The mental health of the school child, the psycho-educational clinic in relation to child welfare

Front matter

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THE MENTAL HEALTH OF THE SCHOOL CHILD

Preface

The publication of these papers and addresses in a single volume was prompted, first of all, by the widespread interest which is rapidly manifesting itself in all sections of the country in the grave social and educational problems which spring from the presence in every populous community of large numbers of mentally abnormal children. It is now generally recognized that many of the most vexatious problems in our present-day social economy are somehow bound up with the mental and educational abnormalities of childhood. Educators, physicians, sociologists, penologists, criminologists, lawyers, clergymen, philanthropists and parents, therefore, welcome any attempt to gain deeper scientific insight into the nature, extent and causes of the mental, moral and educational arrest, deviation or deficiency of children. The papers included in this collection aim to show in slight measure the aid which the practical psychologists and expert educational consultants hope to render in the important work of diagnosing, identifying, studying and training feeble-minded, backward and mentally abnormal children in the schools.

During the last three or four years the writer has published a number of experimental memoirs, articles and addresses in American and European periodicals dealing, from different points of view, with a common theme : the scientific study and the care and improvement of the mental and physical misfits in the schools, or, in a word, the conservation of child life. These studies when brought to a focus form a fairly unitary, but by no means a sym-

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PREFACE metrical or systematic, whole. The more systematic treatment of the study and training of mentally unusual children is reserved for later volumes. A practical motive for bringing together the studies of this volume is the fact that the demand for reprints has exhausted the supply of several of the articles.

Most of the chapters of the book are reprinted, with the kind permission of the editors, from various periodicals. Several of the reprints, however, have been so completely revised that they constitute, in effect, new contributions, while the new chapters added contain important data which have recently been gathered at first-hand and which are nowhere else available.

A certain amount of repetition is ordinarily unavoidable in the pubhcation of a series of scattered studies which deal with very closely related topics. While many articles have been considerably abbreviated and others somewhat expanded — sometimes to the detriment of the unity of the individual articles — in order to avoid needless iteration, certain repetitions have been designedly retained, because there exist today among both lay and professional workers serious and widespread misapprehensions regarding the aims, functions and administrative affiliations of the psychological or psycho-educational clinic, regarding the qualifications of Binet testers, amateur psychologists, professionally trained clinical psychologists, 'special' teachers, nurses and physicians. Owing to these misconceptions we are today tolerating and fostering a type of work in apphed psychology which often is scientifically barren and sometimes positively pernicious. Clinical psychology promises to make a very important contribution to the world's sum total of knowledge, but it is in its infancy, and, therefore, its development needs to be guided

PREFACE ix

into channels that are in accord with the highest standards of scientific work. In view of the present situation — a situation which in many sections allows almost anyone to pose as a psychological or educational diagnostician — I believe that no apology is necessary for the repetitions which have been retained in this series of selected papers, or for the emphasis which I have given my most cherished convictions.

January, 1914.

Chapter I Medical And Psychological Inspection Of School Children'

The question as to the need of the inspection of school children for the detection of contagious and communicable diseases (e-g-, diphtheria, scarlet fever, measles, whoopingcough, chicken pox, smallpox, tuberculosis) may be said to be closed. All intelligent observers are agreed that the schools, unless properly medically supervised, may, and frequently do, become virulent foci for the dissemination of fatal community diseases. As a matter of fact, all enlightened urban communities in this country and in Europe have recognized this imperative need by providing some form of school inspection for the contagious child diseases. The modern school medical-inspection movement, indeed, began as a form of inspection for infectious diseases by officers of Boards of Health.

But there is another function of school medical inspection which is even more important for the proper development of the individual child, though this function is not so generally recognized; namely, the physical examination of school children for the detection of physical defects : defective vision, defective hearing, defective nasal breathing, adenoids, hypertrophied tonsils, cardiac diseases, defective teeth and palate, malnutrition, orthopedic defects, tubercular lymph nodes, lateral curvature of the spine, stoop

1 Reprinted, with extensive alterations, from The Western Journal of Education (now The American School Master), 1909, pp. 433-446.

shoulders, nervous exhaustion and pulmonary disease. We are just awakening to the necessity of this type of pupil inspection because we are just beginning to realize the extent to which cliildren are physically handicapped. The statistics of defective children, wherever gathered, are fairly appalling. Space permits reference to only a few American surveys.

Of more than 5,000 school children examined in Los Angeles, 61 per cent suffered from defective eyesight, 31 per cent from adenoids, 25 per cent from enlarged tonsils and 22 per cent from defective hearing. In Chicago in 1909, 123,900 children were examined (this was not an ultimate examination, only the major defects being noticed), and of these 36 per cent had defective teeth, 22 per cent enlarged tonsils, 13 per cent enlarged glands, 5.5 per cent nasal defects, 3.5 per cent adenoids and 2.3 per cent hearing defects. In another examination of 3,963 cliildren in the same city 60 per cent were said to need the attention of a physician, the most prominent defects requiring treatment being hypertrophied tonsils, enlarged glands and adenoids. Seventy-two and three-tenths per cent of 230,243 children examined in New York City in 1911 were reported as requiring treatment. The percentages of defects found were as follows : Defective teeth, 59 per cent; hypertrophied tonsils, 15 per cent; defective nasal breathing, 11.9 per cent; defective vision, 10.6 per cent ; malnutrition, 2.5 per cent ; cardiac disease, .7 per cent ; defective hearing, .6 per cent ; orthopedic defects, .5 per cent; chorea, A per cent; pulmonary disease, .4 per cent; tubercular lymph nodes, .2 per cent. Of 1,442 children, largely of Irish, Jewish and Italian stock, examined in three schools in this city in 1908, 73 per cent suffered from defective teeth, 59 per cent from nasal breathing, 42 per cent from visual defects, 39 per cent from hypertrophied tonsils and 15 per cent from anemia. Based upon another medical census of 23,000 children in all grades, the following distribution was found at the ages of six and fifteen:

At 6 years At 15 years

Defective teeth 65 per cent 31 per cent

Enlarged tonsils 40 14

Enlarged glands 40 7

Defective breathing 23 9

Defective vision 17 26

About 80 per cent of these children were physically defective in some way. Gland, mouth and throat troubles, it will be observed, are typical cliildhood infirmities, while defective vision (as well as defective teeth) constitutes the bane of youth. In Worcester, 758 pupils examined in two elementary schools showed enlarged glands in 64.5 per cent of the cases, affected tonsils in 37 per cent, adenoids ('suspected') in 21 per cent, eye defects in 15 per cent, anemia in 4.5 per cent, poor nutrition in 5.5 per cent, medium nutrition in 36 per cent and good nutrition in 57.5 per cent. Decayed teeth were found in 86.5 per cent of the pupils, the average number per child being 4.85, and the corresponding averages in the different grades (given in order from the first to the ninth grade), 7, 6.54, 6.08, 4.90, 4, 3.50, 4, 4 and 3.66 per pupil. There is a noticeable falling off in the five upper grades. The figures show a wide variation from grade to grade in some of the defects. Of over 50,000 pupils examined in the public schools of Cleveland, 62.5 per cent suffered from one or more physical defects; and of 1,284 pupils examined in about equal numbers in a congested section and in the east end

(where the hving conditions were more favorable), 18.5 per cent of the former suffered from various kinds of defects as against 28.4 per cent of the latter. Of 156 pupils examined in the seven grades of the school of observation connected with the Summer School of the University of Pennsylvania, 38.5 per cent had decayed teeth, 20.5 per cent suffered from eyestrain, 13.5 per cent from nasal obstruction, 5.1 per cent from defective hearing and enlarged tonsils, 4.5 per cent from poor nutrition and 2 per cent from nervous exhaustion and stoop shoulders. It may be assumed that these children came from the better social ranks. A survey of a special class of 41 Philadelphia retardates — these pupils assumedly came from the lower social strata — yielded 48.7 per cent of eye defects, 34 per cent of defective speech, 26.8 per cent nose and throat troubles, 19.5 per cent nervous temperaments, 17 per cent each of orthopedic defects, lack of motor control and hearing defects. Of the children examined in Jefferson City, Missouri, for eye, nose and throat troubles, 41 per cent were in need of glasses, while 7.7 per cent had defective hearing, usually in one ear. In the rural districts of St. Louis County, 30.6 per cent of the 2,000 cases examined had subnormal visual acuity in one or both eyes, 14 per cent had less than two-thirds normal vision and 3 per cent less than one-half normal vision (these figures do not include hyperopia or mild astigmatism), 7 per cent had defective hearing in either of the ears, somewhat less than 2 per cent could not hear a whisper with either ear and .9 per cent were seriously troubled with adenoids. From a study of twenty-five Massachusetts, New York and New Jersey cities Rapeer^ estimates that the percentages of serious defects requiring treatment 2 Rapeeh. School Health Administration, New York, 1913, p. 226.

among elementary pupils are as follows : dental defects, 66 per cent; visual defects, 7 per cent; enlarged tonsils, 6 per cent ; adenoids and nasal obstruction, 5 per cent ; malnutrition 2 per cent; anemia and enlarged glands, 1 per cent ; spinal curvature, .8 per cent ; strabismus, .7 per cent ; hearing defects and weak lungs (not tuberculosis), .5 per cent and nervousness, .2 per cent. (See also Chapter XVI.)

School medical inspection statistics, which are now available from the examination of millions of pupils in all sections of the country, show clearly — in spite of the unreliability of many of the reports — that physical defects in children are not restricted to any clime, race, environment or social condition. The children in sunny Southern California no less than the children of the cold or humid North, East and West, the children of the country no less than the children of the city, the children of the rich no less than the children of the poor, labor under various forms of physical handicap which are usually subject to melioration or cure. It is impossible to estimate the percentage of physically defective pupils even with approximate accuracy, because the standards of the examiners differ very widely and because some defects increase with age while others decrease. Any reliable inspection surveys must be made in relation to age. My own estimates, based on the study of numerous statistical surveys, of the percentage of grade pupils seriously affected with various defects are as follows : defective teeth (one or more cavities, serious malocclusion), from 50 to 95 per cent ; defective vision and adenoids and nasal obstruction, from 5 to 20 per cent ; seriously enlarged or diseased tonsils, 5 to 15 per cent; curvature of the spine, 2 to 7 per cent ; malnutrition, 1 to 6 per cent ; weak or tubercular lungs and defective hearing, 1 to 2 per cent. It is estimated that 12,000,000 of the pupils in the public schools of the country are to some extent handicapped by one or more physical defects. The typical American school child in the grades everywhere suffers more or less from some form of physical defectiveness. Sometimes the defects are so numerous and serious that the child's body is but a tissue of malfunctioning, misshapen, diseased or disordered organs.

The defective condition of the physiques of our pupils must be a matter of very serious moment to all people who have the welfare of children at heart. The parent cannot fail to be concerned about conditions which cause discomfort, restlessness, pain or disease in his children. The school administrator and teacher must be vitally interested in any conditions which may cause irregular attendance or impair the pedagogical efficiency of the learner. Likewise the city and the state, because they have made large investments in school plants and school paraphernalia and have appropriated large sums for the support of teachers, have vital interests at stake which must be rigorously conserved. They have set children apart for a long term of years and have thereby denied them the opportunities of engaging in productive labor. This they have done in order to provide for the children such mental and bodily training as will eventually so increase their productive capacity as to insure them increased returns upon their investment of time and energy. In order to guarantee its own perpetuity the state demands an output from the schools that shall manifest a capacity for social and industrial efficiency, and any obstacle to the attainment of this end must be removed. The state demands, as of right, that it secure adequate returns upon the investment of money and human sacrifice which it has made in the interest of the schools.

But are the schools under existing conditions able to meet this just demand imposed upon them by the state? Manifestly not, for numerous investigations have shown that there is a veritable army of handicapped pupils in the schools who are unable properly to profit by the instruction. The slow-progress pupils outnumber the accelerated pupils eight to ten times (the average for twenty-nine cities), while over one-third of all the elementary pupils are pedagogically retarded (see also Chapter II). A certain amount of this pedagogical retardation is undoubtedly due to physical defectiveness. This would seem to be so on a priori grounds, for the body and the mind are indissolubly knit together. They are merely two aspects of the same unitary Hfe process. There can be no psychical activity without a correlated physical activity, no psychosis without a correlated neurosis. When the physical machine is crippled the mental mechanism cannot as a rule work harmoniously. Rarely, perhaps, does the mind reach its highest potential so long as the bodily organs function defectively. It is impossible by ordinary school processes to make defective sense organs to function properly. That physical defects often constitute a positive deterrent to normal mental action and thus produce pedagogical retardation has been shown by various observations and statistical and experimental studies. Those studies are discussed at length in Chapter XV (which see).

It is true that in some investigations no marked correlation between physical defects and retardation in school progress has been found. This may sometimes be due to the fact that the dull, physically defective child has been pushed along irrespective of his merits, or to the fact that the progress of the whole class has been adjusted to meet his needs ; or the factor of age has complicated the question; or physical defects have been included which exert no influence upon neuronic and mental development. But it is certain that one of the causative factors of retardation and elimination (retardation usually results in elimination) is physical defectiveness.

Not only so : the physically defective child tends to become the juvenile criminal. For the physically defective, who tends to make the dullard, becomes dissatisfied with himself and discouraged with his school work and thus plays truant or permanently drops out of school. In one investigation over 95 per cent of truants were found to have physical defects. In many cases these eliminated physical defectives become the street vagrants or loafers ; and the loafers are the embryo criminals. Ninety per cent of criminals began their careers as truants or loafers, according to A. J. Pillsbury. Undoubtedly there is frequently a direct relation between physical defectiveness and moral perversity and youthful criminality. Much precocious criminahty is traceable to physiological maladjustment.

The physical examination of school children would thus seem to be one of the important present-day public duties. It is false economy to allow the progress of whole classes to be impeded by the presence of pupils whose physical defects make it impossible for them to keep step with the normal procession. The mere removal of a physical obstruction will sometimes revolutionize the life history of a child, while years of mental training, with all their attendant strain and depression may accomplish practically nothing for physically handicapped children. The first step in mental training should be the removal of those physical obstructions which stand in the way of the free, spontaneous activity of the mind. Nor is this work needed for the sake of the self-protection of the classroom ; society must assume the work for the sake of its own self-protection. A cliild abnormal in body probably cannot remain normal in mind; he will tend, as has been said, to become morally perverse and criminal. Civilization is thus coming to face a new menace in the presence of rapidly multiplying multitudes of physically defective children in every community. Instead of penalizing and trying to reform the child after he has developed his degenerate tendencies and committed his offense, would it not be more sane for society to turn right face about and remove one of the causes of the young child's perverse tendencies before the latter have become ineradicably ingrained ? This can only be done through the school medical clinic and dispensary. The day will come when the first tiling the schools will do for the first-day entrant will be to give him a thorough physical examination. 'First the natural ; afterward the spiritual.'

That the American public is rapidly becoming awake to the necessity of providing for the inspection of physical defects in school children is apparent on every hand. Although school medical inspection started in this country only about nineteen years ago (Boston appointed fifty school physicians in the fall of 1894; Chicago followed in 1895, New York in 1897 and Philadelphia in 1898), and although thirteen years ago only eight cities had established medical departments in the schools (but without the school nurse), the development has been so rapid during the last decade that in 1911 443 cities (or 42 per cent) of 1,038 cities reporting were supporting departments of school medical inspection or school hygiene (but only 214 were providing 'physical examination by doctors') — this according to a report of the Russell Sage Foundation — while in 1912 nine states had mandatory laws and ten states had permissive laws in regard to school health work. Nevertheless, fully half of the cities of the country are either making no provisions whatsoever or very inadequate provisions for the routine physical examination of school children, while the rural districts are doing practically nothing (Minnesota, Michigan and Virginia employ specialists to visit the rural schools, in order to instruct teachers in school and child hygiene). Very few school systems conduct dental and medical dispensaries for the free treatment of certified indigent children, while only seventy-six cities (in 1911) supported staffs of school nurses and eighty-nine cities employed school dentists. We are still lagging behind Europe, where the school physical examination work had its inception (Sweden appointed school physicians for every secondary school in 1868, France organized departments of medical inspection in 1879, while Germany followed in 1889), and where it has been organized in some countries as a function of the national government, notably in France, Germany, England, Norway, Belgium, Switzerland and Sweden. In England and Wales the Education Act of 1907 makes school medical inspection compulsory and universal (even in the most remote rural districts). The work is conducted by 317 local educational authorities, who employ 943 school medical officers, and is under the administrative control of the Chief Medical Officer of the Board of Education for England and Wales. Every child is given a routine physical examination at the time of entering and leaving school (an intermediate examination at the age of eight will be required after April 1, 1915), which includes an examination of the special sense organs, the heart, lungs, lymphatic system, height, weight and personal and family history. Not only so, in 1913 the educational authorities had established ninety-five medical clinics and fifty-eight dental clinics for the free treatment of minor ailments and physical defects (exclusive of thirty-eight cHnics which provide X-ray treatment for ringworm).

The campaign for the establishment of school medical and dental clinics in the United States must go on until the work has been made compulsory and universal. Not only so, dispensary dental and medical clinics should be established by schools for the free treatment of certified indigents, and nurses should be appointed for examination and follow-up work, for treating and instructing the affected pupils and for socio-hygienic service in the homes. For the work of diagnosis will be largely worthless unless the correction or mitigation of defects can be secured. Moreover, it is not sufficient merely to mitigate or correct the physical defects in the clinic ; the success of the treatment will often depend on the subsequent physiological and mental habits of the cliild. The effects of the removal of adenoids and enlarged tonsils are often rendered nugatory because proper breatliing exercises are not subsequently followed. Since the schools (through their teachers, nurses and medical inspectors) are in a position to follow up and properly supervise the child after treatment, it seems desirable to treat all the minor ailments and defects in a school dispensary. The time must come when physical reclamation work will be recognized as one of the regular, fimdamental duties of the city and state school systems.

Incidentally it may be pointed out that the qualitative standards of many medical inspectors must be elevated if our highest hopes for child betterment from this service are to be realized.

But a further step must be taken in order to supplement and render effective in the highest measure the results of medical inspection and treatment and of pedagogical training. That is the psychological inspection of our large army of mentally exceptional school children. We do not know the complete status of the child when we have merely examined his bodily aspect by the available instruments of precision. The child possesses a mental aspect which needs to be just as thoroughly explored by instruments of precision. For the mental examination the instruments and the methods of medical inspection do not suffice; this work requires a technique of its own. Thus it is important to know how the child's motor functions vary, in respect to strength, steadiness, power to coordinate and speed of reaction ; how his powers of memory, association, imitation, adaptation, observation, attention, judgment, reasoning, speech, abihty to withstand fatigue, pressure and pain thresholds, perception of color (color blindness) and intellectual level vary, etc. Until such facts as these are known, we can have nothing but the most general knowledge of the child's mental constitution. Only by tests of this nature will it be possible to reveal striking departures in fundamental mental make-up ; only thus will it be possible to determine whether the mental variations in a given child are of the nature of aberrations or abnormalities. And only when this knowledge has been obtained will it be possible to make the training of a mentally defective or unusual child scientifically accurate, because the training of exceptional children must be adapted to the exigencies of each case ; it must be made to fit the special needs of every special child. In the absence of thorough knowledge of the child's mental peculiarities instruction must remain a hit-and-miss process. So far as the teacher is concerned, medical inspection and treatment yield knowledge of minor importance for her guidance. Medical treatment is, of course, primarily of value to the individual pupil. It is a means of freeing him from his physical impediments, so that heredity may come to her own. And it is, indeed, a God-send to the schools in the case of the child whose abnormal physical functions impede educational progress. Nevertheless, the psychological examination yields knowledge more directly valuable for the teacher's guidance, because her work is chiefly with the child's psychical functions. In the absence of any exact knowledge of the pecuharities of the pupil's mind her work must blunder along with a mixture of happy hits and unfortunate misses. It is not sufficient that the teacher adapt method to subject-matter; she must also adapt method to the mind which is to assimilate the subject-matter — the latter being the more important in the case of the atypical child.

That the public is rapidly becoming awake to the necessity of segregating the atypical or special child is becoming increasingly evident. This need has been long recognized by the state so far as the idiots, imbeciles and low-grade morons are concerned. More recently this need has been recognized by about 350 cities which have established as an integral part of the school system so-called ungraded and special classes for the retarded, the seriously backward — for pupils whose mental cahber is superior to the feeble-minded but considerably inferior to the normal child — and for the feeble-minded. It is absolutely necessary that we segregate the subnormals in the public schools for at least two reasons: first, they constitute an intolerable drag upon the regular classrooms, impeding their progress and consuming more than their just share of the teacher's time ; and, second, by grouping subnormals together in small classes they may be given individual attention by the teacher, and, what is more important, be provided with a type of school work which fits their needs and which will maximally equip them for the socio-industrial responsibilities which they are able to assume.

Unfortunately the method of classifying and segregating [Subnormal children is in most cities in many respects pitiably inadequate. These children have almost invariably been segregated simply upon the classroom teacher's, principal's, superintendent's or medical inspector's recommendation, because they have been unable to furnish the required classroom output. They have not been subjected to a prior thorough scientific psycho-educational examination, except at the hands of amateur psycho-clinicists. The special teacher usually gets the laggards without adequate diagnosis, or with mistaken diagnosis. Without having any precise or adequate knowledge of their mental and educational abnormalities, she is expected to give them skilled differential pedagogical treatment. As a matter of fact, many special class teachers are simply shooting in the dark, and many administrators seem to feel that provided the teacher 'keeps eternally at' the laggards she is doing all that can be reasonably demanded of her.

In the light of the above facts, does it not seem the part of public wisdom and economy to establish in every school system a psycho-educational clinic for the educational and the psychological examination of all types of educationally misfit children.? Should there not be connected with every school system of any considerable size an expert clinical psychologist to supervise the examination and training of educationally exceptional children?

So far as relates to the medical inspection of all school children, departments have been organized in the schools of all the large cities of the country. But it must be conceded that so far as organized psychological inspection is concerned we have made only a beginning, even in the large city systems. True, a number of schools have done pioneer work of great intrinsic value in this line of endeavor, notably the Chicago public schools, which for years have conducted as an integral part of the school system a department of Child Study and Pedagogic Investigation. Many other city school systems are beginning to establish psychological clinics (see Chapter XVHI), but the work is usually conducted by medical inspectors or teachers who are profoundly ignorant of the detailed psychology and pedagogy of mental and educational abnormalities. This is, I feel, but a temporary stage in the work; eventually the schools will demand the services of competent experts for tliis work. The fact that many institutions for the feeble-minded have established psychological clinics and are demonstrating their value for the proper educational classification and treatment of their inmates, and the fact that many universities have established psychological clinics not only for the examination of cases but for the training of competent examiners, augur well for the rapid development of the public school clinic. (The Russell Sage Foundation has rendered some aid to the 'cause' by the compilation of retardation and elimination statistics, but it has done only a modicum of what, with its vast resources, it could be reasonably expected to do in the direction of establishing the normal mental norms which are so much needed for the more exact psychological diagnosis of mentally unusual children.) The school public will soon come to reahze that their duty toward the educationally exceptional child has not been discharged until, in addition to providing him with the advantages of medical inspection and treatment, they also supply the adequate machinery for determining his psychological and educational abnormalities.

The first line of psycho-clinical work undertaken by the schools should be the expert examination of the so-called laggards or dullards (more properly the feeble-minded and seriously backward). The laggard is the one who creates the grave administrative problems of the schools ; he it is who binds a millstone about the neck of the educational organism, who impedes the progress of the regular classes, who causes expensive repetition or early ehmination; who has bottled up within his self the concentrated mischief of the school community ; who gives little or no returns for the excessive demands which he makes upon the teacher's time and energy. The normal child, thanks to his hereditary endowment, is fairly well able to fight out his own salvation. In him nature will assert herself even in the face of untoward environing circumstances. I would not, of course, have this type of child neglected; he ought to be offered every facility to work at his maximal potential ; the normal and bright pupils are the children of greatest promise to the state. But as long as retarded children are permitted to encumber the progress of the regular grades we cannot do our duty by the gifted pupils. Our first duty, then, is the removal of the laggards from the regular grades: this is the 'Macedonian cry.' Any plan of psycho-educational inspection must first aim to reach the retarded children.