Case Studies in Diagnostic Education
The Psychological Clinic Copyright, 1931, by Lightner Witmer, Editor Vol. XX, No. 6 November, 1931
- Author:
Arthur Phillips, Ph.D.
Formerly Executive Officer, Psychological Clinic, University of Pennsylvania I. Robert, a Case of Aprosexia Robert, aged nine years and five months, was brought to the Psychological Clinic of the University of Pennsylvania because of poor reading and spelling and was examined by Dr Murphy in June, 1929.
He is the oldest of three children. His father is a physician, busy and prosperous, in a suburban town. The home background is one of culture and economic stability. The family is socially prominent in the community, which is considerably above the average in educational and social standards. Robert’s birth was instrumental. His general health was not good until he was five years of age. He had pyloric stenosis. He did not sit up alone until he was a year old. At two and a half his tonsils and adenoids were removed. He has suffered from abscesses in his ears since he was six months old and at five years had a mastoid operation. He was again threatened with mastoid trouble in the summer of 1929.
His school life began at five and a half years when he entered the first grade. He repeated the second grade and at the time of his examination he was in the third grade. His work was very poor in reading and spelling. He was considered good in arithmetic and geography according to his mother. There was a question as to the advisability of his being promoted. In the psychological tests he obtained a Binet-Simon Intelligence Quotient of 112. His Basal Age was nine. He passed all tests at the ten-year level except the vocabulary where his score was 28. At the twelve-year level he passed the ball and field (superior plan), fables, and picture interpretation. His memory span was:
auditory, 5; visual, 6; reverse, 4. His work on the performance tests?the Witmer formboard and cylinders, the Dearborn formboard?was superior to fifty per cent of ten-year old boys. His performance on the Dearborn was slightly better than his performance on the cylinders. The tester remarked that he made a “fair” analysis of this problem and demonstrated good native intelligence. “While his work showed indications of carelessness, his enthusiasm for the performance tests contrasted with his boredom with the Binet-Simon. Dr Murphy diagnosed him as of normal mentality with competency superior to seventy-five per cent of boys his own age. The recommendations were: (1) That he be promoted to the fourth grade; (2) That he have an eye examination; (3) That he have clinic teaching in the fall of 1929.
On November 18, 1929, Robert reported for clinic teaching and has received thirty-four hours of clinic instruction. In neither reading nor spelling did he have good 2B proficiency when he first came. He was behind grade at least one year in both of these subjects. The recommendation that he be promoted into the fourth grade was based upon the boy’s general competency and the expectation that with clinic teaching he would be brought up to grade. His clinic teacher reported that Robert was unable to spell such simple words as “wave,” “cheer,” and “sail.” He paid no attention to sounds and made no attempt at phonic analysis. His reading was slow and inaccurate. He had no drill in synthesis. He looked at a word and guessed from its general formation as to what it was. He read “nailed,” “sailed.” His comprehension of reading material confirmed the report of his teacher that Robert was good in “solid” reading. The method employed in teaching Robert to read up to this time had been the word and sentence method. Consequently, the boy was without any knowledge of the phonic concepts. He showed the usual symptoms of those who have been taught by this method and have failed to profit by it. He knew difficult words but failed on small ones. His analytic discrimination for small differences had not been trained. During the first eleven weeks the progress made was not great. Some progress was made in the development of the fundamental concepts of reading and spelling but the judgment of his teachers was that he needed much drill in phonics and word analysis if his reading and spelling were to improve sufficiently to allow him to succeed in the higher grades.
The greatest difficulty experienced with Robert was due to his lack of motivation. He scored low on effort. His persistence was poor; it was difficult to keep him continually at his task. He gave all the appearance of the boy who had never been held down to a specific task. During the second semester the teaching was continued. It was thought advisable to place Robert, on account of disciplinary aspects of the case, under a teacher who would show decided firmness. His teacher gave Robert at the beginning of the semester in February, 1930, a 3A proficiency test in spelling and reading. He was now in the fourth grade.
Types of errors which Robert made in reading were characterized by his teacher as follows: (1) Careless errors: these accounted for at least a third of his poor reading: A few typical ones were: reading ‘’ through’’ for ‘’ thought,” ‘’ build’’ for ‘’ built,” ” know’’ for “known,” “nearly” for “early,” “brought” for “bought,” “he” for “we,” “the” for “a,” “it” for “at.” That these errors were pure carelessness was demonstrated by the fact that at the teacher’s question, “What?” without further hint or suggestion, Robert, looked more carefully at the word and pronounced it correctly. (2) Errors of omission: in his rapid reading for content, Robert left out words entirely, both small and large, and sometimes letters. Plurals were read as singulars. (3) Guessing: in meeting an unfamiliar word, Robert made guesses that usually were very intelligent. He read “rapidly” for “sharply,” “greeted” for “cheer,” “journey” for “travel,” “arrow” for “bow,” “wigwam” for “village.” This intelligent guessing has gained for Robert the reputation of being a good “solid” reader. He can read a paragraph and retell the meaning of it quite accurately but it is quite obvious that while he is able in this way to get the content of a story, before advancing in school he will have to learn to make analysis and synthesis of each new word. Unless he does this he will never become an independent reader nor use reading as a tool for the acquirement of information and knowledge. An attack was made upon his problem by giving him phonic analysis. In doing so it was discovered that Robert had good auditory and kinaesthetic imagery but that his visual imagery was deficient in the finer points of discrimination. Words that he could not recognize at sight by spelling aloud he could readily pronounce. He is the type of child who has difficulty in learning to read by the word and sentence method. With his good imaginal endowment in the kinaesthetic and auditory field and with the substitution of reading aloud for silent reading and phonic analysis for the context method, there is no reason why from the intellectual standpoint Robert should not make rapid progress in learning to read. In his spelling it was discovered that there was no reason why Robert, with his splendid kinaesthetic and auditory imagery and retention, could not learn to spell. The only cause for a failure was lack of effort. If he were held down to a specific list of words, made to write them and pronounce the letters as he wrote them, and, finally, the whole word when he had finished, in fifteen minutes he could master his school lesson for the day. He showed good trainability and retention. The diagnosis of his poor spelling work was simple?lack of interest and general laziness. His lack of interest was shown in the fact that when he came to the clinic, instead of bringing a spelling book he would bring by mistake another book. Frequently he also forgot to wear the glasses provided for him. During the lesson period he was inattentive, and displayed lack of concentration. Robert was always playing, so much so that his teacher came to refer to him familiarly as the “play-boy.” He would play with the chalk, the eraser, ruler, knife, anything within reach. He would spell aloud in an affected soprano voice; write on the board, now large, now small, now very illegibly. He was not defiant but he was persistent in his foolishness. The best word to characterize his general attitude is to say that Robert is flippant. During a Binet-Simon test given by his teacher in February, he made a miserable showing on the ball and field test at which he had succeeded in June, 1929. His teacher asked him, “Suppose you hadn’t found the ball yet?” Robert replied, “Well, I wouldn’t worry about it; I’d go home and get another one.” And yet this boy in school received an “E” in his deportment. His mother, commenting upon this significant fact, said to his clinic teacher, “So, you see, he is a good boy in school.’’ But as Robert and his mother left the clinic room Robert called out to his teacher, “Now, are you going to be a good boy?” His mother did not reprove him for this exhibition of bad manners. The truth is, Robert is an easy-going, likeable chap. He is a favorite with his teachers. They have permitted him to get away with behavior that would not be tolerated in other children. His mother, apparently, considers his flippancy a mark of superiority. Neither at home nor at school has obedience been exacted. When the mother was asked if Robert had any specific tasks to do around home she replied, “Yes, he has certain chores to do on Saturday and they are usually completed.” But, recently when she made an investigation of the progress of the work assigned for a certain day she found Robert leisurely sitting by and watching his companions doing his assigned task. A mark of intelligence, perhaps, but certainly more distinctly a mark of a boy who has used his intelligence to escape effort and herein lies Robert’s chief difficulty. He is an inattentive, poorly-disciplined boy who has never had to do anything that he did not want to do. His pleasing disposition, his happy-go-lucky ways made him a favorite with teachers and parents who have loved him not wisely. Robert’s failure to learn reading is on a par with his sitting on a log while his companions sawed his wood for him. Only, in this case there was no one to saw the wood. He is a case of aprosexia. He has learned inattention; he has been taught it by his parents and teachers.
Robert’s ambition is to follow in the footsteps of his father and become a physician. He has native ability sufficient, as proved by our tests, to carry him through high school and college, but despite an adequate I.Q. and co-discernment span, despite intelligence, which so far has been sufficient to outwit both teachers and parents in their task of getting him to learn academic subjects and to acquire a tool by means of which information and knowledge may be acquired, Robert stands small chance of reaching his coveted goal unless the problem of a personality spoiled by indulgence and sentimental kindness is solved. Robert needs alertness exercises. He needs to learn persistent concentration of attention so that the abilities that he possesses may be harnessed to a task that is worthwhile. Otherwise, all that he is will be like steam evaporating in the air, instead of steam under pressure and forced to do work. The conclusion of the clinic teaching department is, therefore, that this boy has failed to learn because he has used a highgrade intelligence to beat his teachers at the game which every child plays. The game of the teacher is to teach reading; the game of the boy is to escape learning to read. So far Robert has been successful. The recommendation is that this boy be transferred from the public school system in a community where his family is influential to a private school where he will be under strict discipline and one of a group, instead of an exception.
II. Precocity and Infantilism in a Polyglandular Case Jacob was seven years and seven months old when he was first examined by Dr Lightner Witmer at the Psychological Clinic, November 20, 1928. He was brought to the clinic by his mother because of his failure to make passing grades at school?a failure apparently due to lack of concentration. He had been promoted each year, and was now in the third grade. His work was unsatisfactory. The school that he attended was organized on the Dalton plan, which is presumed to leave large room for the play of individual initiative. Jacob, however, was showing little interest in the projects assigned to him. What initiative he possessed was exhausted at play. There he appeared to have a considerable quantum. Not a fraction of it was available for study. He refused to accept responsibility and to put forth such reasonable effort as would carry his work through to success. Instead of holding his attention to the task at hand, he interested himself in whatever was going on in the class room. The picture was clear: the teachers credited him with ability which he refused to harness to a task. Examined in the Psychological Clinic, he obtained a BinetSimon Intelligence Quotient of 163, which ranked him as very superior on this scale. His mental age was twelve years and four months; his basal age, ten. His memory span, audito-vocal, was 5; visual, 7; and reverse, 4. His visual and reverse spans rated him in the highest decile of boys his age. His audito-vocal span was not consistent with his high I.Q. or other spans. Repeated efforts to get him to give back six digits resulted in failure. In the psycho-motor tests, his performances were both quantitatively and qualitatively excellent. Despite defective eyesight which made him inspect the formboard tests closely, his score in the Witmer Formboard and Witmer Cylinders placed him in the highest decile, on first trial. His second trials on both tests were inferior to his first, his time actually increasing. This may have been due to boredom, as the problems presented were scarcely intelligence tests to him. Or it may have been due to a lack of efficiency or of a willingness and desire to be made efficient. On the Dearborn Formboard No. lc, there was a challenge to Jacob’s intelligence. He met it, obtaining a score on first and second trials superior to fifty per cent of ten-year-old boys. He lessened his time on second trial, though not sufficiently to improve his rating, indicating, perhaps, a lowered efficiency. His approach to this test was analytical. He made few false moves, and showed excellent ability to reason in manipulating concrete material.
Given the school proficiency tests, Jacob proved to have almost 3A proficiency in spelling and arithmetic. In these subjects, his school record for the term was unsatisfactory. He could read all the words in the fourth reader, but skipped lines due to his defective vision. In the Stanford Achievement Tests, given at school, his score was average in spelling, above average in reading, and superior in arithmetic. The tests in the clinic and at school, therefore, demonstrated a competency to do the work in which he was failing.
Despite a superior I.Q. and a demonstrated competency in both the verbal and non-verbal tests, he was presenting a picture of failure to achieve even satisfactory school standing for his grade. A study of environmental, physical and emotional factors is demanded to cast light upon the situation.
Jacob is the second child of a prosperous merchant in a suburban town. His social and economic background is good. His sister, about two years older than he, does excellent work in school, and always stands at or near the head of her class. The parents are in good health, and there is no significant medical history in the family. Conditions at birth were normal. The boy walked when he was fifteen months old, said single words at nine months and talked in sentences at seventeen months. He was not clean until he was two years old?a fact that his mother attributes to his excessive weight. The child had bronchitis, chicken-pox, tonsillitis, measles and mumps between his third and fifth year. At three and one half years, his tonsils were removed.
The three most noticeable physical characteristics of the boy are his excessive blondness, adiposity, and defective eyesight. In height, he was at the median for twelve years; in weight, at the median for fourteen. He has internal strabismus of the left eye, lacking binocular vision. This strabismus had not been noticed by his parents until after the tonsillectomy was performed. A brief acquaintance with Jacob reveals his excessive nervousness. He is in constant motion, never relaxed or still. He chews his fingers, makes grimaces, shifts his position, twitches in some way. The parents report that he has night terrors. During his clinical examination, he rose from his chair time and again, and walked about the room as though unable to remain seated. An oculist whom the family consulted attributed the nervousness to his eye defect and advised a surgical operation which was advised against by a specialist. Several physicians referred his eye weakness to his excessive blondness, which approaches albinism. In spite of apparent intellectual precocity, Jacob is infantile in other respects. A preliminary medical examination revealed that only one testicle had descended. He does not play normally with boys his age. In his play he is more like a girl than a boy. He is slow in dressing. Dr Witmer recommended that a complete and coordinated physical examination be made at the Graduate Hospital of the University with emphasis on his glandular disturbance and lack of binocular vision. It was further advised that an attempt be made to have Jacob excused from school temporarily so that every effort could be concentrated on improving his physical condition.
A report from the optometrist under whose care the boy had been was secured by the Social Worker of the Clinic. This report stated: 11 The left eye converges and is amblyopic, which was caused by non-use. The nystagmus is much less than when I first saw him. Both eyes are highly hyperopic with hyperopic astigmatism.” It was his judgment that with his present prescription, Jacob was able to continue with his regular class room work.
The report of the pediatrician follows: “He has a pluriglandular disturbance. His hypothyroidism does not seem very marked. His basal metabolism is minus 19. The X-ray report is negative. Other ailments present are intestinal indigestion, obesity, pavor nocturnus, undescended testicle and strabismus. His blood chemistry is normal, but his blood count shows a mild secondary anemia.’’ It was later reported that Wassermann was negative. Corrective treatment was prescribed, a modified diet and endocrine therapy being indicated.
The superintendent of schools cooperated readily with the suggestion that the boy be removed from school activity temporarily. No educational treatment was given Jacob until February, when he was admitted to the Clinic Teaching Department of the Psychological Clinic for observation and instruction. Clinic Teaching began February 27, 1929, and continued to the end of the semester. Jacob received a total of sixteen hours of teaching, in two one-hour periods per week.
The observational data accumulated during the period of clinic teaching present the picture of a boy, hyperactive, vivacious, loquacious, who was unable to direct his energy into productive channels, but dissipated it in purposeless activities, which soon exhausted him. He was fatigued at the end of an hour’s period, though watched closely and given every opportunity to rest. When brought to the clinic a distance of ten miles by subway and trolley, he was tired before the lesson period started. His own activities on days when he was especially excitable exhausted him without the expenditure of much effort on his lessons. On such days, it was utterly impossible to keep him at his tasks. A typical example of the way in which he would use his energy in a useless fashion instead of completing his task was to embellish his work with all sorts of fantastic drawings, drawing circles about numbers or letters, adding dollar marks or question marks, or writing a sentence with letters of different heights, reproducing the New York sky line, as he would say, putting flags on the top of some buildings, designating them as the Woolworth Building and so on. He had his good moments, and good days, when a new subject was being presented, or a new device employed in teaching. Then he was all interest and attention. Here he showed the same tendency as was noted in repeated trials on the formboard tests. Novelty interests him, but novelty soon wears off, and then he is plainly bored. He resists all attempts to make him efficient. Routine spells ennui for him. This trait was especially noticeable in learning multiplication tables. He had his own method of finding how much four times three is,?’’ Three and three are six, six and six are twelve.’’ No explanation of the inefficiency of his own method and the effectiveness of knowing the multiplication tables availed until Jacob discovered for himself that such knowledge was helpful in learning a new subject, division.
He had also good periods, when concentration seemed to be no difficulty for him. This was usually in the reading period. Jacob had very little difficulty with reading. He knew how to use the context clues, and was familiar with the mechanical reading skills. He knew the method of analyzing a word into its parts, associating the proper sounds with the letters, and synthesizing the sounds to make the word. The accent might be displaced but the syllables were correctly sounded. He had good comprehension for what he read, and read for content.
His oral reading was, however, unintelligible. Only Jacob knew what he was reading. He was so eager to get on with the story that he mumbled half the words, his voice dying down to a whisper at the end of the sentence. Questioned as to what he had read, he gave a good account. Oral reading also brought to notice his shallow breathing. Breathing exercises were added to his daily program. The reading of dialogues was resorted to in an endeavor to secure better articulation. Under this regime, he made marked progress. At the end of the semester, he read clearly, with enthusiasm and expression, modulating his voice according to the character speaking in the story, frequently adding comments of his own. He had learned to read for the edification of a listener, and had acquired better breathing habits.
In order to improve his writing, he was asked to keep a diary. The requirements were very simple; day and date, and three or four sentences recording daily occurrences. The results were highly satisfactory, showing excellent language ability, good sentence construction and interesting content. The work of writing it became extremely distasteful to the boy. Two or three hours were consumed in the process of making three or four entries. Obviously, the actual writing consumed no such time, but Jacob employed his usual tactics when confronted with a forbidding task ?he consumed the time in extraneous activities. Only the cooperation of his mother secured a completed diary by the end of the term. Spelling was taught in connection with writing. In addition to the diary written at home, Jacob was required to use given words in sentences to be written on the board. Third grade words presented no spelling difficulty, but Jacob was fond of using words too large for him to spell, but which he understood well enough to use correctly. In these exercises the same ability to frame interesting and well-constructed sentences, noted in his diary, was shown. While considerable progress was made in the sixteen hours of clinic teaching, Jacob had not acquired proficiencies warranting his entering the fourth grade when he would return to school in the fall. In intellectual ability, the discernment-comprehension complex, he was found to be distinctly superior. His intelligence in the sense of his ability to solve what for him is a new problem, as shown in the psychometric and academic tests, must be rated high. He is alert and quick in grasping new material, and has a penchant for the novel. On the other hand, he resists mechanization. His efficiency is greatly lowered by this resistance as well as by his lack of persistent concentration of attention and his tendency to waste time and energy in purposeless activities. His general orientation is infantile and not at all comparable to his Binet mental age of twelve years and four months. His motivation for school subjects, reading apart, is inadequate, as well as his ability to carry through to success a specific task or operation. He needs constant supervision and abundant encouragement to secure results that are adequate. Left alone, he is unproductive. His inefficiency and lack of determination are further complicated by fatigue. He is deficient in energy.
On January 31, 1931, Jacob returned to the Psychological Clinic for retesting. Two years and two months had elapsed since the first examination. On the Binet-Simon test, he obtained an I.Q. of 153, a decrease of 10 points. An analysis of the test shows that his basal age had increased from ten to twelve. His vocabulary had increased from a score of 34 to 58, giving him eight points beyond the requirement for the fourteen year level. His memory span, audito-vocal, had increased from 5 to 7; his visual from 7 to 8, and his reverse from 4 to 5.
His time on every trial of three formboard tests, Witmer Formboard, Witmer Cylinders, Dearborn Formboard, showed a reduction, with an average reduction of 40 per cent. The qualitative changes in his performance are more significant. On the Witmer Formboard he showed an excellent competitive spirit, improving on each trial until he succeeded on third trial in 15 seconds. On this trial, he mixed the blocks purposely in order to make the trial more difficult. This may or may not have been intelligent, but it indicated his dislike to doing things over and over again in the same way. The Cylinder test admitted of no such change, and Jacob’s eagerness to improve his time retarded rather than helped him. The Dearborn Formboard was solved on first trial with only one false move. For the second trial, he asked for a different set-up, as doing the problem “the same way made it too easy, as one learned and remembered just how to do it.” Both trials were quantitatively superior to his previous performances. On third trial, he cut his time for the first trial in half. Healy Completion II, which is presumed to test “general adaptive capacity,” was given. He obtained a score of 53, one point under the norm for the eleventh year. He was left alone in the examining room for twenty minutes during the giving of this test to see how he worked without supervision. At the end of the period, the test was completed. This indicates a marked change in the boy, and the presence of a quality totally lacking two years previously. He can now work without supervision, direct his energy purposively, carry through a project to completion.
The picture which Jacob presented after two years shows some very significant changes. During the two-hour examination he showed no overt signs of fatigue. Distractibility was noticeably absent. Instead of needing supervision and urging, he was selfmotivated. His persistence was greatly in evidence, as well as his determination to complete what he had begun as soon as possible. The only sign of nervousness was the momentary confusion when his effort to speed up brought him into difficulty with the Cylinder test. His efficiency in production had increased, partly as a result of the elimination of useless motions, and partly as a result of the appearance of a surpassing motivation, a desire to do better than he had done.
A conversation with his mother brought out the fact that his sense of inferiority based probably on his organic inadequacy was being compensated for by self-assertion and independence of judgment. He feels that his judgment is right, argues for it, and with difficulty is convinced that his parents’ judgment is better. An example of this attitude of self-assertion is seen in the fact that when he was informed he was going to be reexamined at the Psychological Clinic, he exclaimed, “Did you make that appointment without consulting me?” Another instance of a developing superiority complex was furnished when the boy proudly told the examiner that in an examination on the Thought Test Readers, he had earned a “mark of one hundred three times in succession, and was the champion of his class.’’ It was his way of announcing that the old order had passed away and that he was coming into his own.
In his social relations, Jacob’s problem has not approached solution. His appearance is against him as well as his manners. In height he is now superior to the median at fourteen, having grown five inches in two years; in weight, superior to the median at sixteen, a gain of 27.5 pounds, and 24.9 pounds overweight for his height, as against 16.5 pounds in November, 1928. He suggests the fat pituitary type. There is excess distribution of fat about the hips. The general trend of his makeup and manners is towards feminancy. His almost white hair, and defective vision make him fair sport of youths his own age. He refuses to associate with them on equal terms, and prefers younger children whom he can dominate. With a companion his own age, he is argumentative. The friendship soon ceases when Jacob finds he is not able to control his friend. For rough sport, he has no use. His poor eyesight may be urged as a good excuse, but the controlling factor would appear to be his infantilism. Failing to make social contacts, he devotes his time to reading, drawing, making airships with boards and blocks and other material. The range of his moods is beyond normal. He has days when everything goes wrong, and nothing is right; days when he is better balanced, more equable.
Jacob returned to school in November, 1929. He entered the third grade and is now in the fourth grade. His marks are now all “Excellent” and “Good.” There is no complaint on the score of application. His work in arithmetic is not neatly done but it is accurate. His teachers say he is dependable, frank, honest, conscientious. His school proficiency tests taken in the Clinic show that he has the proficiencies necessary for fourth grade work in spelling, arithmetic, and reading. His writing is poor, cramped in style, written with his left hand in small letters. In the finer coordinations necessary in handwriting, he is wanting. At present, he is not a school problem, the trouble that brought him originally to the Clinic having been removed.
The boy remains a medical and social problem. What the future may hold for him depends on the success of glandular and other therapeutic measures, and upon his ability to adjust himself to the demands of his social environment. The level at which he will function will depend on these factors as much as upon his superior intelligence and intellect.
III. The Educational Treatment op a Handicapped Child Walking on his toes with a festinating gait, his arms from shoulder to elbow held close to his body, his forearms bent forward in Simian fashion, each step taken seeming to indicate that the frail body would be plunged to the ground, a boy of five years and seven months entered the Speech Clinic of the University of Pennsylvania, May 25, 1928. He had been referred to Dr E. B. Twitmyer by a physician, who had had the boy under observation since he was eighteen months old. At that time, he was markedly undernourished and carried very definite stigmata of rickets. He was unable to sit erect. The birth history was not very definite, but there was evidence of early paralysis, and probable birth trauma. His speech was unintelligible to strangers. Tonsils and adenoids were removed without noticeable change. There was apparent loss of power in the control of the soft palate, with perhaps, some bulbar involvement as well. So wrote the physician, ready to cooperate with an anxious mother seeking not only articulate speech but education for her handicapped child. Added to this was susceptibility to respiratory infection. Each winter there had been attacks of bronchitis and broncho-pneumonia., obliterating the benefits gained during the summer and retarding progress. Examined by Dr Twitmyer, Lester obtained a Binet-Simon I.Q. of 127 which placed him in a group of ten per cent superior to ninety per cent of six-year-old boys. His discernment span, auditovocal was 4; visual, 4; reverse, 3. His first performance on the Witmer Formboard was superior to thirty per cent of boys his age, despite the spasticity of his arms and hands. He failed to comprehend the Witmer Cylinders, a test at his own age level, on first trial, but after instruction, rendered an excellent performance qualitatively, and quantitatively superior to seventy per cent. His observation, discrimination of form and size, and concentration of attention were good. His muscular control, considering the spasticity, was above average. During the testing, he was willing and cooperative, as far as his strength permitted. There were evident signs of fatigue, particularly in the readiness with which he slid down into his chair. His speech, as described above, was indistinct, due to lingual paralysis. The situation was further complicated because the child realized his physical defects, and was sensitive to them. Dr Twitmyer’s prognosis was that if the boy could be built up physically, given speech training and proper educational treatment, it would be possible to prepare him to be a useful and relatively happy member of society. It was recommended that he should spend as much time as possible during the summer in the open air, and should return to the Clinic in the fall for speech and academic training.
Lester began his speech and academic training in the Psychological Clinic, October 10, 1928, and during the academic year received thirty-seven hours of training. Owing to the condition of his health his attendance Avas irregular. Forty per cent of the time he was absent. Approximately half of the teaching period was devoted to speech training and reading; the other half to arithCASE STUDIES IN DIAGNOSTIC EDUCATION 175 metic. The boy fatigued quickly, and could not be taught for any considerable period without resting. The breathing exercises were distasteful to him because of respiratory difficulty. “What Lester did not like, he had learned to avoid doing by the simple device of saying, “I am tired.” The reading situation showed the same trait. In arithmetic, he was interested, did not resort to his favorite defence mechanism, and made considerable progress. Before the end of the year, he had acquired first grade proficiency in this subject and was ready to take up the work of the second grade. In reading, the word and sentence method was employed; progress was slow. The speech difficulty, complicated by lack of motivation and fatigue resulting from the effort involved, all militated against success in learning to read. Twenty words, recognized at sight, was the total reading result for the year. The speech exercises involved in Dr Twitmyer’s corrective speech treatment were mastered. Excellent cooperation in home practice was furnished by the mother, and marked progress was made toward articulate speech.
It was Lester’s privilege this year to spend an extra hour each day he came to the Clinic with the pre-school group of superior children in their hour of games and handwork. This provided a valuable socializing agency for the boy who had never played with other children, and whose sole companions were his mother and grandmother. He entered with enthusiasm into the games as far as he was able. In the handwork, he tried hard, worked slowly, and became more agile. There were times when the sensitive nature of the boy shrank under the gaze of observers, and it was apparent that he was keenly aware of his defects. If an inferiority complex, so-called, is developed on the basis of organic defect and in proportion to the number of defects, here, surely, was a case that provided an exception to the rule. Aside from a supersensitiveness to the looks of visitors and students, which he resented, he showed no sense of inferiority. His disposition was unspoiled. His reactions in his own group were normal. He held his own with those his equal in age, for in general intelligence he was the equal, if not the superior, of most of them. A remark characteristic of his general attitude towards inquisitive observers is this one. “They think because I can’t talk that I do not understand what they say but I do.” No sense of inferiority lay behind this remark, but rather the reverse. If he was aware of his defects, he was aware also of his ability. Singularly well-balanced was the personality of this handicapped boy.
His general intelligence was revealed also in his comprehension of life situations and practical affairs. A boy who could not use hands or feet efficiently, he was able to describe accurately the movements that one makes in driving an automobile. His comprehension with all the associative processes involved functioned well in all situations where a six-year-old child of superior intelligence may be presumed to take interest. He was a fine bit of mechanism with a very specific damage to the neural background involving hands, legs, tongue. Beyond this, his mentality was normal, surely above average.
Lester was making such progress in his speech without overtaxing his strength, that Dr Twitmyer advised the mother not to enter him in public school in the fall of 1929, but to bring him back to the Clinic for another year. October of that year found the boy beginning his second year of training in the Clinic Teaching Department of the Psychological Clinic. His teaching hours were the same as during the preceding term, and his attendance about as irregular. The progress in arithmetic during the year was notable. In June, 1930, he had attained 3A proficiency in all the mechanical operations and problems; in addition and subtraction, his proficiency was 3B. In this branch, he was competent to take up 3B work in the public schools, being only one semester behind grade. In reading he had attained only 1A proficiency; in spelling IB. Three semesters’ work had been covered in arithmetic; but one in reading.
The relation between seen, heard and spoken language in the case of this boy became a subject of study. Hard c and g, k, q, v, f, the sibilants s, z, sh, ch, th were the most difficult consonants for Lester to master. Final t, d, f, were invariably sloughed off. The sibilant sounds involving the closing of the teeth or jaws were attacked first and yielded to treatment. The greatest difficulty was experienced with sounds involving the posterior part of the tongue and palate. The training here was most tedious and difficult, requiring a great deal of patience on the part of the teacher and pupil, as well as persistent and intelligent effort. The unruly tongue had to be trained to take and keep a position long enough to produce the desired sound. This work was carried on in direct relation to the reading problem. Syllables were used comparable in some respects to the Ebbinghaus nonsense syllables containing the difficult consonants and practice carried on both in the clinic and at home. Care was taken in the choice of syllables to obtain those that could be used later in the reading situation. It was drill work in phonic analysis as well as training in speech. Lester acquired the habit of attacking a word by syllables, patiently striving for the correct position of the tongue in utterance. Correct articulation and a fundamental reading skill, the ability to sense the component letter and sound parts of a word, were developed simultaneously.
Lester’s difficulty appeared to be that while he had a correct auditory image of the word, e.g., kind, and understood its meaning, his kinaesthetic imagery was faulty, for he had never been able to send to the memorial area the correct motor image of the letter k. He was thrown into such mental confusion when called upon to make the difficult sound that all the other sounds in the syllable or word were pronounced incorrectly. He understood the meaning of the word girl when it was pronounced correctly but if he were asked, “What is a dirlf”, girl being pronounced as he pronounced it, he would not understand and would say, “1 do not know.” This was tried on the lad again and again where there was not the slightest suspicion apparently that you were trying to trick him or make sport of him.
It became apparent in the first year that the boy could not be taught to read by relying upon his visual imagery even in the case of words that he was capable of pronouncing. Drill by means of the family method was equally futile as Lester learned to know the word in association with its siblings in the family but was unable to recognize it in his reading lesson. Progress was made and success obtained only by corrective speech work plus the development of reading skills. Considering the difficulties involved, to acquire a proficiency of a half grade in the eighteen hours of speech and reading work, was a considerable achievement. The prognosis for this boy’s education depends, then, upon the success of the corrective speech work. He can not learn to read by methods which rely for the most part on visual imagery. He cannot learn to read by the auditory method of phonic analysis. Though his auditory imagery is good, and his imaginal endowment is of this type, his auditory and kinaesthetic imagery, especially of sounds involving the posterior part of the tongue and palate, are in conflict. The difficulty involved throws the boy into mental confusion, and has lessened his motivation for reading. The method adopted which combined corrective speech work and the development of reading skills seems to hold promise for the future.
The problem of correct walking was also approached. Appropriate exercises were prescribed and a part of each play-hour devoted to practice in stamping out old habits that persisted since the early years of his life, and in developing correct habits. Marked improvement was noted in a short time. There is but a faint resemblance to his former method of walking, which always provoked strangers to catch him lest he fall forward on his face, in his present gait, which is by no means perfect, but is always much better when his attention is called and he is summoned to do his best.
From October, 1930, to the following June, Lester studied under a private tutor, coming to the Psychological Clinic once a day for speech training. With his superior intelligence, good social adjustment, excellent reasoning ability and the evidence of improvement in his speech, there is every reason to conclude that Dr Twitmyer’s prognosis that Lester will become a good and useful citizen has been justified.
From Mental Deficiency to Normality
From mental deficiency to normality condenses the story of a child who has been under the professional care and guidance of Dr E. B. Twitmyer at the Psychological Clinic. This child of four years and nine months was brought to the Clinic, February 11, 1927. “A total loss” bluntly expresses her condition at that date. In three years and three months, through orthogenic speech and academic training, she had acquired speech sufficiently clear to be intelligible, and proficiency in school subjects that warranted her taking her place among her equals in age in the public schools. Whether she will be able to take her place in the competitions of life, the future will decide. A speech defect was the immediate reason that brought Jane to the Psychological Clinic. She had a cleft palate. The palate had been repaired at fourteen months, the repair being pronounced seventy-five per cent successful. Her speech was not only that characteristic of cleft palate cases but so indistinct as to be barely intelligible. Her mother understood her, but her clinic teachers needed not only auditory acuity but considerable familiarity with the little girl before they could translate her speech into language for the benefit of those who asked, “What is she saying?” It seemed another child who stood up before a large audience at the Speech Clinic Demonstration, March, 1931, and recited a poem clearly and distinctly so that it was heard and understood by all her auditors.
Significant as was the cleft palate, it was but a part of the picture. The bulging, glassy eyes, restricted vision, constant necessity, due to myopia, for bending over to see things, told the story of a second congenital defect?glaucoma. Expert optical attention was required and supplied: glasses were provided and from time to time changed. The future of our little girl, her social competency, would seem to hang at present upon the issue of this eye condition which is almost as obscure as its etiology.
Add to these, another condition?glandular dystrophy. She had a bad start in life. In addition to her congenital defects, there was the difficulty of adjusting a defective organism to extra-uterine conditions of living. When she was six weeks old she weighed but four pounds, but gained steadily after that time. Glandular treatment was given for one year, but discontinued by the mother of her own accord. Jane was two years under normal weight and height at the age of six. Her physical appearance was every thing but attractive. A large head suggested hydrocephaly, which judgment was afterwards confirmed by X-ray examination. A flat nose with a malformed bridge nestled between exophthalmic orbs. Her posture was bad, her shoulders stooped. The frail organism failed to produce enough energy for normal child life.
Congenital cleft palate, congenital glaucoma, congenital glandular dystrophy?was it any wonder that she came to the Psychological Clinic from a hospital with the diagnosis of congenital mental deficiency? Without normal speech, sight, glandular functioning, physical growth, or mental development there appeared small hope for this child of four years. Owing to her excessive distractibility and negativism no psychological examination was attempted at her initial appearance at the clinic. On the Witmer formboard, a test at her own age level, her score fell in the lowest decile. Her form discrimination and distribution of attention, however, were good. Upon this single thread Dr Twitmyer hung his hope that something could be done for this child. Possibly, too, there was another reason. It must not be supposed that Jane was absolutely without charm. She was a great conversationalist, dramatic in her recital of events and incidents that interested her. What she was narrating was a mystery to the hearers, but there was no mistaking the interest, enthusiasm, and, perhaps, intelligence of the child. At. the conclusion of her speech examination, she was admitted to the speech training class of the Clinic. Her teacher, a student in. Dr Twitmyer’s course in Orthogenics, noted temperament traits which were to make the task of speech training exceedingly difficult. She was highly distractible and obstinate. She refused to do the lingual tests or to produce on demand the vowel sounds called for in the speech exercises until forced to do so by her mother. She showed herself to be a fluent talker, always ready to tell of some happening, never ready to do what she was required to do. She was obviously in need of strict discipline. In February, 1928, the question of entrance upon school education was considered, and Dr Twitmyer recommended that she be admitted to the Clinic Teaching Department of the Psychological Clinic for academic instruction. Her Intelligence Quotient on the Binet-Simon scale was 88. Her chronological age was five years and ten months; her mental age, five years and two months. Her memory span, audito-vocal was 5.
Jane attended the clinic for instruction from March to June, but only very irregularly. Her teacher found her a problem both in attention and retention. She learned slowly and retained but little. Her achievements at the end of the semester may be summed up as follows: she knew the alphabet, was able to spell ten threesyllable words and four four-syllable words, to count and to write numbers up to twelve.
In May, at Dr Twitmyer’s recommendation, she was examined at the Pediatric and the Nose and Throat Clinics of the Graduate Hospital. The report of the Pediatric Clinic follows: “X-ray of the skull: Sella Turcica within normal limits as to size and contour. Clinoid processes clearly intact. No direct or indirect evidences of neoplastic process either cranial or intracranial. General contour of skull with rarified thinning appearance indicates moderate hydrocephalic tendency. Wasserman?negative.” The report of the Nose and Throat Clinic was hypertrophied tonsils and adenoids. Tonsils and adenoids were removed in the summer of 1928. Her eyes were refracted and glasses provided.
During the college year, October, 1928, to June, 1929, Jane received fifty hours of clinic teaching; during the year, October, 1929, to October, 1930, one hundred fourteen hours in academic subjects. For the major part of the time she had the privilege of attending the recreation hour of the pre-school group of superior children. Association with this group was invaluable as a socializing agency for Jane, as all her contacts had been with adults. She had never played with children. The shy, timid Jane, two years undersize and underweight, with her stooping shoulders, bad posture, bulging eyes, nasal voice, and awkward movements, was in striking contrast to the members of the pre-school group with their alert minds, active bodies, independent and original ways. The ego-centricity of child nature saved her from self-consciousness, but as she grew older, there were moments when it appeared that she realized that “she did not belong.”
The reports of her teachers from October, 1928, to January, 1929, show that the main task of the year was to teach this child to attend. Her attention, as was to be expected, was in inverse relation to her fatigue. The frail organism did not manufacture enough energy for even a minimum of productive work. In addition to this, her sleeping hours were bad. She stayed up with her parents to a late hour and often arrived at the clinic weary before her lesson began. Her motivation for the distasteful work of learning letters and numbers was at the zero point. She was not only indifferent but hostile. She yawned, fidgeted, twisted her dress, turned her body in a tortuous fashion. Streams of conversation poured forth at most unexpected moments. This was her favorite method of ‘’ stalling.’’
The word and object method was employed without result in teaching reading. The analytical method was then tried. Jane proved to have poor visual discrimination of letters, especially those of similar forms as & and d, h and k. She made some progress during the year in phonics, her auditory discrimination being slightly better than the visual. Phonograms were taught as far as possible in the reading situation, but a great deal of drill work, wasteful as it is ordinarily, had to be resorted to; in fact, teaching resolved itself into repetitive drill, because retention was exceedingly poor. Jane learned to recite numbers in rote fashion, but number relations were beyond her. Combinations she could memorize, and repeat glibly enough if sufficiently mechanized. Subtraction seemed to be beyond her understanding. Weeks passed before she grasped the idea that 3 minus 3 equals 0. The results were meager here as in reading. Her greatest advance was in the matter of control. She became in a measure habituated to classroom instruction. She had learned what the concept of “school” meant. On January 28, 1929, her I.Q. was 88. Her chronological age was six years, eight months; her mental age, five years, ten months. As far as the abilities tested by this scale are concerned, Jane had suffered no loss during the year. She was holding her own. Her memory span remained unchanged?5. She had learned to read numbers, and her visual span was equal to her audito-vocal. She could reverse two numbers. The visual and reverse spans indicate some profit from her clinic instruction, a beginning of organization of perceptions. In October, 1929, Dr Twitmyer increased her hours of instruction from two to four per week. At the opening of the semester, her teacher found that she had forgotten practically all her arithmetic, and could spell only the simplest words. Beginning with the simplest arithmetical operations, Jane advanced until at the end of the term she had acquired first grade proficiency. Her proficiency in spelling was of the same level. In reading she had completed the Elson Primer and about fifty pages in the Browne second reader. In spelling, reading and arithmetic, she had acquired a second grade competency. Her attention was variable; her motivation showed considerable improvement. She had become adept in the use of methods for evading tasks she did not like; what intelligence she displayed was manifested in this direction. However, with the sense of achievement, and the gradual awakening of the perception of relations, she found satisfaction and acquired some pride in her new-found power to do.
Her speech showed considerable improvement. Her new glasses were proving much better than the ones originally provided. She did not stoop so low over her reading. The prognosis for future development was hopeful, but hinged largely on continued development of her powers of attention. In June, 1930, after another semester of teaching, her school proficiency in reading was good second grade. She was reading the third reader. Her work in spelling was on a par with her reading while in arithmetic she had 3A proficiency in all the fundamental operations. She was competent, certainly, to do thirdgrade work in all subjects if individual instruction could be provided. On June 2, 1930, her Binet-Simon Intelligence Quotient was 106. Her chronological age was eight years, one month; her mental age, eight years, seven months. Her I.Q. had advanced 18 points. Her memory span was audito-vocal, 6; reverse, 3. In height and weight, she was superior to the mean at seven years. Since the removal of her tonsils, her physical condition had steadily improved. At the end of the semester, Dr Twitmyer advised entering her in the public schools. Owing to the difficulty Jane had in making adjustments to new situations, her peculiar tempermental traits, her physical handicaps, it was thought advisable to recommend placement in the second grade. She was accordingly so entered in October, 1930. In February, 1931, she was advanced to 2B, and is making a successful adjustment to the school situation. It wras further recommended that she should continue to come to the Clinic for speech training, in order to perfect her enunciation. Here, for the present, we leave this interesting child. Orthogenics has brought her far on the road from congenital mental deficiency to normality as judged by the Intelligence Quotient and ability to make progress in school. The prognosis, weighted as it is with factors which make for uncertainty, is in the main favorable.
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