A Case of Inefficiency Due to Physical Handicaps
- Author:
Lorraine L. McNally, Chief Social Worlier
The Psychological Clinic, University of Pennsylvania Falteringly and clumsily Bob came into the Clinic, walking on his toes, his legs looking as though they might at any moment give way under him. His arms were always flexed and his apparently helpless hands hung at right angles to his arms. To stabilize his spastic gait he waved his arms in mid-air as he trudged along. Every step and movement he accomplished with much effort, accompanied by heavy breathing. In spite of his marked motor disability the expression on his face was intelligent, happy, and alert. His imperfect, faltering, mutilated speech did not restrain him from talking. Even before his hat and coat were removed he began asking questions in a normal way.
Bob was the only child of American-born Jewish parents. He was examined at the Psychological Clinic of the University of Pennsylvania January 14,1928 by Dr Lightner Witmer. He was brought to the Clinic by his parents who, because of the boy’s physical handicaps, wanted to know his mental status. They were particularly anxious to know whether he could take his place in school. At the time of the examination Bob was five years, five months of age, born July 21, 1922. Already he had learned to tell time, knew the days of the week and months of the year. From birth his physical condition had been a serious matter.
The mother reported that the birth was said to be dry. Instruments were used, labor lasted twenty-seven hours, and the child was not expected to live. At fifteen months of age he was unable to hold up his head. When three years old Bob had scarlet fever which was followed by complications and then by meningitis. During this illness there was considerable drainage through the ears. As soon as he recovered from the meningitis he began to improve generally, as the physician had predicted if he should recover at all. Habits of cleanliness were established at three years and at approximately four years of age he began to walk and talk, both of which performances were, however, very poor in quality. His speech was difficult to understand and all his movements were clumsy and uncoordinated. From the progress Bob had made since four years of age it did not seem that there could have been a brain inA CASE OF INEFFICIENCY 75 jury at birth. It was more probable tliat a hemorrhage at the time of birth resulted in a blood clot at the base of the brain which may have disappeared during the attack of meningitis when there was considerable inflammation in these parts and drainage took place through the ears and nose. Bob’s general health improved steadily after the meningitis. His height and weight at the time of the examination were well above the median for seven-year-old boys. On the Stanford Revision of the Binet-Simon tests Bob’s Intelligence Quotient was 101. To the examiner this result did not seem a fair estimate of his mental ability. The tests that required him to use his hands such as drawing a square or putting together the divided triangle he was unable to do. His audito-vocal memory span for digits was four. He did not comprehend the reverse span. Ilis difficulty in speech may have affected his response in the memory span test. It was on the performance tests that Bob demonstrated his outstanding defect?lack of efficiency. He completed the Witmer Formboard, a test passed by fifty per cent of four-year-olds in less than five minutes, in two hundred and ninety seconds. On second trial he failed to complete the test, losing interest because of the difficulty he had in placing the blocks. He failed the Witmer Cylinders on first and second trial. He puffed and breathed heavily in his efforts on this test. His extremely poor coordination and control were a great handicap but he demonstrated that he knew when the cylinders were placed correctly. As a result of the examination Dr Witmer diagnosed Bob as having normal mentality. He was normal in every category of behavior except efficiency. It was recommended that he return to the Clinic for orthogenic teaching especially in speech. The prognosis was favorable. Bob came for his first period of teaching in February a few weeks after his examination. This was the beginning of approximately fifteeen months of such teaching. The time devoted to his teaching will be given in the course of the discussion to follow. During this time I was supervising the teaching which was done under the direction of Dr Lightner Witmer in connection with Psychology 33, a course in Orthogenic methods. The actual teaching of Bob was done by May Scliriebman, Rose Pedace, and Pearl Tulin, seniors in the School of Education of the University of Pennsylvania and Nell Cramer, a graduate student in Psychology.
From February to June of 1928 Bob received two hours of individual instruction a week with Miss Scliriebman as his teacher. He was given training in speech, physical exercises, and First Grade subjects?reading, arithmetic and writing. Special attention was given to discipline. Since his speech was so poor and was possibly understood by his mother alone, it was decided to place a great deal of emphasis on that. The movements of the muscles involved in speech were just as incoordinated as his other bodily movements. He ran his words together, dropped initial and final letters of words and formed many sounds incorrectly. Frequently in speaking he would gasp for breath, and he drooled slightly. In speech training it took a great deal of effort and patience on Bob’s part to stand in position for the breathing exercises. He had to have his heels together, toes slightly apart, abdomen in, shoulders back, head erect and chin in. At first this seemed unattainable. He was unsteady, swayed from side to side and his uncontrolled body could not readily be placed in position on command. He tired very easily and was not interested in the work. This was perhaps the first real discipline Bob had ever encountered. At home he was helped with everything and strict discipline was not a part of the daily program. With constant drill there was decided improvement. It was exceedingly difficult for him to take a deep breath. He did not grasp the idea of inhaling and then holding his breath. In taking a deep breath he had a tendency to hold his head back and let his abdomen protrude, thinking he had accomplished the task. Although progress was very slow, he was able at the end of four months to hold his breath for twelve seconds. Whatever he accomplished gave him great joy; his face beamed and he would claim that he was a very good boy. Along with the breathing exercises Bob was given further drill in using the vowel sounds singly and in combinations. He disliked this work and protested openly. This was a natural reaction because the work required so much effort and in return produced so little improvement. After much drill, the vowel sounds became less difficult for Bob. He could open his mouth and exhale saying ah; in a smiling position he would say ee; and with his lips partly puckered he tried to make the oo sound. The breathing exercises produced a decided improvement over his usual panting and breathless speech. He was taught how to pronounce many of the consonants as s, t, m, n, hard c and k. Those sounds which had to be made by different positions of the tongue were very difficult for him because of his lingual paralysis. Consonants and vowels were then combined into words. The number of words which he learned to say correctly increased slowly. Various methods were used to remove monotony and to prolong and hold his easily distracted attention. One little device was to have Bob climb an imaginary ladder. A line represented a step and on each step a word was placed. By pronouncing the words he climbed to the top of the ladder and as a means of repetition he would climb down by pronouncing the words again. A similar drill was employed with the different families of words. Sentences with an increasing number of words were formed, as, “I eat meat.”, “Send me meat.”, “Beat that mat.” Bob’s speech had improved greatly after the four months of training but it was not entirely clear. In connection with the speech training Bob was being taught to read. In learning the correct pronunciation of the vowels and consonants, the foundation for phonic analysis became well established. It was not until May that Bob was allowed to read from a primer. Progress in reading was slow but this was due chiefly to his difficulty in speech. He was interested in the story but the amount of effort which was required in pronunciation caused fatigue and with it a loss in persistent concentration of attent ion. I lis comprehension of the material he read was excellent.
Very little of the clinic teaching time was devoted to arithmetic. Before coming to the Clinic, Bob had learned to recognize many numbers and he was able to count from one to a hundred, though with very poor articulation. He recognized denominations of money and was able to tell time. After his teaching period in the Clinic, he would go about fixing each of the daily calendars that did not appear to be correct. His knowledge of arithmetic showed that the most important problem was to clear up the pronunciation of the numbers, and an oral drill was given on the simpler plus and minus combinations. On days that he felt exceptionally well, he was very ambitious. He was curious to count all the objects in the room and anxious to do more than was expected of him. Arithmetic for him was a pleasure.
Bob’s motor control was so involved in all his work that it was almost impossible to give training in a particular subject without meeting the same difficulty. The part of arithmetic, for example, that he disliked most was writing the numbers. For this reason in addition to academic training, part of each hour was devoted to physical exercises. At first he was drilled on the larger muscular movements; his arms were so flexed that an attempt was made to straighten them with regular exercises of extending the arms forward, upward, outward and downward. He was taught how to lift his knees in walking to overcome the dragging of his feet. When he could accomplish these gross movements with more ease, a further step was taken in the finer movements. The performance tests on which Bob had shown a decided lack of coordination were used as teaching material. He finally came to the point where he could replace the blocks in the Witmer Formboard and Cylinders with considerable facility. He practiced stringing large beads, putting picture puzzles together, and coloring squares, circles, and similar forms with crayon. Bob learned quickly and needed only constant practice to increase his efficiency.
With the close of school in June it was recommended that Bob return for summer school. He had made definite progress and much of the training that he had received would have been wasted if it had not been continued.
Four days a week for five weeks during Summer School Bob reported for orthogenic teaching and physical exercise, receiving an hour of instruction daily. His teacher for this period was Miss Cramer. She reported that his progress was most gratifying. He had his “off” days but that was expected with the thermometer around ninety. How he was able to put forth the effort required by his muscular incoordination and to maintain his interest and pleasure throughout the work was remarkable. It was easy to appeal to Bob and he worked hard so that it was a real joy to teach him. His memory was excellent, as were his comprehension and initiative. He tired readily and for this reason his ability to sustain continued concentration of attention was somewhat lowered. Praise brought smiles but he was easily depressed by the merest suggestion of disapproval or criticism. The day was usually begun with breathing exercises and the more formal reading work as Bob was less tired then and the best results were obtained. The instruction was broken up into seven and ten minute periods, however, with two or three minutes of rest and change to conserve his vitality. This more formal work was followed by various kinds of games, bean bag, hide and seek, lifting games, “conquer,” etc., with a view to improving coordination. In all this work, as at all times, his posture, his tendency to use only the right hand while the other hung limp or was held up helplessly, his habit of dragging his feet, were watched and corrected. On particularly hot days, it was necessary to reduce the breathing exercises and physical effort and resort to quiet games at the table. Bob was also encouraged to get his own chair, put the blocks and beads away and to erase the blackboard. At first he banged at the board and made a great deal of dust but by practice he learned to do it very well and with a minimum of dust. He learned sufficient manual control so that he could stay within bounds in coloring forms, draw straight lines and make the numbers one to ten. He was practicing on the word moon when the term ended?a word that contains the up and down and curve movements required in writing.
Reading now became a definite part of his instruction. His previous training had greatly improved his speech and facilitated the work in reading. The story “Goose-Goose and Pig-Pig” from the Book of Fun was used as the text. The story was first told by the teacher with sufficient “local color” to appeal to Bob’s imagination. He loved the story immediately and wanted it told again and again. He particularly liked the part that told how Pig-Pig put his feet on the table and turned his cup over with his nose, or again where he ran and jumped into bed when Goose-Goose came to have dinner with him.
When a desire to read the story had been created in Bob, it was first developed sentence by sentence on the blackboard and then he read it from the book. He learned readily and was very much pleased and excited when he began to “read from the book.” He wanted to take the book home immediately but was persuaded to wait until he could read the entire story and surprise his mother. Each day the new and more difficult words were developed on the board before giving him them in the story. A review of the previous day’s work by giving additional sentences proved useful. Bob’s retention was very good and he rarely missed a word. The story ran like this:’’ Goose-Goose lived near Pig-Pig. One day Pig-Pig went to see Goose-Goose. Pig-Pig said, ‘ I have come to eat with you,’ ‘’ etc. These were alternated with “Bob lived near the school,” “I have a cat,” “Her name is Spot,” “Spot drinks milk,” “Bob drinks milk too,’’ etc. During the five weeks Bob learned to read four pages of the story; and many original sentences were also formed using new combinations with the old words. He learned to articulate well so that even visitors unaccustomed to his speech could understand him. He had developed a very good posture and much better coordination. He was encouraged to talk and each day was led to discuss some of his own interests and by the end of the term had told us about his little cousin, his games, liow he spent his time outside of school and even about the bacon, oatmeal and milk he had for breakfast. If he seemed sluggish or inclined not to work, a mere suggestion that he was being a little boy or that it would be necessary to erase “A good boy” from the blackboard would cause him to settle down. This practice of writing “A good boy” on the blackboard grew out of a suggestion made by Bob one day when some new sentences were being put 011 the board for additional exercises. Bob said, “Bob, a good boy. You write that.” This was done and he read it a number of times. The idea pleased him so much that the device was resorted to every day and the words were erased when Bob fell down on the job.
At the close of Summer School in 1928, Bob had just passed his sixth birthday. As a result of his training he had developed and learned about fifty new words, and an ability and interest in expressing his own thoughts as well. His teacher felt that he needed continued supervision and that clinic teaching should be continued. He seemed too advanced for kindergarten and would probably not get the individual attention he required in the average First Grade with forty or fifty other children. Ilis physical handicap while improving was still too great to make it possible for him to take care of himself in a large group, though he liked other children and would have profited by opportunities to play with them. lie had First Grade competency but his poor motor control and the resulting inefficiency, in Dr AVitmer’s opinion, made it inadvisable for him to attend school for at least another year. Because he used a great deal of energy in his movements, he fatigued so easily that a five hour day at school would have been injurious to his health. Consequently, Bob returned to the Psychological Clinic in October of 1928 and continued until the following May. Miss Pedace was his teacher the first four months of this year, followed by Miss Tulin. He received an hour of individual instruction twice a week. So far as educational progress was concerned, this year was extremely profitable for Bob. He practiced his breathing exercises daily, showing a decided improvement in speech and general attitude. He learned to recite nursery rhymes such as “Humpty-Dumpty” and “Jack and Jill.” One could understand him more easily although some lingual paralysis still remained. More formal work was carried on this year in arithmetic. He was given the plus combinations, starting with one and one, up to combinations of which the sum did not exceed twenty. Subtraction was a trifle more difficult for Bob. Color blocks were used in teaching him what was meant by “take away.” In setting up the blocks and taking away the correct number, he had, in addition to learning the combinations, practice in motor coordination. In placing the problems on the board, Bob and his teacher would take turns in writing them down. He enjoyed this and it was a means of improving his concentration of attention as well as providing practice in writing. His progress was remarkable when one considers his decided handicap and that he received only two hours of instruction each week. On the other hand, it must be noted, all days were not record breaking. Bob fatigued easily and as before he had his ups and downs.” An entire hour of instruction might often have been counted a decided loss as Bob was irritable, shifted his attention and made no attempt to try; he was too tired. Such behavior was the result of his rising too early in the morning, which was his practice, and playing too vigorously before he arrived at the Clinic at ten o’clock. Bob learned to write legibly the digits from one to twenty. Oral and written drills were given on the plus and minus combinations, of which the sum did not exceed twenty and the remainder was not greater than nine. He learned to count by 2’s, 5’s and 10’s to one hundred. Bob was alert; his motor control was still poor but he showed decided improvement. By the end of May he had 1 B proficiency in arithmetic. Four pages of the El son Primer had been completed during summer school and instruction was continued in the same book during the following school year. Sentences were taken from the reader and placed on the board and, when Bob was able to recognize all the words, he read the lesson from his book.
In addition to arithmetic and reading, Bob went through a series of physical exercises as part of his hour of instruction. His general posture improved; he did not drag his feet so much as before; he made every effort to keep his hands at his side in walking; he had more control and tried hard to write with crayon on the board. His speech still was marked by the lingual paralysis although his pronunciation of many sounds had cleared up. Bob had F irst Grade proficiency in reading and arithmetic; his writing was his poorest subject. He was ready for Second Grade. When school closed in May of 1929 it was recommended that he enter an Orthopedic Class in the Public Schools the following September. During the summer of 1929, Bob was taken to the seashore by his parents where he remained two months. He came home in excellent physical condition, having spent most of his time out of doors. His mother made application for him to enter school. He was examined by the Department of Special Education and was accepted in an Orthopedic Class for a trial of one month. As he was not eight years of age the public school was not required to have him remain unless he was able to take care of himself. As a member of an Orthopedic Class, the school provided a bus to take him to and from school. The group of which he became a member represented different grades of mental development and a great variety of physical disabilities.
A month having passed by, I visited the school in order that I might know how Bob had fitted into the new situation. He had completed his probationary period and was accepted as a regular member of the class. His teacher stated that for a time he was unaccustomed to school regulations and would leave his seat at the wrong time and wander about the class rooms disturbing other children. He was amenable to discipline, however, and came around nicely. In regard to his academic work there was no complaint. Nothing further was heard from Bob’s parents until December of 1929. A telephone conversation with his mother revealed that Bob was doing well in his school work but was absent a great deal due to colds. After spending five hours in school, he had used up all his energy and was extremely tired when he reached home; thus his vitality was low and he took cold easily. His mother was anxious to know just what she should do. She did not want him to lose the school work, yet he did not have the necessary strength. Her plan was to take him out of school and provide him with a private tutor until spring at which time she would place him back in the class. A decision was not reached until I had made another school visit. The Principal of the school suggested that Bob return to school and after his lunch each day they would provide a cot for him so that he could rest for at least an hour. The mother was pleased with the recommendation and immediately decided to have Bob return to school.
About the first of February, 1930, Bob’s mother reported that everything had turned out very satisfactorily. Bob rested every day after lunch for more than an hour. During the month of January he attended school regularly. He received his report card and had a rating of “B” which meant that he was doing good work.
Disclaimer
The historical material in this project falls into one of three categories for clearances and permissions:
Material currently under copyright, made available with a Creative Commons license chosen by the publisher.
Material that is in the public domain
Material identified by the Welcome Trust as an Orphan Work, made available with a Creative Commons Attribution-NonCommercial 4.0 International License.
While we are in the process of adding metadata to the articles, please check the article at its original source for specific copyrights.