Psychological Classification Versus Clinical Diagnosis
- Author:
Ruth A. Prouty, M.A.
Psychologist, Wrentham State School, Wrentham, Massachusetts The question of the validity of the I.Q. for diagnostic purposes has been a pertinent one ever since the use of mental tests to guage mental development became widespread. The tendency has been to accept the Intelligence Quotient as sufficient for a diagnosis of the mental condition of a retarded or subnormal child. When a child has been given a mental test the question most frequently asked by interested parties is: “What is the Intelligence Quotient?”?as if that would give a complete picture of the child and exactly determine his status among his fellows. This I.Q. more often than not becomes a tag to be pinned to the child throughout his school life. Cases have been known where the I.Q. has actually been told to the child, producing an abnormal trend toward introspection. The clinical diagnosis of a child’s condition is made after a complete survey of the child’s heredity and environment, history of his personal development and his personal reactions toward society. It involves a physical and mental examination in order to give a complete picture. The whole life of the child is seen from all possible angles before a diagnosis is attempted. The ten point examination devised by Dr Femald, and in use by the traveling clinics in the State of Massachusetts, is an excellent aid in making such a diagnosis. The present study of 1,136 feeble-minded children in the Wrentham State School was made to ascertain what part the I.Q. can play in making a clinical diagnosis, and how much consideration should be given to it as a quantitative or a qualitative factor. This involves a study of the tendency toward stablity or fluctuation in the I.Q. We wished to know whether the I.Q. remained constant, that is, changing not more than four points in successive tests, or whether there was much deviation from the first examination. The question arose whether the clinical diagnosis would remain the same if the I.Q. of the child in successive examinations remained in the same psychological classification of idiot, imbecile, moron or borderline, or if the diagnosis changed when the I.Q. changed considerably, passing from one classification to another.
The present study made use of the Intelligence Quotients of 1,136 children in residence. This study could not include those children who had not been re-examined, those who because of deafness have been given a mental rating on the basis of performance tests, or those who were rated by the Irwin Hayes Adaptation for the Blind. The children studied had their first examinations following from August, 1921, as at that time all the children in the institution were examined and have since been routinely re-examined. The first and more recent tests were compared disregarding intervening results. These first examinations were divided into two groups, the children under sixteen, 554 in number, and those over sixteen, 582 in number, since this age is the chronological age used in obtaining the I.Q. of the adults.
Table I. Classification of the Total Number of I.Q. ‘s Studied Classification Under 16 Over 16 number per cent number per cent 70 over 44 8 40 7 50-69 208 38 227 39 26-49 189 34 252 43 25 under 113 20 63 11 By far the largest number fall in the groups classified as imbecile and moron. It is an interesting fact that children whose I.Q. ‘s fall in the borderline and dull normal groups are placed in a State School. Their clinical diagnosis is one of feeble-mindedness. Because of their incapacity to adjust themselves to their environment, and their conflict with the laws of society, they have been placed where they can have twenty-four hour supervision and specialized training.
The following table shows the total number of children divided into three groups according to the constancy or variability of the I.Q.
Table II. Constancy and Variability of the I.Q. TJnder 16 Over 16 Total number per cent number per cent number per cent Constant 270 49 452 78 722 63 Increase 50 9 107 18 157 14 Decrease 234 42 23 4 257 23 The distribution of the 722 cases which show a constant I.Q. is given in Table III according to psychological classification.
Table III. Constant I.Q.s Under 16 Over 16 Total number per cent number per cent number per cent 70 over 11 4 26 G 37 5 50-69 87 32 161 36 248 35 26-49 96 36 209 46 305 42 25 under 76 28 56 12 132 18
The larger percentage of constant I.Q.’s in the older group is readily understood. The effect of constancy is produced in part because the chronological age remains a constant quantity in the I.Q. reckoning. With children under sixteen the Intelligence Quotient in successive examinations can show more variability as there are two variable elements in its production?the chronological age and the mental age.
It was a matter of interest that in those cases where the I.Q. did not vary more than four points, there was nevertheless a frequent change in the psychological classification. For instance, the I.Q. change from 68 to 72 was counted as a constant I.Q., whereas the classification changed from moron to borderline. Evidently the child cannot be a moron one year and a case of borderline mentality several years later. Only a complete consideration of all the characteristics of the child could be the foundation for clinical placement in either one of these groups. There is a tremendous difference between the borderline child and the moron. A child whose I.Q. changes from one group to the other, sometimes bears all the characteristics of those in his new group, and at other times, he does not have these characteristics and it is felt that the clinical picture of the child is at variance with his raised or lowered I.Q. In considering the changes of more than four points in the I.Q., the question was: “What diagnosis could be given a child whose I.Q. had made a clearly defined change. Was the I.Q. representative of the child as a whole, or did the child present the same clinical picture, no matter how wide a fluctuation in his I.Q.?” The I.Q. decreased in 257 of the total number of children as shown in Table IV. Most of these 257 children, or 91%, were under sixteen, showing that the tendency for the I.Q. to decrease is ten times as marked in the younger group as among the older children.
Table IV. Decrease in I.Q. Classification Under 16 Over 16 number per cent number per cent 70 over 28 12 2 9 50-69 99 42 10 43 26-49 79 34 9 39 25 below 28 12 2 9
Of the whole number of younger children 234 or 42% showed a decrease in I.Q. As 49% of this younger group were shown to have a constant I.Q., it is demonstrated that the tendency of these children is almost equally divided between decrease and constancy in the I.Q. The amounts of decrease are shown in the following table.
Table V. Amount of Decrease in I.Q.?Children Under 16 5-10 11-15 16-20 Over 20 Total 70 over 11 12 3 2 28 50-69 59 30 9 1 99 26-49 58 14 6 1 79 Below 25 25 1 2 0 28 Total 153 57 20 4 234 Of the 234 children whose I.Q. decreased, 153, or G5%, show a loss of not more than ten points. The remaining 35% show in decreasing numbers, amounts of wide deviation. Of the four who have lost over 20 points from their first test, one is a girl, who in 1921 had an I.Q. of 95. It was believed she should adapt herself to community life, as she adjusted well to institution life when here for a summer’s observation. Two years later she was admitted. Her mental age has slowly increased, but there is a steady lowering of the I.Q. which is now 22 points lower. The second child stayed at practically the same mental level over five years’ time and the third showed six months’ increase in mental rating over seven years’ time. The fourth had an unexplained drop in I.Q. from 80 to 65, and then showed a gradual lowering to the present I.Q. of 59. The twenty children who showed decreases of from sixteen to twenty points, show one of three tendencies. Either the last mental age was about the same as the first, or it was somewhat lower, showing a stopping off in development, or there is such a slow rate of mental development that the physical age has far outstripped the mental. An example of the latter is that of a girl who gained only sixteen months in mental rating over a period of six years and seven months. There is little decrease in I.Q. among the older children. Only 23, or 9%, of these children demonstrated a lowered I.Q. In all these cases the decrease was less than fifteen points, and in only one case was it more than ten points.
A decrease in I.Q. where the chronological age remains a constant quantity, means a loss in mental age rating. These results show that few of the older children fail in tests which they previously passed. In other words, there is very little mental deterioration demonstrated as shown by the Intelligence Quotient. Two children were noted who possibly show deterioration?one is a boy who has become more shut-in and difficult to test. He showed embarrassment and confusion, indistinct speech and a capriciousness about verbal response. His mental age dropped two years. The other is a girl whose I.Q. dropped ten points. She was very excited and talkative during the examination. At times she displayed much nervous energy, and at other times she seemed dreamy. A study was made of the increase in I.Q. shown in Table VI.
Table VI. Increase in I.Q. Under 16 Over 16 number per cent number per cent 70 over 5 10 12 11 50-69 22 44 56 52 26-49 14 28 34 32 25 below 9 18 5 5 There is little tendency toward increase found with the younger group as shown in Table VII.
Table VII. Amount of Increase in I.Q.?Children Under 16 5-10 11-15 16-20 Over SO Total 70 over 4 0 0 1 5 50-69 19 1 0 2 22 26-49 12 1 1 0 14 25 under 5 1 0 3 9 Total 40 3 1 6 50 218 THE PSYCHOLOGICAL CLINIC While most of these children showed an increase of not over ten points, there were six who made the tremendous jump of over twenty points. An actual increase in I.Q. with these younger children means an increase in mental age more than commensurate with the chronological age increase. This tends to show definite development on the part of the individual. The six children whose I.Q.’s increased more than twenty points were all boys. One boy made an unexplained increase between the ages of fifteen and twenty, when the mental age changed from nine to fourteen years. The other five were small boys or nursery children. They were two or three years old at admission. With physical care, institution routine, supervised play and sense training, they have shown outstanding development. However, their lateness in walking and talking, their lack of initiative and acquisitiveness, and their difficulty in concentration, makes it probable that their development is very short-lived. Even though they showed an advance their I.Q.’s were not high, with one exception. The child whose I.Q. is now 94 shows some promise of continued development. The clinical diagnosis of these children, regardless of their increase in mental rating, is that of definite feeblemindedness, as the child’s complete clinical picture is not encouraging. It is found that young children whose I.Q.s place them in a higher psychological classification, have a clinical diagnosis placing them in a lower classification, as they have all the tendencies and characteristics of children at the lower level. The following table shows increase in the I.Q. of children whose first test was given at sixteen or after.
Table YIII. Amount of Increase in I.Q.?Children Over 16 5-10 11-15 16-20 Over 20 Total 70 over 8 4 0 0 12 50-69 49 5 1 1 56 26-49 32 2 0 0 34 25 under 4 0 1 0 5 Total 93 11 2 1 107
What is true of these children seems to hold for some of the younger children who were not far from sixteen at the time of their first examination; namely, a continuous steady gain shown by steady increase in mental age rating and a steady rise in the I.Q. Many of these children have the I.Q. of the first test in either the high grade moron classification or borderline and dull normal group. As an example of this, we have a girl whose I.Q. when she was seventeen years old was 77. It went up to 83, and now that she is twentythree, her I.Q. is 90 with a mental age of fourteen years, five months. This mental age was confirmed by the Army Alpha examination, with a score of 83 points giving a mental age of fourteen years, three months. With many of these children there has been a corresponding gain in general effort in their institution life, better control of their impulses, and they have become candidates for parole. With these children the whole clinical diagnosis Avas the deciding factor in considering their readiness for extra-institutional life, and the I.Q. served as a confirmation of their own mental advancement, as well as their greater development by comparison with other members of their group. The fact that some of these children when placed in the community proved to be poor parole risks, shows that their clinical diagnosis of feeble-mindedness holds. They were unable to use their increased powers of judgment and comprehension for their adaptation to society.
Summary
The psychological classification is frequently at variance with the clinical diagnosis, but is nevertheless a pertinent factor to be considered in the cross section of the child’s clinical picture. The value of the I.Q. is qualitative rather than quantitative. It is a clue or guiding factor among other factors necessary for correct diagnosis.
The child’s I.Q. should be withheld as a numerical value and only the clinical diagnosis divulged. This is already done by some social agencies, and is much fairer to the child involved. Many children who have I.Q.s over 70 are clinically feebleminded, their defect being shown in the field of will-power and emotional make-up, rather than intelligence per se. Vice versa, there are children with I.Q.s under 70 who could not clinically be termed feeble-minded, as they have characteristics and personality traits which will make them adaptable, stable, peaceful and law abiding. The I.Q. is apparently constant in a large number of these children. It is found that this is partly due to the presence of only one variable in the reckoning of the I.Q. for children over sixteen. Where it is to be considered a constant there is frequently a change from one psychological classification to another. This is shown where an I.Q. is located near the borderline of another group. The gradation between the groups is not a hard and fast division, but an imperceptible shading from one group to another. Many children have I.Q.s varying between the different classifications, and a child who is clinically a member of one group may have an I.Q. of another group. Thus the I.Q. may be a temporary one and prove to be misleading.
The I.Q.s for the younger children show a tendency to remain at the same level, or to drop lower and lower, due to very slow improvement. There is little real mental deterioration as shown by the Binet test among the older children, as the I.Q. has dropped in a very small number of cases.
There is little tendency for increase in I.Q. among the younger children, where a gain in mental age more than commensurate with their chronological age would be necessary. Nursery children sometimes show a rapid gain which is not continuous, and which does not alter their clinical diagnosis. With the older children there seems to be in some cases a prolonged slow development going on up to, and possibly beyond, twenty years, which results in an increased I.Q. An improvement in I.Q. confirming a general improvement, may lead to the child’s being placed on parole. The clinical diagnosis of feeblemindedness would still hold true, inasmuch as such a child still continues to need much supervision in the management of his affairs, and is sometimes returned from the community.
The conclusion drawn is that the clinical diagnosis deals with the child from all possible angles. The I.Q. represents only one of these angles and therefore cannot in itself along be considered a reliable index on which to base a true diagnosis. The I.Q. is subject to change, while the diagnosis which deals with the whole aspect of the child remains constant.
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