The Importance of a Complete Social History in Clinical Examination
- Author:
Margaret C. Brooke,
Social Service Department, Psychological Clinic, University of Pennsylvania.
The principal of one of Philadelphia’s orthogenic schools, in which the majority of those enrolled are non-conformed socially, recently made an appointment for the examination of one of her charges, with the request that she be allowed to give only the absolutely necessary preliminary information on the case until after the psychological examination was completed.
On the appointed day the Clinic was confronted by a well groomed, good looking and decidedly immaculate colored boy of nearly thirteen summers, who was so polite as to be almost impudent. He has a meek, appealing look. We began to group him with the rest of his class and ventured to remark that he was probably normal dull or a borderline case with, no doubt, a school retardation of perhaps several years. A glance at the preliminary information sheet, however, dispelled that diagnosis, for it registered the fact that he was in the fifth B grade and had not been admitted to school until eight years of age. When it was suggested that the reason for his coming was poor school work, the principal lost no time in bringing to light monthly school reports showing passing and, in some subjects, better than satisfactory grades. There were no stigmata on which to blame any abnormality and his physique was proof positive, even to a lay person, that medical care was unnecessary. Nor was there a record of any disease in his lifetime other than chicken-pox. His pedagogue escort was very nonchalant and passive over the conjectures concerning this boy, but knowing her in her school work and from her repeated contacts with the Clinic, we felt assured that he was a decided problem with her or she would not have taken the trouble to personally conduct him to the Clinic on her free Saturday, especially when it is customary for her assistants to handle the clinic cases. As the boy progressed with the tests we were more and more nonplused, for he solved the Witmer formboard the first time in 34 seconds with splendid coordination and distribution of attention ? using both hands. The Witmer cylinders were solved (1) 1 minute 8 seconds, (2) 47 seconds, (3) 45 seconds, in which he displayed great interest and solved it with more intelligence than some college students. He apparently realized at once that this test demanded more of him than the formboard. Healy A was solved with little or no effort and his Healy B performance showed excellent trainability, interest and initiative. His auditory memory span was six digits and he gave the same number backwards with apparent ease. He undoubtedly would have reduced the time on all the performance tests had he resorted to the trial and error method rather than attempting to think out each step and he was always conscious of his stupidity. Quantitatively his performances were good, and for a colored child his qualitative results remarkable, with the only defect a high degree of fatigueability and lack of persistence of attention. His intelligence quotient on the revision of the Binet Simone Tests was 109.4 with a mental age of fourteen years. He displayed good language ability in these tests, especially when correlated with those of his race.
In the light of his performances and reactions in the Clinic, he was diagnosed as having normal mentality with superior competency. At this point, however, the principal gave her angle of the case and reported that the morale of her school is entirely broken up whenever and wherever he puts in an appearance. Because of his effeminate speech and manner he keeps the entire school continually amused. Schoolmates, both older and very much younger, are highly entertained because, when teased and taunted, he makes no attempt to defend himself but sits down to weep, begs for mercy or kneels in a prayerful attitude and pleads for clemency. Naturally the whole school works overtime to bring on these scenes, and as a result the recesses, noon hours, change of classes, etc., are one continuous side shoAv with Sam as the leading lady. His behavior with adults was reported courteous and satisfactory, which fact he demonstrated during his short stay with us. This is a clear-cut case of an intellect rather superior, but social non-conformity so unusual that the former is of little importance; consequently, it is necessaiy to label him defective and recommend that he be kept in an orthogenic backward or disciplinary class. Had it not been for the cooperation on the part of this principal, who supplemented information very often ignored by teachers and social workers, and often purposely omitted by parents, the record of this case would have been completed and recorded in a very misleading manner, especially had it been referred to for placement at some future date, as is the case with a large number of the current and closed records of any mental clinic. Infallible diagnoses cannot be expected without a detailed report from every possible angle, most especially the home and school. How often does the Clinic make a wrong interpretation of a case because of inadequate preliminary information? A boy sixteen years of age is likely to be self-conscious under ordinary condition, but to be conducted to a clinic for a psychological examination under the chaperonage of a fond mother and an overzealous music teacher, is not likely to improve matters. Under these conditions Harry was piloted to our Clinic. His pedagogical history showed him to be in the first year of the high school, having repeated the second and seventh grades with good for conduct but poor for academic work. He had been the victim of a light attack of scarlet fever, had had measles and suffered at present from a catarrhal condition. His family physician reported that he was growing too fast and his music teacher said he could not “use his head” even though his heart and soul were wrapped up in music and he wanted to learn.
In the performance tests he displayed excellent coordination, immediate comprehension of a problem, wide distribution of attention and good analytic discrimination and he solved all with splendid scores and reaction times. His intelligence quotient on the Binet was 96, his basal age being a few months below the chronological due to limited vocabulary.
It so happened that just before this trio retired to the Clinic for the examination, a graduate student who knew the family vouchsafed a remark that proved very valuable as a solution to the situation, and the clinician, in view of the fact that the mother gave evidence of being a hysteric and the father’s violent temper was casually referred to, decided to investigate the case from several different angles before venturing anything but a tentative diagnosis on this perfectly normal, adolescent boy. So in a tactful way arrangements were made for a second visit of the boy to the Clinic, unaccompanied.
Before this second contact the graduate student was questioned and from her some information was obtained which proved invaluable in the interpretation of the case. She reported that an older brother was very cruel to the boy, abusing him physically and tormenting him by destroying his music. His original compositions were promptly destroyed by the brother or father. His only ally in the household was his hysterical mother, who is also a religious fanatic of the emotional type, believing all ministers to be saints and therefore insisting that her son study for the ministry. Not being interested in this, he is constantly reminded forcefully, and often cruelly, by his father and brother and calmly but repeatedly by his mother that he will never amount to anything. Is it surprising that the boy alternated between fits of anger and depression?
This information proved to be extremely important, for the music teacher was blissfully unaware of this home condition, the mother too loyal to the other members of the family to disclose it and the boy so cowed that a recital of home conditions would not have been revealed by him because of the persecution likely to be endured as a consequence.
When the boy reported for his second contact he was advised to leave home and live with relatives or friends or stop school, get a job and attend night school until such a time as the older brother married or the family guaranteed better treatment if he consented to return.
How valuable this information, accidentally obtained, proved to be in the handling of this case!
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