A Retarded Pupil Restored to Grade
By Herman Campbell Stevens, M.D., and Lelah C. Russell, Chicago, Illinois.
A report of this case is deemed important for the reason that it demonstrates the necessity for a correct diagnosis of retarded school children, in order that teachers may know how to proceed with their training. The essential features in the story are a paralyzed arm, which was wrongly supposed to indicate a brain lesion; failure to learn to read or write by ordinary school methods; discouragement and lack of interest, resulting from the fact that the boy’s first teachers had not understood his condition; and his subsequent rapid progress and eventual restoration to his proper grade as a result of correct diagnosis and intelligent teaching.
Thomas entered the first grade at the Wadsworth School, in September, 1914, at the age of 6 years, 2 months. He made no progress during the first school year, which led to an examination by the Child Study Department, September 24, 1915. The report rendered upon examination, was that Thomas showed up fairly well with tests of mental ability suitable to his age, except for the fact that he had gained nothing at all in ability to read. It was stated, also, that just how much of a brain lesion accompanied the paralysis of his right arm could only be determined through observation. It was suggested that he be given a further trial in the regular grade, as his attendance had been irregular. After six months more in the regular first grade, Thomas was examined again by the Child Study Department, January 21, 1916, and the following report was submitted: Thomas has been in the first grade one year and six months and has not learned to read and write. Since, in a six months’ trial in the regular grade he has made no appreciable progress, it is recommended that he be given a place in a subnormal room.
Thomas entered the subnormal room, March 6, 1916. Upon careful examination and close observation, his teacher, Mrs. Russell, found that he knew nothing at all about school work. The faculties of learning seemed to be dormant, undeveloped, and imperfect. He showed no interest in anything. If given a dissected puzzle to put together, he made no effort to do it. It was supposed that as he probably would never learn to do any school work, and was incapacitated for handwork by the paralysis of his right arm, the only ‘From the Psychological Laboratory of the University of Chicago. thing to do for Thomas, was to make him happy. After one week of observation, however, Mrs. Russell obtained from the boy’s parents a history of his development and secured their consent to a physical examination by Dr Stevens. The history and the results of the examination are here given in detail.
Thomas was a full term baby; weighed thirteen pounds; instruments were used; a very difficult birth; it was necessary to work with him for several minutes, as he was black and blue. There was a deep groove in the center of the head and each side was puffed out as though full of water. The back of the head was flat. Behind the right ear and extending down the throat was a very noticeable and hard enlargement: the mother states that it seemed like a bone. The right arm was paralyzed and the child could move only one finger of the right hand. He was given electric treatments for ten months; swelling behind the ear disappeared; the head was still rather large but not puffed out; he gained movement of fingers of right hand. Fontanelle was a long time in closing. An attempt was made to get an X-ray plate of head, but the child would not hold still. He was a cross, irritable baby and cried most of the time; needed almost constant care for two years. Cut first tooth at six months; walked at seventeen months; talked at two years. Was breast fed for four months; then given several kinds of food, the only one that finally agreed being a brand of condensed milk.
Diseases of infancy. There were no convulsions. At the age of three, he had scarlet fever with suppurating ears, followed directly by chicken pox, measles, and dropsy; was in the hospital for ten weeks. From the age of four until one year ago, Thomas had frequent sick spells. He would get up and dress, go to the table, put his head down and say that he was sick; a vomiting spell would follow and then he would want to sleep all day; he would seem stupid and want to be let alone. At times he would go to school in the morning and have these spells at noon. He has not had them during the last year, but occasionally complains of a pain in his back. Age, 8}4 years.
Mental age, by Yerkes-Bridges point scale, 8 plus. Norms Height, Sitting, 66 cm. Height, Sitting, 67.72 Standing. 126.7 cm. Standing, 123.48 Strength of Grip,Right, 0.5 Grip, Right, 12.41 Left, 13.5 Left, 11.16 Vital Capacity, 1350. Vital Capacity, 1316. A RETARDED PUPIL RESTORED TO GRADE. 273 Circumference of Head, 19.75 cm. Circumference of Head, 20.51 cm. Cephalic Index, Cephalic Index, Breadth, 140 Breadth, 143 Length, 170 : 82.34 Length, 180: 78.71 Auditory Acuity, Right ear, 8 inches. Left ear, 8 inches. Visual Acuity, Right eye, 10/100 E Chart, Right eye, 10/20 Left eye, 10/30 Left eye, 10/20 The Wassermann reaction on the blood serum was negative. Head.?There is an asymmetry of the skull; the right occipital region is flatter than the left. The vertex is broad and high. The right side of the face is fuller than the left. The conchie are large and symmetrical. The pupils are round, equal in size and react to light and accommodation; there is unsteadiness in fixation but no nystagmus. In the right temporal region there is a small scar. There is partial obstruction of both nostrils. There is a slight deviation of the tongue to the left. The frenulum is slightly short. The tonsils are large on both sides. The palate is symmetrical but shallow in front. The anterior cervical glands are slightly enlarged. Chest.?The area of superficial cardiac dulness extends 6 cm. from the mid-sternal line. There is no thrill. The heart tones are negative. The axillary glands on the left side are slightly enlarged. There is bronchial breathing in both apices, but otherwise the lungs are negative.
Spleen.?The spleen is not enlarged or palpable. Liver.?The liver dulness extends from the fifth rib to the costal margin.
Abdomen.?There is some tenderness in the epigastrium. There is no tenderness over McBurney’s point. The patient states that there is pain in the mid-thoracic region of the spine. Genitalia.?There is partial phimosis. The testes are in the scrotum. The scrotum is somewhat lax.
Reflexes.?The biceps and triceps are absent in the right arm. They are present in the left. The umbilical reflex is present in all four quadrants; it is normal except that the right lower quadrant is less active than the left. The cremasteric is lively. The patellars are lively. The plantar is normal in direction. The Chaddock, Oppenheim, and Gordon signs are negative. Co-ordination.?The Romberg sign is positive.
Arms.?The right shoulder hangs forward. The infraspinatus group of muscles on the right side is atrophied. The deltoid is atrophied. The strength of the biceps is fairly good. There is a wrist drop on the right side. The extensors of the wrist are weak. The flexors of the fingers are fairly strong. He is unable to raise the right arm more than 45?.
Legs.?The left leg measures 63.5 cm. in length. The right measures 63 cm. There is a hairy mole on the left leg on the lateral surface just above the knee. Abduction, rotation, extension, and flexion of both legs from the hip joint cause no pain.
Posture.?The lumbar spines are somewhat conspicuous. There is scoliosis to the left in the lumbar region, and to the right in the upper thoracic, there is a marked depression of the sternum in the region of the fifth, sixth and seventh ribs. There is a Harrison’s groove.
The essential feature in this examination from the point of view of the child’s school work, is the fact that it showed the paralysis of the arm to be a lower motor neurone lesion, and not a brain affair at all. Traction upon the arm at birth may have torn the roots of the motor nerves of the arm. The atrophy of the muscles, and the absence of certain of the arm reflexes point to a nerve lesion. This, together with the fact that the child was practically at age according to the mental tests, and also judged from his behavior, seemed to indicate that he could be trained if proper methods were employed. His subsequent history bears out this prognosis. The general idea, underlying the method used in teaching Thomas, is as follows: A child’s life is largely made up of action, and his birthright is free motor activity. Therefore, if we aim to awaken his mental powers, we must begin with play, which stimulates spontaneously and yet harmoniously. In this way games furnish a better field for the development of child nature than any other exercise which can be employed in a school course. That which spontaneously holds the child’s attention is the line of least resistance, and by means of his play interests, correlated with the school work, the power to think quickly, to judge accurately, and to act, as well as the qualities of politeness and self restraint, can be unconsciously acquired. Thomas’ work was planned along this line. In his reading, which was the first problem, as it is the center about which the entire primary work revolves, the first words and sentences were ones for him to act. For the first sight words, run, march, walk, fly, jump, etc., were given. Through play he soon learned to know a long list of action words, and the reading matter selected as he was ready for it, was also full of the action of real life. Along with this sight word play, he began on the very first day to learn, also through play, the sounds of the letters. With these mastered he had the key to the English language, for simultaneously with learning of the sounds his ear was trained to blend the sounds and form words. When he had had sufficient practice to recognize a word from sounding it, he was started on word building, beginning first with the simplest phonograms, as at, an, un, etc. These phonogram drills are excellent, and should be kept up with any child during the whole first three grades.
Thomas responded in a remarkable degree to the play and activities. He soon felt that he was living in a child’s world, suited to his needs. He applied himself attentively to his work. He quickly learned the sounds of the letters and was able to pronounce any phonetic word. It was keenly interesting to watch the unfolding of his little mind. From March until June, 1916, Thomas read four primers, and during the long summer vacation lost little of what he had learned. He returned in September intensely interested and alert for more. He read four first readers from September to November; learned to write creditably with his left hand; to spell any easy phonetic word; and did very good weaving with his left hand. On November 15th, Thomas was returned to the regular second grade with the little people whom he left last March. He has read two second readers and has acquired a knowledge of number combinations suitable to his age. He is proud to say that he is in advanced second grade.
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