THE CLINICAL STUDY AND TREATMENT OF NORMAL

AND ABNORMAL DEVELOPMENT

A PSYCHOLOGICAL CLINIC

BY LIGHTNER WITMER, PH.D.,

Professor of Psychology, University of Pennsylvania, Philadelphia.

I have said to the president of the American Academy that I would demonstrate for the benefit of the members of the Academy, the nature of the work which is being conducted here under the caption of the Psychological Clinic.

In the time at our disposal it will be impossible for me to give you more than a very superficial view. Some of you doubtless are interested in the scientific aspects of the problem. You would like to know what a psychologist is doing, what are the tests which he applies. This phase of the work I shall not be able to demonstrate. The tests which I shall make here this morning are very simple indeed, and are intended merely to put before you a few of the multifarious aspects of the problems with which we have to deal. They will have the purpose of making you acquainted with some of the physical and mental characteristics of the children in whom we are interested. I am going to proceed this morning just as I would in an ordinary clinic.

This little girl, whom I know quite well, has consented to come here this morning and make one or two of these simple tests.

(Professor Witmer takes the form board, which is a shallow oblong tray of light oak, having depressions of various shapes in its surface, into which fit ten blocks of dark walnut shaped like the depressions.—a square, circle, triangle, star, cross, semi-circle, and so on. He removes the blocks from their places and throws them on the table.)

Q. I am going to give you a new name this morning; you are going to be called Gertrude. What is your name going to be this morning?

A. Gertrude.

Q. Now if I make a mistake and call you by any other name, don't you answer. Gertrude, will you put these blocks back again? Do it just as quickly as you can.

It is an extremely simple test, but a very valuable one for those on the border line between normality and abnormality. The fact that she uses her vision and hands co-ordinately and without hesitation is proof enough in my opinion that the child is of approximately normal intelligence. Now I am going to ask a few questions.

Q. What is that (showing Gertrude a doll) ?

A. A doll.

Q. What is that (showing her a toy dog)?

A. That is a dog.

Q. Have you a dog yourself?

A. No.

(Miss Elliott and Fannie enter, and the former is warmly greeted by Gertrude.)

This demonstration is just as important a disclosure of character as any test we may give.

Fannie, you take those blocks out (spoken in a low tone).

This child is deaf. I was lowering my tone in order to bring out that fact. She seems to be hearing quite well this morning, Miss Elliott.

(Miss Elliott.) Some days she can hear very well, and sometimes not so well. Sometimes it is normal.

It seems very nearly normal to-day.

(Miss Elliott.) In this kind of weather you might say it is all right. Fannie, take up the doll for me. (Repeated louder and louder.) Pick up the doll. (She does so.) Sit down in your chair. (She does so.) Her hearing is very much better this morning than it usually appears to be.

Fannie, would you be willing to read a little for us? I do not know whether you have this reader in your school.

(Fannie reads.) See-my doll's-funny-carriage.

She has a lisping voice, that is a defect of articulation.
(Fannie reads.) I-have-brought-the-doll-with-me.
That will do Fannie, much obliged.

I want to say that the appearance of this child here before this large assembly, her ability to read before you, is really surprising to me. When I first saw this child about two years ago, she was one of the shyest children I have ever encountered, in fact part of her trouble was shyness. That shyness was bred of continued failure, without any doubt, and the reason this child is able to appear here this morning and read a few sentences, meagre as the performance may appear to you for a child of her age, is due to the fact that she has had the encouragement of success; she has been shown that she is able to do something.

Another cause of shyness was deafness. Originally her hearing was about one-fourth normal, perhaps worse than that. To-day it has considerably improved. Defective hearing produces shyness.

Defective hearing also produces other characteristics which were marked in this child,-sullenness and stubbornness. It was at first impossible for us, even in the quiet of the recitation room, with only one or two children, to get anything out of her at all.

These fits of sullenness and stubbornness were pathological, in the sense that they would come on apparently without sufficient cause, and would persist for half an hour or an hour. They were overcome simply through improvement in physical condition, and through subjection to the proper kind of educational treatment. I mention the fact because I want you to observe her actions here this morning. She is apparently a perfectly self-possessed

child, not at all shy, not at all sullen. The first time I ever showed this child at a clinic of this kind, she positively refused to do anything. She is the kind of child who, in the public school, if sent to the principal simply sits down in a chair or stands absolutely sullen, refusing to answer any question. Now young man (turning to the boy R. S.). I am going to give you something very easy to do. I am going to ask you to read something for me. (The boy reads very low and hesitatingly. The children are then all sent out of the room.)

I am going to speak to you about these three children, Gertrude, Fannie, and the boy R. S. The boy you saw last is a child who is in course of treatment here. This morning is the second time I have seen him. The first time he came here was April the tenth. He came with a statement from the principal of the school which he was attending, that he was about to be expelled from that school or sent to truant school because of persistent stubbornness. The statement was also made that he is extremely backward in his studies.

He is an overgrown boy of twelve years of age. He is only in the third school year, so he has lost three years of the invaluable six or eight years of school life. He is not likely to get into the high school until he is eighteen, so he will undoubtedly be cut short in his educational work. This boy comes to the Psychological Clinic with the request that I find out what is the matter with him, and send some report to the principal and to his teacher. He is brought to me by his mother, who is perfectly willing to give a complete history. She has a family consisting of a number of girls. This is the first and only boy. Apparently she has always had trouble with him. She is one of those women who are always voluble about their troubles, and in his presence she tells how bad and obstinate he is,-practically giving up the task of discipline before her twelve-year-old boy. She cannot manage him any longer. This boy as I saw him for half an hour, does not appear to me to be a child who could be suspected of mental enfeeblement, and does not look or behave to me like a boy who would be especially difficult to manage.

When a boy comes into the school and manifests obstinacy there, we must remember that his behavior is in large part a product of his home treatment. The discipline of the child should begin the day he is born, and many children show lack of discipline in the schools when eight. fifteen, or perhaps twenty years old, because the initial lack of discipline was in the first, second, or third year of the child's life. These problems are being turned over to the schools. The home is practically asking the school to remedy its defects. We must assist the home in the better training and disciplining of these children before and after they enter school. Part of our work must be to send a competent social worker or teacher into the home.

This mother is perfectly willing to learn. Whether she is competent to learn I do not know. Perhaps she will be very resistive of an education, as many mothers are, but we must try to do it, and undoubtedly we shall find some who can be instructed and assisted. The usual fault is too much affection or too much and ill-advised discipline. Now we see in this boy certain marks or signs which suggest the advisability of suspending judgment for a

while. He is an extremly shy boy, and I wished to say very little about him in his presence, nor did I desire to put him to any test. His heart was beating violently, without a doubt, while he was in the room, and I did not wish to increase the strain in any way, so I let him go quickly.

This boy I suspected of having adenoids. I sent him over to the University Hospital, where a physician diagnosed the presence of adenoids, and on Monday morning he will be operated on for them. In addition he was sent to the medical dispensary, and in this work I may say that we are assisted greatly by Miss Ogilvie, who has charge of the social service department of the University Hospital. When we tell a parent or a teacher to take a child to a medical dispensary for adenoids or medical treatment, we have not assured ourselves that the proper treatment will be accorded to the child. We must follow the child into the dispensary and see that the child really gets the necessary attention. It is a question of time on the physician's part. He is overloaded with work in most dispensaries, and the very child for whom we think it is most important that he should give time and attention, is sometimes the child who may be brushed aside. If I suspect adenoids, and I get a negative report from one dispensary, I sometimes send him to another. Corroborative opinions are particularly necessary where one suspects defective action of the internal organs. It is easy to have adenoids diagnosed and cut out, but it is extremely difficult to find anyone who will make a careful investigation where there is some chronic digestive trouble, and who will give the prolonged and careful treatment which is required in these cases.

This boy seems to be on the verge of going to destruction. He is obstinate, likely to be thrown out of school. He is overgrown, precocious physically. He is already beyond the control of his family. I would say that his condition is just as critical as that of a patient who must be operated upon for appendicitis. Some do not think so. It is a chronic state; he is not going to suffer particularly to-day, to-morrow, or within five years possibly. Nevertheless it is critical, if we are interested in his taking the narrow path in preference to the broad road. We must see, therefore, that these children obtain the kind of medical treatment which we believe necessary for them. This child is reported from the University Hospital to have a mild myocarditis, and an arhythmia of the heart, a fibroid lesion of the heart perhaps not active at the present time.

The redness of the hands was evidence to me of some circulatory disturbance. I am not a physician. I never diagnose,-not even a case of defective vision. My work is simply to find out what are the danger signs displayed in the child's mental and physical make-up, and when I find these danger signs there, I send the child to medical experts for diagnosis and treatment. If it would not overload the dispensaries, I should send every child for a thorough medical examination of eyes, ears, nose and throat, nervous system and internal organs.

This boy may be a moral degenerate for all I know at the present minute, and my work in a large number of cases means suspended judgment for a

time. Trust nobody's report of what the child has been like. One must rely chiefly on what can be found from direct observation and examination.

This other child, Gertrude, is a very interesting case illustrating just this particular point. She was brought to the clinic one morning by Miss Campion, a representative of the Children's Aid Society in this city. She had previously told me that the child came from a county poor-house in the state; that she had been brought by the authorities of that county to the city of Philadelphia with the statement that she was a menace to the other inmates of the institution.

In the care of the Children's Aid Society, the child had been placed in a hospital in this city, and the report from the hospital was that the child was a danger to the other children and they wanted to get rid of her as soon as they could. At the time I first saw her, the child was living in a boarding house in this city, being boarded out by the Children's Aid Society, and the report was made that the woman in charge of the boarding house found it necessary to give the child valerian every day in order to keep her quiet. Gertrude was subject to outbursts of passion, in which she was dangerous to other children of her own age or older, and to adults. With little children the statement was made that she was usually kind, and Miss Campion herself made the same observation.

There was a report from a physician who had examined the child, which warned the Children's Aid against putting her with normal children, and the question was put to me whether I thought there was any likelihood that the care of this child could ever be confided to some family who might be willing to take her for adoption. On her history, no society would be justified in getting anyone to look after the child. When Gertrude first came into the clinic, I felt that this was a case I could dispose of in a moment. I then had before me the physical picture of degeneracy, and at times,-I do not know whether you felt so this morning.-the child's appearance is such that one could easily suspect her of mental and moral degeneracy. But when you receive a report like the reports spread about this child, you may be sure your interpretation of what you see in her face will tend to substantiate the reports. Fifteen minutes' examination showed me that I had to deal with a child not mentally deficient, but rather above than below ordinary mentality. Subsequent observation has confirmed that judgment.

I came to the conclusion that any retardation the child showed in her school work (and she was retarded,—she cannot really read at the present time), was simply due to the fact that she had not been educated. Why, I am not able to say, but it is lack of education, not lack of ability.

As to the existence of moral symptoms, no examination of fifteen minutes can be conclusive. I simply said, "I will have to keep the child under observation." I put her with a woman in whom I had confidence, in order to try her out. Miss Campion succeeded in raising the money for the child's support. After she had been ten days in this house, living with the little girl Fannie, not being a serious menace but nevertheless rather troublesome,-she was entered in the first grade of a public school. She stayed in that grade two months, but did not get on particularly well. The principal reported that