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The school medical officer and mental inefficiency in the child
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children under school age was very largely a financial one, and that obstacle was encountered at every point. Continuity of service from the time the child was a small infant to the time it left school was a factor the importance of which could not be overestimated. Dr. Macmillan had suggested there was difficulty in getting pre-school children to attend the clinic, but his ,own figures had shown that the trouble could be largely overcome. Similar objections were raised with school medical, and maternity and child welfare work, in its early stages, and any objection to the clinic for pre-school children would die down in the course of years. Dr. Sire \Valtace's views on the cause of dental decay were well known. He had said that in certain areas where dental decay was much in evidence, rickets was absent. It had often been claimed that rickets was absent in an area. Dr. M'Gonigle had been told that there were no rickets in the metropolis, but the medical officers of the London County Council had stated that there was something like 80
per cent. among the children. H a d the same standards been used in looking for rickets in other countries where dental decay was extraordinarily prevalent? Dr. Emslie had raised the question of Dr. Cassie's omission to include anaemia in her table. R e p l y i n g for Dr. Cassie (who had been unable to remain to the end of the meeting), Dr. M'Gonigte said it would be realised that the assessment of anaemia in y o u n g children was a very difficult matter, and that probably accounted for the omission. In conclusion, he held that, in child welfare work and in work amongst pre-school children, the medical officer must get away very largely from the point of being a doctor and, to be successful, must be a sort of super health visitor.
The
President (Professor
Harold
Kerr,
O.B.E.), on behalf of the Society, thanked the readers of the papers and those who had taken part in the discussion for their extremely interesting contributions on the subject of the pre-school child.
T h e S c h o o l M e d i c a l O f f i c e r and M e n t a l I n e f f i c i e n c y in t h e Child. By A. A. E. N~:WTH, M.B., B.S., D.P.H., Senior Medical Officer, City of Nottingham :Education Committee.
D
This paper, read before the East Midland Branch, will be enjoyed because of its" originality, enthusiasm and optimism. Ascertainment of Mental Defectives.--A E N T A L retardation is a question that
is very lara'eP¢ ~ h ~ concern of school medical officers. S o m e ]aa~ve to make dlagn o s e s . i n v d I v i n g legal responsibility in the more serious f o r m s of mental retardation. Every school medical officer has frequent opportunities of helping the teachers to salve from the"i:ubbish heaps of the schools the lesser retarded and sometimes misunderstood children so as to enable them eventually to become more or less efficient citizens. Mental abnormality is found in children in all degrees, from the incurable helplessness of the idiot to the temporary aberration of the genius. But while for legal and administrative purposes it is convenient to divide children into idiots, imbeciles, "mental defectives, dull, backward, a n t i normal, it should never be forgotten that there is no definite line of demarcation between these grades; they merge insensibly into one another and overlap to a considerable degree.
most definite duty was laid on the school medical service by the Mental Deficiency Act of 1913, which required every local education authority to ascertain the mentally defective children in their area and to provide education for them. This work was carried out in varying degrees of efficiency, and in 1928 Sir George Newman in his annual report calculated from the returns of school medical officers that there were 33,000 mentally defective children in E n g l a n d and Wales. In the following year the report of the Joint Committee of the Board of Education and the Board of Control (the W o o d Report), was published, giving" the results of Dr. :E. O. Lewis's investigations; this report revealed the amazing fact that he estimated that there were no less than 105,000 mentally defective children in E n g l a n d and W a l e s ; that is to say, more than three times the number actually ascertained by local authorities.
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Surely this discrepancy is a severe indictment of the school medical service. I think we have every excuse. In the first place, the difficulties of ascertainment in rural areas are very great. Seeing that there is such a great preponderance of mentally defectives in rural areas over those in urban areas (33"82 per 1,000 school population in rural areas as opposed to 18"84 per 1,000 in urban areas) this would account for some of the discrepancy. In the second place, there is no doubt that school medical officers have been disheartened b y the lack of proper accommodation in the special schools. In 1.929 there were only 16,750 places in the special schools. But although we may have some excuse in the past, it would seem that it is essential for .us to carry out this work with greater efficiency in the future. After all, it is important. It is generally wise for officials to carry out legal requirements, and those of the Mental Deficiency Act of 1913 were definite enough. In addition to this, the presence of the mentally defective child in the normal class is detrimental to the teaching of the normal children in that class, and for the mentally defective child it is extremely harmful for him not to have training suitable for his low intelligence : it accentuates his failings, and as a result he leaves school in an even more helpless condition than his limited capabilities warrant, so that failure in life comes on at once and he is quickly a liability to the State. Furthermore, the figures, of the W o o d Report demonstrate that in one generation (from 1904 to 1929) the proportion of mentally defectives to normals in the community has almost doubled, and the problem is becoming one of national and racial importance. It may be asked w h y the duty of ascertainment should be thrown on the doctors. The present definition of mental deficiency in the child is an educational o n e - - " in the case of children that they appear to be permanently incapable by reason of such defectiveness of receiving" proper benefit from the instruction in ordinary schools." Is i t n o t the duty of the teachers to decide which children are not capable of benefiting by their instruction ? Manifestly not. Mental retardation is so closely associated with medico-psychological quest{ons that it is definitely a problem for the medical man. Again, teachers are too kind-hearted to dia)-
juLY,
nose mental deficiency without prejudice• Dr. Lewis asked head teachers to estimate by their own standards the degree Of educational retardation in certain children, and he compared their estimates with the results of educational tests. The teachers' estimate of the amount of retardation was found to be nearly half the actual retardation; 2'7 against 5 years. The opinion of an experienced and observant teacher is of the greatest value, and may be more reliable than results furnished by intelligence or educational tests, but to rely on an unchecked opinion is to rely on personal equation which is always so unreliable. Undoubtedly the diagnosis of mental deficiency is the duty of the school doctor. The Act of 1927 defines mental defectiveness as ~' arrested or incomplete development of mind existing before the age of eighteen years, whether arising from inherent causes or induced by disease or injury." This new definition is framed to cover those cases of amentia which develop some years later, perhaps after the ' early age ' of the 1913 Act. It suggests the distinction between the inherent and the other forms of amentia, but a more scientific distinction is secured by the terms primary amentia and secondary amentia. T h e latter is due to causes operating on a brain which started normally but has had its development interfered with by trauma or b y disease occurring generally at or after birth. It also includes cretinism due to hormone insufficiency. The primary amentias have had a bad start from t~e first, and in the vast majority of c a s e ~ : ~ ~ p o hereditary causes, an exception be!,~g*'~o~n~'~'i-A;~ich is probably due to ~ p e r f e c t . , d i ~ v e l o ~ n l ~ . o f the ovum at the t i m e ' o f concept{on). It iaTegfi,~ mated that quite 80 per cent. of all cases of mental deficiency are due to hereditary causes. Tredgol.d thinks that the hereditary factor is a germ impairment of the developmental potentiality of the neuronic determinant, prod u c e d by some adverse factor in the environment, such as those causing certain physical diseases--tuberculosis, alcohol, etc. Many other authorities would assign the factor to some germinal variation of unknown origin, but inherited according to the Mendelian law. Owing to the complexity of heredity in human beings, many generations may have to be studied before the point is conclusively determined. But whatever may have been the original cause of the germinal abnormality, the important point is that mental inefficiency •
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is in the vast majority of cases a hereditary characteristic just as are such constitutional diseases as diabetes, physical features such as the colour of the iris, or mental attributes such as musical ability. It is not necessary to demand as evidence of heredity that either parent should be mentally defective; they may both be apparently normal, but instances of mental disturbance will be found in other members of the family. (It may be noted in passing that those parents from whom it is most important to obtain a family history are ,he very ones who are generally least able to give any accurate details of their forebears.) Nor is mental deficiency the only criterion o.f defective stock; insanity, illiteracy, alcoholism, chronic pauperism, recidivism, gross immorality, etc., may all be indications of mental instability of which mental deficiency is 7~nly one manifestation. And in these days of small families one is tempted almost to regard fecundity as evidence o.f a similar degeneracy. Large families of normal intelligence are becoming increasingly rare. In Nottingham, for instance, I have found that the average number of children per family from which a mentally defective child came was 5"43 against 3"7 for ~he family of the normal child. Although it has been suggested that this is a natural phenomenon due to a loss of fertility in normal stocks, it is far more likely to be due to purely artificial causes--late marriage, use of contraceptives, etc. T u r n i n g to the secondary amentias, I am inclined to think that in addition to such obvious causes as meningitis, birth-injuries, etc.., it may be t.haf, severe emotmnal disturbance of~fIie m o t h e r d u r i } ~ pregnancy is one of the causes of mental d4.~ciency in the child, due to endocrine disturba}ices. And I often wonder whether (he mental deficiency of the single illegitimate child may not have been produced by the unsuccessful use of abortifacients. But in m a n y of such cases there is often sufficient evidence in the family history to suggest hereditary deficiency. It is frequently stated that the eldest or the youngest member of the family is mo.re likely to, be defective than the other children, but I find no evidence of this. In my cases 15"3 per cent. were first-born; 31 per cent. were last born, and 53"7 per cent. were intermediate. Again, although there is some evidence that the elderly mother is more likely to. bear a mongol, with regard to. the other forms of
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mental deficiency the age of the parent seems to have but little influence. Most of my parents were aged between 31 and 35 at the time of the child's birth, and in only one instance was there any marked incongruity between the age of the father and that of the mother. ~Ve cannot rely on the findings of an ordinary routine inspection to furnish us with the information we require about mentally defectives, as there is no time at such examinations to go fully into the question. W e rrTust devise some ad hoc method of ascertainment. My predecessor, Dr. "VVyche, drew up such a scheme for Nottingham, and it has worked well. The head teachers are required by the directo.r of education to submit all children at the age .of 7 to Ballard's oneminute educational tests. The names of those falling below 85 per cent. are sent in to the senior school medical officer. Each case is then investigated by a member of his staff-not a doctor--in consultation with the head tea'cher. Eyesight and hearing are tested, opportunities for previous education noted, illnesses, etc., and in some cases intelligence tests are given. The results of these investigations are reported to the senior medical officer, who decides whether the children should remain in an ordinary class, or be sent to a dull and backward class, or be submitted to a further special examinatio.n by himself or his senior assistant who alone possess the power of certification for the special schools. This final examination is carried out at the clinic in the presence of the parent. The tests chiefly used are Burt's adaptation of the Stanford Revision Tests. T h e Porteus Maze, Drever's, Burt's Educational Tests, etc., are also used from time to time. Alt h o u g h there may be a few who are sceptical about the value of these tests, I think the more one uses them the more one realises their value, provided one is careful to take all other factors into consideration. -We sadly need some equally efficient tests for emotionality. After all, intelligence is only one of the factors influencing success in life; temperament is just as important. At present we have to rely on tile evidence furnished by the parent or teacher, and on our own observations of the child at the time of the examination. It is most important for the examiner to go carefully into the physical condition of the child. The dull child is frequently also
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physically defective, and much mental inefficiency of a temporary nature may be due to ill-health. It might be thought superfluous to emphasise the importance of testing the sight and hearing. But it is amazing to find how easy it is to miss gross defects of sight or hearing, unless they are specifically tested in each case. It is not infrequently very difficult to decide on the degree of deafness, especially when it is associated with nervousness or with mental deficiency. The greatest care should be taken to avoid being prejudiced by the presence or absence of stigmata. Many mentally defective children show no stigmata, while some normal children may show them. They may be evidence of defective stock, although the member of that stock under examination may himself be normal in intelligence. Left-handedness is more common amongst mentally defectives than amongst normal children, but it obviously by no means follows that a left-handed person is probably mentally defective. Such abnormalities should be recorded, but their presence or absence should not influence the diagnosis. A history of late commencement of speech and of walking and of cleanly habits is very suggestive, but the information is often very unreliable. An account of the child's behaviour at school and at home should always be obtained. But gross abnormalities of behaviour of a serious nature--stealing or sexual misconduct--are not incompatible with normal intelligence, and may merely be evidence of temporary emotional disturbance. The difference between the normal and the mentally defective is but slight in earlier years. As the child gets older the difference becomes more easily recognisable ; especially marked is the lagging behind of the educational ratio. How often one hears the parent of a hopelessly defective child say that some doctor has told her, when she herself
tion should be secured as soon as possible after this age, the borderline case should be sent to a dull and backward class for a year or two. After the child gets to the special school, he should still be watched. If care is taken in diagnosis, it will be very exceptional for a child to advance sufficiently to be sent back to an ordinary school. But it should be done if the circumstances warrant it. Again, although the majority of mentally defective children are inefficient in everything, handwork as well as ordinary educational subjects, occasionally one finds a child who is really above the normal in some special subject, such as art. I have had one child who came under observation first on account of fits, simulating epilepsy and serious psychological outbursts, threatening suicide, etc. He was mentally defective, with an I.Q. of 64 and an E.R. of 54. He was sent to a special school (not without a good deal of anxiety on my own part) and it was soon found that he possessed artistic ability. This was encouraged, and as he gained confidence in drawing he gained confidence in reading and other subjects. Later on he was sent to the school of art where the principal reported that in certain forms of art he was distinctly above the average of his fellow students. At the same time his reading had improved enormously, so that at the age of 14 he was able to read as well as a child of 13. With Drever's Performance Test he came out at 120 per cent. His so-called epileptic fits had ceased from the time he entered the special school, but his general intelligence is still extremely limited. He is now earning a living wage in a sign-writer's business. "Such cases are very exceptional, but they are always worth fighting for. Does the association of a borderline case with other children worse than himself Cause him to deteriorate ? I do not think so. The special school teacher is always keen to push on her most promising cases, and we can
it is kind to let a parent go on hoping against hope in this way, when the ugly truth is bound to be revealed to her sooner or later. It is not permissible to certify a child for the special school before he is seven, and even at this age with the greatest care mistakes may be made. So that, although for the definitely mentally defective child, special school educa-
and represent 10 per cent. of our school population. It is an important group to the teacher because the methods applicable to normal children are not applicable to the backward children. It is important to the doctor, because the backwardness is so often due to medical causes, and is nearly always associated with medico-psychological factors. It is of
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importance to the sociologist because it is from this group that we get so many of our neuropathic, delinquent, unemployable, and criminal adolescents and adults. More than this, it is from the ranks of the dull that are drawn a large proportion of the mentally defectives of the next generation. Burt defines backward children as those " who, though not defective, are yet unable, about the middle of their school career, to do the work even of a class below their age," viz., 15--30 per cent. retardation. This is the most interesting group to the school medical officer, for it includes not only the border-line mentally defectives, but also perhaps some exceptionally brilliant children who have been thrown back by illness or other causes. In past days the dull or backward children used to be allowed to subside to the bottom of the class; as they got older they were dragged up class by class, always at the bottom, where they were ignored or beaten. Now, it is recognised that they are worth studying; they are not ignored, and they are but rarely beaten. The necessity for this altered treatment is clear when we remember that, as Burt insists, " the feeling that he is not wanted, not understood, not like other children, in short, sub-normal and a nuisance, damages the child far more than the subnormality itself." It is convenient to divide the dull and backward into the permanently retarded or the dull, and the temporarily retarded or the backward. Dulness is due to the same causes as mental deficiency, but in a lesser degree. Inborn inferiority in gener.a~intelligence is probably the common.est~ condit'ioa, but there are many childrer,~whose only d~fect is some special disability, such as ~b.~d' memory, unstable attention; incapacity for verbal or abstract symbols, etc.,, associated perhaps with a normal capacity for manual work. There are also the temperamental defects, such as emotional instability, emotional apathy, and so on, generally accentuated by environmental difficulties at home or at school. The backward group is one which the school doctor should observe carefully, for it includes the children with defective sight, defective hearing, the tonsil and adenoid cases, the debilitated, &c., &c. Such conditions lead not only to temporary or permanent inefficiency of the senses, but often also to mental dulness, relieved when the condition is remedied. We all know of instances where removal
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of adenoids has had a remarkable effect on a child's mental alertness, and not infrequently similar results follow a course of ultra-violet therapy. The open air school will often enable a child to leap ahead in a miraculous way. My predecessor demonstrated that in one of the open-air schools of Nottingham the children advanced educationally on an average 17-4 months in one chronological year, in spite of the alleged difficulties of education in cold and damp weather. Epilepsy is often accompanied by mental deficiency or dulness, but some epileptics do veell at school and there seems no need to exclude the occasional epileptic if the parents bear the responsibility of accident, and if the frequency of the fits do not disturb the school. The so-called hystero-epilepsy is, I believe, not an uncommon condition in children, and I have known more than one case cured by the simple expedient of enforcing school under a wise teacher. In addition to the dulling of the mind by such conditions mentioned above, the loss of education by absence from school owing to prolonged or repeated illness is a very important factor. Sometimes I feel we are apt to be misled by over-anxious parents, and we forget that the modern school is often a much healthier place than the home. Many doctors are too apt to ignore the psychological and educational life of the child in their interest in the physical condition. Chronic neglect and lack of sleep are conditions that often lead to continued blunting of the mind, and the latter is one of the things that we school medical officers must be continually fighting. Sometimes we get disheartened by the appalling conditions we meet with, and we may be inclined to shrug our shoulders and say that nothing can be done under the circumstances short of taking the children away from their parents and putting them under more ideal conditions. But the results attained by enthusiastic teachers in some of the worst districts should teach us that by dint of dogged perseverance a tremendous improvement can in time be secured. In this connection it is interesting to watch the results of slum clearances from the overcrowded areas, and of re-housing in better districts. Some of the families have risen nobly to the occasion, and the consequent improvement in the mental outlook of parents and children is most striking.
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No doubt some of these results may be due to the improvement in the physical conditions, but to no small extent it is owing to a different psychological outlook. Dull and backward children need careful educational treatment in dull and backward classes (preferably called by some euphemistic title) which may often with advantage be run on open-air school lines. It is most important that the teacher of the dull and backward class should be one of suitable ability and personality. The ambitious teacher should not be allowed to feel that the dull and backward class is rather a blind alley occupation; the work is sufficiently important to attract the best type of teacher. The Problem Ghild.--The problem child has received a great deal of attention lately, not only in America but also in this country. And rightly so, because although children are sometimes able to overcome physical disability to a remarkable degree, they experience much greater difficulty in overcoming psychological troubles. In tackling the question of the problem child, it is neither necessary nor advisable for the school medical officer to attach himself to any particular school of psychological thought. But it is necessary for him to follow the trend of modern psychological teaching in order that he may delve into the minds and lives of difficult children. Parents are the last people in the world to understand such children. They themselves are frequently of psychopathic tendency and may, indeed, be partly the cause of the child's breakdown. They are too close to the problem to view it with unprejudiced eyes. They exaggerate unimportant details, and overlook incidents which to the trained observer are of the deepest significance. The problem child may do most outrageous things or he may just be a nervous child. He may be a weakling; he is not infrequently innately mentally dull. He is thus faced with failure both in school and in play. He hears his mother say a hundred times a week that he is a bundle of nerves, and feeling that he is unable to distinguish himself in any other way, he soon learns that he can acquire notoriety by continuing to be a bundle of nerves. Such a child may have some remediable physical complaint. He may have nothing at all the matter with him, or he may be suffering from some most serious disorder. In any case, the nervous child needs the most scrupulously
JULY,
careful examination, partly to exclude physical defects and partly to convince the mother. It is no use trying to treat the nervous child till you have won the confidence of the mother ; having won it, you may find it difficult to get rid of, but you can adjust this when you have cured the child. It is true that sometimes the mother may fail to understand your advice ; sometimes she may have so little control over herself that she is unable to carry it o u t ; or she may be of the vampire type who is so selfish that she refuses to alter her ways. In such cases the only thing may be to try to get the child away from the mother for as long as possible in the day by sending him to an openair school where he can stop from nine in the morning till five or six o'clock at night, or by sending him away to a convalescent home, or to a sensible relative in the country. The only child is always somewhat of a difficulty. We are apt to assume that he is spoilt, and he very frequently is. Often the parents, realising the danger of this, go to the other extreme and treat him harshly. In other cases the spoiling is alternated with severity, treatment which is so confusing to the child that it leads to serious psychological upheavals. The presence of a grand-parent in such a household is a very dangerous complication. The mother of the only child is often above the normal in intelligence and may be quite willing to alter her ways, and yet the treatment may not succeed because of mental instability in the child. The abnormality in the child may be due less to environmental causes than to innate and hereditary factors. How often one finds that the mother 'of the.~only child is herself neurotic. Is it'that the neuroti~ parent is more likely to resort to contraceptive methods, or is it that he or she is naturally infertile ? If the latter, it may be nature's-way of protecting the race from becoming fleurotic. While the problem of the only child is obvious, we should not forget that one child of a large family may possess a temperament different from the others ; he may be just as lonely as the only child, and I am inclined to think his position may be even more dangerous. The child guidance clinics in America are ~ highly organised affairs. They have their physicians, psychologists, psychiatrists, neurologists, pathologists, sociologists, and a host of other " ists." Excellent as such team work may be, away from the largest centres in this country we cannot make such a show as this,
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Nor is it generally necessary. Much may be done by simple treatment if only things can be adjusted before the abnormality becomes too marked. Juvenile Delinquency.--It is impossible to discuss mental retardation without speaking of juvenile delinquency. The Departmental Committee on the Treatment of Young Offenders recommended that the school medical records should be obtained when a child appears
thorough medical and psychological examination, and it is the school medical officer with his knowledge of child life who should carry out this duty. Magistrates will then be able to mete out treatment indicated by the cause of the delinquency, rather than by the trial and error method usually adopted. I n s a n i t y . ~ T h e passing of the Mental Treatment Act has given prominence to the importance of early treatment of mental disorders.
logical examination. This again is therefore a subject in which we must take an interest. Criminologists tell us that 10 to 20 per cent. of criminals are mentally defective, and many more must belong to the more recently recognised group of dull and backward. Furthermore, inasmuch as the majority of habitual criminals are said to receive their first conviction before they are twenty-one, it is assumed that if only the juvenile could be prevented from becoming delinquent, much recidivism could be prevented. The true moral defective is a rara avis, although there are many individuals who are lacking in moral sense in varying degrees. The delinquent is generally more or less mentally retarded. The normal child brought up in moderately normal surroundings does not commit crime, but the dull child is easily lead into mischief. As Burt proves in his works on juvenile delinquents, there is in a large proportion of the cases defective home circumstances of .some kind or another. It is by no means ~lways the bad or careless ..... ~'~rhn~ ohHdren ~et int~ trouble :
may save the child from going over the border later on. Conclusion.---As school medical officers, we are all the time working for prevention rather than cure. Although in many cases we find ourselves powerless to prevent an individual from inevitable disaster sooner or later, there is no reason why we should not interest ourselves in the social conditions that are contributory to, if not actually causative of, the enormous amount of mental retardation there is amongst elementary school children. Widely divergent views are held as to whether slumdom, alcoholism, illegitimacy, delinquency, and so on, are the result or cause of mental backwardness. But there is complete agreement that such conditions cannot be anything but harmful, and working as we do amongst children that are the victims of these evils, we cannot be indifferent to them. If we feel that the only solution to the problem of mental deficiency lies in eugenic measures, there is a great deal of field-work to be done before the legislature can be persuaded to adopt drastic remedies. l-[owever, the ouestion is comin~ to the fore
simple adjustments of the environment may effect a cure. For instance, some behaviour disorders such as truancy, wanderings, or more serious sex misdemeanours or stealing, may be due to a quite normal and healthy self-assertiveness which has been unwisely repressed. A talk to the parents and the child may secure for the latter those opportunities for self-assertion which he needs, such as the boy scouts or some suitable hobby. Sympathetic as is the atmosphere of the children's court, it is not the proper place for thrashing out these problems. Every child charged should be submitted to a
the words of the Joint Committee, " is one of the major social problems which a civilised community may be called upon to face." The school medical officer will also find himself acquiring a breadth of outlook which will add enormous interest to his work. THe: Second International Congress for IAght is to be held in Copenhagen from August 15th to 18th, 1932. A detailed programme will be issued in the autumn o.f 1931 from the Congress Bureau, Finsensinstituttet, Copenhagen.
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children under school age was very largely a financial one, and that obstacle was encountered at every point. Continuity of service from the time the child was a small infant to the time it left school was a factor the importance of which could not be overestimated. Dr. Macmillan had suggested there was difficulty in getting pre-school children to attend the clinic, but his ,own figures had shown that the trouble could be largely overcome. Similar objections were raised with school medical, and maternity and child welfare work, in its early stages, and any objection to the clinic for pre-school children would die down in the course of years. Dr. Sire \Valtace's views on the cause of dental decay were well known. He had said that in certain areas where dental decay was much in evidence, rickets was absent. It had often been claimed that rickets was absent in an area. Dr. M'Gonigle had been told that there were no rickets in the metropolis, but the medical officers of the London County Council had stated that there was something like 80
per cent. among the children. H a d the same standards been used in looking for rickets in other countries where dental decay was extraordinarily prevalent? Dr. Emslie had raised the question of Dr. Cassie's omission to include anaemia in her table. R e p l y i n g for Dr. Cassie (who had been unable to remain to the end of the meeting), Dr. M'Gonigte said it would be realised that the assessment of anaemia in y o u n g children was a very difficult matter, and that probably accounted for the omission. In conclusion, he held that, in child welfare work and in work amongst pre-school children, the medical officer must get away very largely from the point of being a doctor and, to be successful, must be a sort of super health visitor.
The
President (Professor
Harold
Kerr,
O.B.E.), on behalf of the Society, thanked the readers of the papers and those who had taken part in the discussion for their extremely interesting contributions on the subject of the pre-school child.
T h e S c h o o l M e d i c a l O f f i c e r and M e n t a l I n e f f i c i e n c y in t h e Child. By A. A. E. N~:WTH, M.B., B.S., D.P.H., Senior Medical Officer, City of Nottingham :Education Committee.
D
This paper, read before the East Midland Branch, will be enjoyed because of its" originality, enthusiasm and optimism. Ascertainment of Mental Defectives.--A E N T A L retardation is a question that
is very lara'eP¢ ~ h ~ concern of school medical officers. S o m e ]aa~ve to make dlagn o s e s . i n v d I v i n g legal responsibility in the more serious f o r m s of mental retardation. Every school medical officer has frequent opportunities of helping the teachers to salve from the"i:ubbish heaps of the schools the lesser retarded and sometimes misunderstood children so as to enable them eventually to become more or less efficient citizens. Mental abnormality is found in children in all degrees, from the incurable helplessness of the idiot to the temporary aberration of the genius. But while for legal and administrative purposes it is convenient to divide children into idiots, imbeciles, "mental defectives, dull, backward, a n t i normal, it should never be forgotten that there is no definite line of demarcation between these grades; they merge insensibly into one another and overlap to a considerable degree.
most definite duty was laid on the school medical service by the Mental Deficiency Act of 1913, which required every local education authority to ascertain the mentally defective children in their area and to provide education for them. This work was carried out in varying degrees of efficiency, and in 1928 Sir George Newman in his annual report calculated from the returns of school medical officers that there were 33,000 mentally defective children in E n g l a n d and Wales. In the following year the report of the Joint Committee of the Board of Education and the Board of Control (the W o o d Report), was published, giving" the results of Dr. :E. O. Lewis's investigations; this report revealed the amazing fact that he estimated that there were no less than 105,000 mentally defective children in E n g l a n d and W a l e s ; that is to say, more than three times the number actually ascertained by local authorities.
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Surely this discrepancy is a severe indictment of the school medical service. I think we have every excuse. In the first place, the difficulties of ascertainment in rural areas are very great. Seeing that there is such a great preponderance of mentally defectives in rural areas over those in urban areas (33"82 per 1,000 school population in rural areas as opposed to 18"84 per 1,000 in urban areas) this would account for some of the discrepancy. In the second place, there is no doubt that school medical officers have been disheartened b y the lack of proper accommodation in the special schools. In 1.929 there were only 16,750 places in the special schools. But although we may have some excuse in the past, it would seem that it is essential for .us to carry out this work with greater efficiency in the future. After all, it is important. It is generally wise for officials to carry out legal requirements, and those of the Mental Deficiency Act of 1913 were definite enough. In addition to this, the presence of the mentally defective child in the normal class is detrimental to the teaching of the normal children in that class, and for the mentally defective child it is extremely harmful for him not to have training suitable for his low intelligence : it accentuates his failings, and as a result he leaves school in an even more helpless condition than his limited capabilities warrant, so that failure in life comes on at once and he is quickly a liability to the State. Furthermore, the figures, of the W o o d Report demonstrate that in one generation (from 1904 to 1929) the proportion of mentally defectives to normals in the community has almost doubled, and the problem is becoming one of national and racial importance. It may be asked w h y the duty of ascertainment should be thrown on the doctors. The present definition of mental deficiency in the child is an educational o n e - - " in the case of children that they appear to be permanently incapable by reason of such defectiveness of receiving" proper benefit from the instruction in ordinary schools." Is i t n o t the duty of the teachers to decide which children are not capable of benefiting by their instruction ? Manifestly not. Mental retardation is so closely associated with medico-psychological quest{ons that it is definitely a problem for the medical man. Again, teachers are too kind-hearted to dia)-
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nose mental deficiency without prejudice• Dr. Lewis asked head teachers to estimate by their own standards the degree Of educational retardation in certain children, and he compared their estimates with the results of educational tests. The teachers' estimate of the amount of retardation was found to be nearly half the actual retardation; 2'7 against 5 years. The opinion of an experienced and observant teacher is of the greatest value, and may be more reliable than results furnished by intelligence or educational tests, but to rely on an unchecked opinion is to rely on personal equation which is always so unreliable. Undoubtedly the diagnosis of mental deficiency is the duty of the school doctor. The Act of 1927 defines mental defectiveness as ~' arrested or incomplete development of mind existing before the age of eighteen years, whether arising from inherent causes or induced by disease or injury." This new definition is framed to cover those cases of amentia which develop some years later, perhaps after the ' early age ' of the 1913 Act. It suggests the distinction between the inherent and the other forms of amentia, but a more scientific distinction is secured by the terms primary amentia and secondary amentia. T h e latter is due to causes operating on a brain which started normally but has had its development interfered with by trauma or b y disease occurring generally at or after birth. It also includes cretinism due to hormone insufficiency. The primary amentias have had a bad start from t~e first, and in the vast majority of c a s e ~ : ~ ~ p o hereditary causes, an exception be!,~g*'~o~n~'~'i-A;~ich is probably due to ~ p e r f e c t . , d i ~ v e l o ~ n l ~ . o f the ovum at the t i m e ' o f concept{on). It iaTegfi,~ mated that quite 80 per cent. of all cases of mental deficiency are due to hereditary causes. Tredgol.d thinks that the hereditary factor is a germ impairment of the developmental potentiality of the neuronic determinant, prod u c e d by some adverse factor in the environment, such as those causing certain physical diseases--tuberculosis, alcohol, etc. Many other authorities would assign the factor to some germinal variation of unknown origin, but inherited according to the Mendelian law. Owing to the complexity of heredity in human beings, many generations may have to be studied before the point is conclusively determined. But whatever may have been the original cause of the germinal abnormality, the important point is that mental inefficiency •
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is in the vast majority of cases a hereditary characteristic just as are such constitutional diseases as diabetes, physical features such as the colour of the iris, or mental attributes such as musical ability. It is not necessary to demand as evidence of heredity that either parent should be mentally defective; they may both be apparently normal, but instances of mental disturbance will be found in other members of the family. (It may be noted in passing that those parents from whom it is most important to obtain a family history are ,he very ones who are generally least able to give any accurate details of their forebears.) Nor is mental deficiency the only criterion o.f defective stock; insanity, illiteracy, alcoholism, chronic pauperism, recidivism, gross immorality, etc., may all be indications of mental instability of which mental deficiency is 7~nly one manifestation. And in these days of small families one is tempted almost to regard fecundity as evidence o.f a similar degeneracy. Large families of normal intelligence are becoming increasingly rare. In Nottingham, for instance, I have found that the average number of children per family from which a mentally defective child came was 5"43 against 3"7 for ~he family of the normal child. Although it has been suggested that this is a natural phenomenon due to a loss of fertility in normal stocks, it is far more likely to be due to purely artificial causes--late marriage, use of contraceptives, etc. T u r n i n g to the secondary amentias, I am inclined to think that in addition to such obvious causes as meningitis, birth-injuries, etc.., it may be t.haf, severe emotmnal disturbance of~fIie m o t h e r d u r i } ~ pregnancy is one of the causes of mental d4.~ciency in the child, due to endocrine disturba}ices. And I often wonder whether (he mental deficiency of the single illegitimate child may not have been produced by the unsuccessful use of abortifacients. But in m a n y of such cases there is often sufficient evidence in the family history to suggest hereditary deficiency. It is frequently stated that the eldest or the youngest member of the family is mo.re likely to, be defective than the other children, but I find no evidence of this. In my cases 15"3 per cent. were first-born; 31 per cent. were last born, and 53"7 per cent. were intermediate. Again, although there is some evidence that the elderly mother is more likely to. bear a mongol, with regard to. the other forms of
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mental deficiency the age of the parent seems to have but little influence. Most of my parents were aged between 31 and 35 at the time of the child's birth, and in only one instance was there any marked incongruity between the age of the father and that of the mother. ~Ve cannot rely on the findings of an ordinary routine inspection to furnish us with the information we require about mentally defectives, as there is no time at such examinations to go fully into the question. W e rrTust devise some ad hoc method of ascertainment. My predecessor, Dr. "VVyche, drew up such a scheme for Nottingham, and it has worked well. The head teachers are required by the directo.r of education to submit all children at the age .of 7 to Ballard's oneminute educational tests. The names of those falling below 85 per cent. are sent in to the senior school medical officer. Each case is then investigated by a member of his staff-not a doctor--in consultation with the head tea'cher. Eyesight and hearing are tested, opportunities for previous education noted, illnesses, etc., and in some cases intelligence tests are given. The results of these investigations are reported to the senior medical officer, who decides whether the children should remain in an ordinary class, or be sent to a dull and backward class, or be submitted to a further special examinatio.n by himself or his senior assistant who alone possess the power of certification for the special schools. This final examination is carried out at the clinic in the presence of the parent. The tests chiefly used are Burt's adaptation of the Stanford Revision Tests. T h e Porteus Maze, Drever's, Burt's Educational Tests, etc., are also used from time to time. Alt h o u g h there may be a few who are sceptical about the value of these tests, I think the more one uses them the more one realises their value, provided one is careful to take all other factors into consideration. -We sadly need some equally efficient tests for emotionality. After all, intelligence is only one of the factors influencing success in life; temperament is just as important. At present we have to rely on tile evidence furnished by the parent or teacher, and on our own observations of the child at the time of the examination. It is most important for the examiner to go carefully into the physical condition of the child. The dull child is frequently also
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physically defective, and much mental inefficiency of a temporary nature may be due to ill-health. It might be thought superfluous to emphasise the importance of testing the sight and hearing. But it is amazing to find how easy it is to miss gross defects of sight or hearing, unless they are specifically tested in each case. It is not infrequently very difficult to decide on the degree of deafness, especially when it is associated with nervousness or with mental deficiency. The greatest care should be taken to avoid being prejudiced by the presence or absence of stigmata. Many mentally defective children show no stigmata, while some normal children may show them. They may be evidence of defective stock, although the member of that stock under examination may himself be normal in intelligence. Left-handedness is more common amongst mentally defectives than amongst normal children, but it obviously by no means follows that a left-handed person is probably mentally defective. Such abnormalities should be recorded, but their presence or absence should not influence the diagnosis. A history of late commencement of speech and of walking and of cleanly habits is very suggestive, but the information is often very unreliable. An account of the child's behaviour at school and at home should always be obtained. But gross abnormalities of behaviour of a serious nature--stealing or sexual misconduct--are not incompatible with normal intelligence, and may merely be evidence of temporary emotional disturbance. The difference between the normal and the mentally defective is but slight in earlier years. As the child gets older the difference becomes more easily recognisable ; especially marked is the lagging behind of the educational ratio. How often one hears the parent of a hopelessly defective child say that some doctor has told her, when she herself
tion should be secured as soon as possible after this age, the borderline case should be sent to a dull and backward class for a year or two. After the child gets to the special school, he should still be watched. If care is taken in diagnosis, it will be very exceptional for a child to advance sufficiently to be sent back to an ordinary school. But it should be done if the circumstances warrant it. Again, although the majority of mentally defective children are inefficient in everything, handwork as well as ordinary educational subjects, occasionally one finds a child who is really above the normal in some special subject, such as art. I have had one child who came under observation first on account of fits, simulating epilepsy and serious psychological outbursts, threatening suicide, etc. He was mentally defective, with an I.Q. of 64 and an E.R. of 54. He was sent to a special school (not without a good deal of anxiety on my own part) and it was soon found that he possessed artistic ability. This was encouraged, and as he gained confidence in drawing he gained confidence in reading and other subjects. Later on he was sent to the school of art where the principal reported that in certain forms of art he was distinctly above the average of his fellow students. At the same time his reading had improved enormously, so that at the age of 14 he was able to read as well as a child of 13. With Drever's Performance Test he came out at 120 per cent. His so-called epileptic fits had ceased from the time he entered the special school, but his general intelligence is still extremely limited. He is now earning a living wage in a sign-writer's business. "Such cases are very exceptional, but they are always worth fighting for. Does the association of a borderline case with other children worse than himself Cause him to deteriorate ? I do not think so. The special school teacher is always keen to push on her most promising cases, and we can
it is kind to let a parent go on hoping against hope in this way, when the ugly truth is bound to be revealed to her sooner or later. It is not permissible to certify a child for the special school before he is seven, and even at this age with the greatest care mistakes may be made. So that, although for the definitely mentally defective child, special school educa-
and represent 10 per cent. of our school population. It is an important group to the teacher because the methods applicable to normal children are not applicable to the backward children. It is important to the doctor, because the backwardness is so often due to medical causes, and is nearly always associated with medico-psychological factors. It is of
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importance to the sociologist because it is from this group that we get so many of our neuropathic, delinquent, unemployable, and criminal adolescents and adults. More than this, it is from the ranks of the dull that are drawn a large proportion of the mentally defectives of the next generation. Burt defines backward children as those " who, though not defective, are yet unable, about the middle of their school career, to do the work even of a class below their age," viz., 15--30 per cent. retardation. This is the most interesting group to the school medical officer, for it includes not only the border-line mentally defectives, but also perhaps some exceptionally brilliant children who have been thrown back by illness or other causes. In past days the dull or backward children used to be allowed to subside to the bottom of the class; as they got older they were dragged up class by class, always at the bottom, where they were ignored or beaten. Now, it is recognised that they are worth studying; they are not ignored, and they are but rarely beaten. The necessity for this altered treatment is clear when we remember that, as Burt insists, " the feeling that he is not wanted, not understood, not like other children, in short, sub-normal and a nuisance, damages the child far more than the subnormality itself." It is convenient to divide the dull and backward into the permanently retarded or the dull, and the temporarily retarded or the backward. Dulness is due to the same causes as mental deficiency, but in a lesser degree. Inborn inferiority in gener.a~intelligence is probably the common.est~ condit'ioa, but there are many childrer,~whose only d~fect is some special disability, such as ~b.~d' memory, unstable attention; incapacity for verbal or abstract symbols, etc.,, associated perhaps with a normal capacity for manual work. There are also the temperamental defects, such as emotional instability, emotional apathy, and so on, generally accentuated by environmental difficulties at home or at school. The backward group is one which the school doctor should observe carefully, for it includes the children with defective sight, defective hearing, the tonsil and adenoid cases, the debilitated, &c., &c. Such conditions lead not only to temporary or permanent inefficiency of the senses, but often also to mental dulness, relieved when the condition is remedied. We all know of instances where removal
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of adenoids has had a remarkable effect on a child's mental alertness, and not infrequently similar results follow a course of ultra-violet therapy. The open air school will often enable a child to leap ahead in a miraculous way. My predecessor demonstrated that in one of the open-air schools of Nottingham the children advanced educationally on an average 17-4 months in one chronological year, in spite of the alleged difficulties of education in cold and damp weather. Epilepsy is often accompanied by mental deficiency or dulness, but some epileptics do veell at school and there seems no need to exclude the occasional epileptic if the parents bear the responsibility of accident, and if the frequency of the fits do not disturb the school. The so-called hystero-epilepsy is, I believe, not an uncommon condition in children, and I have known more than one case cured by the simple expedient of enforcing school under a wise teacher. In addition to the dulling of the mind by such conditions mentioned above, the loss of education by absence from school owing to prolonged or repeated illness is a very important factor. Sometimes I feel we are apt to be misled by over-anxious parents, and we forget that the modern school is often a much healthier place than the home. Many doctors are too apt to ignore the psychological and educational life of the child in their interest in the physical condition. Chronic neglect and lack of sleep are conditions that often lead to continued blunting of the mind, and the latter is one of the things that we school medical officers must be continually fighting. Sometimes we get disheartened by the appalling conditions we meet with, and we may be inclined to shrug our shoulders and say that nothing can be done under the circumstances short of taking the children away from their parents and putting them under more ideal conditions. But the results attained by enthusiastic teachers in some of the worst districts should teach us that by dint of dogged perseverance a tremendous improvement can in time be secured. In this connection it is interesting to watch the results of slum clearances from the overcrowded areas, and of re-housing in better districts. Some of the families have risen nobly to the occasion, and the consequent improvement in the mental outlook of parents and children is most striking.
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No doubt some of these results may be due to the improvement in the physical conditions, but to no small extent it is owing to a different psychological outlook. Dull and backward children need careful educational treatment in dull and backward classes (preferably called by some euphemistic title) which may often with advantage be run on open-air school lines. It is most important that the teacher of the dull and backward class should be one of suitable ability and personality. The ambitious teacher should not be allowed to feel that the dull and backward class is rather a blind alley occupation; the work is sufficiently important to attract the best type of teacher. The Problem Ghild.--The problem child has received a great deal of attention lately, not only in America but also in this country. And rightly so, because although children are sometimes able to overcome physical disability to a remarkable degree, they experience much greater difficulty in overcoming psychological troubles. In tackling the question of the problem child, it is neither necessary nor advisable for the school medical officer to attach himself to any particular school of psychological thought. But it is necessary for him to follow the trend of modern psychological teaching in order that he may delve into the minds and lives of difficult children. Parents are the last people in the world to understand such children. They themselves are frequently of psychopathic tendency and may, indeed, be partly the cause of the child's breakdown. They are too close to the problem to view it with unprejudiced eyes. They exaggerate unimportant details, and overlook incidents which to the trained observer are of the deepest significance. The problem child may do most outrageous things or he may just be a nervous child. He may be a weakling; he is not infrequently innately mentally dull. He is thus faced with failure both in school and in play. He hears his mother say a hundred times a week that he is a bundle of nerves, and feeling that he is unable to distinguish himself in any other way, he soon learns that he can acquire notoriety by continuing to be a bundle of nerves. Such a child may have some remediable physical complaint. He may have nothing at all the matter with him, or he may be suffering from some most serious disorder. In any case, the nervous child needs the most scrupulously
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careful examination, partly to exclude physical defects and partly to convince the mother. It is no use trying to treat the nervous child till you have won the confidence of the mother ; having won it, you may find it difficult to get rid of, but you can adjust this when you have cured the child. It is true that sometimes the mother may fail to understand your advice ; sometimes she may have so little control over herself that she is unable to carry it o u t ; or she may be of the vampire type who is so selfish that she refuses to alter her ways. In such cases the only thing may be to try to get the child away from the mother for as long as possible in the day by sending him to an openair school where he can stop from nine in the morning till five or six o'clock at night, or by sending him away to a convalescent home, or to a sensible relative in the country. The only child is always somewhat of a difficulty. We are apt to assume that he is spoilt, and he very frequently is. Often the parents, realising the danger of this, go to the other extreme and treat him harshly. In other cases the spoiling is alternated with severity, treatment which is so confusing to the child that it leads to serious psychological upheavals. The presence of a grand-parent in such a household is a very dangerous complication. The mother of the only child is often above the normal in intelligence and may be quite willing to alter her ways, and yet the treatment may not succeed because of mental instability in the child. The abnormality in the child may be due less to environmental causes than to innate and hereditary factors. How often one finds that the mother 'of the.~only child is herself neurotic. Is it'that the neuroti~ parent is more likely to resort to contraceptive methods, or is it that he or she is naturally infertile ? If the latter, it may be nature's-way of protecting the race from becoming fleurotic. While the problem of the only child is obvious, we should not forget that one child of a large family may possess a temperament different from the others ; he may be just as lonely as the only child, and I am inclined to think his position may be even more dangerous. The child guidance clinics in America are ~ highly organised affairs. They have their physicians, psychologists, psychiatrists, neurologists, pathologists, sociologists, and a host of other " ists." Excellent as such team work may be, away from the largest centres in this country we cannot make such a show as this,
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Nor is it generally necessary. Much may be done by simple treatment if only things can be adjusted before the abnormality becomes too marked. Juvenile Delinquency.--It is impossible to discuss mental retardation without speaking of juvenile delinquency. The Departmental Committee on the Treatment of Young Offenders recommended that the school medical records should be obtained when a child appears
thorough medical and psychological examination, and it is the school medical officer with his knowledge of child life who should carry out this duty. Magistrates will then be able to mete out treatment indicated by the cause of the delinquency, rather than by the trial and error method usually adopted. I n s a n i t y . ~ T h e passing of the Mental Treatment Act has given prominence to the importance of early treatment of mental disorders.
logical examination. This again is therefore a subject in which we must take an interest. Criminologists tell us that 10 to 20 per cent. of criminals are mentally defective, and many more must belong to the more recently recognised group of dull and backward. Furthermore, inasmuch as the majority of habitual criminals are said to receive their first conviction before they are twenty-one, it is assumed that if only the juvenile could be prevented from becoming delinquent, much recidivism could be prevented. The true moral defective is a rara avis, although there are many individuals who are lacking in moral sense in varying degrees. The delinquent is generally more or less mentally retarded. The normal child brought up in moderately normal surroundings does not commit crime, but the dull child is easily lead into mischief. As Burt proves in his works on juvenile delinquents, there is in a large proportion of the cases defective home circumstances of .some kind or another. It is by no means ~lways the bad or careless ..... ~'~rhn~ ohHdren ~et int~ trouble :
may save the child from going over the border later on. Conclusion.---As school medical officers, we are all the time working for prevention rather than cure. Although in many cases we find ourselves powerless to prevent an individual from inevitable disaster sooner or later, there is no reason why we should not interest ourselves in the social conditions that are contributory to, if not actually causative of, the enormous amount of mental retardation there is amongst elementary school children. Widely divergent views are held as to whether slumdom, alcoholism, illegitimacy, delinquency, and so on, are the result or cause of mental backwardness. But there is complete agreement that such conditions cannot be anything but harmful, and working as we do amongst children that are the victims of these evils, we cannot be indifferent to them. If we feel that the only solution to the problem of mental deficiency lies in eugenic measures, there is a great deal of field-work to be done before the legislature can be persuaded to adopt drastic remedies. l-[owever, the ouestion is comin~ to the fore
simple adjustments of the environment may effect a cure. For instance, some behaviour disorders such as truancy, wanderings, or more serious sex misdemeanours or stealing, may be due to a quite normal and healthy self-assertiveness which has been unwisely repressed. A talk to the parents and the child may secure for the latter those opportunities for self-assertion which he needs, such as the boy scouts or some suitable hobby. Sympathetic as is the atmosphere of the children's court, it is not the proper place for thrashing out these problems. Every child charged should be submitted to a
the words of the Joint Committee, " is one of the major social problems which a civilised community may be called upon to face." The school medical officer will also find himself acquiring a breadth of outlook which will add enormous interest to his work. THe: Second International Congress for IAght is to be held in Copenhagen from August 15th to 18th, 1932. A detailed programme will be issued in the autumn o.f 1931 from the Congress Bureau, Finsensinstituttet, Copenhagen.