.'i A .^^^ ^""''>^ ^""^^^^^^''^ ^''^:^^"^% ^.^'^-- J^ f" ^^ << J (S ■' . V i % .^^ .-'^i&'t ^^-".^ THE MENTAL HEALTH OF THE SCHOOL CHILD THE PSYCHO-EDUCATIONAL CLINIC IN RELATION TO CHILD WELFARE CONTRIBUTIONS TO A NEW SCIENCE OF ORTHOPHRENICS AND ORTHOSOMATICS y By J. E5 WALLACE WALLIN, Ph. D. Professor of Clinical Psychology and Director of Psycho-Educational Clinic, School of Education, University of Pittsburgh Director-Elect of Psycho-Educational Clinic St. Louis Public Schools New Haven: Yale University Press London : Humphrey Milford Oxford University Press MDCCCCXIV e.^' Copyright, 1914, by Yale University Press First printed June, 1914, 1000 copies JON 29 1914 ©CI,A374654 / 6^7 9i ^ To G. STANLEY HALL Founder of the Modern Child Study Movement AND The World's Second Psychological Laboratory 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 prob- lems which spring from the presence in every populous community of large numbers of mentally abnormal chil- dren. 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, sociolo- gists, penologists, criminologists, lawyers, clergymen, phi- lanthropists 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 diag- nosing, identifying, studying and training feeble-minded, backward and mentally abnormal children in the schools. During the last three or four years the writer has pub- lished 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- Vlll 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 unavoid- able 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 itera- tion, certain repetitions have been designedly retained, because there exist today among both lay and professional workers serious and widespread misapprehensions regard- ing 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 miscon- ceptions we are today tolerating and fostering a type of work in apphed psychology which often is scientifically barren and sometimes positively pernicious. Clinical psy- chology 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 stand- ards 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. J. E. W. W. January, 1914. CONTENTS Preface ........ vii Chapter I Medical and Psychological Inspection of School Children 1 Chapter II The New Clinical Psychology and the Psycho- clinicist ....... 22 Chapter III Clinical Psychology: What It Is and What It Is Not 121 Chapter IV The Functions of the Psychological Clinic . . 137 Chapter V The Distinctive Contribution of the Psycho-educa- tional Clinic to the School Hygiene Movement . 156 Chapter VI Human Efficiency . . . . . . 166 Chapter VII Eight Months of Psycho-clinical Research at the New Jersey State Village for Epileptics, with Some Results from the Binet-Simon Testing . . 182 Chapter VIII The Present Status of the Binet-Simon Graded Tests of Intelligence . . . . . . 196 xii CONTENTS Chapter IX Current Misconceptions in Regard to the Functions of Binet Testing and of Amateur Psychological Testers 209 Chapter X Re-averments Respecting Psycho-clinical Norms and Scales of Development . . . . . 216 Chapter XI Individual and Group Efficiency . . . . 231 Chapter XII The Euthenical and Eugenical Aspects of Infant and Child Orthogenesis ..... 246 Chapter XIII Experimental Oral Orthogenics: an Experimental Investigation of the Effects of Dental Treat- ment on Mental Efficiency .... 275 Chapter XIV The Relation of Oral Hygiene to Efficient Mentation in Backward Children ..... 291 Chapter XV Methods of Measuring the Orthophrenic Effects of the Removal of Physical Handicaps . . . 300 Chapter XVI Medical and Dental Inspection in the Cleveland Schools 315 CONTENTS xiii Chapter XVII Efficiency in School Organization and the Conserva- tion of the Mental Health of Children . . 337 Chapter XVIII Public School Provisions for Mentally Unusual Children ....... 383 Chapter XIX A Schema for the Clinical Study of Mentally and Educationally Unusual Children . . . 429 Note to Chapter IV 447 Index . . . . . . . .451 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, whooping- cough, 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 dis- eases by officers of Boards of Health. But there is another function of school medical inspec- tion which is even more important for the proper develop- ment 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 : de- fective vision, defective hearing, defective nasal breathing, adenoids, hypertrophied tonsils, cardiac diseases, defective teeth and palate, malnutrition, orthopedic defects, tuber- cular 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. 2 MENTAL HEALTH OF SCHOOL CHILD 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 re- quiring 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 per- centages 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 INSPECTION OF SCHOOL CHILDREN 3 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 Adenoids 23 3 Defective breathing 23 9 Defective vision 17 26 About 80 per cent of these children were physically defect- ive 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, ade- noids ('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 4 MENTAL HEALTH OF SCHOOL CHILD (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 tempera- ments, 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 nor- mal vision and 3 per cent less than one-half normal vision (these figures do not include hyperopia or mild astigmat- ism), 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. INSPECTION OF SCHOOL CHILDREN 5 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 ; mal- nutrition 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 coun- try 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 esti- mate 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 6 MENTAL HEALTH OF SCHOOL CHILD 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 dis- comfort, restlessness, pain or disease in his children. The school administrator and teacher must be vitally inter- ested in any conditions which may cause irregular attend- ance 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 parapher- nalia 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 attain- ment of this end must be removed. The state demands, as of right, that it secure adequate returns upon the invest- INSPECTION OF SCHOOL CHILDREN 7 ment 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 instruc- tion. 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 un- doubtedly 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 posi- tive deterrent to normal mental action and thus produce pedagogical retardation has been shown by various obser- vations 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 corre- lation 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 8 MENTAL HEALTH OF SCHOOL CHILD 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 defect- ive, 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 fre- quently a direct relation between physical defectiveness and moral perversity and youthful criminality. Much precocious criminahty is traceable to physiological mal- adjustment. 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 practi- cally nothing for physically handicapped children. The INSPECTION OF SCHOOL CHILDREN 9 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-protec- tion. 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 com- munity. 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 estab- lished 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 depart- 10 MENTAL HEALTH OF SCHOOL CHILD ments of school medical inspection or school hygiene (but only 214 were providing 'physical examination by doc- tors') — 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 exami- nation 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 dis- pensaries for the free treatment of certified indigent chil- dren, 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 incep- tion (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, Switzer- land 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 INSPECTION OF SCHOOL CHILDREN 11 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 estab- lished by schools for the free treatment of certified indi- gents, 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. More- over, 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 12 MENTAL HEALTH OF SCHOOL CHILD 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 supple- ment 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 instru- ments of precision. The child possesses a mental aspect which needs to be just as thoroughly explored by instru- ments 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 coordi- nate 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 INSPECTION OF SCHOOL CHILDREN 13 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 treat- ment yield knowledge of minor importance for her guid- ance. 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 neces- sity of segregating the atypical or special child is becom- ing increasingly evident. This need has been long recog- nized 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 back- ward — 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 neces- sary that we segregate the subnormals in the public schools 14 MENTAL HEALTH OF SCHOOL CHILD for at least two reasons: first, they constitute an intoler- able 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-indus- trial responsibilities which they are able to assume. Unfortunately the method of classifying and segre- gating [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 inspec- tor'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 peda- gogical 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 INSPECTION OF SCHOOL CHILDREN 15 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 con- ceded 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 Inves- tigation. 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 ab- normalities. 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 examina- tion 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 16 MENTAL HEALTH OF SCHOOL CHILD 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 educa- tional organism, who impedes the progress of the regular classes, who causes expensive repetition or early ehmina- tion; 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 poten- tial ; 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. INSPECTION OF SCHOOL CHILDREN 17 As a matter of fixed school policy every child who has spent not more than two years in the same grade {i.e., who is retarded not more than one year) should be given a physical examination by a medical expert for the detection and treatment of defects of the eyes, ears, nose, throat, teeth, glandular system, lungs, heart, nutrition, nervous disorders, etc. ; and a psychological examination by a competent consulting psychologist for the detection of intellectual retardation and anomahes of sensation, move- ment, memory, imagination, association, attention, imita- tion, color perception, speech, number sense, fatigue and for the determination of indices of stature, weight, vitality and dynamometry, etc. The determination may very well, in each case, be restricted to the most essential tests. These examinations, together with the previous academic record and family history of the child, would determine whether he should remain in one of the regular classes or whether he should be assigned to one of the special classes for backward or feeble-minded children. It would also determine details of pedagogic treatment. A retarded child found mentally defective through this winnowing pro- cess should be compelled, by school enactment, to enter the special class where he can be educated with a small number of his hkes. The first attention which some of these chil- dren should receive should be medical : any physical handi- caps which impede the efficient activity of the mind should be removed before the child is compelled to undergo the educative processes of the schoolroom. Whether such treatment could by due process of law be made compulsory would be a matter for judicial decision. The child is com- pelled under the law to attend school; is it not his right, under a parity of reasoning, to demand that the state put him in such condition that he can assimilate those con- 18 MENTAL HEALTH OF SCHOOL CHILD tents demanded of him by a compulsory attendance law? Certain it is that mere recommendation is not sufficient: there is a large gap between advising a parent to provide proper medical treatment for his child, and actually getting the child treated in accordance with the recom- mendation. Until the public is sufficiently educated on the question, some form of pressure must be applied. Fol- lowing this, however, each child should be subj ected to such pedagogical and mental treatment or training as the prior psychological and medical examinations have indicated as specially pertinent to his case. When a child is trans- ferred to a 'special' school a brief transcript of the psycho- logical examination, together with the examiner's recom- mendation, should accompany him. With tliis record in her possession the classroom teacher will be able to proceed with eyes open to a systematic and rational development of those functions which have become atrophied or remained dormant. In order that there be no misapprehension it should be stated that a large percentage of subnormal children are purely educational and not medical cases. Their mental improvement depends almost entirely upon proper peda- gogical training and little, if at all, upon medication or surgical interference. Under the above scheme of segregation of the feeble- minded and backward from the average and bright pupils, the psychological clinic (together with the special classes) would naturally become an educational clearing house. Some pupils sent to the special classes would eventually be returned to the regular classes ; others, on the contrary, would be sent to the feeble-minded institutions. Some of those who proved to be retarded because of physical defects would eventually catch up with their fellows after having INSPECTION OF SCHOOL CHILDREN 19 received proper medical treatment and special mental training, and could thus be returned to the regular class- rooms. Likewise, many pupils merely standing in need of specific, corrective pedagogic treatment would be con- siderably improved, and often could be restored to their regular grades. On the other hand, those who failed to make any appreciable progress would thereby indicate that their trouble was more fundamental, a condition of general neural and mental arrest. Such incurably weak pupils should, after due training, be relegated to institu- tions for the feeble-minded or institutions of a similar nature. Their defects are an irremediable condition and not a disease or a specific defect amenable to curative treatment. Even moronic defectives can be trained to become self-supporting under direction only, and should be permanently isolated in custodial institutions where the conditions render it possible for them to support them- selves, instead of being turned adrift upon society, to become the victims of its vicious members and designing rapscalHons, or to become fresh recruits to its armies of vagabonds, miscreants, social delinquents and criminals. This rational method of selecting, treating and educat- ing the mentally defective or subnormal pupils must appeal, not only to the generous instincts aroused in any normal human soul by the contemplation of the sad story of these unfortunates, but also to our sense of business econ- omy and instinct of self-preservation. Society must do this work for its own protection. Preventive medicine, preventive philanthropy, preventive didactics, mental hygiene, are better and cheaper in the end than alms- houses, jails, prisons and an army of penal officers. The plan here advocated would yield results out of all propor- tion to the money expended. 20 MENTAL HEALTH OF SCHOOL CHILD The psychological inspection in the city schools, to which I have referred, might be made a function of the department of psychology of training schools for teachers supported by municipalities,^ until the work has been thoroughly organized and developed in a separate division of the school systems. The director of the psychological laboratory (but only provided he possesses adequate clini- cal training and experience) might serve as the director of the psychological clinic. Three-fourths of his time might properly be devoted to the work of routine inspec- tion, and one-fourth to the work of regular classroom instruction in the school of education. This plan would render it possible to inaugurate the work with a compara- tively small outlay of money, as the laboratory apparatus could be used for a twofold purpose: instruction in the normal school and pupil inspection. This plan would tend to vitalize the instruction in psychology by bringing the instructor into first-hand contact with important concrete situations. It would give a new significance and content to 'child study,' and afford enriched opportunities for the students in the 'observation courses.' What 'appHed' science signifies in contrast with 'pure' science, 'individual' psychology would come to mean in contrast with 'general' psychology. Individual psychology would assume a clini- cal significance, and become of service for mental diagnosis and educational guidance. Psychology is destined to have not only a pedagogic but a clinical value for education. Eventually we shall have an independent science of clinical psychology or clinical education, instruction in which w\\\ be afforded in all of the large progressive normal schools and colleges 3 Schools of education under private or state control could make similar arrangements with public school systems. INSPECTION OF SCHOOL CHILDREN 21 of education. And we shall also have psychological or psycho-educational clinics in the large school systems, manned by psychological and educational experts, for the purpose of classifying the educational misfits. CHAPTER II THE NEW CLINICAL PSYCHOLOGY AND THE PSYCHO-CLINICIST^ Scientific psychology is essentially a modern creation. It is only about a half century since the scientific methods of induction and experimentation were systematically applied to the study of mental phenomena. Yet we pos- sess, after this brief half century of labor, not only a fairly complete body of reliable theoretical psychology, but the promising beginnings of a number of applied psychologies. The methods and results of the new psychology have been applied, with gratifying results, during the last decade or two to the study of problems in history, literature, art, anthropology, sociology, eco- nomics, business, hygiene, medicine, insanity, feeble- mindedness, criminology, law, education and paidology. Its services thus far have been most valuable, perhaps, to education and medicine, and the outlook in these fields justifies the expectation that we shall soon have to christen various new independent sciences, namely, the sciences of experimental pedagogy, experimental psycho-pathology (with psycho- therapy) and clinical psychology (or better still, perhaps, psycho-educational pathology). In the present chapter we shall discuss one of the most promising of the recent applications of psychology, namel}'^, the new psycho-clinical movement, which has won 1 Reprinted, with extensive alterations, from The Journal of Educational Psychology, 1911, pp. 121-133, and 191-210. NEW CLINICAL PSYCHOLOGY 23 recognition, within a decade, in a number of universities, normal and medical schools, hospitals for the insane, insti- tutions for the feeble-minded and epileptic, reformatories and correctional institutions, immigration stations, juve- nile courts and public schools. The discussion will per- tain more particularly to the educational aspects of the movement — the psycho-clinical and psycho-educational examination of school children. 1. The psychological clinic in the higher institutions of learning: the universities, colleges, normal schools and medical schools. Dr. Lightner Witmer, to whom we owe the name clinical psychology,^ is the pioneer psycho- clinician in connection with the university laboratories of psychology. His interest in the phenomena of mental re- tardation began in 1889, when his attention was drawn to a boy who suffered from retardation through speech defect ; but it was not until INIarch, 1896, that he opened the Psy- chological Clinic of the University of Pennsylvania and received his first case, a chronic bad speller (34, 35). Since that time Witmer's work has continued uninterrupt- edly and has grown apace, so that three hours daily are now (since 1909) devoted to the examination of children. These children come from homes, institutions, public and private schools and juvenile courts of Philadelphia and the 2 Clinical psychology is not synonymous with medical psychology or psychopathology or psychiatry (see Chapters III, V and X). Clinical means literally bedside, and was applied originally to the first-hand (bedside) method of studying the individual patient. In psychology it designates the method of determining the mental status or peculiarities of an individual by a many-sided process of first- hand observation, testing and experiment. The clinical method may be used in the study of normal as well as of abnormal mentality. I suggest the use of the words psycho-clinical, psycho-educational and medico-clinical to designate, respectively, psychological, educa- tional and medical examinations by the clinical method. 24 MENTAL HEALTH OF SCHOOL CHILD surrounding territory. Witmer's work embraces a physi- cal, psychological and sociological examination, in which a number of experts cooperate — a psychologist, neurologist, dentist, oculist, nose and throat speciahst and social worker. The social worker makes a first-hand examination of the child's home conditions, renders aid in the mitigation of bad environmental influences, and by means of 'follow- up work' sees that the treatment prescribed for the child is carried out. The clinic does not limit itself to the problem of diagnosis ; an orthogenic home school, or 'hospital school,' was estabhshed in July, 1907, for the medical and pedagogical treatment of pay and free cases. This is a combined home, hospital and training school, where the child is provided with proper food, baths, out- door exercise, sleep, medical attention, discipline, motor training and intellectual drill in the. rudiments of the school fundamentals. This school also serves as a school of observation and a clinic for further diagnosis. Records of the child's hereditary, family and personal history (accidents, diseases, educational record, present mental and physical status) are preserved for reference. Courses in clinical psychology are offered to teachers during the regular and summer sessions, while classes for mentally exceptional children are conducted during the summer for purposes of training and observation. Witmer also edits The Psychological Clinic, now in its eighth volume, which is devoted to the study of the psychology, hygiene and education of children who are mentally and morally deviating. Within the last few years the psychological clinics have multiplied very rapidly. In order to obtain more accurate knowledge concerning the psycho-clinical work attempted, and the courses offered in the psychology and pedagogy of NEW CLINICAL PSYCHOLOGY 25 mentally exceptional children in the colleges, universities, medical and normal schools in the United States, a ques- tionnaire was sent out in January and again in September and October, 1913, to the professors of psychology or education in all the universities and in all the larger col- leges, to the principals of all the state and city normal schools and to the deans of all the medical schools of the country. My thanks are due to the many respondents whose repHes made this study possible. The following were the questions asked : 1. Do you conduct a psychological clinic for the actual examination of all mentally exceptional cases referred to you? (Date of organization, name and preparation^ of clinician, and equipment.) 2. What per cent of the clinician's time is given to the actual clinical examination of cases ? What per cent of his time is given to teaching.'' To teaching branches other than clinical psychology and the study, care and education of exceptional children } 3. Do you conduct a training clinic for training students in the methods of psycho-clinical and anthropometric exami- nation and diagnosis } 4. What didactic courses (lectures or recitations) are offered in clinical psychology and the psychology and peda- gogy of exceptional children .'' 5. Do you conduct training classes for exceptional chil- dren? If so, are they open to students for observation and cadet teaching? 6. What plans are being made for the organization or extension of this type of work? Replies were received from sixty-six colleges and uni- versities, thirty-three state and city normal schools and 3 The academic data are given in the subsequent pages only for specialists who are actually conducting psychological clinics. 26 MENTAL HEALTH OF SCHOOL CHILD twenty-five medical schools. The replies are topically summarized under the above captions in the following pages. When the questions are left blank it is to be inferred that the answers are negative. The dates given refer to the time when the clinical work or courses were first organized. 'Hours' means the number of hours per week. Several institutions which were known to offer the type of work contemplated in the questionnaire failed to make reply, although two or three inquiries were addressed to them. In some of these cases data have been gathered from the catalogues and included in this tabulation. The replies are tabulated separately for the universities and colleges, the normal schools and the medical schools, in accordance with the following grouping: Group I comprises institutions which have established bona fide psychological or psycho-educational clinics ; that is, laboratories whose regular, primary and essential function is the psychological or educational examination of individual cases, for purposes of diagnosis and advice. Group II comprises institutions which either have given in the immediate past or which do at the present time give a slight amount of attention to the psychological testing of children with a view to arriving at individual mental diagnosis. These institutions can scarcely be said to conduct psychological clinics, although more or less psycho-clinical work may be attempted in the laboratories of psychology, education or psycho- or neuro-pathology (in the case of medical schools). Group III comprises institutions which do absolutely no clinical work in psychology or education (or at most a very negligible amount of it), but which either give NEW CLINICAL PSYCHOLOGY 27 some attention to the study of mentally exceptional children or which are ready to develop certain lines of this work. Universities and CoiiLEGEs Group I University of Pennsylvania (From the catalogue, 1912-1913) 1. 'Psychological Clinic' organized in March, 1896, in the department of psychology. Director, Lightner Witmer, Professor of Psychology (Ph.D. in psychology), assisted by a staff of psychologists, physicians and social workers. 3. Yes. 4. (1) 'Growth and Retardation' (Witmer). (2) 'Tests and Measurements,' 3 hours one or two terms. (3) 'Social Research in Clinical Psychology,' 4 hours one term. (4) 'The Exceptional Child,' 1 hour one term. (5) 'The Training and Treatment of Exceptional Chil- dren,' 1 hour one term. (6) 'Clinical Psychology,' 1 hour one or two terms. (7) 'Mental Defects,' l^/o hours one term. (8) 'Orthogenics,' 1% hours one term. 5. Yes. Didactic and clinical courses and an observation class are conducted during the summer term. University of Washington 1. Clinic in operation in the department of psychology since the fall of 1909; conducted since 1911 by the Bailey and Babette Gatzert Foundation for Child Welfare. A fund of $30,000 was given to the University in December, 1910, for the maintenance of a Bureau of Child Welfare in the 28 MENTAL HEALTH OF SCHOOL CHILD School of Education^ whose purpose is to provide expert diagnosis of mentally and physically exceptional children, to cooperate with local authorities throughout the state in the establishment of psychological laboratories and special classes, to furnish teachers and experts for the work, and to collect and publish data. Director, Stevenson Smith, Assistant Professor of Orthogenics (Ph.D. in psychology; additional work in the Psychological Clinic of the University of Penn- sylvania and in the Vanderbilt Clinic, New York City) ; one assistant, two graduate student assistants and four medical assistants. The Director holds the appointment of psycholo- gist to the Public Schools and Juvenile Court, and does a certain amount of field work throughout the state. Rooms are provided in the university psychological laboratory. 2. Seven-eighths of Director's time given to clinical exami- nation and instruction of children ; rest of time given to teach- ing. No teaching of subjects other than those pertaining to the clinical work. 3. Instruction given to graduate and undergraduate stu- dents in psychological, anthropological and medical methods of diagnosis, in courses given in 4 below. 4. (1) 'Psychology and Education of Exceptional Chil- dren,' in School of Education, 4 hours during one semester (Smith). (2) 'Laboratory Course in Experimental Child Study and Clinical Psychology,' in department of psychology, 8 hours (4 credits) for one semester. (3) 'A Graduate Course in the Education of Exceptional Children' (practical work in the Psychological Clinic and special classes in the public schools), in the School of Education, 4 credits (Smith). (4) 'A Practical Graduate Course in Clinical Methods,' in the Department of Psychology, 4 credits. All of the above given since September, 1911. 5. Classes are conducted at the university for feeble- NEW CLINICAL PSYCHOLOGY 29 minded, backward and speech-defective cases. Open to student observation. Partly in charge of graduate teachers. 6. Plan to increase didactic courses at the university. The courses are also offered during the summer term. University of Minnesota 1. 'Free Clinic in Mental Development,' organized in the year 1909-1910, in the department of psychology. Director, J. B. Miner, Professor of Psychology (Ph.D. in psychology), assisted by Herbert Woodrow, Instructor in Psychology (Ph.D. in psychology) ; by Fred Kuhlmann, Director of Psychological Research, Minnesota School for Feeble-Minded and Colony for Epileptics (Ph.D. in psychology and educa- tion) ; and by J. P. Sedgwick, M.D. Full laboratory equip- ment in special room at University. Examinations are also made in reserved room in City and County Court House and in public school buildings. 2. One or two days a week, including work in Juvenile Court; work, which is divided among several men, is equivalent to three-fourths of the time of one man. 3. Students attend psychological clinic; they have their attention directed to the simpler matters in medical diagnosis ; and are privileged to visit pediatric clinics and the State School for the Feeble-Minded at Faribault. 4. 'Mental Retardation,' since February, 1910, 3 hours for one semester (Woodrow) ; given to a separate division during the fall of 1912 by Kuhlmann. Also includes psycho- clinical examinations, and lectures on the application of facts to delinquents, by Miner, and medical examination by Sedgwick. Optional to students with one year's work in psychology. 5. Graduate students sometimes work with individual chil- dren. A class was at one time conducted for the correction of stuttering. Courses are offered by various specialists in the summer school. 30 MENTAL HEALTH OF SCHOOL CHILD Johns Hopkins University and Phipps Psychiatric Clinic 1. Psychological clinic established in February, 1911. Director, E. B. Huey,^ Lecturer on Mental Development in the Johns Hopkins University, and Assistant in Psychiatry in the Phipps Clinic of Johns Hopkins Hospital (Ph.D. in psychol- ogy and education; special work in institutions for the feeble- minded and in clinics here and abroad) ; under the general direction of Dr. Adolf Meyer. Several rooms available in the new Phipps Clinic, but no apparatus secured as yet. 2. Six hours per week. About one-half of the Director's time is given to examination and treatment. 3. No training clinic, but students in medicine and psy- chology assist in the testing. 4. (1) 'Feeble-minded and Backward Children,' January, 1911, 1 hour for one term (Huey). (2) 'Clinical Psychology,' in the Medical School, consisting of lectures and tests, 1 hour for one term (Huey). No courses in other than clinical work. 5. Experimental class for defective children was to be established in the Baltimore schools, enrollment limited to 15, none under the mental age of six, under Huey's direction. University of Kansas 1. Clinic established in 1911, in department of education. Director, A. W. Trettien, Assistant Professor of Education (Ph.D. in psychology and education; additional work in hos- pitals in Worcester). Two rooms available; use of equipment in Medical School. Visits to homes. Have tested inmates in Boys' Industrial School. 2. Two hours, 3. No. 4. (1) 'Educational Pathology,' since 1910, 2 hours for 4 Dr. Huey died December 30, 1913. No data as to what extent of the work in this clinic will now be devoted to psycho-educational as distinguished from psycho-pathological examinations. NEW CLINICAL PSYCHOLOGY 31 18 weeks, with clinical work (Trettien and Prof. R. A. Schwegler). (2) 'School Hygiene,' 3 hours for 18 weeks, covers certain aspects of the work (Trettien). (3) 'Mental Measurements,' 2 hours (Schwegler). 5. No, but have placed children under instruction and observation. 6. Plan to enlarge the work, under the direction of the School of Education and School of Medicine. Leland Stanford, Jr., University. 1. Clinic established in the year 1911-1912, in the School of Education. Director, Louis M. Terman, Associate Pro- fessor of Education (Ph.D. in psychology and education). Work done in the laboratory of the department of education and in neighboring schools. About $400 worth of materials for mental and physical testing. 2. One to 5 hours per week. About one-half of the Director's time. 3. No, but major students in education are afforded prac- tice in giving Binet and other tests. 4. (1) 'Clinical Child Psychology,' since 1911-1912, 2 hours throughout the year (Terman). (2) 'Seminary and Research Course in the Psychology and Pedagogy of Backward Children' (Prof. Percy E. Davidson). 5. A class was conducted from 1910 to 1912; now con- ducted by the town of Palo Alto, with the aid of the university clinic; enrollment, 15. University of Missouri 1. Clinic organized in the year 1911-1912, in the School of Education, by W. H. Pyle (Ph.D. in psychology). 2. Irregular; in fall about two afternoons per week for two or three months. The chief duties consist in teaching educational psychology. 32 MENTAL HEALTH OF SCHOOL CHILD 3. Yes, in connection with the clinic and a course on 'The Scientific Testing of Method.' 4. 'The Abnormal Child/ since fall of 1911, 1 hour (Pyle). 5. No, but plan to conduct classes eventually. 6. Plan to train teachers of subnormal children, and to develop this work in the state. University of Pittsburgh 1. 'Dispensary Psycho-Educational Clinic,' established in March, 1912, in the School of Education. Director, J. E. W. Wallin, Director of Psychological Clinic and Professor of Clinical Psychology and Mellen Research Fellow on the Psy- chology of Smoke (Ph. D. in psychology, philosophy and education; special work in institutions for epileptics, feeble- minded and insane, and in medical clinics and schools). Rooms in temporary quarters in the School of Education. An initial supply of about $350 worth of equipment for psychological and anthropometric testing. Student assistant for record work on part time. Clinical examinations conducted in cities in Western Pennsylvania and various other states. 2. Varies from 10 to 20 hours per week. Somewhat less than two-thirds of Director's time devoted to clinical work; the rest to teaching. One course temporarily offered in another department. 3. 'Clinic Practicum,' since June, 1912, optional. Open to a restricted number of students who desire a practical com- mand of the technique of mental and anthropometric examina- tion methods. Designed particularly, though not exclusively, for capable students who seek expert preparation for research or clinical work. 4. (1) 'Clinical Psychology and the Clinical Study of Mentally Exceptional Children,' lectures with demonstration clinics, since April, 1912, 2 hours for one term. Elective, but required in the department (Wallin). (2) 'The Care and Education of Feeble-minded and Back- NEW CLINICAL PSYCHOLOGY 33 ward Children/ lectures, with clinics and visits to institutions, since April, 1912, 2 hours for two terms. Elective, but required in the department (Wallin). (3) 'Psycho-educational Pathology and Educational Thera- peutics,' a detailed treatment of corrective pedagogics, since September, 1912, 2 hours throughout the year. Elective, but required in the department (Wallin). (4) 'Social Investigation,' field work, since September, 1913, 2 to 4 hours throughout the year, elective but advised (Wallin). (5) 'Manu-mental and Industrial Work for the Backward, Feeble-minded and Insane,' since April, 1913, 2 hours through- out the year (Prof. H. R. Kniffin and Mr. Leon Winslow). 5. No; expect to utilize the special classes in the public schools for observation and cadet teaching. Have selected pupils for many public school classes. 6. Plan to expand the scope of the work in various direc- tions. The didactic and clinical courses are repeated during the summer term, and classes of feeble-minded and backward chil- dren are conducted for training, observation and practical teaching. Yale University 1. 'Juvenile Psycho-clinic,' established in April, 1912, in the department of education ; examinations conducted in dis- pensary of Medical School. Director, Arnold Gesell, Assistant Professor of Education (Ph.D. in psychology and education; additional work in the Medical School). 2. Half of Director's time given to teaching subjects other than clinical psychology. 3. OiFer a 'Clinical and Research Course for Advanced Students,' 1 hour; includes visits to institutions and schools. 4. (1) 'Backward and Defective Children in the Public Schools,' since October, 1912, 2 hours throughout the year. Elective graduate course (Gesell). 34 MENTAL HEALTH OF SCHOOL CHILD (2) 'Norms of Development/ scheduled 1 hour for second half of second term. 5. No. Harvard University 1. Clinic conducted in the out-patient department of the Psychopathic Hospital, Boston, since September, 1912. No technically trained clinical psychologist, but consultation and examination work is divided betvreen E. E. Southard, M.D., Director; R. M. Yerkes, Ph.D., psychologist; W. F. Dearborn, Ph.D., psycho-educationalist; Herman Adler, M.D., chief of staff; V. V. Anderson, M.D., and F. D. Bosworth, Jr., M.D., examiners. 2. Clinics conducted by different examiners every after- noon except Sunday. No data as to what extent the examina- tions are psycho-educational. 3. Clinical training afforded in Psychopathic Hospital. 4. (1) 'Psychology of the Abnormal,' since 1912, summer session, 39 lectures, with clinics (William Healy, M.D.). (2) 'Mental Heredity and Eugenics,' in department of psychology (Yerkes). (3) 'Educational Psychology,' in department of education (Dearborn). (4) Aspects of Mental and Physical Development,' in department of education (Dearborn). (5) 'Psychopathology,' in department of psychology, with clinics, since 1913-1914 (Adler). 6. No. 6. Plan to perfect clinical and educational organization in the out-patient department of the Psychopathic Hospital. Certain courses are offered during the summer term. University of Cincinnati 1. Clinic established September, 1912, in department of psychology. Director, B. B. Breese, Professor of Psychology NEW CLINICAL PSYCHOLOGY 35 (Ph.D. in psychology), assisted by Mr. S. Isaacs. Use of six rooms in the Psychological Laboratory of the University. 2. Three hours per week, or one-seventh of Director's time. 3. Yes. 4. 'Mental Measurements/ since September, 1912, 3 hours for 36 weeks (Breese and Isaacs). 'Psychology of Mentally Defective Children' (seminar), 2 hours. 5. No; cooperate with special classes in public schools. Tulane University 1. Clinic established in October, 1912, in School of Edu- cation of H. Sophie Newcomb Memorial College for Women. Director, John Madison Fletcher, Assistant Professor of Experimental and Clinical Psychology (Ph.D. in psychology and education) ; supported jointly by Tulane University and the New Orleans Board of Education.^ Board of Education contributes $1,500 annually. Clinic rooms in Psychological Laboratory of School of Education. Assistants comprise a supervisor of social investigation, a recorder and secretary, student assistants and an advisory medical staff. 2. Three-fourths of Director's time given to clinical exami- 5 The joint arrangement was terminated during the summer of 1913, owing to the resignation of Dr. David Spence Hill* from the acting directorship of the School of Education. Dr. HiU is now director of the recently created Department of Educational Research in the New Orleans public schools. The department at present has a budget of $3,500 and during the present year is undertaking the following program of work: a vocational survey, the individual study of exceptional children and statistical studies of retardation. A brief lecture course is also offered to the students at the city normal school. A psychological laboratory is being equipped in the director's rooms in the city hall. * Hill. Notes on the Problems of Extreme Individual Differences in Children of the Public Schools. Department of Educational Research, New Orleans Public Schools, 1913. 36 MENTAL HEALTH OF SCHOOL CHILD nation and teaching in the department; rest of time given to teaching experimental psychology. 3. No. 4. (1) 'The Psychology of the Abnormal Mind/ 3 hours for one term (Fletcher). (2) 'Clinical Psychology,' advanced course (Fletcher). (3) 'The Psychology of Retardation and Mental Defi- ciency' (Fletcher). 5. No, but classes have been organized in the public schools. University of North Dakota 1. Clinic started in September, 1913, in the department of psychology. Director, John W. Todd (Ph.D. in psychology, educational psychology and philosophy). Modest equipment. Aim to examine both normal and deviating children. 2. Varies; the laboratory is regularly open from 2 to 4 p.m., Mondays, Wednesdays and Thursdays. 3. No. 4. None. 5. No. State University of Iowa 1. Clinic established in department of psychology, Sep- tember, 1913. Director, R. H. Sylvester (Ph.D. in psychology; special preparation in clinical psychology). Aim to examine children anywhere in the state. 2. Indefinite. 3. Plan to conduct a training clinic. 4. (1) 'The Backward Child,' 2 hours throughout the year (Sylvester). (2) 'Orthogenics,' 2 hours one semester (Sylvester). (3) 'Tests and Measurements,' 2 hours for one semester (Sylvester and Mabel Clare Williams). 5. No, but expect to treat speech defectives. Courses are offered during: the summer term. NEW CLINICAL PSYCHOLOGY 37 University of Oklahoma 1. Clinic work conducted in conjunction with city schools and the state asylum for the insane, since the fall of 1913, in the School of Education, by W. W. Phelan, Director of the School of Education and Professor of Psychology and Educa- tion (Ph.D. in psychology). 3. No. 4. Seminar course, 2 hours, since September, 1913 (Phelan). 5. No. 6. Plan to organize the work in the School of Education. Group II Clark University 1. No psycho-clinic at present, but more or less clinical work, supplemented by a course of lectures, has been carried on by various men during the last four years in the department of psychology. Cornell University 1. No, but occasional cases are referred to Educational Laboratory for examination, by G. M. Whipple, Ph. D., Assist- ant Professor of the Science and Art of Education. The laboratory has been examining by Binet scale and other tests various children in the George Junior Republic, with a view of determining advisability of requiring in future a prior psycho- logical examination of all candidates for admission. 3. No, except as noted in 4. 4. (1) 'Education of Exceptional Children,' since 1908, 2 hours for one semester. Elective (Whipple). (2) 'Conduct of Mental Tests,' since 1908, for graduate and advanced students, 8 hours for one semester. Also given in summer session since 1912, 2^ hours daily, with examina- tion of cases (Whipple). 38 MENTAL HEALTH OF SCHOOL CHILD School of Pedagogy, New York U niversity 1. A psychological clinic is conducted for demonstrating cases in connection with the lecture course given by Henry H. Goddard, Director of Research, New Jersey Training School (Ph.D. in psychology and education). 3. Yes, in the summer session. 4. 'Education of Defectives/ since October, 1906, 3 hours on alternate Saturdays during the academic year. Also given during summer term (Goddard). 5. Six special classes conducted during summer session 1912, 15 pupils in each class. Numerous courses are offered during the summer term by various instructors. Girard College 1. Boys in the school and candidates for admission have been examined since September, 1910, by Ralph L. Johnson, A.M. (University of Pennsylvania and New Jersey Training School). Have a laboratory with two rooms. 2. Half of examiner's time given to examination and half to teaching morons. 3. No. 4. No didactic courses given. 5. Conduct classes for morons. Group III Alfred University 4. Brief discussions on mental defectives in courses in child study and educational psychology (Bessie L. Gambrell). Barnard College 4. Occasional reference to topics in courses in experimental psychology (L. H. Hollingworth). NEW CLINICAL PSYCHOLOGY 39 Bryn Mawr College 1. No. 3. No, but students visit the psychological clinic of the University of Pennsylvania and schools for deficient children. 4. 'The Psychology of Defective and Unusual Children,' a graduate seminar throughout the year, first given in 1913- 1914. Five months (J. H. Leuba). College of the City of New York (From the catalogue, 1913) 4. 'Education of Backward and Defective Children,' lec- tures, demonstrations of tests, visits to classes (S. B. Heckman). Columbia University, Teachers College (From the catalogue, 1913) 4. 'The Psychology and Education of Exceptional Chil- dren' (Naomi Norsworthy and E. A. Thorndike). 'Normal Diagnosis and Anthropometry,' with demonstra- tions (W. H. McCastline). Didactic courses are offered during the summer session. Dartmouth College 1. A few of the students of the department of psychology tested the pupils in the public schools during the fall of 1912 by means of the Binet scale (W. B. Bingham). DePauw University 4. 'Abnormal Psychology,' including some clinical work, formerly given. Mount Holyoke College 3. No, but use is made of Whipple's Manual in course in Experimental Psychology (Samuel P. Hayes). 4. Reference reading on exceptional children in course in Educational Psychology. 40 MENTAL HEALTH OF SCHOOL CHILD Northwestern University 4. 'Abnormal Psychology/ since 1909-1910, 3 hours for one semester, elective (R. H. Gault). A certain amount o£ time devoted to mental tests in course in Educational Psychol- ogy- 6. It is possible that psycho-clinical work will be under- taken within a year or two by the public schools or the University. Ohio State University 4. 'The Defective Child/ lectures, recitations and demon- strations, one semester, 3 credit hours (T. H. Haines). Ohio University, Athens 4. Incidental reference to these topics in courses in psy- chology (Oscar Chrisman), and 'Educational Psychology' (Willis L. Gard). Expect to give a systematic course in the near future. Pennsylvania State College 4. Occasional lectures given to students on exceptional children (A. Holmes). Princeton University 4. Topics are referred to incidentally in course in 'Genetic Psychology,' since February, 1910 (Howard C. Warren). Rutgers College 4. About 10 hours in all given to these subjects in courses in Elementary, Advanced and Educational Psychology and School Administration (W. T. Marvin and Alexander Inglis). 6. Plans for future development not yet matured. NEW CLINICAL PSYCHOLOGY 41 University of California 1. No. 4. During the summer session of 1913, the following courses were offered: 'Clinical Psychology and the Teaching of Exceptional Chil- dren/ with demonstration clinic (F. G. Bruner, Ph.D., Clinical Psychologist to the Board of Education, Chicago). 'Clinical Examination and Training of Subnormal Children' (Mrs. Vinnie C. Hicks). 5. 'Training class for Subnormal Children,' open for observation (Mrs. Vinnie C. Hicks, Miss Nellie Goodhue and Miss Frances H. Ney). 6. Plan to establish a psychological clinic, in affiliation with departments of education, psychology and medicine. University of Chicago, School of Education 4. 'Psychopathic, Retarded and Mentally Deficient Chil- dren,' 4 hours for twelve weeks, given only in 1910-1911. University of Idaho 4. Referred to incidentally in courses in Educational and Experimental Psychology (P. H. Soulen). University of Illinois 1. No clinic, but apparatus is available for starting work. 4, Three hours during one semester devoted to these topics in course in Educational Psychology (W. C. Bagley). University of Indiana (From the catalogue of the summer session, 1913) 4. 'Orthogenics,' recitations and laboratory work, open to advance students 5 credit hours (E. E. Jones and Mr. John E. Evans). 5. 'School of Orthogenics,' for diagnosis, laboratory study, observation and training of a 'limited number of defectives.' 42 MENTAL HEALTH OF SCHOOL CHILD University of Michigan 1. No. 3. No, 4. 'Education of Backward and Defective Children/ since July^ 1911, 2 hours for one semester (C, S. Berry). 6. No, but a class for backward children in an affiliated public school is open to students for observation. Dr. Berry has recently been appointed consulting psycholo- gist to the public schools of Detroit and to the Michigan Home for Feeble-Minded and Epileptics, at Lapeer. Courses for the training of teachers will be offered at the latter institution during the summer of 1914. University of Montana 4. 'Mental Pathology/ 2 hours for one semester; visits to institutions (Bolton). 'Exceptional Children,' lectures and laboratory work, summer term, 1913. 6. Will establish a clinic at the University. Director, Thaddeus L. Bolton, Professor of Psychology and Education (Ph.D. in psychology). Courses are offered during the summer term. University of Nevada 4. Lectures on exceptional children in course in 'Child and Adult Psychology,' during six weeks, in Department of Psy- chology (George Ordahl). University of North Carolina 1. Have tested suspected cases in several city school sys- tems and have induced Boards to provide training for special class teachers (H. W. Chase). 4. Treated incidentally during regular and summer terms in course in Educational Psychology (Chase). NEW CLINICAL PSYCHOLOGY 43 University of Oregon 4. Three or four lectures on the subject are given in course in Mental Hygiene and Abnormal Psychology (Edmund S. Conklin). University of Southern California 4. 'Education of Exceptional Children/ given since 1911- 1912, 2 hours for one semester; visits to institutions (Howard L. Lunt). University of Tennessee 4. Was emphasized in a course in Child Study and Adoles- cence given in summer session 1913 (Bird T. Baldwin). Two brief didactic courses will be offered during summer of 1914. University of Texas 4. These topics treated only incidentally in course in Educational Psychology (J. C. Bell). Will establish a clinic in School of Education. University of Utah 6. Legislature has been asked to establish a clinic in the Department of Psychology and provide for didactic courses. Thus far only a few cases have been examined (Joseph Peterson). University of Wisconsin 6. Plans already considered to establish a Psychological Clinic in the Department of Education. William and Mary College 4. These subjects are treated briefly in the course in Child Study (H. E. Bennett). 44 MENTAL HEALTH OF SCHOOL CHILD State and City Normai. Schools Group I Colorado, The State Teachers College, Greeley 1. Psychological clinic, established in 1908 in the depart- ment of psychology. Director, J. D. Heilman (Ph.D., special training in clinical psychology). Physical and mental exami- nations are provided. Children in the Denver schools have been examined once every two weeks. One room with fair laboratory equipment. 2. About 5 hours. One-third of clinician's time given to teaching clinical subjects and two-thirds to teaching other subj ects. 3. 'Psycho-clinical Practice,' elective, 2 hours, fall term (Heilman). 4. 'Clinical Psychology,' since March, 1910, elective, 3 hours throughout the term; also given to Denver teachers and principals (Heilman). Lectures on retardation and exceptional children, summer term, 1913, by various psychological specialists. 5. Yes. Special classes for the feeble-minded, backward and dull, and for children with speech, reading, spelling and number defects; from 1 to 4 pupils per class, although the classes for the dull are larger. Group II California, Los Angeles State Normal School 1. Since 1912 have examined a few children from the training school and juvenile court, and a few delinquent girls and feeble-minded children. Examiners : Grace M. Fernald (Ph.D. in psychology; special work in the Psychological Insti- tute of the Juvenile Court, Chicago), and C. W. Waddle (Ph.D. in psychology and education). Limited equipment. Two rooms provided for in plans for new building. NEW CLINICAL PSYCHOLOGY 45 2. One or two hours per week, not programed. 3. No; a week or two in the course in Child Study is given to familiarize students with the signs, and the means of dis- covering, physical defects, with demonstrations. A few stu- dents are taught to give psychological tests. 4. Frequent reference to these topics in the courses in Child Study and Advanced Psychology. 5. Some work with exceptional children done in training school. One or two special rooms provided for in the new training school. 6. Plan to enlarge work if the legislature authorizes extension of course to four years. Michigan, Central State Normal School, Mount Pleasant 1. Clinic conducted by Department of Psychology and Education for testing children in the training school. Examiner, E. C. Rowe (Ph.D. in psychology and education). Have the usual supply of apparatus. 2. Four hours per week. 3. No, but testing of pupils in training school is observed by students of the Normal Department. 4. 'Clinical Psychology,' since January, 1911, 4 hours for 12 weeks (Rowe). 5. No. Group III Alabama, State Normal College, Florence 6. It is possible that at some future date some of this work may be programed. Connecticut, State Normal Training School, Willimantic. 5. Pupil teachers do individual work with exceptional children. 46 MENTAL HEALTH OF SCHOOL CHILD Illinois Chicago Normal College 1. No, this work is done by the department of child study of the public schools. 2. No work regularly programed. 3. Students and instructors (John T. McManis and Mabel R. Fernald) make a simple anthropometric and psychological examination of normal and exceptional children in the courses in education. One large room equipped with apparatus for psychological tests. 5. No, we conduct classes for the deaf only in one of the practice schools. Expect to train teachers for backward children. State Normal University, Normal 3. No, but students assist in physical measurements. Physical and mental data are entered on a card which accom- panies the child through the training school. Massachusetts State Normal School, North Adams 5. A class for defectives is being established. State Normal School, Worcester 4. Two special lectures and incidental reference to feeble- minded children, and an annual excursion to the School for the Feeble-Minded at Waltham, since February, 1910 (J. Mace Andress). Michigan Northern State Normal School, Marquette 1. A few pupils in the training school have been tested since 1910 (G. C. Fracker). 2. Nominal. NEW CLINICAL PSYCHOLOGY 47 3. No, but students are afforded some training in giving the Binet tests. 4. A few lectures are given on exceptional children, and on methods of diagnosis and treatment, in courses in Psychology and Principles of Education (Fracker and G. L. Brown). The diagnosis and treatment of physical defects are considered in the course in Hygiene and Sanitation. Western State Normal, Kalamazoo 1. No programed work, but Binet-Simon tests are used and teachers are in touch with the problems. Minnesota State Normal School, Duluth 4. Treated incidentally in courses in Psychology and Pedagogy. State Normal School, Winona 1. No, but a few cases have been examined since 1898 (J. P. Gaylord). 5. Some special provision has been made for retarded (especially) and bright pupils. Open to observation by student teachers. 6. If course is lengthened will develop work with unusual children. Nerv York City, Brooklyn Training School for Teachers 3. Teachers in training give anthropometric and psycho- logical tests to pupils in the ungraded room. 4. 'Psychology of Mental Defectives,' since November, 1912, 5 hours for six weeks; now 60 hours (W. J. Taylor). Required of those teachers already conducting ungraded classes who may be designated by the supervisor of ungraded classes. 5. One ungraded class, with one teacher and sixteen pupils (high grade imbeciles and morons). 48 MENTAL HEALTH OF SCHOOL CHILD Oregon, Normal School, Monmouth 4. About five weeks is devoted to these topics in course in Educational Psychology (E. S. Evenden). 5. A flexible scheme of grading in the training school allows better adjustment of work to the needs of backward and bright pupils. 6. Contingent on growth of school^ it is planned to oiFer a separate course in this work. Pennsylvania Bloomsburg State Normal School, Bloomshurg 4. Treated incidentally in courses in General Psychology and Child Study. East Stroudsburg State Normal School, East Stroudsburg 4. Incidental attention is given in course in Educational Psychology to tests of intelligence, and methods of studying and training exceptional children (D. W. LaRue). Indiana State Normal School, Indiana 4. Brief presentation of subject of defective eyes and ears to senior class in Methods, since fall of 1911 (Frank Drew). Millersville State Normal School 4. Incidental lectures in pedagogical courses on the Psy- chology of Abnormal and Subnormal Children. Philadelphia Normal School for Girls 4. The mental and physical differences of children are studied in the course in Child Study. Students are given some training in giving tests, since 1910 (Grace Hamill). NEW CLINICAL PSYCHOLOGY 49 Washington, State Normal School, Bellingham 4. No, but Binet and deSanctis tests are used in a course in Child Study (Frank Deerwester). 5. Special attention is given to dull, bright and peculiar children in the training school. West Virginia, Training School of Marshall College, Huntington 6. Plan to develop some phases of this work in future. Wisconsin, State Normal School, Milwaukee 6. Psychological Laboratory is gradually being equipped and some clinical work may be done next year (W. T. Stephens). Medical Schools Group I Columbia University, College of Physicians and Surgeons 1. Clinic in psychology and psychotherapy, conducted in the Vanderbilt Clinic (out-patient department of the college), since 1908, especially for the examination of the 'exceptional and psychopathic child' (idiotic, imbecile and psychotic chil- dren are not received). Director, J. V. Haberman (M.D., Columbia and Berlin), and several assistants. 2. From 9.20 to 12.00 a.m. three days a week. 3. Yes, in connection with clinic and didactic course. 4. 'Psychopathology and Therapy,' which includes mental examination methods and pedagogical treatment, since 1909, optional in fourth year, 2 hours during one-quarter year (Haberman). 5. No. 50 MENTAL HEALTH OF SCHOOL CHILD 6. Hope in near future to affiliate with (a) Children's Courts^ for the purpose of examining the psychopathic cases ; and (b) the public schools, for the purpose of examining and treating children afflicted with abnormalities of disposition, the psychopathic constitutions of Ziehen (rather than the mentally defective and backward), who if not given timely treatment tend to recruit our classes of hystericals, inst'ables, delinquents, criminals and the insane. A very interesting program which, however, will not touch the psycho-educational problem of many educational deviates. Harvard Medical School See Harvard University, p. 34. Johns Hopkins Medical School See Johns Hopkins University and Phipps Psychiatric Institute, p. 30. Nerv York Post-Graduate Medical School and Hospital 1. Clinic, since May, 1911; has served as clearing house for the New York Department of Public Charities since January, 1913. It is reported to be a 'part of the city system of caring for the feeble-minded children' at Randall's Island. Director, Max Schlapp, M.D., assisted by seven neurologists and three psychologists. Twelve clinic rooms and a 'com- pletely equipped laboratory.' 2. Every day from 9.00 a.m. to 1.00 p.m. 3. Graduates in medicine are permitted to witness the examinations. 4. 'Amentia, Dementia and Exceptional Children,' daily (Schlapp). 5. No, we attempt supervision of the classes in the city residential institution for the feeble-minded. NEW CLINICAL PSYCHOLOGY 51 University of Chicago, Rush Medical College 1. Clinic started in the fall of 1912, as part of neurological department. Two rooms, with psychological and neurological apparatus. Clinician in charge, Josephine E. Young (M.D., supplementary work in psychology in the University of Chicago and Columbia University). 'No clinical psychologist as such.' No data as to what percentage of the work is strictly psycho-educational. 2. Two periods per week. 3. None as yet. 4. None. Later will give a course to medical students in psychological methods of examination, eugenics and the path- ology of the feeble-minded. 5. Conduct a class Saturday mornings for all grades, one teacher. 6. As soon as the money is available, expect to organize a well-equipped school, with a specially trained teacher in charge, assisted by cadets from the University of Chicago. Will also engage a field worker who will see that patients report at the referred medical clinics and that they receive proper care and attention at home. Aim to work in the school classes with border-line cases difficult to diagnose, and with small groups of low-grade children. The latter will come two or three times a week with their mothers, who will be instructed by the teachers how to care for the pupils at home. Ultimately hope to have a small institution where research can be prosecuted. Yale University Medical School 1. Psychological clinic conducted by the Department of Education in the New Haven Dispensary, since April, 1912 (Arnold GeseU, Ph.D.). 3. No. 4. None. 5. No. 52 MENTAL HEALTH OF SCHOOL CHILD Students entering the medical school without elementary psychology are required to take such a course in the university. A course on the physiology of the special senses is given in the psychological laboratory to second-year students (R. P. Angier, Ph.D.). Group II Georgetown Medical College 1. No purely psychological clinic, but the 'Child Study Laboratory' in the dispensary division of the University Hos- pital affords opportunities for giving the Binet-Simon tests and an anthropometric and physical examination to children who are referred because they do not get along well at home or in school. By D. Percy Hickling, M.D., J. J. Madigan, M.D., and Miss Margaret Stewart (public teacher in ungraded schools). Surgical and medical treatment is afforded in the dispensary; parent or guardian is told how to apply hygienic treatment. 3. Cases examined in the child-study laboratory are explained in clinics given to the fourth-year class. 4. 'Psychiatry/ including facts of psychology, 60 hours each year, to third- and fourth-year classes (Wm. A. White, M.D., and Hickling). 5. No, but cases are recommended to 'ungraded' classes, or sometimes mothers are instructed in home treatment and training. Two years of required work for entrance involves a certain amount of instruction in psychology. University of Michigan, State Psychopathic Hospital 1. This hospital is available for mentally abnormal and insane children. Psychology required for entrance in the Medical School. NEW CLINICAL PSYCHOLOGY 53 Group III Boston University School of Medicine 4. Incidental reference in courses in Nervous and Mental Hygiene, 'Psycho-analysis and Psychotherapy/ since 1913- 1914 (A. S. Boomhower-Guilbord, M.D.). 5. No. Cornell University Medical College 1. No psychological clinic, but abnormal children from the schools are frequently referred to out-patient clinic for examination and advice (C. L. Dana, M.D., and August Hoch, M.D.). Hahnemann Medical College, Chicago 1. No, not apart from other clinical work. 4. None. 6. Are planning to organize didactic and clinical courses in a department of psychology for the study and care of exceptional children and all kinds of mental deviates. New York Homoeopathic Medical College and Flower Hospital 1. No. 3. No. 4. Treated only incidentally in courses in Neurology and Psychiatry. Tufts College Medical School 4. 'Mental Diseases,' lectures vrith eight or ten clinics at the Boston State Hospital, and two clinics on defective children at the Massachusetts School for Feeble-Minded Children, from January 1 to May 15 (Edward B. Lane, M.D., assisted by Walter E. Fernald, M.D.). 'Psychopathology and Psychotherapeutics' (Morton Prince, M.D., J. J. Thomas, M.D., and A. W. Fairbanks, M.D.). 54 MENTAL HEALTH OF SCHOOL CHILD University of Buffalo, Medical Department 6. Now conduct a psychiatric clinic, and plan to open a psychological clinic with laboratory equipment in the dis- pensary for the examination of exceptional children. University of Wisconsin, Medical School 1. No. 4. A course in Psychology is given to medical students which includes reference to methods of psychological diagnosis (Joseph Jastrow). Also a course in Abnormal Psychology. Washington University, Medical School 6. Plans are gradually crystallizing for the development of a psychological clinic. Results and Conclusions It is difficult to state unequivocally from the returns just how many genuine psychological clinics there are in the higher educational institutions of the country. The difficulty is due to the fact that the psychologists, educa- tionists and physicians do not as yet have a clear idea — a definite standard — as to what constitutes a psychological clinic. The physician tends to confuse the neurological clinic, and especially to identify the psychiatric or psycho- pathological clinic, with the psychological clinic. He inclines to the view that no special preparation is needed to conduct a psychological clinic for the examination of mentally exceptional school children, beyond taking the ordinary courses in neurology and psychopathology, learning how to administer a few stock tests in psychology and spending a few days visiting psychological clinics. Ninety-nine out of every hundred physicians have no tech- NEW CLINICAL PSYCHOLOGY 55 nical knowledge of those branches of psychology and peda- gogy which bear on the teaching of educationally excep- tional children. As a result we are today confronted with an anomalous situation throughout the country ; medical inspectors and physicians, very few of whom have any special training in neurology and psychopathology and nearly all of whom lack technical training in education, are attempting to differentiate educationally exceptional children in the schools and to direct their educational train- ing. It ought to be evident to anyone who has worked in the neurological, psychopathological and psychological clinics, or who has taken serious pains to inform liimself, that the methods of examination employed in these three clinics frequently differ very widely, while the standpoint and aims of the examinations often have little in common. Owing to these confusions medical schools are incHned to report that they have psychological clinics when the clinics are really neurological or psychopathological clinics. Again, the psychologist or educationist is inclined to regard a psychological or educational laboratory — any room containing psychological and educational apparatus and test materials, and a psychologist or educationist — as a psychological clinic, although it ought to be evident that a psychological laboratory and an experimental psycholo- gist no more constitute a psychological clinic than do an anatomical laboratory and an anatomist constitute a medical clinic. The psychologist also seems to feel that he, too, is qualified to mentally examine children without special training in mental examination methods, and in case-taking and in clinical procedure. He seems to think that the ordinary courses in psychology and education prepare him for this work (most of the respondents did not answer the question regarding the character and 56 MENTAL HEALTH OF SCHOOL CHILD extent of the special, technical training possessed by the director of the clinic, whether the latter was a psychologist or a physician). In consequence of these opinions certain universities report that they have a psychological clinic although the examiner has no special training for the work. In other institutions the practice obtains of parceling out the clinical examination work among the members of the departmental staff, none of whom may have definitely prepared for the work. The fact is that we have recently developed a new type of clinical work without the full recognition that it cannot successfully be done by either the physician or the psychologist without a definite technical preparation. The time must come when the work of educational diagnosis and guidance for men- tally and educationally exceptional children will not be entrusted to physicians who have no definite preparation in psychology and education, or to psychologists or educators who are wholly lacking in clinical training and experience. We are met with a further difficulty in attempting to evaluate the existing clinics : some of the clinics are devot- ing a bare hour or two per week to clinical work, while the remaining time of the chnicist is given to teaching, usually branches quite remote from clinical psychology and the education of juvenile mental deviates. With these clini- cists the clinical work is entirely incidental, albeit the laboratory may have been established as a bona fide clinic. It is evident that a clinic in which the actual work of psycho-educational examination is regarded as a mere by- play to teaching, to be indulged in an hour or two a week, cannot afford even sufficient practice to keep the clinicist instrumentally efficient. It is, therefore, only by a liberal construction that such an exercise can be called a clinic. Fortunately some of the laboratories in higher institutions NEW CLINICAL PSYCHOLOGY 57 of learning are devoting themselves very largely if not exclusively to clinical work. In the University of Wash- ington seven-eighths of the director's time is devoted to the actual examination of cases ; the clinic is supplied with a considerable staff of assistants, and all the teaching courses of the director are limited to the study and educa- tion of exceptional children. At the University of Pitts- burgh about two-thirds of the director's time has thus far been given to the work of clinical examination and to the supervision of the examination and investigation of chil- dren, but two courses foreign to the department have temporarily been carried. The ideal university clinics, from the standpoint of the amount of time actually given to clinical examinations, are those of the University of Pennsylvania, the University of Washington, the Univer- sity of Minnesota (save for the division of the work among several experimental psychologists rather than its assign- ment to a duly qualified specialist), and the University of Pittsburgh. Recognizing that the definition and standards of any science must be more or less fluid during its early stages of development, it has seemed advisable to place a rather liberal construction on what constitutes a psychological clinic and this has been done in the grouping attempted in the above classification. Accepting this grouping as approximately correct we have today in the higher insti- tutions of learning nineteen psychological clinics in Group I and seven in Group II, or a total of twenty-six (exclusive of Girard College). Sixteen of the clinics are in universities. Thirteen of these are in Group I, namely those of the University of Pennsylvania, Washington, Minnesota, Kansas, Leland Stanford, Missouri, Pittsburgh, Yale, Cincinnati, Tulane, 58 MENTAL HEALTH OF SCHOOL CHILD North Dakota, Iowa and Oklahoma. Three are in Group II: Clark, Cornell and New York University. Seven are in medical schools. Of these five are in Group I: the Vanderbilt Clinic of the College of Physicians and Sur- geons of Columbia University, the Psychopathic Hospital connected with the Harvard Medical School, the Phipps Psychiatric Institute of the Johns Hopkins Hospital and Medical School, New York Post-Graduate Medical School, Rush Medical College of the University of Chicago; and two are in Group II : Georgetown Medical School and the State Psychopathic Hospital of the University of Michi- gan. Three are in normal schools : one in Group I, Colo- rado State Teachers College ; and two in Group II : Los Angeles State Normal School and Mount Pleasant, Michi- gan, State Normal School. It is thus evident that over 61 per cent of the psychological cHnics in the higher educational institutions are in the universities. Fourteen of the clinics are in private institutions and twelve in state institutions. All the clinics in the normal schools, one clinic in the medical schools, and exactly one- half of the climes in the universities (including the city institution in Cincinnati), are in state institutions. Sixteen of the clinics are in populous centers (nine university, six medical and one normal), as against ten in small cities (seven university, two normal and one medical). The urban centers, no doubt, offer a very much better field than the rural districts for the successful organization of psychological clinics. Thirteen of the clinics are in departments of education (including the clinics in the three normal schools), seven are in departments of medicine (including the Johns Hop- kins and Harvard Clinics) and six in departments of psy- chology. The clinics at the University of Washington and NEW CLINICAL PSYCHOLOGY 59 Yale are supported by the department of education, al- though the laboratory of the former is in the department of psychology and of the latter in the dispensary of the medical school. It is significant that one-half of the clinics are in departments or schools of education. Three years ago I expressed the opinion that the university clinic dealing with mentally exceptional children (specifically the feeble- minded, backward, retarded, speech-defective, blind, deaf, precocious, word-blind, word-deaf, children with specific deficiencies in reading, spelHng, number work, writing) should preferably be located in the school or department of education. I am more strongly convinced than ever of the wisdom of that judgment. There seems to me to be no very convincing reason for locating the clinic in the college department of psychology. As well might we place the medical clinics in the college department of biology. Psychology is a science rather than an art, while the psy- cho-chnical examination of children is primarily an art (which, to be sure, presupposes a groundwork of scientific knowledge), just as teaching and medicine are primarily arts. Moreover, the aim of a clinic in the department of psychology cannot be other than the aim of a psycho- educational chnic, namely correct educational classifica- tion and advice regarding the corrective pedagogical training of the cliild. Similarly there is no very convincing reason why the psycho-educational clinic deahng with the types of men- tally unusual cases mentioned above (which are primarily educational cases and not medical) should be located in the medical school, unless it were placed in charge of a psycho-educational expert thoroughly trained to prescribe pedagogically for the school cases examined. To be sure. 60 MENTAL HEALTH OF SCHOOL CHILD there are certain positive reasons that can be advanced for locating the psychological clinic in the central clinic or hospital of the medical school: parents customarily bring children who appear to be 'not right' to medical clinics ; it facilitates the transfer of cases coming to the psychologi- cal clinic which require medical care to the appropriate medical specialists, and, vice versa, cases coming to the medical clinics which require special educational care can be readily transferred to the psychological clinic ; it will foster greater harmony and cooperation between examin- ing physicians and examining psycho-educationists, and this will remove some of the misguided opposition and unjustified prejudice against the psychological examiner which now obtains in various quarters. On the other hand, if the clinics are located in the medi- cal school they will frequently, perhaps generally, be manned by physicians who are neither psychologists, educationists nor experts in the differential methods of edu- cating pedagogical deviates. On the whole, the best plan for the organization of a psycho-educational clinic in a university is to place it under the direction of a well- trained psychological and educational examiner, and to affiliate it with, or place it under, the joint administrative control of, the schools of education and medicine, or of the schools of education and medicine and the department of psychology. In so saying, however, I wish to voice the opinion that every first-class medical school ought to establish a psy- chological clinic in conjunction with its clinics in neurol- ogy, psychiatry and psychopathology, primarily for the more detailed psychological study of neurasthenic, psy- chotic, psychopathic and psycho-neurotic cases, and only secondarily for the study of the types of cases which appeal NEW CLINICAL PSYCHOLOGY 61 primarily to the educational clinic. The director of the medical school psychological clinic (preferably a neurolo- gist or psychopathologist with extensive training in normal, abnormal and chnical psychology) should offer didactic, clinical and experimental courses (covering mental tests and psychological diagnosis) to all students specializing in psychiatry, psychopathology, psychas- thenics, neurology and psychotherapy. Not only have the medical schools of the country neglected adequately to provide for these and :allied courses for students specializing in psychopathology (our returns indicate that about a dozen medical schools are attempting a certain amount of this instruction and training; possibly a couple of dozen schools in this coun- try are offering measurably satisfactory courses) ;*' but until recently any student who did not have the bachelor's degree could graduate in any medical school in the coun- try without having taken a single systematic course in psychology — a fact which physicians themselves have lamented (Jones, Munro, Taylor, 17, 22, 27, 4). 'Most physicians are given not five minutes' training in psy- chology in the five years of their student life. There is no teacher of clinical psychology in any medical school in the country' (Jones). The average physician probably has less technical knowledge of the science of psychology 6 See, however, the recent report of the committee of physicians and psychologists appointed by the American Psychological Association (7): 'It is apparent that students and graduates in medicine who incline toward practice in diseases of the mind and nervous system have few or no opportunities in the medical schools in this country to acquire a broader acquaintance with the subjects of neurology and psychiatry, than the clinical courses which are offered.' 'At present the teaching of psychiatry appears to be in an earlier stage than surgery was in the two- or three-year course in medicine twenty years ago.' 62 MENTAL HEALTH OF SCHOOL CHILD than the average city grade teacher — all normal school graduates have been required to take at least one system- atic course in psychology. And yet the physician is expected to minister not only to the bodily but also to the mental well-being of his patient. Happily the situation in the medical schools is gradually changing for the better. Franz finds in his recent census that 'ten medical schools have already introduced, or plan to introduce next year, psychology into the curriculum or require it for entrance, and one advises students to take a course in psychology in the preparatory premedical years.' Moreover, of the sixty-eight medical deans or professors who answered the question, 75 per cent favored giving the medical students special instruction in psychology, while only 10 per cent gave negative and 15 per cent qualified affirmative or negative replies (7). There is, therefore, no need to hold a brief for the introduction of a required course in psychology for all the students in the premedical or medical curriculum. But it is well to reemphasize that the medical schools should make distinctly better provisions for teaching the special- ties in psychology for students preparing to specialize on mental cases. In justification of this contention it is only necessary to say that it is becoming generally recognized that the malfunctioning of mental processes may play a dynamic role in the production of certain nervous and mental disorders, and that mental factors play an impor- tant role in therapy (psychotherapy). The influence of suggestion, mental strife, latent complexes, suppressed wishes, morbid fears, obsessions, etc., in the causation of certain forms of abnormal behavior has been established by the researches of Freud and Jung and many of their followers, by the clinical observations and results of NEW CLINICAL PSYCHOLOGY 63 Dubois (5) and of other medical practitioners, and by the net results, however distorted, exaggerated and unreliable most of the reports are, of healing cults of a pseudo- scientific character (24). Among the disorders which are now believed by many to be largely psychogenic in origin are the neuroses proper (neurasthenia and anxiety neuroses, both related to dis- ordered sexuality, according to the Freudians), the psycho-neuroses (classical or Freudian conversion hys- teria, anxiety hysteria and compulsion neuroses, all re- lated, so says Freud, to suppressed yearnings or wishes of a sexual nature), the Hghter forms of hypochondria and melancholia, and various disequilibrations bordering on insanity. Since the pathology seems to be partly or wholly psychogenic, the treatment of these disorders must be partly or wholly ideogenic. It must consist in the modification of the patient's abnormal stream of thought, his faulty associative mechanisms, his morbid emotional complexes and attitudes and his perverted instinctive reactions, by the methods of suggestion, reeducation or psycho-analysis. The efficacy ascribed to drugs, physical agencies, 'healing thoughts,' or 'absent treatment' in the treatment of the true psycho-neuroses probably comes from the force of suggestion: the innate impulsiveness or tendency of ideas to express themselves in appropriate physiological adjustments or glandular activities (the law of dynamogenesis). Whatever the explanation, there is nothing occult in scientific psychotherapy: it is a legiti- mate division of psychology and medicine. The successful operator must be, first and foremost, a skilled clinical or medical psychologist. He must be able to inspire con- fidence by his manner and by a correct diagnosis and prognosis, to awaken hope by emphasizing the favorable 64 MENTAL HEALTH OF SCHOOL CHILD symptoms throughout the course of the treatment, to remove conflicting thoughts and suggest appropriate thoughts, to bring to the surface and to dissipate psychic complexes which cause mental strife, etc. Mental hygiene and therapy should not be left to dilettante and fakirs, as has been done: in psychotherapy 'the public has been left largely to its own devices, to become the victims of Chris- tian Scientists and dabblers in the occult, or misguided clergymen.' Various forms of mental affliction which have baffled medical skill have been left to untrained empirics and irregular practitioners, because medical curricula have made little provision for training physicians in the scientific mental therapy of psychic disorders. In conse- quence, we have for years been reaping a rich harvest of pseudo-psychotherapies. If now — to repeat — suggestion and psycho-analysis are the basal principles in the psychic treatment of the above varieties of mental disorders, and suggestive and psycho- analytic therapeutics are a legitimate branch of psy- chology and medicine, the conclusion follows that every complete medical school should make provision for instruc- tion and training in the science and art of psychological medicine. One of the divisions in the department of psy- chological medicine should be a laboratory of clinical psy- chology, in which the student may receive training in the psycho-clinical and psycho-laboratory methods of examin- ing patients. Training should be aff'orded in the methods used for testing specific mental deviations, for ascertaining the extent of the involution changes resulting from various dementias, and for measuring the degree of subnormaHty and supernormality. Practice should be given in the hypnotic, psycho-analytic and association-reaction meth- ods of mental diagnosis and treatment, possibly with NEW CLINICAL PSYCHOLOGY 65 some attention to the psychomotor or galvanometric tests. Lectures should be given on the psychological and thera- peutical aspects of suggestion, psycho-analysis, hypnotism or any of the methods which enable us to lay bare dormant, unrecognized, suppressed mental complexes or conflicts, disorders and blockages in the associative mechanism, tendencies toward repetition or perseveration of test words, sensory and motor automatisms, dissociation phe- nomena, obsessions, fixed ideas, phobias and confusions, and which will enable us to construct a differential psy- chology of various psychic disorders. When the medical schools have given proper attention to these matters, psychological criteria will attain a diagnostic value which they do not yet possess. In attempting to determine how many institutions are conducting training clinics for preparing students to psy- chologically and educationally examine mentally excep- tional children, we are again obliged, because of the vague standards of what a psychological training clinic is, to attempt an evaluation of the existing clinics. Some insti- tutions offer merely didactic, demonstration or experi- mental courses in mental tests and regard these as training chnics ; some institutions have the students test and experi- ment upon each other and regard these exercises as train- ing clinics; and others open their dispensary clinics (often neurological or psychopathological rather than psycho- logical or psycho-educational) to students for observation, and regard these as training clinics. It is clear that a genuine psychological (or psycho-educational) training clinic must afford students training in studying actual cases of mental deviation by the methods of psychological observation, testing and experimentation ; it must afford training in the larger aspects of case-talcing and clinical 66 MENTAL HEALTH OF SCHOOL CHILD procedure; it must have access to a large variety and an ample supply of clinical material; and it must provide instruction, supervision and guidance at the hands of an expert psycho-chnical (and psycho-educational) diagnos- tician. It is evident that a student who has been trained in a clinic frequented by a limited number of feeble-minded or backward children may be entirely ignorant of the great variety of perplexing cases of mentally and educationally exceptional children which are certain to come to the psychological clinic in the large urban centers. And it is entirely clear to my mind that no student can be gradu- ated from a university psycho-educational clinic as a thoroughly competent examiner unless he has made first- hand studies during an extended period of time (from two to four years, certainly not less than two) of a great variety of educationally unusual children — feeble-minded, border cases, backward, dull, normal, precocious, epilep- tic, aphasic, speech-defective, etc. The best provisions for training students in the art of psychological diagnosis are probably offered in the fol- lowing institutions : University of Pennsylvania, University of Washington and University of Pittsburgh. New York University offers good opportunities during the summer session — but the period is entirely too limited to make it possible to train experts. Among the other institutions reporting which afford students more or less opportunity for making observations, for conducting clinical examina- tions, or for making psychological tests and experiments are the following: the universities of Minnesota, Missouri, Yale, Leland Stanford, Cincinnati and Cornell ; the Col- lege of Physicians and Surgeons of Columbia, the Psycho- pathic Hospital of Harvard, the Phipps Clinic of Johns Hopkins, the New York Post-Graduate Medical School NEW CLINICAL PSYCHOLOGY 67 and Hospital and the Georgetown Medical College ; the State Teachers College of Colorado, the Brooklyn Train- ing School, the Marquette, and Mount Pleasant, Michigan, State Normal Schools, the Los Angeles State Normal School, the Chicago Normal College and the Philadelpliia Normal School for Girls. Classes for the purpose of training subnonnal children and for affording opportunities for observation are con- ducted in the following universities : University of Penn- sylvania, University of Washington, University of Indiana, New York University (summer session), Uni- versity of Pittsburgh (summer session) and the Uni- versity of California (summer session) ; in the follow- ing normal schools : Brooklyn Training School, Los Angeles Normal School, the State Teachers College of Colorado and the North Adams, Mass., State Normal School, while special attention is given to exceptional chil- dren in the Winona, Minnesota, State Normal, Monmouth, Oregon, State Normal and the Willimantic, Conn., State Normal; and in Rush INledical School (one morning only for all grades, which is an almost negligible amount). Clinics in especially the following institutions are assisting public school systems in the diagnosis and selection of cases, or in the supervision of the classes, or in utilizing the classes for purposes of observation : the University of Pennsylvania, the University of Pittsburgh, Leland Stan- ford, the University of Cincinnati, the University of Miclii- gan, the University of Minnesota, the University of Iowa, the University of Washington, Yale, the Phipps Psy- chiatric Clinic and the New York Post-Graduate Medical School and Hospital. On the whole, very few of the clinics in any kind of higher institution of learning have at their disposal satis- 68 MENTAL HEALTH OF SCHOOL CHILD factory 'special classes' in which mentally exceptional chil- dren can be properly trained, in which they can be studied under laboratory conditions and observed in a superior educational environment, and in which students in train- ing may be afforded superior opportunities for observation and cadet teacliing. Possibly this state of affairs does not invite serious criticism, for it is scarcely the function of departments of psychology in the universities or of medi- cal schools to conduct elementary classes for mentally unusual children. The duty of providing training for these children clearly rests with the public schools, and (although perhaps not to the same extent) with the observation and practice departments of colleges of edu- cation and normal schools. It is very desirable that classes for the educationally exceptional types of children be established in the practice schools of the latter institu- tions, in order that the diagnosis and training of these children may receive proper scientific study, in order that opportunities for follow-up work may be afforded, and in order that proper facilities may be afforded for training special teachers and expert examiners. But, after all, the colleges of education and the normal schools cannot care for 5 per cent of all the children who require special edu- cational treatment, and it is clearly the duty of the public schools to make adequate provisions for training 'all the children of all the people.' 2. The psychological laboratory and clinic in the hos- pitals for the 'insane.' The psychological chnic is rapidly finding a place in the public and private institutions for the mentally diseased and the mentally defective classes. In the hospitals for the mentally alienated much of the recent work of value in psychiatry has been done by psy- chologists or by alienists trained in the methods and NEW CLINICAL PSYCHOLOGY 69 imbued with the spirit of the new psychology. The pioneers in the new psychiatry are Wernicke, who, to be sure, recognizes the paramount importance of physical etiology in the consideration of mental diseases, but finds it inadequate for classification, and who makes the dis- orders of the content of consciousness primary (from liim we derive the concepts of psychosensory, intrapsychic and psychomotor disorders ; allopsychoses, somatopsychoses and autopsychoses ; afunctional, parafunctional and hyper- functional disorders) ; Ziehen, whose classification is thoroughly psychological (based upon the Herbartian and association psychology) ; Kraepelin, who employs the methods of psychological experimentation and the longi- tudinal method of analysis of the stream of consciousness (sequential course) for making a composite picture of the distinctive traits of various disease types ; and Freud, who has elaborated a unique method, the method of psycho- analysis, for purposes of diagnosis (disclosing submerged morbid mental complexes) and treatment, and who main- tains that the etiological factors in various neuroses are of purely psychic origin. In tliis country the psycho-bio- logical conception of various mental disorders has been ably championed by Adolf Meyer, M.D., the director of the recently opened Phipps Psychiatric Clinic at the Johns Hopkins Hospital, who has made notable contributions to the psychology of dementia praecox. Among other psy- chopathologists who are giving considerable study to the psychological aspects of mental disturbances may be men- tioned Drs. T. A. WilHams, A. A. Brill, Morton Prince, I. H. Coriat, Wm. A. White, Smith E. JelHfFe, Boris Sidis and August Hoch (the director of the Ward's Island Psy- chiatric Institute). Dr. Ernest Jones of the University of Toronto is an enthusiastic exponent of Freudian methods. 70 MENTAL HEALTH OF SCHOOL CHILD Psychological laboratories, manned by trained psycholo^ gists, have been established in the following institutions: McLean Hospital, Waverly, Mass., since 1904, with F. Lyman Wells, Ph.D., as director; the Government Hos- pital for the Insane, Washington, D. C, since January 1, 1907, with Shepherd Ivory Franz, Ph.D., as psychologist and scientific director; Friend's Asylum for the Insane, Frankford, Pa. (work temporarily suspended), and the New York Psychiatric Institute at Ward's Island (now apparently without a psychologist). Both Franz and Wells have published a considerable number of valuable experimental papers ranging over a wide field in the psy- chology of mental disease. The Massachusetts General Hospital maintains a psychologist (L. E. Emerson, Ph.D.), and more or less psychological research is being conducted at the King's Park Hospital, in New York State, by A. J. RosanofF, M. D., and very probably in numerous other hospitals for the insane and in psycho- patliic sanitaria. Many clinical examinations and investigations of the aHenated and psychopathic are necessarily partly psy- chological in nature, so that it is probable that psycho- logical research and psycho-cHnical examinations are conducted to some extent in the majority of state and private institutions throughout the country. 3. The psycho-climcal laboratory in institutions for the feeble-minded and epileptic. The initial impulse toward the organization of laboratories of psychological research in these institutions came from Dr. A. C. Rogers, who, in 1898, engaged a psychologist (who later also qualified as physician). Dr. A. R. T. Wyhe, to devote about half of his time to the psychological study of the patients in the Minnesota School for Feeble-Minded and NEW CLINICAL PSYCHOLOGY 71 Colony for Epileptics at Faribault. The fruits of Wylie's work, which continued for about three years, appear in a number of studies of the emotions, instincts, senses, memory, reaction time, and height and weight of the feeble-minded. The main impulse, however, toward the development of the work came from Superintendent E. R. Johnston of the New Jersey Training School for Feeble-Minded Boys and Girls at Vineland who, in 1906, appointed H. H. Goddard, Ph.D., as director of research. The work in Goddard's laboratory has progressed uninterruptedly during the last seven years, and has covered a wide range of interests in psychology and heredity. The laboratory at present commands the services of seventeen men and women includ- ing student assistants and heredity field workers. The following divisions have been organized : psychology ( with Mr. E. A. Doll as assistant psychologist), physiology (directed by A. W. Peters, M.D.,) and psychopatholgy (directed by W. J. Hickson, M.D.). The Vineland institution has also developed into a semi- nary of instruction. During the summer it offers training courses to teachers of retarded and subnormal cliildren, and to school medical inspectors. Beginning with the summer of 1914 only teachers who have already specialized in the study of the subnormal will be admitted to the teachers' courses. (Other institutions for the feeble- minded which recently have conducted, or are conducting, training classes for teachers are The Herbart Hall Insti- tute for Atypical Children, Plainfield, N. J. ; Rome State Custodial Asylum, Rome, N. Y., and Michigan Home for Feeble-Minded and Epileptic, Lapeer, Mich.) The result of the Vineland work is appearing in a num- ber of studies of the psychology and heredity of feeble- 72 MENTAL HEALTH OF SCHOOL CHILD mindedness, including percentile growth curves of height, weight, vital capacity, hand dynamometry, endurance; mental classifications ; heredity charts and studies ; record forms ; translations of graded tests for developmental diagnosis, etc. (10, 11, 12). The psychological labora- tory has a fair equipment of apparatus and a well-chosen hbrary of technical books and periodicals, domestic and foreign. Tliis laboratory may be regarded as the first genuine laboratory of clinical psychology to be established at an institution for the feeble-minded, and has exerted a very wide influence in its special field. Within the last few years departments of psychological research have been organized in a number of institutions for these defectives. In the fall of 1909 a laboratory — the second of the sort in the country — was established in the Lincoln State School and Colony of Illinois, under the directorship of Dr. E. B. Huey (14). This laboratory is now in charge of Dr. Clara H. Town. In the fall of 1910 the Faribault laboratory was reestablished with Dr. Fred Kuhlmann as director, and two new laboratories were established, one at the Iowa Institution for Feeble-Minded Children at Glenwood (this laboratory has been tem- porarily discontinued, but will probably be reopened in the near future), and one in the New Jersey State Village for Epileptics at Skillman. The latter laboratory, which was organized by the writer, is the pioneer psycho-clinical laboratory in colonies for epileptics. The work in this laboratory has been temporarily discontinued. In 1914 the Michigan Home for Feeble-Minded and Epileptics appointed a consulting psychologist (see p. 42). Among the private schools for feeble-minded and back- ward children which are making some provisions for the psychological examination of their pupils may be men- NEW CLINICAL PSYCHOLOGY 73 tioned the Bancroft Training School, Haddonfield, N. J. (E. A. Farrington, M.D., president) and Herbart Hall, Plainfield, N. J. (M. P. E. Groszmann, Pd.D., educational director). The latter institution is now fostered by the National Association for the Study and Education of Exceptional Children. During the summer and fall of 1913 its director traveled extensively throughout the far West and North- west, delivering addresses and organizing state associa- tions in affiliation with the national organization. Institutional positions in psychological research offer certain advantages. The incumbent is relieved of teaching duties and has ready access to an abundance of clinical material. He may also count on the sympathetic coopera- tion of the governing and administrative officers of the institution, for the view is now gaining acceptance that the functions of public hospital, custodial, training, correc- tional and penal institutions should not be limited to the care, treatment, occupational supervision and restraint of the inmates, but should include the scientific investigation of their present mental and physical status, and the condi- tions and causes which underlie various kinds of defective- ness and delinquency. Pubhc institutions should be laboratories of research as well as places for treatment, refuge, confinement and profitable employment. In order to be made attractive centers of scientific research, how- ever, the prerogatives and regulations affecting the research positions (in respect to the matter of stipend, rank, hours of service, vacations, publishing rights, per- sonal prerogatives, freedom from unnecessary restrictions, and from the absurd regulations of tyrannically inclined superintendents, etc.) should be made to conform with the rules which govern similar positions in the universities and 74 MENTAL HEALTH OF SCHOOL CHH^D research institutions. Only thus will the best scientific talent find the field sufficiently attractive to forsake the scientific, cultural, library and laboratory advantages which the universities furnish in such rich measure. At the present time the universities have practically a monopoly on the scientific producers of the country. According to Cattell's statistical study of American men of science, 75 per cent of the 1,000 scientists of the first rank are located in the colleges and universities (3). There is an inviting virgin soil for scientific investigators in institutions for defectives. Pro^dded that proper in- ducements are offered, these institutions bid fair to become large productive centers of scientific work in the near future. So far as psychological work is concerned, it is pertinent to point out that the function of the psychologist is to study mind in all its manifestations and under all its con- ditions. The psychologist should, therefore, have the free- dom of the institution ; he should have ready access to the patients in the cottages or schoolhouse or in the field, no less than in the laboratory. There may be a certain arti- ficiahty and formality about psycho-laboratory work, a certain unnaturalness in the attitude or the reactions of the subject toward the tests. This will sometimes render the results one-sided or partial, and, therefore, makes it desirable to do supplementary work under otheif conditions. 4. Clinical psychology in the juvenile court. The appHcation of the methods of clinical psychology to the study of the juvenile and adult offender is making rapid strides. The department of child study and pedagogic investigation of the Chicago public schools has for years done incidental work in this direction in connection with the schools for truants and delinquents. The first labora- NEW CLINICAL PSYCHOLOGY 75 tory to be directly connected with a juvenile court is the Juvenile Psychopathic Institute, organized in Chicago in April, 1909, by Dr. William Healy, who secured a fund of $30,000 with which to defray the expenses of con- ducting clinical examinations of juvenile court delinquents for a period of five years. It was considered that five years was sufficiently long to demonstrate the value of the work. Dr. Healy, with the aid of psychological and sociological assistants, is engaged in the study of the underlying factors, physiological, psychological, social and heredi- tary, of juvenile criminality, and is working particularly with the juvenile recidivist. According to press reports this Institute is now supported by Cook County. The city of Seattle established a division of diagnosis as an integral part of its juvenile court in 1911, with Dr. Lilburn Merrill as director, and Dr. Stephenson Smith as consulting psychologist. In September, 1913, Dr. V. V. Anderson was appointed assistant probation officer of the municipal criminal court in Boston, for the purpose of making psychological and medical examinations of crimi- nal offenders. Various charitable agencies in many cities are now attempting to supply the facilities for the psycho- logical, medical and sociological examination of juvenile court cases {e.g., according to report. New York, Newark, Baltimore, Minneapolis, Washington, Cleveland) ; but the psychological examinations are often made by amateurs or by physicians with little or no technical training in psychological diagnosis, or by psychiatrists with a distinct psychiatric rather than psychological and educational bias. Let me, in passing, express the conviction, however, that the problem of the juvenile delinquent is less the problem of the juvenile court than the problem of the public schools. 76 MENTAL HEALTH OF SCHOOL CHILD Listead of haling, a la wholesale, incipient or active child delinquents into court, only to parole the large majority of them — a procedure little calculated to impress the youthful offender with the gravity of his possible perver- sity, or with the respect due the legal statutes of the com- munity, or with the dignity and importance of court pro- cedure, and which in all events imposes a heavy tax on the community for the support of elaborate court machinery — all possible effort should be made to keep the young de- linquents out of court altogether. This can most success- fully be done by so organizing our schools that they will minister educationally to the peculiar needs of mentally and morally exceptional children. It is the public schools rather than the juvenile courts that should maintain in their educational divisions laboratories for the study and diagnosis of subnormal and delinquent children. Just as soon as the child manifests evidences of subnormality, or tendencies toward incorrigibility and truancy- — according to A. J. Pillsbury, 90 per cent of criminals began their criminalistic careers as truants in the schools — he should be examined in the psycho-educational clinic of the schools, which should also afford a medical, hereditary and socio- logical examination. As a result of the examination the child should be provided with appropriate physical treat- ment, if such is indicated ; he should be correctly classified psychologically and educationally, and he should be placed in the type of class which can provide the educational training which he requires. With a proper adjustment of the course of study to meet the needs of the individual delinquent the problem of juvenile delinquency largely solves itself. If you give abnormal children the kind of school work that they can do and that they Kke to do, and place them in a school environment that they enjoy, you NEW CLINICAL PSYCHOLOGY 77 will supply the most efficient and humane system of correc- tives for juvenile truancy and delinquency. Very suggestive in this connection is the experience of Los Angeles (Psychological Clinic, 1913, p. 84). In the public schools of this city special classes for persistent truants (boys) were started in 1905, dedicated to the proposition that no pupil shall fail or be suspended or expelled. In these classes the boys were provided with adaptable men teachers and with curricula more closely related to the life interests of boys. The boys were given the type of school work which appealed to their interests, and was adapted to their varying capacities. In 1912 there were nine of these classes. Among the notable results of this experiment are the following : (1) No boy was ever suspended or expelled from the special classes : the habit of suspending and expelling boys from the public schools practically ceased. (2) The average attendance in these classes for a period of seven years was 99 per cent: the fit school environment practically solved the non-attendance and truancy problems. (3) The truancy work of the juvenile court was prac- tically abolished: before the classes were organized all persistent truants were arrested and haled before the court. In 1905-1906 there were fifty-six of these cases; in 1906-1907, thirty; after that, never more than three a year, and one year none at all. Now the schools handle the truants, and more economically and efficiently. I repeat: the problem of the juvenile delinquent is pri- marily a problem for the schools — first, a problem of scientific diagnosis and, second, a problem of supplying a fit school environment. Juvenile courts should be courts of last appeal — for the persistently refractory cases and 78 MENTAL HEALTH OF SCHOOL CHILD for cases which cannot be brought under the compulsory education laws. 5. The psychological laboratory in penal institutions and correctional homes. Psychological tests (usually only the Binet and other simple tests by amateur psychologists) are now being given as a matter of daily routine to the boys and girls in a considerable number of reformatories and correctional institutions throughout the country. Examinations have been made since 1908 of the inmates (whose average age is 20.5 years) in the Massachusetts Reformatory for Boys at Concord, in order to determine their mental and moral status. These examinations have been made by Guy G. Femald, M.D. Physical tests are also employed for the purpose of selecting and segregating mental defectives. The most notable research institute in a correctional institution is the Laboratory of Social Hygiene in the New York State Reformatory for Women at Bedford Hills, occupying a ten-room building, equipped at a cost of $250,000 for the study of the causative factors and the best methods of training female (social) delinquents. The work in this laboratory began in July, 1911, under a $1,500 grant from the New York Foundation, but is now fostered by the New York Bureau of Social Hygiene. The director of psychological research and field work is Jean Weidensall, Ph.D. The staff will include a psychopatholo- gist, sociologist and educationist. The Indiana Reformatory, Jeffersonville, organized a department of research August 12, 1912, with Prof. Rufus B. von Klein Smid as director, F. C. Paschal and W. Beanblossom as assistants in psychology, R. W. Merrifield as assistant in social research and J. M. Walker, M.D., as consulting physician and assistant in medical NEW CLINICAL PSYCHOLOGY 79 research. The cost of the psychological equipment to date amounts to about $500. The department administers the problem of the discipline of the inmates, and controls the disposition of their time {i.e., it determines the char- acter of the work suitable to each case, the character of the schooling to be given different boys and the transfer of cases to other state institutions in which they more properly belong). Among the institutions which have more recently estab- lished departments of psychological investigation are the following: Girls' Industrial Home, Sleighton Farm, Dar- lington, Pa. (Miss Helen F. Hill in charge since 1913), and the State Home for Girls at Trenton, N. J. (Mar- garet Otis, Ph.D., resident psychologist). Psychological examinations are also conducted in the Massachusetts Reformatory for Women at South Framingham. In April, 1912, the New York Probation and Protective Association appointed Frederick Ellis, Ph.D., to conduct psychological studies of the socially delinquent girls who are in the care of the association. Mention may also be made at this point of the fact that several states (thus New Jersey and Minnesota) have within the last two or three years made definite legislative appropriation for the study of the heredity and psychol- ogy of their mentally and morally abnormal dependents and delinquents. The time is near at hand when our criminals and delin- quents, juvenile or adult, whether in juvenile courts, jails, prisons, reformatories, houses of rescue or detention homes, will be given individual study from the points of view of anthropology, medicine, sociology and of clinical and criminal psychology. Not only so, the time must come when the truthfulness of testimony and the veracity of 80 MENTAL HEALTH OF SCHOOL CHILD witnesses will be tested by methods other than the crude method of cross-examination (23). The laboratory method of determining capacity for correctness of descrip- tion and report will prove an aid to the jurist. Psychol- ogy is destined to contribute something toward making criminology and jurisprudence more scientific. When the methods of science have been appKed to the study of the delinquent and criminal, we shall be in a position to adapt the penalty, qualitatively as well as quantitatively, to the nature of the offender rather than to the nature of the offense. Frequently the roots of criminality lie embedded in a criminal neuropathic heredity, or in certain irresistible habits which have been engendered by vicious or criminal influences in the social environment, in a diseased or physi- cally malformed organism which thereby has become func- tionally maladapted to its physical and psychical environ- ment, or in mental deficiency. The role of the different causal factors must be rightly estimated for every indi- vidual offender before we can deal scientifically with the problems of crime and criminology. Our methods of crim- inal procedure have too long been on a par with that type of cure which treats effects but ignores causes. The Binet-Simon and other psychological tests will aid the ahenist and jurist in determining the mental status and responsibility of persons in commitment. The arrest, deviation or degeneration revealed by such tests will often be found to affect precisely those higher psychical powers without whose integrity of function the individual cannot attain that standard of conformity to law demanded by his social environment. It will frequently be found that the arrest or atrophy of various mental processes may be so serious as to produce permanent mental and moral maladjustment to the community ethical requirements. NEW CLINICAL PSYCHOLOGY 81 Offenses by such individuals may be without conscious criminal intent. There is no immorality of intent in their criminal actions, though there is immorality of act. Such individuals are, subjectively considered, unmoral, like the infant who cannot appreciate the distinction between right and wrong. Their immorality and criminality are resolv- able into mental deficiency. None the less, these persons are a menace to society, and require permanent restraint as a protective, rather than a punitive, measure. 6. The psycho-educational clinic in relation to voca- tional guidance. There are six essential functions of a vocational bureau. First, the maintenance of a free placement agency. This is the function apparently exalted above all others by the existing bureaus. Second, the making of a local vocational or industrial survey. This survey should include a tabulation of all the establishments of the community which afford employment to youthful wage-earners ; an appraisal of the moral, hygienic, sanitary and labor conditions surrounding each plant or type of industry; a determination of the initial and prospective ultimate financial returns yielded by dif- ferent occupations ; a determination of the chances for promotion together with the probable rate of advance- ment, and the prompt listing of positions as they become available. Third, the ascertainment of the physical health index and the salient anthropological indices of the applicants. It is unscientific and pernicious to place pupils in lines of employment for which they are unfitted by virtue of specific constitutional or acquired diatheses, diseases or defects, such as tubercular predisposition, gouty or rheumatic diatheses, neuropathic heredity, nasopharyngeal disorders. 82 MENTAL HEALTH OF SCHOOL CHILD certain auditory, visual or olfactory defects, or palsies or deformities of certain bodily members. How many of the existing so-called guidance bureaus pay any consideration to the vital factor of bodily efficiency? Many of the directors of these bureaus have no technical knowledge of the physiological factors concerned, and apparently many do not seek to obtain this knowledge. Fourth, the ascertainment of the individual vocational preferences, proclivities or inclinations of the applicants. 'Vocational guidance' which directs children into lines of employment for which they have no taste and in which they lack all interest is not only a misnomer, but it is culpable, inexcusable, blundering empiricism. Most children, pro- vided they possess the requisite psychomotor capacity, will succeed in any line of work in which they manifest a keen healthy interest. They will just as surely fail, or achieve an indifferent success, if they are placed in uninteresting, disagreeable occupations. Success in life work usually turns on hitching the right job to the right interest. How many existing bureaus make any effort to ascertain the real inclinations of the appKcants beyond asking a few perfunctory questions? How many make any effort to secure the independent judgment of the observant teacher or parent or the psychological specialist? Fifth, the determination of the general functional level of capacity or achievement — the mental or moto-industrial age — of the applicants. It is worse than folly to 'guide' children into vocations to whose efficiency demands they cannot adjust themselves because of all-round lack of mental or motor capacity. Many of the adolescent break- downs and adult neuroses and psychoneuroses are due to the inability of the persons to meet the exacting require- ments of the vocations in which they happen to find them- NEW CLINICAL PSYCHOLOGY 83 selves. To place a child with a nine-year mentality in a position which requires a fourteen-year mentality is to condemn him to repeated failure, perennial job-hunting and ultimate dependency, delinquency or mental and nervous collapse. Many children seeking the aid of the bureaus will rank in capacity with the pupils who are now in up-to-date schools placed in the special classes for morons, border-line and backward cases. We know that most of these children will not be able to support themselves in trades which require any considerable degree of technical skill or endurance. Without attempting to review all the available data as to the industrial inefficiency of the gradu- ates of the special classes of the public schools, I may state that the 'Royal Commission on the Care and Control of the Feeble-minded' concluded that 47 per cent of the pupils from the special classes of the London schools will never be able to earn their own living, 28 per cent probably will do so under proper direction, while only 22 per cent may be regarded as 'possible wage-earners.' The 'After Care Committee of Birmingham' followed up the careers of 650 graduates from the special classes of the city schools during nine years and found that only 18 per cent were doing remunerative work (at an average weekly wage of 6s. Id.) ; a later statement (School Hygiene, February, 1913, p. 7) indicates that 42 per cent of those reported were employed. Because the children were unable to retain their jobs, particularly as they grew older, the committee abandoned the free employment bureau which it conducted for four years. In Liverpool only 28 per cent were em- ployed, in Leeds 45 per cent were found in 'good promising or fair employment,' while the combined statistics in 1908 from nine English cities showed that only 22 per cent were at work and 6.8 per cent were in irregular work. Of fifty 84 MENTAL HEALTH OF SCHOOL CHILD cases selected at random from the 'ungraded classes' in the New York City schools only 4 per cent held permanent positions, 10 per cent had 'worked steadily for a few weeks at an average of $3.50 per week,' and the majority were 'utterly incapable.' Of ten graduates of the subnormal classes in the Chicago schools who were investigated three were wholly unfit for responsible positions, and the average weekly wage of the others was only $5.73. In Germany the record is better — 70 to 80 per cent of the auxiliary pupils can earn their living, according to Bottger — ^but that is largely because the pupils are placed in the type of work that they can do, and are given supervision by guardians and by masters-of-trade, under whom many of them labor. Recently it was my fortune — or misfortune — to witness a director of a pubhc school bureau of vocational guidance 'guide' a boy of fourteen into a line of work in which he must certainly fail. It would have been quite evident to a psycho-clinical specialist from a cursory examination that the boy was a microcephalic moron! Was it not essential for purposes of scientific guidance that this director should have known that he was negotiating with a feeble-minded boy who presumptively cannot stand the strain of skilled factory employment under the conditions of modern competitive industrialsm .^ What justification is there for calling this a guidance bureau when it makes no attempt to call in the consulting psychologist to determine the general level of functioning of at least the obviously abnormal cases.'' It is very clear to me that employers will not continue to go to school vocational bureaus for appHcants whose powers and capacities the bureaus have made no scientific attempt to evaluate. The present nation-wide interest in the establishment of bureaus of vocational guidance is commendable. But NEW CLINICAL PSYCHOLOGY 85 let us not forget that many if not most of the existing bureaus are unconscious of any obligation to the com- munity except that of making vocational surveys and list- ing and finding jobs for work-certificate pupils. They are merely free employment agencies. They fall far short of their highest function, namely, expert scientific guid- ance. It would seem to be more rational and profitable to establish the bureaus as a division of the department of psycho-educational diagnosis, than as independent depart- ments in the public schools, so that at least the more ob^aous cases may be given a psychological examination (not to mention the anthropometric and medical) to deter- mine their general mental status. This should be done before any attempt is made to direct them into a vocation. To repeat : vocational guidance should include more than making industrial surveys: it should include the making of human surveys, that is, surveys of the mental (and physi- cal) status of the applicants themselves. Only thus shall we be able to find the right man for the right job and the right job for the right man. Sixth, the determination of the specific motor, mental or industrial gifts or deficiencies of each applicant. Suc- cessful workers in specific trades, handicrafts and occupa- tions must possess a certain minimal amount of the specific traits or talents, or combinations of traits, demanded by the occupations in question. Those who possess in maximal degree the required traits constitute the preferred or talented class of workers. It is evident, for example, that successful typewritists must possess a high degree of psychomotor rapidity and accuracy ; successful motor men require, for certain of their duties, a high degree of rapid- ity, accuracy and range of obser^'ation, of celerity of response and of presence of mind. It is possible experi- 86 MENTAL HEALTH OF SCHOOL CHILD mentally to determine what mental capacities are required by successful telephone operators, ticket sellers, paper wrappers, railroad engineers, or any operative engaged in any line of skilled work whatsoever, and it is also possible to determine to some extent by psychological tests whether a given applicant for a job possesses the qualifications required by that job (25). However, we are better able with our existing diagnostic refinements to determine an individual's all-round grade of mental development than his specific vocational 'longs' or 'shorts.' Mention should be made in this connection of the study made of children who go into industry by the Schmidlapp Bureau and a number of private contributors, in Cincin- nati. The investigation includes a study of the effects of industrial work upon the physical and mental development of fourteen-year-old work-certificate children (comparative physical and mental measurements are made of fourteen- year-old children who remain in school), a study of the children who fail in industry (including a comparison of their performances in psychological tests), the establish- ment of age-norms for various psychological tests, and a study of the children's earnings, pay increases and amount of unemployment. The scientific work is directed by Helen T. Woolley, Ph.D. So far as I have been able to gather information no examinations have been made with a view to determining the general functional level or specific capacities of the appHcants for clinical purposes, hence the bureau cannot be classed as a psychological clinic, as some writers have done. 7. The psychological clinic in the immigrant station. At the fifteenth International Congress on Hygiene and Demography held in Washington in September, 1912, I NEW CLINICAL PSYCHOLOGY 87 took occasion to comment substantially as follows, at one of the sessions of the subsection on mental hygiene : 'Recently an attempt was made to induce Congress to enact a law excluding immigrants on the basis of tests of information or literacy. The bill passed by Congress deserved to be vetoed, because, in my opinion, it failed utterly to meet the situation. What we need on the side of diagnosis for detecting mentally defective foreigners is primarily not tests of information, erudition, literacy or mere acquisition, but tests designed to determine the strength of the power of acquiring information, psycho- logical tests of the inherent strength of various funda- mental mental traits. lUiteracy and mental deficiency (feeble-mindedness) are not synonymous terms. Many illiterates come to our shores who are perfectly normal in mental potentials, who are capable of making the best citizens, intellectually, morally, socially and industrially, and who should, therefore, not be deported. Their illiteracy is due to lack of educational opportunities or proper mental training. The problem is to distinguish this type of illiteracy from the type that is due to mental sub- normality. Really it is not a problem of literacy or illit- eracy as such, but a problem of capacity and incapacity. It is therefore evident that what we want are not chiefly tests of literacy, but tests of mental capacity. If so, the task of diagnosing mentally defective or feeble-minded foreigners is distinctly a psychological problem, and requires the services of an expert consulting psychologist who has had extensive first-hand experience with feeble- minded cases. The average medical immigration inspector is just as fully "at sea" when he tries to identify the sub- normal immigrant as the average medical school inspector is "at sea" when he tries to diagnose the various types of 88 MENTAL HEALTH OF SCHOOL CHILD educationally unusual children in the schools and prescribe appropriate orthogenic pedagogical treatment for each case. Neither the immigration nor the school medical inspectors have been specifically or professionally trained for these lines of highly technical and difficult work. Neither type of inspector would be able adequately to quahfy for this branch of service in less than two or three full years of technical training — this is especially true of the school medical inspector. Moreover, it may be said that the stock psychiatric methods of examination have little value except for the psychotic cases. The specialist on the feeble-mindedness of immigrants must receive a course of training which is just as specific and technical as that received by the specialist on the eyes, on dental sur- gery, on metallurgical engineering, or on kindergarten teaching.' The position thus taken has been regarded as far- fetched, but I believe it is essentially sound. Strong con- firmatory evidence that this is so is afforded by an experi- ment carried out during the course of one week at the immigrant station at Ellis Island by the psychological assistants from the training school for feeble-minded chil- dren at Vineland, N. J., the results of which have since appeared in print (Training School, 1913, p. 109). The experiment indicated that the government physicians on duty were able to recognize only about 10 per cent of a given number of the mental defectives passing through the port. Moreover, more than half of those whom they selected were incorrectly chosen, while seven-eighths of those selected by the Vineland workers were properly identified, as determined by later tests. Without raising the question as to the absolute relia- bility of the above data, there is no doubt that our immi- NEW CLINICAL PSYCHOLOGY 89 grant stations, because of their defective and inadequate examining machinery/ are annually permitting many hundreds of morons and imbeciles to land upon our shores. These immigrants will eventually become public charges and, unless restrained, will produce a prolific progeny of social and industrial incompetents. As long as the govern- ment allows this situation to continue, little headway can be made in the effort to reduce the defective, delinquent and dependent classes. The way to check this national evil is to establish psychological clinics in the immigrant sta- tions, and put them in charge of thorouglily trained experts — either physicians or psychologists — who must do more than give a few psychiatric, literacy, or hap- hazard commonsense psychological tests. They must attempt a fairly comprehensive and systematic survey of the stage of mental development of the suspect. 8. The psycho-educational clinic and bureau of re- search in the public schools. Unquestionably one of the most fruitful fields for the application of clinical psy- chology is education. Nowhere are the practical benefits to be derived more patent. American public schools have shown commendable enterprise in securing increased physi- cal comforts, the erection of costly material plants, the equipment of expensive laboratories for instruction, the organization of new courses to meet the enlarged demands of the altered social and industrial conditions of the twentieth century, but it must be confessed, to our shame, that they have lagged considerably behind the institutions ^ Two questionnaires were addressed to the chief surgeon of one of the immigrant stations, with the expectation that definite, unam- biguous information would be obtained regarding the character of the psychological examinations made of subnormal immigrants, but without avail. A psychological clinic, however, is evidently conducted at the ElUs Island station. 90 MENTAL HEALTH OF SCHOOL CHILD for the abnormal and defective in respect to the establish- ment of laboratories for discovery and research. So far as promoting or conducting departments for the scientific study of the problems which concern the normal health and development of the child's body and mind, the condi- tions under which such development can be most economi- cally secured, the questions of the most expeditious learn- ing and the most economic teaching methods, of fatigue, of the length of the school day and of the school year, of the scientific examination, and classification, segregation and treatment of the retarded, accelerated and delinquent, they have until recently done practically nothing. The one outstanding exception is the public schools of Chicago, in which a department of child study and pedagogic inves- tigation was established in 1899 (20). This department, which now commands the services of D. P. MacMillan, Ph.D. (director), F. G. Bruner, Ph.D., and Miss Clara Schmitt, has, since its organization, made various studies or educationally normal and misfit children — the blind, deaf, truant, retarded, feeble-minded, etc. — ^has regularly examined candidates for admission to the city normal school and has issued a series of valuable annual reports embodying its findings. During the last few years there has come a radical and gratifying change of attitude on the part of educational experts toward the exceptional child — the subnormal (idiot, imbecile, moron, border-line, backward and dull), the supernormal (bright, gifted, talented, precocious), the cripple, epileptic, speech-defective, blind, deaf and mute. It is now recognized by the intelligent public everywhere that the mentally deviating child sets a special problem. On a conservative estimate from 2 to 4 per cent of the retarded children in the schools are idiots, imbeciles, NEW CLINICAL PSYCHOLOGY 91 morons, border-cases, epileptics and pronounced neurotics and psycho-neurotics. From 15 to 30 per cent grade all the way from the border-line or seriously backward cases to the merely dull or slow-progress pupils. Fully one- third (in many systems one-half) of the public school children are pedagogically retarded when measured by the age-grade standard (approximately 6,000,000 pupils in the United States). About 2 per cent suffer from some form of speech defect. There is no more vital problem in educational administration, constructive philanthropy or race conservation than the organization of intelligent preventive, reconstructive, educational and reeducational work for the large army of mentally deviating children which encumber our schools. To neglect properly to care for these children would be to invite national disaster. The only effective method of dealing with defective chil- dren is to segregate them into special groups and to pro- vide special treatment, care, training or restraint. Not only will this policy tend to remove dead weights and irri- tating impediments from the regular classes, so that the typical, hopeful, progressive children may receive their just dues, but in the long run it will prove the only way in which the mentally handicapped child can be saved to society from a life of idleness, pauperism or crime. He can be saved only by being sufficiently prepared to discharge the industrial and social responsibilities of citizenship or, in cases where special training proves unavailing because of grave permanent arrest or defectiveness, by being iso- lated from society in custodial institutions. Let us not forget that the first step in the successful solution of this vital school problem is the earli/ selection of the abnormal children in the scJwols by the qualified psycho-educational examiner. 92 MENTAL HEALTH OF SCHOOL CHILD Owing to the combined influences of the laboratories of the Chicago schools, the University of Pennsylvania and Vineland, psychological tests are now being carried out in many public school systems throughout the country. In order to obtain accurate data in regard to the character of the work done in psychological diagnosis, as well as the educational provisions made for mentally unusual children in the public schools, a questionnaire was addressed October 29, 1913, to the superintendents of public schools in the United States. The returns will be given in Chapter XVIII. At this point reference may appropriately be made to the state law enacted in California in 1908, authorizing the establishment of departments of 'health and develop- ment supervision' in the public schools under the control of boards of education or of school trustees. The program of work contemplates the annual physical examination of pupils and a 'follow-up' service, in order to correct physi- cal abnormalities and to provide the conditions essential for the maintenance of continuous health and normal growth; the adjustment of school activities to meet the developmental needs of the individual in respect to health and growth; the scientific, systematic study of mental retardation and deviation; proper sanitary supervision; the physical examination of candidates for teaching posi- tions and of teachers in service to determine their vital fitness and the amount of work which may reasonably be required of them without imperiling efficiency, and the appointment of expert educator-examiners to conduct and supervise the work. These examiners must qualify as experts in child hygiene and physiology. Above all, they should, in my judgment, be trained in the methods of clinical psychology and educational diagnosis. The pro- NEW CLINICAL PSYCHOLOGY 93 jected California work thus rests upon a far broader basis than the system of medical inspection now in vogue, and will make it possible to grade children in health as well as in studies. The law is not mandatory. Under this law quite a number of school systems in Cali- fornia have established departments of health and develop- ment supervision (although the work done is probably largely restricted to the ordinary medical inspection rou- tine). But it is interesting to note that two of the most progressive school systems of the state have established psychological clinics independently of the department of health and development supervision, namely Los Angeles (with Mr. George L. Leslie, who was responsible for the 'health and development law,' as director) and Oakland (Mrs. Vinnie C. Hicks, director). While theoretically it would seem desirable to locate the psychological clinic in the department of health and development supervision, practically it may be better to conduct the psycho-educa- tional examinations in a separate department of the schools, in order that the work may not be identified with the usual routine of medical inspection, in order that it may not be unduly hampered by the red tape which attaches to large departmental organizations, and in order that this important work may not be assigned a wholly minor role in a department whose primary interests may be quite foreign to the pedagogico-corrective treatment of mentally unusual children. The Possibilities of a Bureau of School Research In view of the fact that the intelligent educational public is gradually becoming reconciled to the proposition that the changed industrial and social conditions of modern life necessitate the organization of various new school 94 MENTAL HEALTH OF SCHOOL CHILD agencies — departments of medical and dental inspection, of school hygiene, of experimental pedagogy-, of social survey work, of psycho-educational laboratories for the examination of exceptional children — I wish to pause a moment to outline briefly the work which a bureau of school research might profitably undertake for the good of the schools. At the outset it should be said that the results of the various agencies which are being organized in the schools for purposes of educational investigation and diagnosis are liable to run to sand unless they are properly unified, correlated and brought to a focus. There is need, there- fore, of a central, unifying bureau or department of school research, in charge of a director of school research, where the data collected by the various examining agencies may be gathered, preserved, compiled, compared, corre- lated, interpreted and turned to practical use. The director of such a bureau should be an expert in child, educational and clinical psychology, who has done productive work of recognized merit in these fields. He should be thoroughly familiar with the methods employed by these sciences and by experimental pedagogy, and should have some knowledge of medical inspection work (a minimum of knowledge in regard to physical diagnosis and the signs and symptoms of physical defectiveness and nervous instability). He should be a technical education- ist, with practical teaching experience, preferably in public and teacher-training schools, and must possess the ability to plan and direct the work along broad, progres- sive lines. His should be distinctly a position of leadership in the educational work of the schools, ranking as a direc- torship or assistant superintendency, and nothing but a thoroughly trained, broad-gauge, technical, psycho-edu- NEW CLINICAL PSYCHOLOGY 95 cational consultant should be able to qualify. (Paren- thetically let me say that since the above was first written, bureaus of statistics, reference or research have been estab- Ushed in the public schools of New Orleans, Rochester, Baltimore and New York City. Cleveland also maintains a statistician. While these bureaus have other functions than those given below, the program of work in some of them includes statistical and clinical studies of retardation and the giving of efficiency tests.) The materials to be collected and correlated by our bureau should be derived from the following sources : 1. Records and charts of physical (medical and dental) examinations and treatment — nasopharyngeal and dental charts, showing the locations of nose and throat obstructions and defective dentures ; vaccination records and charts, showing the dates of inoculation and the num- ber of vaccine scars ; abnormalities of the respiratory, cir- culatory, nutritive, muscular, osseous and nervous systems ; sensory defects (visual, auditory) ; records of operations and of medical and dental treatment, with the carefully determined results of such treatment, etc. The data should be recorded annually, if possible, on duplicate cards, which should accompany the child from grade to grade. The originals should be filed in the bureau of records. It would lead the discussion too far afield to consider what should be the detailed functions and relations of the department of physical or medico-dental examination. The matters in dispute revolve around the questions whether the work should be entirely confined to examination, or whether it should include free treatment, at least for the minor ailments (22) ; whether the system should be under the control of boards of health or of school boards ; whether inspection should be supplemented by follow-up educational 96 MENTAL HEALTH OF SCHOOL CHILD care, treatment and supervisory work by a corps of school nurses, both in and out of school; whether it should em- brace the sanitary inspection and supervision of the school plant ; whether it should include instruction and supervision in individual and school hygiene; whether it should include provision for, and supervision of, school lunches, gratuitously available to indigent anemics, for school baths, gymnasia, etc. These questions cannot be answered in the abstract; in the near future they will loom large in the educational discussion of the day. They constitute one phase of the large eugenics or euthenics movement which has recently been forced into the focus of public attention by the threatened dangers of national degeneracy and racial decay of highly civilized races — dangers which, e.g., are evidenced in a lessened rate of fertility under the conditions of civihzed life (which is man's conscious attempt to domesticate himself) ; con- tinued high infant mortahty in spite of hygienic progress ; the enormous presence of physical defectiveness (cf. Chap- ters I and XVI), and the alleged prolific increase of de- generate or neuropathic offspring (feeble-minded, epilep- tic, criminal and insane). These problems cannot, in the face of present knowledge, be solved in any rule-of-thumb fashion; they must be solved according to the exigencies of the case and according to the results of experience. The ancient Spartans found it essential to their national safety to exercise practically unlimited supervision over the physi- cal, hygienic, social and educational regimen of the child, and they therefore removed him entirely from the family home. During these latter days we have been rapidly approximating the Spartan ideal, because recent condi- tions have been at work which have forced a return toward it. The first law of individual as well as of national life NEW CLINICAL PSYCHOLOGY 97 is the law of self-preservation ; against this primal law pre- conceived notions and paternalistic or communistic phobias avail naught. The patrons of the schools demand, as of right, that the schools shall foster those agencies and practices without which they cannot realize proper divi- dends upon their investments, and without which the forces in the modem environment which are destructive of the public weal cannot be successfully combated. Ultimately all those measures must surely be introduced into the schools which are essentially for national self-preservation ; the fundamental imperative of national self-preservation will take precedence over all other considerations, and theoretical scruples will be powerless. There is another important question affecting medical school inspection which we can here merely raise: Who should be eligible for appointment as medical or physical school inspectors .f* Many of the present incumbents pos- sess neither technical training nor interest in the work. This is one reason why so much of the inspection work is perfunctory and thoroughly unscientific. A class of experts for this work scarcely yet exists, because at the present time there is probably not a university or medical school in the country that provides special, technical training in medical school inspection. Recently short courses of this character have been given by Dr. W. S. Cornell in the New Jersey Training School at Vineland. Until we secure a class of expert school health examiners — specialists in the neuro-physical and developmental defects and maladies of childhood, in school hygiene and sanita- tion, and in the theory and practice of dento-medical school inspection — appointees should be selected from the expert pediatricians or from the general medical practitioners who show a vital interest in the distinctive problems of 98 MENTAL HEALTH OF SCHOOL CHILD medical school inspection. The dental work should be directed by a doctor of dentistry. 2. Sociological, personal and family data. We cannot satisfactorily diagnose a subnormal or defective pupil by merely examining his present bodily conditions. There are other influences, hereditary, developmental and envi- ronmental, which have contributed to make him what he is. These we must understand. We must know something of the social organism of which he is a constituent member — something of his home, his community, his street life. The out-of-school activities and the economic, sanitary, hygienic, moral and intellectual conditions of the home and neighborhood often make or mar the individual. Properly to diagnose his condition we must know some- thing about his food and drink, about the adequacy of his raiment and sleep, about the purity of the air he breathes, about the wholesomeness of the games and amusements which he enjoys and the resorts which he frequents, and about the care and treatment which he receives in the home. We should obtain a record of his developTnental history, of his past habits, diseases, disorders and eccen- tricities. Particularly important are records of early dangerous tendencies, tantrums, fits, outbreaks or dis- orders or diseases which are 'prodromal' of oncoming adolescent or adult instabilities, neurasthenias and psy- chasthenias. And properly to estimate his hereditary dower — his inborn capital or native handicap — we must know something of the stock from which he springs, his direct and collateral antecedents. The two fundamental factors which make or mar the life of every child are heredity and environment. But it is impossible to determine offhand, and frequently even after considerable study, which of these two factors is more NEW CLINICAL PSYCHOLOGY 99 largely responsible for a child's degeneracy or delinquency. The view that acquired degeneracy exceeds the inherited became rather prevalent some time ago, perhaps as a reaction against the Italian or Lombroso school of crimi- nologists who manifest an exaggerated tendency to refer all mental abnormalities to biological causes, and who maintain that there is a very prevalent degenerate (spe- cifically criminal) type which is born and not made. But recent heredity studies of feeble-mindedness, epilepsy and insanity show the preponderant influence of neurotic ancestral strains. Be this as it may, it is unquestionable that a vast amount of abnormal conduct is acquired from, or accentuated by, a bad environment ; from physically and morally unclean slums, from squalid or unhealthy homes, from vicious resorts, social vices, unhygienic school prac- tices and habits, etc. The first treatment which a child reared in the underworld needs is to be rescued: he must either be removed from his evil surroundings or his environ- ment must be reformed. This accomphshed, he must be supplied with proper training, food, sleep, exercise and clothing. Instances of children who have been transformed in body and mind by these measures have been frequently recorded ; modern 'hospital' or 'orthogenic' schools are demonstrating what can be done through the work of scientific, educational and social reclamation. Obviously it would be folly to aim to include in the above survey all the pupils of the school. At best we must be satisfied to include only the problematic or defective cases. Much valuable information can be gathered, of course, by teachers, principals and school nurses ; but a field worker, trained in social survey work, should be added to the staff for this particular type of service. 3. Pedagogical records from the schools. The bureau 100 MENTAL HEALTH OF SCHOOL CHILD we are advocating should also keep on file the pupil's school reports and records, particularly the records of the 'problem' pupils — feeble-minded, backward, neurotic, truant, etc. These records, to be made out by classroom teachers and principals, should contain facts in regard to the child's age and grade (pedagogical retardation), the number of months he has been in school, the grades re- peated, the amount and type of work that he has been able and that he has not been able to do, his attitudes, disposi- tions, demeanor, behavior, dominant interests and aver- sions, vocational bias, regularity of attendance, etc. Such records will attain a unique value when studied in the light of the data from other sources. 4. The results of controlled educational experiments. A department of experimental pedagogy should be one division of a complete bureau of school research. This department should study, under principles of scientific control, the important school problems in pedagogy: methods of teaching and learning various branches, rest and work periods, fatigue, recreation, the relation of temperature to working efficiency, the content and articu- lation of courses, etc. It should standardize efficiency tests and apply pedagogical measuring scales in the various branches of study. Some of the problems would be solved experimentally in the laboratory; others could best be solved by controlled school tests, and others would be studied in special experimental schools. The laboratory connected with the Chicago schools has devoted a slight amount of attention to problems of this character. The results of the pedagogical experiments should be corre- lated with the other data in the bureau. 5. Psycho-clinical records from the department of clinical psychology. One of the most important divisions NEW CLINICAL PSYCHOLOGY 101 of the bureau should be a laboratory of clinical psychology for the individual study of pupils, particularly subnormal, supernormal and delinquent children. The central aim of this department — we shall discuss it somewhat in detail presently — should be the scientific investigation of abnor- malities of psycho-educational development. Conceived in this large way, the bureau of school research would become a large scientific, educational clear- ing house, a vital agency for the scientific correlation of pedagogical facts and a potent instrument for the dis- semination of reliable educational data. It is only when we view the child from all angles — from the bodily, the psychical, the pedagogical, the sociological, the develop- mental and the hereditary — that we are in a position thoroughly to understand him, and that we are able to deal effectively with the problems of mental exceptionality. Perhaps we can best illustrate the point we wish to make by reference to the questions of retardation and accelera- tion, which are far more complex than would be supposed at first blush. When we are dealing with the development of a child we are dealing not with a single equation, but with a number of variable equations. Instead of one con- stant age, we may speak of a child as having six ages : a chronological, a physiological, an anatomical, a socio- industrial, a pedagogical and a psychological. So far as the chronological age is concerned, there can be no question of retardation ; a child born precisely fifteen years ago is chronologically exactly fifteen years old. But physiologi- cally, anatomically, pedagogically, socio-industrially and psychologically his development may spread over a number of ages. Physiologically, our fifteen-year-old child may be, say, only thirteen years old. Measured by the ma- turity of bodily functions, e.g., by the degree of pubertal 102 MENTAL HEALTH OF SCHOOL CHILD or pubescent development (or size, which it is claimed, rouglily corresponds, 6), he has the body of a normal child of thirteen. He is physiologically two years re- tarded. Anatomically — i.e., measured by structural changes, particularly by the degree of ossification of the cartilage, Rotch's X-ray method — he may be fourteen years old, or only a year retarded. Measured by the socio-industrial or motor standard — i.e., by his rate of acquiring the fundamental social functions and various motor or industrial operations — he may be sixteen years old, or a year accelerated. Similarly, our fifteen-year-old child may be retarded 'pedagogically three years ; i.e., assuming that he started school on time and has arrived at his present grade three years later than his classmates in the first grade, he has a pedagogical development of twelve years. He is pedagogically retarded, whatever the cause — mental defect, physical handicap, frequent absence, transfer, lack of application, etc. Finally, the psychical age of our fifteen-year-old may be, say, only eleven ; he has the mental development of a child of that age. It might be assumed that the pedagogical and mental ages would coincide. At times they will, but by no means always. The child's pedagogical retardation may be due merely to late entrance, irregular attendance, frequent transfers, lack of interest in the particular tasks set by the school, or because some temporary handicap may have especially crippled those mental functions {e.g., memory and atten- tion) which play an important role in the learning processes of the school, in which case the pedagogical retardation may be greater than the mental. On the other hand, his pedagogical retardation may be less than his mental, for he may have been promoted undeservedly (32) ; or his abilities may have been overestimated, owing NEW CLINICAL PSYCHOLOGY 103 to a heightened development of some special mental func- tion {e.g., memory) ; or he may have been pushed forward because of the pressure brought to bear on the classroom teacher to eliminate failures or to minimize the number of non-promotions. Accordingly, the child's actual mental development needs to be determined independently by serial graded age-tests, which are sufficiently compre- hensive to include tests of the fundamental mental func- tions, capacities and powers. Until recently we had no such tests — no measures of mental age that were regarded as scientifically valid. Now, thanks to the laborious and ingenious investigations of Binet and his co-worker, Simon, we have a set of graded tests which render it possible somewhat approximately to ascertain, in terms of age, the intellectual status of a child below the teens or the degree in which his intellectual development varies from the aver- age or typical child of his chronological age. While these tests are neither exhaustively comprehensive, 'amazingly accurate' nor 'infallible' — as recent experimental studies show (1, 12, 15, 19, 21, 28, 31) and as I shall point out in later pages, they give us a consistent, practical, im- personal, objective, scientific method of determining psychological retardation, which is of considerable service to the expert psycho-diagnostician. Standardized, graded intelligence tests should be given in all the large school sys- tems under the direction of a qualified expert. The Schoot. Psycho-educationai- Laboratory Where the establishment of a bureau of school research upon the comprehensive plan sketched above is not feasible, the most urgent need should be provided for, namely, the establishment of a clinical laboratory for the examination and grading of retarded children. 104 MENTAL HEALTH OF SCHOOL CHILD I do not intend to imply that only the retarded child should receive the advantages of scientific diagnosis. No type of child has, perhaps, been so thoroughly neglected as the supernormal child, the child on the plus side of the curve of efficiency. This is probably due largely to the fact that 'accelerated' children are not nearly so numerous as retarded children, as shown by the available surveys, and to the fact that they do not encumber the machinery of the schools as do the retarded pupils. The supernormal or precocious child is the incipient genius ; and it is chiefly through the constructive achievements of its geniuses that civihzation advances. Both of the extreme types of the 'special' child merit special study and treatment: the sub- normal child, in order that he may be relieved, so far as possible, of his physical and mental handicaps, so that he may become as little of a burden to society as possible ; and the supernormal child, in order that he may be surrounded with those conditions which, on the positive side, make for the freest and largest development of his potentialities, and which, on the negative side, will not serve to distort, abort or repress his natural powers. Since it is probable that most of the new laboratories which will be established will be dedicated to the study of the subnormal child, it is to be hoped that a laboratory will be established with the express and exclusive aim of studying the supernormal child, and that, eventually, all the large public schools will organize definite plans for conserving and furthering the interests of its incipient geniuses. Nevertheless, the enor- mous prevalence of retarded as compared with accelerated pupils makes the identification and segregation of feeble- minded and backward children the problem of paramount importance. In New York City there are eight slow-progress pupils NEW CLINICAL PSYCHOLOGY 105 for every rapid-progress pupil ; in a Massachusetts city the relation was found to be 21 to 1 ; in a Pennsylvania city, 14 to 1 (13) ; among 8,942 graded pupils in Bureau County, Ilhnois, 57.5 per cent were behind the normal, while only 8 per cent were ahead, and among 2,090 rural pupils, 53.5 per cent were retarded, and only 12 per cent ahead; of the 137 pupils whose records were traced through the grades in Princeton, 111., 69.3 per cent were behind time, and only 4.6 per cent accelerated (8, 9) ; in a Baltimore class, where the progress and retardation was likewise traced for 43 pupils from the first to the eighth grade, 77 per cent arrived late, while only one arrived ahead of time (16) ; in three Chicago schools the per cent retarded was 68.1, the per cent accelerated 8.1 ; in Cin- cinnati (report of 1907: 26) the proportion was 58.4 per cent to 9.6 per cent ; in Mauch Chunk township. Pa., 34.5 per cent to 16.6 per cent (for 842 pupils studied; most of the accelerated started early: 30) ; in five cities studied the retarded were from 10 to 150 times as numerous, and in 29 other cities from 8 to 10 times as numerous (Ayres). It has been said that three out of every four must do one room twice, and statistics show that from 33 to 50 per cent of the pupils in the schools are over age for their grade. In the light of these statistics — and I have given a mere hint of the available data — it becomes imperative to under- take a thorough study of the extent, causes, results and treatment of retardation — the great threatening colossus of the modern school. It is particularly important to make psycho-educational examinations to determine the degree of the mental deficit of the retardate, to determine whether the retardation is a case of inherent deficiency or subnormal mental development, or whether it is the result of adventitious factors, such as late entrance, transfer, 106 MENTAL HEALTH OF SCHOOL CHILD irregularity of attendance, illness, physical defectiveness, language deficiency, home abuse, poor teaching, lack of individual tuition, maladapted courses, indifference, etc. Until the schools make greater efforts to discover the cause of the lack of progress of the individual retardate, the orthogenic treatment cannot be made scientifically accurate or practically effective. It is the worst sort of possible economy to attempt to train subnormal children without a prior scientific educational diagnosis. The Specific Functions of the School's Psycho- educational, Laboratoey 1. The clinical exaimnation of exceptional children. Every child retarded pedagogically over one year should be given a special preliminary medical examination, and then referred to the laboratory for a psycho-educa- tional examination. The tests should, where possible, include graded serial tests for determining mental age, form-board tests, sensory-motor tests, which have a diag- nostic value (auditory and visual acuity, motor skill, co- ordination, hand dynamometry, endurance, body sway) ; selected standardized tests of fundamental intellectual traits (memory, spontaneous and controlled association, accuracy and quickness of perception and observation, recognition, linguistic construction, learning capacity) ; speech tests, certain physical and anthropometric growth measures (sitting and standing height, weight, thoracic perimeter, spirometry, head circumference, together with vital, ponderal and statural indices, and perhaps tests of anatomical age), and certain reflex action tests. In selected cases the psycho-analytic (Freud) and reaction- association (Jung) tests may be relevant for purposes of NEW CLINICAL PSYCHOLOGY 107 diagnosis of more fundamental or obscure mental abnor- malities. Anthropometric percentile curves and indices should be plotted for each child, showing his status relative to the normal child of the same chronological, and perhaps also anatomical and psychological age. To plot such curves we stand in need of reliable norms for typical, average or normal children. Since we do not now have fully satisfactory norms, one of the functions of the laboratory at the present time should be : 2. The establishment of thoroughly reliable anthropo- metric norms for normal children. To be sure, we already have anthropometric norms for certain functions, e.g., those worked out by the Department of Child Study and Pedagogic Investigation of the Chicago schools. These norms are perhaps reliable so far as they go, and have sufficient validity to enable us to proceed at once, without awaiting confirmatory or more elaborate measurements, to measure and grade, with considerable confidence, any given cliild, whether subnormal, normal or supernormal. Yet the fact remains that it is still desirable to repeat Smedley's percentile measurements (or measurements designed to give anthropometric indices, Avhichever type of measurement ultimately will prove the more valuable) on height, weight, vital capacity, manuometry, endurance and other functions on a much larger scale and under more satisfactory conditions.^ For Smedley's norms are not entirely satisfactory in four respects : In the first place, they are based upon the examination of too few persons. To secure thoroughly reliable normal norms we should examine at least 1,000 persons of each 8 The task involved in gathering reliable mental and physical norms, for both children and adults, is herculean, and would require the combined efforts of many workers. The work should be organized 108 MENTAL HEALTH OF SCHOOL CHILD sex for each year, and each one-half year during early childhood. Smedley's numbers for given ages ranged from 44 (ages nineteen and twenty, boys) to 448. I do not believe that in a country like the United States where so many nationalities commingle we can be satisfied with one hundred for each age. In the second place, we have no evidence that the norms are normal norms; i.e., that they are based upon the exami- nation of typical or normal children. In fact, the proba- bility almost amounts to a certainty that a considerable number of the pupils examined were more or less subnormal or abnormal. It is, therefore, possible that the percentile curves or indices for any case of retardation plotted on the basis of these results will misrepresent the development of the pupil in comparison with normal children. Measure- ments seem to show that anthropological indices are atj^pical for mentally abnormal persons. Of course, the concept of a normal norm — a typical, normal individual — is quite fluid or elastic. How shall we determine who is normal in advance of making the tests.'' by a public or endowed private bureau of research, so that it may be done with sufficient thoroughness, so that uniform or standardized methods may be used, and so that the results may be worked up in the most serviceable form. Properly to study any given individual — normal, criminal, insane, demented, amented — we must have individual and typical percentile curves or indices of physical development, and standards of mental attainment for various ages. I know of no form of public service which merits more fully the liberal support of philanthropic persons who have the interests of child reclamation or eugenics at heart. It is a work that should be munificently endowed. One of the essential functions of the Russell Sage Foundation, and the Government Bureau of Child Welfare, might well be the establishment of mental and physical norms of development. Meanwhile, our psycho-clinical school laboratories should contribute their mite toward obtaining these norms for persons of school age. NEW CLINICAL PSYCHOLOGY 109 This is extremely difficult to say. Unless we are satisfied to use random, unselected groups and assume a symmetri- cal curve of distribution, we must adopt some criteria. So far as I know there are only two criteria which are at all available for selecting normal school children : namely, school grade (pedagogical status) and degree of physical defectiveness. On the basis of the first standard, the pupils of a given age who satisfactorily carry the work of the school grade to which they chronologically belong (or of an earlier grade in case of late entrance), may be considered mentally normal. The other method of selection is based upon the physical and medical examination of the child. That child may be regarded as physically normal who does not possess serious physical defects, or in whom the ravages of infant and childhood diseases have not resulted in pronounced physi- cal impairment. In other words, those children would be physically normal who suffer only from the ordinary amount of physical defectiveness. Even under the best conditions of modern life, the cliild with assumed 'normal' motor and sensory equipment will show some traces of physical defectiveness (21, 22). It is, therefore, chiefly important to exclude all the extreme departures from physical normality. Both of these methods of selection are practical, and the norms obtained by them ought more genuinely to represent normal norms than the norms obtained by testing unselected cases. The vahdity of the latter must always rest on the assumption that there are just as many super- normal or accelerated as subnormal or retarded indivi- duals. This I regard as improbable. Norms secured according to the above suggestions would not only give us 110 MENTAL HEALTH OF SCHOOL CHILD valuable measures of the mental and physical powers and capacities of people of the present generation — racial and national indices — but indices by means of which to deter- mine the character and extent of the changes in human functions which are gradually taking place through hered- itary propulsion and environmental influences. In the third place, Smedley's range of ages, from four to twenty-one (or 'twenty-one years and over'), is too limited. It embraces merely the periods of childhood and adolescence. We need norms for infancy and the adult or the ebb period of life as far as the age of forty or fifty, at least. Such norms would perhaps have no immediate practical value for the public schools, juvenile courts or correctional and rescue homes for the young, but to the student interested in the scientific study of the problems of human evolution or in the study of the degenerative, involution, senescent changes peculiar to the process of aging, or in the study of the various physical and mental deviations peculiar to various classes of defectives (feeble- minded, epileptic, insane, criminal, paralytic, etc.), they would possess unusual value. At the present time we have little knowledge that is scientifically accurate regarding the growth (developmental or retrogressive) changes peculiar to middle and old age, because the norms are practically nonexistent. In the fourth place, Smedley's percentiles are given for whole ages only — 4, 5, 6, 7, 8, 9, etc. A child who is six years and one day old is grouped with one who is six years and 364 days old. Consequently, children who are prac- tically one year apart in age may be grouped together. This tends to introduce a considerable error, owing to the kaleidoscopic developmental changes which occur during the growth period. During this period the results which NEW CLINICAL PSYCHOLOGY 111 are valid for the youngest child of a given age may grossly misrepresent the oldest child of that age. Accordingly, a better plan would be to group children by half -ages, thus : 4, 41/^, 5, 5l^, etc. Thus, the six-year group would include children from five years ten months (beginning of tenth month) to six years three months (end of third month), while the six and one-half-year group would include cliil- dren from six years four months (beginning of fourth month) to six years nine months (end of ninth month). (I am now establishing certain norms according to this plan.) In other words, children are grouped under a given age-designation whose age is within three months in either direction of that designation. For the years following, the early growth period of the present grouping by whole ages is probably satisfactory. What has been said above applies to all kinds of norms : it must be emphasized that the norms required are not merely physical and anthropometric, but also psychical and pedagogical. 3. The establishment of thoroughly reliable psycho- logical norms of development for normal children. Every- thing that has been urged in respect to the need of estab- lishing normal anthropometric norms and indices applies to the establishment of normal mental age norms of the important intellectual, motor and emotional functions. It will be impossible to make strictly reliable tests until these norms are available on a much larger scale than we now have them. It is also important to establish reliable objective pedagogical age-norms: but this work is large enough to demand the services of a special division of peda- gogic research. 4. The psycho-clinical laboratory, in the fourth place, should serve as a clearing-house for all types of mentally 112 MENTAL HEALTH OF SCHOOL CHILD and educationally unusual children — a function which it should discharge jointly with the special schools or special classes. At the present time the special schools serve this function very inadequately ; they have become rather a dumping ground for the ne'er-do-wells, the offscourings, of the schools — a place to which they may be relegated indiscriminately in order to relieve the regular rooms of an intolerable incubus. After the backward child has been examined in the laboratory, he should be sent to a special class (one in charge of a teacher specially trained for special- room work), with specific recommendations, for further careful pedagogical observation and psychological study. He should be given a well-planned try-out for a while, the results of which should be sent to the laboratory. On the basis of these results — the clinical examination and special-room observation and testing — the director should recommend the transfer to, or the placing of the child in, his proper place — the special class for the feeble-minded, the special class for the backward, the ungraded class for the retarded (those merely retarded in one or more of the academic branches), the classes for the blind, deaf, crip- pled, tuberculous, anemic or speech-defective, or the insti- tutions for the feeble-minded or epileptic. Most elementary pupils who are mentally retarded more than four years are suffering from very serious permanent arrest, and are institutional cases. They should be separated from the merely retarded and the backward. The recommendations of the director should not be subject to reversal, except through action by the board or the superintendent. As a clearing-house for mentally unusual pupils, the laboratory would render an important service to the schools not per- formed by any existing agency. It is evident that to perform this service in the best possible manner the NEW CLINICAL PSYCHOLOGY 113 laboratory must be directed by an authoritative specialist and have available full data from the other sources which we have already discussed. Where there is no complete bureau of school research, the psycho-educational labora- tory would logically assume the functions of such a bureau. 5. A fifth function of the laboratory is the psycho- logical examination and efficiency appraisal of some of the applicants for vocational guidance. As already stated, it is preposterous to assume that the mass of children can be scientifically guided into vocational pursuits without such an examination. The director of the vocational bureau should be a psycho-educational expert, or the services of such an expert should be available to the bureau for the examination of at least all the candidates whose educational record indicates that they are mentally exceptional. 6. The laboratory may also undertake the training of special-class teachers in the psycho-clinical methods of testing pupils. If it were feasible, the teachers might assist in giving some of the tests in the special schools under the supervision of the laboratory director. The percentage of retarded children is so large that it would probably be beyond the means of the laboratory to examine all the pupils who should be examined in a large school system. To apply merely the Binet-Simon tests thoroughly requires from forty minutes to an hour. How- ever, a distinctly better plan is to specially train one or two adaptable teachers in the methods of psychological testing, and let them devote all their time to giving some of the simpler tests. The more difficult tests and the final review of the cases should invariably be made by the expert clinical psychologist. 114 MENTAL HEALTH OF SCHOOL CHILD 7, Finally, another function of the laboratory might be the supervision of the curricula of the special schools and the offering of courses in the training school on the psychology and pedagogy of the various types of mental deviation or deficiency. No teacher should ever be assigned to special class work who has not received special training. It is obvious that to perform all these functions the laboratory would have to be organized on a compre- hensive basis. The Qualifications of the Clinical Psychologist or Psycho-educational Examiner 1. He must be temperamentally adapted for the work. I do not know that this is first in importance, but mere knowledge of the methodological technique peculiar to psycho-clinical work does not necessarily make a successful examiner. The examiner must have the ability or knack to draw out the best the child has to give ; if he is obliged to force it out he is lacking in the very essentials of the work. Psycho-cHnical examination is not a forcing-out process. The examiner should, through word, action, demeanor and bearing, be able to calm, pacify, set at ease the nervous, excitable child ; and to encourage, incite, stim- ulate the phlegmatic, timid, taciturn, obstructed child. He must be genial, friendly, sympathetic, quick to praise and slow to criticise, and must be able to win the confidence of all. He must possess an unlimited reserve of patience with the frivolous, the resistant and the snail-like plodders. He must be versatile and resourceful, so that he can change his attitude and method of attack to suit all types of persons. There are persons who will respond only to NEW CLINICAL PSYCHOLOGY 115 pressure and with whom stem measures will produce the best results. But they are entirely exceptional, 2. It is not enough that he has a thorough grounding in the methods and results of analytical, descriptive, experimental, child, social, physiological and educational psychology ; he should have a definite, technical prepara- tion in clinical psychology. He should be conversant with its methods, standpoints, aims and results. Knowledge of structural psychology is not sufficient ; the best structural and experimental psychologist may make the sorriest clinical psychologist. Often the paramount need is the ability to tear loose from the abstractions, schematizations and viewpoints of the structuralist. The clinical worker must use the 'case' method of procedure; he must be familiar with the clinical method ; he must be able to indi- vidualize each case (a capacity that is likewise needed by the special-class teacher), to study it in the concrete, to frame a clinical picture of it — in a word, to examine clini- cally. To do this requires more than a mastery of the framework of psychology or of the technique of laboratory experimentation ; it requires ready powers of observation, keenness of insight, power to interpret, ability to notice signs and symptoms, a knowledge of symptomatology and of the best available methods of psycho-clinical diagnosis, and an extensive first-hand acquaintance with education- ally abnormal children — three to four years of observation and testing in and out of institutions of a considerable variety of child deviates, such as the feeble-minded, back- ward, retarded, accelerated, epileptic, incipient and devel- oped neurotics and psychotics, speech defectives, moral imbeciles. Until recently it was impossible to obtain adequate training in clinical psychology except through an apprenticeship with one of the few experts in the field. 116 MENTAL HEALTH OF SCHOOL CHILD Now a few universities — although very few — are able to oifer satisfactory didactic and clinical courses in the psy- chological and educational examination of children. 3. A knowledge of anatomy and pathology, of public and personal hygiene, of the common physical defects, of nervous and mental diseases, of psychopathology and psy- chotherapy, of pediatrics and normal physical diagnosis, is essential for a clinical psychologist working on juvenile cases in the medical school; I incline strongly to the opinion that the psychological and educational examiner of mentally unusual children in the schools should also have a working knowledge of these specialties, 4. The chnical psychologist should be thoroughly grounded in the science and art of normal pedagogy. He will certainly be able to render a higher type of service if he has had practical teaching experience in the elementary grades of the public schools, so that he has had the oppor- tunity to come directly in touch with the problems of the training, growth and development of the child mind, and so that he is thoroughly conversant with the normal peda- gogy of the elementary branches (particularly the methods of teaching handwork, reading, spelling, number and writing). He will likewise be better prepared for his work if he has taught educational psychology or the prin- ciples of teaching in training schools for teachers, so that he is alive to the vital educational problems concerning pedagogical methodology (questions regarding methods of studying, learning, instructing, drilling, memorizing, initiative, working efficiency, hours, rests, alternation of subjects, etc.) and so that he may thus turn his investi- gations to wider pedagogical use. 5. He must have made a very exhaustive study of all phases of corrective pedagogics. He must be thoroughly NEW CLINICAL PSYCHOLOGY 117 grounded in the differential pedagogy which applies to the types of cases he expects to handle. This may seem like an extremely exacting course of training but it is not more exacting than the training now demanded of the various medical specialists and it will certainly only make a reasonable demand on the time of the student who from the outset — at least from the bacca- laureate — shapes his work towards the career of a psycho- educational examiner. Certainly the work is so varied, complex and technical that complete mastery is out of the question without three or four years of preparation. Eventually the well-trained specialist in this field must command the respect and the emoluments accorded to the specialist in the allied medical fields. References 1. BoBERTAG. Uber Intelligenzpriifungen (nach der Methode von Binet und Simon). Zeitschrift fiir ange- wandte Psychologie, 1911, 5: lOSfF. 2. BoEHNE. Special Classes in the Rochester Schools. Journal of Psycho-Asthenics, 1909-10, 14:83. 3. Cattell. a Further Statistical Study of American Men of Science. Science, 1910, N. S., 32: 672f. 4. Dearborn. Medical Psychology. Medical Record, January 30, 1909. 5. Dubois. The Psychic Treatment of Nervous Disorders. New York, 1906. 6. Foster. Physiological Age as a Basis for the Classifi- cation of Pupils Entering High Schools — Relation of Pubescence to Height. The Psychological Clinic, 1909, 3: 83f. 7. Franz. On Psychology and Medical Education. Science, 118 MENTAL HEALTH OF SCHOOL CHILD 1913, 38: 555f. See also the statistical study of Abbot, Psychology and the Medical School. American Journal of Insanity, 1913, 70: 447f. 8. Gayler. Retardation and Elimination in Graded and Ungraded Schools. The Psychological Clinic, 1910, 4:40f. 9. Gayler. A Further Study of Retardation in Illinois. The Psychological Clinic, 1910, 4: 79f. 10. GoDDARD. The Grading of Backward Children. The De Sanctis Tests and the Binet and Simon Tests of Intellectual Capacity. The Training School, November- December, 1908. 11. GoDDARD. Binet's Measuring Scale for Intelligence. The Training School, 1910, 6: No. 11. Revised edition, 1911. 12. GoDDARD. Two Thousand Normal Children Measured by the Binet Measuring Scale of Intelligence. Peda- gogical Seminary, 18:232f. 13. GuLicK. Causes of Dropping Out of School. World's Work, August, 1910, 13285f. 14. HuEY. Backward and Feeble-minded Children. Balti- more, 1912. 15. HuEY. The Present Status of the Binet Scale of Tests for the Measurement of Intelligence. Psychological Bulletin, 1912, 9: 160f. 16. J. Progress and Retardation of a Baltimore Class. The Psychological Clinic, 1909, 3: 136f. 17. Jones. Psycho-analysis in Psychotherapy. Montreal Medical Journal, 1909, 38:495f. 18. KuHLMANN. Binet and Simon's System for Measuring the Intelligence of Children. Journal of Psycho- Asthenics, 1911, 15: Nos. 3, 4. 19. KuHLMANN. The Present Status of the Binet and Simon Tests of the Intelligence of Children. Journal of Psycho- Asthenics, 1912, 16: No. 3. NEW CLINICAL PSYCHOLOGY 119 20. MacMillan. The Physical and Mental Examination of Public School Pupils in Chicago. Charities and Com- mons (now The Survey), December 22, 1906. 21. Meumann. Sammelreferat iiber die Literatur der Jugendkunde. Archiv fiir Psychologic, 25: 85f. 22. MuNRo. Psychotherapy in Relation to the General Prac- tice of Medicine and Surgery . The Medical Herald (St. Joseph), June, 1910. 23. MuNSTERBERG. On the Witness Stand, Essays on Psy- chology and Crime. New York, 1908. 24. MuNSTERBERG. Psychothcrapy. New York, 1909. 25. MuNSTERBERG. Psychology and Industrial Efficiency. Boston, 1913. 26. ScHMiTT. Retardation Statistics of Three Chicago Schools. The Elementary School Teacher, 1910, 478f. 27. Taylor. The Widening Sphere of Medicine. The Har- vard Medical School, 4: (Quoted under 'The Doctor and the Public'), Science, 1910, N. S., 32: 664. 28. Terman and Childs. A Tentative Revision and Exten- sion of the Binet-Simon Measuring Scale of Intelligence. Journal of Educational Psychology, 1912, 3: 61 f. 29. Town. Translation of Binet and Simon's A Method of Measuring the Intelligence of Young Children.' Chicago, 1913. 30. Wagner. Retardation, Acceleration and Elimination in Mauch Chunk Township, Pennsylvania. The Psycho- logical Clinic, November, 1909, 3. 31. Wallin. Experimental Studies of Mental Defectives. Baltimore, 1912. 32. Wallin. The Rationale of Promotion and Elimination of Waste in the Elementary and Secondary Schools. The Journal of Educational Psychology, 1910, 1: 445f. 33. Whipple. Manual of Mental and Physical Tests. Balti- more, 1910. Chapter 13. (Indispensable to examiners of children.) 120 MENTAL HEALTH OF SCHOOL CHILD 34. Wither. Clinical Psychology. The Psychological Clinic, 1907, 1: If. 35. Wither. The Psychological Clinic. Old Penn, 1909, 7:98f. 36. WooLLEY. Charting Childhood in Cincinnati. The Sur- vey, 1913, 601 f. Additional references: Groszhann. The Study of Individual Children. Plainfield, 1912. HoLHEs (Arthur). The Conservation of the Child. Phila- delphia, 1912. HoLHES (W. H.). School Organization and the Individual Child. Worcester, 1912. Wither (and others). The Special Class for Backward Chil- dren. Philadelphia, 1911. CHAPTER III CLINICAL PSYCHOLOGY: WHAT IT IS AND WHAT IT IS NOT^ On an occasion like this" it would seem proper, repre- senting as I do one of the newest of the sciences, that I address myself to some of the basic questions of this science. Perhaps the very first question with wliich one is con- fronted is simply this : 'In view of the rapid multiplication of the sciences, by what right does clinical psychology lay claim to an independent existence?' That is a question which may perturb some sensitive minds, but it does not disconcert the clinical psychologist, for he regards the 1 Reprinted from Science, 1913, pp. 895-902. 2 Substance of an address delivered before the Conference on the Exceptional Child, held under the auspices of the University of Pitts- burgh, April 16, 1913. Lest misapprehensions arise, it should be clearly understood that in this discussion I am concerned only with the relation of clinical psychology to mentally exceptional school chil- dren; and that I distinctly recognize a different type of exceptional children, namely, the physical defectives. The physical defectives should be examined by skilled pediatricians. The clinical psychologist is interested in physically exceptional children when they manifest mental deviations. Moreover, while I hold that the psycho-clinical laboratories must become the clearing houses for all types of mentally or educationally exceptional children in the schools, nearly all mentally exceptional children should be given a prior physical examination by consulting or associated medical experts. Physical abnormalities should, of course, be rectified, whether or not it can be shown that they sustain any causal relation to the mental deviations which may have been disclosed in the psycho-clinical examination. They should claim treatment in their own right. 122 MENTAL HEALTH OF SCHOOL CHILD question as perfectly legitimate and capable of satis- factory answer. It is just and proper that a new claimant to membership in the family of sciences should be required to present her credentials. It is a natural human trait to challenge or contest the claims of a newcomer. It has ever been thus. Every branch of knowledge before winning recognition as an independent science has been forced to demonstrate that it possesses a distinct and unique hody of facts not ade- quately treated by any other existing science ; or that it approaches the study of a common hody of facts from a unique point of view, and with methods of its own. Psy- chology, bio-chemistry, dentistry, eugenics, historiometry and many other sciences have been thus obliged to fight their way inch by inch to recognition as independent sciences. It is not long since physiology claimed psy- chology as its own child and stoutly contested her rights to existence ; nor is it long since medicine denied any right to independent existence to dentistry. It is no surprise that a number of sciences now claim clinical psychology as part and parcel of their own flesh and blood, and that they deny her the right to 'split off from the parent cell' and establish an unnursed existence of her own. Just as nature abhors a vacuum, so science abhors the multiplication of sciences; just as the big corporation octopus in the indus- trial world tries to get monopolistic control of the sources of production and distribution, so the various sciences, naturally insatiable in their desire for conquest, attempt only too often to get monopolistic control of all those elements of knowledge wliich they may be able to use for their own aggrandizement, whether or not they have devel- oped adequate instruments for scientifically handling those elements. CLINICAL PSYCHOLOGY 123 Clinical psychology, however, is quite ready to contest the attempts to deprive her of her inalienable rights to the 'pursuit of life and happiness.' Fundamentally, she bases her claims to recognition as an independent science on the fact that she does possess a unique body of facts not ade- quately handled by any existing science, and that she investigates these facts by methods of her own. These facts consist of individual mental variations, or the phe- nomena of deviating or exceptional Tnentality. In other words, clinical psychology is concerned with the concrete study and examination of the behavior of the mentally exceptional individual (not groups), by its own methods of observation, testing and experiment. In the study or examination of individual cases, the clinical psychologist seeks to realize four fundamental aims : 1. An adequate diagnosis or classification. He attempts to give a correct description of the nature of the mental deviations shown by his cases ; he tries to deter- mine whether they are specific or general, whether they affect native or acquired traits ; he attempts to measure by standard objective tests the degree of deviation of various mental traits or of the general level of functioning ; he seeks to arrive at a comprehensive clinical picture, to disentangle symptom-complexes and to reduce the disorders to various reaction types. 2. An analysis of the etiological background. His examination is bent not only on determining the present mental status of the case, but on discovering the causative factors or agents which have produced the deviations — whether these factors are physical, mental, social, moral, educational, environmental or hereditary. In order to arrive at a correct etiology, the psycho-clinician makes not 124 MENTAL HEALTH OF SCHOOL CHILD only a cross-section analysis of the case, but also a longi- tudinal study of the evolution of the deviation or symptom- complex. Therefore, he does not Kmit himself merely to a psychological examination, but requires a dento-medical examination and a pedagogical, sociological and heredi- tary examination. The physical examination should be made by experts in dentistry and in the various specialties in the field of medicine. The psycho-cHnicist, however, should be so trained in physical diagnosis that he can detect the chief physical disorders, so that he can properly refer his cases for expert physical examination. 3. A determination of the modification which the dis- order has wrought in the behavior of the individual. He should determine what its consequences have been: what effects it has had upon his opinions, beliefs, thoughts, dis- position, attitudes, interests, habits, conduct, capacity for adaptation, learning ability, capacity to acquire certain kinds of knowledge or various accomplishments, or to do certain kinds of school work. He should seek to locate the conflicts between instincts and habits which may have been caused by the deviations. 4. The determination of the degree of modifiahility of the variations discovered. Can the deviations be cor- rected or modified, and if so to what extent and by what kinds of orthogenic measures? A clinical psychologist is no less a scientific investigator than a consulting special- ist ; he diagnoses in order to prognose and prescribe. His aim, first and last, is eminently practical. Basis of Selection of Cases The clinical psychologist selects his cases not so much on the nature of the cause of the deviations (whether social, hereditary, physical, pedagogical or psychological) CLINICAL PSYCHOLOGY 125 as on the nature of the deviations themselves, and the nature of the treatment. He is interested in cases wluch, first of all, depart from the limits of mental normahty. Exceptional mentality, or, if you please, mental exception- ality is his first criterion. In the second place, he is inter- ested in those cases in which the nature of the treatment — the process of righting the mental variations, of straight- ening out the deviations, the orthogenesis- — is wholly or chiefly or partly educational. In the term educational I include training of a hygienic, physiological (in Seguin's sense), pedagogical, psychological, sociological or moral character. Grouping of Cases It is thus evident that the clinical psychologist may group his cases into two main classes. A. Those in which the mental variations are funda- mental or primary, and the physical disabilities only acces- sory or sequential. With these cases the treatment must be primarily educational and only secondarily medical. What types of children are included in this group .'^ 1. Feeble-minded children. Feeble-mindedness for- merly was regarded as an active disorder — a disease — and was accordingly treated exclusively medically. The theory of causation was wrong and so the results were unsatis- factory. Since the year 1800 (Itard, the apostle to the feeble-minded) and particularly since the year 1837 (Seguin, the liberator of the feeble-minded), it has become increasingly apparent that feeble-mindedness is an arrest of development ; and accordingly since that time the condi- tion has primarily been treated educationally instead of medically. This change in point of view has revolutionized 126 MENTAL HEALTH OF SCHOOL CHILD the treatment of the feeble-minded. The person who did most to amehorate their condition is Seguin, whose method, almost entirely educational, has served as the model for the effective institutional work for the feeble-minded done since his day, although we have outgrown various details of his system. Moreover, it served as the chief inspiring force for the constructive orthogenic work done for the feeble- minded within the last decade or so by Montessori. She, herself a physician, but with special training in psychology and pedagogy, tells us that in 1898, as a result of a careful study of the problem of feeble-mindedness she became per- suaded that the problem was primarily a pedagogical and not a medical one. It is granted without question, of course, that there is a medical side to the care of the feeble-minded just as there is a medical side to the care of the normal child. Nay, owing to the heightened degree of suscepti- bility to disease and accidents found among the feeble- minded, the medical side looms larger in the care of the feeble-minded than in the care of normals. Indeed, no institution for the feeble-minded can be properly organized without an adequate staff of medical experts ; but funda- mentally the problem of ameliorating the sad lot of feeble-minded children is an educational one — their hygienic, pedagogical and moral improvement, as well as their elimination by the method of colonization or sterili- zation. 2. Retardates, technically so-called — of which there are probably on a conservative estimate 6,000,000 in the schools of the United States. Some of these are retarded (1) merely pedagogically in a relative sense — relative to an arbitrary curricular standard. Many children do not fit the standard, because the standard itself is off the norm. It is largely a case of a misfit curriculum instead CLINICAL PSYCHOLOGY 127 of a misfit child. So far as this class of misfits is con- cerned, the problem is simply one of correct adjustment of the pedagogical demands of the curriculum. A considerable percentage of the retardates, however, are retarded because of (2) genuine mental arrest of development. They are as truly arrested or deficient as the feeble-minded, but to a lesser extent. The difference is a quantitative and not a qualitative one, and the prob- lem of correction consists fundamentally in providing a right educational regimen. Then there is (3) a smaller proportion of retardates who are mentally retarded because of environmental handi- caps, such as bad housing, home and neighborhood condi- tions, bad sanitation, lack of humidity, lack of pure air or excessive temperature in the schoolroom, vicious or illiterate surroundings, frequent moving or transfer, emi- gration which may cause linguistic maladaptation, etc. With such retardates the problem is partly sociological, partly hygienic and partly pedagogical. We have a final group of children (4) who are mentally retarded because of some physical defect. With children of this type the problem is partly medical and partly educational. The first eff^orts made in behalf of such children should be medical and hygienic. Undoubtedly the removal of physical handicaps will restore some pupils to normal mentality, while in the case of other pupils the results will be negative. Unfortunately many of the studies in this field (see Chapter XV) have a questionable value because of the obvious, but evidently unconscious bias of the investigators. Some desire to show favorable results and, therefore, unconsciously select only the favor- able cases ; others are swayed by the opposite motive and 128 MENTAL HEALTH OF SCHOOL CHILD accordingly tend to select the negative cases. Hence, at the present time we find considerable diversity of opinion as to the orthogenic influences of the correction of physical disorders. The opinion of John J. Cronin, M.D., probably approximates the truth : The successes simply mean that a large number of children were perfect except for some one abnormality The alleviation of any single kind of physical handicap is merely one step towards the successful result sought, and many other factors must obtain before some measure of success is assured. Likewise A. Emil Schmitt, M.D. : It should constantly be borne in mind that if every physical defect has been successfully removed the mental unbalance or deficiency can remain unaltered, inasmuch as it was primarily a mental defect and can be reached only by methods of educa- tion or psychological treatment. While I am quite convinced that all mentally retarded children should undergo a careful physical examination, and that such physical corrective measures should be applied as are indicated by expert medical opinion, yet it needs to be reemphasized that the removal of a physical disability is frequently only the first step toward restora- tion. If the child has fallen behind pedagogically or mentally, he will in many cases need special pedagogical attention if he is to catch step with the class procession; moreover, after a certain critical age has been passed, the removal of physical obstructions exercises only a slight orthophrenic influence, and the reestablishment of effective mental functioning, if it can be done at all, will require the prolonged application of a special corrective pedagogy. 3. The supernormals. Both of the above types of children come on the minus side of the curve of efficiency. CLINICAL PSYCHOLOGY 129 On the other side we find the plus deviates — the bright, brilHant, quick, gifted, talented, precocious children. These children may present no peculiarities on the physi- cal side, if we except the type of nervously unstable, pre- cocious children. With the healthy supernormal child the problem is almost entirely an educational one: the intro- duction of schemes of flexible grading; of fast, slow and normal sections, and of supernormal classes ; providing special opportunities for doing specialized work, and a special pedagogy, which should probably be as largely negative as positive. If there is any one child in our scheme of public education which has been neglected more than any other, it is the child of unusual talents. A nation can do no higher duty by its subjects than to provide those conditions wliich will rescue its incipient geniuses from the dead-level of enforced mediocrity. 4. Speech defectives, particularly the 2 per cent (approximately) of stutterers and hspers who encumber our classes. In few fields of scientific research is it possible to find such astonishing diversity of so-called expert opinion as on the question of the causation of stuttering (or stammering). It is claimed to be a gastric, pneumo- gastric, lung, throat, lip, brain, hypoplastic, nervous and mental disorder. It is said to be a form of epilepsy, a form of hysteria and a form of mental strife, or repression, between latent and manifest mental contents. Moreover, few writers show such a consummate genius for self-con- tradiction as writers on stuttering. Before me lies a reprint of a recent dissertation on the 'Educational Treat- ment of Stuttering Children.' The writer begins by saying that stuttering is a 'pathological condition,' a disease, and that, therefore, its treatment belongs to a specialist on dis- eases. The disease appears, however, on the second page 130 MENTAL HEALTH OF SCHOOL CHILD to be merely 'a purely functional neurosis,' while on the last page the trouble is nothing more than a 'mental one,' caused by influences acting on the mind. As a matter of fact, the treatment which the writer recommends is, through and through, educational and largely psychologi- cal. It consists of certain physical exercises, designed not so much to strengthen certain organs as to win the patient's interest and restore his self-confidence ; and certain psycho-therapeutic and hypnotic exercises. Waiving for the time being the nature of the cause, we can agree on one thing; namely, that the methods of treating stuttering (and lisping) which have been proved effective are almost exclusively educational. Many of the neurotic symptoms ('functional neuroses') found in the stutterer are the results of mental tension and will dis- appear with the correction of the stuttering. 5. Incipient psycJiotics, or children who show develop- mental symptoms of mental disorders or mental alienation. Here we meet with the same controversy between the advo- cates, on the one hand, of a somatogenic theory, and, on the other hand, of a psychogenic theory of causation. While it must be admitted that many of the psychoses are certainly organic, others almost as certainly are functional and are produced by idiogenic factors (a view entertained by such well-known psychiatrists as Meyer, Freud, Janet, Dubois, Jones, Prince). Now, irrespective of whether the cause is chiefly physical or mental, it is being recognized by a number of the leading present-day psychiatrists that drug treatment for the majority of the insane, whether juvenile or adult, is secondary to the educational treat- ment. Instead of merely prescribing physical hygiene for the insane, leading alienists are now prescribing mental hygiene. The cure is being conceived in terms of a CLINICAL PSYCHOLOGY 131 process of reeducation. Moreover, so far as concerns the mentally unstable child in the schools, the chief reliance is obviously on hygienic and educational guidance. B. Cases in which the physical deviations are funda- mental or primary, and the mental variations sequential, but the remedy partly or chiefly educational. Here we include malnutrition, rickets, marasmus, hypothyroidism, tuberculosis, heart trouble, chorea and similar diseases. In all of these the treatment must be primarily medical, although there should be a special temporary educational regimen for these children. This group also includes the blind and the deaf. But here the treatment is almost wholly educational. The physical defects are incurable, but the mental defects can be partly overcome by proper compensatory educational treatment. The epileptic also must be added to this group. Epilepsy is evidently an active disorder or disease process, although the pathology is wrapped in the deepest obscurity. The epileptics appear like purely medical cases. The medical aspect certainly is important, but the records show that only from 5 to 10 per cent are curable, and that the attacks can be as readily modified or regulated in most cases by proper hygienic treatment as by drug medication or surgical interference. To quote Montessori: Benedickt, and following him, the principal authorities among medical specialists, are at present condemning the use of depressing bromides, which hide the attacks as an anes- thetic hides pain, but do not cure them. The cure, says Bene- dickt, depends upon hygienic life in the open in order to absorb the poisons, and upon work, rationally measured and graded, provided, however, that the malady is still recent and has not assumed a chronic form. The treatment consists in educating them. 132 MENTAL HEALTH OF SCHOOL CHILD Even with these unfortunates, it can be said that the best results come from a proper medico-educational regime — colonization, outdoor employment, industrial schooling, bathing, etc. Summary of Important Conclusions We are thus brought to the two following conclusions : 1. There is a set of unique facts — facts of individual mental variation — which no existing science has adequately treated. It is with these facts that the work of the clinical psychologist is concerned. Just as psychology became an independent science by demonstrating that it possessed a legitimate claim to a unique world of facts, so clinical psy- chology is ready to make her declaration of independence and dedicate herself to the investigation of a body of facts — facts of individual mental variation — not hitherto adequately handled by any existing science. It is con- cerned with the study of individual cases of deviate men- tahty, particularly with those types which are amenable to improvement or correction by psycho-educational pro- cesses. 2. The proper handling of these cases, whether for purposes of examination, recommendation or prescription, can only be done by a psycho-educational specialist who possesses the training indicated in Chapter II. The Relations of Clinical Psychology — Some Affirmations and Denials There are a number of sciences with which cHnical psy- chology is, will be or should be closely related, but which are not synonymous with clinical psychology. 1. Clinical psychology is not the same as psychiatry CLINICAL PSYCHOLOGY 133 (and psychopathology) . The typical alienist is concerned with the study and treatment of mental disorders (tech- nically called psychoses) ; the clinical psychologist, on the other hand, is concerned particularly (though not solely) with the study of plus and minus deviations from normal mentality. The aUenist works cliiefly with adults, the clinical psychologist with children. Few alienists possess any expert knowledge of the literature bearing on child or educational psychology, mental deficiency, retardation or acceleration, stuttering or lisping, special pedagogy or psycho-clinical methods of testing. An alienist accord- ingly is not to be considered a specialist on the mentally exceptional child in the schools unless, indeed, he has sup- plemented his general medical and psychiatric education with a technical study of the psychological and educational aspects of the problem. The alienist of the future will certainly have to secure a different preparation from that now furnished in the medical schools, if he is to enter the field of pedagogic child study. Before me lies the report of the department of medical inspection of a large school system. Six hundred retarded children were examined in this department, which is in charge of an alienist, who, as I am told, is an expert on the questions of adult insanity, but who has no specialized preparation in the psychology and pedagogy of the men- tally defective cliild. Of these cliildren 49.7 per cent are recorded as feeble-minded. Applying this figure to the 6,000,000 retardates of the public schools of the country, we get a total feeble-minded school population of 8,000,- 000. This figure, it need scarcely be said, is monstrously absurd. It is fully ten times too large. Feeble-mindedness and backwardness in children, it must be said, are distinct problems from mental alienation, and require for their 134 MENTAL HEALTH OF SCHOOL CHILD satisfactory handling a specialist on mentally deviating children. A high-grade feeble-minded child can not be identified merely by some rule-of-thumb system of intelli- gence tests. Feeble-mindedness involves more than a given degree of intelligence retardation. At the same time, lest I be misunderstood, it should be specially stated that psy- chiatry and clinical psychology will be mutually helped by a closer union. Clinical psychology has many important facts and a valuable experimental technique to offer to psychopathology, and psychopathology in turn is able to contribute facts of great value, and more particularly an effective clinical method of examination, to clinical psy- chology. As the idiogenic conception of the causation of various psychoses wins greater recognition, clinical psy- chology will become more and more indispensable to the psychiatrist and psychopathologist. It is also certain that the efficiency of the clinical psychologist will be greatly increased by a study of mental alienation — not a study of texts on psychiatry, but a first-hand study in in- stitutional residence of individual cases. Any one intend- ing to do psycho-clinical work with mentally deficient children certainly should spend at least a year or two in residence at institutions for feeble-minded, epileptic and alienated children. The clinical psychologist should be prepared to recognize cases of incipient mental disorder, so that he will be enabled to select these cases and refer them to a psychiatric or psychopathic specialist for further examination. 2. Clinical psychology is not neurology. There are important neurological aspects involved in the study of mentally exceptional children. Mental arrest can be largely expressed in terms of neurological arrest, and a clinical psychologist should have a first-hand knowledge of CLINICAL PSYCHOLOGY 135 nerve signs and a practical acquaintance with the methods of neurological diagnosis. His knowledge of neurology should be sufficient to enable him to pick out suspected nervous cases and refer them for expert examination by a neurologist. However, it must be emphasized that neurol- ogy touches only one side — though an extremely important side — of the problem of exceptional mentality. 3. Clinical psychology is not synonymous with general medicine. The average medical practitioner certainly knows far less about the facts of mental variation in chil- dren than either the psychiatrist or neurologist or even the classroom teacher. This fact should occasion no sur- prise when it is stated that the study of psychology as a science has been practically ignored in medical curri- cula throughout the country. The clinical psychologist, however, as I have already said, should be able to detect the chief physical defects found in school children, so that if the laboratory of the clinical psychologist assumes the function of a clearing house for the exceptional child he may be able to refer all suspected medical cases to proper medical clinics for expert examination and treatment. 4. Chnical psychology is not pediatrics. To be sure, the pediatrician deals with children. But his attention is focused on the physical abnormalities of infants ; his inter- est in the phenomena of mental exceptionaHty is liable to be incidental or perfunctory. In fact, one may read some texts on pediatrics from cover to cover without so much as arriving at a suspicion that there is a body of unique facts converging on the phenomena of departure from the limits of mental normality which require intensive, special- ized, expert study and diagnosis. So far as the physical ailments or disabilities of young children are concerned the pediatrician is in a position to render valuable service to 136 MENTAL HEALTH OF SCHOOL CHILD the psycho-clinicist ; likewise so far as concerns the mental deviations of children the psycho-cHnicist is able to render valuable aid to the pediatrician. But one must not confuse pediatrics with clinical psychology. 5. CHnical psychology is not the same as introspective, educational or experimental psychology. It differs from these in its method, standpoint and conceptions. While the clinical psychologist should be grounded in introspec- tive and, especially, experimental, educational and child psychology, expertness in these branches of psychology does not in itself confer expertness in practical psycho- clinical work. Such expertness comes only from a technical training in clinical psychology and from a first-hand pro- longed study by observation, or experiment, or test of various kinds of mentally exceptional children, particu- larly the feeble-minded, the psychopathic, the epileptic and the retarded. The skilled specialist in experimental or educational psychology or experimental pedagogy is no more qualified to clinically examine mental cases, than is the skilled zoologist, physiologist or anatomist able to clinically examine physical cases. Clinical work, both in psychology and medicine, requires clinical training. The assumption that any psychologist or educationist (and, forsooth, any physician or medical inspector) is qualified to do successful psycho-cKnical work, after learning how to administer a few mental tests, is preposterous and fraught with the gravest consequences. CHnical psychol- ogy can have no standing in the professions as long as we permit this absurd notion to prevail. CHAPTER IV THE FUNCTIONS OF THE PSYCHOLOGICAL CLINIC The psychological clinic is a very modern American creation. The first clinic was started in a small way only eighteen years ago in the University of Pennsylvania. The growth of these clinics was at first very slow, but during the last three or four years they have rapidly mul- tiplied (see statistics in Chapters II and XVIII). Besides the clinical psychologists there are a considerable number of teachers, nurses, physicians and others who are tyros or amateurs in psychology and psycho-educational thera- peutics, who are testing cliildren in schools, juvenile courts and institutions, but the work of most of these amateurs can scarcely be considered in speaking of clinical psychol- ogy or of psycho-clinical technicians. Professor O'Shea has recently predicted (School Review, April, 1913, p. 285) that within a decade there will be a psychological clinic in every community with 2,500 or more school chil- dren. That may be so if we agree to call any place in wliich mental tests may be given a 'psychological clinic' The psychologist, however, would probably just as strenu- ously object to having these testing stations called 'psy- chological clinics' as the psychiatrists would object to having them called 'psychiatric chnics.' 1 Reprinted, with alterations and additions, from The Medical Record, September 30, 1913. 138 MENTAL HEALTH OF SCHOOL CHILD The development of the psychological clinic has come in response to a demand for more accurate psychological diagnosis — and this is the first function of the psycholo- gical clinic which I wish to discuss. 1. Expert diagnosis of mentally deviating cases and expert prescription and consultation. The central aim of the psychological clinic is psychological diagnosis and con- sultation and advice in regard to mental cases, particularly children. In other words, the aim of the clinic is essen- tially practical. The clinical psychologist is engaged in serious work and not mere play. His interests are not confined to the theoretical or academic. His efforts are in the field of human conservation, individual orthogenesis and remedial philanthropy. All the psychological clinics, so far as I know, are doing philanthropic work. The psycho-clinicist is concerned with the proper mental hygiene, the correct educational classification and the skilled pedagogical training of the mentally exceptional child." The aim, in one word, of his basic effort is ortho- genesis (particularly that phase of orthogenesis to which I have applied the term 'orthophrenics'). It is rapidly becoming generally recognized that the nature and extent of mental variations or abnormalities cannot be adequately ascertained by the method of mere observation or inspection, or by the ill-adapted methods of specialists in the fields of medicine. Many mental devia- tions are so subtle that they entirely escape common obser- 2 It would seem better to call the psychological clinics in the schools psycho-educational clinics, just because of the fact that the character of the diagnosis attempted is distinctly both psychological and educational, and because the aims of the diagnosis are dis- tinctly the scientific pedagogical training, correct educational classi- fication and mental hygiene of the educationally exceptional child. THE PSYCHOLOGICAL CLINIC 139 vation. Common observation, moreover, rarely penetrates so far as to reveal the cause of the defect. Before the advent of experimental and clinical psychology, mental diagnosis was based almost wholly upon common observa- tion, if we except the pedagogical tests of the schools and a few tests of the trained psychopathologists. Many mental variations or abnormalities, however, are harder to get at by mere observation than many physical disorders. Many of the latter can be detected by the methods of so- called inspection, auscultation, palpation, percussion or mensuration. Nevertheless, the skilled physician does not depend solely upon these methods of diagnosis, but has developed a more refined laboratory technique, consisting of radiographic and microscopic inspection, serum reac- tion tests, mechanical and electrical tests of nervous sensitivity and response, etc. Likewise the psychologist within the last decade or two has developed a new science, which is now usually called 'clinical psychology,' and a delicate, controlled laboratory technique. This technique sometimes involves the use of the most delicate apparatus for precisely measuring the functional capacity of the various sensory, motor and intellectual processes. At other times it involves the use of less elaborate testing appliances. For purposes of practical mental diagnosis the tendency at the present time is to make a more extensive use of the simpler forms of testing devices, such as test blanks, form and construction boards, set questions and graded scales of intellectual, motor and socio-industrial capacity. The most popular of the developmental scales is the Binet- Simon scale of intelligence, which consists of a series of tests (sixty-two in the 1908 series if ages one and two are included) gradually increasing in difficulty and arranged in age-steps. There are from three to eight tests in each 140 MENTAL HEALTH OF SCHOOL CHILD of the first thirteen years of Kfe in the 1908 series. Many of these tests are extremely simple. To illustrate : a child who can follow visually a lighted match moved in front of his face, who can grasp and handle a block placed in his hand and who can grasp a suspended cylinder is credited with a mentality of one year. A child who can state his sex, who can recognize and name common objects, such as a knife, penny and key, who can repeat three numerals heard once, and who can designate the longer or shorter of two lines differing by one centimeter, is rated as four years' old mentally. The scale is constructed merely to test the stage of the intelligence, and not emotional or motor development. The stimulus to the development of this scale was the enactment in Paris in 1904 of an edu- cational measure which required the individual examination of all mentally defective children. At first this work was left to the medical inspectors, but it soon became evident that they could do no more than they already had done in the way of medical inspection — namely, detect physical defects and diseases. It became evident that there was no scientific method of examining mentally exceptional chil- dren in existence, and hence Binet and his assistant, Simon, set about to establish normal mental age-norms by examin- ing certain pedagogically average children in the elemen- tary schools of Paris (children of the working classes from the poorer sections). They arranged certain tests in age-steps, and it is tliis arrangement of the tests into age- norms that has made the tests so popular. This scale is of considerable value for grading intelligence, but it has recently been subjected, particularly in this country, to indiscriminate exploitation and popularization, so that many erroneous ideas have arisen in respect to its real function or the real function of psychological examinations THE PSYCHOLOGICAL CLINIC 141 in general. Almost everything that has been written about the Binet scale (until very recently) has been in the nature of praise— both judicious and extravagant, rather more of the latter. I think it is worth while, therefore, to call attention to some of the current misconceptions and to sound a few warning notes, regarding psychological examinations. 1. Very many persons who are not trained mental examiners seem to think that the Binet testing is all there is to a mental examination ; that it is the only serviceable method we have ; that it is the Alpha and Omega of psy- cho-clinical work. Indeed, that is about all there is to the mental examinations conducted by amateurs. This is a preposterous notion. It is quite possible to give from one hundred to five hundred other valuable psychological tests in the examination of a case. Of any one single scheme of testing, the Binet scale is probably at present our most valuable instrument, but it is only one among many diag- nostic devices at the command of the trained psychological examiner. 2. Another fact that needs to be emphasized again and again is that simply putting a child through the Binet scale does not tell one very much about his real mental idio- syncrasies, the peculiarities of his mental constellations, his particular shorts or longs. It does not give us a differ- ential diagnosis of type or of cause or a prognosis of outcome, except in certain very obvious cases. What the Binet scale does is to give one a preliminary, rough or approximate rating of the child's mental level. If the child is in the schools and has been carefully classified, we already have, through the pedagogical tests and grading, an approximation of his mental standing — often inaccu- rate, to be sure, just as the Binet rating sometimes is. 142 MENTAL HEALTH OF SCHOOL CHILD All that can be expected from the Binet testing by persons who are not expert psychological examiners is usually merely an independent confirmation of the pedagogical rating already assigned the child in the schools. This may be of value. Sometimes, however, the Binet rating will be at variance with the teacher's rating, and I have known of cases in wliich teachers maintain that, because they have been coming into contact with the child and have been studying its mentality, day by day for months or years, their judgment in regard to the cliild's mental standing is more rehable than the judgment of a teacher, nurse or physician who has spent only a few minutes with the child in putting him through the Binet tests. It is doubtful whether the Binet tests will afford to an amateur in clinical psychology deeper insight into the operation of the child's mind than the pedagogical tests afford to the observant teacher. Certainly the Binet testing of itself will not confer any remarkable insight or comprehension upon any person using the scale. If he I already has accurate knowledge and deep insight into mental mechanisms, the Binet testing will better enable liim to use his skill, but without prior erudition or technical skill, the Binet testing is not a magical something that wiU transform a person into a mental wizard and give him occult powers to penetrate into a child's mental peculiari- ties and reveal the treatment he requires. The Binet testing is not a device for supplying brains or a substitute for a technical university course. It is just as preposter- ous to think that one can become a skilled mental examiner merely by reading books on mental tests, as to think that one can become a skilled surgeon by simply reading books on surgery. A clinical psychologist uses certain formal tests merely as the physician feels the pulse or takes the THE PSYCHOLOGICAL CLINIC 143 temperature. A physician must know a good deal more than how to take the pulse or temperature in order to physically diagnose his cases. Because of the large num- ber of mental defectives in the schools, we shall always need a number of assistants to give certain psychological tests, but their function is that of the nurse in relation to the physician (see Chapters IX and X). 3. In the third place, the notion has gotten abroad that the Binet scale is 'infallible' or 'amazingly accurate.' I have attempted to show that both of these statements are false, by minutely analyzing the results of the daily appli- cation of the scale for eight months to epileptics. Since these results have either been ignored^ or criticised because they have been based upon the testing of epileptics, I have used precisely the same method in giving the tests to public school clinic cases. Here there is space to give in briefest form the results merely of a threefold method of testing the scale with the public school cases which have been examined in the psycho-educational chnic of the School of Education, University of Pittsburgh. (For criticisms of the tests growing out of their use with epileptics, see Chapters VI, VII and VIII.) First, I have compared the Binet rating or classification with the pedagogical classification of the consecutive cases which were thoroughly examined. Age six to seven was considered as the normal age for Grade I. Briefly, the Binet rating gave 80.5 per cent as retarded, 2.7 per cent as exactly at age and 15.7 per cent as accelerated (based on 184 cases), while the pedagogical rating gave 89.4 3 One of my recent critics ascribes the inaccuracy of the Binet work to the testers and not to the scale. My investigations, which have revealed the inaccuracy of the scale, have not yet been experi- mentally refuted; they cannot be refuted by bare denial. 144 MENTAL HEALTH OF SCHOOL CHILD per cent as retarded, 8.5 per cent as on time, and only 2 per cent as accelerated. Second, I have determined in units of years the gross amoimt of mental and pedagogical retardation and accel- eration of all those children tested whose school records were such as to make it possible to determine the degree of pedagogical deviation (134 cases). The mental variations were recorded in years and fractional parts of years by the point system used in the Binet scale; and the peda- gogical deviations were determined more or less according to the age-grade method. The difference between the point in the course where the child was at the time of the examination and where he should have been according to his age was determined in years and fractions of years. Graph I shows that the gross amount of Binet retardation amounted to 343.3 years as against 359.3 years of peda- gogical retardation; and the corresponding figures for acceleration were 24.4 years as against 6 years. By both of the above methods the retardation is seen to be less by the Binet than the pedagogical rating, while the amount of acceleration is decidedly more by the Binet than by the pedagogical rating. These methods of comparison, however, are subject to criticism, and I shall, therefore, pass on to the third and more important method. According to this, all the con- secutive cases which had been thoroughly examined (184 cases) were first classified strictly according to the Binet system, with the exception that only those who were retarded more than three years were classified as feeble- minded, while children less than nine years chronologically, who were retarded two years or over or less than three years were not so classified. It is thus apparent that I have classified less cases by the Binet tests as feeble-minded TOT/JL /JMOUriT or BINET- siMon mo PED/JGOG/c/JL vmi/i- TION SHOWN BY 154 PITTSBURGH SCHOOL C/iSES. Retardation. 545.3 Ljrs. 559.5 i/rs» B-S. Peda-^ ^o^icaf. /Acceleration. GRAPH I. 24.4 yrs. I B-5. 6.yrs» Peda- gogical, CL/JSSIFIC/ITION or COnSECUTIVE CLimC CASES. Psychol, Clinic , Univ. of Pitt. Based on the Binef Testing (1908 scale). /9.5SS GRAPH II. /6,3% H.4% 7.0% 4.8% f.0% I N 3.2% (N CM id Feeble -Minded^ 27.7% 17.3% &2%? 2.7%i 3M 2.7% t t t r S, s ^ :5^ CO CM O o 9,' CM CM CM CM ^ •K. o 1 CM tM c\i /Jccelerafed -^ /5,7X Normal 2%2'A Retarded 60.5Z CL/Jss/F/c/fT/on or COtiSECUT/VE CLIhlC C/15ES. PsLjchol. Clinic, Univ. of Pitt. Based on all the pivailable Facts. 39.2% GRAPH III. tt.6% 8.855: 6.6?'o .5% o V) o /./% o Feeble -Minded I7.0Z 10 I. o b Subnormal 77. 3 y. If. OX ".0% 9.9% I b 148 MENTAL HEALTH OF SCHOOL CHILD than the Binet system permits. In the second place, I have gathered all available data on the cases by other psycho- logical tests and by other inquiries, and have based my own diagnoses on a careful study of all the facts thus secured. A comparison of graphs II and III shows that there is a certain degree of correspondence between the two classifications. The Binet rating gives 4.7 per cent more supernormals and 2.6 per cent more subnormals. The most important difference, however, is in the number of feeble-minded and backward cases. The Binet rating gives 10 per cent more feeble-minded and from 15 to 20 per cent less backward cases than the final estimate. If we also consider the pupils who were retarded three years (or two years if under nine years of age) as feeble- minded, the discrepancy would be perceptibly increased. It is entirely clear to my mind that 27 per cent of these I children (as shown by the Binet tests on the above basis) were not feeble-minded. I am entirely clear on the propo- I sition that the Binet rating in the hands of mere Binet \ testers will give us entirely too many feeble-minded cases. This conclusion seems to be abundantly confirmed by recent reports from Binet testers in the public schools. To cite only two instances : In one city 49.7 per cent of 600 re- tarded children (unselected retardates so far as I can gather) and in another 80 per cent of about 300 admis- sions to special classes, were classified as feeble-minded. In the latter city, the astonishing statement is made that this number includes only 15 per cent of the subnormals in the school system who should be in special classes. What a terrible focus of feeble-minded degeneracy this city must be ! Apply this same ratio of feeble-mindedness to the 6,000,000 retarded children in the schools of the country, and we get a feeble-minded school population of from THE PSYCHOLOGICAL CLINIC 149 3,000,000 to 4,800,000. Of course, this is ludicrously absurd. Even if the cases examined were rather extreme, the figures are still entirely extravagant. Very probably not more than from one-fourth to one-half of these retard- ates were feeble-minded. I will venture the assertion after years of teaching in the public schools and clinically exam- ining public school cases, that the oft-repeated statement, that '2 per cent of the general school population is defect- ive' (if by this is meant feeble-minded), exaggerates the real situation. The actual number is probably about 1 per cent. Incidentally I may say that the percentage of feeble-minded found among prostitutes by Binet testers is also too large. It is important to emphasize that so far as concerns the diagnosis of individual cases (rather than the statistical classification of homogeneous groups of cases), no system of formal intelligence tests yet devised can be used as an infallible measuring rod of intelligence. It is quite certain that if the psychological diagnosis of school children is to be intrusted to laymen, whether teachers, nurses or special- ists other than psychological experts, some very inaccurate and pernicious diagnoses will be made of individual cases. In my own laboratory my diagnoses of individual cases are often quite at variance with the Binet findings. I have sometimes diagnosed cases with only a slight degree of intellectual arrest as 'feeble-minded' because that is the prognosis (one two-year old who will probably remain at two, tested normal), while I have sometimes diagnosed others with a very considerable degree of deficiency as 1 merely 'backward.' Thus, to cite only two cases : 'A' is a gentleman, twenty- eight years of age, who has spent five years in university work. He has been diagnosed as a 'moron,' as a 'degener- 150 MENTAL HEALTH OF SCHOOL CHILD ate,' as 'a case of constitutional inferiority,' as 'a case with paranoid trends,' etc. According to the Binet tests he was clearly 'feeble-minded,' as he measured only 11.4 years in the 1908 series. Anyone knowing no more about the technique of psychological examination than the Binet- Simon scale would at once have classified him as 'feeble- minded,' but he did not impress me at all as being feeble- minded. His appearance, speech and conduct suggested the polished and cultured gentleman. Accordingly, I put him through approximately thirty sets of mental tests (other than twenty-five individual Binet tests) and thirty moral tests. These tests demonstrated that there was a considerable difference in the strength of his different mental traits. Some traits were on the twelve-year plane, some on the fifteen-year, some on the sixteen-year, and some on the adult plane. In some mental tests he did as well as college men. He passed correctly practically all of the moral tests. Here is a case showing more or less deficiency in respect to various mental traits ; but the man lis not feeble-minded, contrary to the Binet rating (a sexual complex was at the root of his trouble). 'B' is an attractive girl of considerable culture, age seventeen, studying Latin, history, algebra and EngHsh in the tenth grade of a private school. She entered school at the age of seven, but has attended rather irregularly because of precarious health. Her school work is not very satisfactory. The most marked mental defect noticed by her teacher is her forgetfulness. By the Binet tests she would be rated as 'feeble-minded,' since she graded only 11.4 years. But no one but a psychological tyro or a mere Binet tester would so classify her. (Her condition borders on psychasthenia.) While intelligence defect is the most obvious trait of THE PSYCHOLOGICAL CLINIC 151 feeble-mindedness, there are other clinical and develop- mental phases which must be taken into consideration before a positive diagnosis can be pronounced in many cases. It is a hazardous and unscientific procedure to per- mit amateurs to brand children as 'feeble-minded' solely because they show a considerable degree of intelligence re- tardation ; it is a serious matter always to classify any child as 'feeble-minded.' Parents ought to have a right to de- mand an independent examination by a competent psycho- educational speciahst before a child can be placed in a special class. In London, parents, by statutory right, may demand an examination of children placed in special classes every six months. The London County Council has recently appointed an expert psychologist to mentally examine school children. In Paris, a special examination for mentally defective children is enjoined by law. But this examination, at least the final diagnosis, should be made by a specialist whose verdict is authoritative. It is certain that parents will be far more ready to accept a mental diagnosis if it is made by a competent psychologi- cal expert. In some cities considerable friction has arisen because parents and teachers have not always been willing to accept the diagnosis of feeble-mindedness made by teach- ers, nurses or physicians who are amateurs in psychologi- cal work. As already stated, learning how to give a few tests is no substitute for a prolonged course in psycho- clinical diagnosis. Mere tests, whether in psychology or medicine, are not always conclusive. Even positive or negative serum reactions sometimes prove nothing. The psychologist, just Hke the physician, must base his diag- nosis on both laboratory and clinical studies. The tests used by the trained psycho-clinicist are invaluable in that they enable him to arrive at a more accurate clinical pic- 152 MENTAL HEALTH OF SCHOOL CHILD ture of the mental condition of his case. But once the men- tal condition has been determined, there remains the more difficult task of locating the causes of the trouble and pre- scribing a differential treatment for each case. The accu- rate determination of the causation can only be made by investigating the personal and family history of the case; the hereditary factors, birth condition, record of diseases, physical and mental development, school history, mental habits, social heredity, environments and present physical and mental condition. In order to secure all the desired data, the psycho-clinicist should be able to command the services of social workers, nurses, medical specialist,^^ trained helpers to assist in some of the formal testing and record and filing clerks. Some of the university psycho- educational clinics have a physician on their staff; others, have a staff of consulting physicians in the medical school or affiliated hospitals or dispensaries. To repeat: the first function of the psychological clinic is to make an accurate diagnosis of mentally deviating children, in order to give expert advice in regard to the child's mental hygiene (and in regard to the physical treatment in so far as this is orthophrenic in its bearings) and educational care and training. II. The second purpose of the psychological clinic is to serve as a clearing house for mentally exceptional cases. The psychological clinic has no special interest in cases which are not mentally or pedagogically exceptional or abnormal. Moreover, its interests thus far have been largely, if not entirely, restricted to juvenile cases. The psychiatric clinic, on the other hand, deals more largely with adult than juvenile cases; and technically these cases are psychotic or incipiently psychotic in character. The psychological {i.e., the psycho-educational) clinic aims to THE PSYCHOLOGICAL CLINIC 153 serve as a focal point where the data bearing on mentally and educationally exceptional children may be brought together for careful analysis and collation, and where the cases may be finally disposed of — some to institutions, some to special classes, some to hospitals or medical clinics or private practitioners and some to special courses of corrective pedagogics. Some psychological chnics also conduct medico-pedagogical schools. They conduct classes during the regular or summer terms and offer special work in corrective pedagogics (particularly in speech training). Many of the psychological clinics in this country which are properly organized have become clearing houses of this character for juvenile cases in the schools and courts. Thus in Seattle the university psycho-clinicist is also the consulting psychologist to the public schools and the juvenile court. He also spends part of his time examining cases throughout the state. In Minneapolis the university psychologists are doing work both for the public schools and for the juvenile court. Here the juvenile court has a room equipped for the examination work in the court house. In New Haven the Yale clinical psychologist, who is in the department of education, but who has his labora- tory in the medical school, does what psycho-clinical work there is done in the city. In Baltimore the study of men- tally abnormal children is undertaken by the clinical psy- chologist, who is (or was until his death) connected with the Phipps Psychiatric Clinic. The University of Kansas examines cases at Lawrence and elsewhere in the state. The clinic in the State University of Iowa also aims to do state-wide work. The clinic in the School of Education, University of Pittsburgh, is examining cases not only from Pittsburgh, but also from the surrounding towns and country. 154 MENTAL HEALTH OF SCHOOL CHILD III. The third function of the psycho-clinicist is re- search, particularly with a view to increasing and perfect- ing diagnostic tests and to extending our knowledge of the nature, causes and treatment of mental abnormalities. Owing to our ignorance in this field, the need for systematic research is paramount. IV. A fourth function of the psycho-clinic comprises education and propaganda — the dissemination of reliable information and knowledge regarding the condition and needs of the mentally abnormal classes. This is done through the offering of lecture and clinical courses, the publication of memoirs and investigations, the conducting of demonstration clinics, etc. There is constant need, e.g., to develop a sympathetic and enlightened public opinion in regard to the needs of the unreached children in the public schools, in order that they may be properly classified and segregated, so that they may receive the pedagogical training which befits their peculiarities. There is need for enlightened pubhc agitation right here in Pittsburgh, to the end that facilities may be provided for the large army of subnormal school children in our public schools. Over 10 per cent of all the elementary pupils in the Pittsburgh public schools are retarded three years or more. It is safe to say that one-half of this 10 per cent or about 3,000 pupils should be in 'special' classes instead of in the regu- lar, 'ungraded,' anemic or tubercular classes. And yet Pittsburgh today does not have a single special class in which differentiated training is provided for feeble-minded and backward cliildren. It is the one city of its class in the United States without special classes for these chil- dren.* In March, 1911, there were 319 cities in the country 4 One special class was started during the school year 1913-1914. THE PSYCHOLOGICAL CLINIC 155 which had estabhshed classes for 'mentally defective' and 'backward' children (the former including epileptic classes and the latter those in which 'special teachers are employed to assist slow pupils'). This is an entirely new phase of educational work in Pittsburgh, where it must be organized from the very beginning. (See note following Chapter XIX.) CHAPTER V THE DISTINCTIVE CONTRIBUTION OF THE PSYCHO-EDUCATIONAL CLINIC TO THE SCHOOL HYGIENE MOVEMENT' It is only in the twentieth century that we have come to recognize that the conservation of school children involves more than inspection for physical diseases and defects, more than medical treatment and physical hygiene, more than the provision of school lunches, sanitary drink- ing fountains, schoolhouses properly regulated in regard to temperature, fresh air and humidity, open-air classes for the tubercular and anemic and special classes for the crippled, deaf and blind. It is only within the last few years that the laity, and also very many of the experts, have so much as suspected that there is a realm of mental orthogenesis (or ortho phrenic s) independent of, although supplementary to, the realm of physical orthogenesis (to which I have previously applied the term orthosomatics) ; that there is a psycho-educational type of school inspec- tion entirely different from physical, medical or dental inspection ; and that there is a sphere of corrective peda- gogics and psycho-educational therapeutics paralleling the sphere of dento-medical care and the surgical removal or correction of physical handicaps. 1 Delivered before the session on Mental Hygiene and the Hygiene of the Mentally Abnormal Child, at the Fourth International Con- gress on School Hygiene, Buffalo, August 37, 1913. THE PSYCHO-EDUCATIONAL CLINIC 157 How loath the human mind is to recognize or sanction new movements may be best indicated by the fact that while this International Congress has a section devoted to school inspection (or health supervision), it appears from the announcements that the connotation of the words 'school inspection' is confined to physical inspection (medi- cal and dental), although numerous theses^ have been pre- sented in the public prints during a number of years to show that there is a psycho-educational type of inspection radically different from dento-medical inspection, and although this type of inspection is now an accomplished fact in many of the leading centers of educational endeavor throughout the country (see Chapters II and XVIII). It is evident, therefore, that we must extend the connotation of the term 'school inspection' so that it will include three distinct phases : medical, dental and psycho-educational. The clinical psycho-educationist performs certain func- tions which no other specialist had previously been trained to perform. The pedagogue, even though he be amply trained, was merely prepared to instruct, educate and discipline children, but had no qualifications for making anything but the crudest psychological and educational diagnoses. He was in no sense a clinicist. The pediatri- cian knew much about the physical diseases of young chil- dren and a good deal about the diseases of older children ; but his knowledge of children's mental and educational 2 Thus articles written by the author in 1909 (Medical and Psy- chological Inspection of School Children, The American School Master, p. 435), in 1911 (The New Clinical Psychology and the Psycho-Clinicist, Journal of Educational Psychology, p. 121, 191) and in 1913 (Clinical Psychology: What It Is and What It Is Not, Science, p. 895; The Functions of the Psychological Clinic, Medical Record, September; Re-averments Respecting Psycho-Clinical Norms and Scales of Development, Psychological Clinic, p. 89). 158 MENTAL HEALTH OF SCHOOL CHILD deviations was limited to the merest generalities, and his knowledge of the examination technique of the psychologi- cal laboratory and of educational methodology and cor- rective pedagogy was extremely meager or practically nil. The neurologists and psycho pathologists were versed in the nervous disorders of children and adults, and they knew a good deal about the phenomena of disordered or alienated mentality ; but they knew far less about the minor forms of mental and pedagogical variation which more frequently occur in exceptional school children, and they had made little, if any, technical study of educational, experimental and clinical psychology, of child study, of the principles of teaching and of the differential pedagogic treatment required by each type of mentally deviating child. Likewise the ordinary psychological expert knew a good deal about experimental and physiological psychol- ogy and more or less about educational psychology and child study ; but usually he had no professional training in elementary methods or special pedagogics, he had no training in clinical technique and he lacked that first-hand experience with cases which is essential in order to become skilled in diagnosis. Here, then, was a field of diagnosis for which the exist- ing types of specialists, whether medical, psychological or educational, had practically no scientific preparation whatever. But this gap, the existence of which is now quite obvious to the intelligent observer, is being rapidly filled by the development of psychological or psycho- educational clinics. To America belongs the chief honor for constructive achievement in this field of applied psy- chology. In America we are rapidly developing a new type of psychologist or educationist trained in psycho- educational diagnosis and orthogenesis. THE PSYCHO-EDUCATIONAL CLINIC 159 Y With the rapid multiphcation of the psychological clinics during the last few years, there has developed a feel- ing in the medical profession that the clinical psychologist is encroaching upon a field preempted by, and held sacred to, the physician. This fear, however, is entirely without foundation. The work of the clinical psychologist {i.e., the psycho-educational clinicist) and the medical man are not competitive or duplicative, but supplementary and correlative. To be sure, the clinical psychologist (psycho- educational clinicist) wants his cases medically and den- tally examined in order that he may more accurately inter- pret his findings, but he leaves this work to the medical and dental specialists. If his clinic is well endowed, he will have a medical specialist or a number of medical specialists on his staff; otherwise he will utilize medical consultants from the dispensaries, hospitals and medical schools. The I educational clinicist seeks all the medical data available on his cases precisely as he seeks all the sociological, heredi- tary, pedagogical, psychological and anthropometric facts that he can secure. But all these data are merely contri- butory to his chief purpose: the interpretation of the mental and educational peculiarities, abnormalities, reduc- tions or intensifications revealed by his psychological and educational tests and analyses. And the purpose of an accurate interpretation of the psychological and educa- tional symptoms is, in turn, to enable him to prescribe appropriate orthogenic treatment. This may consist in giving advice to the parent or teacher regarding the proper mental hygiene of the child and regarding its proper educational classification and pedagogical train- ing, or it may consist in referring the case to the dispen- sary, hospital or a private practitioner for medical, dental or surgical care. In any case, the function of the psycho- 160 MENTAL HEALTH OF SCHOOL CHILD educational clinic is distinctly orthophrenic ; namely, the righting or correction of the mental functions which are deviating or abnormal, either by the removal of physical handicaps or by proper mental and educational treatment ; the stimulation by appropriate stimuli of functions which are slowed down or retarded, and the placing of the child in the right educational classification or environment, so that he may attain with the least expenditure of energy and the least amount of friction to his maximal potential. The clinic strives to determine what are the inherent mental and educational peculiarities and what the inherent strength of various mental functions in the child ; whether he is only apparently or genuinely abnormal, subnormal or supernormal ; in which mental planes he is deficient and in which functions he is talented. But always the purpose of this detailed psycho-educational analysis is to furnish that insight which will enable the psychologist to place his case in the right place in the educational system, or to so adjust the educative materials and methods that they will minister effectively to the child's peculiar needs. From what I have said, it is evident that the interest of the psycho-educational clinicist is in children who are mentally and educationally unusual and who can be helped by special psychological or educational treatment. This group includes, among other types, supernormal, bright, backward, feeble-minded, epileptic, psychasthenic, neu- rotic, speech-defective and morally and emotionally unstable children. At the University of Pittsburgh we are conducting a free dispensary psycho-educational clinic, to which the above and other types of children, including child prodi- gies, children with alexia, agraphia and motor defects but without corresponding intellectual impairment, have been THE PSYCHO-EDUCATIONAL CLINIC 161 brought by parents, teachers, nurses, physicians and social and settlement workers. Of a limited number of consecu- tive examinees (the first 184 who were thoroughly exam- ined) which I have tabulated, 11 per cent were classified as bright or supernormal, 11 per cent as normal and 77.9 per cent as subnormal. Most of the subnormals were back- ward; namely, 39.2 per cent of the entire number examined. Seventeen per cent of all the cases were classified as feeble- minded, 11.6 per cent as border cases and 9.9 per cent as merely retarded. Eight and eight-tenths per cent were classified as morons, 6.6 per cent as imbeciles and .5 per cent as idiots. While very few of the feeble-minded belonged to any special type, there were two Mongolians, one cretin, one paralytic and one case of infantilism. The average amount of time devoted to the study of these cases was about one and one-half hours, while the maximum time given to any one case was over twenty hours. This case had been variously and fallaciously diagnosed as a moron, a moral imbecile, a degenerate and a mild paranoiac, but the mental factors which were found to be responsible for his abnormal behavior pointed to an entirely different diagnosis. Some of the advice which had been given to parents concerning many of these cases would be termed ludicrous, were it not that it was actually tragic. Parents had been told by so-called experts, 'not to bother about their child as he was all right ; not to worry, because the child would outgrow his trouble when he attained the age of six or seven, or thirteen or fourteen.' In consequence practically all of these cases, which proved to be utterly hopeless so far as concerns restoration to normality, had been educa- tionally neglected for years. They had wasted their child- hood in the regular grades in the vain endeavor to do work 162 MENTAL HEALTH OF SCHOOL CHILD for which they were utterly unfitted. Because of their inability to advance they had either been neglected in despair by the teachers or they had unduly monopolized the teacher's time and robbed the normal pupils of the attention which by right was theirs, or they had been pro- moted irrespective of their deserts merely to relieve the room of an intolerable burden. The crime was not the pupil's or the teacher's, but society's. Society still com- placently tolerates many a school system which utterly lacks the requisite machinery for the scientific psycho- educational classification of its educationally exceptional children, but it also must be conceded that one of the stumbling-blocks to progess in work with mentally abnor- mal children is the schools themselves. During the past year I have had the interesting experience of having several teachers report to me that they wanted to send cases to the clinic for examination, but the principals refused permission. The principals said: 'The children are all right ; we will leave well enough alone, and proceed as we have done before. The fault is not with the children but with the inefficient teachers.' And now an interesting point is this : two parents brought me two cases which the principal had refused to send. Both of these children proved to he imbeciles. And yet the omniscient principal had said that they were all right and that the fault was the teacher's. As a general proposition the teachers who work daily with the pupils can gauge their mentahty more accurately than many principals or superintendents. The moral of my story is simply this : just as the schools now pedagogically examine children as a matter of course, of legal right and of routine, in order properly to grade and promote them, so must the schools as a matter of legal THE PSYCHO-EDUCATIONAL CLINIC 163 right and as a matter of fixed routine, psychologically examine all mentally unusual children, so that they may be more accurately mentally and educationally classified and diagnosed. Only thus can we economically and scien- tifically train all the children of all the people. Every large school system should employ a psycho-educational specialist who is as thoroughly trained in this work as the best medical, neurological or psychiatric specialists are trained in their work. Discussion following the reading of the above paper. In answer to Dr. Ira S. Wile's remarks : Under ideal conditions we ought to subject every school child to a psycho-educational examination at the time that it enters school for the first time, and periodically there- after in case it does not develop normally. But I do not advocate this in practice, because to carry out such a program of work would require larger staffs of experts than the taxpayers will be ready to support. I do say, however, that every child who is retarded not more than two years in his school work, and every child who is obvi- ously or even apparently mentally peculiar or abnormal, should be given a special psycho-educational examination, in addition to the regular dento-medical examinations which are now regularly given in all large school systems. The methods and aims of a psycho-educational examina- tion are not the same as those of a medical examination. The psycho-educational clinic, while closely related to, is not identical with, the neurological or psychopathic clinic. I should say that the average physician would require three or four years of technical training in order to be able to learn skillfully to psychologically and educationally 164 MENTAL HEALTH OF SCHOOL CHILD examine a mentally unusual child and skillfully to direct his educational development, just as I should say that it would require a similar period of time for the average psychologist to fully qualify himself to examine children medically (as well as psychologically), I do not think we shall soon reach the point where either the medical men or the psychologists (or the clinical educationists) will be ready to spend three or four extra years of prescribed study, in order to qualify themselves as double examiners (medical and educational). Therefore, I maintain that we need, as a minimum, two types of specialists for the work of examining and directing the care and training of mentally exceptional children; an educational specialist thoroughly trained in the art of psycho-educational diag- nosis and in the differential, corrective pedagogics apper- taining to the different types of educationally exceptional children ; and a medical man who has had special prepara- tion in the art of detecting physical defects and in pedi- atrics, neurology and psychiatry. The problems concern- ing the diagnosis, care, training and education of the many types of mentally and educationally exceptional children are so varied and complex that one type of specialist very probably cannot develop sufficient skill to satisfactorily handle them all. In answer to the question: What do you do for your cases after you have examined them? That depends entirely on the results of the examination. There is no specific of universal applicability. There are, indeed, certain cases which can profitably be subjected to the same educative processes, but many cases require dif- ferentiated educational treatment. In the case of a peda- gogically retarded child who rates normal mentally and whose school retardation is due to adventitious factors THE PSYCHO-EDUCATIONAL CLINIC 165 (frequent transfer from school to school, absence because of illness, disinterest, etc.), I should not prescribe a special curriculum of corrective work, but more individual atten- tion. His is a problem for the 'ungraded teacher,' and not for the special class teacher. On the other hand, speech-defectives, the feeble-minded, children weak in spelling or reading, etc., require special courses of correc- tive exercises. Moreover, every peculiar case should be carefully followed and subjected to later examinations so that the treatment may be modified to meet individual developmental needs. CHAPTER VI HUMAN EFFICIENCY^ A Plan for the Observational, Clinical and Experi- mental Study of the Personal, Social, Indus- trial, School and Intellectual Efficiencies of Normal and Abnormal Individuals The questions of first importance in the study of mental defectives are the questions of etiology, medical treatment, educational training and guidance and criminal responsi- bility. Etiology naturally claims a large share of con- sideration, because it is only after the etiological factors or agents of different abnormalities have been precisely deter- mined, that we are in a position to prescribe effective remedial and prophylactic treatment, or to deal success- fully with the educational problems affecting defectives. The criminal and legal aspects likewise deserve a large measure of attention. Various forms of mental (and pos- sibly anthropometric) abnormality predispose toward criminahty. It is of vital social importance to determine what types or classes of defectives lack moral insight and appreciation of moral values, the ability to distinguish between right and wrong, or truth and error, the power of self-control, and the feelings of shame, obligation and guilt. What classes of defectives are incapable of living in a normal human environment? How do criminalistic 1 Read, in part, before the New York Branch of the American Psychological Association, February 4, 1911. Reprinted from the Pedagogical Seminary, 1911, pp. 74-84. HUMAN EFFICIENCY 167 tendencies and moral discernment vary with degree of defect, type of disease {e.g., delusional insanities, epileptic manias), duration of disease, transitory states (well known are the occasional or transitory states of moral irresponsi- bility in some forms of epilepsy and in delusional and manic-depressive forms of insanity, which show themselves in maniacal outbursts, and kleptomaniac, suicidal and homicidal tendencies) and environmental conditions? The obligation of the state properly to protect the lives of its subjects, renders the study of questions affecting the moral responsibility of various kinds of defectives of fundamental social importance. The solution of the practical educa- tional, custodial and legal problems concerning defectives will hinge largely upon the answers which scientific investi- gation gives to questions of this nature. While the medical and legal questions are thus of great importance, it is also important to secure accurate knowl- edge concerning the personal, social, industrial, school and intellectual capacities and incapacities of various grades and classes of defectives, such as idiots, imbeciles, morons, laggards, epileptics and insane, blind, deaf, mute and crippled persons. There are thus five sides to the question of efficiency. First of all, what is the personal efficiency of a given grade or class of defectives .f* What can the individual do for his own care and protection? Can he feed and clothe himself, avoid dangers and temptations, control the primal instincts of appetite, sex, love, hate, anger, fear, jealousy, pugnacity, etc.? Where does he stand in the personal efficiency scale? What is the amount of his personal effi- ciency retardation, as measured in tenns of the personal capacities of a normal person of the same age? The answers to these questions involve the establishment of age- 168 MENTAL HEALTH OF SCHOOL CHILD norms of personal efficiency — a task that probably cannot be done with any nicety except for the first years of Hfe, In the second place, what is the nature of the social capacities or incapacities of a given defective, or a typical defective of a given class? Is the individual able to com- municate his ideas or desires through written or oral lan- guage or through cries or gestures? Can he converse coherently or intelligently? Does he seek or avoid social intercourse, conversation, entertainments, games, etc.? Is he socially-minded or anti-social? Is he chummy, enter- taining, generous, sympathetic, timid, retiring, fretful, suspicious, deceitful, quarrelsome, slanderous, brutal, murderous, lascivious, sexually immoral, subject to exhi- bitionism or negativism, lying, thieving, etc.? Does he fit into the social organism? Can he so adjust himself to the customs and rules of society that he will not become a public menace? In short, what is the character of the individual's social deviation? What is his social efficiency age? Is he on the level of the morally undiscerning civi- lized young child or in the stage of the brutal adult savage ? In the third place, what is the industrial and vocational, or motor, efficiency of various defectives? What kinds of work can they do, and how well? How much can they do for their own support? What particular capacities are present or lacking? What special existent occupational interests may be utilized? What is the individual's atti- tude toward work and toward supervision and correction? What are his learning capacities? What working habits can he form? What new tasks can he master? To what extent are his industrial capacities improvable by training? What is his best Hne of work? How does his industrial efficiency vary from time to time? (Witness the striking HUMAN EFFICIENCY 169 variations in epileptics.) What is the productive capacity of a given defective in comparison with a normal person of like maturity, and to what extent can the productive capacity be increased? In a word, what is the amount of the motor or industrial defect, or what is the motor and industrial age, of a given defective? These questions demand solution before the pedagogy of the industrial and vocational training of defectives can be placed upon a satisfactory basis, and before the labor of the patients in institutions for defectives can be so organized as to afford maximal returns. In the fourth place, what is the nature of the academic or school capacities of different grades and classes of defectives? What sort of lessons can be mastered? In which branches do they make progress? Which subjects are worth teaching? What methods must be employed to obtain maximal results? How does the rate of progress differ from the normal rate (the rate with normals)? What is the precise rate and character of the improve- ment from month to month or year to year, as measured by scientifically devised serial tests of equal difficulty, of those mental functions which are central in the learning process ; namely, perception, attention, association, mem- ory, imagination, linguistic construction and reasoning? What kinds of improvement prove to be permanent, what merely transitory? What are the special difficulties of a given defective? What are his native or acquired inter- ests, attitudes, ability to observe, judge, reason, form habits, adapt himself to changed schedules and new condi- tions, to learn by instruction, or imitation, or hit-and- miss experimentation, or repetition (drill processes), or reasoning? How many years over-age is the child for his grade? That is, what are the nature and extent of his 170 MENTAL HEALTH OF SCHOOL CHILD pedagogical retardation? What is his pedagogical age? We cannot hope to adapt our curricula to the varying needs of defective children until we have thrown the search- light upon these vital school problems. Finally, we have the basal question of the character of the intellectual disorganization and the degree of the intellectual arrest of various defectives. This question is fundamental, because all the other capacities depend more upon the intellectual integrity of the individual than upon the integrity of any other group of functions. Here we must ascertain, not so much the range of the individual's information or his erudition, as the degree and character of his native and acquired intellectual grasp, capacity or ability. Is his intellectual development normal, or has it been arrested from the start, or has it become atrophied with time.f* What particular intellectual functions have suffered the greatest impairment ? Where along the intel- lectual highway from the low-grade idiot up through the imbecile, moron and laggard to the normal person, has the individual stopped? What, in a word, is the individual's intellectual age? Can this be determined in definite units, or by diagnostic age tests, more precisely than can be done by observation or by the use of school grades ^ The above are fundamental questions which must be properly answered before we can presume to deal intelli- gently with the problems affecting the housing, segrega- tion, care, treatment and education of public school and institutional types of defectives, or before we can deal intelligently with normal and supernormal children. At the New Jersey State Village for Epileptics^ it was 2 A laboratory of clinical psychology was established by the Board of Managers at this institution in October, 1910, under the director- ship of the writer. HUMAN EFFICIENCY 171 my privilege recently to inaugurate investigations of the above questions by observational, clinical and experimental methods, and to prepare a series of record blanks on wliich to record the data. These forms are uniform in size with the other forms in use in the institution and are so made that they can be gathered into book form and thus provide a case history for each patient. In order to determine the patient's intellectual status we have been giving the form-hoard test, which throws light upon the patient's ability to visually identify forms, upon his constructive capacity and his power of muscular co- ordination; the hand dynaTnometry test, which roughly tests the power of voluntary attention and effort, and par- ticularly the power of muscular exertion ; the Binet-Simon tests of intellectual development (all of the above are on Form I) ; and a set of six serial or consecutive controlled group tests {Form V^). The latter tests were given serially (one set each month) to somewhat over thirty of our brightest epileptic school children, and to somewhat less than 100 dull, average and bright pupils from the second to the third high-school grades in a nearby public school. Owing to our late start, and the writer's removal from the institution, these tests could be given only during five months ; it would have been better to have given them once every second month during the course of the entire year. These group measurements embrace tests of various mental processes fundamental to intellectual operations : accuracy of perception, perceptual discrimination, obser- 3 Four of the forms were distributed at the meeting. Form I also contains a number of miscellaneous tests; Form II deals with the 'effect of convulsions on mental traits and capacities'; Form III is a 'personal, social and industrial efficiency report'; Form IV is a 'school efficiency report'; and on Form V is recorded 'serial experimental tests of the growth and improvement of mental traits and capacities.' 172 MENTAL HEALTH OF SCHOOL CHILD vation and reaction; the capacity to memorize and the power of immediate and prolonged retention ; the rate of forming spontaneous associations with determinate ante- cedents, the ability to form such controlled associations as are involved in adding columns of ten one-place digits and supplying antonyms to a set of simple words ; the ability to retain a list of logical and illogical sequents with determi- nate antecedents from one reading by the experimenter, during a period of a couple of minutes and during a period of four weeks ; the capacity for visual imagination ; and the capacity for linguistic construction as evidenced by the ability to construct a maximal number of sentences each of which must contain three suppKed nouns or verbs. The aim has been to make each of the six successive tests in the same series different but at the same time equally difficult, and all so difficult that no one can make a perfect score, so that they may serve as an experimental measuring scale of the growth and improvement which various mental capacities or traits undergo from month to month or year to year as a result of normal maturation, education, train- ing, familiarity, removal of physical defects, proper regu- lation of temperature and humidity, or abstention from tobacco or alcohol. By giving these tests to many normal children from season to season or year to year it is possible to establish normal rate norms of development for the traits tested, by which to measure individual retardations or accelerations, as well as the differences in the capacities of various classes of children (normal, bright, dull, back- ward, epileptic, feeble-minded) . Several of these tests were originally prepared for use with a 'dental squad' of Cleve- land school children receiving special prophylactic and operative dental treatment, in order to measure in definite units the effects of such treatment upon mental efficiency. HUMAN EFFICIENCY 173 The use of these tests for this purpose gave very gratify- ing results. The twelve tests which I have worked out — two are repeated during the following sitting in such a way as to transform them into new tests — may not afford the best measuring scales, but they furnish an initial set which can be altered and improved as experience demands. The materials for these tests, together with the directions for giving them, may be secured from the C. H. Stoelting Co., Chicago, 111. The results of the experiment have been tabulated, but have not yet appeared in print. The Binet-Simon measuring scale, with which I have made a survey of the entire village, enables us to make a fairly satisfactory determination of the degree of intel- lectual arrest of the patients, although the tests are faulty in various particulars (see Chapters IV, VIII, IX, X). Here it may be pointed out that the aggregate difficulty of the tests for a given age may be greater than that for a higher age ; some tests are of questionable utility, notably those for the higher ages ; the tests need to be extended so as to include more of the teens, and this is more difficult because in the teens one year makes less diiFerence in intel- ligence than one year during the early years of childliood. Moreover, it is not yet certain whether the scale is appli- cable to the higher grade adult dements or to slightly retarded adolescents (it seems to apply fairly well to most demented idiots, and particularly to amented idiots, imbeciles and low-grade morons) ; nor is it certain that the same tests are applicable to both boys and girls, except during the preadolescent period, owing to the difference in the physiological, psychological and pedagogical maturity of boys and girls of the same chronological age. After some tests have been repeated sufficiently often in a given school or locality to render them familiar, it is 174 MENTAL HEALTH OF SCHOOL CHILD possible for the higher grade examinees to compare notes and coach one another. This has happened in my experi- ence both with pubhc school and high-grade institutional cases. This will enable some pupils to pass the tests beyond their intellectual age, and will transform the meas- uring scale into a series of tests of the ahility to learn par- ticular facts or to acquire particular accomplishments, by dint of direct instruction. But the tests are not designed to try the momentary capacity to acquire a determinate set of facts by special instruction, but to measure the capacity to solve certain problems without special preparation. They are intended to be a measuring rod of the intellectual capacity or strength which normal children of various ages and of a given type of civilization should have developed as a result of normal growth and development. They thus supply a series of age norms of native and acquired mental capacity ; not of native capacity only, as has been assumed. It would be fatuous to attempt to construct a scale for the measurement of pure native capacity, for pure native capacity, after the first few months of life, is a pure fig- ment of the imagination. Only by excluding the psychical and social environmental influences would there be any possibility of measuring native endowment independent of acquired capacity. A measuring scale will, therefore, measure both native and acquired capacity. Just as native capacity differs with individuals, so will the capacity to acquire diff^er with individuals ; but there is probably a certain rate of acquisition which is fairly normal in a given order of civilization, so that it will be possible to establish norms which hold for the great mass of average or typical individuals. Fortunately the difficulty of which we have just spoken, the possibility of being coached so as to pass HUMAN EFFICIENCY 175 some tests, can be met by devising substitute or variant forms of equal difficulty for some of the tests. The basis of initial rating and the corrective formula or the method of giving advance credits (one year for every five points passed in higher ages) sometimes create diffi- culties. This is due to the fact that the number of tests in the various ages in the 1908 scale is not uniform, and to the fact that subjects may pass superior ages while failing on lower ones. In four ages in the 1908 scale the number of tests is four (ages four, five, ten and twelve) ; in two it is five (three and eleven) ; in two six (eight and nine) ; in one seven (age six) ; and in one eight (age seven). The con- sequence is that the subject sometimes receives too few and sometimes too many credits. To illustrate cases from my experience: if the subject passes age six by virtue of two failures in age seven, he can obtain one and one-fifth year of credit for age seven ; i.e., one-fifth of a year more credit than if he were credited outright as having passed age seven. If he fails on age six but passes age ten he can still be rated as ten years mentally. The maximum discrep- ancies which I have found arising from different bases of rating have amounted to over three years, wliile for 39 per cent of 103 epileptic cases studied they amounted to one year or over. This difficulty, however, is not innate in the tests themselves, and can be overcome by equalizing the number of tests in each age, as has been done in the 1911 revision, b}' rearranging the tests, or revising the corrective formula as may be needed. There are two methods by which to scientifically elimi- nate, revise, add or amplify tests in the Binet scale. First, by testing masses of physically and mentally normal public school children. But it is necessary to emphasize that the testing must be a thoroughgoing try-out. To examine five 176 MENTAL HEALTH OF SCHOOL CHILD or six pupils in an hour at a given level in the scale, as has been done, means partial and perfunctory work, and will render the try-out essentially unscientific. We cannot hope to establish reliable norms for children by a slap-dash examination of wholesale quantities of pupils. It is better to try the scale out thoroughly with 1,000 pupils than partially with 10,000. A second way in which to improve the scale, is to under- take a systematic survey of the intellectual capacities of normal boys and girls at different ages. What, e.g., can the typical six-year-old or twelve-year-old boy or girl do intellectually.'^ To answer this question fully we need to gather and compile extensive observational data from classroom teachers, expert paidologists, parents and intel- ligent observers who come into direct daily contact with children. At the Skillman institution I initiated an attempt to gather such data for the epileptic school children by pre- paring a syllabus on the school efBciency of the pupils. School efficiency depends primarily upon intellectual capac- ity and thus furnishes an index of intelligence. From the reports, made by the teachers, it should be possible to gain information regarding the characteristic intellectual capacities of epileptics of various chronological and Binet- Simon ages and of various degrees of mental arrest. The information thus gathered should possess a unique value when brought into correlation with other reports and the various experimental tests. As soon as we have extensive data of this character for large masses of normal children, we shall not only know something definite regarding the intellectual capacities of children of different ages, but we shall have taken an important step toward the construction of an adequate measuring scale of intellectual develop- HUMAN EFFICIENCY 177 ment. Such a program of work as this can only be carried to a successful conclusion by a properly organized and a well-manned department of clinical psychology, or bureau of research, in the public schools, in a university or in an endowed private research foundation. It is probably not necessary to hold a brief in this day for the necessity of undertaking such a survey as this. There is a vast army of repeaters in the schools which threaten to become a national menace. At the present time, our ignorance concerning, and our neglect of, the best care, treatment and education of arrested children, stand out as a national disgrace. We know little at present that is scientifically accurate regarding the degree or character of the physical and mental arrest of our repeaters. We do, therefore, stand in need of comprehen- sive serial graded tests of intelligence, so that we may determine, not only the intellectual age of deviating chil- dren, but the nature of the mental functions most seriously affected, and the character of the arrest (whether per- manent or temporary). It is sheer folly to spend millions of dollars trying to educate for an intellectual career children who are permanently retarded. There are in- stances on record where arrested pupils have made prac- tically no progress during a dozen years of schooling, or where they have actually retrogressed. We have with us nineteen-year-old epileptics who are doing second and third year work. We should be able to determine by means of a scientific diagnostic (intelligence) scale (aided always, of course, by comprehensive 'case-studies') whether a given subnormal is a custodial or institutional case, or a case for one of the special classes in the public schools (for retarded, blind, deaf, mute children, etc.). Binet has given us a 'first-aid-to-the-sick' device, just at the time that we 178 MENTAL HEALTH OF SCHOOL CHILD are awakening to a realization of the magnitude of the problem of mental deficiency. While the intellectual measuring rod is fundamental, we stand in need of a tnotor or industrial scale of development, or a combined intellectual-motor scale. This need arises from the fact that a sixteen-year-old child chronologically may have a twelve-year-old intellect and a fourteen-year- old musculature. Such a child is fairly strong muscularly ; he is able to execute and coordinate his movements with skill ; he can perform quite complicated manual operations ; he can master fairly difficult industrial tasks ; he can retain motor acquisitions and form stable muscular habits. Although he may be accounted an intellectual laggard, he ranks quite high in motor capacity and manual dexterity — a fact which is being demonstrated day by day in the manual training and industrial classes in the pubHc schools. Such a child would, then, be fairly normal on the motor side. Since, therefore, the intellectual and the motor develop- ments will not in all cases coincide, we need a series of motor diagnostic tests arranged in a graded scale, in order that we may know what a normal girl and boy can do industrially, or in motor performance, at different ages. It should be possible to construct such a scale for, at least, the periods of childhood and early adolescence. Having both the intellectual and the motor scales, separate or com- bined, we shall be in a position to say whether the child's defects involve in equal measure the intellectual and the motor functions, or which of these two have suffered the most impairment, and to what extent the arrest has set in. The pedagogical value of such a differential diagnosis is obvious. Instead of allowing teachers to consume their energies and the energies of the pupils for years, trying by HUMAN EFFICIENCY 179 some sort of intellectual legerdemain to fit round boys and girls into square holes, we shall be able to prognosticate by means of standard tests (together with accompanying exhaustive clinical studies) the probable future pedagogi- cal development of the arrested child, and thereby be able to plan a course in which he will make the greatest pro- gress. This will not only redound to the good of the child, but prevent much pedagogical blundering, loss of time and money, and vexation of spirit. Unfortunately there is no existent motor or industrial scale of development for normal children comparable with the Binet-Simon intellectual scale. At Skillman I had the pleasure of launching an attempt to construct such a scale for epileptics, by collecting extensive observational data from the officers, supervisors, attendants and employees of the institution, bearing upon the industrial capacities of the patients who are employed in various forms of indoor and outdoor work. From the results thus obtained it should be possible to construct a motor scale of develop- ment for epileptics for each Binet-Simon age. (Informa- tion is not now available as to whether these inquiries are still carried on.) It is evident that such a motor scale would possess greater value if we were in a position to turn, for purposes of comparison, to a motor scale for normal and supernormal individuals. The need of a normal industrial scale is felt as keenly by the student and trainer of the special cliild, whether subnormal or supernormal, in the public schools, as by the student and trainer of institu- tional types of defectives. Departments of child study in the public schools and research departments in institutions for defectives should make an attempt to gather extensive industrial or motor data by some such means as those we are now using. 180 MENTAL HEALTH OF SCHOOL CHILD Finally, we must make a survey of the personal and social traits and capacities, the moral characteristics and criminal tendencies of our patients. The data on the per- sonal capacities will supply additional material for our comparative measuring scales. There is need of a similar systematic study particularly of the moral and criminal traits of the abnormal, mischievous and delinquent pupils who people our schools, and of the criminals who menace our civilization. These data should be secured, in the first instance, for the socially maladjusted child in the pre- adolescent years, before the criminalistic tendencies have become confirmed. Only when we have in our possession extensive facts of this character will we be in a position to place our pedagogical and moral training and prophy- laxis, and our custodial care and treatment of abnormal and criminal individuals upon a satisfactory basis. When we have given the same amount of careful, expert study to our normal and abnormal human population that the government is giving to the study of Indian corn or the American hog; when we have devoted the same scien- tific attention to the production of superb brain crops that experts, under government subsidy, are now giving to the growing of superior grain crops : then we may hope to make education a genuine science, and the school and insti- tutional training, care, treatment or penalization of defect- ives, dependents or criminals a real art. The view that public institutions, in addition to their recognized duties, should function as research laboratories, is rapidly gaining acceptance. Just now we stand in great need of extensive mass studies : a broad survey of the total field of human capacity. It is with this idea uppermost that the set of efficiency blanks at Skillman were prepared for the sys- tematic recording of observations. Our methods of inves- HIIMAN EFFICIENCY 181 tigation must at present necessarily be somewhat crude. But in time we shall have just as refined a technique for studying the human animal as we now have for studying chickens and pigs. CHAPTER VII EIGHT MONTHS OF PSYCHO-CLINICAL RE- SEARCH AT THE NEW JERSEY STATE VILLAGE FOR EPILEPTICS, WITH SOME RESULTS FROM THE BINET- SIMON TESTING^ The functions of a clinical psychologist in an institu- tion for defectives, in a public school system, in a univer- sity, in a psychiatric institute or in a juvenile court is twofold: first, that of tJieoretical investigation, or the increase of knowledge under controlled and verifiable con- ditions. This is essentially the field of the research psy- chologist or of pure science, so-called. Second, that of practical application, or the utilization of the truths dis- covered for the educational, hygienic, medical and custodial treatment of the sufferers. This is the work of the con- sulting psychologist as distinguished from the pure re- searcher, and constitutes the sphere of orthogenesis, mental hygiene or applied clinical psychology. While the line of demarcation between these two aims should not be 1 Read at the tenth annual meeting in St. Louis, Mo., of the National Association for the Study of Epilepsy and the Care and Treatment of Epileptics, and reprinted from the Transactions of the Association, 1911, pp. 29-43, and from Epilepsia (Amsterdam), 1912, pp. 366-380. A volume of studies, based on my Binet-Simon testing of epileptics, will be found in Experimental Studies of Mental Defectives: A Critique of the Binet-Simon Tests, and a Contribution to the Psychology of Epilepsy, Warwick & York, Inc., Baltimore, 1912. PSYCHO-CLINICAL RESEARCH 183 made too fast and hard, logically the work of investigation in an infant science naturally takes chronological prece- dence to the work of consultation, as, indeed, science logi- cally precedes art. The art of righting defectives cannot rise above the empirical until it is based upon a foundation of assured facts. Until we thoroughly understand the dif- ferent types of nervous and mental abnormalities our treatment cannot be made maximally effective. For these reasons the work in the psycho-clinical laboratory at Skill- man during the past eight months has been devoted entirely to investigation. During these eight months a number of lines of investi- gation have been started, some of which have been con- cluded. Among the surveys of the village which have been completed (completed as far as testing each patient is concerned) are the following: Measurements of standing and sitting heights, of weight, of lung capacity, of the strength of right and left hand grip, of station or body sway, of the speed of performing the form-board test (replacing ten blocks of various forms in corresponding holes in a board), of intellectual capacity or the extent of intellectual retardation, as evinced by the Binet-Simon scale, and of the rate of growth and development, as well as the character and extent of the deviation or disorgani- zation of a number of particular mental traits and capaci- ties which play a basic role in mental development. The latter tests (described in Chapter VI) when given to normal children are intended to supply normal rate curves of mental development. The desirability, or even the feasibility, of establishing psychological rate norms of development has, strangely, scarcely dawned upon us until recently, although the prac- tical value of such norms is probably greater than the 184 MENTAL HEALTH OF SCHOOL CHILD value of the corresponding anthropometric standards of yearly development during the growth-period of standing and sitting height, weight, chest perimetry, dynamometry and vital capacity. The importance of a set of anthropo- metric norms, arranged on the grade or percentile basis, has been eloquently set forth by the lamented Francis Galton, to whose comprehensive intellect many sciences have become indebted. Thanks to the labors of a few of Galton's followers, notably Bowditch, Porter and Smedley, and to the labors of the Italian anthropologists, we now possess a set of fairly reliable physical development norms and indices for certain ages, by means of which we are able to determine the physical station of a given child of a given age, and by means of which we can say whether his physical progress is normal or satisfactory as measured by the per- centile grade for the age to which he belongs (using height as the basis of comparison) , and by means of which we can determine the character of his anthropological indices. But we are now beginning to realize that we cannot prop- erly diagnose developmental defects of the mind until we have constructed a similar set of psychic norms of develop- ment of various traits and capacities. When we have such norms for specialized capacities we shall be able to locate the mental station of a given child at a given time, and determine whether his rate of mental evolution is normal for the grade in which he classifies. These norms will possess fundamental value for purposes of developmental diagnosis, in the study of not merely the lesser deviations but also the more profound mental abnormalities. To supply these mental developmental scales is chiefly a matter of time, labor and ingenuity ; the instrumental and techni- cal difficulties are secondary. Such scales will not, of course, attain the accuracy of refined physical measures, PSYCHO-CLINICAL RESEARCH 185 but they will be far superior to our present 'common sense' judgments. The fair degree of success attained by the simple Binet-Simon tests of intelligence justifies the belief that this problem, baffling as it seems, is not insoluble. By means of the serial group tests which I have been giving during the past year, I am hoping to make some little addition to our knowledge in this largely unexplored, but inviting and important, field of inquiry. Aside from the value which the data from these tests will have for develop- mental diagnosis, the results may also be used as a means by which to check up the Binet-Simon tests, which have recently come into wide use in institutions for defectives and in the public schools in our country.^ I turn now to a consideration of some of the results of our Binet testing. The space at my disposal permits only a brief reference to a few of the more obvious facts, particularly those which concern the characteristics of the curve of distribution, or the classification of the epileptics at Skill- man by this method. Taking the gross or group classification, the 333 patients^ included in the curve (Graph IV) classify as 2 For other studies undertaken in the psycho-clinical laboratory at Skillman during the same year by means of the printed question- naire or syllabus method, see Chapter VI. 3 Those epileptics were excluded from the tabulation who had not had a convulsion within a period of two years, and a few others who were not thoroughly tested because of certain sensory defects. The patients were in their normal condition during the tests. The grading in all cases is based upon the highest age passed, plus the advance credits provided for in the scale, irrespective of whether or not the patient failed at a lower level. Patients who passed in two of the thirteen-year tests were credited with this age, provided they also passed at least five tests in ages eleven and twelve. Draw- ing one triangle was accepted for the first of the thirteen-year-old tests. 186 MENTAL HEALTH OF SCHOOL CHILD follows: 5.7 per cent are idiots (mentality of one and two years), 27.3 per cent are imbeciles (mentality of ages three to seven), 61.5 per cent are morons (mentality of ages eight to twelve), 5.4 per cent have a mentality of thirteen years or over (see the table and the curve), and 82.8 per cent have a mentality of less than eleven years. The idiots and thirteen-year olds are about equally infre- quent, while the morons are decidedly preponderant. These results will attain a new significance if we compare them with the Binet curve for 378 feeble-minded inmates at Vineland.'* In this 19.2 per cent grade as idiots; 54 per cent as imbeciles ; 26 per cent as morons ; none as thirteen years of age; and 96.4 per cent less than eleven years of age. The feeble-minded idiots are about three and one-half times as numerous as the epileptic idiots, but the epileptic morons are more than two and one-half times as numerous as the feeble-minded morons. While the great mass of epileptic and feeble-minded defectives have a mentality of less than eleven years, the proportion is 13.6 per cent greater among the feeble-minded than among the epilep- tics. The typical epileptic category is that of the con- dition of moronity, which contains five-eighths of the entire number of the epileptics, while the typical feeble- minded station is that of imbecility, which includes more than one-half of the feeble-minded. It is apparent that there is a marked difference between epileptic degenerates and feeble-minded retardates in the matter of intelligence. 4 GoDDARD. Journal of Psycho-Asthenics, 1910, 15 : Nos. 1 and 2. The per cents for each age for the feeble-minded are as follows: Age I, 9.5 per cent; II, 9.7 per cent; III, 10.5 per cent; IV, 9.8 per cent; V, 11.1 per cent; VI, 10.2 per cent; VII, 12.4 per cent; VIII, 11.6 per cent; IX, 7.9 per cent; X, 3.7 per cent; XI, 1.3 per cent; XII, 1.8 per cent. Age X in the curve is placed somewhat too high. Graph IV Classification of 333 epileptics (Skillman) and 378 feeble- minded (Vineland) by the Binet-Simon method. 25 20 15 10 5 "" J . j 1 / \ / \ < J \ y 1 / ^ 1 \ ^^ < >, / / N f \ \ ' ,*• s r ' V / \ I / \ f \ \ / \ _\ ,.J / \ / \ \ i / N / \ / \ \ f / \ 1 < ^^ 1 \ 1 \ Ages 5 10 Idiots Imbeciles Morons Per cent Per cent Per cent Per Cent Epileptics 5.7 27.3 61.5 5.4 Feeble-minded . . 19.2 54.0 26.0 0.0 The thirteen-year-olds may be classed as deviates, retard- ates or normals. 188 MENTAL HEALTH OF SCHOOL CHILD The intellectual superiority of the epileptic defective is conspicuous. This superiority will attain added promi- nence if we constitute the thirteen-year-olds into a separate class above the feeble-minded line, which we may regard as normal, or as retarded or deviating but not sufficiently to render them feeble-minded. We should then have to add to this class all the children who are retarded less than three years (certainly many adolescent children retarded less than three years would not be feeble-minded). There are nine of these, five boys and four girls. These with the thirteen-year-olds, make a total of twenty-seven noi-mals, or deviates, which is 8.1 per cent of the entire group. ^ This figure we are justified, I believe, in regarding as a lower limiting value for two reasons. First, the tests in the higher ages are very probably too diflScult for the typical American child for the ages to which they are assigned. To get a line on these higher tests I made use of the following means. A few of the supervisors and officers at Skillman who had known the patients intimately for a con- siderable length of time were asked to prepare estimates of the number of patients whom they regarded as ranking above the feeble-minded station. Three made identical estimates, unknown to each other, for the total population, namely 10 per cent. Five men made separate and inde- pendent estimates of the total male population, as follows : 11, 11, 13, 14 and 20 per cent. With one exception, these estimates agree fairly well. With the tests as at present constituted, it is a question whether the line of feehle- 5 It is interesting to note, that among these twenty-seven there is only one who can be regarded as supernormal, a boy somewhat less than twelve years who grades as thirteen years. PSYCHO-CLINICAL RESEARCH 189 mindedness shoidd be drawn (if indeed it can be definitely drawn anywhere) between twelve and thirteen, as has been tentatively done by the American Association for the Study of Feeble-Mindedness. A number of our twelve- year-olds are certainly very slightly, if at all, feeble- minded. A second reason why the percentage of normals may be too low is the fact that the institutional cases at Skill- man may not be representative. Our curve in general is valid on the assumption that the epileptics tested are typical. According to the theory of the probability sur- face we are justified in regarding them as typical if the selection represents a chance distribution. But it is possi- ble that two selective processes have operated in a way to distort both extremes of the curve. The reason that the idiots are so few may be due to the fact that the higher- grade epileptics have received preference in admission to the institution. The introduction of a constant factor of this sort would skew the frequency curve in the direction of the upper limit. This tendency would probably stop short, however, before it reached the extreme end of the curve, because it is likely that the highest grade of epilep- tics from the better social classes are very rarely found in public institutions. We shall not be able definitely to settle this point until other institutions have undertaken similar studies on a large scale. But three general con- clusions seem assured: first, that the great mass of epilep- tics fall below the feeble-minded line ; second, that they do not fall below this line to such an extent as the class of amented feeble-minded; and third, that the curve of dis- tribution is markedly different for the two classes. Just how much inferior the high-grade epileptics are to those persons, taken at random in the general population whose 190 MENTAL HEALTH OF SCHOOL CHILD schooling and training are about of the same character, cannot now be said. One of the most striking peculiarities of the epileptic curve is its decidedly skewed or anomalous character, noticeable particularly between ages eight and eleven. The curve presents a marked contrast with the curve of feeble-mindedness in this respect. The latter is character- ized by a fairly uniform rise up to and including age seven, and by a rapid and uniform fall after age eight. It has more or less of the normal bell-shaped appearance. But in the epileptic curve there are two irregular drops in the ascending portion, a minor at five and a major at nine. The former does not possess much significance, because of the small number of subjects tested in the lower ages. It may be regarded merely as a fortuitous phenomenon. But in a typical curve of frequency the rise from age six should have been continued without any marked break at nine to the apex at ten. It is, therefore, apparent that the accidental factors which normally operate to produce an unskewed or bell-shaped curve of frequency, were inter- fered with in our testing by some constant factor or factors. These factors can only reside in the method of giving the tests, or in the nature or arrangement of the tests themselves, or in the peculiar mental organization of the epileptics resulting from their inborn constitution or from processes of degeneration.*' There must either be certain defects in the mentality of epileptics, that is, at the nine-year level, for we find 24.9 per cent of epileptics grading ten years old as against 6 Another factor may have to be considered, the relative propor- tion of children among the epileptics and feeble-minded. One-third of the epileptics were under twenty-one years of age; the correspond- ing figure for the feeble-minded is 54 per cent. PSYCHO-CLINICAL RESEARCH 191 only 8.4 per cent grading nine years old ; or we must con- sider the ten-year-old tests as normally too easy and the nine-year tests as too difficult ; or otherwise some factor extraneous to the tests themselves has been operative. The method of testing possibly plays a minor role, for while the method used has followed that in vogue at Vine- land, there is this possible difference : my testing has been done with great thoroughness in this respect, that instead of confining the testing of the patients to the ages imme- diately beneath or above the ages in which they grade, I have tested the majority throughout the greater part of the scale. This was done, not merely to arrive at a more complete clinical picture — to reveal the peculiar mental lapses, gaps and remnants which may be assumed to ac- company degeneration changes- — but in order to test the reliability of the scale itself. For tliis purpose nothing but a thoroughgoing try-out will suffice. '^ This thorough testing has given some interesting results, which we cannot enter upon here further than to say that scores of low or medium grade epileptics were found who passed one or more tests in a half dozen higher age levels, and who received from ten to twenty (in a few cases from twenty-five to thirty) advance points from the first age actually passed. Certain mental remnants from higher psychic levels remained to tell the story of the wreckage wrought by the disease. At the same time, scores who passed the higher age tests failed in individual tests at lower levels. Two years particularly proved veritable pontes asinorum, namely ages six and nine. No per cent of those who are classified in age six passed the tests of this age (that is, all the tests or all but one), while only 10 per T Such a try-out must be made, of course, primarily on large masses of normal children. 192 MENTAL HEALTH OF SCHOOL CHILD cent of the Binet-Simon nine-year-olds passed the tests of this year. Only 29 per cent of the groups of patients who grade six, seven, eight, nine and ten years old passed the six-year-old tests, while only 40 per cent of the nine, ten, eleven, twelve and thirteen year olds passed the nine-year tests. But what is of special interest to the question at issue now is the fact that the method of extensive testing used made it possible for patients to attain a different or higher classification on the basis of advance credits from numerous higher ages. That is why there is no fall in the curve at six, e.g., although not a single one of the six-year- olds actually passed all of the tests but one of that age. While tliis factor is thus of some importance, it does not explain why there is such a large number of ten-year-old patients, because the greater number of these (94 per cent) passed the ten-year-old tests while 84 per cent of them failed on the nine-year tests. There is some evidence to confirm the belief that the nine-year tests are too diffi- cult: the first obvious break in the curve of feeble-minded- ness comes at this age, while Katherine Johnstone,^ testing a considerable group of normal girls in the Sheffield, Eng- land, schools, found this year to be the most difficult. After making due allowance for these two factors — the thoroughness of the testing, and the intrinsic difficulty of the tests themselves — the facts would seem to force us to include a third factor. A detailed analysis of the records, and particularly of the failures at various levels, shows that the inabiUty to pass ages six and nine (eleven may also be included) is due, at least partly, to certain inherent defects in the epileptic mind. These defects, so far as 8 Katherine L. Johnstone. Journal of Experimental Pedagogy, l:34f. (She also finds that some normal children pass higher levels while failing at inferior levels.) PSYCHO-CLINICAL RESEARCH 193 pertains to these ages, arise : first, from a fundamental deficiency in memory span, as shown by the inability to repeat a sentence of sixteen syllables heard once, to recall six units or facts from reading a short passage once, and to correctly state their ages in years ; second, from an inability to define common objects in terms of description or classification, or to define simple abstract qualities in terms of the essential idea ; third, from a blunting of the muscular sensibility, or a raising of the threshold of mus- cular sensory discrimination of weight ; fourth, from a fail- ure to grasp the essentials of a simple situation, as e\adenced by the inability to execute a simple triple com- mand, or to arrange shuffled words into an intelligible sentence ; and fifth, from a marked obstruction or retarda- tion of the stream of thought, as evidenced by the inability to utter sixty words in three minutes. From the very fragmentary account which we have thus given of certain aspects of our Binet work, we are able to frame a picture of an interesting spectacle : a case of mental wreckage, whereby the integrity of various mental functions has been impaired in various levels of mental development, and whereby various lower psychic levels have been swept away while higher levels remain intact. The mentality of epileptics makes up a constellation that is extremely irregular. To what extent the minds of the epileptic males differ from the females, and the children from the adults, as determined by the Binet scale, time does not permit us to discuss. Nor can we detail the interesting results obtained by plotting age curves (for the thirteen Binet ages) for various individual tests by which it appears that, although the scale surely does not accurately meas- ure every individual, it is, in the hands of the expert, a surprisingly serviceable means of classifying homogeneous 194 MENTAL HEALTH OF SCHOOL CHILD masses or groups of individuals. These can all be graded relatively by means of a uniform measuring rod. To this statement we must except the highest grade epileptics, however. The capacities of a considerable number of these lie outside of the range of the scale. Altogether, the Binet-Simon scale offers an ingenious but simple, practic- able, objective and rapid device for estimating and classi- fying defectives. No other available scheme gives such a satisfactory preliminary survey. It can tell us in one hour facts regarding new admissions which would otherwise come only after weeks of observation and experience. To an audience of this kind, the great need of a practical and simple means of grading and classifying institutional cases, and the conspicuous present lack of a generally accepted or satisfactory method need not be emphasized. It is pertinent to lay stress on the fact that the Binet method marks a decided advance step, in spite of all its imperfec- tions. Supplemented by corresponding scales of personal, social and industrial efficiencies, this scheme of graded intelligence-tests offers considerable aid in the solution of a vexing problem. a . NO •<* CM 1-1 CM ON OO' I— 1 1^ CO CO On VO i-l 00 1—1 1—1 NO eg o t^ ■* CNJ 1-1 •* ON 00 6 o CO 00 1-1 O ^ rt CO CM \D t>- 1-1 On !>. NO lO 00 LO 00 CO 1-1 CO 1-1 eg 1-1 CO NO "0 \o 1—1 I— 1 00 r^ ■* T-l ■^ rH 1—1 Tt '^ On NO CO 1—1 t^ eg 1-1 t:!- eg NO I— 1 1—1 CM 00 iH CO CM CNJ 00 o rH > "3 ■a < a D E o c 6 d # d CO rH ^' CO C^ rH 1-1 00 ■* 1—1 CO CO lO ON o cm' CM On "0 1* ON Lo r^ 00 NO od CO iH eg NO CO t^ o ^ t^ t^ CM.-I 1-1 CM iH O On ONO CO ■* 1-1 lo eg NO 1— 1 0^ vo LO VD !>. vo 1-1 ^ CO ■* 1-1 1—1 o CM lO CO NO NO t^ 00 Co" ON *" CM 1-1 eg CO NO NO 00 ON T-l "0 VO O lO ■* lO CM 1— I NO CM O On CN] lO CO eg CO On NO .-1 I-H CO 'rj- t^ VD 1-1 00 CO 1-1 (Nl v£) t^ NO 1-1 CM •*!>-■* O CO t^ 00 CO CO ■*' TH eg 1-1 00 no" NO iH I— 1 CM eg ^ Tt CM CO t^ ON CM o o !>• "0 lo CM 1-1 CM 1-1 0) -d c a . o d d d eg m I— 1 00 CO 1-1 t^ O O vo 00 CM c^ o CO NO CO NO 1-1 00 CO t^ CO 00 1-1 t^ eg i-( eg NO CO 00 iH CM o o 1—1 rH CO VO 0^ f^ On CO O 1-1 1—1 1—1 o lO ON ■* 00 CO r-t eg On LO O CO VD O O r- On ■* T}- ■* i-i 1— ( On CO -* O O NO NO CO ■>* !>■" CO tJ-" eg" 1—1 1—1 NO O CM CM CO ■* CM NO vD i-t CM NO CO CO eg 1-1 o CM 5 NO o CO d tH ON-* "0 ON'* lo r^ th lo c^ 1—1 00 CM ■* ON 00 ON o CO CO CO 00 CO 1-1 CM O Oo' wo O CO eg CO iH 1—1 cort- t^ 1* lO 1-1 ■ OJ u o =<-H -l-> <1) Q on3 3 O ~5 u s CS !U a c >S tj 5« c CS d O •> > bf a) o 03 3 CS 0) 3 cr a "1 ^^ 4) Pi a a 0) b en a a CS r/) a) o « CS a, y CO a; cS O 4-> ? .2 JH -rt a -4-1 J3 (11 c "3 o CB J3 cS -a 0) Pi 3 aJ3 be -C o crt J3 -^ >• a c CO C CS o l-l > CS O