CHAPTER IV. WHAT PERCENTAGE IS FEEBLE-MINDED
A. Kinds of Social Care Contemplated
At first it seems like a hopeless task to try to bring harmony out of the confused estimates of the proportion of the feeble-minded in modern society. Authoritative estimates by commissions or by recognized experts range from less than 0.2% to 5.0% that is, from 2 to 50 per thousand. Further study of these estimates shows that they reflect not so much a difference in expert opinion about the same problem as differences in the problems which were considered in making the estimates. As soon as we compare only those estimates that have been made to answer the question, what percentage of low grade minds should be provided with a certain form of social care? it is rather surprising how much less the discrepancy becomes. An analysis of important estimates will therefore be undertaken in order to try to discover some of the sources of disagreement.
The most significant thing about an estimate is that the estimator is thinking of providing for his group of deficients in a special way. This is the purpose of the estimates. Three important groups of the mentally deficient now demand attention. They are: (1) The group which, for moral and eugenic reasons, society is justified in isolating for life or an indefinite period. (2) The group which needs special simple industrial training in order to get along with social assistance without isolation. These deficients may be cared for in their home towns by special schools, public guardians, and after-care committees. (3) The group which needs special school assistance, but is socially passable after leaving school. These individuals are incapable of competing in school with their fellows, but they are able to get along in the simplest employments without social assistance. We may designate these three groups as those needing (1) social isolation, (2) social assistance, and (3) only school assistance. The largest estimates of feeble-mindedness, it will be found, include the third group, while the smallest intend to include only the first group. The first and second groups are clearly below the limit of feeble-mindedness designated by the verbal definition of the British Commission. They are socially unfit. The language of that definition is ambiguous enough to include the third group, but the plan of the Commission, judged by its consideration of the number to be sent to special schools, would regard only the first two classes as feeble-minded. Following this common conception I have regarded those in the third group as above the feeble-minded. It will help to find harmony among the estimates if we estimate separately those mentally deficient enough to need social isolation, social assistance, and only school assistance. This discrimination of the retarded by the kind of social care needed should also make the social definition more useful.
B. Estimates of the School Population Versus the General Population
Before we consider the percentage estimates in detail for these different forms of social care, let us note the effect on them of two other considerations. The first of these is the discrepancy between estimates of the proportion of feeble-minded among school children and estimates as to the proportion in the general population. Since feeble-mindedness is regarded as a permanent arrest of mental development occurring at an early age and usually due to hereditary causes, it is plain that a school child who is feeble-minded would be expected to remain so for life. Nevertheless we find that estimates of 0.3% of the general population are accompanied by estimates of 1.0% or 2.0% of the school population as feeble-minded. I have not been able to find any careful attempt to account for these discrepancies. The excessive mortality among the feeble-minded is hardly adequate to explain so great a difference.
It is interesting to note some of these comparisons. Goddard, for example, considers it conservative to estimate that 2% of the school population is “feeble-minded” (112, p. 6). In the same publication he says: “There are between 300,000 and 400,000 feeble-minded persons in the United States” (p. 582). Since the elementary school enrollment is about 20,000,000 ([208]), the feeble-minded school children alone on his first estimate would account for 400,000 feeble-minded in the United States without allowing for any feeble-minded outside of the ages in the elementary school.
The report of the British Royal Commission, published in 1908, forms the starting point for many of the estimates made today. The commission added together the number of school children which were thought to require special classes with the number of defectives found in institutions, prisons and almshouses, or reported by its medical investigators. The total gave 0.46% of the general population as “mentally defective persons,” not including certified lunatics. From this amount should be deducted .06% who were insane but had not been certified as such, leaving 0.4% mentally deficient. This was not regarded by the Commission as an estimate, but was the number actually “enumerated by the medical investigators” in sixteen typical districts studied in England and Wales with a total population of 2,362,222 (83, VIII, p. 192). Turning to the school children we find that in the areas investigated there were 436,833 school children of whom 0.79% were found defective. Since this was an enumeration and not an estimate, the commission paid no attention to the discrepancy between 0.79% of the school children and 0.31% of the rest of the population. Tredgold, moreover, based his estimates of the frequency of the mental deficiency in England and Wales on the data of the Royal Commission without attempting to harmonize this discrepancy. This oversight has apparently been one source of the not uncommon difference between the estimates for school children and for the general population. One suspects that the fact that the elementary school population is about a fifth of the general population, has also mistakenly contributed to this error. The discrepancy of three to five times as large a frequency of deficiency among school children as in the general population certainly needs clearing up.
There is an escape from this dilemma which seems more reasonable than to attempt to account for the discrepancy by excessive mortality. When estimates are made concerning the school population the estimator is usually thinking of that group of feeble-minded which needs special school training and probably social assistance afterward. When estimates are made of the general population the estimator is likely to be thinking of that group which must be cared for permanently by society, mainly in institutions or colonies. For some time at least the state cannot be expected to undertake the indefinite care of all the deficients who should have, at once, simple industrial training, in special local schools or classes in order to survive, even with social assistance. This difference in the type of care contemplated seems most naturally to account for the discrepancy found with many writers, between their estimates for the school population and for the general population.
C. Desirable Versus Immediately Advisable Social Care
A second source of confusion arises when one investigator is thinking of the number of feeble-minded, the care of whom it is desirable that society should assume, and another is thinking of the feeble-minded, the care of whom it is advisable for society to assume at once. Considered in connection with a specific case the distinction is quite obvious. It is one thing to say that it would be desirable for the state to assume the indefinite care of a particular person, it is quite another thing to say that it would be advisable for the state to assume that care immediately, when one remembers the crowded condition of the institutions, the necessity of caring for the worst cases first, the possibility of the person being cared for by his own family or in a local school, the added public expense, the necessary neglect of other movements for social welfare if society assumes this expense, etc., etc.
When you magnify this problem in the mind of the estimator who is interested in the question of caring for the groups of feeble-minded, the result is that his estimates of the size of the groups are decidedly affected. For example, few would deny that the Site Commission of New York appointed to locate the colony for mental defectives, now known as the Letchworth Village, was emphasizing a program of permanent social care when it estimated the number of feeble-minded in New York. The Commission, “after taking into consideration the figures of the State and National census, and other data collected from institutions,” estimated that there were in New York state possibly 12,300 mentally defective persons (Editor's Note, 205, p. 84). This is less than 0.15% of the population and very low compared with most estimates.
The low estimates will generally be found to be influenced by considerations of public expense rather than the social unfitness of the lower group. Inasmuch as there are no sharp distinctions between different degrees of mental ability this consideration of public expense is perfectly proper. At the other extreme, however, are the eugenists who are convinced that it is desirable to isolate a large group at the lower range of ability. The member of the legislature will be concerned mainly with the question how much money will the public be willing to appropriate now for the care of these unfortunates. The eugenist will be thinking of an ideal rather far in the future towards which to work.
The diagnostician should take a conservative intermediate ground. He may leave to the court or other authorized tribunal to decide whether the public has the facilities available at present for caring for a particular weak-minded person, but he must decide whether expert scientific opinion at the present time will justify diagnosing this degree of deficiency as suitable for the special care provided for the feeble-minded. Whether it is advisable to care for the particular deficient at home, in a special local school, or in a state institution would be left to the legal authority to decide. Under present conditions, the diagnostician may possibly indicate whether the individual is deficient enough to justify social isolation, or merely to justify sending to a local elementary day school for deficients.
D. Percentages Suggested to Harmonize the Estimates
It is from the point of view of the diagnostician that we shall attempt to focus this question of the percentage of feeble-minded. We shall tentatively suggest limits as to the degrees of intellectual deficiency which we might be justified in regarding, under the present conditions of scientific knowledge as being low enough in intellectual capacity to justify particular forms of social care. Such estimates will be of value if they help to harmonize the conflicting opinions by bringing them into relation with the above analysis. We shall, therefore, compare the suggested percentages with a number of authoritative statements of the frequency of feeble-mindedness. By considering the differences in the nature of the estimations we may approach nearer to an understanding of the problem.
Since the percentages to be suggested are chosen from the point of view of diagnosis, they do not represent the number for which every community should immediately make financial provision. The expense is a local or a state question. It is so much affected by state conditions and by public policy that it probably must be determined in any state by a special commission. On the other hand, the laws already provide for caring for the feeble-minded in institutions or colonies and in special schools or classes, so that the estimates may help to guide diagnosticians who are called upon to decide whether a particular person might be rightfully regarded as deficient enough intellectually to justify committing him for permanent care to a state institution. In the present practise it is fairly clear that this distinction is made in the minds of different diagnosticians. It may ultimately be desirable that this differentiation between the types of social care be introduced into the law. Until then it will remain the duty of the court to determine what degree of social unfitness is intended by a particular law. The social concept of feeble-mindedness is just now undergoing a rapid evolution so that it would be impossible to predict how it may legally crystallize a generation hence.
To begin with the lowest group of the feeble-minded, we should consider those whom the state might be clearly justified in isolating indefinitely on the basis of their tested lack of intellectual capacity, the social isolation group. For purposes of comparison let us place this degree of intellectual ability as that possessed by the lowest 0.5% at fifteen years of age. Above these let us estimate a group of uncertain cases so far as isolation is concerned, but cases which the diagnostician would be justified in regarding as intellectually deficient enough to justify sending to special local schools for training the feeble-minded. After special training the majority of these cases might be expected to require social assistance indefinitely. They would form the social assistance group. Isolation would be justified for none of them on the basis of their test records alone. Those in this group who were persistent delinquents would, by that additional fact, fall into the lowest group so far as social care is concerned. Let us estimate this social assistance group tentatively as the next 1.0% at fifteen years of age.
These estimates have been made as at fifteen years of age since the effect of the excessive mortality especially among the isolation group is uncertain and may need to be allowed for in a discussion of the percentage deficient at different ages. If the mortality were as great as has been described among institutional cases in the previous chapter, a rough estimate of the percentage intellectually deficient in the general population places it at less than 0.5%. This estimate may be made by using the estimated deficiency at the median age of those under 15 years of age and at the median age of those 15 years of age and over. According to the age distribution of the 1910 census, there were 32% under 15 years with a median age of 6 years. At age six 0.67% would be presumed as low as 0.50% at 15 years. The older group (68% of the population) has a median age of 32 with a corresponding percentage in the isolation group at that age of 0.30%, after allowing for differences in mortality on the plan indicated in Table II. This rough estimate for the lowest group indicates that 0.42% of the general population would be of as low a degree of intellectual capacity as the lowest 0.5% at 15 years. Our plan presumes, therefore, that between 0.4% and 0.5% of the population are unable to pass their entire lives outside of institutions under ordinary conditions; i. e., make an honest living and live within the law even with social assistance and supervision.
The corresponding estimate for those requiring only social assistance would be between 0.8% and 1.0% of the general population above the lowest group. This might vary from approximately 1.34% at 6 years to 0.59% at 32, the median age for those over 14 years. Since the mortality is probably less among deficients not in institutions, as they average higher in ability, the changes in the percentages are probably extreme estimates. We should keep in mind, however, the possibility that with the excessive death rate the lowest 1.0% at 15 may mean an ability corresponding to the lowest 1.34% at 6 years and the lowest 0.60% at 32 years.
The next higher group in intellectual ability is so high as not to require social assistance outside of school. When we ask how large a per cent. we should be justified in placing in this group and separating merely for special instruction in school, we reach a condition which is at present so ill-defined even in the minds of educators that it seems best to fall back on the general advice that our school systems should provide just as nearly individual instruction as the public purse and managing genius can devise. Mannheim, Germany, for example, takes care of 18 per cent. outside of its regular school classes. The ideal is individual instruction for all. School authorities would be justified in providing special instruction for every degree of mental ability, if the cost would not restrict other more important social undertakings. This less degree of retardation in the group needing only school assistance should not, however, be classed as feeble-minded. We shall see later the percentages for which some authorities have considered it already advisable to provide special school instruction. We need not attempt to estimate the size of this group, as it is beyond the limit of feeble-mindedness.
The purely conative cases are not taken care of in the above estimates, which are intended for tested deficients. If the conative cases unaccompanied by intellectual deficiency should be regarded as frequent enough to replace those in the social assistance group who ultimately care for themselves, plus those subtracted by the excessive death rate, we would have a total of 1.5% of the general population feeble-minded enough to warrant social care of some sort. About 0.5% might justly be isolated. The reasonableness of this program can be judged by comparison with authoritative estimates now to be reviewed. The problem here is whether this is an unreasonable program for the diagnostician to assume as scientifically justified, remembering that these estimates are for tested deficients at 15 years of age and do not include purely conative cases which might occur above these intellectual borderlines.
E. Comparison With Important Estimates
The Social Isolation Group. We are now ready to consider some of the important estimates which throw light upon the reasonableness of the percentages we have named. First, what percentage would we be justified in socially isolating? In the United States Census Report on the Insane and Feeble-Minded in Institutions in 1910, we find that the number then actually in institutions for feeble-minded was only about 0.02% of the population. At the most frequent ages this rises to about 0.05%. It is evident that the number actually isolated is of little significance except as a check on the estimates. The report, however, refers to the special estimate made by the public authorities in Massachusetts which also included feeble-minded in state hospitals for the insane, other asylums, those reported by the overseers of the poor and those enumerated in the general population. The U. S. report says: “The census was not regarded as being complete, but it is of interest to note that if the number of feeble-minded in proportion to the total population was the same for the entire United States as it was in Massachusetts according to this census, the total number of feeble-minded would be over 200,000. Probably this may be regarded as a conservative estimate of the number of feeble-minded in the United States and would indicate that not over one-tenth of the feeble-minded are being cared for in special institutions” (205, p. 183). This estimate, which thus amounts to about 0.2%, may probably be considered as a reasonable program of expansion from the institutional viewpoint. The diagnostician who is considering the individual and not the mass must supplement it by considering who should be isolated if facilities were available. If the census bureau can contemplate institutional care for ten times those at present thus provided for, it gives us some indication of a reasonable limit as to the increase in institutional care that can be assumed to be reasonably contemplated at present.
Dr. W. D. Cornell, director of medical inspection of the Philadelphia public schools, after the personal examination of those cases which in the opinion of the teachers should be sent to institutions, places the “institution cases” at a minimum of 15 per 10,000 school children. He adds: “The number of evidently feeble-minded above 6 years of age may be said to be 1 to every 500 of the population. These figures are conservative and have been accepted by experts for years.” This then is the minimum estimate and quite clearly refers to institutional cases.
A committee of the Public School Alliance of New Orleans, of which Prof. David Spence Hill was chairman, reported in 1913 a careful census of the public school children in that city the previous year made by the teachers in co-operation with the Newcomb Laboratory of Psychology and Education. Each teacher was asked to state her opinion as to how many in her room were “feeble-minded or insane children who should be under institutional or home care, rather than in the public schools.” Also the number of backward children not in the above class “who urgently need special educational methods in special classes within the special schools.” About a fifth of the total of the 38,000 school children in the city are colored. The grand total showed 0.28% in the first class mentioned above, and 7.7% in the second. Speaking of those “thought by teachers to be feeble-minded” and needing institutional care the report says:
“The figure 0.28 of 1% coincides exactly with the estimate of the Philadelphia Teachers' Association made in 1909 in a census of 150,000 school children. Secondly, while the teacher's estimates are open to revision, nevertheless her judgment, as inevitably evidenced in her attitude toward the child, is the practically effective judgment” (157, p. 6). It is a well-known fact that teachers tend to underestimate the frequency of mental deficiency, so that it would certainly be a matter of regret if this were to continue to be the “practically effective judgment.”
Another census of the institutional type of feeble-minded made by the Director of Public Health Charities in Philadelphia and reported in 1910 enumerated 0.2% of the population as in this group. It included cases in the institutions for feeble-minded, the insane hospitals, almshouses, hospital, reformatories, orphanages and known to charity workers (168, p. 13).
One of the most careful surveys of individuals who, because of mental abnormalities, show such social maladjustment as to become the concern of public authorities was made under the auspices of the National Committee for Mental Hygiene in 1916.[[5]] It selected Nassau County as representative of New York state. Part of the survey consists of an intensive house to house canvass of four districts of about a thousand population each. The result disclosed that 0.54% of the population of this county were socially maladjusted because of “arrests in development” and 0.06% more, because of epilepsy. This was in a population of 115,827.
The Children's Bureau in the U. S. Department of Labor in 1915 made a census of the number of “mental defectives” in the District of Columbia. The census included only those whom we have termed feeble-minded. The report states that 798 individuals, 0.24% of the population, were found to be “in need of institutional treatment; and the number reported, allowing for the margin of error in omission and inclusion, is probably a fair representation of the number in the District who should have custodial care” (88, p. 13). Over a quarter of the population of the District is colored. The census was taken in connection with plans for immediate care. The same Bureau also made in 1915 and 1916 a Social Study of Mental Defectives in New Castle County, Delaware.[[6]] This county had a population of 131,670 and the survey disclosed 212 “positive cases of mental defect” and 361 “questionable cases,” a total of 0.44% of the general population in this county. Among the positive cases, 82.5% were in need of public supervision or institutional care. Among the questionable cases, information was obtained about only 175, and 165 of these were either in institutions, delinquent or uncontrollable, or living in homes where proper care and safeguarding were impossible.
Two other important attempts to enumerate carefully all the feeble-minded in definite areas in the United States have been made in recent years. Lapeer County, Mich., was chosen for such a study, as it was of average size and contained no large city. The census as reported in 1914, showed 36 feeble-minded from that county in the state institution and 116 others living in the county, a total of 1 from every 171 inhabitants ([145]). A special children's commission was appointed by the state of New Hampshire to investigate the welfare of dependent, defective and delinquent children. Its report in 1914 contained a section by its chairman, Mrs. Lilian C. Streeter, on feeble-mindedness ([40]). This comes the nearest to a complete enumeration for an entire state which has ever been attempted. The commission tested with the Binet scale the inmates of the State Hospital for the Insane, the County Farms, the State Industrial School and the Orphanages within the state. The borderline which it used for the scale was high. It counted all those testing three or more years retarded and under XII as feeble-minded. Taking its figures as they stand we find that they listed 947 as feeble-minded in institutions and 2,019 outside, a total of 0.69% of the inhabitants of the state. Outside the institutions the commission sent a questionnaire to all school superintendents and to chairmen of school boards, physicians, overseers of the poor, county commissioners, probation and truant officers, district nurses and charity workers throughout the state, by which means they listed 792 additional cases. This questionnaire gave the following description of the type of case it was trying to list as feeble-minded.
“The high grade imbecile, frequently known as the moron, is one who can do fairly complicated work without supervision, but who cannot plan, who lacks ordinary prudence, who cannot resist the temptations that are common to humanity. The high grade imbecile is most dangerous because, except to the expert, he is apparently not feeble-minded and is, therefore, usually treated as normal, and permitted to multiply his kind, and to corrupt the community.”
This description would tend to include cases above our isolation group. Besides the questionnaire the commission made an intensive study of 52 towns in which it says practically complete census returns were obtained by consulting doctors, school and town officials. With these supplementary cases it secured a list of 2,019 cases outside of institutions, making a total of 2,966 recorded cases within the state or 0.69% of the population. When it estimated the proportion for the entire state on the basis of the rate of canvass returns to questionnaire returns, this proportion rose to 0.95%. The commission does not advocate compulsory isolation for all of these people although it recommends custodial care for the feeble-minded women and girls of child-bearing age, apparently of the degree of deficiency represented by its criteria. This enumeration of 0.69% of the people of a state as feeble-minded is the most liberal general census of the feeble-minded in any large area. It clearly shows the trend of diagnosis since the British Census.
The Extension Department of the Training School at Vineland, N. J., states regarding estimates of the number of feeble-minded in the general population: “Conservative estimates give one in three hundred as the probable present number.” Under the discussion of estimates of the general population I have already cited Goddard's estimate which was approximately 0.3 to 0.4% and the enumeration of 0.4% by the British Royal Commission in 16 districts with over two million population. While all of these estimators are speaking broadly of the feeble-minded, in the general population, we shall not be far wrong in supposing that they are considering mainly those deficients for whom the state might well expect to provide care for life, isolating all those who cannot be eugenically guarded at home. We shall later quote the estimate of Van Sickle, Witmer and Ayres of 0.5% of the school population as “institution cases.”
Our estimate of 0.5% in the group justifying isolation on the ground of intellectual deficiency seems to be conservative and to harmonize fairly this type of estimate.
The Social Assistance Group. Passing now to the next higher group of deficients, those needing special training in order to get along with social assistance, the estimates have been based almost entirely upon the study of school children. Francis Warner was the moving spirit in the early investigations in Great Britain, which were made without tests from 1888 to 1894. The census which he directed included about 100,000 school children who passed in review before medical examiners. As cited by Tredgold ([204]) the estimate growing out of this work was that 1.26% of the school population should have instruction in special classes. Of these 0.28% required special instruction because of physical defects only ([204]).
About the same time Will S. Monroe ([155]) on the basis of a questionnaire sent to California teachers, who reported on 10,842 school children, found that they estimated 1,054 of these as mentally dull in school, 268 feebly gifted mentally, and 6 imbeciles and idiots. He summarized his conclusion as follows: “A long experience teaches that every school of fifty pupils has at least one child that can be better and more economically trained in the special institutions than in the public schools.” In his estimate of 2% he was probably thinking of care in special local schools and not permanent isolation.
A government inquiry of school teachers in Switzerland, who had charge of 490,252 school children, reported that 1.2% were so feeble mentally as to need training in special classes. Only about a tenth of this number were then being instructed in separate classes (181, p. 17).
Great Britain first gave legal recognition to the class of feeble-minded above the imbeciles in its Education Act of 1898, following a report of a departmental committee of its National Board of Education growing out of the inquiries of Francis Warner. This committee estimated the proportion of this class as approximately 1% of the elementary school population ([181]). In discussing the comparative estimates on the general and school populations I have already referred to the estimate of Tredgold based upon an elaborate analysis of the most extensive data ever collected,—that gathered by the British Royal Commission on the Care and Control of the Feeble-Minded. While the Commission's investigators enumerated 0.79% among the school as mentally defective, Tredgold's estimate based on his analysis of their report was that 0.83% of the school population in England and Wales were above the grade of imbecile but still feeble-minded (204, p. 157). The variability of the estimates collected by the Royal Commission from various cities probably indicates the subjective character of the standards of deficiency. They varied from an estimate of 0.24% of the elementary school population in Durham to 1.85% in Dublin (204, p. 159). The Commission says regarding estimates as to communities other than those reported by their medical investigator, for Newcastle the “number of feeble-minded children of school age” (morons) was 0.25%, for Leeds the estimate was 0.80%, for London 0.50% or 0.60%, for Bradford 0.50%, for Dublin about 1% and for Birmingham about 1% of the school population. Dr. Francis Warner's general estimate was 0.8%. We have thus variations in estimates from 0.25%, 0.5%, 0.80% to 1% and some 2% (167, p. 90). For the rural areas the estimates were generally less.
A careful estimate has been made with a different method by Karl Pearson on the basis of a classification by teachers of school children in Great Britain into nine different classes each especially defined and extending from the imbecile to the genius. This distribution of the children was then fitted to the normal probability curve. On this basis Pearson estimated that 1.8% would fall in the “very dull group,” defined as having “a mind capable of holding only the simplest facts, and incapable of grasping or reasoning about the relationship between facts; the very dull group covers but extends somewhat further up than the mentally defective.” Lower down would be 0.1% in the imbecile group. He says further regarding this estimate: “It is deduced from three series covering between 4000 and 5000 cases, and the three separate results are in several accord. It will, I think, be possibly useful for other inquirers, and it endeavors to give quantitative expression to our verbal definitions of the intellectual categories” ([166]).[[7]]
In 1914 Pearson cites estimates of mentally defective children in several cities by teachers and medical officers based upon the recommendation of elementary school children for special schools and classes. These were, for London: boys, 1.59%; girls, 1.09%. For Liverpool: boys, 0.827%; girls, 0.618%. The corresponding figure for both sexes in Stockholm is 1.23%. He concludes that “something between 1% and 2% is true for England. Dr. James Kerr, Medical Research Officer, thinks that the final estimate will be nearer the latter value.”
After giving a table of the percentages at each age in the elementary schools of Stockholm, Pearson says: “Judged from this table it would seem that the most reasonable estimate of the prevalence of mental defect is to be formed when all the mental defectives have been definitely selected and the normal children have not yet begun to leave school, i. e., at the ages 11 and 12. For Stockholm this leads up to a mentally defective percentage of about 1.5” (167, p. 6-8). In another place he says that the members of special classes are selected practically for the same reason, i. e., because they are school inefficients, the bulk of whom will, no doubt, unless provided for become “social inefficients” (164, p. 48). Since some were not selected because of intellectual deficiency, our social assistance group should be somewhat smaller.
In 1909-10 the actual number in the schools for mental defectives maintained by the London County Council was 0.9% of the enrollment of the London elementary Schools ([143]). The 1912 report of the London County Council shows 7357 children enrolled in its local schools for mental defectives, which is 1.1% of the average attendance from 1912-1913 in the elementary county council schools and voluntary schools of London (144, p. 44).
Following a discussion in the Australian Medical Congress of 1911 the Minister of Public Instruction called for returns as to the number of feeble-minded in the Australian public elementary schools between 5½ and 14 years of age inclusive. The questionnaire used the definitions of the British Royal Commission as a description of the various degrees of retardation and brought returns from 2,241 of the state schools, all except 57. For their average attendance of 175,000 children, these teachers classified 1.9% as backward from accidental causes, 2% mentally dull, 0.42% feeble-minded imbeciles or idiots, and 0.6% epileptics. To this would be added 0.19% for children in the idiot asylums. The report states that “the teachers' estimates will thus be realized to be an absolute minimum, dealing only with the intermediate grades, and not including the gross cases (idiots, etc.) on the one hand and the less marked high grades of feeble-minded on the other” ([70]).
The census made by the Bureau of Health of Philadelphia through the principals of schools in 1909 covered 157,752 elementary school children of whom 1.9% above the 0.28% who could “properly be in custodial institutions 'were classed' as backward children who require special instruction by special methods in small special classes” ([168]).
A survey of the school population in the Locust Point District of Baltimore was made by Dr. C. Macfie Campbell.[[8]] The district surveyed was, however, not considered typical of Baltimore, but was a sample of an industrial district in which the majority of families are “close to the poverty line, and too often below it.” Out of a school population of 1,281 children, 166 (13%) were “found to have special requirements on account of their mental constitution.” Among these, 22 (1.7%) “showed a pronounced mental defect, which eliminated any prospects of their becoming self-supporting.”
The city of Mannheim ([147]), which perhaps cares for its exceptional children better than any other in the world, was in 1911-1912 caring for 0.7% of the children in its Volkschule in Hilfsklassen which do not take them beyond the fourth grade. There were 12% more who were backward in school and being taught in Forderklassen where they may reach the sixth grade. Including the exceptionally bright who were also in special classes, 18% all together of its school children were not in the regular Hauptklassen of the eight grades. To these would be added those sent to special institutions. When we estimate, therefore, that we are justified at present in sending 1% of the children in school to special classes because their intellectual deficiency is such that the bulk of them cannot get along without social assistance, we are naming about the proportion already thus cared for in several foreign cities.
Among the authoritative estimates of the number of feeble-minded, which have been made by estimators who had in mind the evidence from mental tests, is that made by James H. Van Sickle, Lightner Witmer, and Leonard P. Ayres in a bulletin published by the United States Bureau of Education in 1911 ([209]). They state that, “if all children of the public schools could be ranked, it is probable that a rough classification would group them about as follows—Talented, 4%; Bright, Normal, Slow, 92%; Feeble-Minded, 4%. The 4% may for administrative purposes be divided into two groups. The lower one includes about one-half of one per cent. of the entire school membership.... They are genuinely mentally deficient, and cannot properly be treated in the public schools. They are institution cases, and should be removed to institutions. Ranking just above these are the remaining three and one-half per cent. who are feeble-minded but who could be given a certain amount of training in special classes in the public schools.” The estimate of institutional cases practically coincides with that adopted above in this paper. The extension of the term feeble-minded to include the lowest 4% seems to be extreme. The authors do not suggest what portion of these they think might require social assistance indefinitely, but are interested primarily in provision for special classes in the public schools. If the term feeble-minded were to mean only unfit for regular school classes and not socially unfit, I have already suggested that the limit for special instruction might be increased indefinitely. In Mannheim 18% are not cared for in the regular classes.
The only estimate of feeble-minded which I have found that is so large as this 4% is that of Binet. It is also intended to cover all cases that should be sent to special classes regardless of subsequent social survival. His statement as to those who are so abnormal or defective as to be suitable for neither the ordinary school nor the asylum is as follows:
“As to France, precise information has not been available until the last year, when two inquiries were held—one at the instance of the Ministerial Commission, the other organized by the Minister of the Interior. According to the former inquiry we find that the proportion of defectives amounts to scarcely 1% for the boys, and 0.9% for the girls. These percentages are evidently far too small, and we ourselves have discovered, by a small private inquiry, that many schools returned “none” in the questionnaires distributed, although the headmasters have admitted to us that they possessed several genuine defectives. In Paris, M. Vaney, a headmaster, made some investigations by the arithmetic test, which we shall explain presently, and reached the conclusion that 2% of the school population of two districts were backward. If we were to include the ill-balanced, whose number is probably equal to that of the backward, the proportion would be about 4%. Lastly and quite recently a special and most careful inquiry was made at Bordeaux, under the direction of M. Thamin, by alienists and the school medical inspectors, and it was found that the percentage of abnormality amongst the boys was 5.17. Probably the true percentage is somewhere in the neighborhood of 5. All these inquiries are comparable because they deal with the school population” (77, p. 8).
In this estimate of 5%, Binet was considering those to be sent to special classes regardless of whether or not they would require indefinite social assistance after their schooling. It is therefore not directly comparable with our estimate of 1.5% presumably or doubtfully intellectually deficient.
The estimate of Dr. Henry H. Goddard, who has done the most to introduce the Binet Measuring Scale in this country, is stated as follows: “It is a conservative statement to declare that 2% of public school children are distinctly feeble-minded, the larger part of them belonging to this high-grade group which we call morons” ([118]). In another ([114]) place he says: “The most extensive study ever made of the children of an entire school system of two thousand has shown that 2% of such children are so mentally defective as to preclude any possibility of their ever being made normal and able to take care of themselves as adults.”[[9]] The study to which he refers gives individual results with the Binet 1908 tests made on 1547 school children in the first six grades (114, p. 43). Since the sixth grade does not include the better children who are twelve years or over in age this group is clearly selected in such a way that it would show an excessive percentage of mentally retarded children. We find in the investigation referred to that he says: “Then we come to those that are four years or more behind their age, and here again experience is conclusive that children who are four years behind are so far back that they can never catch up, or in other words, they are where they are because there is a serious difficulty which can never be overcome—they are feeble-minded. They constitute 3% of the children in these grades.”
Since we have a random selection of school children in his table for only those children who are 6 to 11 years of age inclusive, I find that only 1% at these ages are retarded four years intellectually. On his own basis, therefore, 3% is evidently too large an estimate. Later he seems to have reduced his estimate to 2% of the school population. Of those who test in the lowest 1.5% including our doubtful group, I believe that there is no clear evidence that more than 1% will require even social assistance as adults.
Many more estimates of the number of feeble-minded among school children might be cited, but they would add little to these authoritative samples. At the present time an estimate by health officers or teachers who are not familiar with the results of mental testing has little significance, as the whole complexion of the problem has been changed since the work of Binet and Simon.[[10]] We may, however, cite three estimates based upon familiarity with test results, which fairly cover the range of estimates among school children. In connection with the Springfield, Illinois, survey conducted by the National Committee for Mental Hygiene under the direction of the Russel Sage Foundation, we find that three typical schools with a total of 924 pupils were studied. The report states that “the mentally defective children” constituted 3.8% of the number in attendance in March. The number of children in the schools examined, for whom instruction in special classes would be desirable, is about 7% of the entire enrollment of these schools (203, p. 10).
In connection with the Stanford Version of the Binet Scale, Dr. Lewis M. Terman says: “Whenever intelligence tests have been made in any considerable number in the schools, they have shown that not far from 2% of the children enrolled have a grade of intelligence which, however long they live, will never develop beyond the level which is normal to the average child of 11 or 12 years.... The more we learn about such children, the clearer it becomes that they must be looked upon as real defectives (57, p. 10). Again in placing the borderline for feeble-mindedness” with the Intelligence Quotient used, he suggests that “definite feeble-mindedness” lies below an I. Q. of 70 which with 1000 quotients was found to exclude about the lowest 1%. Above this is a group with I. Q.'s 70-80 which he describes as “borderline deficiency, sometimes classifiable as dullness, often as feeble-mindedness.” This group would include, as judged by the results of these tests, over 4% more.
Dr. Wallin, who has had wide experience in testing both school children and defectives, states: “I will venture the assertion, after years of teaching in the public schools and clinically examining public school cases, that the oft-repeated statement that 2% of the general school population is defective (if by this is meant feeble-minded), exaggerates the real situation. The actual number is probably about 1%” (211, p. 149).
After reading a paper on “A Percentage Definition of Intellectual Deficiency” before the American Psychological Association in 1915 ([151]), I was pleased to discover that Prof. Rudolf Pintner and Donald G. Paterson were also about to propose a percentage definition of feeble-mindedness for those who are dealing with mental tests ([44]). While their idea seems to be fundamentally similar, their paper shows that their conception is to be sharply distinguished in several particulars from that which I am advocating. They would limit the use of the term “feeble-mindedness” to individuals who test in a rather arbitrarily chosen lowest percentage of the population. As opposed to this I suggest continuing the present social definition of feeble-mindedness and supplementing it, for the purpose of aiding in the diagnosis, by indicating the social significance of those testing in certain lowest percentages. Such tested deficients I designate as “intellectually deficient.” It is important to consider their statement and to note what percentage they have chosen to regard as feeble-minded. They say:
“It is in order to avoid this vagueness and uncertainty attaching to the term that we suggest a definite psychological concept. The lowest three per cent. of the community at large, that is, the lowest as determined by definitely standardized mental tests, are to be called feeble-minded. Such a definition will be unambiguous and the dividing line between this and other groups will become clearer and clearer as we increase the accuracy of our measuring scales and the adequacy of our standardizations. Furthermore, if evolution is raising the degree of intelligence the three per cent. at the lower end will still remain, for, whatever the degree of their intelligence may be, they will still be feeble-minded as compared with the normal.
“Such a definition will in addition restrict the term to such as are lacking in intelligence and will differentiate them from the moral defectives and the psychopathic personalities, which are at present often confused with the group that we propose to call feeble-minded. An individual may be at the same time a moral defective and feeble-minded, but there is reason to believe that moral deficiency may exist without such intellectual defect as to warrant a diagnosis of feeble-mindedness. The same may be said of the psychopathic personality.
“The further question, whether all those coming within the proposed definition of feeble-mindedness are to be confined in institutions, is purely social and will be determined by the social needs of each community and does not concern us here. It is obvious that many more in addition to the feeble-minded as defined by us will require the restraint of an institution, even though no real mental defect exists.
“It is immaterial for the purposes of this hypothesis whether three or a smaller or larger percentage be designated as feeble-minded. The important point is the agreement upon some fixed percentage, and we have chosen three per cent. as covering presumably all the cases of marked mental deficiency. A brief glance at the chief estimates of the number of feeble-minded in civilized communities would indicate that our percentage is somewhat higher than the conservative writers give, but we shall show later on that it is much lower than the results obtained from groups of children tested by intelligence scales” (44, p. 36).
With those who understand that deficiency is mainly a question of degree, it would seem that there might be some agreement as to the plan for defining tested deficiency. In order to make this plan more useful to those dealing with the social care of the feeble-minded, it would be necessary to supplement the bare percentage definition by relating it to expectations of social failure somewhat after the manner I have attempted. In particular it will gain its main value for diagnostic purposes, it seems to me, if the percentage is so chosen that it may receive the support of conservative scientific opinion. To be most useful it seems evident, also, that the percentages must be chosen with regard to the sort of social care which it is anticipated would be justified for the particular degrees of deficiency.
Let us recall the percentages suggested to harmonize the estimates: the lowest 0.5% to be regarded as presumably deficient enough to justify isolation and the next 1% as doubtful, but low enough to warrant special training and probably requiring indefinite social assistance. If these percentages for tested intellectual deficiency have been shown to be fairly conservative estimates in the light of the authoritative judgments with which they have here been compared, the laboriousness of this comparison has been worth while. Further light upon the social assistance group may be thrown by the study of the success of those children who have already had the advantage of training in local classes for the deficient.
F. The Ability of the Mentally Retarded, Especially Those Receiving Special Training.
That we are not justified in isolating all whom we class as feeble-minded is best indicated by the evidence as to the number of these sent to special local classes for deficients who are able to float socially with the assistance of capable after-care committees. A fair picture of the present situation may be obtained by thinking of these pupils in the help-classes and schools as representing about the next 1% above those who have been isolated in institutions. With this picture in mind let us see what has been the outcome of their special instruction and social assistance thereafter.
In his book on Les Enfants Anormaux, Binet collected the evidence available at that time (77, p. 140). He says:
“Mme. Fuster, after a stay in Germany, where she visited some Hilfsschulen and Hilfsklassen (literally, 'help-schools' and 'help-classes') made a communication to the Société de l'Enfant, from which it appears that in the case of 90 classes for defectives in Berlin, 70% to 75% of the defective pupils who were there became able to carry on a trade; 20% to 30% died in the course of study, or returned to their homes, or were sent to medical institutions for idiots.
“According to a more recent inquiry, made under the auspices of M. de Gizycki at Berlin, and published in a book by Paul Dubois, 22% of the children were sent home or to asylums; 11% were apprenticed; 62% worked at occupations which required no knowledge and yielded little pay (laborers, crossing-sweepers, ragmen). If we add together these two last groups, we reach a proportion of 73% of defectives who have been made, or who have become more or less useful....
“Dr. Decroly has kindly arranged at our request a few figures relating to the occupational classification of the girls discharged from a special class in Brussels.... Finally, then, out of nineteen feeble-minded subjects, regarding whom particulars have been supplied, one-half, or 50%, have been apprenticed, or more than half, 75% if we count the defectives who 'work....'
“Through the intervention of an inspector, M. Belot, we have inquired of twenty heads of schools what has become of the defectives whom they notified to us two years ago. We have made these inquiries with regard to sixty-six children only.... If we subtract the two first groups, those about whom the particulars are wanting, and those who have not yet left school, there remain twenty-seven children, of whom seventeen have been apprenticed, or 76%.... Now this proportion is, by an unexpected agreement, identical with that obtained in the classes of Berlin and Brussels.”
A more recent report concerning the Hilfsschulen in Berlin by Rector Fuchs is in close agreement. It indicates that from 70% to 80% of the former pupils of these schools make a living after they leave school.
To compare with these reports indicating that about three-fourths of those leaving the special schools of Paris, Berlin and Brussels by social assistance attain occupational classifications, we have less favorable reports from Great Britain. Shuttleworth and Potts (181, p. 23) say:
“At the Conference of After-Care Committees held in Bristol on October 22, 1908, a paper read by Sir William Chance, Chairman of the National Association for the Feeble-Minded, dealing with the reports of the After-Care Committees of Birmingham, Bristol, Leicester, Liverpool, London, Northampton, Oldham and Plymouth. The combined statistics from the nine centers showed that 22% of those who had attended special schools for the mentally defective were in regular work, and 6.8% had irregular work.... To illustrate the necessity for continuous supervision and the futility of temporary care, we cannot do better than quote the records of the Birmingham After-Care Committee, as embodied in their report for 1908, after seven years work. It was found that, 'out of 308 feeble-minded persons who have left school and are still alive, only 19.8% are earning wages at all, and only 3.9% are earning as much as 10 s. per week'” ([181]).
Tredgold summarizes other data on this question of industrial success as follows:
“We may next turn to the reports of 'After-Care' Committees regarding feeble-minded (moron) pupils of the special schools. In London the proportion of pupils known to be in 'good or promising' employment was 37.5%. Two years previously it had been 45.7%, and Sir George Newman, the Chief Medical Officer to the Board of Education, attributes the falling off to two causes—firstly, insufficient after-care; and secondly, the two additional years. He remarks: 'The longer the test the more severe it is.' In Birmingham, the 'After-Care' Committee compiled information regarding 932 cases which had passed through the schools during the previous ten years. Of these, excluding the normal and dead, 272, or 34%, were engaged in remunerative work. At Liverpool, of 712 children passing through the hands of the 'After-Care' Committee during a period of six years, 85, or 11.9%, were doing remunerative work.
“Finally we may refer to some figures concerning 'After-Care' work compiled by Sir William Chance from the returns of the National Association for the Feeble-Minded. These were based upon an inquiry made of sixteen centers of the Association, and referred to a total of 3,283 persons. Of this number, 798 were doing remunerative work, 89 were 'doing work, but not reported;' 202 were useful at home; and 941 were returned as 'useless members of society.' If we exclude 340 who were transferred to normal schools (not being feeble-minded), we have 27% engaged in remunerative work.
“With regard to the term 'remunerative work,' however, it is to be remarked that the person employed is not being paid the standard wage. On the contrary, it is my experience that this is practically never the case, and this is corroborated by the observations of the secretary of the Birmingham center, who says: 'Although some of our cases have been at work for more than ten years, only 34 of the whole number (173) earn as much as 10 s., 2 d., per week. Of these only 6 earn as much as 15 s., and only 2 earn 20 s., which is the highest wages earned.... While it is not very difficult for some of our higher-grade cases to get work when they first leave school, it is almost impossible for them to retain their situations when they get older, and the difference between them and their fellows becomes accentuated. Uncontrolled and often quite improperly cared for, they rapidly deteriorate, the good results obtained by the training and discipline of the special school being under these circumstances distinctly evanescent.... There are few workers over twenty years of age'” (204, p. 425, 435).
The 1912 report of the London County Council ([144]) covers those who left its special schools for mentally defective children during the years 1908-1912 inclusive. These schools have accommodation for about 1% of the elementary school enrollment. Of 2010 children who left these schools during these five years, and who were still alive, 1357 were employed and 311 more employed when last heard from, a total of 79% employed at last accounts. Those out for five years show about the same proportion employed. This is a more favorable showing and fairly in line with the results of other European help-schools. The average weekly wages of those employed ranged from 4 s. 6 d. for those just out to 10 s. 10 d. for those leaving five years before. A considerable proportion who live at home thus have been meeting their necessary living expenses as the result of this special training and subsequent assistance.
Dr. Walter E. Fernald reported to the British Royal Commission on the Care and Control of the Feeble-Minded concerning the inmates of the institutions for feeble-minded in the United States. These institutions receive a much lower grade of cases on the whole than the local help-schools abroad: (83, Vol. VIII, p. 159)
“Some of the institutions where only the brightest class of imbeciles are received, and where the system of industrial training has been very carefully carried out, report that from 20% to 30% of the pupils are discharged as absolutely self-supporting. In other words at other institutions, where the lower grade cases are received, the percentage of cases so discharged is considerably less. It is safe to say that not over 10% to 15% of our inmates can be made self-supporting, in the sense of going out into the community and securing and retaining a situation, and prudently spending their earnings.... But it is safe to say that over 50% of the adults of the higher grade who have been under training from childhood are capable, under intelligent supervision, of doing a sufficient amount of work to pay for the actual cost of their support, whether in an institution or at home.”
The wages of the women at the Bedford Reformatory before entering prostitution as given by Davis (133, p. 210) have a direct bearing on the earning capacity of the higher grade feeble-minded. The Binet tests of Bedford women by Weidensall indicate that about 38% of the successive cases admitted to Bedford test in the lowest 0.5% intellectually, and 75% in the lowest 1.5% intellectually. Davis' table shows that for 110 whom she classes as mentally low grade cases at the reformatory, the median wage of those in domestic service, as claimed by the women, was nearly $4.50 before entering prostitution. These feeble-minded women, if their statements of earnings can be accepted, are therefore feeble-minded by reason of their low intelligence plus delinquency, and not by reason of inability to earn the necessities of life. The best of these mentally low grade cases earned as high as $5.00 in addition to board and lodging in domestic service and $25.00 outside of domestic service.
In this country we have fewer studies of the results of training the mentally retarded in special local classes and schools. Miss Farrell has made a preliminary report of 350 boys and girls out of the 600 children formerly in the ungraded classes in New York City during the preceding 8 years ([102]). Omitting seven whose status was unknown and 10 who had died, only 6% were known to have failed to survive socially with assistance. These were in penal or other institutions. On the other hand a strict analysis of her returns shows only 28% earning $5.00 a week or more and thus possibly surviving independently. Of the above group of 333, 86 were at home, 192 employed, 31 unemployed and 3 married.
In Detroit among 100 children over 16 years of age who had attended its special classes and been out of school not over 5 years, 27 had been arrested, but 39 of the boys had been at work and received an average wage of $7.00 per week, while 16 girls had averaged $3.75 in weekly wages, although few held their positions long ([97]).
Bronner ([6]) compared a random group of thirty delinquent women at the detention home maintained by the New York Probation Association with an intellectually similar group of 29 women all of whom had been earning their living in domestic service and none of whom had been “guilty of any known wrong doing.” The delinquents were 16 to 22 years of age while the servant group was somewhat older. Only two or three of the delinquent group were worse than the poorest of the servant group in any of the five intellectual tests, so that, if more than this number were intellectually deficient, they were no more deficient than those who had survived in society. No Binet scale records were published so that we have no means of determining how many of these delinquents might fall within either of our deficient groups.
The principal deduction from this evidence on the earning capacity of those of low intellectual grade is a caution against demanding the social isolation of all the intellectually weak until we have more definite information as to what portion of them are able to live moral lives, as well as earn their living with social assistance, without being cared for entirely in isolation colonies. That a significant number of the lowest 1.0% intellectually next above the lowest 0.5% have led moral lives and have shown considerable earning capacity after attending special schools, when they are given proper after-care, has probably been demonstrated. They should, therefore, be treated as an uncertain group whose feeble-mindedness would never be decided purely on the ground of the intellectual tests. Most of them will, however, probably be found mentally deficient enough to need at least social assistance and protection.
In concluding this summary on the estimates of the frequency of feeble-mindedness, it need only be added that so far as concerns the use of the percentage definition for fixing the borderline in any particular system of tests the percentages chosen are not essential to the plan. The principles of the method apply whatever percentages might be adopted. For such important purposes as the comparison of the relative frequency of deficiency in different social groups and harmonizing the investigations with different mental scales, agreement upon a particular percentage is not essential. In diagnosis, of course, it is a matter of fundamental importance in order that injustice may not be done individuals. For this reason the estimate should be conservative, possibly more conservative even than our tentative 0.5% at 15 years of age. Any investigator who disagrees with the above estimates of the degree of tested deficiency justifying isolation may substitute X per cent. with a doubtful region extending Y per cent. further. Provided such a census were legally authorized and funds available it would be not impossible to get a reliable determination by a house to house canvass showing the number of adult deficients, say 21 years of age, in typical communities, who were not able to survive socially without assistance. This number would then give the key for a conservative percentage and the movement for early care would be immensely advanced.
With the recent introduction of psychological tests into the cantonments of the national army, the goal of symptomatic borderlines as determined by objective tests seems to be almost at hand. Since the men are brought practically at random to the camps by the draft and are under military command, it may be possible to find out the social history of a large enough group at the lower limit of tested ability to establish the question of the necessary capacity for independent moral and social survival. These borderlines could then be transferred from the army tests to positions of equivalent difficulty in other test systems.
The remainder of this study will show some of the advantages of the percentage definition for fixing the borderlines with a system of tests and the result of applying such an interpretation to the particular problem of delinquency. The advantage in increased definiteness should already be evident. When a person is classed as presumably deficient it will mean that he is in the lowest 0.5% in intellectual development or within the lowest 1.5%, if he is a persistent delinquent.
[5]. Aaron J. Rosanoff. Survey of Mental Disorders in Nassau County, New York. Publication No. 9, National Committee for Mental Hygiene, 1917.
[6]. Emma O. Lundberg. A Social Study of Mental Defectives in New Castle County Delaware. U. S. Dept. of Labor, Children's Bureau, Publication No. 24, 1917, pp. 38.
[7]. This statement in 1906 seems to be the earliest attempt at a quantitative definition of deficiency. As I discovered it after the present monograph was practically completed, it furnishes evidence of the natural tendency of attempts at more exact definition to take the percentage form.
[8]. C. Macfie Campbell. The Sub-Normal Child—A Study of the Children in a Baltimore School District. Mental Hygiene, 1917, I, 96-147.
[9]. Italics mine.
[10]. The report of the Massachusetts Commission on Mental Diseases (Vol. I, p. 198) shows that social agencies systematically using mental tests reported 19.2% as mental cases, while those using examinations only for obvious cases reported 1.3%.