A Problem in Social Adjustment
A Statistical Study of the Mentality and Personality Types of More than Thirteen Thousand Consecutive Cases, Examined at the Neuro-Psychiatric Clinic of the Municipal Court of Philadelphia Anna Spiesman Starr, Ph.D.
Formerly Psychologist at the Municipal Court of Philadelphia Apart from its judicial function and yet inextricably related to it, the Muncipal Court of Philadelphia is one of the largest social agencies of any city. Its purpose may be said to be the social adjustment of each individual whereby citizenship is the more fully and truly achieved. Its emphasis is upon restitution as complete as possible and upon awakened personal responsibility rather than punishment. The law provides that this Court shall have exclusive jurisdiction (1) in all Juvenile cases (children up to sixteen years of age), (2) in cases of disorderly children from sixteen to twenty-one, and (3) of all disorderly street-walkers. Its jurisdiction also extends to (4) cases of desertion and non-support of wife and child as well as to other types of homes-in-the-breaking; (5) to indigent and abandoned parents, and (6) in a limited degree to criminal and civic cases. Hence it is primarily the great tribunal dealing with the welfare of children and with home problems in the city of Philadelphia. Statistics of the Neuro-psychiatric Division of the Court are now available for the first five year period (1920-1925) of its present organization. During this time, at its central clinic, upward of thirteen thousand individuals have been examined, more than a thousand of whom have had subsequent re-examinations. The records of so extensive a Diagnostic Clinic may be assumed to indicate rather definitely the types of people who appeal to such a Court for help in the adjustment of their difficulties or who have so failed in their social and civic obligations as to have been arrested as lawbreakers. To consider what have been the results of these examinations and to interpret the conditions indicated thereby is the Purpose of the present study. In passing, it may be worthy of note that during this period there was no change in the Examining Staff at the Clinic,* which fact adds considerably to the uniformity of terminology and thereby to greater accuracy in the statistical treatment of the data.
The work of the Neuro-psychiatric Division has been purely diagnostic. With the limited staff and pressure of work, no treatment has been possible except as suggestions at the time of the examination and recommending special placement or treatment at Hospital Clinics. Probation Officers have been free to consult the Examiners about any case and they frequently avail themselves of the opportunity to discuss the practical solution of their problems. The value of such a Clinic lies primarily in presenting to the Court a more accurate evaluation of a client’s potential adjustability than casual observation could possibly do. Psychological and Psychiatric examinations determine the zone within the limits of which an individual is capable of functioning. In a practical way, the Clinic advises what the Probation Officer may expect to accomplish with a particular case, thereby eliminating all effort to attempt the impossible.
Cases of Children
Whether it be a question of dependency or delinquency, of neglect or vicious mischief, every child coming within the jurisdiction of the Court has a physical and a mental examination prior to the hearing. The results of the examinations are before the Judge at the time of his decision, along with the report of the home and school investigation. This indicates how important the Court has found the child’s physical and mental health to be in determining his responsibility. Experience has shown how intimately they influence the success of the Probation Officer’s efforts toward establishing the individual’s economic and social sufficiency. In the Courts of several other cities, physical and mental examinations are made in those cases designated by the Judge, but in the Philadelphia Muncipal Court all children are examined before the Court hearing.
Table I records the diagnoses made of 7,664 children under sixteen years of age. As individuals, they may have been referred from any one of the divisions of the Court and involved in any are examined while awaiting Court; a second at the Women’s Misdemeanant’s Detention House and the third at the General Medical Building. The records here considered are entirely from the last mentioned place to which cases of all ages are referred from any of the Court divisions whatsoever. type of case. As in all instances throughout this consideration, the diagnosis tabulated has been the primary or outstanding one. In many instances dual diagnoses have been made especially in the Moron and Subnormal Groups where unstable and psychoneurotic personalities are so frequent. However, the diagnoses recorded here are unqualified and refer to that group which most nearly covers the case.
Table I. Juvenile Cases?Infancy to 16 Yrs. Diagnosis Number of Cases Percent Normal 3150 ? Retarded 1542 ‘ Subnormal (Moron) 1912 ? Low Grade Defective (F.M.) 332 ? Idiot and Imbecile 1^5 ‘ Epilepsy 50 ‘ Psychoneuroses 221 Psychoses ^ Organic Nerve Disease and Chorea… 56 Post Encephalitis 21 Constitutional Psychopathic Inferior. 100 All Others 1015 1*3 TOTAL 7664 100.0
The most apparent and outstanding facts indicated by Table I are, first, that the group is roughly divided into half as between the Normal Children and those presenting some abnormal nervous or mental condition; secondly, that children tend to express their mental deficiency chiefly along intellectual lines. This is probably due to the fact that problems of childhood are those of Learning both in and out of school, and any mental deficiency is expressed in their failure to meet this problem adequately. The 41 per cent diagnoses as Normal may be held by some to be too large a proportion. It must be admitted that several hundred of these children were very young at the time of examination and that defect other than the grosser kind may not have been discernible so early in their development. Also, children functioning within the limits of normality at pre-school age may be deficient later on through injury, illness or a failure to develop. On the other hand, many of the children in the Retarded Group are func88 THE PSYCHOLOGICAL CLINIC tioning below their best possibilities due to an environmental, a nutritional or an organic handicap and it is therefore to be expected that under the Court’s supervision these obstacles may be removed and a fuller and more active mental development result.
Next to the Normal Group is the Deficient Group?those of subnormal (moron) intelligence. The extent of this group (25 per cent) is not surprising when we realize that lack of judgment and adequate appreciation of the causal relationships in every day living are characteristic deficiencies of this class. This is largely the group charged with the petty and even more serious delinquencies. In most cases life demands too much of these children. Their deficiencies are either not generally recognized or they lie along a particular ability and the resulting behavior and transgressions are too often considered “devilish” when the offender may be just as surprised as anyone at finding himself in difficulty. “I did it because he asked me to. I didn’t think I would get caught. I just did it.” This group can be helped by probation only when their defects and possibilities are both recognized and their environment and social demands so adjusted as to be more nearly proportional to their possibilities.
Among the children, there were 6.4 per cent of low grade mental defectives including the so-called feebleminded, imbeciles and idiots. This large percentage is due to the fact that it is through the Juvenile Court that all such children are committed to institutions and most of these cases were referred for that specific purpose.
The children of the Psychoneurotic Group (3 per cent) were those of excessive fears and emotionally overactive. Their success in life is imperiled by their emotional instability rather than by their intellectual capacity, any degree of which they may possess. They range all the way from the child afraid of the dark to those unhappy ones who meet no situation with confidence and cripple their self expression by vague fears of their own inferiority. The diagnosis CPI (constitutional psychopathic inferior) denotes those who so lack moral impressionability as to be incapable to a considerable extent of appreciating social or group responsibility of any kind. They are impulsive, unchecked by inhibitions and have a minimum of emotional development. Their delinquencies are characterized by a bold audacity and a cheerful disregard of consequence.
Adolescent Cases
In the cases of those above the juvenile age, i.e., the adolescent and the adult group, mental examinations were made at the request of the Probation Officer in any case where probation had failed or wherever there appeared any symptoms of “nervousness” or complaint of mental or physical disorder. Other cases were referred directly from the Court Room at the discretion of the Judge or by direction of the physician attending Court. In this study the records of the older groups are therefore not so inclusive nor unselected as in the younger class. However, 5,721 cases above sixteen years are here recorded, which number is sufficiently large to be at least suggestive in the differentiation of types, but not to be taken as establishing definite percentages.
Table II records about 1,000 cases between 16 and 21 years of age. They consist largely of runaway and incorrigible boys, unTable II. Adolescent Group?16 to 21 Yrs. Diagnosis Number of Cases Percent Normal 119 12.3 Retarded 32 3.3 Moron 444 45.8 Low Grade Defective (F.M.) 90 9.2 Imbecile, Idiot 15 1.5 Epilepsy 23 2.3 Psychoneurosis 154 15.8 Psychosis 26 2.7 Organic Nerve Disease and Chorea… 5 0.5 C.P.I 53 5.6 All others 10 1-0 TOTAL 971 100.0 married mothers and young husbands and wives who have early encountered marital difficulties. The drop in the percentage of the normal group is not as significant as would at first appear, because this older group is somewhat selected while the Juveniles were entirely not so. The bulk of normal children came to be within court jurisdiction because of economic dependency. Many were merely asking for maintenance, while in the adolescent group no such financial aid is awarded. Each case in Table II indicates an individual in difficulty more or less of his own making. The decided increase in the percentage of emotional instability is, however, significant. It indicates that the adolescent reacts to his insufficiency with increasing emotion. To any intellectual deficiency the adolescent delinquent is likely to add emotional instability, often to the extent of making this emotional instability his chief handicap. The increase in the number of developed psychoses is also to be expected, as a corresponding increase takes place in the general population during the adolescent years.
The adult group was largely recruited from the Domestic Relations Divisions and from those cases involving cruelty or neglect of children. The results of their examinations are tabulated as Table III and further demonstrate the tendency indicated in Table Table III. Adult Group?above 21 yrs. Diagnosis Number of Cases Percent Normal 854 17.8 Moron 760 16.0 Low Grade Defective (F.M.) 76 1.6 Epilepsy 50 1.5 Psychoneuroses 1860 39.1 Alcoholism 131 2.7 Senility 147 3.1 Psychoses 456 9.5 Organic Nerve Disease, and Chorea. . 139 2.9 C.P.I 152 3.2 All others 125 2.6 TOTAL 4750 100.0 II, viz., that with increasing age, individuals fail to meet their problems more and more because of emotional instability. In this group (4,750 cases above 21 years) it appears to be the chief causative factor. If we add the cases of deficient (not F.M.) mentality to those of psychoneurotic makeup, we have 55 per cent of the entire adult group. This means that more than one half of the adults examined were to a considerable extent mentally or emotionally handicapped?yet still within the range of being somewhat adjustable. In comparison with the other deficient group, their prognosis under treatment is favorable. This is an astounding fact, the consequences of which are far reaching indeed and a recognition of which must be made if any lasting social adjustment is to be effected. One should realize that this is the group whose economic status is so often barely adequate and hence is readily upset by unfavorable labor conditions. In their lives emergencies are met by expenditure of capital in health and ideals as readily as material extravagances are indulged in during times of temporary opulence. Furthermore, theirs are frequently the homes of incorrigible children, many of whom are mentally deficient, physically handicapped or both. When we appreciate these facts and conditions we begin to sense the enormity of the problems confronting such a Court and Clinic and realize how involved aie the vicious circles which all but defy untangling.
Table IV is a summary of all the cases examined and in this form admits of a closer comparison of the three groups. First, it Table IV. Summary. Diagnosis Normal Retarded Subnormal (Moron)… Psychoneuroses All others. Total number of cases.. Juvenile 41.1 20.0 25.3 2.9 10.7 100.0 7664 Adolescent 12.3 3.3 45.8 15.8 22.8 100.0 971 Adult 17.8 16.0 39.1 27.1 100.0 4750 Total 23.7 36.8 19.3 20.2 100.0 13,385 Social Status Adjusted Borderline or adjustable Non-adjustable indicates that about one fourth of the entire group were of normal intelligence and were free from any mental, emotional or neurological disorders. Secondly, and undoubtedly this is the most striking and suggestive determination brought out by the whole study, that 56 per cent of all individuals examined over a period of five years belong to a “Borderline Group”?each member of which presents in varying degrees some defect either in the field of intelligence, of emotion, or both. Yet these individuals function within such limits as admit of considerable adjustment and for the most part reflect very plainly in their behavior the forces of their environment. This group may well be recognized as being in special need of such therapeutic measures of Mental Hygiene as will increase their stability. Unless they do receive such treatment, they will succumb to the chance forces of their environment, which will tend to make their condition the worse through their very lack of critical discrimination. This group may be termed “Adjustables” in contradistinction to those of grosser defect whose prognosis is more unfavorable, the Non-Adjustables. Thirdly, we note that the Non-Adjustables under the caption of All Others approximates the Normal Group in size; also, that the percentage of NonAdjustables increases with age?there being almost three times as many of them in the adult as in the juvenile. Fourthly, this table clearly emphasizes the shift in the type of defective reaction characteristic of each group. Children’s problems involve the learning processes and their failure therein indicates their defect and deficiency. By adolescence their problems involve more of judgment and planfulness and when their defective mentality or their instability inhibits (prohibits) success, their reaction is complicated by increased emotional disturbance. This condition is further intensified in maturity especially in marital and family problems when they no longer accept parental supervision and so much depends upon their personalities. Many who were well able to cope with the school curriculum by their rote memory, fail in maturity because of the complexity and fluctuation of circumstances. Their resulting behavior is like the youngster beating his head against a stone wall and then crying because it hurts.
The relatively small proportion of normals in the older group as compared with the children is partially due to the fact that in this study the Juvenile Group is wholly unselected while the others are not. Then, too, the normal child does not necessarily become the normal adult. Some individuals attain their mental stature at an early age, beyond which the increasing years bring nothing of mental acumen, and increased skill, due only to practice and experience, is but increased efficiency on no higher plane. Yet, if fairly well poised, they are capable of being “good citizens.” The increase of the normal cases in the adult group over the adolescent is due in part at least to this, that in the Domestic Relations cases, the diagnosis of mental abnormality in either husband or wife results in the request for the other one to come to the Clinic, for whom there might otherwise have been no question of a mental examination.
This statistical data presents a fairly definite picture of the mental status of the group considered. Of the 13,385 individuals examined, somewhat less than one-fourth (23 per cent) were diagnosed as normal, more than one-half (56 per cent) constitute a “Borderline Group,” as herein defined, while the remainder were either those of uncertain diagnosis or so impaired mentally as to he considered non-adjustable from a social point of view. The first conclusion to be drawn from such findings, is that deficiency in mental alertness or emotional stability or both characterizes the majority of individuals whose social and civic problems Philadelphia’s Municipal Court was called upon to adjust. It would therefore appear that some causal relation exists?viz., that mental deficiency and emotional instability largely contribute to social incompetency. This is universally recognized wherever there is gross defect, but in this study we find that more than half of the entire group were not grossly nor irreparably defective but that from a functional viewpoint, they were sufficiently deficient in their particular environment as to be, for the time being, socially inadequate. This fact raises the whole question of “partial responsibility” and challenges some satisfactory solution.
The second conclusion is that, since the Adjustables, as such, functioning below their possibilities are socially incompetent, it is reasonable to expect that functioning at their best they would become much more sufficient in their social relations, if not entirely so. This necessarily involves the concept of making it possible for each to attain his highest norm.
The Court knows that families and individuals enmeshed in the most tragic and intricate problems of poverty and suffering can be helped toward rehabilitation and expected to maintain their regained position in direct proportion to their intelligence and the stability of their personality. The individual must be such as can be relied upon to cooperate in the guidance offered and must help himself to face the issues squarely, not passively indulging in disproportionate self-pity or indifference. Otherwise he hinders his own progress by poor judgment or chronic depression. This is particularly true in cases involving financial conditions when irritation and family friction are so easily stimulated. Most family problems as well as all cases of dependency involve this point. Mere financial problems can be adjusted and with careful analysis ?f the situation it is possible to evolve some plan of rehabilitation through cooperation and mutual effort. But, it is when illness or defect complicate the situation that the problem is really serious. However, all persons cannot be adjusted to live happily in a community and for their own good should be removed to custodial care as soon as possible. It is poor social management to keep some families together and it is a miscarriage of justice to try to do so. Energy should not be wasted in attempting the impossible but rather should greater effort be concentrated upon that which can be done.
Social problems seem to arise directly from the type of personalities concerned rather than from purely environmental circumstances. A very frequent cause of maladjustment is the instability of the hysteric or the moron’s lack of judgment. Not every one who bears financial or social burdens comes to Court and the stories of some who finally do come are records of selfsacrifice and cheerful heroic effort almost beyond belief. These are, however, in the great minority and their problem is external to themselves. By far the greater number of Court Clients are involved in difficulties because of their inadequate meeting of a situation fairly well within their possibilities. Comparatively few function at their best unless definitely trained under supervision more or less enforced.
Through experience the Court knows all of this and knows too that unless there is some change within the individuals themselves, the solution of this year’s problems bears no guarantee that next year they will not return with similar ones. The needed change may be only one in the point of view or having some ambition keenly stimulated. It needs to be that “something,” the absence of which results in the individual being a social deficit and by its presence makes him more nearly an asset. Most individuals who are at all socially competent have some aptitude, the expression of which arouses justified pride and self-respect. This ability asset is what the Probation Officer or Counselor fosters and encourages. All unadjusted individuals need a more accurate appreciation of their possibilities and some recognition of their limitations plus an ambition to function at their best. Somehow they need to be conscious of a philosophy?i.e., an explanation or justification of life which to them is rational and satisfying, even though they have no idea what philosophy is. They need a goal which lies within their ability to reach, and a sense of it being worth their effort to attain it. In other words, they need more insight into their lives and condition. Like all the rest of us, when they are without vision, they easily run amuck. It is by the methods of mental hygiene that such disclosures are made and they constitute in reality the essential accomplishment in every successfully adjusted case whether specifically done through a Clinic or not.
It is unfortunate that the daily press so often features with maudlin sentimentality any innovation in the treatment of breakers-of-the-law, regardless of possible intrinsic value. In the attempt to portray the sensational, the emphasis has been placed upon the offender as “the poor criminal” even to the extent of picturing prisons as gentlemen clubs. The concept of partial responsibility has been misunderstood, too, and mental examinations to determine such responsibility, are by some considered mere palliative measures to impress and confuse the Jury. But with the Court itself, such conditions do not hold. Being informed as to the type of person before him, the Judge can the more intelligently not only “make the punishment fit the crime,’’ but considering the individual, may impose such a sentence as will tend to remove the cause and opportunity of repeating the offense. The study of these statistics shows how much salvaging needs to be done even with the Clients of but one Court in a single city. By inference they indicate how wide spread is the need for rehabilitating the socially maladjusted.
Summary
A statistical study of 13,385 consecutive cases examined at the Neuro-Psychiatric Clinic of the Municipal Court of Philadelphia, over a period of five years, ascertains the following facts: 1. Of the total number examined, 23.7 per cent were diagnosed as normal; 36.8 per cent as subnormal (moron) ; 19.3 per cent as psychoneurotic and the remaning 20.2 per cent cover the Psychoses, and pathological neural conditions, the undetermined diagnoses and all others not previously accounted for.
2. The Juvenile Group (7,664 children under 16 years of age) Was wholly unselected and consists of dependent children as well as those charged with delinquency. It is roughly divided in half as between the Normal and those presenting some abnormal nervous ?r mental condition. This group expresses its abnormality chiefly m the field of intelligence.
3. The adolescent delinquents (971 cases between 16 and 21 years of age) react with increasing emotion. Intellectual deficiency is further complicated by emotional instability, often to the extent of making it their chief handicap. This group is somewhat selected being largely comprised of the “more difficult cases” referred from the Misdemeanants (male) and the Domestic Relations Divisions. 4. The adult group (4,750 cases above 21 years, chiefly from the Domestic Relations Division) confirms the tendency toward emotional instability observed in the adolescent group. Here the psychoneuroses more than double the cases of deficient intelligence. 5. Of the total number examined, 56 per cent belong to a Borderline Group?i.e., in spite of their defect or instability they are capable of considerable social adjustment. 6. The total non-adjustable group, those of unfavorable prognosis, approximates the normal group in extent.
Conclusions
Since some degree of deficiency in mental alertness or emotional stability characterizes the majority of individuals coming to court for social and civic adjustment, it is obvious 1. that a causal relation exists between social inadequacy and mental deficiency, even though the deficiency be of relatively small degree; and 2. that unless such individuals as do not require custodial care, receive adequate mental treatment and training, no permanent social rehabilitation is possible.
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