Three Case Studies in Diagnostic Education
The Psychological Clinic Copyright, 1931, by Lightner Witmer, Editor Vol. XX, No. 3 May> 1931
- Author:
Richards, M.S.
Clinic Teacher, The Psychological Clinic, University of Pennsylvania
I. David David’s early history is an interesting one. He was born after a pregnancy of only six months; during the pregnancy the mother developed a toxic condition, and one month before the child s birth she had her tonsils removed. David weighed but one and threefourth pounds at birth. It was difficult to find food which he could digest, and due probably to malnutrition he had at least ?ne convulsion during this initial year of his life. At two months age lie had chicken pox. During this entire year his parents despaired of his life, yet he continued to live, and likewise through a second year, not much more hopeful. During the third year the child began to pick up. He learned to walk at three years, he Sained weight much more rapidly, he grew stronger. At four he “Was completely broken of enuretic habits.
We learned from the family history that the maternal grandParents were alive and that the paternal grandparents were dead. The paternal grandfather had died of influenza, the paternal grandmother of angina pectoris. The health of David’s parents was good. The eldest child, David’s only living sibling, fourteen years ?f age, was in the first year of high school, doing satisfactory work a*id in good health. A second child, a boy, had died of diphtheria at the age of three. David was the third and youngest child of the family.
It is at once apparent from the medical history that David got to a bad start. It was almost a miracle and probably a misfortune that he survived the first year of his life, and the fact that he developed from such a delicate infant into the physical specimen we had before us for psychological examination was nothing short of remarkable. There is in the boy’s appearance a suggestion of malnutrition, but when examined at the age of eight years and one month his weight was equal to the median for boys of nine and his height was equal to the median for boys of ten. Of the anthropometric measures taken, only the head girth of 47.5 cms. was subnormal. This head girth is so decidedly inferior as to raise grave suspicions.
Psychologically, the history reveals evidence of retardation almost from the start. David did not learn to talk until he was five years old, and even now his speech is mutilated very noticeably with an infantile type of enunciation. School was not considered possible by the parents until the boy was seven years old. At this age he was entered in a private kindergarten. David was extremely unsociable until he entered this class. He disliked playing with other children and his whole reaction to social situations was marked by a tendency to isolation, to play by himself. The school did much for him here; gradually he learned to enjoy the company of other children, to play with them. His teacher noted that the boy’s greatest defect was an inability to concentrate on problems, no matter how simple, and to maintain his attention on a specific thing for any length of time as compared with the others in her group. It was this teacher who referred the case to the clinic for examination.
David was examined by Dr Murphy in July, 1930. The quantitative results as shown in the record of the boy’s performance on the tests were generally poor. His time on the “Witmer formboard as compared with norms for first grade children was, on the first trial, inferior to twenty per cent, and his second and third trials were worse. He failed the Witmer cylinder test, which is passed by fifty per cent of first grade children, though on the second trial he improved to the extent of being inferior to but twenty per cent. He gave an auditory memory span of four on the third trial, which is inferior to sixty per cent, and a visual span of four, inferior to but forty per cent, but a lack of ability to give any reverse span placed him inferior to fifty per cent.
On the Stanford Revision of the Binet-Simon Scale, David was given a mental age of six, and an Intelligence Quotient of 74, but subsequent testing, six months later, yielded an Intelligence Quotient of only 66. In this later testing he was unable to pass two tests for which he was given credit in the earlier trial?counting thirteen pennies and describing the pictures.
It was evident from the results of the examination that David could not be given a higher rating than borderline mentality. There was little evidence that the boy would ever develop to the extent that he could provide independently for himself. The tendency in diagnosis was toward feeblemindedness rather than toward normality. David had demonstrated his competency to be inferior to at least eighty per cent of boys his age. Handicapped by a poor physical constitution, despite present good health, and also by an infantile mutilation of speech, improvement for which could not he predicted because of the low mentality and slight degree of trainability, constructive educational guidance was extremely difficult. How might we estimate David’s chance for school piogiess, how determine whether any schooling would be worth while? Granting that the boy could be taught to perform successfully a few useful tasks, what might their nature be, and how might they be taught most profitably ? The opportunity to start the first grade at the usual age of entrance into school had been denied the boy because of physical retardation. Was it possible that because ?f this fact David was naturally not readily comparable to fust grade children ? If he fell markedly below those standards, could it not be attributed to this educational retardation, and not to feeblemindedness? These questions demanded answer, for they were of vital importance to intelligent parents anxious to provide for their children the best of opportunity. Occasionally the social implication of retardation as it affects the family becomes alarmingly evident. Here was a case in point. With a certain position ?f influence in the community,?the father was a business man of some importance, the mother was deeply and intelligently interested in her children,?what was there to do with this unfortunate child ? Had lie been only one more child in a poverty-stricken family, institutionalization of some sort would have been obvious. Or, on the other hand, had he been a child of the rich, and had there been less of family attachment, this freak might have been hidden f 1 om iew by placement in an expensive home for exceptional children. W ith a family pride which precluded dependence upon the state, jet not in a position to pay the price of expert private attention, the question of doing what was right for the boy and for themselves was a real one to the parents.
It was in an attempt in part to answer these questions, to determine the degree of trainability, of educability, precisely of mental status, that clinic teaching at least for the fall term was recommended. David was placed for teaching from October until the early part of January under Miss Margaret Shank, a student teacher in the course in orthogenic teaching. He received, in all, seventeen hours of teaching.
David learned very little during this time. His teacher found in the early part of her teaching that the boy could recognize letters printed on the blackboard and that he could pick them out of groups of letters printed each on a cardboard square, and mixed up in random fashion in a box. He attached to each letter a meaning which he had learned earlier: for Z he said “zebra,” for A “apple.” He could count to ten; he was able to write his name and his telephone number. It was in one of these first periods of teaching that he was tested a second time and received the Intelligence Quotient of 66 mentioned above. His memory span, auditory and reverse, was the same as in July, though soon after this test he gave a reverse span of two.
An attempt was made first of all to teach David to read. The method adopted by his teacher was one which included the assignment of two or three words each day, having the boy write them in his note-book, read them as he had written them, spell them, and finally present them in the reading material used each day so that he might learn to use them in text. The result was discouraging. Although David was able at the end of the term to recite without error a page of printed material, and give what might in the first instance be called “reading,” it was impossible for him to progress independently. His reading was a matter of approaching each word, spelling it, T-H-E, then looking up in a questioning way at his teacher, saying “THE, is that right?”, waiting for her assurance before proceeding to the next word, then starting again, ” F-O-X,” and so on. Certainly this performance, no matter how accurately he analysed and said each word after he spelled it, could not be called reading. There was no carry-over from learned material to new words, there was no comprehension of material read in this fashion, there was no increasing ability to read even thus crudely. His teacher wrote “… his reading is doubtful for he is lost with material other than that which has been reviewed over and over through the three months of teaching.’’ In oral spelling David was lost. Asked to spell a given word he would invariably write it on the blackboard or on paper. He had little or no auditory imagery which was of service to him, in spite of the fact that he was sometimes echolalic in his responses. He had built up a kinesthetic-visual habit in spelling, and it was impossible for us to carry it over into the auditory field. His knowledge of arithmetic when his teaching began consisted of knowing how to count to ten,?nothing more. As the result of teaching in the clinic he learned to count to fourteen, and to say “one and one are two, two and one are three, three and one are four,” and so on, but when asked “three and one are what? it was necessary for him to start through the series again from “one and one’’ and thence upward. The rote method he used in reading was used in almost the same way in arithmetic; hence it was as impossible to assume that he learned what is essentially arithmetic as it was to call his recitation of material on the printed page reading. The most notable achievement in the teaching was the fact that David learned to give a reverse memory span of three. This was accomplished only after constant application through the three months of contact with him, but it definitely indicated some ability to grasp the units presented and to organize them intellectually in the required pattern.
From the results of the clinic teaching in the case of David, Dr. Murphy concluded that the boy was feebleminded beyond doubt. The reports from his first teacher, from the parents, from the physician, the psychological examination, and now the report of the teaching administered in the clinic,?all were evidence of a general retardation made manifest in almost every aspect of the boy s behavior. He had learned to give a reverse memory span of three, he had shown some trainability in rote types of learning, which ability had not been demonstrated in the psychological examination because of the child’s lack of persistence. Throughout the teaching David demonstrated this same deficiency in control of attention ?r persistence?the “lack of concentration” of which his teacher had complained?but the greater time allowance given him in clinic teaching as opposed to the psychological examination permitted him in part to prove that, although he was low in this trait, he was not wholly lacking. In spite of some ability to improve in efficiency we could find no indication that the boy would improve intellectually, that is, David showed some trainability but no educability. His teacher stated that David “can be trained but he can never educate himself. For instance, he can spell some words I can give him, but he does not comprehend the meaning.’ Hence, although he was efficient in a small measure, he had so little appreciation of ends to be sought that the efficiency was poorly directed. His dependence upon his mother and teacher was so great that it was impossible to determine what sort of motivation David possessed. That it was infantile there is no question. He wished only to please those who became most gratified when he performed in a certain fashion in preference to others. His extreme distractibility, characterized by an infantile flow of questions at all times, as well as by excess movement, did not permit of persistent, well-motivated effort of a sustained sort.
The possibility that David will ever take a place in life independent of others is negligible. Prognosis for his case is unfavorable, for he will always need supervision. He may learn simple tasks: sweeping, washing dishes perhaps, shovelling snow, and in this way he may become a useful member of the household. The educational recommendation would, however, include his placement in a school for backward children where he will learn to get along with others, and where he can develop as far as possible the low order of ability which he possesses.
Martha
Martha was an unusual child among unusual children. Such a distinction placed her for a considerable period of time under the supervision of the department of Clinic Teaching, as much because she was an object of interest to students in clinical work as because of the fact that it was extremely difficult to determine her mental status satisfactorily at the time of her examination. Referred as she was by the University Hospital, where she had been given much attention, we had throughout our subsequent contact with the little girl a clear picture of her physical condition, and we knew that our task was to determine, in short, what mental ability there was to work with, and whether a training program could be established which would bring satisfactory results.
Martha’s parents, too, were unusual. The mother had undergone an operation so that she might have children. We never saw very much of the father but from what we could learn directly from the mother and from our own observation of her behavior toward Martha, we concluded that in the home the balance hung on the side of too much parental affection and interest rather than too little. We came to appreciate this fact more deeply as our contact with the case developed. There had been an earlier child, a boy, who had died of measles at the age of six and shortly after a severe fall. Later conclusions pointed to some form of encephalitis, ?”sleeping sickness,” the mother told us.
In tlie first month of her pregnancy with Martha the mother had fallen. At the time of birth, the child was delivered by the head nurse in the lying-in hospital. The cord was twisted about the child’s neck, and rupture of the navel brought 011 a convulsion in three days. From this period on convulsions were exceedingly common; the child suffered them as often, sometimes, as eight or nine in a day. During these episodes the child turned blue, was spastic and rigid. Although she now has convulsions at most only ?nce in three months, and then only when she cannot have her own way, during the period of early childhood they were extremely frequent. Evidently the child in these early years was undernourished, for at five years she was rachitic. The mother told us that the little girl talked at two years, and that she ceased wetting the bed at night at two-and-a-half. She did not walk until four. Her tonsils were removed at two years. During childhood she was often constipated, but the only diseases she had were measles and one attack of bronchial pneumonia.
An examination by the University Hospital at the age of fie years and three months?five months preceding her examination at the Psychological Clinic?revealed the fact that Martha had a right dorsal left lumbar scoliosis, and spastic paralysis of the lower limbs. She had been walking but a year, and even in that period she had been able only to walk on her toes in an extremely awkward fashion. Although she was extremely active, she tired easily. It was learned at the hospital that the child had been examined at the city hospital a year before their own examination, but no report concerning this original examination and the treatment that may have followed was ever received by us.
A recommendation was made at the Hospital that Martha attend a Seashore Home for some time. This suggestion was carried out during the summer that followed, a short time before the child “was examined in the Psychological Clinic. It is reported that Maitlia “Was well and happy during the day, but that at night she grieved so for her mother that it seemed wisest to send her home after tin ee Weeks. The discovery, soon afterward, that she had been suffering from a tooth suggested to her mother that this may have explained m part her restlessness while in the home.
Martha’s parents were extremely anxious about her future and although both the hospital and the Psychological Clinic believed the mother to be intelligent and interested in a practical way in her child, it was evident that she could not comprehend the nature of the case. It was her dream, her anxious belief, that Martha might some day pass through high school and college. She seemed to understand the necessity, mentioned in turn by the family physician, by the hospital, and now by ourselves, for the child to develop proper social contacts through play with other children, but rather than expose her to the rough but well-meaning play of normal children of her own age, the mother felt that it would be best in every way to adopt an older girl of eight or ten years to play carefully with Martha, as well as to absorb, perhaps, some share of her own clearly over-developed interest in the child. It was suggested to the mother as a further solution of her problem that she have another child, but the fear that in the condition of this unfortunate little girl there was too much of an hereditary nature dispelled from her mind almost immediately the advisability of such a step.
Here was a problem. What was there to do with a child, physically handicapped in such a way that she could not be other than a burden to her parents for many years to come, perhaps forever? What could be done with parents so keenly interested, so fond of children, so hopeful that in the present condition of their child, tragic as it was, there was still hope that she would develop as other children do ?
Late in the summer session of 1930 Dr Murphy examined Martha in the Psychological Clinic. It was impossible to accomplish very much in the way of objective measurement. On the Stanford Revision of the Binet-Simon Test the child responded fairly well. At three she passed all the tests, and at four she counted pennies satisfactorily and seemed to comprehend the questions asked at that level, but she failed all tests at five and above. With a mental age of three years and six months (her chronological age was five years and seven months) the child received an Intelligence Quotient of 63. Her forward auditory memory span was two; she could give no reverse span, and could not read numbers. On the Seguin three-disc (ungraded) board the child replaced all the blocks in five seconds, and on the first trial of the Seguin threefigure board she replaced them in fifteen seconds. Her trial on the Witmer formboard was a complete failure, though in a time well over five minutes she did manage to replace correctly each block as it was handed to her. Her attention had constantly to be directed to the detail upon which she was working. She matched colors, and “when pressed to it handed to the examiner the block asked for.”
Martha was an extremely pleasant little girl. Throughout the examination she seemed tremendously interested in going from one to another of the tests, on and on, to the new tiling. Tiring quickly of the blocks on one board she asked eagerly for those of another. Catching sight of the brightly colored cubes she stretched out her hands for them. On the Binet tests she asked, “what do we do next?”, ‘’anything else to play with?”, “may I play?”, “give me the pennies,”?these and countless other questions suggestive of her boundless curiosity and the urge ever to be at something new and different. Her attention wandered incessantly, her distractibility was exceptional. She was a child of a few months reaching from her carriage for a bright ball shown to her; she was a child of two looking eagerly about her for something new to play with; she was a child of three trying obviously to do the task before her, impeded by a distractibility which was part of her. Never was she a child of five, almost ready for school,?ready for activity of an intellectual sort. Her movements were at times incoordinate. Her walking quite naturally was poor, although she wore the brace recommended by the physicians at the hospital. She drooled at the mouth occasionally, but hastened to wipe her face when asked to do so. Her questions indicated a quick perception of changes about her; they, only, were an indication that she was more than an infant, that she was eager for information. Her performances with all the material given to her were clearly infantile, and the hyperactivity characterized by her running about from one thing to another, according as each attracted her fancy, indicated a lack of control found in a child half her age. All this,?but the occasional gleam of intelligence as shown by her questions and in lier remarks suggested caution in diagnosing her as belonging definitely to that class wherein her Intelligence Quotient and her work on the performance tests would place her. This child, handicapped physically and mentally, overactive, infantile, without the control of a child her age, was more like a child of three. Yet, strangely, she was a bright child of three,?bright in her response to the environment which surrounded her, quick to notice details, quick to see what she wanted and that she could get it if she worked hard enough, eager for attention, willing to use her mutilated language in asking for a desired object. Never negativistic, yet headstrong ? willing to submit, yet only because submission would bring her out where she wanted to be. Clearly she was spoiled.
Clinic teaching was recommended for the purpose of further observation and a more analytic diagnosis. Martha was given about eight hours of teaching under Miss Sylvia Lenson. The teaching covered a period of about six weeks during the fall term following the summer school in which Martha was examined. Starting on the first day with the performance material the teacher noticed at once that if anything at all were to be accomplished it could come about only as the result of firm disciplinary treatment. The fact that the child was spoiled, as suggested by her behavior during the examination, was now very clear. We had occasion to observe more closely the mother in her relation to the child, and the constant affection which she poured out upon her in speech and in gesture was regarded as symptomatic of the treatment accorded her in the home, probably by both parents. Well aware as the result of our suggestion to her that this was not the best attitude to maintain, the mother realized her error too late. Her child had seemed so unfortunate to her that it was only fair to act toward her in a manner more affectionate than that shown to other children. An only child, the sole object of parental affection, calling out by her condition more than the usual sympathy, the child learned literally to run ragged over others. Even the hospital reported that in the week spent in the observation ward she demanded constantly the attention of nurses and physicians.
Her teacher adopted a strict attitude toward Martha. She resolved that nothing should be started which could not be completed within the hour. Starting with the Wallin pegs, proceeding from there to the Witmer formboard, the child learned a better method than the hit-or-miss system with which she began, which could not be dignified by the term “trial and error” because there was little to suggest “trial.” In spite of her extreme distractibility the child learned gradually that she had a job to do, and that she could do nothing else until it was completed. Gradually she learned to do the Witmer formboard, then the cylinders. At the end of three weeks the child performed the formboard test in about a minute and a half, though under pressure of constant urging. Her teacher did not believe that Martha had shown less distractibility, nor a real degree of trainability; she had merely continued at a thing familiar by this time which she could have done in the first place had she been held to it strenuously enough. By this time her teacher felt that a new set of material might profitably be introduced into the teaching procedure. The Witmer cylinders were used. Although obviously she failed in her first trial with this test the teacher reports: “On the fifth trial of the cylinders I had a perfectly terrible time to finish it. She would throw the blocks around, get up and start to walk away and do everything in her power to make herself a general nuisance. In the following Weeks we continued to work on the cylinders and she improved in that she knew how to complete it. But she showed no signs of attention or discernment and was always trying to force the large cylinders into small recesses and vice versa.’’
The teacher noted in addition that Martha definitely knew her colors, that is, red, blue, yellow and green. She could with some help count to twelve, and when the teaching was discontinued after six weeks she could count to fifteen. She was unable to recognize letters. Because poor visual discrimination for form was suggested in most of her performances her teacher tried to teach her letters by a kinesthetic graphic method. Martha did show some improvement here: she learned finally to draw 011 the blackboard two semivertical lines, and a crossed one in the middle, to form the letter A, but she seemed never to join the lines in an apex at the top. There seemed to be the “feel” of the letter, but it had 110 significance to the child, and the movement could not be transferred successfully to writing on paper. I11 her cut-out work (though her mother here stated that she thought the child quite adept) there was little or 110 semblance of form in what she produced.
In addition to these simple tasks, Martha’s teacher stressed better walking. The child had each day to walk a certain distance with her heels down, a task possible of execution but ignored because it was so little stressed except in the Clinic. Here the child showed a slight tendency to improve, and we believe that were such procedure emphasized daily by those in the home the child might improve greatly in this respect. Emphasis was placed as well on the drooling at the mouth. Here the teacher sought to develop in the child a sense of personal responsibility for her own cleanliness to replace the dependence she had upon others, to remind her that her “hankie” was needed. In this teaching we were unsuccessful, yet the improvement in her walking suggested that the child could learn a task more simple than that, and the fact that she was so well trained to obey the suggestion on the part of another that she wipe her mouth indicated that perhaps she would be further trainable in this habit.
The teacher reports: “During the last two hours of clinic teaching, I tried to do a bit of reviewing. I gave her both the Witmer formboard and the Cylinders. Her performances were qualita76 THE PSYCHOLOGICAL CLINIC tively far better than they had ever been. She went about doing them in a very satisfactory manner and recognized her mistakes immediately. Quantitatively the performances were bad, because of her lack of attention and inability to concentrate. I then reviewed the few letters that I had taught her. (She) … knew A and T and I perfectly. C and 0 were half-learned. She knows 1 and 7 perfectly and had a vague idea as to how to make 2. In this review … (she) … showed some improvement in her walking which, when called to her attention, made her even more conscientious and she didn’t do so badly. She knew her colors, she remembered the names of a few objects, and she could count to fifteen.” In the terms of analytic diagnosis it was clear that the child had evinced nothing of an intellectual sort during her contact with us, except the occasional lucid query she would direct, and this seemed to be founded less upon a curiosity than upon the same type of chance response with which all her behavior was characterized. Her lack of control permitted her to act spontaneously always, and it was the chance use of language along with that of gesture which made her questions appear pertinent. At best, they were those of a child of three who sought to possess and do that which was new, rather than to know. We do not mean that the child lacked comprehension, for she seemed to understand spoken directions, although she lacked the ability to understand their import, in terms of their indication of a task to be done. Her discernment was not of an intellectual sort, though her improvement with such material as the making of letters would suggest that it might become so in a crude fashion. Certainly she lacked the persistence to do even a simple task independently. She could talk, babble incessantly, grasp for a thing, and hold fast to what she wanted, but with a task set before her which was unpleasant, or one which demanded the attention she would prefer to direct upon something more to her taste, there was no evidence of the persistence required to complete it in even an elementary way. “We believe that were it not for the always wandering attention she might have demonstrated some motivation of a constructive type. Certainly she possessed motivation, but it was so multiple in its manifestations due to the deficit of control and directing power that it was not productive. She was ever active, physically and mentally. Quick to respond to a pleasant situation, alert to an environment that might furnish a temporary source of entertainment, there was some degree of intelligence manifested. This, we believe, was her long suit, though in the face of her physical handicap and the tremendous exertion that would be required to compensate for it, the suit was not long enough. Efficiency was impossible from a physical standpoint, and to develop that type of efficiency which is characterized by mental production would assume a degree of mentality which was not hers in the first place.
We could do little more for Martha at present. She was too young to profit from schooling, too strange in her behavior to be left alone. The chance that she would ever be able to shift for herself seemed quite negligible; if she had had the physical capacity she might have been able to do so. In the civilization about us there are individuals, possessed of no more mental ability than Martha has, producing enough to keep them alive, independently. They do it by means of physical activity, the privilege of engaging in which has been denied to Martha since birth. Education as it is administered to most children would avail her nothing?she might some day, perhaps, have been able to learn the work of the first grade, but it could have been of practically no value to her. Hers was a case of borderline mentality,?deficient largely because of her physical handicap. Constant supervision was the unhappy recommendation: perhaps the attempt to teach her a few letters and words, to dress herself, to keep herself tidy. School in a year or two to keep her occupied; play with other children who would be kind but not too kind to her; discipline, most of all, so that the burden of the misfortune might not forever rest only upon the shoulders of her parents. In the fulfillment of this last recommendation would seem to rest the opportunity that the child would have to become an individual, to become independent in any way, and to divorce herself from the level of the three-year-old, whose life is so entirely self-contained.
III. Freda Freda came to us late in the spring of 1930. Her mother had learned of the work of the Psychological Clinic with problem children in one of the radio programs offered by the Department of Psychology during that year. Freda had been having difficulty in school, particularly with arithmetic, and in the opinion of the school the progress she was making at the time did not indicate normal promotion through the grades above.
The marriage of which Freda was the only child was a second one for both of her parents, who were born in Germany. The father, a baker who had been in the same place of business for eighteen years and thus must have been a steady sort of man, had had three children by his first marriage. These ranged in age from twenty-two to thirty-eight. The youngest of these was a girl who, as a nurse, had to spend most of her time away from home. Another of Freda’s half-sisters had married and given birth to four children, all of them feebleminded. The health of both parents at the time of Freda’s examination in the clinic was described as good.
Freda was eight years old when examined. Her mother told us that her birth was normal, and that the child had always been in good health, although she had been inclined to “nervousness.” At thirteen months the child walked, and she talked as early as sixteen months. At two years of age she became clean. The only disease of which there was record was a mild case of measles. Tonsils and adenoids had been removed. After spending a year in kindergarten Freda had entered the first grade at the age of six. She made normal progress through the sections of that grade, and was promoted at the end of the year to the second grade. For the year preceding her examination she had done work that was below average, but satisfactory enough to warrant her promotion into the third grade soon after her first appearance at the Psychological Clinic. Although the school evidently considered Freda’s work adequate to justify promotion from grade to grade, they gave her consistent marks of failure in arithmetic. Freda’s mother realized that greater difficulty lay ahead in spite of the fact that she was promoted; and because she believed Freda’s ability to be greater than would be judged by her marks, that she was capable of better work than she was doing, she brought the child to us for our opinion.
In the psychological examination made by Dr Murphy, Freda proved herself to be inferior in general competency to about seventy per cent of children at her age, superior, however, to ten per cent. In both of her trials on the Witmer formboard she was inferior to forty per cent of first grade children, and in the lowest decile of children at ten years of age. Her trials on the Witmer cylinder test placed her in the lower fifty per cent of first grade children, and again in the lowest decile of children at ten. On the two trials of the Dearborn formboard Freda proved herself to be inferior respectively to eighty and ninety-nine per cent of girls ten years of age. Compared with first grade children as regards her memory span, with an auditory forward span of five the child was inferior to twenty per cent, and with a visual span of six inferior to but one per cent. These spans as compared with the norms for girls at ten years of age are inferior respectively to fifty and sixty per cent. In her reverse auditory span, however, the child fell down, for here she was inferior to forty per cent of first-graders, and to ninety-nine per cent of girls at ten years. The inferiority of her rating on this test as compared with her ratings on the test for forward span will be emphasized further, for it proved to be of significance from the diagnostic point of view.
On the Stanford Revision of the Binet-Simon Scale Freda was found to have a mental age of six and one-half years, which, with a chronological age of eight years, gave her an Intelligence Quotient of 81. The results of tests for school proficiency showed Freda to have second grade ability in reading and spelling, although the need for drill Avas evident in her performance with the latter. She had so little ability in arithmetic, however, that it could not be granted even a first grade rating.
The psychological examination, the results of which Ave have listed above, indicated that Freda was of normal mentality, but that she was inferior to at least 60 per cent of children at her age. These results help in a large measure to explain her difficulty with school work, but they suggest that with some well-concentrated instruction in the fundamentals of reading and spelling, but particularly in those of arithmetic, the child should be able at least to do the work required in the third and perhaps the fourth grade. There was little in these results to indicate the need for clinic teaching of a diagnostic sort. What was more significant than anything we have so far mentioned was the striking personality picture. We read in the report of her examination: ” (Freda) presented an unusual and interesting appearance. When first seen in the waiting room of the clinic she looked like a boy… . (She) had a very pleasant smile, … alert blue eyes, and blonde hair … cut like a boy’s. Her complexion was fair. Her mannerisms, method of walking and the use of her arms and hands seemed more masculine than feminine. She wore boy’s clothes, except for a skirt, hidden by a boy’s coat, and her whole appearance was that of a boy rather than a girl. Her mother knows that (Freda) looks like a boy. She says that (Freda) will not wear girl’s clothes or have her hair grow. She refuses to play with dolls or girls. She plays cowboys and Indians, also soldiers. Slie likes guns and wants to be a soldier. When asked about her appearance (Freda) says, ‘I am not going to let my hair grow’; ‘I won’t wear ruffles’; ‘Girls are sissies!’; ‘I won’t play with girls’; ‘I don’t like dresses.’ Her mother says that since she began to walk she has been like a boy. Her interests and desires appear at present to be masculine. She cannot dress herself. She never helps her mother… . (Freda) showed signs of resentment occasionally when it was suggested that she let her hair grow or that she wear girl’s clothes.’’ It was the personality picture of Freda in combination with her educational retardation which suggested the advisability of diagnostic procedure covering a greater period of time. Dr Murphy believed that the clinical picture was of such peculiar nature that it merited further observation. Certainly the diagnosis of homosexual tendency, which first came to mind, could not be made without much more evidence. He felt also that an attempt, at least, should be made to develop in the child the interests of a girl, to guard against the increasing influence of a dangerous trait in the girl’s personality.
In October, as had been recommended in May, Freda was enrolled for clinic teaching, two one-hour periods per week. She was placed under Mr. Harold Susskind and Mr. John Bernheimer. The child attended clinic regularly for about seven weeks, receiving in all thirteen teaching hours.
Freda’s teachers also noticed the striking similarity of her appearance to that of a boy. We read in their report: “Her appearance … was striking. Of normal height … and weight … the most arresting feature was her phenomenal resemblance to a boy. When (Freda) was presented to her teachers, both immediately thought her a boy. Her hair was cut in a boy-bob. She wore a shirt and tie. Her skirt was so pleated as to create the illusion of trousers. She had on boy’s stockings and sport shoes. She swaggered like a boy, and when she sat at a table she cupped her chin (like a) boy. All in all she presented a most remarkable picture.” A brief re-test was given Freda in the first hours of teaching. No improvement was found in the memory span. On the Stanford Revision she received an Intelligence Quotient of 77, not much lower than that given her in the original examination. Her teachers found her school proficiency to be as poor as it had been estimated, if not poorer. Instructed as they were to observe her parSTUDIES IN DIAGNOSTIC EDUCATION 81 ticularly in arithmetic, tliey found that she could scarcely count to twenty. Her addition was fair, as was her multiplication, but in subtraction and division she was a failure. Early in their teaching they found that they were unable to teach the child to give a reverse memory span of more than two, whereas, in relation to her forward spans, they felt that it should have been three, if not four. This deficiency in the ability to reverse, they felt, might account in some part for her disability in subtraction and division, for it demands the same type of organizability as is required in the performance of these operations. She had been unable to count backwards from twenty to zero when tested on the Binet-Simon Scale, and they found now that she could not count backwards even from ten to zero. Asked to perform this feat, the child would give back all the numbers in the series, without repeating any one, but she could not re-present them in the correct sequence, and was unable to do so until she had had thirteen practice trials. Even after this successful performance, she was unable to give them again with any degree of certainty, as if she knew what she was supposed to do. She seemed to lack what her teachers termed the ability to “reason backwards.’’
Her teachers sought further to develop this diagnostic point by presenting to Freda a list of ten three-digit numbers, reading them as, for instance, two-forty-six, five-thirty-nine, four-seventy-five, and so on. The list was repeated three times. The result was that on every trial of this makeshift test the girl wrote the numbers as dictated on the board with the second and last digits reversed: 246 she wrote 264, 539 she wrote 593, 475 she wrote 457. With thirty numbers presented the child wrote correctly only three, or ten per cent. This experiment was re-tried at intervals through the teaching, and each time the result was the same. They had noticed earlier that when words were dictated orally for the child to spell in writing, although she knew the correct letters and number of syllables for many words, she would stand at the blackboard for long periods of time, experiencing difficulty in setting down the letters in the correct sequence. An auditory confusion of a specialized sort was evident. This explained the deficiency in reverse span. Hers was a short-lived perseveration, easily disturbed by the necessity for conscious intention, as required in the organization of units in a specific way for the reverse span, or for the utilization of letters in a specific way for spelling words. She was able, however, to give back instantly a relatively long series of discrete units, in the same order, as she had demonstrated in her performances with the forward spans. Auditory perseveration was not entirely lacking but there was a lack of auditory imagery. This deficit in imagery, plus her demonstrated lack of ability to organize, was so evident throughout all of our contact with Freda that it seemed entirely reasonable so to explain her difficulty in arithmetic.
Very little was accomplished in the attempt to teach Freda subtraction. She profited to some degree from drill in counting, in simple addition combinations, and very slightly in subtracting simple combinations, but her educability proved to be so low that the hope for progress in arithmetic is very slight. AVith a low general competency difficulty in all subjects could be predicted. It seemed unlikely that she would ever be able to do third, or at best, fourth grade work. Her discernment for such material as numbers and letters was not lacking except when the material was presented to her for auditory perception and retention. Her intelligence was low, and although her persistence was demonstrated to a degree almost abnormal in the remarkable amount of patience she displayed, it was not productive in the sense of its being intelligently directed. Lacking as she was in power of comprehension, the prognosis for school work was unfavorable. The results of clinic teaching as thus far described would indicate an unhappy picture for Freda, for in the attempt to improve her status in one of the deficiencies noticed when she was examined, namely arithmetic, we had done little or nothing. In respect to her other deficiency, however,?that in the field of social conformity?a great amount of improvement was shown. Her teachers through interviews with the mother, through casual as well as pointed talks with Freda, through the application of drastic disciplinary measures, through the attempt to inspire within the child the confidence in themselves which was imperative if ever they were to get at the bottom of her difficulty in conforming to the accepted standard, amassed data which removed quite definitely the suspicion of a fundamental homosexual motivation. They found that influences upon the child’s life had much to do with her behavior in this respect. Freda’s mother, it was learned, actually encouraged the child in her masculine preference in clothes, companions, manner of behavior, and so on, although she denied this when the child was first examined. When asked what she did when Freda dressed in boy’s clothes, as she often did, the mother answered, ‘41 say, ‘ Off mit dem pants.’ ” It was found that in the neighborhood in which Freda lived there were many more boys than girls, and that for a girl fundamentally as sociable as Freda there was little to do but join in with the boys in their games, if they would have her. She learned quite naturally to talk as they did; she swore as healthily as the best of them; she grew used to their toys, their interests, their manner of living. The first step taken by her teachers in the re-education of Freda in regard to the development of femininity was to call the girl from the start in all their contacts with her “Miss Freda.” Mother as well as daughter was not only instructed, but commanded, to change in her attitude: to let the child’s hair grow, to cease the use and endorsement of all language which could not be called lady-like, to replace guns and soldier suits with jacks and pretty dresses, to continue the child’s play with boys but to see that it did not exceed the amount of play with girls, and to have her play, when with boys, as if she were indeed a little girl. When Freda broke faith with these precepts while in clinic she was punished severely, for it was soon recognized that the child was far more responsive to the discipline of the traditional German home than she was to the rational exposition of her errors in order to bring about an intellectual appreciation and penitence.
One day about three weeks after the teaching began, Freda burst out in anger over an error she had blunderingly made in one of her problems, with ” … damn it!” Punishment was immediate. She grew penitent, was silent for a moment, and then burst out, “I know why I swore before. It’s because the kids around the neighborhood do. The other day, only, I was playing with some kids in front of the house and one of them said ‘Hell!’ So my sister came out and said, ‘You kids get the hell away from here, or 1 ‘11 report every damn one of you.’ ” It was evident that though such language and manner of expression were probably not actually encouraged in the home, at least they were tolerated to the extent that they quite naturally influenced the child. Freda’s mother was told definitely to see that such language was not used in the presence of the child. The treatment was effective, and the transformation it brought about, even in the few weeks during which we observed Freda in clinic, was indeed remarkable. In six weeks’ time a little girl was reporting to us in place of the hard-boiled boy who appeared in October. Here was a child with the interests of a girl, dressed in girl’s clothing, with not-long-enough-to-put-up hair, yet hair dis84 THE PSYCHOLOGICAL CLINIC tinctly not that of a boy, already broken in some measure of her boyish walk and her masculine manual expression. Perfectly normal on the scale of social competency, the problem had indeed been an orthogenic one. Had we subscribed to an unduly theoretical consideration of the child’s sex life, we should have delved into her inner life, and found there mechanisms grave and fatal and foreboding. We chose rather to present the healthy and happy side of the girl to her, for her consideration. We sought to direct her interests toward feminine goals, to develop within her a respect for girlhood, but more than that, to uncover a pride in the fact that she was a girl rather than a boy, and that it was her duty to behave in a manner which this responsibility implied. Freda’s was a pleasing personality; what it needed, and needed badly, was the conviction that it was to be preserved by an encouragement of the normal and healthy, rather than disintegrated by the stimulation of a pattern which was not rightly hers, and the conformity to which could have resulted only in misunderstanding and grief as she grew older.
Freda was unquestionably not of the intellectual type. For her capability there is a future of sewing and cooking and housewifery, ?the responsibility, perhaps, of motherhood. She will never read grave books and compute columns of figures. Her development must be along social lines, not so ambitious that she will learn to want that which is impossible for her, but sufficiently wholesome to provide the fullest possible cultivation of her natural charm as a girl, and later as a woman.
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