Choreic Conditions as Shown in Five Case Studies
The Psychological Clinic Copyright, 1931, by Lightner Witmer, Editor Vol. XX, No. 5 October, 1931 THE PSYCHOLOGICAL MANIFESTATIONS OF POST :Author: Elizabeth Davies, M.A., and T. W. Eichaeds, M.S.
The Psychological Clinic, University of Pennsylvania
Introduction
Kecently we have had opportunity in the Psychological Clinic to observe five cases which were referred for examination because of school retardation following a history of chorea, or of what is more commonly known as St. Vitus’ Dance. It has been estimated that the common type of chorea comprises twenty per cent of the nervous disorders of children, and that, from one investigation reported by Wallin,1 forty-five per cent of these cases occur between the ages of six and ten, that is, generally between the first and fifth grades. The importance of these cases not only to the worker in clinical psychology but to any one connected with school children cannot be too strongly emphasized. Although chorea is the type of problem which demands medical attention, many of its symptoms are those which in the minds of most people should be called to the attention of the psychologist or mental hygienist. The following quotation will suffice to illustrate the condition as it confronts the classroom teacher. It lias been a matter of astonishment to the examiners in this department to find so many cases of unrecognized chorea in the schools. These children are disciplined for their involuntary muscular twitchings, their irritability, and their sensitiveness, whereas all these are symptoms of the disease. They have difficulty in concentrating; their attention is fleeting. To remain in school is very dangerous for them because of the added nervous strain and frequent heart complications.2
i Wallin, J. E. W., Clinical and Abnormal Psychology. New York. Houghton Mifflin Co. 1927. - Bentley, Inez A., and Bronislaw, Onuf. The Work of the Medical Inspectors of Ungraded Classes. Ungraded, Vol. 11, p. 108.
For a description of the medical aspects of chorea the reader is referred to any standard text of nervous diseases, particularly those of children. The psychological factors of the clinical picture, which concern us here, have been indicated briefly by Bronner,3 who has this to say:
The irregular mental functioning of chorea must be interpreted in the light of the nervous disturbance. The findings on tests are often curiously bizarre and may lead to fallacious conclusions concerning special defect if the fact of the disease is not taken into account. Clinical psychologists should remember that in rare cases the only sign of chorea may be the mental disturbance and that some authorities contend that in every case mental functioning is at some time affected.
George
The first case which came to our attention was that of George, aged thirteen years and six months, who was brought to the Clinic in February, 1931, by his aunt because of retardation in school due to chorea. The history of his case is typical of the choreic. During her pregnancy with George the mother complained of pain and weakness, due, probably, to undernourishment. The child’s birth was normal, however, and the labor easy. At one year he walked and talked. During the pre-school years George suffered chicken-pox, measles and whooping cough. At seven he entered school, where he made normal progress through the first and second grades, bringing him up to the time of his first attack of chorea. The family and social histories are characteristic of the background which is so often found in these cases. They include generally poor surroundings, probably undernourishment and lack of proper social contacts. George’s father, a laborer, was occupied only when there was work to be had, while the mother, from all reports, was a woman of limited mental endowment. When he was seven George and an older brother of twelve were taken into the home of a maternal aunt. Her husband, employed until a few years ago as a steam-fitter, made sufficient wages to provide fairly satisfactory home surroundings for his wife and nephews until illness made it necessary for him to cease work. Although George’s older brother had, since his removal into the home of the aunt, worked as an errand boy, it was difficult for him to find work and the little family leaned for its income upon the bustling, energetic 3 Bronner, Augusta F. The Psychology of Special Abilities and Disabilities. Boston, Mass. Little Brown & Co. 1917. P. 31.
aunt, who did cleaning about the city as often as she could find such work. The poverty of the home in which he lived until he was seven, and the unfortunate circumstances which befell the new and better home, provided George with a generally poor social environment, probably leading to lack of proper nutrition and, also, to a dearth of healthy social contacts basic to the development of normal emotional life.
The first signs of George’s present illness were noted in January, 1927, when he was nine years old and in the third grade. He began to drop food and eating utensils, which behavior was followed soon after by peculiar motions of the face, right arm and right leg. He became restless in school, annoying the misunderstanding teacher, who reproved him for his inability to keep still. Within two months the boy’s illness developed to a degree which necessitated his removal from school. The period of rest and quiet thus provided tended to restore him somewhat, but when he entered school again in the following September he was far from well, and after four months had to be dismissed again. At this time, January, 1928, a year after the first symptoms had appeared, he was taken to the hospital, showing definitely all the signs of acute chorea. Here lie was treated and improved sufficiently to be discharged three days later. In March of that year George weighed 65 pounds, superior to the median for boys of ten years, but as hot weather approached he commenced to lose weight in spite of treatment and augmented diet. In August George was sent to a hospital camp where he gained six pounds and his general condition improved remarkably. He was put in the 3B grade in September, 1929, and progressed extremely well until February, when lie began to lose weight and to show signs of increased nervousness. In March George was readmitted to the hospital; he was suffering an acute recurrence. For a week he was very ill, but after that he improved gradually, and was sent a month later to a children’s home at the seashore, where he remained for about seven weeks. In July he was reexamined at the hospital. Although he had gained slightly in weight, his improvement did not warrant a complete reinstatement in the home. The strain on the boy which would result from such a move seemed too great, so he was placed for institutional observation two months longer. Since his return from this institution, in September, 1930, there had been some slight improvement, but it was felt that he should not return to the regular school routine. Further treatment as part of the hospital’s out-patient contact made for some gain in weight. “When the hospital referred the case to the Psychological Clinic there was nothing further to report on the boy’s condition.
The problem which George now presented was psychological as well as medical. Should the boy be replaced in school, in a routine which twice had proved too great a strain! Here was a boy, now thirteen years of age, who had completed but two and a half years of elementary school work, of normal mentality although definitely in the dull group, able from the purely intellectual viewpoint to go further. What were the chances that the boy would now be able to stand the strain ? How much work could he stand ? It was with these questions in mind that George was referred to the clinic for examination. He was examined by Dr Miles Murphy in February of this year.
It was reported that, according to a psychological examination made at the hospital, the boy had been given an Intelligence Quotient (Stanford Revision of the Binet-Simon) of 73, and a memory span of 6 audito-vocal, 7 visual, and 3, and occasionally 4, reverse. According to our own tests the boy received an Intelligence Quotient of 68 (same test used), and a memory span of 6 audito-vocal, 8 visual, and 4 reverse. The performance tests had been given to the boy by the hospital, but the results of these trials were not reported to us. When these tests were given him here the boy proved inferior generally to about fifty per cent of boys in the fifth grade. On these tests good coordination was shown, as was a definite ability to improve in successive trials. He worked with a fair degree of success on the maze tests, and showed improvement especially on the harder Young Maze C. His school proficiency was generally little better than 2B. He had difficulty with fourth grade reading, reading carelessly and showing his long absence from that type of study. Some of the spelling errors he made?such as chand for children?were absurd. The examiner felt that the boy could be trained to spell quite easily by the use of an auditory method. His visual imagery seemed to be poor. In arithmetic he had forgotten most of the fundamental number combinations. The principle of borrowing was completely forgotten.
During the examination there was no sign of “nervousness” or abnormality of behavior in any way. To the examiner he seemed to be “very poor physical material” generally. He lacked the vitality characteristic of a boy of thirteen in good health. There was an absence of general tonicity. Whether due to a poor intellectual and social environment, or to a weak physical basis, the boy was inferior intellectually probably to eighty per cent of boys his age. Intermittent schooling, poor environmental background, weakened nervous condition as the result perhaps largely of chorea, were all factors which contributed toward a low mental status. On a verbal test like the Stanford Revision of the Binet, the boy proved himself little superior to the child of eight years, especially on tests such as that for vocabulary, and those involving the use of language, like the Absurdities. He lacked comprehension, but there was evidence that a task once comprehended could be improved upon greatly. Though his school proficiency was low, he demonstrated sufficient capacity to the examiner to warrant the prediction that he could ‘’ easily be brought up to 4B grade.’’ The chance that the boy had of returning to the school routine, however, without having relapse of his choreic symptoms, seemed slight. Dr Murphy felt that George might well be placed in one of the orthopedic classes of the public schools, where his inadequacy for the normal load of school work might be a primary consideration in his education. Regular school was out of the question. Clinic teaching as a follow-up measure seemed to be a wise plan for the present, for it would be necessary to determine how much the boy could stand before a definite placement in school was effected.
George was accordingly assigned for clinic teaching to Miss Marguerite C. MacLennan, in March of the past year. He received, from this time until May, about fifteen hours of teaching. A few brief excerpts from the report of his teacher will suffice to indicate the impression he left as the result of the clinic teaching observation. “At the present time George is the picture of an undernourished, small-sized boy, with large hands, old face and hollow eyes. The most striking thing concerning him is the rapidity .. . of the fluctuation of vitality which he experiences from day to day, and probably within a single day. He never gives the impression of possessing even an average amount of energy but there are times when he appears pathetically haggard and old-looking. It has been practically impossible to trace the energy slumps to a cause, and to determine whether or not they are a result of the disease (chorea) or to the fact that at some times more than at others, more is expected in the way of household duties at home. … Does this fund of energy vary decidedly from day to day ? It seems wholly possible,?and yet as the hour spent in clinic passed he never gave evidence of fatigue brought about by the work unless he came in at the beginning of it with that ‘ day after the night before’ look.” She concludes, however, that George probably “does actually suffer spasmodic attacks of lack of energy, or at least that that ‘draggv’ feeling, as he describes it, returns at regular intervals. ‘’ As the result of her observation of the boy, George’s teacher felt that the boy’s intellectual environment was of the barest sort, and that it would quite naturally account for his lack of vocabulary. She felt that he lacked sufficient vocabulary to express adequately those interests which were normal for a boy of thirteen, and that he often used words in speech as well as in his reading which he did not understand. In spelling she found that there were few actual spelling errors, but that George often substituted words he knew for those he could not spell, such as went for when. In arithmetic, where he had most difficulty, George showed least improvement. His teacher devoted most of the time in this subject to an attempt to teach subtraction through drill methods, but the boy was so poorly motivated and so prone wholly to disregard his homework that little could be accomplished.
A Binet examination was given in the last hour of teaching, with the result that George was given an Intelligence Quotient of 69. His teacher says in reference to this index: “This I. Q. does not give a true picture of the (boy’s) ability. Some probable causes for this may be the fact that George is rather slow in grasping the idea of what is desired of him … that lie cares very little as to whether or not he succeeds. His motivation is very poor,? due perhaps to a lack of physical energy, perhaps to the fact that he has lived quite happily thus far in his life without having been bothered with such things as definitions of words, or their similarities or differences. George’s poor environment and lack of urge toward intellectual things are doubtless factors in coloring this picture of intellectual dullness and physical inferiority.” It was clear as the result of our examination and further observation of George through clinic teaching that the boy was dull, but in no sense was there a suggestion that he was even bordering on the abnormal. Special education was obviously to be recommended. Though the boy needed constant supervision in order that a recurrence of the chorea might be foreseen and avoided, nevertheless his mentality would warrant further education. That he could cover tlie work of tlie fourth grade could safely be predicted, but the process of this acquisition would need, necessarily, to be long, tedious, and careful because of the liability to relapse of the weakened nervous condition. AVere such a program to be followed out, there might be a chance that abilities hidden by the lack of disposable energy might crop out and lend a more hopeful aspect to the psychological picture.
Sylvia
The case of Sylvia, a little Jewish girl of nine years and one month, illustrates quite clearly the emotional component of the clinical picture of chorea. Her pre-scliool history appeared to be quite normal and revealed nothing significant. At one year she walked, talked and was clean. During the pre-scliool period she suffered mild cases of measles and whooping cough.
Sylvia entered first grade at the age of six and a half years. She was a bit afraid during the first few days, but she soon conformed and progressed well in the grade. Her marks were excellent and her conduct good, save for the fact that she squirmed in her seat and wriggled about. At the end of a year she was promoted to 2A. She was struck by an automobile during the intervening summer, but according to the report did not lose consciousness. When she entered school in the fall, she attended class for two months but it was alleged that she was afraid of her teacher and this precipitated the attack of chorea which the mother believes was caused solely by the fear of school. She then had tremors of the arms, legs and face. She remained out of school for the rest of that year, but resumed her work the following summer and made up the 2A grade without trouble. When she returned to school in the fall she again had the teacher of whom she was afraid. It was necessary for the child to have her tonsils removed soon after entering school in September. After the operation she had literally to be dragged to school. The second attack of chorea followed. During the term, she attended school only for one month. Her report was above the average, yet she refused to go to school without her mother. The mother was allowed to sit in the room during that month, but after that time, Sylvia remained at home and has not been in school since. In February, her mother brought Sylvia to the clinic, because of her fear of school. She told us a few things about the child’s life since her removal from school the preceding October. We learned that Sylvia had never slept alone. The parents claimed that she was not a discipline problem, which seemed doubtful. Since she did not go to school, she spent the whole day reading, writing and playing school, we were told, and she pretended always that she was the teacher. After school, she played with children of her own age. She would not go out of doors alone, however, except to visit one little girl. Otherwise, the children had to come to her home to play. If her mother “insisted” upon her returning to school, she hung her head, refused to answer and began to tremble.
The psychological examination gave her an Intelligence Quotient of 106. Her auditory memory span was 5, the reverse 4, and the visual 6. In the performance tests she showed good coordination, precise hand movements and slow rate of discharge. At that time, her school proficiency measures were found to be 3B for reading, IB for spelling, and 2B for arithmetic. Her writing was judged large, legible and irregular.
Dr Morris S. Viteles, who examined Sylvia, recommended that a neurological examination be made. The following procedure was recommended as the result of this examination: No discussion of her disability at home; emphasis on the fact that she was physically like other children and therefore should be treated like them; greater responsibility placed upon her at home; establishment of more social contacts and, finally, when these instructions had been carried out, she was to be informed that she would return to school at a given time. In the report of the neurological examination nothing was said about chorea.
A school visit, made about a month after her examination in the clinic, revealed that the adjustment in first grade was difficult, that the mother had to accompany her to school and stay with her in the room and that in that class she developed what the teacher thought was “worms.” When in the second grade, Sylvia conceived the idea that she would like to be with a chum who was five months ahead of her. This was not possible and although they were soon together, due to the chum’s failure, Sylvia’s “health began to fail rapidly.” The consensus of the teachers’ opinions was that Sylvia’s health was the important factor in the case, not her dislike for school. They believed that the mother was overanxious for Sylvia to make a good record in school. Sylvia first appeared for clinic teaching soon after the school visit, under the impression that she was coming back to play more games. No attempt whatever was made to determine where teaching should begin, as such an approach was impossible due to the nature of the case.
It had been stated that Sylvia was an omnivorous reader. This was proved a fact. The best approach to school work that did not blatantly proclaim itself as such seemed to be through the medium of reading. The book used was The Children’s King Arthur, since it was beautifully illustrated, well written and not at all like a school reader. The first lesson was used for many things. When Sylvia did not recognize a word, she learned to spell it so that she would know it the next time. That was spelling. Arthur was in the company of four men in the story and met two more, how many men were there altogether? That was arithmetic. To vary the work, Sylvia played with the Witmer Formboard and did it with her left hand. It then had to be demonstrated to her teacher that she was not left handed. That was writing. She was asked if she liked to write at home. She replied, “I teach lots of things to my brother.” That day she went home with homework which was given her so that she might have something to teach her brother. Later, Sylvia realized that she would have to know more complicated things to be able to teach her brother the simple things. Moreover, he had nearly reached her natural grade in school. We progressed to multiplication and division in preference to the simpler forms of addition and subtraction. In the course of the teaching, Sylvia learned all about borrowing and carrying, principles which she had not known before. Although at that time homework was assigned to her, she showed no fear even when the material was patently school work. Early in the teaching, she appeared with a copy book which she had purchased herself to contain her home work. On it she had written: Sylvia R , Miss Davis, University Hospitable, 34th and Spruce Streets. She informed us that she was coming to the hospital and that her teacher was her nurse. This idea was a figment of her mother’s imagination.
With the advent of the Easter vacation, Sylvia was given an extra amount of home work which she agreed she should have in view of the holiday and, after that time, no mention was ever made of teaching her brother or of suggestion that she was coming here merely to amuse herself. The next significant point in Sylvia’s progress was the introduction of the word school into the spelling words. There was no emotional manifestation of any sort and although this word was stressed and repeated, she showed no signs of dislike. The next week, Sylvia read a story entitled: “What Is School Without a Teacher?” She liked it and said so. That same day, she appeared before a class in psychology. To all the questions concerning school, which spared her not at all, she replied truthfully and in a straightforward manner. Her mother told us proudly that day that Sylvia had informed the family that she was going to a place that was just like school.
Knowing this, Sylvia was asked how she liked this school and she decided that she liked it very much. “We then agreed that school would not be school without tests and so we indicated Tuesday as our day for arithmetic tests and Wednesday that for our spelling tests. They were conducted exactly as if she were in a class of fifty people and she did fairly well on her first attempts. When it was suggested that she might possibly go into the third grade she seemed pleased but argued that she should be in the fourth grade, as her best friend was there now and they had started together. The impossibility of her going into that grade because of her long absence was pointed out, but she appeared only half convinced of the correctness of the view.
More severe methods were adopted with her in insisting that she learn her multiplication tables without error. The desired procedure was demonstrated to her and the work the next day indicated that the talk had taken root. Further development was reflected when she requested that she have her tests on certain days because she expected to be absent on the regular ones and did not wish to miss them.
Out of twenty-five possible teaching hours, Sylvia had been present for ten. By the end of the teaching period, which finished with the end of the term, we had formed our judgment on the case but felt that an appeal for cooperation on the part of the mother would be useless. We attempted to get at Sylvia once more. She was told that it was the last week in which she could come to this school. She was asked if she liked summer school. She said she did. She was then asked whether she would like to go back to regular school. She hung her head as her mother said she would. She sat like a statue and said not a word, but as soon as the subject was changed she brightened up and spoke freely. The next day, the matter of school was again broached in about the same manner as before, but with the added information that she could not go to summer school if she did not attend regular school. Evidently she preferred to forego the pleasure of summer school. At that time, she was given the school proficiency tests in arithMANIFESTATIONS OF POST-CHOBEIC CONDITIONS 139 metic and spelling. Tlie results indicate a 2B proficiency in arithmetic and possibly the same in spelling, although even at that level she was unable to do better than whta for what. During the course of the teaching, frequent conversations were had with Sylvia’s mother, which led to the conclusion that she could not be depended upon. Time and again, what she said on one day would be contradicted on the next. Always, however, she sought to emphasize the fact that she was gradually wasting away because of this defection of Sylvia’s, that she was the most devoted and self-sacrificing mother in the world and that nowhere was there such a charming, thoughtful, lovable child as Sylvia. Of course, the mother made flagrantly ambiguous statements during the initial examination and she retained this tendency in our further contact with her. It was she, we were sure, who was at the root of Sylvia’s trouble. An example of her extremely ill-advised dealings with the child was the fact that she promised her they would move wherever Sylvia wished to go, if she would only go back to school. This she related herself on two different occasions. We suggested to the mother one day that a few judicious thrashings might do Sylvia a world of good. This was met with great indignation and the assurance that such a thing would be impossible, as Sylvia was too delicate physically and her feelings were too easily wounded.
On the last day that Sylvia was here, the mother was asked how she felt about Sylvia going back to school for the month of June in order that she might be admitted to summer school. The principal had refused to allow Sylvia to go to summer school if she did not attend regular school. This plan seemed to solve the problem tentatively. The mother did not take to it at all. She was dubious about anyone’s ability to get Sylvia within public school walls. When we suggested that Sylvia’s teacher in the clinic call on the principal, she hastened to dissuade us, claiming that the principal was a harsh, unsympathetic man Avho did not understand Sylvia and who frightened her out of her wits.
Still not being satisfied that all the evidence had been gathered in the case, we visited the principal of Sylvia’s school. It seemed wisest simply to present the whole program to him. It was felt that in spite of his definitely expressed aversion and disgust at the R s in general and Sylvia in particular, his statements were not an exaggeration of the truth. He claimed that Sylvia had been treated for the last time as a privileged character. While she was in school, her mother was allowed to sit in the room with her for a whole month, a privilege which was not extended to any other child within the principal’s experience. On one occasion that Sylvia was in the office, she walked up to the principal, threw back her head in defiance and demanded: “Yon put me in grade so and so, or I won’t come to school.” One other time, she was in the office in the presence of the truant officer and several other persons. She kicked, shrieked, stormed and scratched and likewise bit the truant officer. The principal resolutely refused to allow her to return to school until the coming September, for her leave of absence had been extended to that time. He stated to us that he would accept her as a pupil then only on the condition that they might do as they thought best with her and be free from family interference. The principal said, “If I had the opportunity, I would soon settle her. Every time she began to act nastily, I would put her in a room by herself until she was ready to come back and behave decently.” In our opinion the principal would be glad if he had nothing more to do with Sylvia and her family.
Our observation of Sylvia and her reactions in the clinic led to beliefs similar to those which the principal seemed to hold. Sylvia was a spoiled child who had found an easy means to gain her own way and worked it to the limit. As far as one could gather, discipline must have been a lost art in the household and parental control was directed to the detriment rather than the benefit of the children. No doubt each child had been given to understand that she was unique of her kind. There was everything in the mother’s conversation to uphold such a conviction. Possibly when Sylvia went to school, she found she could no longer play queen in her little world and took measures which attracted unusual attention to her. Whether the chorea was natural, acquired or simulated is beside the point. The fact remains that Sylvia had seen the value of a weakened physical condition as a tangible excuse for her purpose and was making a good thing of it. She had an excellent example of worshiping at the shrine of debility in her mother. The more Sylvia was crossed at school and pampered at home, the more resentful she became of restraint and conformity to the demands of others. Sylvia perhaps did not consciously realize the state she was producing in herself, but certainly the development of fear of school was the path of least resistance and it was a sure means of winning the sympathy of the family. As it was, the fear was blamed on the influence of other children.
Being at home suited her beautifully and being at the clinic, though it was school, was quite as pleasant, as she was the center of attention and the sole object of the teacher’s efforts. She was intelligent enough to know all the time that she was going to school, but school as conducted here was to her complete liking. When resumption of public school was mentioned, she sulked, shut up like a clam and refused an utterance of any sort, but she was never confused, “trembly” or choreic. The school work was given a secondary place in this contact with Sylvia and no great progress can be reported there. The approach, however, has served to show her up as a fraud. All the insistence upon delicate physical condition and sensitive feelings is only putting off the evil day when Sylvia must be brought face to face with herself or where all concerned will have a more serious problem confronting them.
Ruth
Ruth, the third in this group of cases, came to us in January, as had George and Sylvia, because of retardation in school. Her history is similar in some respects to those of the two other cases here presented, but the chorea probably had less to do with her difficulty in school and did not appear until she was nearly pubescent. Conditions at the birth of Ruth were normal. Her mother told us that she talked and walked by the time she was one year old. At two years she was broken of enuretic habits. At six years of age she entered the first grade, but very soon afterward suffered a severe attack of measles. No doubt the absence from school which this illness necessitated had something to do with the fact that she repeated the first grade in the following year. At about the time that she was in the first grade, her tonsils and adenoids were removed in the hope that such a measure would make her more resistant to disease. The step seemed to have been taken in vain, however, for her mother told us that she had always seemed abnormally susceptible to diseases, that she caught cold extremely often, and that she contracted “everything that came along.” At eight years of age she had chicken pox, and at ten years she had chorea. We were unable to get a report on the precise proportions of Ruth’s attack of chorea, but were told by her mother that the child had to spend two months in bed.
Although other factors contributed, no doubt, to the retardation in school, it is only reasonable that the periodical absences from school which were caused by these illnesses might explain the difficulty. At the time of our contact with Ruth, slightly under twelve years of age, the child had done well to attain fifth grade standing. Her mother complained that Ruth had particular difficulty in arithmetic, reading, and geography, and she stated, also, that Ruth was a ‘’ slow thinker.’’
When she was examined at the age of eleven years and nine months, Ruth was somewhat advanced in physical development. She had menstruated ‘’ for a few months,’’ she was tall for her age (at the median for girls at fifteen), and though slightly underweight for her height, the ratio of weight to age and height indicated no danger. She appeared to be an attractive girl, with a pleasant and easily aroused smile. The mother’s complaint of “nervousness” was easily understood after observing the child for a short time. Even when she rested she continually moved her fingers and seemed generally upset. She complained always of being tired, and we learned that she was restless in her sleep, that she ate poorly, especially at times when she did not sleep well. She was fussy about her food. Though she was usually willing to help her mother in work about the house she always seemed high-strung. She played poorly with other children, preferring to be alone, although this character trait may have resulted from the fact that there were few children in her neighborhood with whom she could play, a condition of social starvation which had been forced on the child for some years back. She disliked even the moving pictures. Neither of Ruth’s parents was of a nervous type. The father, a tradesman born in America, was in good health, and the mother, born in Russia, seemed to be an intelligent and well-meaning woman. Ruth was an only child. The picture is, from all angles, that of the progressive Jewish family,?honest, hard-working parents, perhaps a little too interested in their child, nevertheless anxious to do what was best for her in every way. Ruth, peculiarly susceptible to diseases of all kinds, developing a rather severe attack of chorea at ten years, had, since menstruation began, grown even worse in her manifestation of the after-effects of the disease. She was getting along in school, but with difficulty. In spite of the hope that had been held out by the family physician, that with adolescence and approaching maturity the “nervousness” would gradually disappear, it was not disappearing, and the mental and physical health of the child needed expert attention.
Ruth was examined by Dr Miles Murphy. The results of her psychological examination originally, and subsequently during lier period of clinic teaching, indicated her to be normal in every way, with no special abilities or disabilities beyond the lack of energy and the constant feeling of being tired. On the performance tests the child showed good discrimination for form, good muscular coordination and control, she had a fair rate of discharge on first trials, but in her anxiety to do well she hurried nervously and made errors, and so defeated her own purpose by lowering the quantitative score she made. On these tests she varied in her rating between the limits of inferior to ten per cent and inferior to ninety. Ruth gave what were, in relation to the quality of her other performances, very high memory spans. In her original examination in January she gave 6 audito-vocal forward, but in April the span was found to be a true 8; the visual span of 8 which was given her in January was, in April, found to be 9 very often; she learned to give a good 7 digit reverse span as against the 5 which she gave in January. From the qualitative report at the time of her original examination and from follow-up in close observation we had reason to believe that the child was not functioning at the highest level of performance when tested in January. She was given an Intelligence Quotient of 87, but when tested more carefully three months later by her teacher, who was able, naturally, to call out a better response, the Quotient was found to be 113, augmented, no doubt, by the increased ability to repeat digits. As a whole, the results of her examination indicated normal mentality, with a deficiency, perhaps, in vitality, and a definite educational retardation. Ruth was at that time in the high fourth grade, but her school proficiency as demonstrated on the day of her examination proved to be about third grade in reading and spelling, and possibly fourth grade in arithmetic, though she was poor on reasoning problems. Her handwriting was legible. It was evident that Ruth needed drill on fundamentals,?work which she had, no doubt, missed or had had to pass over sketchily, because of her frequent and long absences on account of illness.
Dr Murphy felt that a complete medical examination was necessary, as the first step, to be followed by a period of clinic teaching in order further to determine the extent of and reason for her educational retardation, as well as to observe the effect on her emotional and physical condition of working the girl to a greater extent than she was being pushed in school. An examination in the clinic at the hospital indicated that Ruth had an ethmoid inflammation, and that there was a slight tubercular condition. No mention was made of chorea.
Soon after this examination, Ruth was admitted for clinic teaching. She was placed under Miss Edith Lobis, a student teacher in the course in diagnostic education, and received about eleven hours’ instruction over a period of about six weeks. Her teacher found that Ruth’s spelling was of an auditorytype: that is, her errors were logical from the point of view of sound, as characterized by errors such as “brake” for break, “beech” for beach, and that mechanical drill in establishing for these sound-forms the proper visual picture was an effective procedure. In regard to reading, the chief problem was one of motivation. By informal talks with the girl, by attempting to have her see that learning to read well was a matter of her own responsibility, we were able to develop within her an interest which seemed to be permanent. There was no difficulty with reading; there was simply unfamiliarity with words and sentences and paragraphs because of too infrequent exposure to them. Arithmetic was only a problem in small degree : here Ruth’s teacher taught her during the six weeks’ period to add mixed numbers, to change fractions to lowest terms, to change mixed numbers to fractions, all work of the fourth and fifth grades. Her teacher was confident that as far as school work in and of itself was concerned there would, in September, be no difficulty in resuming the fifth grade, to which she had been promoted in February.
It was from the point of view of the clinical picture of the personality that we were interested in Ruth, for although there are many elements in the case that were common to those of Sylvia and George, it differed to a sufficient degree to warrant description. A few quotations from the report of the teacher will suffice to give her impression of this strange girl.
“… Ruth is living in a world of grown-ups; she speaks like an adult on such commonplace topics as the weather and her illness. She conducts herself with the grace of an adult and has ‘put away childish things.’ She does not play with other children and she has no interest in anything at all that fascinates them… . She can sit for hours on end on the door-step of her home, doing absolutely nothing. She does not even read; she merely sits, and stares into space… . When she walks her shoulders droop, and she looks as if she had not the energy to stand up straight… . She has no vitality, she is always tired although she never takes strenuMANIFESTATIONS OF POST-CHOREIC CONDITIONS 145 ous exercise and lias from nine to ten hours’ sleep every niglit and a nap during the day.
“Ruth is exceeding^ self-conscious about her health. She is constantly using her poor health as an excuse for sliding out from under some task. She says she cannot play because she might hurt herself. At the slightest provocation she stays away from school; in fact, Ruth has not been at school more than three weeks in all since February when she was promoted to the fifth grade. She seems to enjoy her poor health, or, rather, the privileges that it gives; her. There is a certain amount of prestige that comes to her when she must be excused from some task which is occupying the attention of the other children. Ruth … is proud of the reputation she makes for herself because ‘ she is sick’ and gets away with a lot of things.” 4
As a final recommendation, it was suggested that Ruth certainly should be able to take her place in the fifth grade in the fall. With a complete rehabilitation of her body she should store up energy sufficient, perhaps, to carry her through school in the fall.
Betty
Betty came to us in February, brought by her mother and grandmother because of “school retardation.” But one month short of twelve years in age, and in the sixth grade, there was no immediate evidence of retardation. A helping teacher in the suburban school which Betty attended had recommended psychological examination because of an apparent deficit in concentration of attention. The history of the case indicated that Betty was the only child in a home of moderate circumstances. The child was born normally, walked first at seventeen months, talked at twenty months, and was clean by two years. During the pre-school period she suffered mild attacks of chicken pox and tonsilitis, and at four a severe attack of measles, which was accompanied by high delirium. Soon after this disease the child was fitted with glasses, which she wore for a time. St. Vitus’ Dance was noticed first at five. According to the story of the mother, the twitching movements were noticed first in the blinking of the eyes; soon the child began to twist her head around in a peculiar fashion. Evidently the first signs were not so outstanding in the eyes of the parents as to demand medical attention, for Betty went to school the following year. It was not until she was a few months past eight years of age that she was examined by a physician, who reported to us later that he then saw the child “with quite a severe attack of chorea; almost continuous muscular seizures. She gradually improved and got well as far as I know. Did not see her again until (about eighteen months later) in a similar condition. She had, at this time, an anemia … and negative kidney findings. Saw her only twice and was informed by her grandparents that she was doing nicely. Have not seen her since.”
More than two years after her last visit to the physician Betty came to us for examination. It is interesting to note what was recorded by the tester in regard to the child’s personality. “Betty is an attractive girl… . She was very reserved and cold during my contact with her. It was hard to establish rapport with iter, not because of opposition but because of indifference. She volunteered no information; in fact, her answers came very slowly. I think she is a good actress and was able to conceal her feelings. She seemed childish but covered this up by not talking. In our conversation she showed very poor motivation in her school work. She complains about her teachers, who ‘do not explain anything..’ Betty apparently gets along well with children her own age. She is the champion checker player of her neighborhood. She showed few signs of nervousness during the examination. There was little or no twitching of the head or neck.’’
In school Betty was said to be inattentive, and negligent in regard to her work. It was evident that the child was having difficulty generally, though arithmetic was especially hard for her. On the performance material Betty did well, displaying, however, more efficiency than intelligence. On the Stanford Revision of the Binet-Simon Test, Betty received a mental age of ten years and eleven months, and an Intelligence Quotient of 92. Although her memory spans: audito-vocal 7, visual-audito-vocal 8, and reverse 5, were each inferior to but one per cent of fifth grade girls, there was suggestion in the results of the Binet examination that the child’s difficulty was in the realm of comprehension of an intellectual sort. She failed such tests between the nine-year level and the fourteen-year-level as that for comprehension, giving sixty words in three minutes, and the twelve-year-level vocabulary. At this upper level she failed also the similarities and the fables. Her interpretation of pictures, however, was excellent.
Betty’s school proficiency was estimated by her examiner to be poor fifth grade generally, but very low in arithmetic. Her comprehension in reading was poor, and oral reading was jerky, in that she read words rather than phrases or sentences.
Dr Witmer, who examined Betty, felt that the child should be enrolled for a few periods of clinic teaching. It was a question whether or not she should be promoted from the sixth grade, in which she had done poorly during the past year, to the seventh, in which she might find more interest in the new material and thus achieve a better motivation. We were not able to register Betty for teaching until the summer session, and by that time the school felt that she should remain in the sixth grade, from which, should she do well, she might in a few weeks be promoted to the seventh. Betty received about twenty hours of teaching through the summer session from Mr. W. Martin Babb. He early found arithmetic to be the largest stumbling block, and drilled for almost the whole period on problems in sixth grade work, or those of the earlier grades in an effort to reestablish a firm background of essentials. As the result of his work in arithmetic, Mr. Babb felt that the child was not prepared to do seventh grade work without definite assistance, though he felt as strongly that she had mastered the main features of sixth grade work. It was his opinion that Betty’s motivation constituted the greatest problem. In the early hours of teaching she was wholly disinterested in any effort toward improving herself educationally, particularly in arithmetic. “She appeared very much bored, answering questions slowly and often not at all. It was impossible to get a smile out of her, no matter what was said… . Only with the greatest difficulty could I persuade her to talk and ask questions. If I indicated that there was a mistake 011 her paper she would look at the paper for about a minute and make no move to locate the error. Often the mistakes were due to carelessness and guessing.”
After about four weeks of teaching, during which Betty remained wholly detached and disinterested, she suddenly took a change of heart. A smile occasionally appeared; her mother told us that she took a new interest in her work; her teacher noted an immense improvement in cooperation, interest even in arithmetic, desire to do her work well. Her teacher had tried definitely to understand Betty, to mold the program of teaching about the child’s individual outlook on life. The deficient motivation which Dr Witmer had marked suddenly appeared to be characterized by a new element: one of dependence upon appreciation of a personal sort. Betty grew to have confidence in her teacher, and so endeavored more heartily to do well for him. As the result of our teaching in the case of Betty, we felt that it would be far better to promote the child on trial to the seventh grade, with the alternative of demoting her to the sixth should she prove incompetent, than to place her again in the sixth grade where the work could not possibly have an intrinsic interest for her. Not at all retarded socially, the child would feel inferior to her friends and equals in that sphere, and would react unfavorably to a re-presentation of material in school, difficult for her, to be sure, but of no interest whatsoever. With additional attention of an individual sort she should have been able to do the work of the seventh grade at least as well as she had done that of the sixth during the past year. At her intellectual level, the child seemed wholly incompetent ever to do high school work, yet because she was adapted socially, because she had a pleasant personality on the whole, because she was pretty, and soon, we knew, to become interested in boys who would admire her for her social graces far more quickly than for her intellectual prowess, it was logical that she attend school at least through the eighth grade.
In the case of Betty we find again the listlessness and indifference of the post-choreic, yet, as in the cases of Sylvia and Ruth, it lacks the “nervousness” present in so many of these cases. There is the suggestion that the nervousness is symptomatic of mild continuation of chorea, perhaps that there is a greater tendency to relapse, or that the chorea was more acute. Again, the disease may have manifested itself rather more psychically in the cases of Ruth, Sylvia, and Betty, than it did in the case of George, and of Ronald, whom we have yet to see.
Ronald
In the case of Ronald we find well illustrated the “nervousness” which characterizes the choreic child, yet it is singular in that the boy’s behavior had none of the signs of malnutrition, listlessness and passivity so prominent generally in each of the other cases presented here. Ronald first appeared at the clinic three years ago, having been referred to the speech clinic because of a jerky type of mutilated speech. He was examined by Dr E. B. Twitmyer. The history at that time indicated normal progress until the boy was about three, when he first started to blink his eyes in a nervous way. This blinking has, since that time, continued to be a prominent symptom in the clinical picture.
The family background in the case of Ronald was good. Both parents were healthy, though soon after Ronald’s first examination the father, who had been employed as a clerk, developed an arthritic condition. This suggestion of rheumatism in connection with the case is interesting. In addition, as a sidelight to a later educational development of the case, it might be mentioned that both parents, as well as Ronald himself, were left-handed. Of the grandparents, at the time of Ronald’s examination in the speech clinic, only the maternal grandfather was dead. He had been a victim of ‘’ stroke and kidney trouble,’’ we were told, and died at 59. Some time after the examination, the paternal grandfather died, at 63. The cause of his death was not revealed. The sisters of the mother had “died early?each had kidney, intestinal and heart trouble.”
Conditions at Ronald’s birth were normal. He was a first and has been an only child. We learned from the parents that he walked at thirteen months, and talked and was broken of enuretic habits at eighteen months. At the age of three Ronald broke his right leg at the thigh. In his present appearance and gait there seems to be no after-effect of this accident. It was at about three, also, that the blinking of the eyes was first noticed. He was examined medically at that time, but health and vision were considered fair enough to preclude any measures such as the prescription of glasses for the boy.
At seven, two months prior to his examination by Dr Twitmyer, Ronald was known definitely to be suffering from chorea. The physician who at that time examined the boy felt the exaggerated blinking and the general picture of nervousness and muscular twitching to indicate an acute chorea. He was unable, however, to determine the cause for the condition, and his advice included a rest cure. The boy was to take a daily nap, and to refrain from any sort of violent activity. Accordingly, Ronald was “kept quiet all summer,’’ and after but two months he seemed better. In the fall he was brought to the Psychological Clinic. Dr. Twitmyer found the boy to be a sturdy, healthy looking child of seven and a half, doing well in the second grade. His speech was characterized rather clearly by an infantile type of stammer, which seemed, however, to be undergoing self-correction. Mutilation was evident in the pronunciation of “hair” for chair, “thmoke” for smoke, “fitli” for fish, “teef” for teeth, “fumb” for thumb, and ‘’ lily’’ for fly. Dr Twitmyer explained to the mother that it would probably be necessary for her to take a few minutes of her time to correct him, but that he would grow out of the stammer himself, and the case was dismissed from the speech clinic as self-corrective. “We heard nothing of Ronald from that time until two and a half years later, in March of the past year. He was brought to the clinic again, now a boy of nine years and ten months, by his school principal because of “reading difficulties.”
During the period between his examinations in the clinic, Ronald had managed to progress to the 4B grade, but he was now repeating this grade. Regarding the medical history, nothing unusual had occurred; the blinking of eyes had continued, and seemed to reach its height always in the spring, but there had been no relapse definitely of chorea.
Ronald was examined this time in the mental clinic, by Dr. Arthur Phillips. On the performance material Ronald proved to be generally inferior to about fifty per cent of boys in the fifth grade, though improvement on the second trial of the Dearborn to the extent of placing him in the highest decile suggested a high degree of trainability, particularly on quasi-intellectual material. His audito-vocal forward memory span of eight and the visual span of nine were superior to ninety-nine per cent, though his reverse auditory span of four was superior to but thirty, inferior to ten per cent. On the Stanford Revision of the Binet-Simon tests Ronald achieved a mental age of ten years and six months and an Intelligence Quotient of 107. In weight he was found to be at the median for thirteen years, and in height slightly inferior to the median for twelve. His head girth of 54.5 cms. was near the median for fifteen years. Ronald was large for his age. There was no suggestion of malnutrition, poor social environment, strained emotional life, as found in our other cases. The picture was rather one of robust pre-adolescence. The boy’s interests in fighting and baseball and selling lemonade were healthy. The only suggestions of physical malfunctioning were the continual blinking of eyes, nervous response to test situations, and an interesting report from the teacher that in physical training the boy showed a definite lack of muscular coordination, as compared with other children in calesthenie drill. In the examination Ronald was cooperative and ‘’ showed no signs of chorea,’’ although it may have been suggested in the ‘’ slow rate of discharge’’ in dealing with the formboards. In regard to school proficiency, the story of Ronald’s status assumes a different aspect. In the 4B grade, we found that the boy was up to grade only in arithmetic; although writing was “fair,” reading was extremely poor for comprehension, jerky, deMANIFESTATIONS OF POST-CIIOREIC CONDITIONS 151 pendent upon word analysis rather than phrase, sentence and thought analysis, and clearly an effort for the boy. Visual discrimination was extremely poor. One had the impression that the boy was struggling so intensively with the pure mechanics of the task that ability to comprehend or to read for meaning was precluded immediately. The advisability of eye examination was clearly indicated, not only because of the seemingly poor visual discernment, but because of the history of ulcer during the preceding summer, and of the blinking. It was clear that Ronald had not learned to read, and that it was imperative that he must learn if there was to be future progress in school. Here was a boy, above the average in mentality?a finelooking and well-behaved little chap, with a specific difficulty in reading, not only requiring remedial treatment, but in itself difficult of diagnosis. An intensive period of clinic teaching during the coming summer session was recommended.
Ronald received about twenty hours of teaching during the summer session under Miss Amber Showers. As has been intimated above, his was a problem in reading, and was treated accordingly. Miss Showers received report both from Ronald and from his school that since he began wearing glasses (about two months before the teaching began) his reading had improved, and she became convinced that many of the boy’s errors in reading were due to poor habits built in as the result of poor vision. His comprehension for material read was good, and though it was not rapid, his silent reading was not poor for a fifth-grade boy. He was extremely hesitant in oral reading, however, due, no doubt, to nervousness arising from chorea, but, equally, to the remnant of his speech defect, and the tendency to read word by word rather than in phrases or sentences. Drill on reading in phrase and sentence wholes, with the object of smooth oral reading as well as comprehension, was effective. The boy made rapid strides, and by the end of the summer period was doing fifth-grade work in reading. Each day he was given a list of words from the course of study in spelling, with which subject Ronald had always had (and, we fear, always will have) trouble. These he studied conscientiously. Throughout all of our contact with Ronald we found him always obliging and desirous of cooperating. He frankly admitted a dislike for school, teachers, and books. His interests lay in the field of fights with the kids, his remunerative lemonade stand, getting on the school football team in the fall, but he resigned himself as152 THE PSYCHOLOGICAL CLINIC cetically to reading as a means to an end: getting promoted. In the clinic he would sit reading for all his worth, blinking his eyes incessantly. Though his movements were not choreic in the sense of being jerky and spasmodic, they were indeed continual and often nervous. He showed none of the listlessness of our four other cases: he was anxious to get to the clinic, get his work over with, and scoot down the street to the trolley for home. A healthy emotional background was reflected throughout; Ronald was a wellbrought-up gentleman, in spite of his haircut, which he described as “criminal, though some kids call it a convict.”
Summary
In summarizing briefly the case studies we have here presented we are obliged at once to recognize the fact that they have few common elements, and we are tempted to feel that the differences between these children assume slightly greater proportion than do individual differences between any five children selected at random. There seem to exist generally, however, a few tendencies common to each: low resistance to disease, likelihood of relapse, a certain proneness to exhibit in the mental life the effect of excitement or strain. To relieve undue excitement, two of the children were removed from school, and in the case of Sylvia an attempt was made so to adjust the school situation as to eliminate strain. Each of the children, excepting possibly Ronald, sought to capitalize his or her physical deficiency in an effort to get away with as little work as possible. Restlessness, emotional instability, sensitivity to criticism, peevishness, listlessness, and mental irritability,?all these made their appearance in varying degrees. In the case of George we find well-illustrated malnutrition and poor home environment as predisposing causes. On the other hand, emotional upset leading to a more psychic manifestation of chorea seemed to be causal in the case of Sylvia. This latter factor is said to be common in the etiology of twenty-five per cent of cases. The tendency to eat and sleep poorly and to lose flesh is suggested in each case but that of Ronald, best in those of George and Betty and of Ruth, who was, it will be remembered, slightly tubercular. In the case of Ronald we find best illustrated the “nervousness” which so often comes to the attention of the teacher, and, as well, the suggested connection with rheumatism. It is obvious that with so few cases we cannot relate the five here presented at all closely, nor can our clinico-psychological picMANIFESTATIONS OF POST-CHOREIC CONDITIONS 153 tures describe that of chorea in any sense completely. We have tried to picture each child separately, hoping thus to illustrate that though differences between them are apparent, there are common elements in the case histories, slight though definite. The motor manifestations of acute chorea cannot be mistaken, yet, in comparison with the more psychological features of the syndrome, they are of shorter duration and of no more diagnostic importance, if we are thinking in terms of adjustment to home and classroom. It is possible that the child who is ‘’ nervous,’’ irritable, hard to manage, inattentive, is in need of quite as much medical attention and consideration as is the child whose jerky and irregular movements are quickly suggestive of diagnosis. The tendency to relapse in cases of nervous disease warrants, in addition, a consideration of the after-effects of the acute attack. Unless the medical history of the post-choreic child is taken seriously into account by teacher and parent he is very likely to suffer relapse, and the need for consideration of any type of nervous instability should be at once apparent.
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