A Possible Restoration Case.
The Psychological Clinic Copyright, 1916, by Lightner Witmer, Editor. Vol. IX, No. 8 January 15, 1916 :Author: Gertha Williams, A.B.,
Moore Fellow in Psychology, University of Pennsylvania. For several years the Psychological Clinic of the University of Pennsylvania has been interested in the study of restoration cases. By a restoration case is meant a child who is socially incompetent because of deficiency on the ability or on the conformity scale, but who can be restored to plenary competency by some kind of special treatment. A child’s pedagogical grading has been taken tentatively as the measure of his social competency. He is socially incompetent if he is pedagogically retarded or if he does not conform to the standards of conduct for children of his age. As the measure of pedagogical retardation, I have taken the relation between a child’s chronological age and his grade in school, assuming that a child of seven should be in the first grade, a child of eight in the second grade, and so on. A child who is pedagogically retarded is a restoration case if he can be restored to the grade to which he belongs according to his chronological age. In addition he must conform to the standards of conduct for children of that grade. In the summer of 1915, from the records of children examined at the Psychological Clinic fifteen children were selected who appeared from the examination to be restoration cases. These fifteen children were placed in an observation class conducted by the Psychology Department for the six weeks of the summer session, and were given instruction under two teachers who had been especially trained. Besides the academic work the children had training in handwork, including bench work. They had physical exercises and folk dancing. They were served a hot lunch at noon. They had outdoor games and trips around the University grounds. If a child needed medical attention, he was given it at the University Hospital. The children were under constant observation for the six weeks to determine whether they really were restoration cases. This is a study of Bertha B, one of these fifteen cases. In May, 1913, she was first brought to the Psychological Clinic because of troublesomeness and laziness in school. So she was already diagnosed by the school as socially incompetent because of nonconformity and was brought to the Clinic for confirmation of this diagnosis. Bertha has been under the observation of the Clinic ever since May, 1913. The Social Service Department has made many calls both at the school and the home. She was re-examined at the Clinic in February, 1915.
When Bertha first came to the Clinic in May, 1913, although she was then almost seven years of age, she had only the height and weight of a five-year-old girl. She was well-proportioned in spite of her small size. The right shoulder was low. Her lung expansion was excellent. In the examination she was prompt, lively, and intelligent. She tried many of the tests on the examiner, imitating his mannner very well. She was quick and alert, excitable and very talkative. Her school work was poor for first grade. She recognized only very simple words in reading and in number work showed a tendency to guess at results rather than work them out. Yet she was able to work out simple sums when she applied herself. No specific mental defects were discovered in the examination except that her tendency to guess at results in number combinations suggested a deficiency of analytic and persistent attention. She was diagnosed as “not mentally defective” and a special class was advised.
The school report at the time of this first examination was not unfavorable as to the quality of her work. She was then in the first grade, having entered in September, 1912. Her teacher in May, 1913, reported that she was “a perfect nuisance and would not work.” In October of the same year she was reported as doing well in school, but this latter report was given when a special class for Bertha was being urged and the principal was unwilling to place her name on the list. By November, 1914, the principal himself was urging a special class as Bertha was “not getting along Avell in a regular grade.” But Bertha’s parents would not give their consent to her being placed in a special class. She was promoted to second grade in June, 1914. In February, 1915, the principal reported that he had tried Bertha under five different teachers but without result. She seemed to him nervous and backward, although not feebleminded. He was considering having her excluded from school since her parents would still not consent to a special class for her. Bertha was then given a second examination at the Clinic. Her age was eight years and eight months. Again no specific mental defects were discovered, except the same defects of attention discovered in the earlier examination. In school subjects she showed considerable retardation. Her reading was good first grade reading, her mistakes being largely careless ones. Her spelling was about the first grade level. Her number work was poor even for first grade. She was able to do only the simplest combinations either abstractly or concretely with colored blocks. Transference to a special class was again urged and attendance at the University Restoration Class recommended.
A school report was obtained in June, 1915. Bertha’s average standing was 60, with arithmetic, spelling, and penmanship unsatisfactory. Her effort was poor and her conduct sometimes poor, sometimes fair. The teacher reported that she was lazy and could not apply herself or concentrate. She had memorized several poems and “can draw when she puts her mind to it, but usually smears and crumples her paper before it is handed in.” She came to school hungry and dirty. There were sixty-eight children in the room, which was dark and gloomy.
A rather detailed report of Bertha’s work in the restoration class during the summer of 1915 follows. Restoration Class of 1915.
At the opening of the session, Bertha was able Arithmetic to write numbers up to two digits from dictation and to read them when written. She could also count by ones and by fives to fifty. She was able to add the simplest combinations like 2 and 2 or 4 and 1 abstractly but did not know how to obtain the results concretely. She was taught addition by making it as concrete as possible. She was allowed to make cakes in the sand and then sell them to one of the other children, adding up her results on the number frame. This method served the further purpose of arousing her interest in addition through her interest in the sand table.
Bertha was very soon able to add concretely either with the number frame or by making marks on the board or on paper. She was inclined to be more interested in the method of obtaining the result than in the result itself. She liked to add by making nests of colored eggs on the board like the younger children and had to be forced to use the more abstract method. She was very careless even when obtaining results concretely, e. g. 6 plus 5 equals 10, and she was very easily distracted. She was usually more interested in what was going on about her than in arithmetic.
By the beginning of August she had learned a few of the combinations like 7 plus 4, 5 plus 3 abstractly, but she was not serious about her work and would answer at random even with combina224 THE PSYCHOLOGICAL CLINIC. tions that she was able to do abstractly. In a lesson on short division in which the class was taught to divide 2 into 2 to 10 concretely, Bertha was one of the first to comprehend and very readily learned the combinations without the need of appealing to concrete aids. But even after learning the combinations, she answered at random until the teacher spoke sharply to her. Then she buckled down and answered correctly. In the afternoon she did on paper in about one minute all the combinations she had learned in the morning.
Bertha accomplished very little in number work during the summer session. She learned to obtain results in addition and in division concretely and also learned a few combinations in addition and division abstractly. When she gave good attention to her work, she learned simple combinations in arithmetic rather readily, but would answer at random even when she knew the combinations abstractly. She showed little interest in numbers and made almost no effort to concentrate her attention upon the work. Her lack of persistence was very marked. She would leave her work with the slightest excuse or with none at all. Occasionally, however, when forced to by the teacher, Bertha would concentrate her attention upon her work and persist for short periods, but as soon as the teacher’s attention was directed elsewhere, Bertha would give a minimum of attention to her number work and would look about her for something which appealed more to her interests. As a result her work was uneven. Most of her number work was very inaccurate but during these occasional short periods of good concentration she would obtain correct results quickly and readily.
The first reader which Bertha had been using Reading in school before the summer session, was far too easy for her. She was given a second reader during the session which she read easily. Her recognition of words is good, but because of inattention she makes many careless mistakes, such as leaving off or adding final letters or misreading one word for another similar one. Her lack of persistence of attention is very great. To keep Bertha’s attention upon a reading lesson throughout the lesson required almost the entire attention of the teacher. Her persistence of attention is sufficient while she is reading herself but she does not give attention for any length of time while others are reading. If forced to attend while others are reading, she constantly interrupts by calling out words and makes little effort to control herself in this respect. Her interest in reading, although greater than her interest in arithmetic, is still deficient and succumbs to her greater interest in her surroundings. The imagination which she displays in reading is good. She shows sufficient ability both to produce images and to associate them, but her imagination is lacking in complexity. In answering questions about her reading she draws upon her fancy instead of following out the line of thought of the author. Her fancy is not sufficiently controlled by her memory. In this respect she is like a much younger child. She comprehends what she reads and her powers of observation are good whenever her attention is upon her reading. Her spelling is only fair. She is by no means Spelling as proficient in spelling as in reading. This is due, I believe, to the fact that recognition of words requires less close attention than the exact spelling of a word. She has sufficient knowledge of phonics and sufficient intelligence to help her in spelling new words. But, unfortunately for Bertha, a knowledge of phonics alone is not sufficient to spell words in the English language. Her imageability and associability are sufficient, I believe, for good spelling; nor is she deficient in retentiveness, but she does not concentrate her attention to a great enough degree upon her work, nor does she persist for a long enough time to conquer the difficulties of spelling English words. Bertha’s oral language is better than her written Language language. This is chiefly because of her lack of proficiency in spelling and because written language requires greater concentration of attention than oral. Bertha shows in her language work good powers of observation and some intelligence in her answers to questions; but she shows the same deficiency in complexity of imagination that she displays in her reading, as she makes no attempt to control her fanciful imagination. If a language lesson is too long it makes too great a demand on her persistence of attention, and her interest wanes. Bertha chooses by preference the handwork Handwork which is easy for her, like stringing beads or spool work. Her lack of persistence of attention was very evident in her handwork. She worked intermittently, discarding the handwork for anything which appealed more to her interest at the time. She did not succeed in completing even one piece of handwork during the session; not that her interest was deficient but it was transitory. Her movements were well controlled and coordinated. Nor did she lack initiative; she needed no help in deciding what she wanted to do and would work on the handwork of other children. She showed ready comprehension in learning new handwork. She showed little planfulness, and showed her intelligence rather by contriving to do what she had been forbidden to do or by doing her handwork in periods intended for other lessons. She was very untidy in her handwork as in everything else.
At first in the exercises she depended almost Physical wholly 011 imitation and was unable to keep up with Exercises the rest of the class. Her interest soon flagged and she wished to give up. She showed much energy but wasted it in superfluous movements, and was easily distracted by her surroundings. She often paid no attention to the signal to stop, but went right on until she herself was ready to stop. By the third week she had learned some of the commands and was able to interpret them without depending on imitation. From then on to the end of the session she learned more and more commands and was able more and more to depend on interpretation rather than 011 imitation. But her work was very uneven because of the varying amount of attention she gave to it. She constantly watched the other children and “bossed” them, and her own work suffered. She was not always ready to start on signal nor did she always keep in time.
She showed then good energy in her physical exercises and her rate of movement was rapid. She appeared to fatigue rapidly but this apparent fatigue was probably due to a lack of persistence of attention and to waning interest. Her concentration of attention was uneven, usually poor but sometimes good. Her attention was very alert. Her movements were well controlled and co-ordinated. Her initiative was good. She was usually responsive but her responsiveness lacked complexity. She would sometimes comprehend part of the movement but not all, and would execute the part she had comprehended without seeming to realize that she was not making the entire movement. Her response was often like that of a younger child. This lack of complexity of response may be due somewhat to a defective imaging of the movement to be executed and to a defective associability, as her errors were made with the more complicated commands. Her observation was good. She watched the instructor or, if he were not in sight, other members of the class. Her understanding was not sufficient for the interpretation of new commands and she was almost wholly dependent upon imitation until she had memorized the movement. After memorizing the movement, her understanding was sufficient for execution of the commands without imitation. I should say her understanding as shown by her behavior during physical exercises was normal for her age, or at least only slightly subnormal. Her retentiveness as shown by her memory of commands was good.
The folk-dancing made much more of an appeal Folk-dancing to her than the physical exercises. She learned the steps readily and changed quickly from one step to another. Her movements were quick and graceful and she thoroughly enjoyed the work. Her concentration and persistence of attention were good. Her attention was very alert. Her movements were well controlled and co-ordinated. Her initiative was good. Her responses were sufficiently complex and vivacious. Pier observation and memory were good.
By the end of the first day, Bertha had estabAttitude toward lished herself as “boss” of the younger children. other children The three smallest children and an idio-imbecile of eleven were her especial responsibility. The idioimbecile greatly interested her, as he was the biggest boy who would submit to her bossing. Her jurisdiction extended over both work and play. She bossed the games, taught Charles to articulate and supervised William’s gymnastics. She had little respect for the rights of the other children. She would pull down their houses in the sand, take their rulers and pegs and work on their handwork. The younger children did not resent her attitude toward them, but her popularity with the older children suffered.
Bertha has very little respect for authority.
Attitude toward She is always slow to obey and is even openly disthe teacher obedient when she dares. When the class was told to clear the desks, Bertha would open her drawer, or she would use ink when the class had been told to use pencil. She showed great ingenuity in figuring out just how far she dared go in defying authority. One day she changed her seat during the rest period, watching the teacher to see if it were safe to make a second change. Again, when refused permission to string beads by one teacher, she went to another teacher and received the permission. Bertha is not willing to submit herself to class Attitude discipline, to give up her individual inclinations for toward class the good of the whole. The “ego” looms large on organization her horizon. She can be very responsive when the thing the class is doing fits in with her own inclinations. Then she will tell stories and sing songs and thoroughly enjoy the class activities. Then again, she will respond slowly or not at all to class commands, take out her handwork when the rest of the class is singing or working at academic subjects. The influence upon her of an audience such as was provided by the observation class of teachers is very bad. She constantly played to the gallery and tried to attract attention to herself. Bertha’s attitude toward class discipline was very little better at the end of the six weeks than at the beginning. She was still far from ready to submit herself to class organization.
Bertha’s work for October averages 70 with no School report, subject unsatisfactory. Her effort is fair and her Nov., 1915 conduct good. The teacher reports that Bertha is really trying and even stayed after school to ask the teacher to help her improve her writing. She comes to school clean and tidy. This improvement in Bertha is really remarkable, in spite of the fact that this is her third term in lower second grade. This is the first favorable school report that has been made of Bertha since October, 1913.
I will now summarize upon Dr Witmer’s chart used at the Psychological Clinic, the mental qualities which Bertha has displayed. This summary is based on the two mental examinations, the school and personal history and more particularly on the observations made in the restoration class of 1915. In explanation of the chart I will say that to evaluate the qualities a scale of one to five has been used, five being the highest, one the lowest, and three the median. Intelligence is used in the specific sense of ability to solve a new problem. Description of the Chart.
The financial condition of the family is below Financial the median. The family is not able to subsist at condition present without outside aid, although previous to Care February, 1915, they would accept no help. They Discipline seem to have become pauperized by the assistance which has been given them. The mother helps to support the family by doing washing and is very much overworked. The whole family is undernourished. The house is very dirty and poorly ventilated.
Discipline in the home is severe but probably ineffective. Bertha’s height of 106.4 centimeters is the Height and mean for a girl of five years; her weight of 19.7 Weight kilograms is the mean for a girl of six years. On the species scale, she has no signs of atavGrowth ism. On the age scale Bertha shows an anatomical retardation of at least three years. She does not seem like a case of simple mental retardation although in some things, specifically in complexity of responsiveness and of imagination, she is very like a younger child. ii. in Bertha B. Born F M Growth. Sex. Culture. Competency (social). Vitality. Attention. Movement Responsiveness Imagination (general). Imagination (specific). Memory. Sensitivity. Proficiency. * Anatomical. 1. F. C.D. 2. Height 106.4 cm. 3. Weight 19.7kg. 4. Species. 5. Age. 6. Masculinity. 7. Femininity. 8. Civilization. 9. Education. 10. Ability. 11. Conformity. 12. Energy. 13. Rate. 14. Fatiguability. 15. Health. 16. Concentration, Analytical 17. Persistence. 18. Distribution. 19. Alertness . 20. Interest, Range. 21. Control. 22. Co-ordination. 23. Initiative. 24. Complexity. 25. Vivacity. 26 Imageability 27. Associability. 28. Complexity. 29. ” Range. 30. Observation. 31. ” Range. 32. Understanding. 33. ” Range. 34. Planfulness. 35. ” Range. 36. Intelligence. 37. ” Range. 38. Trainability. 39. Retentiveness. 40. ” Range. 41. Liminal. 42. Discrimination. 43. ” Range 44. Efficiency. 45. Operations, Range. V V
There are no signs of primitivism on the civilizaCulture tion scale. On the education scale she shows at least one year of retardation.
Bertha has not at present sufficient social comSocial petency. This is due to doubtful ability and competency deficient conformity. The important question in regard to Bertha is whether she has sufficient ability to be able to attain full social competency and whether, by some form of not too expensive special treatment, her conformity can be brought up to normal.
She has great energy and her rate of movement Vitality is rapid. She appears to fatigue quickly but this apparent fatigue may be due to lack of persistence of attention or to lack of interest. Her health appears to be good in spite of her retarded physical development.
Her concentration of attention is variable, Attention Most of the time it is poor, but at times and for short periods it is good. When her concentration of attention is good, it seems to be dependent on interest or on outside force. Her persistence of attention is consistently deficient. Distribution of attention is good and her attention is normally alert. Her range of interests is limited and her interest in any one thing, with the possible exception of games and folk-dancing, is rarely maintained for any length of time, showing the influence, probably, of her lack of persistence of attention.
Her movements are Avell controlled and coMovement ordinated and she shows good initiative. In responsiveness she is vivacious but lacking in complexity. Her responses are like those of a younger child. Her imageability and associability are sufficient Imagination for a girl of her age, but her imagination is lacking in complexity. It is too fanciful and is not sufficiently controlled by memory. It is the type of fanciful imagination which one sees in a younger child. Her powers of observation are good although Imagination the range is limited somewhat by her narrow range (specific) of interests. She shows less inclination to exercise her powers of observation in academic subjects than in activities like folk-dancing and games which appeal more to her interest. Her understanding and range of understanding are normal. Her planfulness and intelligence are good, although here again the range is limited by her interests. In trainability of memory, Bertha is probably slightly deficient. Her associability and imageability are sufficient for a good memory, but she is deficient in persistence and usually in concentration of attention. The trainability of her memory depends largely, then, on the train ability of her concentration and persistence of attention. Her retentiveness is also deficient and the range of retentiveness is even more deficient. Where good persistence of attention is essential to retentiveness, as in spelling and arithmetical combinations, her retentiveness is deficient; but where a less degree of concentration and persistence of attention are sufficient, as in the recognition of words in reading, her retentiveness is good.
Her sensitivity, so far as tested, is normal both Sensitivity as to limen and discrimination. It has been tested only for vision, audition, and kinaesthesis and then incompletely. There is nothing in her general behavior, however, to suggest a deficiency in sensitivity.
Bertha has not the proficiency of a normal nineProficiency year-old girl. This is due to deficiency both in particular efficiencies and in the range or number of operations. She is not proficient in any school subject, with the possible exception of reading and language, and she is markedly deficient in spelling and number work.
Etiology.
We have to account for her deficiency on the ability and conformity scale, and for her physical retardation. The birth history is negative: while her birth was instrumental, labor was easy and she was not injured. She suckled naturally. Nor does her medical historjr throw much light on the etiology. After diptheria in 1911 she had some trouble with a running ear, but this trouble has disappeared and her hearing is normal. The combination of whooping cough and bronchial trouble seems serious in view of the fact that her mother is tubercular, but her chest expansion is excellent and there are no indications of tuberculosis. There is a history of indigestion in babyhood which suggests the probability of malnutrition, especially as she was bottle-fed. This is significant in connection with her physical retardation and deficient ability.
In the family history there is a report of one miscarriage, but as the Wassermann reaction is negative in Bertha’s case, syphilis is excluded. Two children died in infancy but the information is too meager to explain the cause of their death. There is a baby now a year old who is normal so far as can be ascertained. The mother is tubercular but there is 110 evidence that she had tuberculosis at the time of Bertha’s birth, and the mother herself report232 THE PSYCHOLOGICAL CLINIC. ed that her health was good while carrying Bertha. The father has diabetes, which suggests a glandular disorder. This may be of importance in explaining the physical retardation and deficient ability, but Bertha presents no symptoms of any specific glandular disorder. There are no anomalies of growth: she is well proportioned in spite of her small size. The care which Bertha has received is of considerable importance to the etiology. While the family had never required outside aid previous to February, 1915, they have always been very near the poverty line and the probabilities are that Bertha has always been undernourished? This, especially combined with the report of indigestion in babyhood, is significant in accounting for her doubtful ability and retarded physical development. School conditions I think we can exclude as an etiological factor in her possible deficiency on the ability scale. She has never changed schools, and while the school is crowded, other children have made normal progress under the same conditions.
As to conformity, the severe but unintelligent and probably ineffective discipline in the home is the important etiological factor. Is Bertha a restorable case? Can she, in addition to doing as good work as the average child in the grade she is now in, make up her one year’s retardation? Can she be brought to conform herself to school room conditions so that she will profit by the instruction given without being a disturbing factor to the other children, as she is at present? And can this restoration be made without too great expense to society? One must remember that while in reading she is possibly slightly above the second grade level, in number work and spelling she is not even up to the second grade level. While she has good intelligence and good imagination she is deficient in attention, especially in persistence of attention. She also lacks complexity both of responsiveness and of imagination. Her defective attention has affected her retentiveness. She shows no inclination to conform to class discipline and very little desire for self-control. Little help can be expected from her home as her mother is overworked and probably lacking in proficiency. It seems unlikely, when one considers all these factors, that Bertha can ever be restored to the grade to which she belongs according to her chronological age. Under a very good teacher who could give a disproportionate amount of time to Bertha, there would be a chance, it seems to me, of her ultimate restoration. But this would be too expensive and also unfair to other children even under special class conditions. Her school report for this fall is favorable, but two months of good behavior is hardly sufficient to counterbalance her past history. Even if she continues to do good work, a possiblity which we certainly must recognize, she is doing what is good work for an eightyear-old but not for a nine-year-old. While the chances of Bertha’s being restored to the grade to which she belongs are slight, does this mean that she will not have sufficient social competency to earn her living? Unskilled laborers are able to earn a living for themselves and family, and yet it is probable that their ability is not greater than that represented by the fifth grade in school. Bertha spent two years in the first grade and will spend at least as long a time and probably a longer time in the second grade. But even so, the chances of her being able to complete the fifth grade by the time she is sixteen are excellent under special class conditions. Her chances of sufficient social competency so far as conformity is concerned are not so good. At nine years of age she is very badly conformed. Her mother has very little control over her, and her teachers, on the whole, very little more. If Bertha is not better conformed at sixteen than she is at nine she will be a serious problem to society, and I believe it will be cheaper for society to attack the problem of her restoration to sufficient conformity now instead of waiting until she is sixteen. While her restoration to sufficient conformity is somewhat doubtful, it is by no means hopeless. Her present improvement in conduct is hopeful whatever its cause. The chances certainly warrant an attempt at restoration. This attempt at restoration should be made under special class conditions. Removal to a special class is necessary, as much for the sake of the other children to whom she is a disturbing factor, as for Bertha’s sake. It will be easier for her to conform to the discipline of a small class than to that of a larger. A special class will be of benefit to her because of the unevenness of her work. In a special class she can read in a third reader and do first grade work in spelling and arithmetic. To sum up, I believe all attempts to restore Bertha to the grade to which she belongs according to her age should be given up. Instead, an attempt should be made under special class conditions to bring her up to the fifth grade level of school proficiency by the time she is sixteen and also to restore her to sufficient conformity so that she will not be a menace to society. I believe her chances of reaching the fifth grade level in school proficiency are good, and that while her chances of being restored to sufficient conformity are not quite so good, they are good enough to warrant an attempt at restoration. I think, further, that if Bertha makes good our prognosis by reaching the fifth grade level of proficiency and is restored to normal conformity we will be obliged to call her a restoration case.
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