as the making of such an ideal list is concerned.
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