Critical Issues in Neuropsychology

Handbook of
Clinical Child
Neuropsychology
Critical Issues in Neuropsychology
Series Editors:
Cecil R. Reynolds Antonio E. Puente
Texas A&M University University of North Carolina, Wilmington
Editorial Advisory Board:

Erin Bigler, University of Texas, Austin
Raymond S. Dean, Ball State University
Hans J. Eysenck, University of London
Charles J. Golden, Drexel University
John Gruzelier, University of London
Lawrence C. Hartlage, Fairfax University
Merril Hiscock, University of Saskatchewan
Lawrence Majovski, Huntington Memorial Hospital
Francis J. Pirozzolo, Baylor University School of Medicine
Karl Pribram, Stanford University
ASSESSMENT ISSUES IN CHILD NEUROPSYCHOLOGY

Edited by Michael G. Tramontana and Stephen R. Hooper
HANDBOOK OF CLINICAL CHILD NEUROPSYCHOLOGY

Edited by Cecil R. Reynolds and Elaine Fletcher-Janzen
MEDICAL NEUROPSYCHOLOGY: The Impact of Disease on Behavior

Edited by Ralph E. Tarter, David H. Van Thiel, and Kathleen L. Edwards
NEUROPSYCHOLOGICAL FUNCTION AND BRAIN IMAGING

Edited by Erin D. Bigler, Ronald A. Yeo, and Eric Turkheimer
NEUROPSYCHOLOGY, NEUROPSYCHIATRY, AND BEHAVIORAL

NEUROLOGY
R. Joseph
RELIABILITY AND VALIDITY IN NEUROPSYCHOLOGICAL

ASSESSMENT
Michael D. Franzen
A Continuation Order Plan is available for this series. A continuation order will bring
delivery of each new volume immediately upon publication. Volumes are billed only
upon actual shipment. For further information please contact the publisher.
Handbo ok of
Clinical Child
Neuropsychology
Edited by
CECIL R. REYNOLDS
and
ELAINE FLETCHER-JANZEN
Texas A&M University
College Station, Texas
Springer Science+Business Media, LLC

Library of Congress Cataloging in Publication Data
Handbook of clinica! child neuropsychology 1 edited by Ceci! R. Reynolds and Elaine
Fletcher-Janzen.
p. cm-(Critical issues in neuropsychology)
Includes bibliographies and index.
ISBN 978-1-4899-6809-8 ISBN 978-1-4899-6807-4 (eBook)
DOI 10.1007/978-1-4899-6807-4
1. Pediatric neuropsychology. I. Reynolds, Ceci! R., 1952- . II. Fletcher-Janzen,
Eiaine. III. Series.
[DNLM: 1. Brain-growth & development. 2. Child Behavior. 3. Child Development
Disorders-diagnosis. 4. Child Development Disorders-therapy. 5. Neuropsychological
Tests-in infancy & childhood. 6. Neuropsychology. WS 350.6 H2364]
RJ486.5.H26 1989
155.4-dc19
DNLM!DLC 88-39536
for Library of Congress OP
1989 Springer Science+Business Media New York

Originally published by Plenum Press, New York in 1989
Softcover reprint of the hardcover 1st edition 1989
AII rights reserved

No part of this book may be reproduced, stored in a retrieval system, or transmitted
in any form or by any means, electronic, mechanical, photocopying, microfilming,
recording, or otherwise, without written permission from the Publisher
Contributors
RusseU M. Bauer Department of Clinical and Eileen B. FenneU Department of Clinical and
Health Psychology, University of Florida, Gaines- Health Psychology, University of Florida, Gaines-
ville, Florida 32610 ville, Florida 32610
Thomas L. Bennett Department of Psychol- Charles J. Golden Departments of Psychol-

ogy, Colorado State University, Fort Collins, Colo- ogy, Sociology, and Anthropology, Drexel Univer-
rado 80523 sity, Philadelphia, Pennsylvania 19104
Richard A. Berg Department of Behavioral
Medicine and Psychiatry, West Virginia University Jeffrey W. Gray Neuropsychology Laborato-
Medical Center-Charleston Division, Charleston, ry, Ball State University, Muncie, Indiana 47306
West Virginia 25326
Frank M. Gresham Department of Psychol-
Erin D. Bigler Department of Psychology, ogy, Louisiana State University, Baton Rouge, Loui-
University of Texas at Austin, Austin, Texas 78712; siana 70803
and Austin Neurological Clinic, Austin, Texas
78705 Ruth Adlof Haak Balcones Special Services
Cooperative, Austin, Texas 78746
Kathi A. Borden Department of Psychology,
Pepperdine University, Los Angeles, California
90034
Thalia Harmony Neurosciences Research
Program, Iztacala School, National Autonomous
Ronald T. Brown Division of Child and Ado- University of Mexico, 54030 Tlalnepantla, Mexico
lescent Psychiatry, Emory University School of City, Mexico
Medicine, Atlanta, Georgia 30322
Lawrence C. Hartlage Department of Psy-
Manuel L. Cepeda Department of Psychiatry, chology, University of Arkansas, Fayetteville,
University of South Alabama College of Medicine, Arkansas 72701
Mobile, Alabama 36617
Patricia L. Hartlage Department of Pediatrics
Raymond S. Dean Neuropsychology Labora- and Neurology, Medical College of Georgia, Au-
tory, Ball State University, Muncie, Indiana 47306; gusta, Georgia 30902
and Indiana University School of Medicine, Indi-
anapolis, Indiana 46282
Robert L. Hodes Department of Neurology,
University of Wisconsin, Madison, Wisconsin
Robert W. Elliott Department of Special Edu-
53792
cation, South Bay Union High School District, Re-
dondo Beach, California 90277 Stephen R. Hooper Clinical Center for the
Study of Development and Learning, The University
BryanFantie DepartmentofPsychology, Uni- of North Carolina, and Department of Psychiatry,
versity of Lethbridge, Lethbridge, Alberta TlK The University of North Carolina School of Medi-
3M4, Canada cine, Chapel Hill, North Carolina 27599
v
vi CONTRIBUTORS
Arthur MacNeUI Horton, Jr. Veterans Ad- Daniel J. Reschly Department of Psychology,
ministration Medical Center, Baltimore, Maryland Iowa State University, Ames, Iowa 50011-3180
21218; Department of Psychiatry, University of
Maryland Medical School, Baltimore, Maryland Cecil R. Reynolds Department of Educational
21201; and Psych Associates, Towson, Maryland Psychology, Texas A&M University, College Sta-
21214 tion, Texas 77843
Randy W. Kamphaus Department of Educa- Becky L. Rosenthal Department of Educa-

tional Psychology, University of Georgia, Athens, tional Psychology, University of Georgia, Athens,
Georgia 30602 Georgia 30602
Marcel Kinsbourne Department of Behav- MarionJ. Selz Rehabilitation Psychology, St.

ioral Neurology, Eunice Kennedy Shriver Center, Mary's Hospital, Tucson, Arizona 85703
Waltham, Massachusetts 02254
Phyllis Anne Teeter Department of Educa-
Bryan Kolb Department of Psychology, Uni- tional Psychology, University of Wisconsin, Mil-
versity of Lethbridge, Lethbridge, Alberta T1K waukee, Wisconsin 53201
3M4, Canada
Cathy F. Telzrow Cuyahoga Special Educa-
Linda K. Krein Department of Psychology, tion Service Center, Maple Heights, Ohio 44137
Colorado State University, Fort Collins, Colorado,
80523 Michael G. Tramontana Department of Psy-
chology, Bradley Hospital, East Providence, Rhode
Che Kan Leong Department for the Education Island 02915; and Department of Psychiatry and
of Exceptional Children, University of Saskatche- Human Behavior, Brown University, Providence,
wan, Saskatoon, Saskatchewan S7N OWO, Canada Rhode Island 02912
John C. Linton Department of Behavioral Marie L. Walker Department of Educational

Medicine and Psychiatry, West Virginia University Psychology, University of Texas, Austin, Texas
Medical Center-Charleston Division, Charleston, 78712
West Virginia 25326
Timothy B. Whelan Department of Psychia-
Charles J. Long Psychology Department, try, Bay State Medical Center, Springfield, Mas-
Memphis State University, Memphis, Tennessee sachusetts 0 ll99
38152
Greta N. Wilkening Department of Neu-
Lawrence V. Majovski Huntington Medical rology, The Children's Hospital, Denver, Colorado
Research Institutes, Advanced Neurosurgical Labo- 80218
ratories, Pasadena, California 91105
Sheryl L. Wilson Department of Psychology,
Nancy L. Nussbaum Learning Diagnostic University of Arizona, Tucson, Arizona 85721
Center/ Austin Neurological Clinic, Austin, Texas
78705 Robert Henley Woody Department of Psy-
chology, University of Nebraska at Omaha, Omaha,
Antonio E. Puente Department of Psychol- Nebraska 68182
ogy, The University of North Carolina, Wilmington,
North Carolina 28403-3297
Preface
Alexandra Luria sometimes would use one or two such as localization, prognostication, and differential
tests with a child and other times ten or fifteen tests. diagnosis of emotional versus brain-behavior prob-
His diagnostic ability was unpredictable, irretrieva- lems with adults become geometrically more ab-
ble, and sometimes appeared magical. Attempts to struse with the interactions present in the course of
copy his genius in assessment instruments or clinical the child's development. This volume thus tries to
methods have varied in success, and years later he take a developmental view in examining neuropsy-
still stands out as a unique and imaginative pioneer in chological function and development that is both nor-
clinical neuropsychology. Today we have come mal and abnormal. We also try to take a stand on the
much further in our ability to assess children uni- necessity of principles of scientific inquiry, psycho-
formly. We have a plethora of informal assessment metric methods, and clinical acumen as central to
instruments that can be given in clinics and in the clinical aspects of child neuropsychology. None can
schools to screen children, saving countless hours stand alone; the volume presents diverse approaches
and money for parents, children, and the medical ranging from the heavily clinical to the near actuarial.
community. We have the latest sophisticated equip- Ideally, this work will foster a melding of such ideas,
ment that can scan the brain for pathology, giving practices, and concepts into stronger clinical prac-
precise localization of problems in a moment. tice. The work is eclectic in the theoretical ap-
This is certainly a time to celebrate in the devel- proaches touted as well. There is no more complex
opment of the field of child neuropsychology. Al- problem in all of the sciences than understanding
though a relatively young field, clinical neuropsy- developing brain-behavior relations, and we have
chology has moved far and fast and is now far to go. We also have much to offer, a good deal of
recognized as a necessity in most medical schools which is reviewed and discussed-along with its lim-
and in professional preparation programs in clinical, itations-in this Handbook.
pediatric, and school psychology. Neuropsychology There is another side of the coin, however.
is also clearly present in the public schools and, al- There are many quasi-professionals with perhaps a
though most prominent in the area of learning dis- weekend of training using neuropsychological as-
abilities, contributes to all areas of handicapping con- sessment, overinterpreting the results, and scaring
ditions. Children with severe head injuries are no parents with pseudoscientific neurological in-
longer relegated to special schools or institutional terpretations. Clinical neuropsychology is young and
settings. The child neuropsychologist, then, works in popular and too many people fail to recognize appro-
liaison with schools, not just in purely clinical set- priate educational standards or even the need for
tings. Never before has science worked in the years of training and supervision. This Handbook
schools. Thousands of school personnel actively as- also addresses these highly controversial issues.
sess soft neurological signs (that may or may not There are also heavy criticisms of neuropsycho-
affect learning) and they communicate directly with logical assessment instruments, rehabilitative ther-
child neurologists and neuropsychologists who eval- apies, and the inferential level of neuropsychological
uate the hard neuropsychological signs. This is defi- research studies; there are even some who negate any
nitely a field at work. objective involvement at all.
The practice of clinical child neuropsychology This book is intended to serve the children who
remains an enigma in many ways. Children are grow- need neuropsychological services in several ways:
ing and developing physically, neurologically, be- ( 1) as a text for undergraduate and graduate courses
haviorally, and emotionally, albeit in lawful if not in clinical child neuropsychology; (2) in a more gen-
well-understood ways, in uneven spurts, and not at eral way, as a text that crosses all aspects of this
all in concert across dimensions. Difficult problems rapidly growing field; (3) as a reference source to
vii
viii PREFACE
practitioners and professors in the discipline; and (4) surement theory, neuropsychological frameworks
as a potential "idea book" for researchers in the such as hemispheric specialization, and bases for
field. We feel that it is important to include varied psychopathology. Part II addresses neuropsycho-
aspects of opinion on proper clinical practice to rep- logical diagnosis. Part III focuses on techniques of
resent the field faithfully. Clinical neuropsychology intervention, and Part IV speaks to new aspects such
is too young for a consolidation of opinion that would as the neuropsychologist in private practice and es-
give it a singular approach to practice. Knowledge is tablishing neuropsychological assessment and prin-
developing too rapidly as well to allow us such lux- ciples in the schools.
ury. Unfortunately, this has led to a polemic-at We hope that the inclusion of so many applica-
time vitriolic-division of the field into divergent tions to the public schools will not offend those in the
theory-driven camps. It is too easy, with a subject field: After all, that is where the children are.
this size, to use reductionist tactics to forward a cause We would like to express our appreciation to
or ideology that may not be in the best interests of several people who aided us in the completion of this
children. The radical behaviorist position, which work. Angela Bailey, who.performs superbly as our
seems to deny us the convenience of metaphor and administrative editor on a variety of projects, was
the use of inferential constructs we see as so essential instrumental in coordinating our own work and keep-
to the scientific process, is represented in a chapter by ing track of many of the details of the project. Mike
Reschly and Gresham. Although we find the views in Ash and Victor Willson of the Department of Educa-
the chapter myopic at best, it is an accurate portrayal tional Psychology at Texas A&M University deserve
of the behaviorist view of clinical neuropsychology appreciation for their moral support and the precious
and its application to disorders of learning. We have places they always fmd to house our special projects.
presented this disagreeable view to help provide bal- To each of our families, we express our thanks for
ance and to show the contrasting stance of other the- your patience in our hours away. C.R.R. would like
oretical positions. They are particularly harsh on the to extend a special note of gratitude to Julia; E. F. J.
use of neuropsychology in educational settings, expresses her appreciation to David, Emma, and
which seems appropriate because-in the remainder C.R.R. We also extend appreciation to Lawrence
of the volume-we have included information not Hartlage for the demonstration of his remarkable
only on clinical applications in the schools but also on clinical acumen, which continues to interest us in this
developing neuropsychology services in the public field. Eliot Werner, Senior Editor at Plenum, as al-
schools. For those who are in the field, we hope to ways proved a valuable ally and supporter in the
have provided some exciting arguments from chapter entire development of the work. Last, we are grateful
to chapter. For those new to the field, we hope to to our authors, for without their hard work this Hand-
have provided a grand but no less than geode under- book would not exist.
standing of the entire scope of the field.
Part !-Foundations and Current Issues-gives
an overview of the history and development of the Cecil R. Reynolds
field and introduces basic foundations such as mea- Elaine Fletcher-Janzen
Contents
I. Foundations and Current Issues
1. Historical Perspectives in the Development of Neuropsychology as a Professional

Psychological Specialty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ANTONIO E. PUENTE
2. Development ofthe Child's Brain and Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

BRYAN KoLB AND BRYAN PANTIE
3. Higher Cortical Functions in Children: A Developmental Perspective . . . . . . . . . . . . . . 41

LAWRENCE v. MAJOVSKI
4. Mechanisms and Development of Hemisphere Specialization in Children . . . . . . . . . . 69

MARCEL I<INSBOURNE
5. Neuropsychology of Child Psychopathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

MICHAEL G. TRAMONTANA AND STEPHEN R. HooPER
6. Neuropsychological Sequelae of Chronic Medical Disorders. . .................... . 107

RICHARD A. BERG AND jOHN C. LINTON
7. Neuropsychological Bases of Common Learning and Behavior Problems in

Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
MARION J. SELZ AND SHERYL L. WILSON
8. Measurement and Statistical Problems in NE:uropsychological Assessment of

Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
CECIL R. REYNOLDS
ix
X CONTENTS
9. Models of Inference in Evaluating Brain-Behavior Relationships in Children 167

EILEEN B. FENNELL AND RUSSELL M. BAUER
II. Neuropsychological Diagnosis
10. Halstead-Reitan Neuropsychological Test Batteries for Children 181

NANcY L. NussBAUM AND ERIN D. BIGLER
11. The Nebraska Neuropsychological Children's Battery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

CHARLES J. GOLDEN
12. Applications of the Kaufman Assessment Battery for Children (K-ABC) in

Neuropsychological Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
CECIL R. REYNOLDS, RANDY w. KAMPHAUS I AND BECKY L. ROSENTHAL
13. Neuropsychological Applications of Common Educational and Psychological Tests 227

CATHY F. TELZROW
14. Radiological Techniques in Neuropsychological Assessment . . . . . . . . . . . . . . . . . . . . . . 247

ERIN D. BIGLER
15. Psychophysiological Evaluation of Children's Neuropsychological Disorders 265

THALIA HARMONY
16. Techniques of Localization in Child Neuropsychology 291

GRETA N. WILKENING
17. Neuropsychological Sequelae of Substance Abuse by Youths 311

ROBERT W. ELLIOTT
III. Techniques of Intervention
18. Neuropsychological Models of Learning Disabilities: Contribution to Remediation 335

CHE I<AN LEONG
CONTENTS xi
19. Neuropsychological Approaches to the Remediation of Educational Deficits . . . . . . . . 357

PHYLLIS ANNE TEETER
20. The Biofeedback Treatment of Neurological and Neuropsychological Disorders of

Childhood and Adolescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
ROBERT L. HODES
21. Approaches to the Cognitive Rehabilitation of Children with Neuropsychological

Impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
JEFFREY w. GRAY AND RAYMOND s. DEAN
22. Neuropsychological Aspects of Epilepsy: Introduction and Overview . . . . . . . . . . . . . . 409

LAWRENCE C. HARTLAGE AND PATRICIA L. HARTLAGE
23. The Neuropsychology of Epilepsy: ~sychological and Social Impact 419

THOMAS L. BENNETT AND LINDA K. KREIN
24. Neuropsychological Effects of Stimulant Medication on Children's Learning and

Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443
RoNALD T. BROWN AND l<ATHI A. BoRDEN
25. Nonstimulant Psychotropic Medication: Side Effects on Children's Cognition and

Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475
MANUEL L. CEPEDA
IV. New Aspects of Neuropsychology
26. Establishing Neuropsychology in a School Setting: Organization, Problems, and

Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
RUTH ADLOF HAAK
27. Current Neuropsychological Diagnosis of Learning Problems: A Leap of Faith . . . . . . 503

DANIEL}. RESCHLY AND FRANK M. GRESHAM
28. Child Behavioral Neuropsychology 521

ARTHUR MAcNEILL HoRTON, JR.
xii CONTENTS
29. Coping and Adjustment of Children with Neurological Disorder . . . . . . . . . . . . . . . . . . 535

TIMOTHY B. WHELAN AND MARIE L. WALKER
30. Child Neuropsychology in the Private Medical Practice 557

ERIN D. BIGLER AND NANCY L. NussBAUM
31. Public Policy and Legal Issues for Clinical Child Neuropsychology 573
ROBERT HENLEY WOODY
32. Training and Credentialing in Child Neuropsychology . . . . . . . . . . . . . . . . . . . . . . . . . . . 585

LAWRENCE C. HARTLAGE AND CHARLES J. LONG
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595
I
Foundations and Current Issues

1
Historical Perspectives in the

Development of Neuropsychology as a
Professional Psychological Specialty
ANTONIO E. PUENTE
The growth of neuropsychology, and clinical neuro- discussion of the growth of publications, organiza-
psychology in particular, has been rapid though tions, and continuing education activities in clinical
poorly documented. Although clinical neuropsychol- neuropsychology. Recent trends in professional
ogy texts provide overviews on theories of brain practice, certification, and credentialing are also ad-
function, only a few review how the field developed. dressed. The chapter concludes with suggestions for
This lack of information is not typical of related disci- maximizing the growth and efficacy of the field.
plines (e.g. , neurology) or of other specialties within
psychology (e.g., clinical psychology). Clinical psy-
chology, for example, has experienced rapid growth Historical Perspectives in the
over the past 25-40 years and its development is well
documented (Fox, 1982; Fox, Barclay, & Rogers,
Development of Neuropsychology
1982).
Documentation is helpful for a variety of rea- Localization of brain function has been the
focus of philosophers, physiologists, and psychol-
sons. First, students must be provided with a compre-
hensive analysis of the discipline's development. ogists for many centuries. Around 400 BC, Hippoc-
Historical perspectives should serve as foundation rates attempted to correlate his behavioral observa-
for a more comprehensive appreciation of current tions with what he knew about anatomical
trends and limitations. Similarly, health profes- localization; this was conjecture because he was le-
sionals not directly involved in the field should have a gally and socially prohibited from dissecting the
clearer understanding of our techniques and trends, if human body, especially the cranium. Later, Aristotle
not for the professional welfare of clinical neuropsy- (not Plato) surmised that the heart was the seat of the
chology, at least for the welfare of consumers ser- mind. Almost 600 years after Hippocrates, Galen
viced by the discipline. Finally, and becoming in- shifted the site of the mind to the brain. Clarification
creasingly important, documentation must be of overall mind function was later offered by De-
available to individuals outside of health care who are scartes who suggested that the soul was localized in
in a position to affect the discipline through funding the pineal gland. In 1810, Gall described cortical
and legislation. localization of function through the concept of
This chapter chronicles and critiques the devel- phrenology.
opment of clinical neuropsychology as a professional Flourens and Broca introduced more accurate
or practitioner specialty in psychology. A brief histo- observations of brain function during the mid 19th
ry of research and clinical developments precedes a century, forcing physiologtsts to research localiza-
tion of function more systematically and with more
precise measurement tools. This research was in-
ANTONIO E. PUENTE Department of Psychology, Uni- formed by early recordings of brain function or dys-
versity of North Carolina, Wilmington, North Carolina function which can be traced to at least the 17th cen-
28403-3297. tury (Gibson, 1962) when several cases describing
3
4 CHAPTERl
traumatic brain injury were documented. Precise ex- normative approach." Such an approach builds on
perimental, rather than observational, analysis began the uniqueness of the individual and on the complex-
with the electrical stimulation work of Fritsch and ities of syndromes by tailoring the assessment. How-
Hietzig in 1790. New scientific techniques were in- ever, unlike the Russian methods, the British ap-
troduced to the study of brain function by one of proach does rely on psychometric tests. An
Catell's students, Sheperd Franz, during the early evaluation may begin with the Wechsler Adult Intel-
part of this century. While in Washington, D.C., ligence Scale and proceed to the Wisconsin Card
Franz taught KarlS. Lashley who, in turn, advanced Sorting Test, Halstead Category Test, or Trail Mak-
the understanding of brain-behavior relationships as ing Test, depending on the functions that are to be
well as the theory of equipotentiality. During the mid examined. Gaps in the assessment are filled with
20th century, Nobel laureate Roger Sperry and col- more experimental (i.e., poorly standardized) and
leagues extended this earlier work by developing pro- individual tasks. A final yet important aspect of the
cedures for experimentally examining disconnection British approach is the shift from strict localization
syndromes. (which is central to Luria's approach) to an under-
As noncultural variables have traditionally been standing of behavioral and psychological deficits.
attributed little value in neuropsychological informa- Canadian and American or North American ap-
tion, it is surprising to note that different approaches proaches to clinical neuropsychology have historical
to the application of neuropsychological knowledge roots in the work of Franz and Lashley in Wash-
have developed across three major cultures, i.e., ington, D.C. However, the clinical or applied study
North America, Russia, and Great Britain. of brain dysfunction in the United States could be
The approach to clinical neuropsychological un- traced back to Kurt Goldstein. Goldstein's (1939)
derstanding in Russia grew from the classical psy- approach to the study of brain dysfunction was sim-
chophysiological reflexive studies of Pavlov and ilar to that of Luria's in the sense that he did not use
other Russian physiologists (Bechtereva, 1978). psychometric tests and that an extensive clinical case
Clearly the best recognized individual to apply this study was favored over short, structured contacts
orientation to clinical assessment of neuropsychol- (Hanfmann, Rickers-Ovsiankina, & Goldstein,
ogical dysfunction was A. R. Luria (1902-1977). 1944).
According to Luria (1970), there are two basic princi- Early psychometric approaches to brain assess-
ples that guide assessment of brain dysfunction: lo- ment can be traced to Babcock (1930). However, it
calization of brain lesions and analysis of psychologi- was Ralph Reitan who launched clinical neuropsy-
cal activities associated with brain function. The chology in North America toward the now-accepted
Russian approach to assessment is based on a psychometric tradition. In his seminal paper in 1955,
qualitative, rather than quantitative or psychometric he indicated that the purpose of a neuropsychological
method. Specifically, this approach attempts to pro- evaluation was to measure deficits accurately in a
vide a "clinical description using flexible but sys- standardized psychometric fashion. An interesting
tematic sets of tests" (Luria & Majovski, 1977, p. comparison of Reitan's and Luria's approach to brain
962). The foundation for this flexible approach is assessment is found in Diamant ( 1981). An extension
based on the concept that strong individual dif- of Luria's approach into the psychometric realm of
ferences preclude development of accurate norms. brain assessment served as the foundation for the
Empirically derived analyses cannot replace a com- work of Golden, Hammeke, and Purisch ( 1980) with
prehensive understanding of brain or individual pa- the Luria-Nebraska Neuropsychological Battery.
tient functioning. Each client presents with an indi- Although numerous criticisms have been leveled at
vidual set of symptoms; thus, individual hypotheses this battery and approach (Adams, 1980), the battery
and experiments must be performed. Observation of continues to be used and with increasing regularity
form and content, replication, and flexibility of (Seretny, Dean, Gray, & Hartlage, 1986; Lubin,
thinking are central to this approach. Larsen, Matarazzo, & Seeven, 1986). Although neu-
Whereas the methods of Luria represent the his- ropsychology as a field of investigation has a long
torical foundations for the clinical application of past, formal efforts in clinical neuropsychology have
neuropsychological principles in Russia, Henry a more recent onset and more of a divergent geo-
Head and Hughlings Jackson represent the founda- graphical origin. Nevertheless, the discipline has re-
tion for British approaches to clinical neuropsychol- cently made significant strides toward the under-
ogy. According to Beaumont (1983), British clinical standing of brain function from both research and
neuropsychologists favor the "individual-centered clinical perspectives.
HISTORICAL PERSPECTIVES 5
Journal and Book Publications Georgemiller, and Hymen ( 1982) analyzed the affil-
iation, geographic region, and context of manu-
The proliferation of head-injured World War II scripts published between 1979 and 1983 in these
veterans into Veterans Administration domiciliary journals. Whereas the University of Nebraska repre-
settings occurred with the rapid growth of clinical sented 11.3% of articles in CN, a wide variety of
psychology. Such growth was steady though not nec- universities (e.g., City College of New York) were
essarily remarkable through the 1950s and 1960s. represented in JCN. Southern and north central states
This growth is well chronicled in research and were the geographic origin of articles in CN, whereas
clinical studies published in various journals. For northeastern states and Canadian locations were bet-
example, Reitan's (1955) classical psychometric ter represented in JCN. Furthermore, institutional
study of head-injured adults appeared in the Journal contribution did not overlap from one journal to the
of Comparative and Physiological Psychology other. CN was found to be more assessment oriented
(JCPP). However, by about 1950 well over 70% of (e.g., Luria-Nebraska Neuropsychological Battery)
the studies in JCPP used the Norway rat and close to whereas JCN focused more on methodological and
80% of the studies dealt either with conditioning and theoretical articles, 17.1 and 30.2% of articles, re-
learning or with reflexes and simple reaction patterns spectively. In summary, Ryan et al. (1982) sug-
(Beach, 1950). In many respects, Reitan's article gested that ''one journal (CN) will become more
was not mainstream physiological psychology. identified with practical issues while the other (JCN)
To document publication trends, all clinical will deal more with academic interest.''
neuropsychological citations in Psychological Ab- Georgemiller, Ryan, and Setley (1986) later
stracts, Biological Abstracts, and Index Medicus as surveyed 115 sites offering neuropsychological train-
well as in three separate computer searches were ing and asked the directors to rate the value of neuro-
chronicled. The trend of published articles approxi- psychology-related journals. In order of perceived
mates two articles per year until about 1960. From importance were Journal of Clinical and Experimen-
1960 until 1975, a sharp rise in publication rate oc- tal Neuropsychology, Journal of Consulting and
curred with an average of 28 articles per year. Be- Clinical Neuropsychology, Clinical Neuropsychol-
tween 1974 and 1985 the rate continued to rise sharp- ogy, Cortex, Archives of Neurology, Brain, Brain
ly to about 66 articles per year. These articles were and lAnguage, Journal of Clinical Psychology, and
found in a wide variety of esoteric and interdisciplin- Archives of General Psychology.
ary journals; to date, 161 different journals have pub- If one examines book publishing, similar
lished articles on neuropsychology. The journals growth patterns emerge. Prior to the 1970s, applica-
publishing the most articles include (in alphabetical tion of neuropsychological principles was rarely cov-
order) American Journal of Psychiatry, Clinical ered in clinical psychology or related texts. Howev-
Neuropsychology/International Journal of Clinical er, such books as Lezak's Neuropsychological
Neuropsychology, Cortex, International Journal of Assessment (1976) and Golden's Diagnosis andRe-
Neuroscience, Journal of Clinical Neuropsychol- habilitation in Clinical Neuropsychology (1978) dur-
ogy/Journal ofClinical and Experimental Neuropsy- ing the 1970s and more recently Filskov and Boll's
chology, Journal of Clinical Psychology, Journal of Handbook of Clinical Neuropsychology (1981) and
Consulting and Clinical Psychology, Neuropsycho- Wedding, Horton, and Webster's The Neuropsychol-
logia, andPerceptualandMotorSkills. TheArchives ogy Handbook (1986) have introduced this "new"
of Clinical Neuropsychology, The Clinical Neuro- field to clinical and nonclinical psychologists. Sever-
psychologist and Neuropsychology are new to the al publishing companies have mounted intensive
field, exclusively publishing clinical neuropsycholo- efforts in the field and one, Plenum, has developed a
gical studies, and have not been in existence long book series entitled Critical Issues in Clinical Neuro-
enough to have been listed but should certainly psychology. This Handbook is one of the ftrst books
achieve such status quickly. to be published in the series.
Until recently, the two major neuropsychol- Wedding, Franzen, and Hartlage (1987) re-
ogical journals addressing clinical issues were cently reported the number of clinical neuropsychol-
Clinical Neuropsychology (CN; now International ogy books published yearly from 1960 to 1986. Be-
Journal ofClinicalNeuropsychology) and Journal of tween 1960 and 1967 an average of less than one
Clinical Neuropsychology (JCN; now the Journal of book was published per year. Twenty years later the
Experimental and Clinical Neuropsychology). In an average number published per year was well over 10,
interesting study of publication trends, Ryan, with close to 25 books published in 1986. This pro-
6 CHAPTER!
liferation of books and journals shows no indication are practicing, rather than academic, professionals
of slowing. and a large majority are involved in direct service,
typically in private practice settings. NAN mem-
bership requirements include specific training and
Professional Organizations experiential components rather than the simple in-
terest criteria of INS.
Along with the proliferation of published find- Division 40 of the APA (Division of Clinical
ings has been the development of three major organi- Neuropsychology) was formed in 1980 to serve the
zations representing clinical neuropsychology. The growing interest of APA members in clinical neuro-
International Neuropsychological Society (INS) was psychology. Initially, APA members from other di-
established in 1970 by individuals of varying disci- visions (e.g., 6 and 12) joined to petition for this
plines interested in neuropsychological issues. In Division. As of January 1986, the Division had 49
1973 the flfSt meeting of INS was convened in New fellows, 1829 members, and 153 associates with
Orleans. Such well-known clinicians as Benton, But- rapid growth expected to continue.
ters, Goldstein, Hartlage, Kinsbourne, Mirsky, Pri- Ancillary divisions within APA as well as nu-
bram, Rourke, and Satz dotted the small yet robust merous non-APA groups have also experienced
program. Others, such as Fred King, now director for growth indirectly associated with clinical neuropsy-
the Yerkes Primate Research Center in Atlanta, rep- chology. The Association for the Advancement of
resented more academically oriented disciplines such Behavior Therapy has members interested in clinical
as physiological psychology and the neurosciences. neuropsychology as does Divisions 38 (Health Psy-
From the 1970 membership of 175 (mostly from chology) and 6 (Physiological and Comparative Psy-
North America), INS has grown to 2000 members chology). In nonpsychologically oriented organiza-
worldwide representing a variety of disciplines, in- tions, similar growth has been observed in groups
cluding speech pathology, clinical neurology, and such as the Society for Neuroscience. Finally, it is
neuropsychology. Of these, over 600 reside outside worth noting that although not associated with specif-
of the United States. To accommodate the large ic national or international organizations, geograph-
number of non-North American members, INS now ically limited groups have surfaced throughout the
holds two meetings per year-one in North America United States and abroad. Groups in New York, Phil-
and the other in Europe. Over 800 attended the 1987 adelphia, California, and Puerto Rico (to name a
USA meeting (Washington, D.C.) with a smaller few) have been formed to serve more local needs.
number attending the European meeting (Barcelona, One particular group, the Philadelphia Neuropsy-
Spain). chological Society, has recently launched its own
According to Hartlage (1987), the National journal. Thus, strong evidence exists that organiza-
Academy of Neuropsychologists (NAN) evolved tions in clinical neuropsychology are and, most like-
from a group of INS and APA members interested in ly, will continue flourishing.
developing a separate organization with national rep-
resentation as well as focusing on the professional
aspects of neuropsychology. The first formal meet- Continuing Education
ing was held in August 1976 at the Washington
School of Psychiatry. Robert Woody, the flfSt presi- Though a relative newcomer to the discipline,
dent of NAN, was instrumental in initiating a news- another area of growth in clinical neuropsychology
letter, Gram-ma. W. Lynn Smith chaired the next has been continuing education and the freestanding
meeting held in cooperation with the annual APA workshop. These activities have served as a central
meeting. In 1981, NAN met independent of APA in focus in providing training for clinical neuropsychol-
Orlando, Florida, with approximately 220 indi- ogists. Recent examples of these workshops include:
viduals registered. Since Orlando, NAN has met in mild head injury in New York; Luria-Nebraska in
Atlanta, Houston, San Diego, Philadelphia, Las Chicago; traumatic head injury in Braintree, Mas-
Vegas, and Chicago ( 1987). Registration for the Chi- sachusetts; head trauma in Kansas City; dementia in
cago meeting exceeded more than 350 and mem- Baltimore; behavioral neurology and neuropsychol-
bership in the organization is currently nearing 1000. ogy in Lake Buena Vista, Florida; and head injury
Although members reside in many different coun- rehabilitation in Williamsburg. Virginia. Many of
tries, including Australia and several countries in Eu- these freestanding workshops now also have free
rope, membership is largely composed of individuals communications or poster sessions as part of the
from the United States and Canada. Most members program.
Although these freestanding workshops often counseling centers. Interestingly, approximately

sharpen the skills of professionals, they potentially 50% of the respondents have secondary employment,
pose significant complications (e.g., retraining engaging in independent group or individual private
involves more than workshops). To avoid these pit- practice. Of those providing health services, over
falls, Meier (1987) outlined the concept of "Learn- half were involved in clinical activities in indepen-
ing and Assessment Center'' for clinical neuropsy- dent practices, clinics, hospitals, or counseling/other
chology practice to define personal insufficiencies service settings (in order of prominence).
and to provide the necessary knowledge, scientific or Although not as current as the Stapp et al.
professional, to respecialize in clinical neuropsy- (1985) data, Dorken and Webb (1981) reported large
chology. Educational materials would be based on increases in the number of clinical psychologists dur-
identified knowledge, skills, and attention needed to ing the mid to late 1970s, supporting the trend that
practice and provide an advanced level of profi- more and more individuals are providing health care,
ciency. regardless of their primary employment. In a recent
The information to be disseminated could take analysis of doctorate productions by subfield, the
one of several forms including workshops, conven- APA Committee on Employment and Human Re-
tions, and published materials. However, of the spe- sources (Howard et al., 1986) indicated that whereas
cific modalities of professional information, some 50 years ago 70% of all new PhD recipients were in
forms of dissemination appear to be more efficient experimental psychology, in 1984 53.2% were in
than others. For example, Allen, Nelson, and health services specialties. Furthermore, "the trend
Sheckley ( 1987) reported on continuing education was for new doctorate recipients in clinical, counsel-
activities of Connecticut psychologists. Books and ing, and school psychology to increasingly assume
contacts with other professional psychologists were positions in organized human service settings''
the most favored continuing education activities, (Howard et al., 1986, p. 1322).
with books rated as the most valuable. Surprisingly, In a review of the 1982 APA's Human Re-
the average respondent read 9.9 books, 3.8 journals, sources Survey, VandenBos and Stapp (1983) pro-
and attended 2.5 workshops and 2.2 conventions per vided a detailed analysis of the characteristics of
year. Continuing education activities appear to be practice settings of service providers, profiles of pro-
critical in the development of professional practice fessional practice, and other aspects of independent
and to date, numerous opportunities have been avail- practice. Whereas the first two issues were addressed
able for those interested in furthering their training in in the Stapp et al. (1985) report, issues of profes-
clinical neuropsychology. sional practice were more comprehensively de-
scribed by VandenBos and Stapp (1983). Health
problems, substance abuse, mental retardation, and
schizophrenia combined represented close to 50% of
Psychological Health Care Personnel the types of client problems seen by health providers.
and Practice In an earlier study by VandenBos and colleagues
(VandenBos, Stapp, & Kilberg, 1981), about40% of
During the 1970s there occurred an influx of the respondents reported performing complete as-
psychology personnel into the workplace. This influx sessments regularly or often.
has continued unabated and has affected clinical neu- These results strongly suggest that the number
ropsychology. According to Stapp, Tucker, and of health providers is rapidly increasing and they are
VandenBos (1985), the estimated number of psy- quickly becoming the majority of psychology per-
chology personnel in the United States was 102,100 sonnel in the United States. Although independent
in mid 1983. Of these, 61.6% were primarily provid- practice groups or individuals appear to be enjoying
ing health services, 49.2% were involved in research the most significant growth, similar trends are seen in
and 63.7% in education. Approximately two thirds of all health service settings (e.g., hospitals). Assuming
these were doctoral level psychologists, and most that a significant percentage of all health service cli-
(both master's and doctorate level) identified them- ents have organic disorders and that few health pro-
selves with clinical psychology (followed by coun- viders limit their practice to one type of service or
seling and educational psychology). University set- client (VandenBos and Stapp, 1983), one may con-
tings were the largest single category of employment clude that a large percentage of psychologists are
for doctorates; approximately 44% of the re- involved either in therapy Ol' in assessment of indi-
spondents were employed primarily in direct service viduals with neuropsychologically based problems.
through independent practice, hospitals, clinics, or According to VandenBos and Stapp (1983), "it is
8 CHAPTER!
interesting to note that psychologists tend not to spe- clinical psychology was the best preparation for de-
cialize with specific problems or with specific age livery of clinical neuropsychology services. Finally,
populations" (p. 1346). Thus, more psychologists Benton and Golden were cited for their unique contri-
will either eventually be involved in or specialize in butions to the development of clinical neuropsychol-
clinical neuropsychological services. ogy as a professional specialty.
Using Social Security Administration data as a In a more recent study, Seretny et al. (1986)
specific example, organic clients do comprise a sig- surveyed members from APA's Division 40 (N =
nificant segment of general clinical practice. In fiscal 314) and the National Academy of Neuropsychol-
years 1984 and 1985, 22.5% (or approximately ogists (N = 300). The purpose of the survey was
250,000 people) of all those applying for Social Se- essentially to follow-up earlier surveys and to expand
curity disability were mental impairment cases (Dap- the information available for specific aspects of pro-
per, 1987). Of these, 6% were classified as organic fessional practice settings. Private practice was re-
mental disorder and 35% as mentally retarded. Retar- ported as the primary work. setting of the re-
dation could be ''caused'' by head trauma, for exam- spondents, followed by (in decreasing order of
ple, as IQs and not etiologies ofbehavioral disruption occurrence) hospitals, medical schools, and academ-
are important in a disability evaluation. This ac- ic settings. According to the authors, there has been a
counts for between 200,000 and 300,000 potential shift to private practice settings over the last 5 years.
neuropsychological clients per year. In summary, it Whether this is due to academicians going into prac-
appears that not only are more psychologists dealing tice or new doctorate recipients choosing profes-
with neuropsychologically impaired clients, but that sional rather than academic settings, or both, is un-
a large number of mental health consumers have certain. Little has changed in terms of the average
organic disorders. number of evaluations per month ( 11.13) or the aver-
age amount of time required to complete a full eval-
uation (7 .30 hours). About half of the respondents
employed technicians. The Wechsler Intelligence
Professional Practice Scales remained the most frequently used instru-
ments followed by the Halstead-Reitan and the
The practice of clinical neuropsychology has Luria-Nebraska Neuropsychological batteries.
become increasingly popular in the last few years. Other single tests frequently used included the
Several surveys over the last 5 years have outlined the WRAT, Bender, and Benton, as well as the MMPI
current practice of clinical neuropsychology in the and the Wechsler Memory Scale. A wide variety of
United States. In 1982, Hartlage and Telzrow com- referral sources was cited. Referrals were primarily
pleted a mail survey of all members of the National from neurologists, although neurosurgeons, psychol-
Academy ofNeuropsychologists. Four major content ogists, general physicians, physical rehabilitation
areas were covered: professional practice, tests, specialists, and attorneys also referred regularly. The
practice preparation, and most important figure in the mean dollar amount for a complete neuropsychol-
history of clinical neuropsychology in the United ogical evaluation was $479.30 or about $65.65 per
States. From these data, one can develop a basic hour. Most respondents indicated that they were in-
sense of a "typical" clinical neuropsychological volved in some nonneuropsychological activities as
practice. The mean neuropsychological evaluation well as cognitive rehabilitation and forensic evalua-
time was 8 hours. Approximately 59% of the re- tions. These results support the fact that specific
spondents used technicians. Only three tests were trends are surfacing in terms of tests used, time used
used by at least 50% of the respondents and these for an evaluation, and the use of technicians. Addi-
included the Wechsler Intelligence Scales (89%), tional longitudinal information would be useful with
portions of the Halstead-Reitan Neuropsychological regard to such issues as cost of service, place of
Battery (56%), and the Wide Range Achievement employment, and referral sources.
Test (52%). The remaining tests used were (in order Ryan, Parage, and Lips (1983) identified psy-
of descending popularity): Bender Gestalt Test, chological health providers in the 1981 version of the
Halstead-Reitan Neuropsychological Battery, Ben- National Register ofHealth Service Providers in Psy-
ton Visual Retention Test, Luria Tests (Christensen chology and the winter 1981-1982 supplement, who
or Golden versions), Wechsler Memory Scale, Mem- offered neuropsychological services in an effort to
ory for Designs, and the Minnesota Multiphasic Per- understand the geographical distribution of persons
sonality Inventory (MMPI). With regard to practice providing such service. The range noted was rela-
preparation, 78% of the respondents indicated that tively large with the District of Columbia having one
neuropsychology provider per 42,510 persons, and Until the I 980s, clinical neuropsychology was
South Dakota with one provider per 690, 178. The top not a formally recognized subspecialty in health care.
ten states in terms of per capita providers were (in Behavioral neurologists, speech pathologists, and
rank order): California, New York, Texas, Pennsyl- clinical psychologists (among others) with an interest
vania, llinois, Ohio, Florida, Michigan, New Jersey, in brain dysfunction worked using informal titles,
and North Carolina. Alaska and several midwestern and in many cases, constructs. Realizing the need for
states had the fewest number of practicing neuropsy- specific professional identity in the applied field of
chologists. It is interesting to note that in Indiana only brain dysfunction, several psychologists within sev-
21 individuals offered neuropsychological services eral Divisions of APA, especially 6 (Physiological
and only one did so in South Dakota. These states and Comparative) and 12 (Clinical Psychology), as
represent the geographical origins of the Halstead- well as within INS and NAN, initiated discussion for
Reitan (Indiana) and Luria-Nebraska Neuropsychol- the development of guidelines that would define how
ogical batteries (South Dakota). a psychologist (and not an individual of a related
Sladen, Mozdzierz, and Greenblatt (1986) also discipline) would be identified as a clinical neuropsy-
examined the geographical distributions of neuropsychologist. Prior to the development of Division 40,
chological service providers using the same subject informal discussions were centered within INS cir-
selection criteria as Ryan et al. (1983). Sladen et al. cles. By the early 1980s, APA Division 40 had been
reported ''marked disparities'' in the distribution of formed, and the original group of individuals devel-
professional psychologists providing clinical neuro- oping these guidelines split into two major factions.
psychological services. These disparities existed One group, who remained entrenched within INS,
both among states as well as between rural and metro- developed the American Board of Clinical Neuropsy-
politan areas. Generally, these services were offered chology, Inc. (ABCN), by late 1982 for the purpose
more frequently in densely populated states and in of awarding specialty diplomas in clinical neuropsy-
metropolitan centers. In a related survey of 316 ran- chology. The initial eligibility criteria required the
domly chosen community hospitals, Anchor (1983) following:
reported on the availability and awareness of neuro-
psychological services. The average hospital in the A. Doctoral degree in psychology from are-
survey had 143 beds and all had emergency rooms. gionally accredited university
Only 8.5% of the hospitals offered any type of neuro- B. Licensed or certified at the level of indepen-
psychological, neuropsychiatric, or neurological dent practice in some state or province
testing services. C. Areas of training and experience included:
A recent article by Molloy ( 1987) indicated that I. Basic neurosciences
conditions facing neuropsychologists appear more 2. Neuroanatomy
difficult in countries outside of North America. Ac- 3. Neuropathology
cording to Molloy, insufficient understanding, preju- 4. Clinical neurology
dicial distrust, and limited reimbursement have ham- 5. Psychological assessment
pered the development of neuropsychology as a 6. Oinical neuropsychological assess-
clinical specialty in Australia. However, lawyers and ment
medical specialists appear to constitute the primary 7. Psychopathology
source of referrals there. Such patterns appear preva- 8. Psychological intervention
lent in other countries as well. For example, in Spain, D. Five years of postdoctoral professional ex-
pockets of practitioners exist only in larger cities perience in psychology which could in-
(Madrid and Barcelona). In other countries such as clude:
Argentina, clinical neuropsychological services are Clinical
essentially nonexistent. Research
Teaching
Administration
Certification and Credentialing E. Three or more years of clinical neuropsy-
chological experience defined as follows:
Although a separate chapter on certification, I. Equivalent of at least I year of full
training, and credentialing is found in this Hand- time supervised clinical neuropsy-
book, the current models of training and credential- chology experience at the postdoc-
ing have their roots in and have an impact on histor- toral level (6 months may be cred-
ical trends and, thus, warrant historical analysis. ited for documented predoctoral
10 CHAPTERl
specialty internship in 2. Licensure by a state board of psychology

neuropsychology) 3. At least 5 years' postdoctoral experience in
2. Equivalentofat]east 1 yearofaddi- professional neuropsychology
tional experience as a clinical 4. Combination of coursework; additional
neuropsychologist training such as continuing education work-
3. In the absence of any supervised shops, supervised pre- or postdoctoral train-
clinical experience, the equivalent ing; and relevant work experience to provide
of 3 years of unsupervised postdoc- evidence of high degree of competence in
toral experience as a clinical professional neuropsychology
neuropsychologist 5. Recommendation by at least two supervisors
or professional colleagues attesting to high
The application fonn also required the submission of:
degree of competencies in professional
1. A copy of current state license or certificate, neuropsychology
2. Names of two professionals who could attest To date, ABCN and ABPN have not made
to the extent, nature, and quality of your strides to merge and appear to be taking independent
experience and competence in clinical courses. However, regardless of the apparent split,
neuropsychology. agreement has been reached on specific guidelines
In April 1985, Manfred Meier, the president of for identifying requirements for clinical neuropsy-
ABCN, announced affiliation of this group with the chology education.
American Board of Professional Psychology To alleviate potential complications for indi-
(ABPP). According to Meier, ABPP voted on March viduals wishing to be trained in the field of clinical
4-5, 1985, to add clinical neuropsychology to the neuropsychology, recent guidelines have been pub-
existing fields of applied competency of clinical, lished by INS and Division 40 (August 1986). The
counseling, school, and industrial/organizational guidelines, in their entirety, are as follows:
psychology. As a function of its ABPP affiliation, Doctoral training in Clinical Neuropsychology should
ABCN adopted ABPP's defmition of a psychology ordinarily result in the awarding of a Ph.D. degree from
graduate program as well as adding several related a regionally accredited university. It may be accom-
requirements (e.g., APA membership). At the cur- plished through a Ph.D. program in Clinical Neuropsy-
chology offered by a psychology department or medi-
rent time, the ABPP/ ABCN examination includes a
cal faculty or through the completion of a Ph.D.
"work sample" (e.g., neuropsychological evalua- program in a related specialty area (e.g., Clinical Psy-
tion or treatment summary) as well as an oral exam- chology) which offers sufficient specialization in
ination. The oral examination involves analyses of Clinical Neuropsychology.
the work sample, ethics, and a sample case. The Training programs in Clinical Neuropsychology
written multiple-choice examination is being stan- prepare students for health service delivery, basic
dardized as of this writing. The new ABCN-ABPP clinical research, teaching and consultation. As such,
examination has become more refmed and extensive they must contain (a) a generic psychology core, (b) a
relative to the original criteria published in 1982. generic clinical core, (c) specialized training in the neu-
The American Board of Professional Neuropsy- rosciences and basic human and animal neuropsychol-
ogy, (d) specific training in clinical neuropsychology.
chology (ABPN) was developed in 1982 under the
This should include a 1800 hour internship which
direction of Lawrence Hartlage and several other should be preceded by an appropriate practicum
ABPP members, most of whom were associated with experience.
NAN. The guidelines for the original diplomate sta-
tus, which are shown below, essentially focused on A. Generic Psychology Core
relevant training and education, work with relevant 1. Statistics and Methodology
2. Learning, Cognition and Perception
populations, and supervision with a qualified practi-
3. Social Psychology and Personality
tioner. At present, the ABPN is being restructured 4. Physiology Psychology
and will probably include actual testing along with an 5. Life Span Development
extensive application fonn. The basic requirements 6. History
have been as follows: B. Generic Clinical Core
I. Psychopathology
1. Minimum educational requirement is the 2. Psychometric Theory
Ph.D. (or similar doctoral degree, e.g., 3. Interview and Assessment Techniques
Psy.D., Ed.D.) a. Interviewing
b. Intelligence Assessment training program in one of the health service delivery

c. Personality Assessment areas of psychology or a Ph.D. in psychology with
4. Intervention Techniques additional completion of a "respecialization" program
a. Counseling and Psychotherapy designed to meet equivalent criteria as a health services
b. Behavior Therapy/Modification delivery program in psychology. In all cases, can-
c. Consultation didacy for post-doctoral training in clinical neuropsy-
5. Professional Ethics chology must be based on demonstration of training
C. Neuroscience and Basic Human and Animal and research methodology designed to meet equivalent
Neuropsychology criteria as a health services delivery professional in the
I. Basic Neurosciences scientist-practitioner model. Ordinarily. a clinical in-
2. Advanced Physiological Psychology and ternship, listed by the Association of Psychology In-
Pharmacology ternship Centers, must also have been completed.
3. Neuropsychology of Perceptual, Cog- A post-doctoral training program in clinical neu-
nitive and Executive Processes ropsychology should be directed by a board certified
4. Research Design and Research Practicum clinical neuropsychologist. In most cases, the program
in Neuropsychology should extend over at least a two-year period. The only
D. Specific Clinical Neuropsychological exception would be for individuals who have com-
Training pleted a specific clinical neuropsychology specializa-
I. Clinical Neurology and Neuropathology tion in their graduate programs and/ or a clinical neuro-
2. Specialized Neuropsychological Assess- psychology internship provided the exit criteria are met
ment Techniques (see below). As a general guideline, the post-doctoral
3. Specialized Neuropsychological Inter- training program should provide at least 50% of time in
vention Techniques clinical service and at least 25% of time in clinical
4. Assessment Practicum "Children and/or research. Variance within these guidelines should be
Adults in University Supervised Assess- tailored to the needs of the individual. Specific neuro-
ment Facility psychology training must be provided, including any
5. Clinical Neuropsychological Internship areas where the individual is deemed to be deficient
of 1800 hours preferably in a university (testing, consultation, intervention, neurosciences,
facility. (As per INS-Div. 40 task force neurology, etc.).
guidelines). Ordinarily this internship Such a post-doctoral training program should be
will be completed in a single year, but in associated with hospital settings which have neu-
exceptional circumstances may be com- rological and/ or neurosurgical services to offer and the
pleted in a two-year period. training should be provided in both a didactic and expe-
E. Doctoral Dissertation riential format and should include the following:
It is recognized that the completion of a Ph.D. in A. Training in neurological and psychiatric
Clinical Neuropsychology prepares the person to begin diagnosis.
work as a clinical neuropsychologist. In most jurisdic- B. Training in consultation to neurological and
tions, an additional year of supervised clinical practice neurosurgical services.
will be required in order to qualify for licensure. Fur- C. Training in direct consultation to psychiatric,
therrnore, training at the post-doctoral level to increase pediatric, or general medical services.
both general and sub-speciality competencies, is D. Exposure to methods and practices of neu-
viewed as desirable. rological and neurosurgical consultation
Post-doctoral training, as described herein, is de- (Grand Rounds, Bed Rounds, Seminars,
signed to provide clinical training, in order to produce etc.).
an advanced level of competence in the speciality of E. Observation of neurosurgical procedures and
clinical neuropsychology. It is recognized that clinical biomedical tests (revascularization pro-
neuropsychology is a scientifically-based evolving dis- cedures, cerebral blood flow, W ADA testing,
cipline and that such training should also provide a etc.).
significant research component. Thus, this report is F. Participation in seminars offered to neurology
concerned with post-doctoral training in clinical neuro- and neurosurgery residents (neurophar-
psychology which is specifically geared toward pro- macology, EEG, brain cutting, etc.).
ducing independent practitioner level competence. G. Training in neuropsychological techniques,
which includes both necessary clinical and research examinations, interpretation of test results, re-
skills. This report does not address training in neuro- port writing.
psychology which is focused solely on research. H. Training in consultation to patients and refer-
Entry into a clinical neuropsychology post-doc- ral sources.
toral training program ordinarily should be based on I. Training in methods of intervention specific to
completion of a regionally accredited Ph.D. graduate clinical neuropsychology.
12 CHAPTER1
1. Seminars, readings, etc., in neuropsychology Scheer and Lubin ( 1980) also published an inde-
(cases conferences, journal discussions, top- pendent survey of ''training" programs in clinical
ic-specific seminars). neuropsychology. In this survey, the authors
K. Didactic training in neuroanatomy, neuro-
sampled the 627 members of INS in 1977. The results
sciences.
indicated that, at most, training included "minimal
Additional experiential training should be offered
as follows: neuropsychological training activities associated
A. Neuropsychological examination and evalua- with primary service function and allied disciplines''
tion of patients with actual and suspected neu- (e.g. , neurology). Several internship programs exist-
rological diseases and disorders. ed at both the pre- and the postdoctoral level. Scheer
B. Neuropsychological examination and evalua- and Lubin noted that a typical pattern of training
tion of patients with psychiatric disorders involved obtaining a standard Ph.D. with 1- or 2-year
and/ or pediatric or general medical patients postdoctoral specialization in clinical neuropsychol-
with neurobehavioral disorders. ogy .. Another pattern of training was to specialize in a
C. Participation in clinical activities with neu- spectfic Ph.D. program (e.g., clinical or neuro-
rologists and neurosurgeons (Bed Rounds,
science) with neuropsychological concentration. The
Grand Rounds, etc.).
D. Experience at a specialty clinic, such as a de-
authors reported that "notable pioneers" such as
mentia clinic or epilepsy clinic, which empha- Benton, Satz, Milner, and Reitan followed this mode
sizes multidisciplinary approaches to diag- of training. One particularly interesting observation
nosis and treatment. by Scheer and Lubin was that "notable pioneers"
E. Direct consultation to patients involving neu- actually "individually designed" their curriculum.
ropsychological assessment. With the recent guidelines or recommendations, it
F. Direct intervention with patients, specific to would appear that such an approach would be in-
neuropsychological issues, and to include creasingly difficult, if not impossible, to accomplish.
psychotherapy and/or family therapy where
Although Meier ( 1982) cogently argued for different
indicated.
G. Research in neuropsychology, e.g., collab-
models of education in clinical neuropsychology, it
oration on a research project or other scholarly
appears that such a variety of models might actually
academic activity, initiation of an indepen- be replaced with one or two specific ones as pressure
dent research project or other scholarly aca- from licensing or credentialing groups becomes more
demic activity, and presentation or publica- defined and intensified.
tion of research data where appropriate. The major reason for certification and creden-
tialing the practice of clinical neuropsychology is to
At the conclusion of the post-doctoral training
program, the individual should be able to undertake
ensure that our clients/patients in particular, and so-
consultation to patients and professionals on an inde- ciety in general, are not harmed by incompetent or
pendent basis. Accomplishment in research should also unethical practitioners (Hogan, 1983a). However,
be demonstrated. The program is designed to produce a unexpected, even undesired by-products of this cur-
competent practitioner in the areas designated in Sec- rent trend are generally not being considered.
tion B of the Task Force Report and to provide eligibili- The first step in regulating a particular discipline
ty for certification in Clinical Neuropsychology by the is not to regulate the practitioners, but to regulate
American Board of Professional Psychology. (1986, educational institutions or formal internships
pp. 4-5) (Hogan, 1983b). This approach was first used in
As strict as these guidelines may be, they pre- 1803 in the state of Massachusetts to regulate the
sumably are more prescriptive of how programs may medical profession (Shryock, 1967). However,
develop neuropsychology tracks than descriptive of Hogan (1983b) argued that despite the fact that so-
existing neuropsychology programs. For example, phistication in the licensing and certification process
Golden and Kuperman (1980) surveyed all APA-ap- grows, "little evidence suggests that the quality of
proved clinical psychology graduate programs in professional services has improved" (p. 121) (see
North America in 1977. Approximately 60% of these alsoKessel, 1970,andGross, 1978). Specifically, he
programs offered clinical neuropsychology courses contended that such an approach is aimed to "elimi-
including lectures, practicums, and work place- nate competition, rather than incompetence." Sec-
ments. Interestingly, however, fewer schools were ond, such restrictions tend to increase the cost of
involved in neuropsychological research. Further- services and limit the services to disadvantaged
more, most schools offered training by one or two groups. According to Dorsey (1983), restrictions
staff members and relatively few had specific neuro- tend to decrease the "lower-quality and price" ser-
psychology tracks. vice that low-income individuals would be able to
use. The possibility exists, furthermore, that indi- may be applied to ensure continued and appropriate
viduals unable to be credentialed by formal pro- growth of our discipline (based on Hogan, 1983b).
cedures would be relegated to less prestigious jobs. First, clinical neuropsychology practice should be
Another issue is that having failed to be accepted at narrowly defined. For example, how is clinical
the highest level, an individual, due to interest or neuropsychology different from clinical psychology,
necessity, would still practice out of the mainstream behavioral neurology, or speech therapy? Second,
of clinical neuropsychology without adequate direc- standards used in defining qualified clinical neuro-
tion, information, or technique (which would bees- psychologist must be based on empirical assessment,
pecially critical in clinical neuropsychology due to its competence, and related to actual (versus hypo-
inherent complexity and novelty). Furthermore, this thetical) performance. Shimberg (1981) provided
trend would probably occur more frequently with specific suggestions as to how these concerns may
minority populations. Indeed, recent statistics pub- apply to psychology, in general, with regard to con-
lished by APA (Howard et al., 1986) indicate that tent, criterion, and construct validity of tests for psy-
although women are becoming increasingly repre- chological certification. Third, alternative paths to
sented, other minorities, including blacks and certification should be kept open (see also Meier,
Hispanics, are not. Analysis of name lists available 1987, for specific suggestions on continuing educa-
from both ABPP/ABCN and ABPN appears to con- tion). This might include internships, postdoctoral
firm this. fellowships, supervision, peer and client review,
An alternative to such efforts is the more recent workshops, and at home/office study. Fourth, reg-
peer review system, first enacted by Congress in ulatory policies should be based on the representation
1972 to monitor federally aided health care programs of appropriate constituencies. This would involve
such as Medicare (Young, 1982). Such an approach clinical neuropsychologists with different ap-
is based on the assumption that if professional work is proaches (even geographical locations) as well as
not acceptable, professionals would learn from their government and possibly health care/insurance agen-
peers through defined interactive methods. Never- cy officials. Most of all, our clients or their represen-
theless, if testing is to be continued as a means to tatives should also be included. Next, our goal should
define clinical neuropsychology or neuropsychol- not be to restrict the right of a competent person to
ogists, a more accurate analysis of an individual's practice clinical neuropsychology, but to restrict the
capabilities would be to have a certification process title clinical neuropsychologist. Finally, the con-
which is based on empirically validated situations. sumers of our product should be educated. Psychol-
As Milton Friedman so aptly indicated in 1962, ogists, neurologists, attorneys, allied disciplines,
'conforming to 'prevailing orthodoxy,' is certain to agencies (to name but a few) who refer to clinical
reduce the amount of experimentation that goes in [a neuropsychologists should be e.ducated.
discipline] and hence to reduce the rates of growth of According to Olson (1983), the unempirical ex-
knowledge" (p. 157). The current trend in clinical clusion of the competent as a legal protection of spe-
neuropsychology appears to be toward greater social interest ultimately has negative effects on the
phistication, efficacy, recognition, and certification. discipline and on society. Mahoney (1985) argued
Sophistication, efficacy, and recognition are needed for the importance of 'open and ongoing exchange''
for the development of a healthy subspeciality in psy- as part of the epistemological processes and that it is
chology. However, more "precise" certification necessary for scientific progress in psychology. As
may be, as Friedman (1962) argued, incompatible Lakatos (1970) suggested, superseding the present
with experimentation. Such experimentation, after by exploration and novelty (rather than assuring ad-
all, was the catalyst for our present growth and status. herence to current orthodoxy) is critical to the devel-
One way to assure such continued growth and status opment of any scientific discipline. Clinical neuro-
is to facilitate a system, in whatever way possible, psychology has too much to offer; the need for our
that meets the needs of the public instead of protect- services, expertise, and knowledge is too critical to
ing the public (Hogan, 1983a). This is especially true focus on limitations.
in a field such as clinical neuropsychology where the If such theoretical arguments do not provide
field of practice and appropriate standards of practice enough support for the continued development of
are being developed. Diversity and experimentation clinical neuropsychology, the work of McCaffrey
with appropriate empirical analysis and validation of and colleagues (McCaffrey, 1985; McCaffrey & Is-
what is professional or acceptable in clinical neuro- aac, 1984) provides additional reasons to be careful
psychology must be encouraged. about our recent trend for excJusivity. In a survey of
If certification is to be used, several methods internship instructors of clinical neuropsychology
14 CHAPTER 1
(with low response rate), instructors fared surprising- must become more reliable and less biased. Creative
ly well on how they compared to INS/Division 40 imagination must have its place next to meth-
guidelines. However, in a separate survey (with bet- odological rigor.
ter response rate), McCaffrey and Isaac ( 1984) found 3. Meier ( 1987) recognized the importance of
that few instructors at the pre- or postdoctoral levels education in the general mission of our discipline.
met the educational requirements of the INS/Divi- Great care must be taken to recruit and train new
sion 40 guidelines. Possibly many of those currently neuropsychologists. Of special significance here is
providing training would themselves be excluded. the alarmingly low number of minorities (including
women, blacks, and Hispanics) entering the disci-
pline. Additionally, Meier ( 1987) also aptly consid-
ered continuing education as critical to the continued
Future of Clinical Neuropsychology development of those practicing in the field. This
becomes especially important as larger segments of
As Fishman and Neigher (1982) aptly noted, the individuals in clinical, counseling, school, and phys-
1980s (and presumably the 1990s) have been and will iological psychology become interested in clinical
be an age of increasing accountability. We have neuropsychology.
taken psychology to the public, to the referral 4. With regard to social policy consultation,
sources, to the government with an overwhelming clinical neuropsychologists must leave their clinics,
degree of success. Indeed by the early 1980s, we hospitals, and laboratories to go to their capitols,
were spending over $2 billion per year in the support both in the United States and abroad. One critical test
of psychological endeavors (Fishman & Neigher, of clinical neuropsychology will undoubtedly be
1982). The public now wants to account for the $2 federal legislation recognizing our discipline (see
billion. One way clinical neuropsychology has pro- DeLeon, VandenBos, & Kraut, 1984). The public,
vided accountability has been to provide the health whether it be lay and uninformed or professional and
marketplace with a plethora of assessment and rein health care settings, must be educated to the unique
habilitation techniques. The assumption has been contribution of clinical neuropsychology. Clinical
that nonresearch or service activities have been built neuropsychologists have typically been sheltered
on a solid foundation of "scientifically derived from outside-institution political issues. Although
knowledge.'' As altruistic and as interesting as these establishing political ties within institutional settings
techniques may be, they must first be subject to the is clearly an important frrst step, national (and possi-
same rigorous scientific tests that other psychological bly international) political advocacy is needed. An
and health practices (e.g., psychotherapy) have excellent example of this was the Home versus
undergone. Goodson case in North Carolina. In this workmen's
In a review of Fishman and Neigher's (1982) compensation case, the testimony of a clinical neuro-
activity by mission matrix of psychology's goals, it psychologist (the author) was considered by the ini-
appears that clinical neuropsychology has focused tial Industrial Commission judge and later by the full
over the recent years mostly on service delivery. Industrial Commission Board of the state as being
However, much effort needs to be placed on other incompetent and not credible because the injury in-
aspects of the activity by mission matrix of these volved physical ''brain damage.'' Despite repeated
authors. These would include, in no specific order, testimony and reports describing the role of clinical
basic and applied research, social policy consulta- neuropsychology as defining behavioral (and not an-
tion, education of the general (and health care) pub- atomical) dysfunction, the pleas went unneeded.
lic, training of new clinical neuropsychologist&, con- With the assistance of both the North Carolina Psy-
tinuing education of both general clinical and clinical chological Association and the American Psycholog-
neuropsychologists, and political advocacy for the ical Association, a comprehensive amicus brief was
discipline. submitted on behalf of the claimant when the case
To illustrate each of these areas, examples are was appealed to the North Carolina Court of Appeals.
presented. While the decision (North Carolina Court of Ap-
I. In terms of research, specific efforts must be peals, 1986) and amicus (American Psychological
placed on replicating existing studies (including Association, 1986) are available elsewhere, the deci-
those historically cited). Furthermore, studies that sion was overruled. In the dissenting opinion, Judge
yield negative results must be considered, especially Phillips stated that it was erroneous to assume .. that
those focusing on rehabilitation. only doctors of medicine can make more reliable
2. In publishing, review and editorial process deductions as to conditions in the brain." According
to Judge Phillips, "psychology is the study of the Dorsey, S. (1983). Occupational licensing and minorities. Law
human mind and how it works and . . . the brain and Human Behavior, 7, 171-181.
controls conduct, thought, speech, feeling and judg- Filskov, S., & Boll, T. (1981). Handbook of clinical neuropsy
ment" (p. 2). Such decisions are clearly necessary as chology. New York: Wiley.
clinical neuropsychology will be increasingly tested Fishman, D. B., & Neigher, W. D. (1982). American psychology
in the eighties. American Psychologist, 37, 533-546.
in the courtroom and beyond.
Fox, R. E. (1982). The need fora reorientation of clinical psychol-
Clinical neuropsychology has made significant ogy. American Psychologist, 37, 1051-1057.
strides in recent times, both in terms of contribution, Fox, R. E., Barclay, A. G., & Rogers, D. A. (1982). The founda-
as well as recognition in the area of brain dysfunction of clinical psychology. American Psychologist, 37, 306-
tion. However, extreme cases must be taken to en- 316.
sure continued growth and development. This chap- Friedman, M. (1962). Capitalism and freedom. Chicago: Univer-
ter chronicles some of our successes and pitfalls. We sity of Chicago Press.
must bear in mind, as Smith (1979) and Costa (1983) Georgemiller, R. J., Ryan, J. J., & Setley, K. N. (1986). Clinical
have, that clinical neuropsychology is indeed ''a dis- utility rankings of neuropsychologically related journals.
cipline in evolution." Our history remains in our Professional Psychology: Research and Practice, 17, 278-
279.
future.
Gibson, W. C. (1962). Pioneers of localization of function in the
brain. Journal of the American Medical Association, 180,
944-951.
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16 CHAPTER 1
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2
Development of the Child's Brain and

Behavior
BRYAN KOLB AND BRYAN FANTIE
Introduction vivo so it is extraordinarily difficult to directly corre-

late structural and functional variables. Further, hy-
Perhaps the central issue in neuropsychology over the potheses regarding brain development are hard to
past l 00 years has been the question of how psycho- verify, especially because the human nervous system
logical functions are represented in the brain. At the cannot be manipulated during development. Nev-
tum of the century, the debate was largely whether or ertheless, despite these impediments, this approach
not functions were actually localized in the cortex. is still possible.
Although today this is no longer a subject of major The second way to examine morphological and
discussion, the general problem of determining what psychological development is to scrutinize behavior
is localized in the cortex remains. One way in which and then make inferences about neural maturation.
to examine this issue is to look at the way in which For example, we might carefully study the emer-
function and structure emerge in the developing gence of distinct cognitive stages, as Piaget (1952)
child. This will be the goal of this chapter. and his followers have done, and then predict what
The development of structure-function rela- alterations must have occurred in the nervous system
tionships can be examined in three basic ways. First, to account for the behavioral change. This approach
we can look at the structural development of the ner- has not been widely used, largely because psychol-
vous system and correlate it with the emergence of ogists most interested in human development have
specific behaviors. At first blush this approach seems not been very interested in brain function and many
ideal, as the development of both the nervous system behaviors considered important to child development
and behavior is orderly and consistent across indi- may not be related directly to neural growth. Never-
viduals. Unfortunately, it is not as simple as it theless, this approach is promising and has been pur-
appears. sued actively by Gibson (1977).
The nervous system matures in a relatively unre- There is a tendency to emphasize school-related
mitting way, unfolding to the dictates of time. Be- skills as the most important for study in child neuro-
havioral change, on the other hand, is often more psychology. This is reasonable because many types
highly dependent upon environmental factors. Thus, of childhood learning disorders are likely related to
the degree of damage caused by sensory deprivation abnormalities in neural development. It must be re-
is largely determined by when it occurs during an membered, however, that the human brain did not
animal's life (Hubel & Wiesel, 1970). In contrast, evolve in a schoolroom. Thus, the basic functions
whether or not someone can ice-skate will be more that are related to neural development may not be
easily predicted when one knows if the person was found easily by studying scholastic behaviors such as
raised in Canada or Brazil. In addition, age-related reading.' Rather, the neural mechanisms underlying
neural changes are seldom immediately observable in reading ability may best be understood by examining
fundamental visuospatial or visuomotor skills.
The third way to study structure-function rela-
BRYAN KOLB AND BRYAN FANTIE Department of tionships is to relate brain malfunction to behavioral
Psychology, University of Lethbridge, Lethbridge, Albena TIK disorders. This method, which is prevalent in re-
3M4, Canada. search dealing with adults, is difficult to apply to the
17
18 CHAPTER2
developing brain. The major problem is that the func- Anatomical Development of the
tion of a specific neural area may change over time.
For instance, Goldman (1974) found that although
Child's Brain
juvenile rhesus monkeys that had sustained frontal
cortex lesions in infancy could solve tasks sensitive The process of brain growth can be understood
to frontal-lobe damage in adults, they subsequently by considering the composition of the nervous sys-
lost this ability as they matured. This result can be tem. The cortex is a laminated structure of approx-
interpreted as showing that some other structure, imately six layers made up of neurons and glial cells.
probably the striatum, initially controlled the behav- Some of the glial cells that, in the brain, are called
iors necessary for the successful performance of the oligodendrocytes, insulate certain portions of many
tasks. Through the natural course of development, neurons by wrapping around them. Other glial cells,
this function is eventually transferred to the frontal mainly astrocytes and microcytes, are believed to
cortex as the original structure takes some other role perform basic maintenance and support functions for
in the production of behavior. Because, in this case, neighboring neurons. Neurons receive input from
the frontal cortex was damaged, it was unable to other neurons across tiny spaces known as synaptic
assume the function when required and the task could gaps through processes called dendrites while send-
not be fulfilled. Therefore, because the association of ing output to other neurons via processes called
functions and brain sites that are applicable at one age axons. Cortical neurons exchange information with
may be inappropriate at other ages, there is not just other cortical neurons as well as neurons located in
one form of the immature brain. subcortical structures. Additionally, the many pro-
The plasticity of the immature brain poses an- jections each neuron usually receives from other neu-
other problem to inferring structure-function rela- rons often use different chemical substances to trans-
tions from malfunction in the developing nervous mit information. Basically, these chemicals excite or
system. Brain damage occurring in infants may pro- inhibit the activity of the target cell and it is the net
duce very different behavioral effects than in adults total of these influences that determines whether or
because early injury has also altered fundamental not the neuron fires. The successful development of
brain organization. For example, Rasmussen and the brain into a properly functioning, integrated
Milner (1977) showed that if neonatal speech zones, organ requires that each component first be formed
usually found in the left cerebral hemisphere, are and then be correctly interrelated with the others. We
damaged, language may develop in the right cerebral will consider each of these developmental processes
hemisphere. Similar damage at 5 years of age may in tum.
cause the speech zones to move within the left hemi-
sphere. In both cases, language would then occupy Neural Generation
space normally serving other functions. The chronic
behavioral loss would manifest itself in some other The human brain follows a general pattern of
cognitive function, such as spatial orientation, even development, beginning as a neural tube and gradu-
though the damage can be shown to have been in the ally acquiring the features of the adult brain (illus-
cortical site that normally subserves language func- trated in Figure 1), that is typical of all mammals.
tions. Identical lesions could result in very different The basic neural tube surrounds a single ventricle
deficits depending upon the age at which the damage where cells are generated along the ventricular wall
occurred. Such effects do not occur in the adult. and then migrate out to their proper location. In hu-
We point out the pitfalls in developmental neu- mans, approximately 109 cells are required to
ropsychology not to discourage the study of the eventually form the mature neocortex of a single ce-
child's brain, but to caution that what follows in this rebral hemisphere (Rakic, 1975). During develop-
chapter must be considered in the light of these prob- ment, the cortex is composed of four embryonic re-
lems. We shall summarize research on neocortical gions: the ventricular, marginal, intermediate, and
development using each of the three approaches out- subventricular zones (as illustrated in Figure 2).
lined above. We begin by considering the anatomical These zones are transient features uniquely related to
development of the cerebral cortex. We then consider early development for each either disappears or be-
functional development and try to draw correlations comes transformed so that they are no longer identi-
between the emergence of particular behaviors and fiable in the adult nervous system.
neural development. Finally, we examine factors af- Sidman and Rakic (1973) combined the exten-
fecting brain development. sive studies of Poliakov (1949, 1961, 1965) with
/ - Q
DEVELOPMENT OF THE CHILD'S BRAIN AND BEHAVIOR 19
.-- _. -~--- - ;{---F -, '-- :;..-----.,,, _r ;--:co:-:."\,
~~) ~l~~~
/ J J " ' f .. ---- . . . .! . .
~ \ ( -- ,. . ~_/ . :, .
25 DAYS 35 DAYS 40 DAYS 50 DAYS 100 DAYS .
FIVE MONTHS
EIGHT MONTHS
FIGURE 1. Prenatal development of the human brain showing a series of embryonic and fetal stages (adapted from Cowan, 1979).
their own observations to produce a summary of the cortex divide and migrate in the human, but cortical
timing and phases of cortical development in hu- ceU proliferation appears to be complete by the mid-
mans. They suggested that there are roughly five dle of gestation; although, at this stage, the cortex by
developmental stages in neuronal development, no means appears like that of an adult. Cell migration
which are summarized in Figure 2. There is some may still proceed for some months after this time,
disagreement over how long cells destined for the possibly continuing postnatally, and the cortical lam-
20 CHAPTER2
STAGE 1Z:
STAGElSl:
STAGE m
STAGE II
Mg
v
<6wks 68wks 8-IOwks 10-11 wks ll-13wks 13-15wkl >16wks
FIGURE 2. Schematic illustration of events occurring sequentially during development of the cerebral cortex (from Sidman & Rakic,
1973). Stage 1: initial formation of the cortical plate. Stage II: primary condensation of the cortical plate. Stage III: bilaminate cortical
plate. Stage IV: secondary condensation. StageY: Conical maturation. CP, cortical plate; Im, intermediate zone; l.lm and O.lm, inner
and outer intermediate zones, respectively; Mg, marginal zone; SGL, subpial granular layer; SY, subventricular zone; V, ventricular
zone. Age is in fetal weeks. (See Sidman & Rakic, 1973, for more details.)
ination continues to develop and ditlerentiate until more superficial positions. Second, the cortex over-
after birth. produces neurons, which are later lost through nor-
Marin-Padilla (1970) studied the sequential mal cell death. Layer IV in the motor cortex is a
lamination of the human motor cortex in ontogenesis particularly clear example of this because cells that
and found that by the fifth embryonic month, cortical are visible there in the seventh month and at birth,
layers V and VI are visible, although not yet com- later degenerate, leaving an agranular layer.
pletely mature. Over the ensuring months the remain- As might be predicted, the precise timing of the
ing layers develop (as summarized in Table l). Ma- development and migration of cells to different
rin-Padilla's results illustrate two principles of cytoarchitectonic regions varies with the particular
cortical development. First, cortical neurons develop area in question. For example, Rakic (1976) showed
in an inside-out pattern. The neurons of layer VI, that that while the ventricular zone is producing layer IV
stratum ultimately destined to lie farthest from the cells for area 17, the neighboring ventricular zone is
external cortical surface, migrate to their locations generating layer III cells that will migrate to area 18.
first, foiJowed by those destined for layer V, and so Thus, at any given moment during cortical on-
on. Thus, we see that successive waves of neurons togenesis, cells migrating from the ventricular zone
pass earlier-arriving neurons to assume progressively are destined for different regions and layers of the
TABLE 1. Sequential Lamination of the Human Motor Cortex in Ontogenesisa.b
Cortical layers
III
Case II Upper Lower IV v VI
5-Month fetus ++ 0 0 0 0 + +
7-Month fetus ++-+++ + + +-++ + ++ ++
7.5-Month fetus +++-++++ ++ ++ ++-+++ ++ +++ +++
Newborn infant ++++ +++ +++ ++++ ++++ ++++ ++++
2.5-Month-old infant ++++ +++ ++++ ++++ Very thin ++++ ++++
8-Month-old infant ++++ +++ ++++ ++++ Agranular ++++ ++++
"From Marin-Padilla (1970).
Key: 0, unrecognizable; +, immature; + +, developing; + + +, established; + + + +, fully developed.
cortex. One implication of this phenomenon is that mm/day. In addition to axons of cortical cells grow-
events that might affect the fetus during cortical de- ing out, axons from the thalamus enter the cortex
velopment, like the presence of a toxic agent such as after the principal cortical target cells complete their
alcohol, will affect different cytoarchitectonic zones migrations and assume the appropriate positions
differently. Furthermore, because specific popula- within the developing cortical plate (Rakic, 1976).
tions of cells are migrating at different times to any
given cortical laminae, it implies that toxic agents, or
other environmental events, could perturb the devel- Dendritic Development
opment of a specific population of cells to a particular Two processes occur during development of the
cytoarchitectonic area. dendrite: dendritic arborization and spine growth.
The dendrites begin as individual processes protrud-
ing from the cell body. Later, they develop in-
Cell Migration
creasingly complex extensions, looking much like
Because cortical cells are born distal to the cor- the branches of trees in winter. Spines are little ap-
tical plate and must migrate there, one can ask how pendages, resembling thorns on a rose stem, that
this occurs, particularly as cells traveling to the outer begin to appear in the seventh intrauterine month
layers must traverse the cells and fibers of the inner (Poliakov, 1961). Before birth they are observed
layers. In a series of elegant studies, Rakic (1972, only on the biggest neurons (mainly those found in
1975, 1981, 1984) showed that neurons migrate to layer V). After birth, they can also be found on other
the appropriate laminae within the cortex along spe- neurons where they spread and densely cover the
cialized filaments, known as radial glial fibers, dendritic surface. Although dendritic development
which span the fetal cerebral wall at early ages. These begins prenatally in the human, it continues for a long
radial glial cells originate in the ventricular zone and time postnatally. In laboratory animals, the develop-
extend outward to the cortical plate. As the cortex ment of both dendritic branches and spines has been
develops, thickens, and sulci begin to appear, the shown to be influenced dramatically by environmen-
radial glial fibers stretch and curve, guiding the mi- tal stimulation (Greenough, 1976), a phenomenon
grating neurons to their correct location (see Fig- that is probably very important in relation to the
ure 3). human child's development.
In contrast to the development of axons, den-
dritic growth usually commences after the cell reach-
Axonal Development es its final position in the cortex and proceeds at a
relatively slow rate, on the order of micrometers per
As cells migrate along the radial glial fibers, day. The disparate developmental rates of axons and
they begin to develop axons that run to subcortical dendrites are important because the faster-growing
areas, other cortical areas, or across the midline as axon can contact its target cell before the dendritic
commissural fibers. The rate of axon development is processes of that cell are elaborated, suggesting that
extremely rapid, apparently on the order of I the axon may play a role in dendritic differentiation
22 CHAPTER2
CP
CP
ON
A B
FIGURE 3. Schematic representations of the pattern of neural migration along the radial glial cells (from Rakic, 1981 ). (A) Migrating
neurons leave the ventricular (V) and subventricular (SV) zones and travel to more superficial layers of the cortical plate (CP). En route
they pass through the deeper neurons (DN), which are already in place. (B) Portion of the fetal cortex showing the radial glial fibers. (C)
Section of the corresponding region in an older fetal cortex showing the changes in the radial glial fibers that allow the formation of gyri.
(Berry, 1982). The morphological changes associ- of the cortex must bypass cortical neurons upon
ated with dendritic growth in the frontal cortex are which synapses have already formed or are in the
illustrated in Figure 4. process of forming.
Little is known of the details of synapse forma-
Synaptic Development tion in humans but simple synaptic contacts have
been observed during the fifth gestational month and
The mechanism that controls synapse formation there is extensive postnatal synaptic proliferation. In-
is one of the major mysteries of developmental neu- deed, in the frontal lobes, synaptic density continues
robiology, largely because synapses are perceptible to increase until about 2 years of age, where it is
only by electron microscopy, which does not allow approximately 50% above the adult mean, then de-
direct observation of their sequence of development creases untill6 years of age (Huttenlocher, 1979). It
in living tissue. The onset of synaptogenesis is abrupt is interesting that the synaptic density of infants ap-
and the appearance of synapses in any particular area pears to exceed that of adults as it has generally been
is remarkably rapid although neurons may be jux- assumed that a larger number, or a greater density, of
taposed for days before they actually make synaptic synapses implies a higher functional capacity. Evi-
connections. Synapses usually form between the dence of decreasing synaptic density coincident with
axon of one neuron and the dendrites, cell body, increasing cognitive skill is thus intriguing, es-
axons, or established synapses of other cells. Be- pecially because high numbers of synapses have been
cause synaptogenesis begins before neurogenesis is found in certain cases of mental retardation (Cragg,
complete, neurons migrating to the superficial layers 1975). It is not surprising that intellectual ability can-
Myelin Development
Myelination is the process by which the glial
cells of the nervous system begin to surround axons
Ill
and provide them with insulation. Although nerves
can become functional before they are myelinated, it
IV
was assumed in the 1920s and 1930s that they only
reach adult functional levels after myelination is
v complete (Flechsig, 1920). This notion now appears
to be an oversimplification but is, nonetheless, useful
as a rough index of cerebral maturation.
In contrast to other aspects of cortical develop-
ment, myelin appears late, at a time when cellular
proliferation and migration are virtually complete.
The primary sensory and motor areas begin to mye-
linate just before term whereas the frontal and par-
ietal association areas, the last to myelinate, begin
postnatally and continue until about age 15 years or,
sometimes, even later. Because different regions of
the cortex myelinate at different times, and myelina-
tion begins in the lower layers of each cortical area
and gradually spreads upward, the upper layers of the
motor and primary sensory areas are myelinating at
the same time that the lower areas of some associa-
tion areas are just beginning to myelinate.
Neurochemical Development
Chemical neurotransmitters serve as the pri-
mary means of interneuronal communication, yet
FIGURE 4. Postnatal development of human cerebral cortex virtually nothing is known about the neurochemical
around Broca's area as taken from camera Iucida drawings of development of the human cortex. Although there are
Golgi-Cox preparations (from Conel , 1939-1967). (A) Newborn; numerous studies of neurotransmitter development in
(8) I month; (C) 3 months; (D) 6 months; (E) 15 months; (F) 24 the rat, knowledge about the relationships among
months. transmitters in the adult neocortex is still limited and
the most completely described neurochemical sys-
tems make only a modest contribution to the overall
synaptic activity of the neocortex (see Table 2).
not be predicted merely by its relation to the quantity There are, however, some recent developmental
of some anatomical feature, such as synapses, and, studies using nonhuman primates that are worth re-
perhaps, the process involved in reducing synap- viewing as the human brain is likely to be similar.
tic density represents some sort of qualitative re- Goldman-Rakic and Brown ( 1981, 1982) inves-
finement. tigated the regional distribution of catecholamines in
rhesus monkeys ranging in age from newborns to
Glial Development young adults. Their overall findings were that, al-
though monoaminergic systems are present in the
The differentiation and growth of neurons, cortex at birth, these networks continue to develop
which are generaiJy produced before their associated for years. Catecholamine development varies greatly
glia, appear to play some role in stimulating the between different cortical regions and the most strik-
growth and proliferation of glial cells, but the mecha- ing postnatal increases in content were observed in
nisms are unknown (Jacobsen, 1978). In contrast to the frontal and parietal association areas. Perhaps
neurons, glial cells continue to proliferate after birth most interesting was their observation that cate-
and may continue to do so throughout life. cholamine development (especialJy that of the mono-
24 CHAPTER2
TABLE 2. Neocortical Neurotransmitters"
Transmitter type Cell location
Afferents
Norepinephrine Locus coeruleus
Dopamine Substantia nigra A 10
Serotonin Raphe
Acetylcholine Globus pallidus magnocellular
Intrinsic
GABA Aspinous stellate (all layers)
Vasoactive intestinal peptide Aspinous bipolar (II, III, IV)
Cholecystokinin Aspinous bipolar and aspinous stellates
Efferents
Glutamate Pyramidal cells (layer V corticostriatal)
"After Coyle (1982).
amines) parallels functional development in the pre- Cortical Function at Birth

frontal cortex over the first 2-3 years of life. These
data support the suggestion that catecholamines may The extreme paucity of behavioral skill in the
play an important role in the development of func- newborn leads to the notion that, shortly after birth,
tional activity in the frontal cortex, and likely affect the cortex has not yet begun to function. Thus, the
the morphological development of various neuronal cortically injured infant was once believed to be in-
processes such as dendritic fields. distinguishable from the normal child at birth
(Peiper, 1963). Several lines of evidence suggest that
the cortex is indeed functioning, if only at a rudimen-
Postnatal Brain Development tary level. It is now known that cortically hemiplegic
infants can be distinguished from normal babies on
After birth, the brain does not grow uniformly the basis of muscle tone (Gibson, 1977) and cor-
but rather tends to increase its mass during irregular tically damaged infants may also have abnormal
periods commonly called growth spurts. In his analy- sleep-waking cycles and abnormal cries (Robinson,
sis of brain/body weight ratios, Epstein (1978, 1979) 1966). There are also several measures of electrical
found consistent spurts in brain growth at 3-10 activity that imply cortical activity is present at birth.
months, accounting for an increase of 30% in brain EEG activity can be recorded from the fetal brain
weight by the age of I i years, as well as between ages (Bergstrom, 1969) and epileptic seizures of cortical
2-4, 6-8, 10-12, and 14-16+ years. The incre- origin can occur in the neonate (Caveness, 1969).
ments in brain weight were about 5-10% over each Perhaps the most compelling evidence of early cor-
2-year period. This expansion takes place without a tical activity comes from the extensive work of Pur-
concurrent increase in neuronal proliferation and is pura (Purpura, 1976, 1982). In his study of cortical
unlikely to be accounted for by increases in the activity in premature human infants, Purpura took
number of glial cells. Rather, it is most likely due to advantage of the fact that, between 26 and 34 weeks
the growth of dendritic processes and myelination. of gestation, cortical pyramidal cells in primary visu-
Such an increase in cortical complexity would be al cortex undergo significant growth and branching.
expected to correlate with increased complexity in These changes are associated with corresponding
behavioral functions, and it could be predicted that maturational changes in the electrophysiological
there would be significant, and perhaps qualitative, characteristics of the visual evoked potentials (VEPs)
changes in cognitive function during each growth in preterm infants. Although, even at birth, the VEPs
spurt. It may be significant that the first four brain are not identical to those of adults, they are present
growth stages coincide with the classically given and indicate that at least primary visual cortex is
ages of onset of the foqr main stages of intelligence functioning in some capacity.
development described by Piaget. We return to this Chugani and Phelps ( 1986) studied glucose uti-
later. lization in the brain of infants using positron emission
tomography. Their results showed that, in infants 5 those events that are most likely to be important to the
weeks of age or younger, glucose utilization, which neuropsychologist: abnormal neural differentiation
can be taken as a crude measure of neural activity, and early brain damage.
was highest in the sensorimotor cortex, a result that is
in accordance with anatomical evidence that this is
Abnormal Neural Structure
the most mature cortical region at birth. By 3 months
of age, glucose metabolism had increased in most In the event that either neurogenesis or neural
other cortical regions, with subsequent increases in migration is abnormal, one would expect gross ab-
frontal and posterior association cortex occurring by normalities in cortical development. Clinically, a va-
8 months. Thus, by about 8-9 months there is evi- riety of conditions are recognized (Table 3) but little
dence of activity throughout the cerebral cortex, al- is known about the details of cell differentiation in
though it probably changes in the years to come. these disorders. The major experimental study of dis-
turbed migration in the cerebral cortex involves the
reeler mouse mutant. Caviness (Caviness, 1982;
Abnormal Development of the Child's Brain Caviness & Rakic, 1978; Caviness & Sidman, 1973)
showed that, in this animal, the cortex is inverted
We have seen that the anatomical development compared to that of a normal mouse: the cells gener-
of the child's brain consists of the proliferation and ated first lie nearest the cortical surface and those
migration of cells, the growth of axons and dendrites, generated last lie deepest. In addition, many of the
synapse formation and loss, myelin growth, and so pyramidal cells are abnormally oriented, in some
on. These processes begin early in embryonic devel- cases with their major dendrites (the apical dendrites)
opment and continue until late adolescence. In view oriented downwards rather than upwards as in the
of the complexity of the cortex and its prolonged normal mouse. Despite their aberrant position, the
development, it is reasonable to expect that normal cells develop connections as they would have had
cortical development could be disrupted by any they been normally situated. Caviness and his col-
number of events. These include abnormalities in the leagues studied the cortex of humans with various
normal genetic program of neural growth, the influ- similar abnormalities, finding some of the same aber-
ences of exogenous factors such as toxic substances rant features (Caviness & Williams, 1979). Thus, in
or brain trauma, and nutritional or other environmen- lissencephalic cortex, Williams et al. (1975) found
tal circumstances. We do not propose to discuss all of that cells failed to migrate into the appropriate layers
these possibilities, but will confine our discussion to and some cells were abnormally oriented, much as in
TABLE 3. Types of Abnormal Development

Type Symptom
Anencephaly Absence of cerbral hemispheres, diencephalon, and midbrain

Holoprosencephaly Cortex fonns as a single undifferentiated hemisphere
Lissencephaly The brain fails to fonn sulci and gyri and corresponds to a 12-week
embryo
Micropolygyria Gyri are more numerous, smaller, and more poorly developed than
nonnal
Macrogyria Gyri are broader and less numerous than nonnal
Microencephaly Development of the brain is rudimentary and the person has low-
grade intelligence
Porencephaly Symmetrical cavities in the cortex, where cortex and white matter
should be
Heterotopia Displaced islands of gray matter appear in the ventricular walls or
white matter, caused by aborted cell migrdtion
Agenesis of the Complete or partial absence of the corpus callosum
corpus callosum
Cerebellar agenesis Portions of the cerebellum, basal ganglia, or spinal cord are absent or
malfonned
26 CHAPTER2
the reeler mouse. The cause of these anomalies re- Motor Systems
mains unknown.
The development of locomotion in human in-
fants is quite familiar to most of us. Infants are, at
Injury and Brain Development first, unable to move about independently, but
eventually they learn to crawl and then to walk. The
If the brain is damaged during development, it is waY. in which other motor patterns develop is less
reasonable to suppose that its development might be obvious but one has been described in an elegant
fundamentally altered. We are unaware of any ana- study by Twitchell (1965) who documented the
st~g_es an infant passes through while acquiring the
tomical studies of human brains with early lesions but
there is a considerable literature from work with labo- ab1hty ~o reach out wi!h one limb and bring objects
toward Itself. Before b1rth the fetus's movements are
ratory animals. In an extensive examination of
~ssentially of the whole body. Shortly after birth the
monkeys with prenatal or perinatal frontal cortex in-
juries, Goldman-Rakic has shown a variety of mfant can flex all the joints of an arm in such a way
changes in cortical development including abnormal !hat it could scoop something toward its body, but it
IS not clear that this movement is executed indepen-
gyral formation and abnormal corticostriatal connec-
tions (Goldman & Galkin, 1978; Goldman-Rakic, dent of other body movements. Between 1 and 3
m~nths it orients its hand toward, and gropes for,
Isseroff, Schwartz, & Bugbee, 1983). Similarly,
objects that have contacted it. Between 8 and 11
Kolb and his colleagues have found abnormal cor-
~onths it develops the "pincer grasp," using the
ticostriatal and subcorticocortical connections, ab-
mdex finger and thumb in opposition to each other.
normal myelination, altered cortical catecholamine
distribution, thalamic shrinkage, reduced gliosis rel- J?e. development of. the pincer grasp is extremely
ative to adult operates, and markedly thinner cortex s1gmficant, because It allows the infant to make a
following early frontal lesions in rats (Kolb, 1987; very precise grasping movement that enables the ma-
Kolb & Nonneman, 1978; Kolb & van der Kooy, nipulation of small objects. In summary, there is a
1985; Kolb & Whishaw, 1981). The thin cortex ap- sequential development of the grasping reaction: first
pears to result not from a loss in the number of cor- scooping, then reaching and grasping with all fin-
gers, then independent finger movements.
tical cells, which seems to be normal, but from a loss
in dendritic arborization, a result also described by The fact that motor cortex lesions in adults abol-
ish the grasp reaction with independent finger move-
Jones and Thomas (1962). In sum, there is good
reason to presume that early damage to the human ments implies that there could be anatomical changes
within the motor strip that correlate with the original
brain produces significant changes in cortical mor-
phology that extend far beyond the boundaries of the development of the behavior. Although there are
probably multiple changes occurring, especially in
tissue directly traumatized. Also, there is no evi-
the development of dendritic arborizations a correla-
dence that the brain-damaged infant (or adult) can
tion has been noted between myelin fo~ation and
show any additional neuronal proliferation to com-
the ability to grasp. In particular, the small motor
pensate for lost neurons.
fibers become myelinated at about the same time that
reaching and grasping with the whole hand develop
while the giant Betz cells of the motor cortex become
Behavioral Correlates of Brain myelinated at about the time the pincer grasp devel-
Development ops. These different motor fibers are thought to con-
trol arm and finger movements, respectively (Kolb &
Whishaw, l985b).
Two types of behavior have been extensively The correlation between myelin development
studied and correlated with anatomical development, and motor behaviors can also be found in many other
namely motor behavior and language. We shall con- activities. Table 4 summarizes the development of a
sider each separately, and then consider the develop- variety of behavioral patterns and myelin formation.
ment of their asymmetrical representation in the cor- It is of course difficult to be certain which correla-
tex. Finally, we will discuss the behavior of children tions are meaningful and, as we have noted, there are
on standardized tests typically used by clinical neu- obviously many other anatomical changes occurring
ropsychologists. We shall not attempt to be ex- concurrently. Careful study of these data, however,
haustive in our coverage of each, but rather try to give does show some intriguing correlations that warrant
a flavor of the findings to date. more detailed study.
TABLE 4. Summary of Postnatal Human Developmenta

Average
Social and intellectual brain weight
Age Visual and motor function function (grams a) Degree of myelinationh
Birth Reflex sucking, rooting, 350 Motor roots + + +;

swallowing, and Moro sensory roots + +;
reflexes; infantile medial lemniscus + +;
grasping; blinks to light superior cerebellar pe-
duncle + +; optic tract
+ +; optic radiation
6 weeks Extends and turns neck Smiles when played with 410 Optic tract + +; optic ra-
when prone; regards diation +; middle cere-
mother's face, follows bral peduncle ;
objects pyramidal tract +
3 months Infantile grasp and suck Watches own hands 515 Sensory roots + + +; op-
modified by volition; tic tract and radiation
keeps head above hori- + + +; pyramidal tract
zontal for long periods; + +; cingulum +;
turns to objects pre- frontopontine tract + ;
sented in visual field; middle cerebellar pe-
may respond to sound duncle +; corpus cal-
losum ; reticular
formation
6 months Grasps objects with both Laughs aloud and shows 660 Medial lemniscus + + +;
hands, will place pleasure; primitive superior cerebellar pe-
weight on forearms or articulated sounds, duncle + + +; middle
hands when prone; "ga-goo"; smiles at cerebellar peduncle
rolls supine to prone; self in mirror + +; pyramidal tract
supports almost all + +; corpus callosum
weight on legs for very +; reticular formation
brief periods; sits + ; associational areas
briefly ; acoustic radiation +
9 months Sits well and pulls self to Waves bye-bye, plays 750 Cingulum + + +; fornix
sitting position; thumb-- pany cake, uses + + ; others as pre-
forefinger grasp; crawls "dada," "baba," imi- viously given
tates sounds
12 months Able to release objects; 2-4 words with meaning; 925 Medial leniscus + + +;
cruises and walks with understands several pyramidal tracts + + +;
one hand held; plantar proper nouns; may kiss frontopontine tract
reflex flexor in 50% of on request +++;fornix+++;
children corpus callosum +; in-
tracortical neuropil ;
associational areas ;
acoustic radiation + +
24 months Walks up and down stairs Two- or three- word sen- 1065 Acoustic radiation + + +;
(two feet a step); bends tences; uses ''I,'' corpus callosum + +;
over and picks up ob- "me," and "you" associational areas +;
jects without falling; correctly; plays simple nonspecific thalmic ra-
turns knob; can par- games; points to 4-5 diation ++
tially dress self; plantar body parts; obeys sim-
reflex flexor in I00% pie commands
36 months Goes up stairs (one foot a Numerous questions; 1140 Middle cerebellar pedun-
step); pedals tricycle; knows nursery rhymes; cle +++
dresses fully except for copies circle; plays
shoelaces, belt, and with others
buttons; visual acuity
20120/0U
(continued)
28 CHAPTER2
TABLE 4. (Continued)
Average
Social and intellectual brain weight
Age Visual and motor function function (grams 0 ) Degree of myelinationb
5 years Skips; ties shoelaces; cop- Repeats 4 digi~s; names 4 1240 Nonspecific thalmic radi-
ies triangle; gives age colors ation + + +; reticular
correctly formation + +; corpus
callosum + + +; intra-
cortical neuropil and
associational areas + +
Adult 1400 Intracortical neuropil and
associational areas + +
to+++
0Source: Spreen, Tupper, Risser, Tuokko, & Edgell (1984).

bfrom Yakovlev and Lecours (1967). Estimates are made from their graphic data(::!:, minimal amounts; +,mild;++, moderate; +++,heavy).
Language Development exclusively by some environmental event is unlikely

because the timing of the onset of speech appears to
Tbe onset of speech consists of a gradual ap- be universal in humans (Lenneberg, 1967). In addi-
pearance of generally well-circumscribed events that tion, it can be shown that an enormous variety of
take place between the second and third years of life. environmental conditions fail to affect the age of
According to Lenneberg (1967), certain important onset of many of the developmental speech mile-
speech milestones are reached in a fixed sequence stones (summarized in Table 5). Thus, the
and at relatively constant chronological ages (as sum- emergence of speech and language_ habits is most
marized in Table 5). Although there is a general par- easily accounted for by assuming that there are matu-
allel between language development and the devel- rational changes within the brain. The difftculty is in
opment of motor capacities, Lenneberg emphasized specifying what these changes might be. Indeed, in
that language development is independent of motor view of the complexity of the neural control of lan-
coordination. In particular, it appears that the precise guage, it is futile to look for any specific growth
movements of the Eps and tongue needed for speech process that might explain language acquisition.
are fully developed well before the acquisition of Nonetheless, it is likely to be instructive to know in
finger and hand control. Furthermore, once children what ways the cortex is different before the onset of
are capable of correctly pronouncing a few words, it language (age 2) and after the majority of language
can be presumed that there is sufficient motor skill to acquisition is completed (about age 12).
articulate many more words and yet expansion of the It will be recalled from our discussion of neural
child's vocabulary is a very slow process. Thus, lan- maturation that by 2 years of age there is no longer
guage development appears to depend upon factors any cell division and most cells have migrated to their
other than simple mechanical skill. This argument is final location in the cortical laminae. The major
further underscored by the observation that for a changes that occur between the ages of 2 and 12 years
small proportion of children (less than I%), who are in the interconnection of neurons, largely through
have normal intelligence and normal skeletal and a decrease in the number of synapses as well as in-
motor development, speech acquisition is markedly crease in the complexity of their dendritic arboriza-
delayed. For example, such children may not begin tions. If one assumes that language acquisition re-
to speak in phrases until after age 4, in spite of an quires the development of functional connections
apparently normal environment and the absence of between neurons, much as hypothesized by Hebb
any obvious neurological signs that might suggest (1949) in his concept of cell assemblies, then these
brain damage. changes in synaptic density and dendritic detail may
It could be argued that language development is be logical candidates as constraints of speech devel-
not dependent upon the maturation of some neural opment. The postnatal changes in dendritic complex-
structure but upon some other factor such as environ- ity within the speech areas are among the most im-
mental stimulation. Although this is possible, the pressive in the brain. As illustrated in Figure 4, the
likelihood that speech development is constrained dendrites are simple at birth and develop slowly until
TABLE 5. Developmental Milestones in Motor and

Language Development
At the completion of: VocaJi~tion and language
12 weeks Markedly less crying than at 8 weeks; when talked to and nodded
at, smiles, followed by squealing-gurgling sounds usually called
cooing, which is vowel-like in character and pitch-modulated;
sustains cooing for 15-20 seconds
16 weeks Responds to human sounds more definitely; turns head; eyes seem
to search for speaker; occasionally some chuckling sounds
20 weeks The vowel-like cooing sounds begin to be interspersed with more
consonantal sounds; labial fricatives, spirants, and nasals are
common; acoustically, all vocalizations are very different from
the sounds of the mature language of the environment
6 months Cooing changing into babbling resembling one-syllable utterances;
neither vowels nor consonants have very fixed recurrences; most
common utterances sound somewhat like rna, mu, da, or di
8 months Reduplication (or more continuous repetitions) becomes frequent;
intonation patterns become distinct; utterances can signal empha-
sis and emotions
10 months Vocalizations are mixed with sound-play such as gurgling or bub-
ble-blowing; appears to wish to imitate sounds, but the imitations
are never quite successful; beginning to differentiate between
words heard by making differential adjustment
12 months Identical sound sequences are replicated with higher relative fre-
quency of occurrence and words (mamma or dadda) are emerging;
definite signs of understanding some words and simple commands
(show me your eyes)
18 months Has a definite repertoire of words-more than 3 but less than 50;
still much babbling but now of several syllables with intricate
intonation pattern; no attempt at communicating information and
no frustration for not being understood; words may include items
such as thank you or come here, but there is little ability to join
any of the lexical items into spontaneous two-item phrases; un-
derstanding is progressing rapidly
24 months Vocabulary of more than 50 items (some children seem to be able
to name everything in environment); begins spontaneously to
join vocabulary items into two-word phrases; all phrases appear
to be own creations; definite increase in communicative behavior
and interest in language
30 months Fastest increase in vocabulary with many new additions every day;
no babbling at all; utterances have communicative intent; frus-
trated if not understood by adults; utterances consist of at least
two words, many have three or even five words; sentences and
phrases have characteristic child grammar, that is, they are rarely
verbatim repetitions of an adult utterance; intelligibility is not
very good yet, though there is great variation among children;
seems to understand everything that is said to him
3 years Vocabulary of some 1000 words; about 80% of utterances are
intelligible even to strangers; grammatical complexity of utter-
ances is roughly that of colloquial adult language, although mis-
takes still occur
4 years Language is well established; deviations from the adult norm tend
to be more in style than in grammar
30 CHAPTER2
about 15 months when the major dendrites are predesigned to demonstrate lateralization of function has
sent. Between 15 and 24 months there is a dramatic emphasized the age at which asymmetry first ap-
increase in the density of the neuropil. A similar pears. Table 6 gives examples of a number of repre-
observation can be made from examination of the sentative functions and the side and earliest age of
cortex of the posterior speech zone. Given the cor- demonstrated asymmetry. A central theoretical issue
relation between language development and matura- is whether or not functions are disproportionately
tion of the language areas, we can infer that language represented in the two hemispheres because they de-
development may be constrained, at least in part, by pend on certain anatomical asymmetries that develop
the maturation of these areas and that individual dif- independent of environmental stimulation. The fact
ferences in language acquisition may be accounted that anatomical asymmetries can be observed in the
for by differences in this neural development. Fur- cortex prenatally (Chi, Dooling, & Gilles, 1977;
thermore, given the known effect of environmental Wada, Clarke, & Hamm, 1975) and, therefore, exist
stimulation on dendritic development, we might also before the expression of the behaviors, implies that
predict that those differences in language acquisition asymmetry is relatively innate. Nevertheless, several
that have some environmental influence may do so by rna' or problems arise when we try to correlate func-
changing the maturational rate of the dendritic fields tional and anatomical asymmetry. First, the func-
within these areas. tions that are most lateralized in adults are not easily
assessed in children. For example, it is extremely
difficult, if not impossible, to determine handedness
Cerebral Asymmetry for writing in infants, unless, of course, one is willing
to assume that some other indirect measure, such as
Just as the asymmetrical function of the adult's hand strength, in this case, will serve as a reliable
brain has been a focal point for neurological study, predictor. Second, correlations between function and
the development of asymmetry has been a focal point anatomical asymmetry in adults are far from perfect.
of developmental studies. As asymmetry is the sub- Although the left planum temporale is thought to be
ject of another chapter in this volume (see Kins- the posterior substrate of language functions, it is
boume), we shall consider this topic only briefly. larger in only about 70% of right-handed people,
Most of the research with children that has been whereas speech is lateralized to the left hemisphere in
TABLE 6. Studies Showing Age of Asymmetry for Different Behaviors
System Age Dominance Reference
Auditory
Speech syllables Pre term Right ear Molfese & Molfese (1980)
Music 22-140 days Left ear Entus ( 1977)
Phonemes 22-140 days Right ear Entus (1977)
Words 4 years Right ear Kimura (1963)
Environmental sounds 5-8 years Left ear Knox & Kimura (1970)
Visual
Rhythmic visual stimuli Newborn Right Crowell, Jones, Kapuniai, &
Nakagawa (1973)
Face recognition 7-9 years Left field Marcel & Rajan ( 1975)
6-13 years Left field Witelson (1977)
9-10 years None Diamond & Carey ( 1977)
Somatosensory
Dichhaptic recognition All ages Left Witelson (1977)
Motor
Stepping <3 months Right Peters & Petrie (1979)
Head turning Neonates Right Turkewitz (1977)
Grasp duration 1-4 months Right Caplan & Kinsbourne (1976)
Finger tapping 3-5 years Right Ingram (1975)
Strength 3-5 years Right Ingram (1975)
Gesturing 3-5 years Right Ingram ( 1975)
Head orientation Neonates Right Michel (1981)
about 99% of right-banders. What then does a similar months to 7 years); stage III (Concrete Operational; 7
anatomical asymmetry in the fetal brain imply? to 11 years); and stage IV (Formal Operational; 11 +
years). In stage I the infant learns to differentiate
Development of Problem-Solving Ability itself from the external world, learns that objects ex-
ist when not visible, and gains some appreciation of
As each cortical layer within an area develops, it cause and effect. In stage II, the child begins to repre-
interacts with and modifies the function of the exist- sent things with something else, such as a drawing.
ing structure. Gibson (1977), therefore, suggested Stage III is characterized by the child's ability to
that behavior patterns would be expected to emerge mentally manipulate concrete ideas such as dimen-
exactly in the manner described by Piaget (1952): sions of objects and the like. Finally, in stage IV, the
child is able to reason in the abstract. Having identi-
Behavior patterns characteristic of different stages do fied the stages, the challenge for the neuro-
not succeed each other in a linear way (those of a given
psychologist is to identify those changes in neural
stage disappearing at the time when those of the follow-
ing one take form) but in the manner of the layers of a
structure that might underlie these apparent
pyramid (upright and upside down), the new behavior qualitative changes in cognitive activity.
patterns simply being added to the old ones to com- The first four brain growth stages described ear-
plete, correct or combine with them. (p. 329) lier coincide with the usual given ages of onset of the
four main Piagetian stages (Epstein, 1979). A fifth
Thus, for example, because the deepest layers stage of development, which would correlate with
of the cortex myelinate first, and these are the the fifth brain growth stage, was not described by
efferent or output layers, one would expect to ob- Piaget but has been proposed by Arlin (1975). The
serve motor responses preceding the development of concordance of brain growth and Piagetian stage is
perceptual capacity. Indeed, according to Piaget, intriguing but, to date, remains too superficial. We
motor actions must come first, as motor actions pro- need to know what neural events are contributing to
vide data from which to build perceptions. The ques- brain growth, and just where they are occurring. Lit-
tion to consider is just how well the stages of cog- tle is known of this in children after 6 years of age but
nitive development coincide with changes in neural the question remains important to the neurop-
maturation. This is a difficult question that has not sychologist seeking to understand the maturation of
been extensively studied. Nevertheless, there is at cortical operations. A detailed hypothetical analysis
least suggestive evidence that there may be a signifi- of stage I has been attempted by Gibson (1977).
cant relationship between cortical development and
the classical Piagetian stages. (We note that the
Piagetian stages of cognitive development are a Development of Neuropsychological Test
source of some debate and there are several other Performance
conceptual schemes to describe the development of
cognition in children (Carey, 1984). We will restrict Neuropsychologists have developed an amazing
our discussion to Piaget, however, because we wish array of tests since World War II with which to assess
merely to demonstrate the type of study that can be the behavior of patients with cortical injuries (e.g.,
done and because we are unaware of any attempt to Lezak, 1983). In principle, it is logical to suppose
correlate other schemes of cognitive development to that if a test is sensitive to restricted cortical lesions in
cortical maturation.) adults, and if a normal child performs poorly on such
Piaget was a biologist by training and consid- a test, it could then be inferred that the requisite
ered the acquisition of knowledge and thought to be cortical tissue is not yet functioning normally. This
closely related to brain function. He believed that logic is seductive but is not without difficulties. First,
cognitive development was a continual process and the method assumes that tests will be sensitive to
that the child's strategies for exploring the world focal lesions: Few tests are. Second, a child may
were constantly changing. These changes were not perform poorly on a test for many reasons. For exam-
simply a result of the acquisition of specific pieces of ple, a child may have difficulty with a verbal test
knowledge but rather' at some specifiable points in because the speech areas are slow to develop or be-
development, were fundamental changes in the orga- cause he or she has an impoverished environment and
nization of the child's strategies for learning about has acquired only a limited vocabulary. Furthermore,
the world. Piaget identified four major stages of cog- just because a child does well on a test does not mean
nitive development: stage I (Sensorimotor; birth to 18 that the child's brain is solving the problem in the
months); stage II (Preoperational or Symbolic; 18 same manner as the adult brain. Indeed, there are
32 CHAPTER2
examples of tests in which children do well, only to objects or animals as they can think of within a fixed
do more poorly the following year, followed later by time. We note that frontal lobe patients perform nor-
improvement again. Thus, in their studies of facial mally at many other tests as well. For example, at
recognition in children, Carey, Diamond, and tests of visual recognition, which are performed
Woods (1980) found that children improved in per- poorly by patients with right posterior lesions, frontal
formance between ages 6 and 10, declined until age lobe patients achieve normal levels of performance.
14, and then attained adult levels by age 16. This One example is a test of facial closure illustrated in
result can be taken to imply that the younger children Figure 5.
were solving the problem in a different manner dian We tested children with these tests and predicted
the older children and adults while, presumably, that if the frontal lobes were slow to mature relative to
using different cortical tissue. In sum, although there other cortical areas, then children should reach adult
are clear limitations to the inferences that can be levels very late, probably in adolescence on tests of
made about the development of specific brain re- frontal lobe function. In contrast, children should
gions, we feel that much can be learned using this perform at adult levels much sooner on the tests per-
type of approach. We will illustrate this by focusing formed normally by patients with frontal lobe le-
on our own studies using tasks that test frontal lobe sions. Figure 6 shows that this is indeed the case.
function and the perception of faces and facial Children perform poorly at all tests when very young
expression. but improve as they develop. As predicted, perfor-
mance on tests performed normally by adults with
Frontal Lobe Tests frontal lobe injuries improves more quickly, howev-
er, than performance on tests sensitive to frontal lobe
Two tests are especially sensitive to frontal lobe injuries.
injury, namely the Wisconsin Card Sorting Test and
the Chicago Word Fluency Test (Milner, 1964). In Face Perception
the first test the subject is presented with four stim-
ulus cards, bearing designs that differ in color, form, Normal adults have a remarkable capacity to
and number of elements. The subject's task is to sort recognize hundreds of faces and to notice and re-
the remaining cards into piles in front of one or an- spond to rather subtle changes in facial expression.
other of the stimulus cards. The only help the subject Patients with right hemisphere lesions, especially
is given is being told whether the choice is correct or posterior lesions, do especially poorly on tasks that
incorrect. The test works on this principle: the correct require these abilities (Milner, 1980; Kolb & Taylor,
solution is frrst to sort by color; once the subject has 1981). Very young children also have difficulty in
figured this out, the correct solution then becomes, recognizing faces (Carey & Diamond, 1977). In view
without warning, to sort by form. Thus, the subject of the apparent right-hemisphere specialization for
must now inhibit grouping the cards on the basis of facial analysis, we studied the ability of children to
color and shift to form. Once the subject has suc- recognize faces and facial expression. As in the stud-
ceeded at sorting by form, the relevant feature again ies using tests of frontal lobe function, we hoped to
changes unexpectedly, this time to number of ele- infer the developmental state of a cortical region, in
ments. This cycle of color, form, and number is re- this case the right hemisphere.
peated. The subject's score is the number of target Children were given four face-related tests and
categories completed after sorting 128 cards, and the one verbal test, a test of dichotic listening. The face
task is terminated when all the cards have been used tests were the Mooney closure test, a split-faces test
or six categories have been completed, whichever (Figure 5), a test requiring the matching of similar
comes first. Shifting strategies is particularly diffi- facial expressions, and a test requiring the identifica-
cult for patients with left frontal lobe lesions. In the tion of the appropriate facial expression for a specific
second test the subject must write as many words as situation. The Mooney closure test simply requires
they can beginning with the letter .. S" in 5 minutes. the subjects to identify the gender and approximate
Following this, they must write as many four-letter age of the hidden face. In the split-faces test (see
words beginning with .. C" as possible in 4 minutes Kolb, Milner, & Taylor, 1983, for a detailed ac-
and the final score is the total number of words gener- count), subjects are asked to indicate which of two
ated. Frontal lobe patients do very poorly on this test. photographs of faces is most like the original (see
This deficit is not simply a problem of verbal ability, Figure 5). The two alternatives are made from com-
however, as frontal lobe patients perform at normal bining the left and right halves of the original face
levels when asked to write the names of as many with their respective mirror image. Normal adults
9 \
FIGURE 5. Examples of face perception tests. Left: In this task the subject must choose, for the character whose face is blank, the
appropriate expression for the situation depicted by the cartoon, from one of six key photographs. Top righi: Split-faces test. The task is to
choose which of the faces in the bottom two composite photographs more closely resembles the face in the photograph on top. The face on
the lower right is a composite of the left half of the face above combined with its mirror image. The face on the lower left was constructed
in the same manner using the left half of the face depicted above. Bottom right: Mooney closure test. 1be task is to identify the gender and
approximate age of the embedded face.
show a bias in their choices, selecting the alternative keys on the basis of the emotion that is expressed in
constructed from two right sides of the original face each photo (Kolb & Taylor, 1981). In the final test,
(i.e., the part falling in the normal left visual field). subjects are shown a cartoon drawing of a situation in
Patients with right posterior lesions choose at ran- which the face of one of the characters is missing
dom. In the third test, the subjects are asked to match (Figure 5). The task is to choose the appropriate ex-
photographs on the basis of facial expression. They pression for the situation from the six key pho-
are shown six key photographs, each displaying a togmphs used in the previous test.
distinctive facial expression, and are subsequently The data of these studies are summarized in Fig-
asked to match a series of 24 photographs with the ure 7. Based on the results of the split-faces test, we
34 CHAPTER2
cialized early to analyze faces, or perhaps for com-

C/)
plex visual material in general . Children are thus able
w to identify hidden faces, choose the side of the face in
a:
g, the left visual field, and can match facial expressions
w quite accurately by about age 5 or 6. In contrast, they
~
u ' have difficulty in identifying what facial expressions
..
go with certain situations. Because it is known that
, 10 H
patients with right posterior lesions are especially
A GROUP poor at the first three tests, we might infer that this
area of the cortex functions relatively early in devel-
opment. We have not yet completed our study of
60 adult patients with cortical lesions on the fourth test
but we might predict from our developmental study
..
so
that this test is measuring the function of some other
C/)
c
~ "' lit;
~:roDI

~ c~ "
w 10
u:
~ ..
e
6 ) '9 10 II 12 ll 1411 J:S ll!o 17 AD F'L
<
8 GROUP ::::> 60
> ..
C/)
FIGURE 6. Summary of the developmental changes in two tests

of frontal lobe function. The open bars differ significantly from the
performance of adult control subjects. AD, adult; FL, adults with
frontal lobe lesions (frontal lobe lesion data from Milner, 1964). 1 l 4 :s & 1 e t 10 11 M n J)
(A) Wisconsin Card Sorting Test. (8) Chicago Word Fluency A GROUP
Test.
..
I
....
u ..
w
~
suggest that the right hemisphere may be specialized 10
8 I~
quite early in development for the analysis of faces.
.z. ..
60
Thus, by age 4, children show a significant bias to-

ward the side of the face in the left visual field. This is ~
~
..
,.
it
~.
11r

not simply a matter of the original face being asym-
metrical in some way that biases the performance, for
even if the negatives are reversed, the result is main-
Q.
20
B' '
.'
' 'GROUP 10 II 0>
"" fl ..
tained: the match is made to the side of the face
falling in the left visual field. Note, however, that the ....
..
0
right hemisphere is not mature for all of the tests at w
a: 10
the same time. Performance on the Mooney closure a:
0
test improves quickly until 5 years of age, and then 0 60
very slowly improves thereafter. This could reflect a ....

z
w
maturation of the basic neural hardware by age 5, 0 ..
a:
with the subsequent improvement being due largely w
Q.
to experience, a conclusion that we favor. The ability ,, ...
" "
to match facial expressions is surprisingly mature by c GROUP
age 6, which is the earliest we have studied, and is
FIGURE 7. Performance of children on three tests of facial per
consistent with the results of two other tests. Note,
ception. For the split-faces test graph the open bars indicate perfor-
however, that 6-year-old children are very bad at
mance that. fails to differ from chance. For the other graphs the
selecting the appropriate facial expression for a par- open bars indicate performance that differs from adults. AD, adult;
ticular situational context; the major improvement FL, adults with frontal lobe lesions; RP, adults with right posterior
coming at about age 14. cortex lesions. Patient data from Kolb, Milner, and Taylor (1983)
The results of the facial recognition study sug- and Milner (1980). (A) Split-faces test. (B) Mooney closure test.
gest that the right hemisphere of children is spe- (C) Matching of facial expression with cartoon situations.
cortical region, possibly the frontal cortex. If this abled children and the presence of left posterior
proves correct, the result would be consistent with abnormalities.
the data from other tests of frontal lobe function dis-
cussed above. Early Brain Injury and Behavior
Abnormal Brain Development and Behavior There is little doubt that humans and other ani-
mals sustaining brain damage in infancy can show
Earlier we described abnormalities in neural mi- more rapid and more complete recovery of a particu-
gration that are probably found throughout the brain lar function than when comparable damage is sus-
but it is reasonable to predict that there will be condi- tained later in life (Kennard, 1936, 1940). At the
tions in which such abnormalities might be restricted same time, there is also little doubt that this apparent
to relatively small zones of cortex. In fact, there is sparing of function is not without some cost
now reason to suppose that at least some forms of (Fletcher, Levin, & Landry, 1984; Milner, 1974;
developmental dyslexia result from abnormal struc- Taylor, 1984; Teuber, 1975; Woods, 1980). Thus,
tural development. Drake (1968) examined the brain although recuperation may appear total for many spe-
of a 12-year-old learning-disabled boy who died of cific verbal and academic skills, more global assess-
cerebral hemorrhage. Autopsy showed that there ments of cognitive status suggest that the recovery is
were atypical gyral patterns in the parietal lobes, an often accompanied by new deficits that affect other
atrophied corpus callosum, and neurons underlying functions and may be overlooked (St. James-
the white matter that should have migrated to the Roberts, 1981; Taylor, 1984). Furthermore, there is
cortex. More recently, Galaburda and his colleagues some evidence that brain damage during the first year
have reported analogous results from several dyslex- of life, a time during which there are tremendous
ic brains (Galaburda & Kemper, 1979; Galaburda & changes in brain morphology, may actually have
Eidelberg, 1982; Geschwind & Galaburda, 1985). more severe consequences than similar damage later.
Thus, in the brain of a 20-year-old male who pre- Consider the following examples.
viously had a reading disability despite average intel-
ligence, they found an abnormal pattern of Effect of Brain Damage on Language
cytoarchitecture, especialJy in the posterior speech
region of the temporal-parietal cortex. Although It is common to find that language deficits re-
other details varied in these cases, the left posterior sulting from cerebral injury in childhood are usually
region was always abnormal. These abnormalities short-lived, and that recovery of conversational
were believed to be the result of disordered neuronal speech is nearly complete (e.g., Hecaen, 1976).
migration and/ or assembly. The right hemisphere Cognitive function is by no means normal, however.
was either completely or largely normal in all of these Studies of children with unilateral brain damage in
cases. Finally, Geschwind and Galaburda (1985) infancy by Woods and Teuber (Woods, 1980; Woods
claimed to have evidence of similar anomalies in & Teuber, 1973) and Rasmussen and Milner (1975,
living dyslexic patients, with arteriovenous malfor- 1977) lead to several conclusions in this respect. {1)
mations in the left temporal region. Language survives early left-side injury. (2) If le-
The finding of left temporal-parietal abnormal- sions are incurred prior to age 5 and include both
ity in dyslexics leads to the question of how these language areas in the left hemisphere, language func-
people, even as children, might perform on tests sen- tions shift to the right hemisphere. (3) If lesions are
sitive to focal cortical lesions. Few studies have di- restricted to the anterior or posterior speech zones,
rectly compared dyslexic children to adults with left only the affected language area is likely to shift, lead-
posterior lesions, but studies of dyslexic children ing to bilateral representation of speech. (4) When
have found behavioral deficits on tests that are partic- language shifts to the right hemisphere, it is not with-
ularly disrupted by left posterior lesions including out a price for visuospatial functions are impaired.
tests of short-term verbal memory, left/right differ- These functions would not be impaired if the damage
entiation, and verbal fluency (Sutherland, Kolb, were incurred later in life. (5) Childhood injuries to
Schoel, Whishaw, & Davies, 1982; Whishaw & the left hemisphere, occurring after age 5, seldom
Kolb, 1984). We must point out that it is likely that change speech representation. The observed recov-
not all children with learning disabilities have left ery of language function is assumed to be mediated
posterior abnormalities. It would be interesting, by some sort of intrahemispheric reorganization. (6)
however, to determine the correlation between neu- Children with lesions incurred before their first birth-
ropsychological test performance in learning-dis- day had verbal and performance IQ scores below the
36 CHAPTER2
mean of the nonnal population. In contrast, the ef- animals: both Kolb and his colleagues (Kolb, 1987;
fects of lesions after the first birthday depend on the Kolb & Whishaw, 1981 , 1985a,b) and Goldman-
side of the lesion. The left-hemisphere lesions Rakic and her colleagues (e.g., Goldman, 1974;
lowered both verbal and performance IQ scores Goldman-Rakic, Isseroff, Schwartz, & Bugbee,
whereas later right-hemisphere lesions adversely af- 1983) have found less than complete recovery fol-
fected only the performance IQ scores. lowing early lesions in rodents and primates, respec-
tively. Indeed, Kolb ( 1987) found that frontal lesions
acquired just as cortical neuronal proliferation is
Frontal Lobe Damage completed (i.e., on the day of birth for rats) have
greater behavioral and morphological effects than
We have already discussed the functional devel- similar lesions even a couple of days later. In particu-
opment of the frontal cortex as inferred from the lar, although the lesion size appears the same at sur-
performance of children on neuropsychological tests gery, the early frontal lesion apparently also inter-
sensitive to frontal lobe function. We now ask what rupts cell migration to the remaining sensorimotor
might happen to performance on these tests if the cortex, resulting in a larger effective lesion in these
frontal lobe was damaged in infancy, before the rats. It is possible that a similar result might hold for
frontal cortex was functioning as in adulthood. the child's brain as well, particularly in those cases of
Milner (1974) found that in those patients with child- prenatal injury.
hood damage to the left frontal lobe, there was a shift To summarize, disruption of the normal growth
in language to the right hemisphere, but there was and differentiation of the human brain is associated
still a marked impairment of the performance of other with a variety of pathological states, the nature of the
tests of frontal lobe function such as the Wisconsin behavioral changes depending upon the developmen-
Card Sorting Test. We have seen similar results in a tal state of the brain at the time of injury. Although it
small sample of patients with unilateral frontal lobe was once believed that there was nearly complete
injuries in childhood (largely head trauma and birth recovery following cortical injuries during develop-
injury) (see Table 7). We have divided these into two ment, the bulk of the evidence does not support this
groups: those who sustained their injuries before age view. Rather, it appears that events that produce ab-
2 and those who sustained their injuries between age normal development of the brain will also produce
2 and 11. The results show that patients with frontal abnormal behavior, although certain behavioral
lobe injury at any age were impaired on the Chicago functions such as speech appear to survive differen-
Word Fluency Test and on a test of copying facial tially relative to other functions, especially visu-
movement sequences (see Kolb & Milner, 1981, for ospatial functions. For the clinical neuropsychologist
details of this test). The results on card sorting were the assessment of children with brain injuries and the
somewhat more variable, the youngest patients doing subsequent prediction of outcome is especially diffi-
the best. In addition, like Woods, we found that the cult for the damage to the frontal and posterior asso-
patients with early injuries had significantly lower ciational cortices because one must wait until at least
IQs than did those with adult injuries, although our 10-12 years of age, the time at which these areas
sample was too small to form a statistically testable assume adultlike function, to determine how well the
group with lesions prior to the first birthday. The child will fare. It seems certain, however, that when
failure to see dramatic recovery from early frontal such children are given a broad assessment battery,
lesions finds support from the literature on laboratory there will be significant neuropsychological deficits.
TABLE 7. Neuropsychological Test Performance of Patients with

Childhood Injuries to the Frontal Lobe
Group n IQ Card sorting Chicago fluency Face copying
Control 20 114.0 6.0 61.5 80.0

Adult frontal 8 114.5 1.9" 27.1" 64.5"
2- 14 year frontal 4 93.0" 2.8" 27.0" 58.3"
<2 year frontal 5 89.811 4.5 30.6" 56.5"
0 Significanlly low score.

Conclusion face recognition-A maturdtional component'! Developmen-

tal Psychology. (6(6), 257-269.
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3
Higher Cortical Functions in Children

A Developmental Perspective
LAWRENCE V. MAJOVSKI
Higher cortical functions in children proceed through Development of the Human CNS
different stages of development. Significant limita-
tions in our knowledge exist as to the process of the Throughout its development, one of the brain's
normal developing human brain with respect to neu- many functions is to act in generating behavior. The
rophysiological, neurochemical, neuroanatomical, question of how the brain effects control over behav-
and other related disciplines. Attempts have been ior is central to the study of human neuroscience. The
made to correlate anatomical and behavioral data in a brain can be viewed as a decision-making center for
direct manner, leading to a surfeit of postulations in information processing. Understanding the develop-
the literature against a shortage of supporting data for ment of the human CNS poses the basic problem of
known brain-behavior relationships in children how inhibition brings about the regulation and inte-
(Taylor, Fletcher, & Satz, 1984). Much emphasis gration of higher cortical processes involved in the
tends to be placed on proposed neural mechanisms brain's development. Two major themes of impor-
accounting for changes regarding development of the tance in this regard are the integrative action of the
human CNS versus description of changes taking component parts of the nervous system and that of
place with respect to normal development of the cellular differentiation, i.e., how the component
child's brain. Difficulties exist in drawing conclu- parts are derived (cellular differentiation) and,
sions because each human brain is unique with re- through the course of embryological development,
spect to its cellular differentiation, acculturation fac- the emergence of relationships in the patterns of its
tors, and neural growth patterns (Cooke, 1980). organization (Humphrey, 1978: Nilsson, 1978).
Luria ( 1969a; personal communication, 1977) Some major plaguing problems in understand-
stressed that what was lacking in the area of clinical ing the brain's development stem from the lack of a
child neuropsychology was an integrative scheme blueprint of nature's original design. Completion of
outlining a conceptual topography of normal brain the human brain took place some 50,000 years ago.
development with concomitant motor, sensory, per- To date, we still have incomplete knowledge as to the
ceptual, and other processes involved in children's original model. Neuroanatomists, in studying the
higher cortical functions. brain's development, have discovered that the brain
The main goal of this chapter is to discuss develops much more rapidly than other organs. Why
important facts and concepts related to formation of this is so is not known at present. The influence of
the normal developing brain from conception acculturation on the brain is incalculable and is
through childhood. Emphasis wi11 be placed on a changing the brain's structure more rapidly today
normal developmental perspective versus patho- than ever before.
logical consequences resulting from abnormal in- The human nervous system contains an esti-
fluences. mated 1Q9 neurons in the CNS, 30 X 109 in the
cerebellum itself, and some 100 X 109 granule cells
in the cerebellum (in terms of the macromolecular
LAWRENCE V. MAJOVSKI Huntington Medical Re- layers studied). In addition, there are an estimated
;earch Institutes, Advanced Neurosurgical Laboratories, Pas- 10 12 glial cells. It is the association of these cells that
tdena, California 91105 makes humans human.
41
42 CHAPTER3
Neuroembryologically, the CNS develops from There is both exteroceptive and proprioceptive sen-
the medullary plate of the ectoderm, which becomes sibility (Afifi & Bergman, 1980; Carlson, 1977).
the neural tube differentiates into the spinal cord and The importance of this phenomenon is seen in
brain. the control and regulation of the muscular responses
The human nervous system can be divided into achieved via sensory cells in the muscles which pro-
three major aspects: central, peripheral, and auto- vide a feedback circuit through sensory nerves to the
nomic nervous systems. All three act in concert to CNS (Crelin, 1973; Kahle et al., 1978). Luria
control behavioral activities (e.g .. motor, sensory, (1973a) and others have pointed out the functional
acoustic, optic). It is commonly held that the brain is interrelations between the nervous system, the orga-
the organ system that controls human behavior (Got- nism, and the environment from which emerge high-
tlieb, 1976a,b). Another key in attempting to under- er cortical processes. These three components to-
stand how the brain works is the problem of inhibi- gether serve conscious perception, voluntary
tion and its role in human behavior; exactly how the movement, and the processing of messages through
brain accomplishes control (inhibition) is not fully the process of polysensory integration. To better ap-
understood at the present time. preciate the interplay between structure and function,
it is important first to understand the development of
Morphology the brain, starting with the formation of the embryon-
ic disk, the nervous system's point of origin (Moore,
The CNS is usually defined as the brain (en- 1974; Humphrey, 1978).
cephalon) and spinal cord (medulla spinalis). The
brain lies in the cranial cavity surrounded by a bony Neuroembryonic Structure Formation
capsule. The spinal cord is situated in the vertebral
canal surrounded by the vertebrae. Both are covered The nervous system starts developing approx-
by cranial or spinal meninges that enclose a space imately 18 days after fertilization. The egg is then
filled with cerebrospinal fluid (CSF). The peripheral composed of ectoderm and endoderm, with meso-
nervous system (PNS) is comprised of cranial and derm developing between the two. The nervous sys-
spinal nerves (31 pairs) with associated ganglia contem is derived from the ectodermal layer. During
sisting of motor fibers and sensory fibers. There are embryological development, the neural plate, the
two types of motor fibers: (1) somatic motor fibers, neural tube, and the neural crest form. The neural
which terminate in skeletal muscles; and (2) auto- crest becomes elevated to form the neural folds,
nomic fibers, which furnish innervation to cardiac which, in turn, approximate each other in the midline
muscle, smooth muscles, and glands. Sensory fibers and then fuse to form the neural tube. Cells at the
receive stimuli from receptive organs of various margins of the folds are not included in the wall of the
types. Nerves of the PNS supply the head, trunk, and neural tube. The partial fusion of the neural folds
limbs. The CNS and PNS together serve conscious occurs approximately 23 to 24 days postfertilization
perception, voluntary movement, and the processing (Lowrey, 1978; Moore, 1974, 1975; Hamilton &
of sensory-based messages and integration (Kahle, Mossman, 1974; Kahle eta/., 1978; Crelin, 1974; Le
Leonhardt, & Platzer, 1978; Arey, 1974; Nilsson, Douarin, 1980).
1978). In its formative stages, the neural tube appears
In the autonomic nervous system (ANS), there as a straight structure. However, during its organo-
are two antagonistic parts, the sympathetic and the genesis, cervical somites deviate. from the shape of
parasympathetic systems, which jointly are responsi- the simple neural tube. This portion, destined to be-
ble for preserving a constant internal environment come the brain, forms various bulges and cavities,
(homeostasis). All viscera, blood vessels, and glands each of which has significance in the embryological
are innervated by the ANS. The human nervous sys- plan of development (Jones & Cowan, 1978).
tem, the organism, and the environment are all func- Three primary bulges appear in the brain region
tionally interrelated. of the neural tube: the forebrain (prosencephalon),
The human organism not only responds to its midbrain (mesencephalon), and hindbrain (rhomben-
surroundings, it acts spontaneously on them as well cephalon). When the development of the caudal end
throughfunctional circuits. The action that is insti- of the tube is completed, the optic vesicles appear and
gated by the CNS (transmitted via efferent nerves) is protrude from each side of the forebrain. Otic invag-
registered by the sense organs and information is then ination also occurs at day 28 postfertilization. In
returned to the CNS via the efferent nerves. An terms of the ventricles of the future brain, a cephalic
itegrative process follows until regulation obtains. flexure and a cervical flexure of the future brain be-
HIGHER CORTICAL FUNCTIONS IN CHILDREN 43
come visible with cavities at respectively the pros- cerebral hemispheres. The second major portion of
ocele of the forebrain, mesocele of the midbrain, and the rhinencephalon forms part of the wall of the cere-
rhombocele of the hindbrain. bral hemispheres, e.g., the hippocampus. A bulging
Each optic vesicle will differentiate to form a mass appears on the medial wall of the lateral ventri-
characteristic pattern: first, an optic cup, then a stalk, cles, bilaterally. In humans, the rhinencephalon in-
and, later on, an optic nerve, which becomes part of cludes, in addition to the bilaterally placed olfactory
the eyeball. The original connection of each optic bulbs and hippocampi, such structures as the bilateral
vesicle becomes located in the diencephalon, a sub- pyriform lobes, midline septeum pellucidum, and
division of the forebrain. midline fornix. The rhinencephalon differentiates
By day 36, the forebrain divides into two parts. into structures referred to as the limbic lobe, which
The caudal subdivision becomes the diencephalon, contains interconnections with structures such as the
and the anterior component further differentiates to thalamus, epithalamus, and hypothalamus. This con-
form the telencephalic vesicles which eventually be- stitutes the limbic system.
come the cerebral hemispheres (Hamilton & Moss- The functional significance of the limbic system
man, 1974; R. Y. Moore, 1977; Jones & Cowan, is that it is associated with emotional responses and
1978; Humphrey, 1978). the integration of olfactory information with both
Simultaneous with the subdivision of the fore- visceral and somatic information. The limbic system
brain, the original cavity (the prosocele) undergoes is involved in "emotional expression," and the hy-
subdivisions. Two telencephalic vesicles (teloceles) pothalamus is involved in the regulation or control of
are formed and become the lateral ventricles. The emotions via hormonal output. The thalamus serves
median telocele, which lies between these two as the portal to the cerebral cortex, but is inextricably
teloceles, together with the diocele, becomes the bound together in the processing of sensory informa-
third ventricle. The mesocele develops into the cere- tion, which leads to conscious activity. Other bilat-
bral aqueduct. erally placed structures of the rhinencephalon in-
As the forebrain divides into the telencephalon clude: the stria terminalis; septum; amygdaloid
and diencephalon, the hindbrain is forming into two bodies; medial and lateral olfactory gyria; parahip-
structures: the anterior metencephalon, which be- pocampal gyrus; and cingulate gyrus (Carpenter,
comes the pons and the cerebellum; and the posterior 1978; Hamilton & Mossman, 1974; R. Y. Moore,
myelencephalon, which becomes the medulla 1977; Crelin, 1974; Kahle etal., 1978).
oblongata. The fourth ventricle forms from the cav-
ity of the metencephalon (metacele), together with Basal Ganglia
the cavity of the myelencephalon (myelocele).
By day 34, the cerebellar plate, cervical and The second part of the telencephalon formed is
mesencephalic flexures, lens invagination, otic vesi- the basal ganglia (or basal nuclei). They are formed
cles, and olfactory placodes are visible. By day 45, in the thickened portion of the striatal region of the
olfactory evagination will have occurred as well as telencephalic area, composed of several groups of
formation of the cerebral hemispheres. Lens fiber neuronal cell bodies. One of the major groups of
migration of retinal cells will begin in earnest at this these ganglia (i.e., nerve cell bodies outside the brain
time. and spinal cord) is the corpus striatum, which be-
Growth and development by 3 months postfer- comes related to the thalamus of the diencephalon.
tilization take place in terms of the two smooth- Up to the third month, the corpus striatum and
walled telencephalic vesicles. These are easily iden- thalamus are separated by a deep groove. The corpus
tified as the cerebral hemispheres. Each emerging striatum then bu.lges into the lateral ventricle while
hemisphere of the telencephalon will have divided by the thalamus protrudes into each side of the third
this time into three parts, each of which has different ventricle. Beginning about the fourth month, the
functions. The first component is the rhinen- groove between these two structures will disappear
cephalon; the second is the thick basal (striatal) re- and fuse into a common mass. When fully matured,
gion, which develops into the basal ganglia; and the the basal ganglia comprise the following main struc-
third is a suprastriatal region, which forms the cere- tures: caudate nucleus, claustrum, amygdaloid body,
bral cortex and related underlying white matter (Kah- and corpus striatum. These structures will be in-
le et al., 1978; Crelin, 1974; Arey, 1974). volved with motor control (Nauta, 1986a,b; Car-
The rhinencephalon starts out as an outgrowth penter, 1978; Kahle et al., 1978).
from the telencephalon, e.g., the olfactory lobes. In the suprastriatal region, the third component
Each olfactory lobe forms part of the wall of the of the telencephalon forms all of the externally visi
44 CHAPTER3
ble cerebral hemispheres. The hemispheres increase vius becomes a long, slender tube connecting the
in size and completely envelope the mesencephalon third and fourth ventricles. Two major foramina be-
and the upper portion of the cerebellum, and the orig- come prominent: the left lateral opening (foramen of
inally smooth surfaces begin to show convolutions at Luschka) and the median opening (foramen of
around 7 weeks. The formation of the surface con- Magendie), both of the fourth ventricle (Kahle et al. ,
volutions, known as sulci, and the deeper depres- 1978; Moore, 1975).
sions, tertnedfissures, allows the outei: layer of neu- A region of invagination of the choroid plexus
rons, e.g., the six cell layers in the cerebral cortex, to will occur along the choroid fissure of the lateral
increase greatly in depth without a major change in ventricle. Functionally, the choroid plexus serves as
the overall size of the brain in relation to its final a source of CSF. CSF serves three main functions: it
volume. By the completion of its development, the supports the weight of the brain in the skull; it pro-
cerebral cortex will range in thickness from 1.5 to tects the brain from physical trauma during injury to
approximately 4.0 nun with a surface area of 2.3 x the skull; and it provides a stable chemical environ-
103 to 2.5 x 103 crn2 (Crelin, 1973, 1974). ment for the CNS, despite plasma's chemical corn-
The first major fissure to appear on the lateral position changes (Afifi & Bergman, 1980).
aspect of each cerebral hemisphere is the lateral Syl- Ependymal cells lining the brain's ventricles
vian sulcus (orfissure) which becomes evident by the form the medial surfaces of each lateral ventricle, the
third month. The slowly growing floor of the sulcus, roofs of the third and fourth ventricles, and portions
which is lateral to the corpus striatum of the basal of the plexus, As these cells grow and invaginate,
ganglia, is the insula. It eventually becomes com- they are accompanied by blood vessels known as
pletely covered by adjacent areas of the hemisphere. choroidal vesseles. CSF escapes through the median
Beneath the convolutions of the cerebral cortex lies (foramen of Magendie) and lateral (foramen of Lus-
the substrate of the highest centers of cortical integra- chka) opening of the fourth ventricle into the sub-
tion in the human nervous system. These (six) cor- arachnoid space surrounding the brain and spinal
tical layers subserve higher cortical functions involv- medulla. The lining of the choroid plexus also forms
ing conscious activity, memory, processing of a physiological barrier known as the brain-barrier
information, decision-making, voluntary action, re- system between the CSF and the blood supply to the
flection, and planning (Luria, 1966, 1969b, 1970, brain.
1973a,b). The brain-barrier system is more permeable in
newborn infants than in adults, becoming less per-
meable as the brain matures. For example, bilirubin
Ventricle Formation and CSF in high concentration in infants can cause brain
damage because it passes through the brain-barrier
Important changes are also occurring in various system. Similar high levels of bilirubin do not affect
parts of the brain after the third month, particularly the adult brain (R. Y. Moore, 1977b; Langman,
ventricle formation. The lateral ventricles each de- 1975; Afifi & Bergman, 1980).
velop three horns that protrude into the various lobes
of the cerebral hemispheres: the anterior horn pro-
jects into the frontal lobe; the inferior horn into the Spinal Cord Formation, Alar and Basal Plates
temporal lobe; and the posterior horn into the oc-
cipital lobe. Each lateral ventricle occupies a more During neuroernbryological development, the
lateral position relative to the third ventricle and the neural tube is divided into longitudinal zones: the
formerly broad interventricular foramen (foramen of ventral half of the lateral wall differentiates early into
Monro) becomes a narrow canal. The third ventricle the basal plate. It is considered by some to be the site
connects with the lateral ventricles of each hemi- of origin of the motor nerve cells. The dorsal portion
sphere by the foramen of Monro and continues of the lateral wall differentiates later and is termed the
caudally into the cerebral aqueduct of Sylvius, ex- . alar plate. It is the site of origin of sensory nerve
panding beneath the cerebellum to form the fourth cells. Between the alar and the basal plates lies an
ventricle (Humphrey, 1978). area from which autonomic nerve cells are thought to
Simultaneously, the egg-shaped thalami bulge arise. Viewing the structural plan of the spinal cord
into a third ventricle. Eventually the two thalami, and brain stem in this fashion aids our understanding
with normal development, bridge this ventricle, of how various parts of the brain are organized. Be-
come in contact with each other, fuse, and produce an cause it is held that the basal plate does not participate
interthalamic bridge. The cerebral aqueduct of Syl- in the formation of the brain areas beyond the mid-
brain (metencephalon), the diencephalic and telen- The hypothalamus, derived trom the alar plate
cephalic vesicles are thought to arise from the alar of the diencephalon, is part of the limbic system and
plate (Kahle et al., 1978). is considered to be the headquarters for central motor
Alar plate cell bodies are comprised of sensory control of the ANS. It regulates emotional responses
and coordinating (internucial) neurons. These are lo- and certain visceral functions, such as appetite,
cated in the layer of gray matter (mantle layer). Gray thirst, digestion, sleep, sexual drive, heart rate, body
matter is the region of the brain and cord that contains temperature, general smooth muscle action of inter-
aggregates of nerve cell bodies, as distinct from nal organs, and control of the anterior lobe of the
ganglia, which are nerve cell bodies that lie outside hypophysis. The hypothalamus is also involved in
the brain and spinal cord. the releasing of neuroregulator factors.
Differentiation of the diencephalon from the By the seventh week, the infundibulum (posteri-
alar plate results in division into dorsal and ventral or lobe of the hypophysis) appears and develops as an
portions. The dorsal part becomes the thalamus and extension of the hypothalamus. The parathyroid
consists of cell bodies of sensory and coordinating structure appears in association with the thyroid
neurons. These nuclei are nerve cell groups within gland. During the eighth to tenth weeks, thyroid folli-
the brain. The ventral portion of the alar plate devel- cles emerge as weU as production of adrena1ine and
ops into the hypothalamus, which is comprised of noradrenaline (Lemire, Loeser, Alvord, & Leech,
motor control neurons. The dorsal (alar) plate thus 1975; Hamilton & Mossman, 1974; Crelin, 1974).
becomes the site of sensory and coordinating neu- The basal portion of each cerebral hemisphere,
ronal cell bodies. The ventral basal plate becomes the situated anterior and lateral to the hypothalamus, is
site of motor control neuronal cell bodies (R. Y. derived from the ventral portion of the alar plate. This
Moore, 1977b; Crelin, 1973, 1974; K. L. Moore, basal area is comprised of the basal ganglia. Other
1977a). important anatomical structures that emerge from the
The thalamus exerts control through its projec- telencephalon include the cerebral cortex and the sep-
tional (internuncial) neurons, which synapse with tal-hippocampal-amygdaloid nuclei complex.
parts of the brain other than the cerebral hemispheres, Fiber tract systems are also developing with
in particular, with the hypothalamus. nerve fibers of the brain and spinal cord that have a
Thalamocortical interaction exists in what is common origin and a common destination. This ana-
known as the thalamocortical projection system. tomical feature should be kept in mind in thinking
Two major structures of importance in terms of cor- about the development and differentiation of white
tical-cortical and cortical-subcortical interneuronal matter versus fiber tract systems. It is the cell bodies
connections are the major fiber tracts that arise in the of neurons-the functional and anatomical unit of
internal capsule and the medial forebrain bundle the human nervous system-that are involved in
(MFB). The last projectional pathway from thalamus human thought, memory, and voluntary and reg-
to cerebral cortex takes place through the nuclealis ulatory motor control over the entire nervous system.
reticularis thalami. It is thought that through this They are localized in the cerebral cortex, and their
projection pathway, there is monitoring and modula- functions have been referred to as higher cortical
tion of information from lower levels of nervous ac- functions in man (Kahle et a/., 1978; Afifi &
tivity to the upper regions of the CNS. The thalamus Bergman, 1980; Crelin, 1974).
also serves a role in pacemaking activities seen in the
electroencephalogram (EEG). Another important
function is involvement with selective awareness in Hippocampus
conscious activity (Bear, 1986; Hamilton &
Mossman, 1974; Crelin, 1973; Scheibel & Scheibel, The hippocampus plays a significant role in the
1961, 1963; Bloom, 1979). generation and retrieval of memory. It is also in-
A significant portion of the human thalamus is volved in the generation of conscious activity in
comprised of a group of nuclei that receive pro- humans.
prioceptive and general cutaneous, visceral, visual, The brain, as it matures, deals with the analysis
and acoustic impulses, which are relayed to the cere- of thought, memory functioning, and decision-mak-
bral cortex via other projectional (internuncial) neu- ing with respect to inputs from voluntary and reg-
rons. The structural and functional relationships of ulatory motor units exercising control over the entire
the component parts of thalamic nuclei are inextrica- human body. It decides whether or not to engage in or
bly comingled (Riss, 1972; Scheibel & Scheibel, refrain from initiating performance. Speculatively,
1966, 1972). autism might be linked to the amygdala, hippocam-
46 CHA.PTER3
pus, or septal areas, or faulty information transmis- other mantle zone neurons. The white matter lacks
sion in terms of sensory influx of the structures of the neurons. Instead, there are bundles of axons arising
higher cortical areas of the brain during development from those nerve cells located throughout all levels of
(Davison & Dobbing, 1968; Altman, Brunner, & the spinal medulla and brain to form various fiber
Bayer, 1973; R. Y. Moore, 1977b; Cooke, 1980). tract systems. White matter, in contrast to gray mat-
Major fiber tract systems that become crucial to ter's large number of cell bodies (neurons), contains
higher cortical activity in children lie in the area of only scattered bodies of cells, which are chiefly sup-
the corpus callosum (anterior and posterior com- portive in nature, e.g., glial cells, which outnumber
missures) and the fimbria. The cerebral hemispheres neurons in the human nervous system by a ratio of
form the major portion of the brain's volume (R. Y. 10: 1. The brainstem's organizational pattern is sim-
Moore, 1977b; Hamilton & Mossman, 1974). ilar to that of the spinal medulla. With increased
specialization of the brain, more complex arrange-
ments of the axonal tracts occur constituting brain
Cellular Differentiation of the Nervous white matter.
System
Structural and functional organization of the Cerebellum
nervous system are closely related to cellular organi-
zation. The neuron is the basic building block of the Research in the past decade indicates that an
nervous system. In terms of the nervous system's enormous amount of integration occurs within the
network, neurons are interconnected in a special way cerebellum, specifically with the bursting of Pur-
via synapses (Koffler & Nicholls, 1977; Lund, 1978; kinge fibers and the quenching of the Purkinge cell
Cretin, 1973, 1974; R. Y. Moore, 1977b). (Ito, 1984). The organizational pattern in the cere-
Inhibitory synapses are as important as excitato- bellum shows pronounced deviation, neurohistologi-
ry ones. Inhibitory synapses limit and select con- cally, from the basic structural pattern of the mesen-
tinual impulse inflow in the sense that chosen signals cephalon, metencephalon, and medulla oblongata,
of importance are transmitted for further information which develop from neuroblasts of the dorsal portion
processing. Unimportant signals are suppressed. of the mantle layer. Cells of the cerebellum are in-
As the neural tube forms, three cell layers devel- volved in motor control, and also have interconnec-
op and differentiate from its walls: the ependymal tions via the basal ganglia that may serve a role in
layer, the mantle layer, and the marginal layer. These monitoring and coordinating muscle activity in rela-
layers form distinct zones: the ependymal zone, the tion to all forms of sensory input (Kahle et al., 1978;
mantle zone (gray matter), and the marginal zone Carpenter, 1978). Two other main deviations from
(white matter). The outermost layer becomes the pia the basic organizational pattern of the neural tube are
mater derived from pial cells. The organizational pat- the development of ventricles of the brain and the
terns formed from these zones are best seen from the tube.
viewpoints of the spinal medulla (cord), the cere- The cerebellum serves many functions. It re-
bellar hemispheres, and the cerebral hemispheres peats activities in a regulated, precise manner;
(Kahle et al., 1978; Cretin, 1974; Arey, 1974; smooths out all motor activities; is concerned with
sensory activity; and may be involved in affectual
Moore, 1974).
responses. It is the center for the smooth coordination
of muscular responses, especially those involved
Spinal Medulla with subconscious maintenance of normal posture.
Due to its primitive three-layer system-molecular,
The basic three-zone pattern of this structure Purkinge, and granular cells-it is also involved in
will be retained into maturity as follows: the epen- feedback and dampening circuits that serve as a ser-
dymal zone remains as columnar cells lining the vomechanistic system to control complicated inte-
lumen of the central canal; the cells of the mantle grative movements such as talking and writing.
zone form the gray matter; and the marginal zone Many cerebellar cells serve as inhibitory ''tum off'
becomes the white matter. The gray matter of the cells such as Mugwump and Golgi II cells (Car-
spinal medulla assumes the anatomical appearance of penter, 1978; Ito, 1984). The cerebellum can be
an H-shaped mass surrounded by white matter. The viewed as being similar to a computer in that it may
association and commissural (internuncial) neurons even be able to generate programs on its own (Schei
of the gray matter of the spinal medulla are formed by bel, 1978).
Thalamocortical Fiber System Glial cells are the supporting structures of the
CNS. There are three types of glial cells in the human
The thalamus receives all types of sensory input
CNS: astrocytes, oligodendrocytes, and microglia
relayed by projectional neurons either to various nu-
cells. Glial cells outnumber neurons 10: 1. Astro-
clei of the brain stem or to the cerebral cortex. Nearly
cytes and oligodendrocytes derive-chiefly from the
all of the axons conveying sensory input to each
spongioblasts in the mantle layer. The latter are ~e
thalamus, cross from the opposite side of the spinal rived from neural tube epithelial cells. Micro gila-
medulla or brain stem. Those fibers that have not
cells primarily arise from mesodermal embryonic
crossed include half of optic nerve fibers entering the
connective tissue, from which all layers of blood
thalamus from the same side. From each thalamus,
vessels of the brain and spinal medulla arise.
projectional neurons relay sensory impulses to the
Astrocytes are composed principally of two dif-
cerebral cortex for which there is a corresponding
ferent functional forms. The first are the fibrous as-
area of the thalamus. Activation of a minute portion
trocytes, which are abundant in white matter, provid-
of the thalamus will stimulate the corresponding and
ing both support and binding for the tracks of nerve
much larger portion of the cerebral cortex via the
fibers. The second,protoplasmicastrocytes, are pre-
axons of the thalamocortical projectional neurons.
sent in large numbers in the gray matter, and serve
The cerebral cortex contains cell bodies of associa-
many different purposes. They establish close con-
tional neurons, which send their axons through the tacts with neuronal cell bodies, blood capillaries, and
white matter of the hemisphere and in another part of
pia mater. The end-feet of protoplasmic astrocytes,
the cortex of the same side. The cortex also contains
in conjunction with endothelial cells of capillaries,
cell bodies of commissural neurons, which send their
form a highly selective blood-brain barrier (Moore,
axons via the hemisphere's white matter to end up in
1975, 1977a; Hamilton & Mossman, 1974; Crelin,
the opposite cerebral hemisphere. It is via the com-
1973, 1974).
missures that a bridge is formed to allow the func-
tional integration between the two sides of the brain
(Carpenter, 1978; Kahle et al., 1978; Crelin, 1973; Cerebral Hemispheres
Arey, 1974). During the third month, migrating neuroblasts
During development, the first commissure to from the mantle zone pass into the marginal zone,
appear is the anterior commissure. It interconnects giving rise to the cerebral cortex. Stratification with-
the olfactory amygdaloid nuclei and cortical portions in the cortex proceeds at an ever-increasing rate and,
of the cerebral hemispheres. Second to appear is the at approximately 6 months, the six layers of cell
hippocampal commissure (region of the fornix), bodies and their associated interconnections that
which will unite the two hippocampal, olfactory por- characterize the cerebral cortex are identifiable. The
tions of the hemispheres. Then, posteriorly, in the fmal differentiation of the outer layers continues until
region of the pineal body, the habenular and posterior the second decade of life (and maybe even longer).
commissures interconnect the diencephalon. The last The outer three layers become more highly devel-
of the commissures and the largest of all is the corpus oped in humans than in any other species of animal
callosum. It is known that myelination begins in the (K. L. Moore, 1974, 1975, 1977a; R. Y. Moore,
brain at about embryonic week 16 and typical layers 1977b; Arey, 1974; Crelin, 1973, 1974).
in the cerebral cortex are found at around week 24. At The pattern of neuronal development in the ce-
birth, there will be continuing organization of axonal rebral cortex during infancy is integral to the complex
networks, cerebral corticospinal tract development, functions of the cortex, which ultimately consists of a
motor coordination, and myelination patterns (R. Y.
vast information storage and processing ensemble.
Moore, 1977b). These will include cognitive reasoning abilities,
memory, communication, reflective thinking, indi-
Glial Cells vidual performance skills. and other functions. From
infancy through the first three to five years oflife, the
White matter and gray matter are made up al- subcortical-cortical interactions serve a prominent
most entirely of cell constituents: white matter con- role as to the storage of many of the patterns of motor
sists chiefly of bundles of axons, glial cells, and responses that can be elicited at will in order to con-
blood vessels; and gray matter is composed primarily trol motor functions of the developing human body.
of neuronal cell bodies, dendrites, axons, glial cells, It is the cortex that gives humans voluntary control
and blood vessels (Afifi & Bergman, 1980). over how they will react to sensory-perceptual stim-
48 CHAPTER3
uli, integrate this information, and decide whether or (those peripheral to the CNS). In contrast, mye-
not to act upon it in a deliberate manner (Scheibel & linated axons are those that are sheathed by numerous
Scheibel, 1973). layers of the cell membranes of either oligo-
In humans, voluntary control of muscles is al- dendrocytes or neurilemmal cells. Major differences,
most exclusively regulated through the descending neurohistologically, do exist between the myelin
projectional tract systems arising from neurons in the sheath formed by each of these. Oligodendrocytes
cerebral motor cortex, e.g., the pyramidal motor sys- and neurilemmal cells form myelin sheaths by similar
tem. One is the corticospinal tract that begins to form processes.
during embryonic week 9, reaching its outer limits by
week 29. Fibers from the projectional neurons lo- Myelin Sheath Formation. Sheath cells be-
cated in the cerebral cortex, form fiber tracts and pass come wrapped around the axon many times, with the
from the cerebral cortex to the other parts of the CNS sheath cell, the axon, or both, causing the spiraling
(Majovski & Jacques, 1982; Bear, 1986; Nauta, motion. Penelope's Web, as it is known anatom-
1986a,b; Carpenter, 1978; Kahle et al., 1978). ically, is spun around the myelin sheath. Fiber tracts
Axons of the pyramidal neurons pass from each begin to function maturely at the time they are cov-
cerebral hemisphere to form the corticospinal tract ered with myelin.
portion of each internal capsule situated in the basal The process of myelination in the human brain
ganglia. Farther on down, these two corticospinal begins some three months postfertilization. How-
tracts pass through the mesencephalon as part of the ever, at birth, only a few areas of the brain and tract
cerebral peduncles through the lower portion of the systems are completely myelinated, e.g., brain stem
medulla oblongata. It is at the level of the medulla centers serving subcortical functions such as certain
oblongata that most of the fibers of the tracts will primitive reflexes.
decussate across the midline to pass down to the As the wrapping process occ~rs around the
opposite side of the spinal medulla and become the axon, the cytoplasm of the sheath cell retracts such
lateral corticospinal tract. The uncrossed fibers, that it is extruded so that the two layers of plasma
which remain ipsilateral, make up the ventral cor- membrane of the sheath cell fuse together. Myelin is
ticospinal tract and eventually cross to the opposite actually formed by numerous fused layers oflipopro-
side at the lower levels of the spinal medulla. It is tein membrane, and axons covered with fresh myelin
estimated that approximately 30% of the cor- assume a white, glistening appearance due to the
ticospinal tract fibers remain uncrossed, and that lipid content.
30% are involved in decussation. Axons of the pyra- Tracts of the white, myelinated axons make up
midal motor control neurons of the cerebral cortex the majority of white matter of the nervous system.
synapse with ventral gray column motor neurons The majority of preganglionic svmpathetic axons are
(Carpenter, 1978; Arey, 1974). myelinated and are responsible for the appearance of
Functionally, the cerebral hemisphere on one the white ramus communicans. In contrast, the ma-
side, from the decussation pattern manifested, exerts jority of postganglionic sympathetic axons are
voluntary motor control over the opposite side of the unmyelinated.
body and also receives sensory inputs from the op- Myelination is a process closely associated with
posite side of the body via fibers that are crossed to the development of the functional capacity of neu-
enter each thalamus (Lund, 1978; K. L. Moore, rons. One of its chief characteristics is the promotion
1977a; Crelin, 1974). of impulse conduction. Unmyelinated neurons tend
Axons, whether myelinated or unmyelinated, to have a low conduction velocity and show fatigue
become surrounded by glial cells known as oligo- earlier, whereas myelinated neurons fire rapidly and
dendrocytes. Within the CNs, commissural, projec- have long periods of activity before fatiguing occurs.
tional, somatic, associational, and autonomic motor Neurons that are capable of rapid transmission of
neurons become encapsulated by parts of other cells. impulses become fully functional at about the time
The only exceptions are the boutons at synapses and their axons are completely insulated with myelin
nodes such as those of Ranvier. From the PNS, the (Moore, 1975, 1977a; Crelin, 1974; Lemire et al.,
neurons become completely encapsulated by parts of 1975).
other cells, except at the terminal endings and at the Formation of myelin in the spinal medulla be-
nodes of Ranvier (Kahle et al., 1978). gins during the middle of fetal life but is not com-
Unmyelinated axons are those that are sur- pleted until puberty. The last spinal tracts to be mye-
rounded (sheathed) by parts of either oligodendro- linated are the descending motor tracts, such as the
cytes (those within the CNS) or neurilemmal cells corticospinal (pyramidal) and the tectospinal tracts.
These become myelinated during the first two leasing hormones that pass to the endocrine cells of
postnatal years. At birth, only a few areas of the 15 the anterior lobe of the hypophysis through the blood
dissectable descending tracts are completely mye- vessels and regulate endocrine hormone secretion.
linated (Yakovlev & Lecours, 1967; Kahle et al., Thus, the sympathetic and parasympathetic compo-
1978; Crelin, 1974). In the human brain, myelination nents of the PNS are under the regulation of the neu-
continues into the second decade of life and perhaps roendocrine system via the pituitary gland (Kuffler &
even beyond that (Yakov1ev, 1962; Yakovlev & Nicholls, 1977; Snyder, 1980; Kaplan, Grumbach,
Lecours, 1967). & Aubert, 1976; Daughaday, 1974; Reichlin, 1974).
Motor neurons of the cranial nerves show mye- In the region of the substantia nigra, the
linization patterns before their sensory counterparts. dopaminergic nigrostriatal system affects motor bal-
Optic nerve fibers begin to show myelinization at ance and affectual response. This site also is impli-
birth; this will be completed by the end of the second cated in the etiology of schizophrenia and parkin-
week. sonism (Majovski, Jacques, Hartz, & Fogwell,
Axons of neurons of the cerebral hemispheres 1981).
are among the last to become myelinated, beginning Serotonin (5-hydroxytryptarnine) molecules are
around birth. At first, only the axons of cortical neu- found in the raphe nuclei of the brain stem. The path-
rons of the olfactory, optic, and acoustic areas are ways that originate from them are distributed in a
myelinated, followed by those arising from cell manner similar to those for adrenergic neurons.
bodies in the somesthetic and motor cortices. Thus, Serotonin produces both inhibition of neuronal ac-
fibers that become myelinated after birth are those of tivity and depression of behavioral activity in the
the projectional, commissural, and associational mature brain (Smith & Sweet, 1978b).
axons of the cerebral hemispheres. Myelination of -y-Aminobutyric acid (GABA) is a transmitter
axons of the associational cortices of the cerebral substance released by inhibitory interneurons, as
cortex continues into adulthood (R. Y. Moore, well as by cerebellar Purkinje cells. High concentra-
1977b; Carpenter, 1978; Crelin, 1973, 1974). tions of GABA are present in the striatonigral path-
way within the substantia nigra. GABA is believed to
Neurotransmitters and Neurohormones. be exclusively inhibitory (Majovski et al .. 1981).
Neurons secrete specific transmitter substances or Acetylcholine (ACh) is released at both excit-
neurohormones at the axonal terminal endings (bou- atory terminals in the sensorimotor cortex, as well as
tons). Boutons are the sites where information is visual cortex, and inhibitory terminals such as the
transferred from one neuron to the next and where olivocochlear bundle. In addition, it has been found
electrochemical changes in the release properties of in the nucleus basalis of Meynert (Dunn, 1980).
the presynaptic terminals take place. Neurohormones Monoamine transmitter substances commonly
attach to the membrane of the cell on which the axon produce inhibition of neuronal activity. When this
terminates and induce internal changes in that cell. effect is exerted on inhibitory neurons, the net result
Neurotransmitter substances serve to either stimulate is often facilitation via noradrenaline. Such a mecha-
or inhibit the secretory process. If the secretory pro- nism may account for the behavioral arousal pro-
cess is stimulated, physiochemical changes occur duced by the catecholamines (noradrenaline and
within the cell that are intimately related to the dopamine), which are believed to be involved in the
changes in the permeability of the cell's membrane facilitation of inhibition (Bloom, 1973, 1979; Smith
(Lehninger, 1968; Zucker & Lando, 1986). & Sweet, 1978b; Majovski et al., 1981).
Neurohistologically, many neurons that become It has been theorized that dopamine (DA) and
highly specialized evolved from glandular cells. Cer- other peptides may play a role in the mechanisms of
tain cells of the body are structurally and functionally memory. A large body of evidence implicates pitui-
intermediate to typical endocrine cells and neurons. tary hormones, particularly adrenocorticotropic hor-
These cells possess axon terminations in the posterior mone (ACTH), melanocyte-stimulating hormone
lobe of the hypophysis (pituitary gland) that are rich (MSH), and vasopressin, in learning. The action of
in both cytoplasmic material and hormones. These ACTH, MSH, and vasopressin may improve memo-
hormones are produced by the neurons and pass ry processes by modifying motivational and atten-
along the axons to the hypophysis, where they are tional factors. ACTH may act to stimulate the metab-
stored for release as required. After being released, olism of DA and/or norepinephrine (NE). It is also
these posterior lobe hormones pass to the responsive thought by some that vasopressin may act to affect
tissues of the body through the vascular system. catecholamine metabolism in a rather complex man-
Other similar hypothalamic cells secrete so-called re- ner. In this regard, arousal has been shown to be
50 CHAPTER3
associated with the activation of central NE systems communication network are axonal conduction, syn-
and the release of hormones such as ACTH, vas- aptic transmission, and local cell processes.
opressin, and glucocorticoids. In the neonate's brain, A further approach is to view the spinal cord as a
modulators (neuropeptides) may play a role in terms model of neural organization. Chief characteristics
of the mode of information storage and not a direct are segmental and suprasegmental reflexes.
effect on information stored at all. Even though not The functional anatomy of sensation is also
completely understood, it is currently thought that important for understanding the human CNS and its
catecholaminergic as well as neurochormonal factors development with these key features: receptors and
apparently do play some type of role in the storage of transduction processes; pain systems; discriminative
memory. sensory systems; and systems for automatic adjust-
Some have suggested that opiate receptors may ment. Other aspects are the descending motor control
even play a role in the filtering of sensory stimuli at systems such as commissural, associational, and pro-
the cortical level involved with emotion-induced se- jectional fiber systems; basal ganglia: extrapyramidal
lective attention. This proposition offers the pos- mechanisms; and brain stem centers of control.
sibility that a neural mechanism exists whereby the The cerebellum is another system crucial in the
limbic-mediated emotional states, essentially for in- functional understanding of the developing brain's
dividual and species survival, may influence which neuroanatomy. It is involved in the modulation of
sensory stimuli are selected for attention (Bear, 1986; motor and sensory mechanisms and may even have a
Kety, 1970; Dunn, 1976). By implication, endoge- role in decision-making responses as well as emo-
nous opiates may exert progressively greater influ- tional expression.
ences at higher levels of sensory information process- Another major system is the brain stem system
ing in the cortex. Whether this holds true in the and internal states. These play a prominent role in the
neonate's brain over the course of the first several regulation of sleep, wakefulness, emotional affect,
years of development is unknown. However, sensory pain, pleasure, and suppression of pain.
stimuli at the cortical level may play a role in selec- Yet another key is the various support systems
tive attention, which has a significant bearing on the and the internal milieu, e.g., the autonomic and en-
processes of cognition and learning mechanisms. docrinological mechanisms that influence neuronal
activity and ultimately human behavior. Finally, the
developing brain's higher cortical functions are the
Summary
ultimate expression of human mental information
Phylogenetically, the brain can be considered as processing consisting of a number of psychological
a blueprint of nature's original design, for which we processes (Luria, 1973a,b, 1980).
do not have a complete set of plans. To explain the
brain's architectural plan today is like looking at a
house to which rooms have been added, but without Factors Affecting Normal Brain
having access to the original plan. Development and Higher Cortical
The clues that have been left behind concerning
the functional aspects of the additions to the phy- Functions
logenetic blueprint of the brain are as follows. At the
midbrain level, anencephalic children will be able to The development of higher cortical pathways
live for only a few days or weeks, but they can exhibit used to the best advantage of the neonate rests on
laughing and crying responses. Another clue is the improvement of conscious and unconscious pro-
phenomenon of supersegmental control over lower grams of behavior. The formation of categories and
processes of the human nervous system which occurs higher mental processes involved in concept acquisi-
at the midbrain level. A major consideration as to the tion is limited by unmatured neural organizational
human nervous system's functional neuroanatomy is patterns that are affected by several variables: timing,
one that has been addressed above in some detail- nutrition, environment, and genetics, among other
ontogenetic development. factors. Knowledge of these factors with regard to
Another approach to understanding the func- normal infant development of mental abilities and
tional neuroanatomy of the developing brain is in cognitive processes is an essential first step to a
terms of its serving as a communication system where clinical exercise in diagnosis and establishment of
there is biological (neurochemical) information remediation programs for neuropsychological defi-
transfer. The principal components involved in this cits in infants and young children (Gaddes, 1980;
Rourke et at., 1983; Spreen, Tupper, Risser, Tuok- The neuroelectrochemical pulses reaching the
ko, & Edgell, 1984). inner ear pass through at least four increasingly elab-
orate stages of analysis and refinement before any
sound reaches conscious awareness for perceptual
General Considerations in Human Brain discrimination.
Growth Insults to the brain early in gestation may arrest
development with resulting gross malformations,
At the time of adult maturation, the human brain such as anencephaly (failure to develop a prosen-
accounts for approximately 2-3% of the body's cephalic outpouching); holoprosencephaly (failure of
weight, but utilizes approximately 20% of cardiac the forebrain to separate and develop normal com-
output (oxygen consumption), and 70% of the body's missures); and lissencephaly (failure of fissures to
glucose, which it is almost exclusively dependent occur, resulting in a smooth surface of the brain)
upon in the oxidative phosophorytation process (Smith, 1976; Langman, 1975; Lemire et al., 1975).
(Davison & Dobbing, 1968; Lemire et at., 1975; Nutritional requirements, as well as effects of
Nilsson, 1978; Humphrey, 1978). Even though the malnutrition (especially protein deficiency, which
body may be starving, the brain receives a dispropor- can affect brain weight and result in cognitive defi-
tionate share of nutrients, thriving almost exclusively ciencies later in life), are critical from postnatal
on oxygen and glucose. Because of these metabolic month 6 to month 18. Throughout childhood and well
requirements and dependence on the above two prin- into adult life, brain function increases tremen-
cipal constituents, and the fact that the human neo- dously, despite a brain weight gain during this time
cortex is poorly vascularized, states of anoxia, hypo- that remains relatively small (350 to 400 g) (Dodge,
xia, and hypoglycemia can seriously damage the Prensky, & Feigin, 1975; Hamilton & Mossman,
brain's normal functions, especially in early infancy. 1974).
A child may suffer from extreme malnutrition and
weigh only half of his or her normal weight and yet
Mass Growth of the Brain
the brain may only be 15% underweight.
Ninety percent of neurons are found in the brain. Brain weight has been used as a quantitative
It is an electrochemical network of some I 0 billion index of brain growth, as well as a traditional indica-
nerve cells, all present at birth, which regulate senso- tor of quantitative aspects of CNS development. The
ry-perceptual, motor, language, and other functions, brain of the newborn weighs approximately 300 to
as well as the higher psychological processes that we 350 g. By 12 months, the weight has more than dou-
define as human behavior. It works whether we are bled since birth and is approximately two-thirds that
asleep or not. For example, breathing alone requires of the adult. The average weight of the adult brain is
the complex coordination of some 90 muscles that from 1300 to 1500 g and is related to body size. That
must be regulated precisely in order to take just one is, larger people usually have heavier brains, al-
breath. though there is no connection between brain weight
Processing some 100 bits of information simul- and intelligence.
taneously, the human brain distinguishes between re- Growth of the CNS during early fetal life re-
ality, memory, and fantasy as it matures. As it devel- flects an increase in volume in the first trimester from
ops in terms of its inhibitory capacity to effect control 4% to 16%, compared to only 42% at birth. The
over behavior, it regulates the various human drives brain's weight is 21% that of the body at the sixth
and emotions that it spawns throughout its develop- fetal month, 15% at birth, and approximately 3% at
mental course. In some brain regions, 107 cell bodies adulthood (Dodge et at., 1975; Yakovlev, 1962;
can fit into a cubic inch; each one of them can be Yakovlev & Lecours, 1967; Hamilton & Mossman,
connected to as many as 60 X I 0 3 and none of them 1974).
exactly alike (Szentagothai & Arbib, 1974; Szen- The increase in volume of the cerebral hemi-
tagothai, 1975, 1978; Scheibel & Scheibel, 1973). spheres is slow and steady between fetal months 2
Some 50 x I0 3 connections are being formed and 6 but rapidly accelerates thereafter. The postnatal
each minute in the visual system at approximately 40 growth of the cerebral hemispheres is due mainly to
days postconception. Experiments have revealed that an increase in myelination. The brain stem grows
at this time, the eyes can respond to a camera's light most rapidly between fetal months 2 and 6 and less
flash (R. Y. Moore, 1977b; Lund, 1978; Crelin, rapidly thereafter. The cerebellum grows slowly be-
1973). tween fetal months 2 and 5, followed by an excep-
52 CHAPTER3
tionally rapid increase in volume commencing at Sensorimotor Functions and the Appearance
fetal month 6 and continuing until postnatal month 6. of Neurological Reflexes
The weight of the brain more than doubles dur-
ing the first nine postnatal months and reaches 90%
of its adult weight by the sixth year of life. Motor control behavior of the newborn is
The hemispheric surface of the brain more than largely under the control of the spinal cord and
doubles during postnatal growth to reach an adult medulla, whereas motor control in adults occurs at
value of approximately 1600 m2 . This growth is ac- different levels of the nervous system.
companied by an increase in the size and number of At birth, several neurological responses are pre-
gyri, so that the intrasulcal ponion ofthe adult cortex sent. The appearance and disappearance of neu-
is about the same as that in the newborn. The adult rological (primitive reflex) signs are essentially tran-
cortical surface area is reached by the second year of sient mechanisms either subserving life-sustaining
life. The entire hemispheric surface is gyrated by functions or forming preliminary patterns of future
approximately fetal week 32, despite the fact that voluntary activity, e.g., the stepping reaction that
these gyri are less numerous than in the adult brain. precedes voluntary step-walking. The most impor-
Normal thickness of brain tissue between the tant responses that appear and disappear in early
ventricles and the cortical surface is approximately postnatal life are as follows: reflexes of position and
4.5 em. There are many reports in the literature that movement, e.g., the Moro reflex, asymmetric tonic
people of normal or above-average intelligence, on neck reflex, neck righting reflex, Landau response,
cr scans, have only a thin layer of mantle between palmar grasp reflex, abductor spread of knee jerk,
ventricles and cortical surfaces measuring 1mm ver- plantar grasp reflex, Babinski response, and para-
sus the normal4.5 em. Several such cases have been chute reaction.
documented in the medical literature (Lorber, 1980). The Landau response and the neck righting re-
flex are the first to appear around the time of birth and
the last to disappear at one to two years (Siqueland &
White Matter Development Lipsitt, 1966). Reflexes to sound that appear at the
time of birth include the blinking response and the
Hemispheric white matter develops slower than turning response.
cortical gray matter during gestation. Postnatally, The reflexes of vision include the following:
white matter will continue to develop long after gray blinking to threat; horizontal following; vertical fol-
matter has reached a specified volume. The growth of lowing; opticokinetic nystagmus; postrotational nys-
the cortex subsides by the second year of life. That of tagmus; lid closure to light; and macular light reflex
hemispheric white matter continues even through the (Franz, 1963; Barnet, 1966). The feeding reflexes
second decade due to accumulation of myelinated include: rooting response-awake, rooting response-
fibers with their increased diameters. Myelination is asleep, and sucking response, all of which appear at
closely associated with development of the func- the time of birth; the last to disappear is the sucking
tional capacity of neurons; they fire more rapidly and response at approximately 12 months.
have a longer refractory period. Different fiber tracts The level of neural functioning during the neo-
myelinate at different developmental periods. The natal period can be determined only with great ap-
component populations of a given tract system may proximation. Some of these reflexes will drop out of
differ as to the timing of myelination (Davison & an infant's behavioral repertoire at around postnatal
Peter, 1970; Dobbing, 1975; Dobbing & Sands, month 3 or 4. This is presumably due to increasing
1973). cortical inhibition of lower centers in the brain. Re-
Myelination of tracts typically follows in a flex arcs exist below the cortical level and before
caudal-cranial sequence. The schedule for myelina- integration occurs between subcortical and cortical
tion was first elaborated by Fleschig in 1876. Around structures, stimulation of the infant elicits an invol-
the fourth fetal month, myelinated fibers appear in untary, subcortically mediated reflex response. As
the ventral and dorsal spinal roots. Last to receive this the maturing cortical centers become integrated with
investment are the associational fibers of higher cor- subcortical areas, primitive reflex behavior then be-
tical centers, e.g., the cerebral cortex's thalami. comes inhibited. The fact that most of the activity of a
Some tracts are not fully myelinated until several normal newborn can be observed in an anencephalic
years after birth (Dobbing & Sands, 1970; Dobbing infant possessing only a brain stem and certain com-
& Smart, 1974; Crelin, 1973, 1974; Hamilton & ponents of the basal ganglia, indicates that the cere-
Mossman, 1974). bral cortex participates very little, if at all, in the
function of the CNS during this stage of life. Children Stratification within the cortex proceeds accord-
with these morphogenetic anomalies do not survive ing to a definite plan in terms of neuronal organiza-
usually more than two months, but while alive, they tion. Neurons with connections in certain parts of the
do show reflex development similar to the patterns of brain differ from others with respect to the cerebral
normal infants of the same age (Smith, 1976; K. L. hemispheres. For example, in the posterior portion of
Moore, 1977a; Davison & Dobbing, 1968; Hum- the cerebral cortex, the development of the layers
phrey, 1964; Schulte, 1974; Dodgson, 1962). proceeds according to a clear-cut, typically six-layer
Concerning development of the cerebral cortex, plan with a distinct layer (IV) as the main site of
upper, central, and hindmost regions tend to mature termination of afferent impulses from the subcortical
early, such as those concerned with bodily sensations divisions of perceptual analyzer regions. There is,
involved in the control of movements, hearing, and then, a difference between the structural differentia-
vision. Frontal and lower sides (frontal lobe area) in tion of the anterior and posterior divisions of the
the region of the temporal lobe mature later. In the cortex in early ontogenesis. This may account for
motor strip area, for example, parts controlling trunk slowly developing cortical-cortical interconnections
and arm movements appear in advance of parts that essential to the final differentiation of the outer three
will control leg and finger movements. layers in middle and later childhood (Luria, 1969b;
Warren & Akert, 1964; Stuss & Benson, 1986).
Prematurity and Low Birth Weight
Nutrition and Malnutrition
The fact that babies who are born prematurely
but go on to develop without complications suggests Human fetal nutrition depends largely on the
that only when the brain is ready, and not before, will size and functional capacity of the trophoblasts in the
it start to develop in earnest. As a rule of thumb, placenta and the villous surface area through which
infants who are 4 weeks preterm generally will, after the exchange of nutrients takes place. In the placenta,
12 months, "catch up." Judging by the immature three phases of growth occur and by about 34 to 36
state of the cerebral cortex, it can be speculated that weeks of gestation, cell division ceases while weight
the latter plays a minor role in the life of the child at and protein increase nearly until full term. Placentas
the time of birth. The infant may be completely de- from infants who had experienced intrauterine
pendent on the inner regions of the brain and es- growth failure tend to show fewer cells and an in-
pecially its subcortical structures. Not until postnatal creased RNA/DNA ratio compared to control pla-
month 3 does the roof of the brain begin to intervene centas. Study of placentas from malnourished popu-
in a dominant manner, in the control of arm move- lations in the world has confirmed that fewer cells are
ments with the first signs of coordination of hand and present than in normal placentas. Maternal malnutri-
eye movements (Lemire et al., 1975; Davies & Stew- tion, vascular insufficiency, and abnormal influences
art, 1975; Spreen et al., 1984; Levene & Dubowitz, with regard to intrauterine growth contingent upon
1982). the placenta, will curtail cell division in the placenta.
During intrauterine life, all fetal organs are in a
Frontal Lobe Maturation hyperplastic phase of growth and probably at no other
time is the human organism more susceptible to nu-
The slowly maturing frontal lobes appear to be tritional stresses. Fetal malnutrition can result from
required for a young child to respond correctly to any number of causes, e.g., reduced nutrients within
verbal instructions. Luria pointed out that in young the maternal circulation, faulty placental transport of
children, the immaturity of brain structures may be specific nutrients, and abnormal maternal circula-
such that it is physically impossible for a child not to tion. Deficiencies in specific nutrients are found to
do what he or she is told not to do (Luria, 1960, affect fetal brain development. Reduction in either
1961). This situation bears close resemblance to that total calorie or total protein intake by the fetus can
of adults with damage to the frontal lobes. Not until lead to retarded growth (Cravioto & Arrieta, 1979,
the front of the brain is well developed can a child 1983).
become capable of obeying certain verbal instruc- Studies of the effects of malnutrition on the
tions. It is usually not until 3 Vz to 4 years of age that growth of human brain cells have been limited. In
children are capable of learning to carry out a com- infants who died as a result of failure to thrive (mar-
plex program of actions deliberately, in accordance asmus) during the first year of life, protein, total
with unrepeated verbal instructions. RNA, total cholesterol, total phospholipid, and total
54 CHAPTER3
DNA content were proportionally reduced. The rate activity lacks organization, rhythmicity, and reg-
of DNA synthesis was reduced and cell division ularity. At 6 months, organization emerges; rhythmic
showed curtailment in terms of reduction of the theta activity (4-to-6 Hz) appears in flurries lasting
number of cells. These factors suggest that if mal- about two seconds. In the seventh month, activity
nutrition persists beyond 8 months postnatally, not tends to become continuous at about l Hz with volt-
only the cell numbers but also size is reduced. ages ranging from approximately 100 to 200 micro-
Malnutrition in humans tends to reduce the rate volts. This slower activity is interspersed with faster
of cell division in all brain areas. Early malnutrition frequencies around the seventh and eighth months;
affects cell division, myelination, and vulnerability differences between active and quiet sleeping states
as to the maximum rate of synthesis of DNA. Nutri- become obvious (Ellingson, 1964; Lindsley, 1939).
tional deprivation before the age of 18 months causes Bursts in the electrical activity pattern at 6 to 7
permanent intellectual impairment. months are associated with an increase in enzymatic
activity in the brain. The major difference between
the immature and maturing infant's brain is the defi-
Cerebral Oxygen Consumption and Blood nite change in EEG between periods of wakefulness
Flow and sleep. As a generalization, the amount of quiet
sleep increases with maturation. In the eighth month,
In the developing brain of the newborn, oxygen during active sleep, fast waves of approximately 2-3
consumption is relatively low but gradually increases Hz appear with no localization and often imposed on
with maturation. That the neonatal brain is able to
low-voltage faster waves, and become dominant.
tolerate states of anoxia is suggested by the low cere- Frequency measurements of photically evoked re-
bral oxygen consumption at birth. This ability to tol- sponses recorded from the occipital area show a pro-
erate anoxic conditions may also be related to the gressive shortening with maturation. Responses to
brain's dependence (prior to birth) on anaerobic gly- auditory stimuli also show clear differences in wave
colysis as an energy source. The level of enzymes form, amplitude, and latency of wave components
needed for aerobic glycolysis just prior to birth shows with maturation (Ellingson, 1964; Hagne, 1972).
an increase as the brain's metabolism begins to Rate of maturation of brain electrical activity
change from anaerobic to aerobic. decreases with age. After birth, maturity of changes
Cerebral blood flow (CBF) is relatively low in occurs within the first 3 years. Fewer alterations are
the newborn but increases with age to a maximum of f 1
3 00 . . bo 3 4 noted between 3 and 8 years o age. Only mimma
105 em /1 g _per ":'mute startmg at a ut or differences are apparent from 8 to 21 years. Due to
~ears_of age. J?1srupt1on ~f C~F, oxygen con~ump- the continually changing aspects of the EEG during
tlon, ~~ tum wdl affect OXIdative phosphorylation ~s . childhood, problems of interpretation are more nu-
the bram dev;lops. The av~rage CBF for an adult IS merous than for adult recordings.
45 to 55 cm/100 g ~r mt~ute. In adults, a val~e Newborns have only brief periods of wakeful-
below2~cm ~~~gwdlbegmaprocesso~meta~hc ness with eyes open. Most EEG recordings are car-
degradation ~1thm neuronal _mitochondria, !eadmg ried out during sleep. Two well-defined types of
to cell dea~h 10 a matter of mmute~. Ano~a!tes that sleep are noted in 32- to 39-week premature and in
pos~ a m~J~r ~hreat to th~ develo~mg bra~n s ?Ieta- full-term neonates: active sleep and quiet sleep. Early
bohc e9uthbnu"?- at. the tt~e ~f btrth are. ~nnatal in the newborn's life, 2- to 4-Hz waves are present,
asphyxta; hypoxtc-tschemtc btrth-~l~ted eptsode_s; which will be replaced by those of 4 to 7 Hz at ap-
and extended ?ecrease of CBF that ts Interrupted~~ proximately 5 years of age. Faster activity in the
terms of cardtac output (Afifi .& Bergman, 1980 occipital regions of the brain begins to dominate (8 to
Roberts,. 1986; . Phelps, Mazzlotta, & Schelbert, 12Hz), and alpha rhythm of the mature brain starts to
1986;_ Fmkelstem, Alpe~, & Ac~erman,_ 1980: emerge. Occipital alpha rhythm changes rapidly in
Mazz10tta, Phelps, & Miller, 1981, Mazzlotta & the first year from a 3- to 4-Hz rhythm to twice that
Phelps, 1985). frequency by the end of the first year. Changes in
frequency most likely result from brain growth and
EEG Development myelination.
Changes in the EEG 's alpha frequency with age
Human fetal EEG activity has been recorded as have important behavioral consequences; for exam-
early as day 43 (Bemstine, Borkowski, & Price, ple, periods of rapid change in EEG activity can help
1955). EEG activity in the fetus evolves in a rapid to identify critical periods for behavioral change.
and specific manner. In a 5-month-old fetus, cerebral One of these periods occurs at the end of the third
month of life when the alpha rhythm first appears. Such diverse elements as neurological maturation,
Another important period extends from the end of the acquisition of fine muscle control, and development
first to the completion of the second year of life when of symbolic formulation abilities crucial to develop-
the alpha rhythm attains adult values. Alpha frequen- ment of cognitive processing of information are all
cy can be construed as an index of brain maturation related to speech. It is these neuroanatomical, neuro-
and thus a reliable marker of reference points for psychological, and neurophysiological aspects that
observing critical behavioral changes. provide the content and control from which speech is
Lindsley and colleagues (1939, 1974) proposed created. In later stages, especially in acquisition of
that the onset of organized rhythmic occipital activity words and sentences, contributions oflearned behav-
reflects a significant change in cortical organization ior emerge (Darley & Fay, 1980; Siegel, 1979: De-
and may mark a point at which the infant progresses Villiers & DeVilliers, 1979; Lenneberg, 1964, 1967;
from a subcortical to a cortical level of functioning. Milner, 1976).
It is suspected that visual behavior in early infancy is In the early prespeech stages, any division of
processed by subcortical mechanisms with the cortex speech development into discrete stages can be mis-
usually taking over in earnest at about the time rhyth- leading. Generally all basic behaviors that appear at
mic occipital EEG patterns begin to emerge. different ages function throughout childhood and into
There are numerous variations in the EEG pat- adulthood.
tern that are considered abnormal. Significant altera- After the prespeech stage from birth to 3
tions can be brought about by changes in level of months, speech starts with the reflex stage. The birth
consciousness. Recordings are usually done in multi- cry is often considered the beginning of speech, but
ple states: wake, drowsy, sleep, and so on. Abnormal any true expression is doubtful. Shortly after birth,
EEG findings should be considered only an aid in reflex crying appears in response to discomfort or
diagnosis and treatment of CNS disorders. Some ab- fear. Cries often vary and become differentiated from
normalities strongly suggest specific types of CNS other noises, such as gurgling, sucking, cooing, and
pathology. However, there are only a few well-estab- laughing. From 3 to 12 months, the babbling stage
lished abnormal patterns that correlate well with the occurs. Basic changes in vocal expression are ob-
clinical state of an infant: hypsarrhythmic pattern served in the rapid increase in the number and vari-
(high-voltage, arrhythmic activity usually associated eties of sounds. As a child develops early awareness
clinically with massive myoclonic epilepsy); of vocalizations and moves into a period of vocal
prolonged general bursts of regular 2- to 3-Hz spike- exploration, practice and repetition are hallmarks. A
and-wave patterns (associated with petit mal or ab- child at this stage begins to modify imitations and is
sence); continuous generalized spiking (sometimes aware that he/she is "imitating" oneself. In many
accompanied by a major convulsion, generalized cases, early imitations of others result from the par-
tonic-clonic seizure disorder); and a flat recording ents repeating sounds that the child has produced.
containing no distinguishable wave forms {usually Later, as the parents initiate imitative responses with
consistent with brain death). familiar new sounds, the basis for learning speech is
discernible. In the earlier phase, all kinds of sounds
are repeated. Sounds that approximate language are
Speech and Oral Communication usually selected based on the most intense reinforce-
Development ment derived by the child.
Another step in the development of speech
Speech (oral communication) is a basic tool in emerges when the child integrates babblings and im-
interpersonal relationships and serves as a key indica- itations into sequential patterns that sound more and
tor of developmental level in the early years of life. more like true speech (at about 12 months). Indi-
Any interference with speech development or subse- vidual sounds tend to be reasonably accurate, vocal
quent distortion of speech may have a profound effect quality approaches that of voices heard, and sounds
on social, vocational, and interpersonal development are grouped into nonsense forms and even phrases.
in the child. It is estimated that 5-7% of all children Occasionally, what appear to be recognizable words
of school age require special help with regard to are heard by adults, but it is doubtful that they repre-
speech (Neville, 1984; Luria, 1969c). sent meaningful speech.
An understanding of the neuropsychological de- True speech stages begin to emerge. Charac-
velopment of the speech process is needed prior to teristic features of the stages include motor control of
any professional advice or instruction with regard to breathing, phonation, and articulation. Ability to
the causes and treatment of speech-related disorders. echo, complex mechanical patterning of speech, and
56 CHAPTER3
other skills are practiced to assist in the leap to a occurs a transition from visual representation to a
distinctly different level of function. Complementary verbalization mode in which the child's ability to
interlanguage is a prerequisite as recognition of fa- participate in sequences of interpersonal exchanges
miliar objects in the environment requires inner Lan- via speech is evident. Children use language perhaps
guage. As the child develops into later years, this as a medium to communicate messages that become
type of language would be what adults use to ''talk to more syntactically refined over age. It is the process
oneself" (Molfese, Freeman, & Palermo, 1975; of assigning a memory code to a symbolic form that
Segalowitz & Chapman, 1980). The child later be- raises the question of "how does a child retain what
comes aware that certain sounds spoken by the paris learned?'' and ''how are coding errors corrected or
ents stand for objects (auditory receptive language); adaptations to a changing environment effected?''
inner language and auditory receptive language pre- (Vygotsky, 1980; Grossberg, 1980).
cede actual production of meaningful words (Luria, It would be a mistake to view speech develop-
1961, 1982; Luria & Yudovich, 1959). ment as an isolated process. It is integrally linked
The word stage emerges from approximately 11 with physical, psychological, and sociological pro-
to 24 months in which true first words are usually gress. Disruptions or distortions in any of these areas
names of concrete objects. Sentences start to appear may have serious repercussions, and it is particularly
at approximately 18 to 36 months. With the advent of important that speech be developed during early
an increasing vocabulary containing a variety of rep- childhood, since there is compelling evidence sug-
resentations for objects, people and actions in the gesting that lack of developmental opportunity or
child's environment provide the opportunity for the severe inhibitory factors may have serious and per-
child to discover more complex meanings and verbal manent effects on Linguistic-symbolic-intellectual
reinforcement. This is a variable period for the begin- development. The child may never become a com-
ning of sentences and there may be periods of little pletely functional human being in the developmental
progress after sentences are first used. sense if speech is arrested or not developed by 7 years
Complex speech takes place from approx- of age (Curtiss, 1979). Professionals and parents in-
imately 24 months up to 7 years. This period in the volved in a child's life have a significant responsibil-
normal child is characterized by an impressive array ity to detect aberrant patterns during development.
of developments. All parts of speech increase at a Symptoms of possible difficulty may be noted in
rapid rate. The word "no" will cover a vast number several ways during the first year of life. In the pre-
of situations, behaviorally, and provide a distinct speech period, the most critical characteristic is the
measure of control over individuals in the child's lack of progressive change in the nature of babbling
environment. Extrapolations of grammatical struc- or, conversely, deterioration of vocalization to that
tures cause difficulty with some irregular verbs, but representing earlier stages of development. At ages
the process of such abstracting indicates an increas- when response to and imitation of sounds of others
ing complexity of symbolic thinking. Categories are may be expected, any unusual delay may suggest
learned, for example, male and female, dog and cat, difficulty in learning to talk. Failure to engage in
but also learned is that matching reality to a symbol jargon conversation is likewise an important indica-
requires relative concepts as well as absolutes. This tor of problems. It is only when more advanced be-
quality of assigning symbol to meaning is usually haviors have failed to materialize that one becomes
lacking in severely autistic children in their develop- concerned in terms of delay. Continuation of earlier
ment of speech (DeVilliers & DeVilliers, 1979; Sie- forms of vocalizations during later months of the
gel, 1979; Luria, 1960; Wertsch, 1979). prespeech period are not evidence that progress is
As the expansion of potential for expression delayed.
continues to develop, not only does oral communica- As long as speech is inclusive enough for useful
tion serve as an efficient tool for exploring and under- communication and can be reasonably well under-
standing the people and the world that surround the stood by strangers by 4 years of age, concern over
child, it also becomes a means for controlling and development of a serious problem lessens. In addi-
manipulating the environment. It serves to provide an tion to articulatory aspects, there is the possibility,
extension in a variety of emotional expressions that during this period of development, of difficulties in
goes beyond older but still used methods such as fluency. For example, all children have numerous
tensing muscles, throwing a tantrum, crying, and dysfluencies in speech. At certain times and under
engaging in uncontrolled movements (Darling & certain circumstances, these are more frequent and
Fay, 1980). noticeable. The distinction between normal dysfluen-
During the child's first 12 to 18 months, there cies and stuttering is not always easy to make, partie-
ularly as there is so much variability from individual mer having slightly greater effect than the latter
to individual. In general, however, major concern is (Oates, 1979; Plomin & Rowe, 1979). What this
not necessary unless there are signs of struggling suggests is that several different cortical-cortical and
behavior, tensions, anxiety, or reactions to specific cortical-subcortical systems are operative during the
dysfluencies in the child. Persistent rudimentary sen- process of learning and information storage. What
tences may indicate a broader developmental delay the infant senses, then, may be in part due to what is
but it must be emphasized that the total environmen- neurally "set" to sense or competent to sense via a
tal background must be considered before assuming selective attending process (Pribram, 1976; Siegel,
that a child has basic inadequacies. 1979).
Recognition of a speech problem versus undue
concern over what are essentially individual dif-
ferences in oral communication patterns can affect a Postnatal Perceptual, Cognitive, and Motor
child's cognitive, social, and emotional develop- Development
ment. In this sense, appropriate evaluation can be
reached by integration of several factors: sequence Perception can be considered a multichannel
and nature of speech skills: relationship of these to process of visuomotor, auditory, sensorimotor, and
the child's experience and development; and the ac- other skills in which motor components of perceptual
culturation process in which others in the child's en- acts may be seen as a control process over sensory
vironment can influence these developments. One input mechanisms. Sensory input data contribute sig-
basic principle that seems to override all stages nificantly to the foJlowing: perceptual processing of
should be the stimulation, encouragement, and information; decision-making; readiness-to-act; and
provision of opportunities for speech without de- motor control commands, all the way from reflexes
mand or punishment. In circumstances where the se- to the highest neocortical levels involving abstract
vere form of speech pathology or abnormalities are thought. The significance of these processes as to the
not present, if speech is rewarding rather than punish- phenomenon of controllies in the success (or failure)
ing, a child will talk when ready and able to do so. ofthe infant's behavior.
However, if speech sounds have not developed by 4 During the first stage (the first 2 years of life), an
years of age, a serious disturbance is present. If there infant changes from a baby with little awareness of
is no speech (or poorly established patterns) by 6 the environment to a child who is aware of the en-
years, most likely there will be intellectual and so- vironment due to the developing perceptual systems
cialization deficiencies of significant proportions and neurological processes. If development is nor-
(Pinker, 1984; DeVilliers & DeVilliers, 1979). mal, the child is capable of discriminating among the
various environmental stimuli. During the second
stage (2 to 5 years), preconceptual representation as
Acculturation Processes described by developmental theorists such as Piaget
and Bruner takes place in which the child develops
Brain growth and the acculturation process are pictorial (ideograph) images as symbols. The child
inextricably bound in human development. Neural also begins to advance in language competency. Dur-
networks are being set and affected by specific expe- ing the third stage (5 to 8 years), symbolic representa-
riences related to environmental events (Szentago- tion occurs in which the child becomes aware that
thai, 1978). Acquisition of cognitive operations, he/she is not alone in the universe and begins to
which stem from a particular culture, is affecting interact with several environmental forces that im-
elaboration, in part, of neural circuits, such as feed- pinge on the child's development. The fourth stage (7
back and feedforward loops. These circuits are built to 12 years) is characterized by operational thinking
during a period of acquisition and development of in which the child begins to recognize certain rela-
cognitive neural codes. Brain morphogenesis during tionships between objects and appreciate their rela-
a prolonged period of exposure to significant novel tive values, e.g., the concept of mass, size, distance,
experiences can be expected to be modeled in accor- length, and time (Bower, 1977; Siegel, 1979; Mis-
dance with ongoing experience (Goldman, 1975; tretta & Bradley, 1978).
Gottlieb, 1976a,b; Taylor, 1969). Several attempts have been made to match de-
Data collected from studies of heredity and en- velopmental stages in cognition with defined struc-
vironment suggest that morphogenetic development tural changes in the brain (Epstein, 1978; Milner,
of the brain's intellectual nature is attributable to both 1976; Ploog, 1979; Vygotsky, 1974). Thus far, such
genetic and social environmental influences, the for- efforts have had only very limited successes. Major
58 CHAPTER3
obstacles in trying to correlate behavioral, motor, events, differ from those that organize and lay down a
and sensorimotor development in finite stages in- long-term memory code?
clude nerve processes showing differentiation, syn- Structures implicated as crucial for forming new
aptic process formation, dendritic arborization, and and enduring memories are the hippocampi. Specula-
myelinated pathway development, to name a few. tion exists that the hippocampi and amygdala process
Actual alterations or modifications also can be due to potential memories and then pass them on to the cor-
metabolic factors that affect function: decreased tex. It is at this level where thought, planning, deci-
CBF; oxygen use by cerebral tissues; glucose use by sion-making, and other higher cortical functions take
cerebral tissues; cerebral vascular alterations that can place and where sensory impressions leave their
lead to ischemic, hypoxic, or anoxic episodes. As "traces" in neurons. How this process works is not
glucose and oxygen are the primary constituents understood. Only certain impressions are allowed to
providing the metabolic energy requirements of the flow into the cortex and how others are kept out
brain, rates at which these substrates are used can (inhibited) is a mystery. How neurons are ''tuned in''
provide a quantitative assessment of the level of neu- to the ongoing events of the environment, such that
ronal function in the brain. they can abruptly change in firing patterns upon sens-
Maturational changes in cerebral function in ining the smell of food, the perception of fear or threat,
fants have been studied by quantitative methods the sight of something stimulating, and so on, is unre-
using 2-deoxy-2-fluoro-o-glucose and positron emis- solved at the present time.
sion tomography (Chugani & Phelps, 1986). Studies A major anatomical site that acts as a
on infants at various times during development re- "gatekeeper" in this process is thought to be the
vealed significant changes in a progressive manner in nucleus basalis of Meynert. One of the implicated
local cerebral glucose use. Chugani and Phelps chemical messengers in this process is acetylcholine,
(1986) studied 5-week-old, 3-month-old, and older which has been found to aid neurons in the cortex to
infants. Glucose metabolic activity increased in ana- retain the imprint of information flowing to the
tomical regions in agreement with behavioral, ana- cortex.
tomical, and neurophysiological alterations that are The question as to how a cognitive code be-
known to occur in the first 12 months according to comes established involves understanding "how"
established patterns of infant development. neurons record symbolization of the representational
Although it is not yet possible to specify which objects from the environment. How representations,
brain 11\echanisms are specifically involved in per- symbolically, achieve distinctiveness as to properties
ceptual processing, it is commonly believed that of global consistency and stability (once encoded) in
many of the events are distributed throughout the the brain remains one of the major challenges for
brain. Perception represents functions drawing from researchers of infant cognitive development
systems at diverse anatomical sites, both in upper and (Grossberg, 1980).
in lower regions of the brain (Livingston, 1978; Ma- Representation of environmental events re-
jovski & Jacques, 1982; Bower, 1977). ceives continuous updating, in part, due to the
Connections conceivably involved with central thalamocortical processing of spatiotemporal events,
information processing of context-dependent and such as formation of a spatiotemporal ''envelope'' of
context-free events in the environment may involve reality leading to consciousness. This latter explana-
cortex-to-basal ganglia and frontolimbic pathways. tion perhaps may account for how the brain, during
Sensorimotor readiness, in part, is dependent on cog- development, is able to maintain an updated version
nitive-spatial mapping properties thought to be car- of reality with global consistency. Lashley, Chow,
ried out in the hippocampal formation and neocor- and Semmes (1958) asserted that the core function of
tical structures (Izquierdo, 1975; Nauta, 1986a,b; Li- the CNS lies in the spatial.and temporal integration of
ben, Patterson, & Newcombe, 1981). perception and motor activity in order to provide re-
Memory underlies the highest functions of the fined adaptation of behavior.
brain, from multiplying two numbers to developing a Some important clues related to how brain
sense of oneself. All memories come from the world mechanisms operate in terms of sensory processing
outside of the mind. Whereas visual images leave and an infant's behavioral output, come from a con-
shadows on the retina for less than a second, sounds sideration of noncorrespondence with past experi-
taper off into echoes lasting no more than four sec- ences. The infant perhaps chiefly discovers through
onds. A major question arises: how does a coded action that stored codes are connected after his or her
memory process, specific to certain environmental behavior achieves success. Perhaps it is at that partie-
ular moment that perception itself is projected in a that may take place prior to actual conscious registra-
appropriate symbolic form in a predictive manner for tion in the developing infant (Cohen, 1979; Cohen,
the desired behaviors to follow. Behavior, in this De Loache, & Strauss, 1979; Mistretta & Bradley,
sense, is essential to the shaping process of stored 1978).
sensory information and not simply its goal. Memory A consideration of how symbolic information is
storage might be deposited in the neural substrates of processed in the cerebral hemispheres raises the issue
various brain centers that are accessed according to a of cerebral lateralization. Studies have shown that
given "contextlike" paging system such as might be matters are not as localized as was previously thought
similar to a library cataloging system. Delays in according to older theories about left and right brain
matching stored percepts to sensory input would then functions. Children as well as adults use both hemi-
be experienced when the context is suddenly altered spheres. Perhaps in early child development, both
(Majovski & Jacques, J982). hemispheres serve linguistic functions, prior to left
Some crucial steps considered operational in hemisphere lateralization in the majority of right-
this process include: rapid matching stage; hypoth- handed individuals for language capacity (Benson &
esis formation; internal sorting from possibilities; Zaidel, 1985). This would suggest the possibility that
and testing the selections made via behavioral acts. greater cortical plasticity is most likely present in the
Siqueland and Lipsitt ( 1966) demonstrated that in- earlier stages of infant language development
fants can exhibit learning during the first day of (Molfese, 1977). Despite the appearance of a high
postnatal life. Head turning is a regular response in degree of hemispheric specialization as the child ma-
which hypothesis testing conceivably is occurring. tures, the human brain efficiently can be viewed as a
Memory storage undoubtedly is taking place, to- ''single-channel system'' in the earlier stages of in-
gether perhaps with suppression of interhemispheric fant development and later shifts due to changes in its
transfer of memory codes. The suppression phe- subsequent cognitive and linguistic development
nomenon introduced here has the potential effect of (Kinsbourne, 1976; Witelson, 1977; Taylor, 1969).
doubling the capacity of the neocortex for memory Some of the rather striking consistent correlations
storage in its early stages. The anterior commissure between maturation of the brain and development of
of the corpus collosum, which interconnects the two behavioral processes are as follows: the visual pro-
temporal lobes, is believed to participate in memory cessing area in the brain develops early in the first
storage bilaterally in a yet unspecified process. Per- year; the limbic areas develop later in the first year;
haps the most plausible mechanism for early stimulus the sensorimotor areas develop in earnest in the sec-
identification and refined feature selection involves ond year; hearing areas continue to develop into the
that of lateral inhibition. fourth year (Bronson, 1982; Bushnell, 1982; Levine,
In studies that have examined the relationship 1982; Seines & Whittaker, 1976). The brain's high-
between abilities of infants and subsequent cognitive est areas (those involved in thinking, abstraction,
functioning, a substantial correspondence has been reasoning, problem-solving, and so on) continue to
found between infant behaviors and cognitive and mature well into the teens and perhaps even into the
linguistic abilities in early childhood, despite rather third decade. Development of social competency is
low correlations of test scores and measurements really a mixture of maturing of perceptual, sen-
from infant intelligence tests (Siegel, 1979). It has sorimotor, motor, and linguistic mechanisms in the
been suggested that later cognitive development cor- brain, in conjunction with the social conditions of the
relates more highly with early problem-solving acculturation process (Oates, 1979; Siegel, 1979).
skills, whereas language development tends to corre-
late more highly with a child's understanding of both
object-concept and means-end relationships (Sie- CNS Maturation in Early Cognitive
gel, 1979). Development
Very little is actually known about the precise
neurophysiological processes that occur in recall and Maturation of cognitive abilities in relation to
comparison of stored memory data. There is a surfeit the growth of the brain, previously discussed, is in-
of theories and conceptualizations and a shortage of fluential also with regard to emotional and person-
consistent, experimental data that specify the under- ality development in children (Emde, Gaensbauer, &
lying mechanisms. What remains clear, however, is Harmon, 1976). A sequence of maturation of cog-
that the processes involve comparisons. They tend to nitive abilities has been proposed by Kagan (1985).
occur at a rather abstract level of cognitive processing First, the infant demonstrates the capacity of memory
60 CHAPTER3
for past experiences; second, active memory forma- fluences a child's behavioral choices in later years in
tion occurs; third, there is a symbolic framework that many subtle ways.
takes shape; fourth, the infant is able to infer
causality; and fifth, the child is able to exhibit self-
awareness. Kagan and co-workers assert that these Cerebral Asymmetry and Cerebral
five steps, in the sequence described, occur by the Lateralization
age of 2 in the normal developing brain (Kagan,
1981; Kagan & Moss, 1983; Kagan, Kearsely, & To date, there is no firm conclusion as to the
Zelazo, 1978). nature and cause of cerebral hemisphere asymmetry.
Kagan asserts that a normal developing child However, the structure and function of each hemi-
can by 8 months show the ability to retrieve hidden sphere are indeed different (Mazziotta & Phelps,
objects, whereas earlier, if "out of sight," it was 1985). An explanation of the functional differences
"out of mind." Beginning approximately at 8-9 solely in terms of a dichotomy of verbal or nonverbal
months, incoming information is related to knowl- nature of information processing also has not been
edge for the first time, giving rise to the emergence of adequately substantiated. Many researchers have
active memory processing. At 8 to 10 months, car- proposed theories and models of the development of
diac acceleration occurs in relation to exposure to the cerebral asymmetry and its function, including: Len-
visual cliff experiment. This does not occur prior to 8 neberg (1967), Kinsboume (1974), Kimura (1967),
months, indicating that the sympathetic nervous sys- Krashen (1973), Witelson (1977), Corballis (1980),
tem is coming into play more influentially and affects Buffery ( 1976), Kinsboume and Hiscock ( 1977), and
what has been commonly termed the separation anx- Moscovitch ( 1977).
iety phenomenon. Infants all over the world have Studies suggest that within the left and right
been shown to manifest separation anxiety features cerebral hemispheres, at all ages and in both sexes,
between 8 and 12 months (Kagan, 1985). different functions are served (Benson & Zaidel,
As growth of the CNS continues, new capacities 1985; Taylor, 1969; Morgan, 1977; Bradshaw &
emerge. At 17 to 24 months, several important be- Nettleson, 1983; Bryden, 1979; Corballis, 1982;
haviors emerge: appreciation of right versus wrong; Witelson & Pallie, 1973; Kinsboume, 1976). It is
appreciation that physical aggression is wrong; ap- believed that bilateral integration of information is
pearance of anxiety in relation to failure; the ability to mainly subserved by the corpus callosum. Problems
experience empathy; and features of acknowledging can typically arise when growth is delayed or when
anxiety in relation to unsolved problems. dysfunctions occur in the between-hemisphere in-
At 1-to-3 years, children begin to recognize terplay during cognitive information processing. A
themselves. It is thought that the maturing brain's majority of studies and theories that deal with scien-
anatomical structures permit the concept of self- tific evidence on cerebral asymmetry have centered
awareness to emerge, implicating the hippocampus on the lateralized aspects of cognitive functioning in
and the thalamocortical projection system. One of the children.
more significant neuroanatomical aspects here is that Studies have shifted in emphasis away from the
between 15 and 24 months, all of the cortex's six content-dictated, verbal-spatial dichotomies of the
layers have achieved maturation. encoding process to a process-determined analyti-
Kagan ( 1981) asserted that in a child of approx- cal/ sequential versus gestalt/holistic information
imately 2-3 years, fear is prevalent. It has been processing style (Bogen, 1969; Levy, 1972; Levy-
shown that the more a child is capable of inhibiting an Agresti & Sperry, 1968; Luria & Simemitskaya,
unfamiliar experience, the better stabilized the child 1977). Kinsboume and Hiscock (1977, 1978) have
becomes. Separation anxiety (attachment) is cog- presented compelling arguments leading away from
nitively mediated and the environmental context dic- the concept of progressive lateralization with age.
tates the value placed on the notion of a child's "in- Kinsboume ( 1982) discussed in some depth the im-
hibitedness" (Smith & De Vito, 1984). portance of the collaborative efforts of the two hemi-
The latter consideration may be causally related spheres of the brain. Arguing from the viewpoint of
to the formation of aspects of temperament that can cerebrallateralization theory, Kinsboume stated that
be changed with experience. The parasympathetic mental activities that relate to action in the real world
system has the capacity to quell sympathetic arousal impose demands for integral and coordinated action
to unfamiliar and nonunderstandable events for the of both sides of the brain.
child. The development of temperament heavily in- Luria's (1966, 1973a) position is one of empha-
sis placed on each hemisphere contributing a differ- mental designs, educational, remedial, diagnostic,
ent strategy of cognitive information-processing and and therapeutic regimens wiJI only be partially
does not isolate each process within a hemisphere of effective.
the brain. He tends to view the human brain as hier- A necessary first step in making scientific pro-
archically organized in order to integrate messages gress is to describe the events and conditions defining
from its lower centers as well as across hemispheres. a process of psychological function before proceed-
Luria asserts that dichotomy of functioning does not ing to hypotheses and constructs of brain-behavior
do justice to the complexity of the human brain's relationships. Experimental studies of brain mecha-
hemispheres. Rather, it is the manner in which the nisms and developmental issues, coupled with neu-
hemispheres organize or represent information ver- rophysiological, neuropsychological, and neu-
sus the type of information organized that is the robiological data will yield not only broader
important distinguishing feature (Luria, 1970, generalizations, but also specific knowledge that can
1973a,b). lead to better understanding of the child's developing
Witelson's (1977) review of developmental brain structures, functions, and cognitive capacities
studies of different sensory modalities pertaining to involved in extracting meaning from the external en-
cerebral asymmetries, handedness, sensorimotor, vironment (Gottlieb, 1976a,b; Lowrey, 1973).
perceptual, and even genetic studies, shows that de-
velopment of cognitive functions follows a definite
order. Several changes occur, some of which can be Research Strategies for Studying
genetically determined (but influenced by the en-
vironment). Hemispheric shifts in which side of the Normal Brain Development and Its
brain handles what type of information, due to altera- Functions
tions in the structural development of the brain, also
occur (Bakan, 1971; Annett, 1978). At present, it is Research Designs and Methodologies
reasonable to assume that cerebral dominance is not
only related to linguistic processes but also to under- The choice of experimental designs and re-
lying cognitive ones influenced by the several factors search methodologies for the investigation of ques-
discussed previously. lntermodal hemispheric pro- tions in the field of developmental neuropsychology
cessing of information can show differential effects poses significant problems such as replication, prop-
when the child reaches 8 years or older, due to the late er statistical means of analyzing sample data, group
structural maturation of the corpus callosum. This differences, and power as to the conclusions that can
can lead to various forms of difficulties, for example, be drawn from research studies. Spreen et al. (1984)
dominance problems, dyslexia, and learning difficul- have recently addressed some of the methodolog-
ties (Satz, Orsini, Saslow, & Henry, 1985; Schon- ical concerns regarding developmental neuropsy-
haut & Satz, 1983). Currently there are conflicting chology.
theories and hypotheses related not only to cerebral The future of clinical research in developmental
dominance and hemispheric specialization but also neuropsychology will radically change in the next
regarding the onset, development, and maturation of few decades, due chiefly to the fact that presently
the brain's lateralization (Geschwind & Galaburda, available instruments are being technologically re-
1984). fined for use with different age levels of people
studied.
The horizon that lies ahead for developmental
Conclusion neuropsychological research and theories that will
emerge, will be shaped chiefly through emerging
Inadequate encoding of early experience, brain technological innovations. These include imaging of
insult, nutritional deficiency, anoxia at birth, per- living brain chemistry, metabolism, and neurorecep-
inatal asphyxia, and congenital hereditary defects, tors; and the measurement of maturational changes in
etc. each can impose severe restrictions on those ca- cerebral functioning by means of mapping brain
pacities essential for processing sensory, motor, vi- function onto structure.
sual, acoustic, haptic, and other information. Until A radically new data base from which to make
normal brain development and the mechanisms for generalizations about normal brain-behavior rela-
higher cognitive processes are more accurately and tionships in the developing infant is to be found,
adequately described by data from improved experi- chiefly in terms of observations and accurate descrip-
62 CHAPTER3
tions regarding structure, function, and metabolic re- cance by pure chance or may have become obsolete.
quirements of tissue competency. (pp. 88-89)
A current review of the literature of develop-
mental psychology and developmental neuropsy- The key to making a systematic investigation of
chology reveals a lack of replication in many studies. the mapping of human brain function onto structure
during development in order to correlate cortical pro-
There exists considerable controversy in the area of
human lateralization studies, cerebral asymmetry cesses in the functional organization of the brain, lies
theories, and implications for brain development. in the combination of many imaging techniques to-
These controversies will abound until research on gether with functional source localization and neuro-
normal brain-behavior relationships in infants and psychological measurement.
young children begins to fill in the gaps in our
knowledge.
Despite the impressive existing array of tech- Conclusion
nological capabilities for measurement, a major as-
pect is missing. Measurement of the brain's sensory, Relatively little is known about the normal de-
motor, and cognitive processes provides only indi- veloping brain with respect to higher cortical func-
rect assessment of task performance. Even nonin- tions, especially in early infancy. Selected studies
vasive techniques, such as the EEG or ERP, are indi- and techniques presented here have begun to make an
rect in that they only measure electrophysiological impact on this situation. Significant information on
phenomena arising from electrochemical brain ac- the development of normal brain-behavior functions
tivity, not actual cognitive activity (Gevins et al., will come about by joint efforts employing imaging
1981). Details of cognitive activities must be inferred methods (which reveal structure); neuropsycholo-
from knowledge of the underlying physiology and gical assessment techniques (Taylor et al., 1984)
the task being performed by the subject (Fender, (which determine consequences of neurological
1985). function); neural source localization techniques
What is needed to overcome these limitations is (which can identify the site of those neural popula-
a systematic, comprehensive investigation correlat- tions that subserve specific brain functions); and met-
ing patterns ofbrain activity with selected behaviors; abolic and spectral measurements of human phys-
and mapping of function onto brain structure. This iology (metabolic tissue competency) (Phelps et al.,
will allow researchers to acquire information about 1986).
the functional organization of the working brain. It is the possibility of standardized, quantitative
It is possible today to map brain function onto correlations of structure, function, metabolism, brain
structure by bringing together neuropsychological electrical activity, and neuropsychological factors
assessment data about structural changes and cor- that will ultimately promote a different and novel
relating structural damage with change in cerebral knowledge base. It will also lead to improvement in
function and altered cortical processes. Various de- our understanding of the development of higher cor-
terminants, which can be quantitatively measured tical functions from a normal developmental per-
and correlated, will allow more accurate description spective.
of the maturational changes in cerebral function in A major criticism that some have leveled at the
humans with some reasonable behavioral correlates usefulness of the correlation between structure, func-
(Fender, 1985; Chugani & Phelps, 1986). tion, and behavior is that such attempts are doomed to
Spreen et al. make the following point regarding fail because it is impossible to localize function in the
the importance of replication in competent research: nervous system. Lesions (or structures) are localized,
not functions. However, there is extensive evidence
. . . The goals of the replication study are to answer the that at least certain stereotypical processes, such as
following questions. Can the original investigator or an sensory input and execution of motor output, are cor-
independent investigator following the information related with highly consistent patterns of electrical
provided by the original investigator replicate the re-
cortical activity. This is considered to be hard-wired.
sults of the original study? Have social, cultural, eco-
As there are characteristic signatures of electrical ac-
nomic, medical, etc., changes in the population made
previous findings obsolete or misleading? Are the find-
tivity associated with some components of behavior,
ings generalizable to a new set of subjects, test items, metabolic (chemical) signatures also have been con-
test settings, etc.? In sum, replication is a powerful sistently drawn. It appears that the possibility now
tester for determining the relevance of an investigation exists of linking structure, function, and cerebral
and for weeding out findings that may show signifi- physiology with powerful imaging techniques in a
cohesive, standardized fashion for gathering data so Carpenter, M. B. (1978). Core text of neuroanatomy (2nd ed.).
as to produce the type of correlation lacking in the Baltimore: William & Wilkins.
above regard concerning developing brain function Chugani, H. T., & Phelps, M. E. (1986). Maturational changes in
and higher cortical processes in children. cerebral function in infants determined by 18FDG positron
emission tomography. Science, 231. 840-843.
Cohen. L. B. (1979). Our developing knowledge of infant per-
ception and cognition. American Psychologist, 34, 894-
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4
Mechanisms and Development of

Hemisphere Specialization in Children
MARCEL KINSBOURNE
The Normative Endpoint of volve the left hemisphere also in more than half of all
Hemisphere Specialization in the instances (Bryden, Hecaen, & DeAgostini, 1983).
Within each hemisphere the territory involved in cog-
Adult
nitive function is more extensive in the left- than the
right-hander. Gender-related differences in later-
The sequences of cognitive development to be con-
alization are more contentious, and the claim that
sidered in this discussion culminate in an endpoint in
language and visuospatial functions in females are
the mature human nervous system that in its broad
more bilateralized than in males, and even that intra-
definition is no longer in dispute. In the right-handed
hemispheric organization on the left differs between
majority, language-related processes are left later-
the sexes, are not as yet well enough substantiated to
a_lized in almost every case. There does appear to be a
have made an impact on the study of the development
nght hemisphere contribution toward certain aspects
of hemispheric specialization. With respect to devel~
of verbal behavior, however {Hecaen, 1978; Searle-
opment, existing knowledge is virtually restricted to
man: 197?, 1983), notably comprehension oflogical
language functions on the one hand and spatial~rela
relat1onsh1ps, metaphor, and humor (Gardner, Ling,
tional functions on the other. This discussion will
~amm: & Silverman, 1975), and at the output stage,
theref~re be confined to considering how peripheral
mtonat1on, particularly when it reflects the emotional
laterahty, notably hand preference, is established in
tone of the utterance (Ross & Mesulam, 1979). The
the developing child, and how the differential hemi-
l~ft hemisphere is also specialized for rapid sequen-
spheric representation of language and spatial-rela-
tial recognition of familiar input, both verbal and
tional functions develops, first in the normal case
nonverbal, as well as the recall and recognition of
and then in a number of different types of develo~
order information and formulation of action plans
plan~ both ~otor and conceptual. Right hemisphere
mental disability.
It is generally accepted that at birth the human
do?lmance 1s best documented for certain spatial re-
latiOnal processes particularly in the visual modality, infant's cerebrum has not yet assumed the functions
as well as the processing of emotional information that it will ultimately subserve. The functions that
(Kinsbourne, 1982). Non-right-banders deviate from will emerge over time can be subdivided into those
the dextral norm in the following manner: in addition for which hemispheric specialization has been ascer-
to left-sided representation of language, which is as tained, and those for which no lateralization has (as
yet) been established. Although a good deal is now
prevalent. in non-right-banders as in right-banders,
known about the changes in number, configuration,
language IS also represented on the right in some 70%
ofthe cases (Gioning, Gloning, Haub, & Quatember, and connectivity of neurons in the two developing
1_959). I~ non-right-banders as in right-banders, spa- hemispheres, none of this has been shown to relate to
ttal-relattOnal functions are right Iateralized, but in- emerg_in_g higher me~tal functions. One can only time
the ongm of the vanous lateralized mental skills by
observing their appearance at the behavioral level.
MARCEL KINSBOURNE Department of Behavioral The developmental sequences involved in the
Neurology, Eunice Kennedy Shriver Center. Waltham, Mas- emergence of language and spatial-relational skills
sachusetts 02254. have been reasonably well specified. Once they be-
69
70 CHAPTER4
gin to emerge, and subsequently as they become The Origin of Bisymmetry

more refined, it becomes possible to ask, what is the
basis of this developing skill? Somatic bisymmetry is an adaptation to the
A distinction has to be drawn between hemi- needs of motile organisms. In addition to the obvious
spheric specialization and lateralization of function advantage of streamlining, the bisymmetric orga-
to a hemisphere. It cannot be taken for granted that nism is well adapted for the major decision constantly
the developing skill in its earliest stages is based on made by organisms as they progress from point to
the same cerebral hemisphere as is ultimately the point: to tum right or to tum left (Loeb, 1918). Given
case. The hypothesis that the lateralization to one that whatever benefits and hazards the environment
hemisphere is constant is termed "invariant later- might present it is likely to do so with equal proba-
alization" (Kinsbourne, 1975). It has been pitted bility to either side, the organism needs to be able to
against an alternative view, namely, that in the earlier deploy its sensorimotor capabilities to either side
stages mental functions in general (and language in with comparable speed and efficiency (Gardner,
particular) are based on the activity of both cerebral 1967). Thus, the receptor equipment and the mus-
hemispheres and that lateralization of verbal func- culature are both bilaterally arranged, and so are the
tions to the left and spatial relational to the right corresponding control centers in the nervous system
occurs over time during childhood. This is the "pro- (contralaterally in the chordate phylum, ipsilaterally
gressive lateralization" hypothesis (Lenneberg, in the other phyla-Hyman, 1940). Sessile orga-
1967). Virtually all that is known about the evolution nisms are not bisymmetric, and organisms that re-
of hemispheric specialization in the child can be for- gress from a motile to a sessile state concurrently lose
mulated in terms of these two hypotheses. their bisymmetric organization. Organisms whose
Insofar as lateralization and its development are life cycle divides into larval and a mature phase and
subject to biological variation, one can ask whether a whose mature phase is sessile, exhibit the rela-
particular topography of hemispheric representation tionship most strikingly. The motile larva is bisym-
of function is more conducive to efficient mental metric, the adult form is not. In the case of fishes,
function than Qthers, and whether some of these other which also freely turn up and down, dorsal-ventral
"abnormal" topographies characterize certain de- symmetry of the body is commonly found (Braiten-
velopmental disabilities and even account for some berg, 1977).
or all of the behavioral deficits involved. These ques- If bisymmetry is an adaptation in the service of
tions can be addressed most directly in the case of the motility, then two considerations follow: (I) bodily
fully mature nervous system, but lags in achieving organs not involved in movement or movement con-
that endpoint can also be considered. trol will not necessarily be bisymmetrically struc-
tured and (2) bodily parts that control motion may
deviate from complete bisymmetry only to an extent
short of inducing a maladaptive bias in movement in
Asymmetries in the Evolutionary ecologically valid situations. Examples that docu-
ment both these propositions abound. The viscera of
Context vertebrates are by no means bisymmetric, though
they are so packed within the bodily cavity as not to
Asymmetric cerebral and somatic functioning distort the bisymmetric form and streamlining of the
are chiefly of interest in clinical child neuropsychol- organism as a whole. Even parts of the nervous sys-
ogy for any implications they might have for adaptive tem, namely, those that control internal rather than
performance and behavior. An appropriate point of externally directed functions (i.e., autonomic), may
departure for considering these issues is therefore an depart radically from bisymmetry. Also, as we shall
inquiry into the evolutionary origin of these asymme- further consider subsequently, the cerebrum in its
tries. Why did they evolve and what might have been most elaborated form in the human is not strictly
their relations to the ongoing response of organisms bisymmetric.
to environmental pressures? If we could determine
what role asymmetry of function plays in adaptive Asymmetry (Somatic)
behavior, then we could better predict the ways in
which lack or distortion of such asymmetry might Minor asymmetries abound and have been doc-
affect the functioning of the human infant, child, and umented in all species studied in sufficient detail
adult. (Ludwig, 1932). An instructive example relates to
HEMISPHERE SPECIALIZATION IN CHILDREN 71
the pelvic and pectoral fins of fishes. These, though space. Bilateral control of such a function would not
bilateral, are asymmetric, it being the general rule seem to be necessary and in fact unilateral control
that the right-sided fins are more bony and muscular prevails. Nevertheless, the mirror image area does
than the left (Hubbs & Hubbs, 1944). This is the case develop and is available as a reserve. This is not to
even though the fishes' musculature itself is bisym- suggest that it is there in order to be in reserve in case
metric. This appears to be because their asymmetry of left-sided brain damage. Rather, nature is conser-
poses no problem for the function of fins as rudders to vative in the manner in which it refines neural control
direct efficient swimming movements. This is an ex- mechanisms, and there was perhaps no provision (or
ample of an asymmetry that does not appear to have environmental adaptive trigger) to preclude the gen-
evolved to meet a specific adaptive need, but appears erally unutilized right-sided area from evolving in
to exist because the engineering of exact bisymmetry parallel with the left. This issue is of interest because
was not needed to meet the particular adaptive pres- there are human phenomena that can be similarly
sures in the context of which the species evolved. interpreted, notably the left-sided control of speech.
If the left speech area is totally destroyed, the right
Asymmetry (Neural) side does seem able to control speech output (Sea-
rleman, 1977, 1983). Should we suppose that in the
In behaviorally simple organisms the functions intact state the unilateral facility in actual control of
of the nervous system distribute across two domains: behavior maintains its control by virtue of actively
the regulation of the internal environment and the suppressing (inhibiting) its potential rival on the
control of behavior oriented in space. The former other side (Kinsbourne, 1974)? If this mechanism
does not call for bisymmetric control, and certain exists, then its impairment could account for certain
striking brain asymmetries in behaviorally limited forms of behavioral deficit.
species may relate to vegetative function (Braiten- The analogy with the bird song captures one
berg & Kemali, 1970). In the more behaviorally so- attribute of human brain organization, the usual vir-
phisticated vertebrates, including mammals and tual restriction of the control of a skill not targeted to
birds, the repertoire includes a third domain: higher a specific external location to one side of the brain. It
mental function as involved in communication, fails to capture another attribute: the complemen-
memory, and problem solving. Not being targeted tarity of human hemispheric specialization
toward specific locations in the physical environ- (Kinsbourne, 1982). A much simper animal model
ment, these processes can serve their purpose without illustrates the device of complementary specializa-
being bilaterally represented. Whereas central repre- tion. The paired claws of the lobster differentiate into
sentation of sensorimotor processes is topographic, a stout crusher driven by slow muscle fibers, and a
representation of higher mental functions is abstract slender cutter, largely driven by faster muscle fibers
(J. z. Young, 1962). If an abstract representation (Govind & Pearce, 1986). The asymmetry develops
deviates, even substantially, from bisymmetry, this under central neuron control, and is mediated by lat-
need not be because the asymmetric topography con- eral differences in the degree of reflex activity. In
fers specific adaptive advantage. The relaxation of humans, the cerebral hemispheres supply differenti-
need for bisymmetry may sufficiently account for ated but complementary components to skilled be-
deviation from bisymmetry (Kinsbourne, 1974). havior, to the point that many real-life activities sim-
A striking example of asymmetry of brain repre- ply cannot be effectively controlled by one
sentation of function is to be found in certain male hemisphere alone. Bresson, Maury, Pierant-LeBon-
songbirds whose song is largely controlled from the niec, and deSchonen ( 1977) found that human infants
left brain (Nottebohm, 1971). The relevant brain area prefer the right hand for some activities, the left for
(hyperstriatum ventrale, pars caudale) is also repre- others. Whether to press the analogy with the lobster
sented on the right side of the brain, though in the one step further is conjectural. Govind and Pearce
intact organism it is not known what its functions are found that exercising one claw facilitated its develop-
on the right. If the left-sided control of song is de- ment into the crusher. In human, we have no com-
stroyed or disconnected from its effector, the right parable observations. But experimentally controlled
side is capable of taking over control of bird song if studies of this kind are hardly practicable. We have
the lesion is made in the young organism before sing- mustered evidence that a child's first words are
ing has fully developed. Here we have a behavior that accompanied by pointing to the named object
has a communicative role, and is targeted not toward (Kinsbourne & Lempert, 1979; Lempert & Kins-
a particular point in space but simply at ambient bourne, 1985). Whether manipulating the side on
72 CHAPTER4
which attention-attracting stimuli appear, or the limb phological findings (Galaburda, 1984) if the amount
used to point, would qualify the preprogrammed left of brain mass in a given area were to correlate with
brain speech laterality is doubtful. But if, as Annett the efficiency with which the individual performs the
(1973) suggested, sinistrals lack an overriding "right activities that this area is specialized to control. Also,
shift factor," it is quite possible that in them later- individuals who lack the asymmetry in question
alization could be influenced in this manner. should have a correspondingly different profile of
When one applies these considerations to the functional capabilities. The evidence is far from con-
human brain, one learns that lateralization of higher clusive along either of these two lines. In particular,
mental functions cannot be assumed to be adaptively by far the greatest variability with respect to relative
necessary simply because it happens to be the general size of parts of right and left brain is to be found in the
rule. Whether the organism that deviates from the non-right-handed population (McRae, Branch, &
norm of lateralization pays a penalty in terms of be- Milner, 1968; Hochberg & LeMay, 1975). No one
havioral control is an empirical issue rather than one has been able to demonstrate any functional dif-
that can be taken for granted. It follows that our ferences between right-banders and non-right-band-
discussion will have to consider. separately the fol- ers that could stem from these morphological varia-
lowing two questions: under what circumstances do tions among the latter.
humans deviate from the usual laterality patterns and That mere bulk of brain may not be a good index
when they do, what if any are the consequences for of functional efficiency is not unexpected as the
adaptive behavior? amount of normal variance in intelligence accounted
for by overall brain size, though significant, is quite
slight. Also, the greater bulk of the male than the
female brain is not accompanied by an overall greater
Morphological Asymmetries in the intellectual capability. A more refined measure of
Human brain size would perhaps take account of local dif-
ferences in the amount of infolding of cortex, the
The internal organs of the human are subject to gray matter being organized around the folds. There
well-known major asymmetries. Deviation from the is a dissociation between the size of Broca's area,
usual pattern has also been well documented, both in which is greater on the right, and its infolding, which
the form of a complete lateral reversal (situs inver- is greater on the left. However, other areas known to
sus), and in terms of such deviations from asymmetry have more bulk on the left side in right-banders, nota-
as horseshoe kidney in which the kidney is a single bly the planum temporale (Geschwind & Levitsky,
bilaterally symmetric organ connected across the 1968), have not been studied in this way. So we do
midline. Deviations from the normal position of the not know whether, for instance, the right planum is
internal organs may generate mechanical difficulties, more infolded than the left. In any case, bulk of a
but the functioning of the organs themselves does not brain area by no means necessarily reflects the
seem to depend on their location. In the human brain number of neurons. There is variation in how tightly
and musculature, a number of less radical asymme- packed neurons are, let alone in the richness of their
tries exist. No one of them has been convincingly tied connections or the excellence of their organization
to function. and normality of their morphology. In the four cases
The right-hander's body is subtly asymmetric. documented by Galaburda, Sherman, Rosen,
Most bones and muscles on the right are reported to Aboitiz, and Geschwind ( 1985) in whom dysgenesis
be somewhat more massive than on the left (Latimer of neurons in various left cerebral areas was found at
& Lowrance, 1965) and there is evidence that this is autopsy, brain bulk as observed on CT scan did not
not secondary to differential use, as this state of af- deviate from the norm.
fairs already obtains in the infant (Pande & Singh, A further impediment to linking brain asymme-
1971). Asymmetries in fingerprints, hair whorls, and try with differential skill in higher mental functions
other ectodermal structures have been documented. derives from comparative data. Yeni-Komshian and
More relevant to brain, the skull is more protuberant Benson ( 1976) showed that the planum temporale is
anteriorly on the right and posteriorly on the left larger on the left than on the right in chimpanzees, a
(LeMay, 1976; LeMay & Culebras, 1977). Corre- species not noted for its verbal ability. In summary,
spondingly the right frontal lobe and the left occipital although it is interesting that morphological asymme-
lobe are somewhat bulkier than the corresponding tries are "invariant" across development, they have
areas on the other side. not been validated as indices of function, and corre-
Function could be inferred from these mor- spondingly their existence in the newborn (Witelson
& Pallie, 1973; Wada, Clark, & Hamm, 1975) can- sphere in LOA, left hemisphere in ROA. This does
not be used as evidence that language precursors are presuppose a staggering amount of birth-related cere-
lateralized. bral damage. If the child predisposed to become dex-
tral has a more vigorous rightward turning tendency,
even in utero, and vice versa, and this is one determi-
Precursors of Lateralization of nant of the presentation of the fetal head, the findings
can be accounted for without invoking uncorrobo-
Function rated pathology.
Subsequent work has shown that 2- and 3-
Peripheral Laterality month-old infants grasp an object longer with the
right than with the left hand (Caplan & Kinsbourne,
The infant is not capable of the activities that are 1976; Hawn & Harris, 1983) and at 5 months reach
used to classify more mature individuals into those more frequently to the right (Cohen, 1966; Seth,
who are right-handed and those who are not. Howev- 1973; Hawn & Harris, 1983). After pointing has
er, certain biases in infant motor behavior may be emerged toward the end of the first year, it more
precursors of hand preference. The newborn infant is frequently is accomplished with the right hand
not capable of behavior so differentiated as to involve (Bates, O'Connell, Vaid, Sledge, & Oakes, 1986).
the use of one hand and arm only. But within his or The situation is complicated by evidence that the
her repertoire is a lateral orienting synergism, the hand preferred for activities at the appropriate devel-
asymmetric tonic neck response, which includes opmental level fluctuates, perhaps systematically,
turning of head and eyes to one side, extension of the within a subject during the frrst year of life (Halver-
ipsilateral arm and leg and flexion of the contralateral son, 1937; Ramsey, 1984; Liederman, 1983). It
arm and leg. This can be seen as a precursor of loco- could be that this reflects epochs in which one or the
motion toward one side, though the infant is lying other hemisphere is in a phase of relatively more
supine. The outstretched arm may be a precursor for active development. A mechanism possibly relating
reaching and pointing. Be that as it may, Gesell and actively developing brain to frequency of corre-
Ames (1947) frrst observed that spontaneous head sponding hand use was provided by Kinsbourne
turning in infants is more often to the right than to the ( 1970) who proposed an activational model by which
left, and in a follow-up study with a small sample activities in a given hemisphere overflow to hemi-
they found a relationship between the direction of the spheric facilities not primarily involved in the ac-
most frequent head turning in the infant and subse- tivity in question. Be that as it may, there is now good
quent hand preference. Notably, all four of the in- circumstantial evidence for a developmental se-
fants who showed predominant leftward head turning quence of peripheral laterality arising from the asym-
subsequently became left-banders. A later study metric tonic neck response first evident after the in-
using a larger sample has not found quite so clear an trauterine age of 32 weeks (Turkewitz, 1977).
outcome, and in particular, instances of predomi- Contrary to the preexisting concept of handedness
nantly leftward turning are few. Nevertheless, emerging from diffuse movement patterns in infan-
Liederman and Kinsbourne (l980a) were able to cy, its antecedents are already differentiated at birth.
show that head turning asymmetry represents a In summary, a motor bias that in most individuals is
motor, and not a sensory, bias, and it is indicative targeted rightward clearly exists as early as at birth or
that an overall rightward turning bias was found in even before, and exerts a major influence on the side
children of right-handed parents but not in a group of of the subsequently preferred hand.
children with one non-right-handed parent (Lieder-
man & Kinsbourne, l980b). It is possible that asym-
metric head turning takes place even in utero. The Central Laterality
most frequent presentation of the fetal head at birth is
left occipita-anterio r (LOA). This indicates that the Several infant studies have documented differ-
infant's head is most often turned to the right as it ential response to speech and nonspeech input de-
descends (headfirst and backward relative to the pending on its side of origin. Entus (1977) used the
mother) through the birth canal. Churchill, Igna, and paradigm of high-amplitude sucking to indicate ori-
Senf ( 1962) reported that more LOA than ROA enting to a change in stimulus state. Infants 2!
babies turn out to be right-handed at age 2 years. months old demonstrated their habituation to a con-
They attributed this to hypothesized hemisphere inju- stant sound source by discontinuing the sucking. If
ry by pressure against the pelvic floor-right hemi- that source changed in nature discriminably, the
74 CHAPTER4
sucking was dishabituated. Entus presented tape-re- control of factors that will cease to operate as matura-
corded speech and music. Given changing speech tion proceeds. Notable is the tendency of infants not
sounds the interruption of sucking happened earlier if to cross the midline when they reach for things
the change occurred in the sound presented to the (Provine & Westerman, 1979). If the target is slightly
right ear and given music the same was true for the to one side of center, the child will reach with the
left. Best, Hoffman, and Glanville (1982) presented ipsilateral limb regardless of hand preference. It is
similar findings using a heart rate dishabituation par- not that there is any motor constraint on crossing the
adigm, as did Molfese, Freeman, and Palmero midline. Ifthe child is already holding a desired ob-
(1975) using amplitude of evoked potential. Ampli- ject with the ipsilateral arm, he or she does cross the
tudes were higher over the left brain for speech, over midline in picking up the target with the free hand
the right brain for music, in newborns. MacKain, (Hawn & Harris, 1983). The "prewired" tendency
Studdert-Kennedy, Spieker, and Stem (1983) found to orient to the side of stimulation (use the hand ip-
infants better able to coordinate visual and auditory silateral to the target) in the infant overrides motor
aspects of an observed speech act when turning right preference. This could account for observations such
toward it than when turning left. Segalowitz and as those of Goodwin (cited in Liederman, 1983) who
Chapman (1980), studying premature infants, found found that right-hand preference on a reaching task at
that a verbal input caused a quieting of movements of 19 weeks strongly predicted hand preference at 3
the right arm and leg and musical input a quieting on years, but left-hand reaching preference did not. The
the left. tendency not to cross the midline seems to be a conse-
These findings are fragmentary and qualitative quence of brain organization. As such it has to be
and not always confirmed (Shucard, Shucard, taken into consideration when failure to establish
Cummins, & Campos, 1981). Nevertheless, the hand preference occurs in developmentally delayed
cumulative evidence demonstrates that precursors of individuals as the latter may perhaps be subject to
aspects of verbal behavior are observably present and developmental lag, the individual remaining under
lateralized as predicted by the invariant lateralization the control of the type of limiting factor that invests
hypothesis as early as at or even before birth. Given the normal infant but not the normal older child. Even
the immature and not yet functional state of the cere- when it becomes possible to observe the child's
brum at that stage in the life span, it becomes evident choice of hand in a number of standard unimanual
that the asymmetry must be laid down at a brain stem activities, the young child differs from the older indi-
level. Evidence for an involvement of left thalamic vidual in sometimes being inconsistent in which hand
nuclei in verbal behavior and of right thalamus in is used for which activity (a factor separate from the
visual behavior (Ojemann, 1977) fits well with the question of which hand is preferred for activities
notion that brain stem mechanisms are involved, if overall). Palmer (1964) observed this so-called am-
not in the actual mental processing, which is not biguous hand preference (Silva & Satz, 1984) in nor-
available to the infant, then in facilitating its occur- mal children and we will return to it later in the con-
rence, perhaps by implementing lateralized ascend- text of children with mental retardation and autism.
ing activation of cortex. The notion that there are Consistent hand preference tends to be estab-
lateralized selector mechanisms at a brain stem level, lished in the preschool years and persist unless the
involved in implementing a categorical (hemi- individual is subjected to contrary cultural pressure.
spheric) mental set (Kinsboume, 1980) could be used Until recently it was customary to encourage if not
to explain difficulties with particular categories of constrain a child who showed left-handed tendencies
thinking exhibited by children with learning dis- to use his right hand instead, generating a mis-
ability, to be discussed subsequently. cellaneous series of shifted sinistrals who would use
the right hand at least for those activities that are
socially conspicuous like writing and holding table-
ware. Such people might still exhibit more dexterity
Lateralization of Function on the left and their left-hand preference may be re-
vealed by giving them a novel activity to perform.
Emergence of Hand Preference in Children Nowadays this type of pressure has been relaxed in
the West, but still persists in the Orient (Teng, Lee,
Even when the child is capable of reaching, Yang, & Chang, 1976). For this reason, in the West,
grasping, and pointing, movements analogous to the offspring have a higher probability of being non
activities observed in older people when hand prefer- right-handed than their parents. Levy (1976) reported
ence is determined, the choice of hand used is under that left-banders were 2.2% of the U.S. population in
1932, but more than ll% by 1972. This presumably along these lines, and actually processing. Laterality
is an effect of relaxation of cultural pressures. effects appear even before the hemispheres are mye-
Recently documented within the left-handed linated. As long as the strategy that the child attempts
population is the position of pen in hand, a distinction does not change over time, the attendant lateral
being made between the inverted position in which asymmetry will also not change.
the point of the pen is below the tip of thumb and For some tasks, however, strategies do seem to
index finger and the noninverted in which the pen is change over the childhood years. Particularly in visu-
held in the same way as right-banders hold their's. ospatial tasks, young children may deploy a mixed
The inverted handwriting posture is considerably strategy involving both sides of the brain. Older ones
more common in males and develops during the rely more exclusively on the right hemisphere. Thus,
grade school period. It is of interest in view of evi- a left lateral "advantage" only gradually emerges.
dence that it reflects certain biological differences in That does not imply that the right hemisphere's spe-
brain organization (Levy & Reid, 1976). With re- cialization has only at that point in time progressed to
spect to motor behavior the noninverter exhibits a a usable degree of maturation. Indeed, there is evi-
more bilateralized or right hemispheric type of con- dence from infant studies of precursors to that spe-
trol and the inverter seems to be more ambidextrous cialization. Laterality effects are event-related mea-
(Parlow & Kinsbourne, 1981). The degree of transfer sures of hemispheric usage: hemispheric usage may
of training between hemispheres also differs between or may not correspond to hemispheric specialization.
these two sinistral subgroups (Parlow & Kinsbourne, It follows that a lateral asymmetry may be pre-
submitted). sent throughout development, indexing the invariant
The prevalence of inverted writing position presence of the corresponding specialization. Or it
among left-handed developmentally disabled indi- may appear at a certain age. If so, it requires a further
viduals is not known. It might be of interest, howev- research effort to determine whether its appearance is
er, because Searleman, Porac, and Coren (1982) due to a recent lateralization of the mental operations
found it more common in subjects with a history of to the indicated hemisphere, or a recently acquired
birth stress. greater reliance on that hemisphere for tasks of the
type set.
A rather straightforward index of the balance of
Development of Central Laterality lateral brain activation is the direction of selective
orienting. Kinsbourne (1972) demonstrated that ver-
Most of the evidence derives from two sources, bal thinking generates righward orienting (gaze and
lateralized brain lesion effects and laterality testing in head turning), whereas spatial thought occasioned
normal children, and relates to the language function. more left than right orienting behavior. Conversely,
Laterality paradigms are designed to reveal, in terms rightward head turning was found to facilitate verbal
of differential performance, effects of functionallat- memory relative to left turning (Lempert &
eralization on the control of behavior. The fact that a Kinsbourne, 1982). This method has as yet been little
hemisphere is dominant for a particular mental opera- used in developmental studies. However, Barrera,
tion is revealed by a bias in how efficiently the rele- Dalrymple, and Witelson (1978) did report more left
vant task is performed when the pertinent informa- gaze during visual processing offaces by infants, and
tional signals originate from the right as compared to MacKain et al. (1983) found infants better able to
the left side of the organism. The hemisphere is also map visual upon auditory components of speech sig-
in control of the elements of contralateral turning: nals when orienting rightward.
faster orienting to that side, with consequent faster The most generally used laterality measures for
information pickup; faster response in that direction input processing are dichotic listening and visual
by limb or gaze. Thus, the task-specific activation of half-field viewing. In dichotic listening, speech
the specialized hemisphere introduces a slight but sounds, syllables, or words are simultaneously pre-
observable contralateral turning bias (Kinsbourne, sented to both ears and the subject is either asked to
1972). Asymmetry of laterality outcome is the per- report as much as he or she can of what is heard
formance consequence of that bias (Kinsbourne, ("whole report") or asked to listen selectively under
1970, 1973). two conditions, to the right ear only and to the left ear
In ontogeny, perceptual asymmetries can only only ("selective listening"). In the first case a later-
begin when children activate one hemisphere more ality index is computed to represent the extent to
than the other in a particular test situation. It is not which the subject is able correctly to report input
necessary that the hemisphere be already specialized through the right ear as compared to the left. In the
76 CHAPTER4
second case the subject's ability to identify input Kinsboume, 1977, 1980a; Geffen, 1978; Geffen &
from the specified ear is compared for the two ears, as Wale, 1979). It follows that the hypothesis of pro-
well as the incidence of responses that represent in- gressive lateralization gains little support from di-
terference from the ear not to be attended. Normal chotic listening studies both in its original strong
right-handed adults as a group exhibit right ear ad- form, positing a gradient of lateralization extending
vantage, i.e., they are better able to identify material until puberty (Lenneberg, 1967), and in its modified
presented to the right ear than the left under both form, restricting that gradient to the first 5 years of
whole and selective reporting conditions. More in- life (Krashen, 1973). Iflateralization develops at all,
truding stimuli from the right ear are normally re- its development is completed by age 3 (Porter &
ported when selectively listening to the left than vice Berlin, 1975), the youngest age at which it is feasible
versa (Treisman & Geffen, 1968). to perform dichotic testing in the conventional man-
In children as young as age 3, a right ear advan- ner. However, Lokker and Morais ( 1985) tested chil-
tage has been repeatedly demonstrated (Nagafuchi, dren aged 1f-3 years old dichotically, using selective
1970; Ingram, 1975; Kinsbourne & Hiscock, 1977; reaching for an object as the response. They too
Piazza, 1977). Thus, a preponderance of left hemi- found a right ear advantage for children of right-
sphere responsibility for verbal auditory processing handed parents.
can be accepted. The question remains: is the degree The visual method of laterality testing is less
of this effect as great in children as in adults or is it generally applicable to young children because it re-
that although lateralization has already occurred to lies on the written word and therefore calls for a
some extent by age 3, it will subsequently further degree of reading skill that is not developed in most
increase? preschool children and only partially developed in
Whereas the direction of group mean ear advan- the early grades. If grade schoolers are presented
tage is an acceptable index of the side of the cortex with words that they can easily read, then the usual
dominant for processing the material in question, the right half-field advantage was found regardless of
degree of asymmetry is a dubious index for "degree age by Marcel and Rajan (1975) and Lewandowski
of lateralization," which is itself a dubious concept. (1982). Studies that find progression in the develop-
There are numerous factors that interact with differ- ment of the right field advantage (Forgays, 1953;
ential hemispheric specialization to generate ear ad- Miller & Turner, 1973; Carmon, Nachson, & Star-
vantages differing in degree, even within the same insky, 1976; Reynolds & Jeeves, 1978; Tomlinson-
subject tested under different circumstances or with Keasey, Kelly, & Burton, 1979) are so much in con-
different dichotic test material. The test-retest relia- flict with each other in detail that their diverse
bility for dichotic listening ranges between about 0.5 outcomes must reflect methodological differences.
and 0.8 (e.g., Bakker, Vander Vlugt, & Claushuis, In any case, no other findings support progressive
1978; Hiscock & Kinsbourne, 1980a), hardly com- lateralization into adolescence.
mensurate with an index of a fixed structural charac- The method used for determining lateralization
teristic. Direction of gaze and direction of movement of speech output control in the intact individual is that
in the visual environment are both capable of influ- of verbal-manual interference (Kinsbourne & Cook,
encing the degree of right ear advantage (Hiscock, 1971; Kinsbourne & Hicks, 1978). Subjects perform
Hampson, Wong, & Kinsboume, 1985). Perhaps a unimanual activity, such as speeded repetitive fin-
more important than any of these is task difficulty. ger tapping, with one hand or the other, with or with-
The extent to which items from one ear have to be out concurrent speaking. If speech control is later-
kept in memory while those from another are realized, speaking interferes disproportionately with
ported (Inglis & Sykes, 1967) can be a major factor if the finger tapping controlled by the same hemisphere
there is a bias to report a particular ear first (Bryden & (i.e., left lateralized speech will interfer more with
Allard, 1981). For all these reasons it would not have right than with left finger tapping). When this para-
been immediately clear how to interpret any interac- digm is used, there is already at age 3 differential
tion between age of child and degree of right ear interference with right-hand performance, indicating
advantage for verbal material, had such been found. that speech is already lateralized to the left at that age.
In fact, most competent studies failed to find such an Moreover, for the age range 3 to 12 years, there is no
interaction. Instead, the degree of ear advantage is interaction between degree of asymmetry and age,
roughly invariant, consistent with the invariant later- supporting invariance of lateralization for speech
alization hypothesis. The proportion of interfering production (Hiscock & Kinsboume, 1978, 1980b;
responses from right versus left ear is also invariant White & Kinsbourne, 1980).
across a wide age range in childhood (Hiscock & Less is known about the ontogeny of lateraliza-
tion for those nonverbal activities that are regarded as If this is so, then what is being indexed is the increas-
right lateralized. Piazza (1977) found a left ear ad- ing specialization of the right hemisphere with in-
vantage for the dichotic presentation of environmen- creasing age, and not a changing neural basis for an
tal sounds in 3-, 4-, and 5-year-olds, and Saxby and already available skill. With further increase in age
Bryden (1984) confirmed this for 5-year-olds (al- the degree of left field advantage will not increase.
though in an earlier study, Knox and Kimura ( 1970) Indeed, it may temporarily diminish at around puber-
found somewhat weaker left ear effects in 5- and 6- ty, in concert with a decrease in performance effi-
than in 7- and 8-year-olds). For tachistoscopic face ciency (Diamond, Carey, & Back, 1983). This find-
recognition, left visual field advantages are found in ing, perhaps related to endocrine changes around
quite young children, unaffected in degree by age puberty, is in its details beyond the scope of the pre-
(Marcel, Katz, & Smith, 1974; Young & Ellis, 1976; sent discussion.
Young & Bion, 1980; Turkewitz & Ross-Kossak,
1984). With respect to the ability to discriminate
shapes by active touching (haptic perception-
Witelson, 1974), the typical left-hand advantage has Degree of Lateralization
been found as early as age 2-3 (Rose, 1984). Other
studies revealed left-hand advantages for nonsense The absence of interaction between degree of
shapes in preschoolers (Etaugh & Levy, 1981) and lateral asymmetry and age in most studies simplifies
grade-schoolers (Witelson, 1974, 1976; Coiffi & the task of explanation. In addition to supporting
Kandel, 1976; Affleck & Joyce, 1979; Flanery & lateralization invariance, it sidesteps the dilemma of
Balling, 1979; Klein & Rosenfield, 1980), only Flan- interpreting between group differences in the degree
ery and Balling finding a developmental trend. Rec- of laterality bias in the same direction. The assump-
ognition of verbalization shapes yields less consistent tion that degree of lateral asymmetry indexes degree
data, perhaps because of variability in the degree of of lateralization of the critical task-related mental
left hemisphere participation in the task (e.g., operation (Shankweiler & Studdert-Kennedy, 1967)
Witelson, 1974; Coiffi & Kandel, 1976). Invariance has never been substantiated. Indeed, it is unclear
is generally supported for males, but there is a ten- what is meant by greater or lesser degree oflateraliza-
dency of younger females to show a right- rather than tion. Does the distinction assume that both hemi-
left-hand advantage. But interpretation is con- spheres participate in the task, though to a varying
founded by the tendency of females more than males extent unequally? If so, are they redundant in their
to use a verbal strategy in coding input (e.g., Caplan contribution, or complementary? If unilateral brain
& Kinsbourne, 1981). damage occurs, should the function in question be
The recognition of briefly exposed faces to ei- compromised by damage on both sides, in proportion
ther side of the midline is another relevant meth- to the degree of lateralization on each side? If so, no
odology. This yields no asymmetry until about age 7 such intimation from lateral brain injury exists.
or later, subsequent to which a left half-field advan- Given the many factors that, for instance, modify
tage begins to emerge, earlier in boys than in girls asymmetry in a dichotic test-task diffiCulty, task
(Carey & Diamond, 1977; Levine, 1985). This find- aptitude and motivation, the extent of stimulus domi-
ing illustrates a fundamental issue in interpretation. nance, and perhaps whatever else the subject is think-
Whereas the gradual emergence of an asymmetry ing about and how (happy or sad) he or she is feel-
could indeed be interpreted in line with progressive ing-it is hardly surprising that the literature on
lateralization, it could equally well be interpreted as degree of lateralization is inconsistent in the extreme.
indicating the emergence of a processor that had not Two related areas to which the concept has been
been represented in the less mature brain. If space vigorously applied are gender differences and age at
perception calls for particular processing skills that puberty difference in degree of lateralization. It is
normally only emerge toward the end of the first little wonder that the literature in both fields
decade of life, then presenting this task to younger (McGlone, 1980, and peer commentary; Newcombe
children will yield a lack of asymmetry by default, & Bandura, 1983, respectively) is a morass ofincon-
rather than indicating that at that age both hemi- sistencies. Operationally, laterality tests (and lateral
spheres were processing the material in question to a brain damage effects) can only guide us in a choice
comparable extent. Carey and colleagues have found between three alternatives: left lateralized, right lat-
support for the view that the manner in which chil- eralized, bilateralized.
dren process face information changes qualitatively An isolated but intriguing finding relates to lat-
at the time that the left half-field advantage emerges. eralization of emotion, which is right-sided in adults
78 CHAPTER4
(Schwartz, Davidson, & Maer, 1975). In infants less hemisphere territories are more likely to assume a
than 1 year old, Davidson and Fox ( 1982) monitored compensatory role the earlier the lesion is, or perhaps
power spectrum EEG changes while children dis- the more extensive it is. It may be that right hemi-
criminated faces. They offered evidence that even at sphere territories that normally play some other role
this early age the right hemisphere is more involved are preempted for purposes of the compensatory
than the left in the discrimination of facial affect. functioning. Huttenlocher et al. (1986) hemispherec-
tomized infant rats. In this preparation an ipsilateral
corticospinal tract develops in addition to the nor-
mally present contralateral tract. The investigators
Lateralization Probed by Lateral subsequently found that the cortical area that con-
Cerebral Damage tained pyramidal tract cells had greatly expanded, in
response to the excision of the contralateral
If language lateralization is invariant, then left hemisphere.
brain damage should be equally likely, and right Supportive evidence derives from studies of
brain damage equally unlikely, to cause aphasia in right hemisphere lesion effects in childhood (Ker-
right-handed children as in adults (acutely-whether shner & King, 1974; Kohn & Dennis, 1974; Ferro,
mechanisms of compensation vary with age is a sepa- Martins & Tavora, 1984; Stiles-Davis, Sugarman, &
rate issue). Contrary to earlier impressions (Basser, Nass, 1985). They all found spatial deficits analo-
1962), this is approximately the case. In Woods and gous to those observed in adults after right hemi-
Teuber's (1978) series, the incidence of aphasia in sphere damage.
children aged 2-14 was about 70 versus 7% percent We conclude that the precursors of language
for left- and right-sided damage, respectively, in function rely on activity of the same hemisphere that
right-banders. The implication that the left hemi- subserves language in its full maturity. The earliest
sphere is specialized early for language is corrobo- manifestation is perhaps a selective activation of that
rated by series of children who suffered lateral cere- hemisphere in a verbal context, well before its neural
bral damage before the onset of language behavior. substrate has matured to the point that language pro-
The long-term language outcome is less favorable if cessing is feasible. As language ability differentiates,
the early damage was left-sided (Kershner & King, language processing may involve, not a shrinking,
1974; Rankin, Aram, & Horwitz, 1981; Kiessling, but an expanding neural base within that same hemi-
Denckla, & Carlton, 1983; Varga-Khadem, O'Gor- sphere (Satz & Strauss, 1986).
man, & Watters, 1985), at least in terms of syntactic The impressively consistent evidence in favor of
proficiency (Dennis & Kohn, 1975; Rankin et al., invariant lateralization for the major functions of
1981; Aram, Ekelman, Rose, & Whitaker, 1985). both hemispheres offers a conveniently simple stan-
But the selective syntactic difficulties are somewhat dard of reference against which to evaluate the pos-
overshadowed by the recurrent finding that early lat- sibility that children with a variety of developmental
eral damage on either side, even when strictly later- disabilities are characterized by anomalies in later-
alized, leads to a moderate impairment across a wide alization, and that these anomalies have a bearing on
range of test performances (Aram et al., 1985). This the causation of the behavioral deficit.
perhaps indicates that brain organization is not strict-
ly modular, but does draw upon distributed as well as
focalized neural processing, at least for purposes of
Lateralization in Developmental
mental development.
Although there is every reason to suppose that Deficit
lateralization of language remains invariant through-
out its development, the locus of compensation after Introduction
damage to the language area of the child's brain does
not. Penfield and Roberts ( 1959) reported on the inci- Perhaps because developmental deficits offer so
dence of aphasia after left temporal lobectomy in few clues beyond the surface phenomenology for the
epileptic adults with early lesion onset. When lesion reason why they came to be, lateralization has often
onset was prior to age 2 years, the probability of been invoked as a possible factor in their patho-
aphasia was much less than when the damage had genesis. Almost always it is suggested that the nor-
occurred subsequently in childhood. It appears that mal lateralization of hemispherically specialized
territories in both hemispheres have the potential to cognitive functions failed to occur, the assumption
compensate for injury to the language area. Right being that cognitive processing when based on both
hemispheres is relatively primitive and necessarily again more particularly among the most severely af-
inefficient. The logic of the suggestions depends cru- fected children, who are to be found in clinical set-
cially on the notion that lateralization is normally tings and in special schools for the learning disabled
progressive and that it is this progression, when im- (Satz, 1976).
paired, that leaves a cognitively deficient end result. Several sharply contrasting explanations for this
As we have seen, the evidence for progressive later- conjunction of findings have been offered. (1) Pre-
alization is lacking, so that if anomalies of lateraliza- suming that peripheral non-right-handedness implies
tion are to be found in developmental disabilities, a corresponding absence of centrallateralization, the
some other explanation for such findings has to be latter itself is incriminated as inducing a processing
sought. In fact, there is plentiful evidence for a rela- inefficiency (Orton, 1937). (2) Some left-handed-
tively greater incidence of unusual forms of later- ness (Satz, 1972) or left-handedness as such (Bakan,
alization in developmental deficits, but the causes 1971) is as a consequence of early left hemisphere
and implications of these differences remain quite pathology (syndrome of pathological left-handed-
obscure. There is a coincidence between absence of ness of Satz, Orsini, Saslow, & Henry, 1985), and
the usual left lateralization of language in various such early pathology is also likely to set up a mis-
disabilities and an increased prevalence of non-right- cellany of developmental disabilities. (3) An influ-
handedness in the same conditions (though the cen- ence active early in development is postulated that
tral and peripheral laterality anomalies by no means tends both to diminish language lateralization and to
correlate perfectly). We first consider the data on impair the evolving function of the language hemi-
hand preference. sphere (Geschwind & Behan, 1982). (4) Susceptibil-
ity to becoming non-right-handed and to suffering
from a wide range of developmental disorders are
Hand Preference in Developmental consequences of an adverse influence on the fetal
Disabilities brain which are apt to occur when the mother is sus-
ceptible to diseases of the immune system
Not only is non-right-handedness more com- (Kinsboume, in preparation).
mon among the mentally retarded, autistic, and lan- The second and third of these models are re-
guage and learning delayed, but the non-right- stricted in their explanatory value to those develop-
handed subgroups of these populations tend to be mental deficits that can plausibly be attributed to mal-
more severely affected by the deficit in question. For functioning of the left (language) hemisphere, rather
example, Hicks and Barton (1975) found severe and than of the cerebral cortex as a whole. Language and
profoundly retarded individuals to be still more often reading disabilities are a case in point, and autism has
non-right-handed than mild and moderate, who in been similarly regarded (Rutter, Bartak, & Newman,
tum were more non-right-handed than the general 1971) although the evidence against this is now very
population. Bradshaw-McAnulty, Hicks, and strong (Fein et al., 1984). For mental retardation and
Kinsboume ( 1984) confirmed and extended this find- perhaps autism, in which conditions a more general
ing, and further related greater severity of the mental cerebral deficit seems likely, explanations (2) and
retardation to a greater probability of right-handed- (3), targeted on the left hemisphere, lose force. How-
ness in one or other parent. In infantile autism, non- ever, there is nothing implausible that more than one
right-handedness is particularly prevalent (Colby & of the above postulated mechanisms might come into
Parkinson, 1977), and several investigators have play. For instance, there is circumstantial evidence
found the more lower functioning individuals to be that right- as well as left-handed members of rela-
more often non-right-handed (e.g., Fein, Humes, tively sinistral families are more at risk for develop-
Kaplan, & Lucci-Waterhouse, 1984) (there being mental deficit, or for having more severe deficit
general agreement that in autism non-right-handed- should damage occur (Kinsboume, 1986). The
ness is far more common than in the general popula- damage to which such individuals are vulnerable
tion (e.g., Tsai, 1982)). Indeed, in mental retarda- could in tum, when it implicates the left hemisphere,
tion, and particularly in autism, hand preference even not only impair cognition, but also cause a shift of
for a single activity is apt to change from trial to trial hand preference phenotype to sinistral, in a genotypic
(ambiguous handedness, according to Silva & Satz, dextral (pathological left-handedness), and thus in-
1984; see also Soper eta/., 1987). Non-right-hand- creasing the prevalence of non-right-handedness
edness is relatively common in stuttering and in lan- among the affected family members to beyond the
guage delay. In selective reading disability (dyslex- level that prevails within their already relatively sin-
ia), non-right-handedness is relatively prevalent, istral family (Bradshaw-McAnulty et al., 1984).
80 CHAPTER4
Central Laterality in Developmental Deficits some case reports at autopsy (Galaburda et a/.,
1985). Alternatively, the left hemisphere might be
The measurement of central laterality requires a undersupplied by ascending activation, rendering it
degree of cooperation from subjects, and perhaps for hard for the child to muster verbal skills in full force
that reason, has been most often attempted in a rela- to solve what is for him or her a difficult verbal
tively mildly disordered population-the learning problem (Kinsboume, 1980). Such an activational
disabled. These consist of two main subgroups: chil- insufficiency might also generate a relatively nonver-
dren with attention deficit and children with control bal (right hemispheric) cognitive style in such chil-
processing difficulties (Kinsbourne & Caplan, dren (Caplan & Kinsbourne, 1982).
1979). A sample of the former was found to be nor- Obrzut, Hynd, Obrzut, and Pirozzola (1981)
mally lateralized by a dichotic (Hiscock, found learning-disabled children better able than nor-
Kinsbourne, Caplan, & Swanson, 1979) and a visual mally reading controls to listen selectively to left ear
(Naylor, 1980) laterality test. Therefore, studies input. Obrzut, Hynd, and Zellner (1983) obtained
have concentrated on the latter, specifically the read- comparable results in visual laterality. The voluntary
ing disabled subgroup (''dyslexics'') under the influ- attentional shift could override rightward attentional
ence of a persistent theoretical approach that incrimi- bias engendered by the presumably relatively weak
nates failure of left language lateralization in its left brain activation of the dyslexics.
pathogenesis (Orton, 1937; Geschwind & Behan, An electrophysiological approach has attempted
1982). According to this view, the visual right side to distinguish subgroups of dyslexics deficient in
advantage for verbal laterality tests should be lacking right and left hemisphere functioning, respectively
in the dyslexic. Although this has sometimes been (Bakker, Licht, Kok, & Bouma, 1980). Evoked po-
reported (Olson, 1973; Zurif & Carson, 1970), tential studies lend support to the view that dyslexic
enough studies have found normal laterality for ver- children may exhibit abnormal responses in one
bal test in learning-disabled children (e.g., Marcel et hemisphere when tested, but the stability of those
al., 1974; Marcel & Rajan, 1975; McKeever & Van patterns has not been proven (Fried, Tanguay,
Deventer, 1975; Bouma & Legein, 1977; Caplan & Boder, Doubleday, & Greensite, 1981; Mecacci,
Kinsboume, 1982) to indicate that failure of left- Sechi, & Levi, 1983). If stable, they could reflect
sided language lateralization is not a viable explana- lateralized activational deficiencies.
tion for selective reading disability. Stuttering is another early arising deficit in
Several sharply contrasting explanations for this which maladaptive rivalry between the cerebral
conjunction of findings have been offered. (1) Pre- hemispheres for control of speech has long been sus-
suming that peripheral non-right-handedness implies pected (Travis, 1927). The concept was dramatically
a corresponding absence of centrallateralization, the supported by case studies of four left-handed stut-
latter itself is incriminated as inducing a processing terers with lateralized cerebrovascular congenital
inefficiency (Orton, 1937). (2) Some left-handed- anomalies (Jones, 1966). They were found bilat-
ness (Satz, 1972) or left-handedness as such (Bakan, eralized for speech by intracarotid Amytal testing
1971) is as a consequence of early left hemisphere before operation. After operation, repeat Amytal
pathology (syndrome of pathological left-handed- testing showed that speech control had become re-
ness of Satz, Orsini, Saslow, & Henry, 1985), and stricted to the normal (unoperated) hemisphere.
such early pathology is also likely to set up a mis- Also, after operation, the patients ceased to stutter.
cellany of developmental disabilities. (3) An influ- However, comparable studies of three more right-
ence active early in development is postulated that handed stutterers without brain damage have not
tends both to diminish language lateralization and to yielded comparable findings (Andrews, Quinn, &
impair the evolving function of the language hemi- Sorby, 1972), and both behavioral and EEG laterality
sphere (Geschwind & Behan, 1982). (4) Susceptibil- were normal in stutterers (Pinsky & McAdam,
ity to becoming non-right-handed and to suffering 1980). As in dyslexia, it is more likely that in stutter-
from a wide range of developmental disorders are ing any cerebral abnormality is of a dynamic rather
consequences of an adverse influence on the fetal than static nature, for instance, an abnormality of left
brain which are apt to occur when the mother is sus- hemisphere activation for stuttered speech acts only.
ceptible to diseases of the immune system We await findings from event-related measures se-
(Kinsboume, in preparation). lectively time-locked to stuttered utterances (nonstut-
This does not imply, however, that the left- tered serving as control). The regional cerebral blood
sided language facility is normal in dyslexic children. flow study of Wood, Stump, McKeehan, Sheldon,
It could be structurally compromised, as indicated by and Proctor (1980), in which stutterers were judged
to have inadequate left hemisphere attention (nor- roanatomy. Annals of the New York Academy of Sciences,
malized when the stuttering was relieved by haloperi- 299, 186-196.
dol), is a step in this direction. Braitenberg, V., & Kemali, M. (1970). Exceptions to bilateral
Lateralization in autism is a contentious issue symmetry in the epithalamus of lower vertebrates. Journal of
(Kinsbourne, 1987). Both failure of lateralization Comparative Neurology, 138, 137-146.
and right brain dominance have been proposed, but it Bresson, F., Maury, L., Pierant-LeBonniec, G., &deSchonen, S.
( 1977). Organization and lateralization of reaching in infants:
seems more likely that heterogeneous patterns of
An instance of asymmetric functions in hand collaboration.
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5
Neuropsychology of Child
Psychopathology
MICHAEL G. TRAMONTANA AND STEPHEN R. HOOPER
Introduction methods used and the subject samples selected for

study. Is brain dysfunction more likely to be involved
What is the relationship between brain dysfunction in certain child psychiatric disorders or behavioral
and psychopathology in childhood? Notice that the syndromes than others? Does its presence help to
question is not posed as to whether there is a rela- explain the particular form of psychopathology man-
tionship because, as we shall see, it is simple enough ifested? How important is it relative to other factors
to answer that there is. Clearly, there are mental, contributing to the child's disturbance?
emotional, and behavioral sequelae for the child who Asking the above questions should not be taken
has sustained brain damage or who shows an anoma- to imply that the field of child neuropsychology and
lous course of brain maturation. In some instances, related disciplines are able to respond with definitive
these symptoms may persist and significantly hamper answers at this time. Clearly, they are not. Nonethe-
the child's psychosocial adjustment. What is not so less, it is important to raise these questions at the
clear, though, is how often this is the case and the outset to underscore the complexity of the topic. This
precise factors that influence it. Does it depend on chapter will provide an overview of current knowl-
the extent or type of brain dysfunction? What about edge regarding the neuropsychology of child psycho-
the age or other attributes of the child at the time of pathology. Key conceptual issues will be discussed,
onset? How might environmental factors potentiate including the role and prevalence of brain dysfunc-
the child's risk? Are certain forms of psycho- tion in child psychopathology. Findings pertaining to
pathology more likely to arise than others? Does the selected categories of child psychopathology will be
form of psychopathology manifested change over summarized and critically evaluated. Although de-
time? fmitive conclusions are not possible on the basis of
Conversely, there is little disagreement that existing research, the work to date certainly does
there are multiple etiologies for psychopathology in serve to set some useful directions for future investi-
childhood, and that in some cases, brain dysfunction gation. These are highlighted, and specific guide-
likely plays an important contributing role. Just how lines for research and practice are discussed.
prevalent this is would be impossible to say. Children
with psychiatric disorders do show a relatively high
rate of brain dysfunction, but estimates of prevalence Conceptual Issues
have varied greatly according to the assessment
Psychiatric Sequelae of Childhood Brain
MICHAELG. TRAMONI'ANA DepartmcntofPsychology, Dysfunction
Bradley Hospital, East Providence, Rhode Island 02915, and De-
partment of Psychiatry and Human Behavior, Brown University, The presence of brain dysfunction in childhood
Providence, Rhode Island 02912. STEPHEN R. HOOPER appears to be associated with a greater risk for the
ClinicalCenterfortheStudyofDevelopmentandLearning, The development of a psychiatric disorder, far more so
University of North Carolina, Chapel Hill, North Carolina 27599, than with other physical handicaps (Brown, Chad-
and Depanment of Psychiatry, The University ofNorth Carolina wick, Shaffer, Rutter, & Traub, 1981; Rutter,
School of Medicine, Chapel Hill, North Carolina 27599. Graham, & Yule, 1970; Seidel, Chadwick, & Rutter,
87
88 CHAPTERS
1975; Shaffer, 1978). Moreover, the effects appear visibly crippling conditions who were alike in all
to persist and impede the child's long-range adjust- respects except for the presence of brain damage. All
ment in many important respects (Breslau & children ranged from 5 to 15 years of age and had an
Marshall, 1985;Milman, 1979;Shaffereta/., 1985). IQ of70 or higher. The two groups were matched in
One of the best investigations on this topic terms of age, sex, psychosocial factors as well as the
comes from the well-known Isle of Wight epi- degree of physical disability. Again, based on both
demiological studies of school-aged children by Rut- teachers' questionnaire responses and psychiatric rat-
ter and his colleagues (Rutter et al., 1970). Using ings, the rate of disorder was about twice as high for
multiple assessment procedures, and controlling for children with cerebral disorders (mostly cerebral pal-
rater bias, Rutter eta/. found that about 6 to 7% of the sy) than for the group with noncerebral or peripheral
general population of children studied had a psychi- conditions (including muscular dystrophy, polio, or
atric disorder consisting of some persistent emo- spina bifida).
tional, behavioral, or social disability. The rate was Clearly, the studies by Rutter et a/. ( 1970) and
nearly twice that (11.5%) for children having chronic Seidel et a/. (1975) provided a strong case for an
handicapping physical conditions not involving the increased risk of psychiatric disorder being associ-
brain. This group consisted of children with disorders ated with the presence of brain damage in childhood.
such as asthma, diabetes, heart disease, and Neither study, however, demonstrated a causal rela-
orthopedic deformities, as well as diseases of the tionship. Although the neurological conditions of the
spinal cord or peripheral nervous system. In contrast, brain-damaged groups typically had an early onset
the rate of psychiatric disorder was over five times that probably preceded the appearance of any psychi-
higher (34.3%) in their neuroepileptic group consist- atric disorder, one still could argue that the rela-
ing of all children ranging from 5 to 14 years of age tionship was merely coincidental. That is, some com-
with cerebral palsy, epilepsy, or some other frank mon vulnerability (whether it be genetic, congenital,
neurological disorder above the brain stem. Even or environmental), which may have predisposed a
when eliminating all cases who had an IQ of 85 or child to cerebral damage, also may have led indepen-
less (as low IQ, itself, was found to be associated dently to psychiatric or behavioral disturbance. A
with an increased risk for psychiatric disorder), the more convincing case for the existence of a causal
rate of psychiatric disorder was still twice as high in relationship would come from demonstrating that
the neuroepileptic group as in the "other physical previously normal children with acquired brain inju-
handicap" group. ries are more likely to develop subsequent psychiatric
Among children in the neuroepileptic group, disorders.
both the severity and the nature of the neurological Children suffering from accidental head injury
condition appeared to be related to the risk of psychi- represent an excellent choice for examining this
atric disorder. Thus, psychiatric disorders were more question, provided that it is recognized that they do
likely in children with bilateral as opposed to uni- not constitute a random sample of the general popula-
lateral brain lesions. Among cerebral-palsied chil- tion. These children, especially those suffering from
dren, it was more likely in those with strabismus, mild as opposed to severe injuries, often show preex-
impaired language, or specific reading difficulties, isting problems with impulsivity, aggression, and at-
and among the children with epilepsy, the risk was tention-seeking behavior that make them more sus-
greater in those with low IQ or psychomotor seizures. ceptible to accidental injury (Klonoff, 1971). The
However, the prevalence was actually less among families of these children also differ from the general
children with the most severely debilitating hand- population in that they show more parental illness
icaps, suggesting that these children may be spared and mental disorder, more social disadvantages, and
from psychiatric difficulties by having conditions less adequate supervision of the child's play ac-
that unambiguously free them from competing in oth- tivities. Thus, the absence of adequate controls in
erwise stressful pursuits. many studies reporting intellectual impairment and
In a further study, Seidel et a/. (1975) were behavioral disturbance following head injury makes
better able to control for the possibility that overt it impossible to determine whether the psychological
stigmata, such as crippling, may have been associ- sequelae stem directly from cerebral damage rather
ated with the higher rate of psychiatric disorder that than preexisting difficulties (Rutter, Chadwick, &
Rutter eta/. found in their neuroepileptic group (nei- Shaffer, 1983).
ther obvious crippling nor other overt stigma was Probably the best controlled examination of this
common in their ''other physical handicap'' group). topic comes from the prospective studies of head-
Here, they compared two groups of children with injured children by Rutter and his colleagues (Brown
NEUROPSYCHOLOGY OF CHILD PSYCHOPATHOLOGY 89
et al., 1981; Chadwick, Rutter, Brown, Shaffer, & chosocial adversities within their homes, but the ef-
Traub, 1981; Chadwick, Rutter, Shaffer, & Shrout, fects were additive rather than interactive. Thus, al-
1981; Rutter, Chadwick, Shaffer, & Brown, 1980). though psychiatric disorders in childhood have a
Children ranging from 5 to 14 years of age who had multifactorial etiology, the evidence from this series
experienced closed head injuries of sufficient sever- of studies indicated that brain injury can play an inde-
ity to result in a posttraumatic amnesia (PTA) of 7 pendent role.
days or more were compared with a group of children Each of the preceding studies dealt with children
having less severe head injuries (i.e., those with a having known or documented brain damage. One
PTA of less than 7 days, but a duration of at least 1 may ask whether a similar relationship exists be-
hour). In addition, these groups were compared with tween psychiatric disorder and so-called ''soft'' neu-
a matched control group of hospital-treated children rological signs or minimal brain dysfunction (MBD)
also suffering severe accidents, but with orthopedic in childhood. This has been a subject of much debate,
rather than cranial injuries. All children were studied as some investigators have regarded sensory or motor
prospectively at 4 months, l year, and 2! years after phenomena such as mirror movements, dys-
their injuries. An important feature of this study was diadochokinesis, dysgraphesthesia, and choreic or
the care taken to determine the children's behavior athetoid movements to be of little diagnostic value
before their accidents. This was done in an unbiased when elicited from patients not having a discrete neu-
fashion by interviewing parents immediately after rological disorder(e.g., Ingram, 1973). Others (e.g.,
their child's injury, but before the child's postinjury Rutter eta/., 1970) have argued that it is important to
psychiatric condition could have been known. differentiate among different types of signs that are
The children with severe head injuries did not labeled as "soft." Some are considered as soft be-
differ from controls in their preinjury behavior, but cause: ( 1) they run a developmental course in which
they showed more than double the rate of psychiatric the signs may subside as the child grows older; (2)
disorder at 4 months and at each subsequent follow- they are rather prevalent among otherwise normal
up period. This was true even when children who had children (with estimates ranging from 8 to 14%); and
psychiatric disorders prior to their accidents were (3) they also have no clear locus of origin and their
eliminated from the study, thereby focusing specifi- neuropathological significance is obscure (Shaffer,
cally on the comparative rate of new psychiatric dis- 1978). They are not necessarily unreliable, however,
orders arising over the course of the follow-up peri- and may show consistency over time (Shapiro,
od. There was a rather high threshold for an effect, Burkes, Petti, & Ranz, 1978). Other signs, such as
however, as definite cognitive or psychiatric se- minor reflex or tone asymmetries, would tend to be
quelae were found only in head-injured children hav- less reliable because they are more difficult to detect.
ing a PTA of at least l week. Whereas persistent Overall, the research on neurological soft signs
psychiatric sequelae were quite common once this has shown that: (I) there is a relationship with age,
range of severity was reached, cognitive impairment IQ, and sex (with soft signs occurring more fre-
lasting for over 2 years generally required aPTA of at quently among boys), (2) they are more prevalent
least 3 weeks. Head-injured children tended to show among children with psychiatric disorders and learn-
greater impairment on timed visual-spatial and visu- ing disabilities, (3) they are related to indices of emo-
al-motor tests than on verbal tests but, apart from tional immaturity and dependency in childhood, and
this, no pattern of cognitive deficit specific to head (4) the relationship with hyperactivity, aggression,
injury was identified. Likewise, the types of psychi- and antisocial conduct is less clear, although soft
atric disorder among the head-injured children were signs are commonly seen among children who are
very similar to those found in controls. The only described as impulsive and distractible (Shaffer,
exception to this was in the case of grossly disin- 1978; Shaffer, O'Connor, Shafer, & Prupis, 1983).
hibited social behavior, which was present only in In a well-controlled prospective study, Shaffer
children with very severe head injuries, and may and his colleagues (Shaffer et al., 1985) examined
have been linked directly to frontal lobe dysfunction. the comparative outcomes in adolescence of children
Children with head injuries showed an increased with early soft neurological signs. Children with (n =
risk for psychiatric disorder regardless of the age, 83) and without (n = 79) documented soft signs at
sex, or social class of the child-factors that or- age 7 received a careful follow-up assessment at age
dinarily show a striking mediating effect in the gener- 17. Compared to controls, adolescents with early soft
al population. Clearly, the risk was greater among signs had lower IQs and were more likely to have a
those children with histories of preaccident behavior psychiatric disorder with symptoms of anxiety, with-
disorders as well as those experiencing various psy- drawal, and depression. These findings mainly per-
90 CHAPTERS
tained to boys, but all of the girls in the study with an Taken together, the studies reviewed in this sec-
anxiety-withdrawal diagnosis in adolescence tion provide strong evidence that brain dysfunction in
showed early soft signs. The relationship was inde- childhood is associated with an increased vul-
pendent of IQ and, when taken together with the nerability for psychiatric disorder. The relationship
presence of anxious-dependent behavior at age 7, the appears to hold both for children with frank brain
presence of early soft signs was strongly predictive of damage as well as those with so-called soft neu-
persistent problems with anxiety and withdrawal. rological signs. The risk is greater for children with
However, no relationship was found with attention more severe neurological disorders (with the possible
deficit disorder or conduct disorder. exception of those with extreme impairment), es-
This was somewhat different than the pattern pecially when accompanied by low IQ and other neu-
that Rutter et al. (1970) found in the Isle of Wight ropsychological deficits. It also is compounded by
study. Children with frank brain damage showed a factors such as psychosocial adversity and any preex-
heterogeneous range of psychiatric disorders without isting tendencies toward behavioral or emotional dis-
specific features. Hyperactivity and psychosis were turbance. The relationship is not trivial, as the effects
more prevalent in their neuroepileptic group, but appear to persist and influence long-range outcomes
these appeared to be related more specifically to the (Breslau & Marshall, 1985; Milman, 1979; Shaffer et
presence of mental retardation. However, besides al. , 1985). This certainly underscores the importance
Shaffer et al. (1985), several other studies have of accurate detection of the functional deficits and
found an association between brain dysfunction and behavioral liabilities in the brain-impaired child as a
the type of behavior problems manifested, although first step in limiting the risk for the later development
the exact findings have varied according to factors or progression of a psychiatric disorder (Tramontana,
such as age and chronicity. 1983).
In a 5-year follow-up of children and adoles-
cents with physical disabilities secondary to brain
damage, Breslau and Marshall (1985) found that Prevalence of Brain Dysfunction among
problems with social isolation rather than aggression Children with Psychiatric Disorders
were more likely to persist. Dorman (1982) found
that the relationship between neuropsychological im- We tum now to a more complicated issue,
pairment and the type of behavior problems observed namely: How prevalent is brain dysfunction among
varied as a function of age in a group of boys with children with psychiatric disorders? Although brain
school problems and no known neurological disor- dysfunction can play a significant contributing role in
der. Whereas poor neuropsychological performance the development of child psychopathology, it is un-
was associated with externalizing behavior problems clear just how often this occurs. Estimates of
in younger (7 to 8) boys, it was associated with inter- prevalence have varied greatly both as a function of
nalizing symptoms in the older (9 to 14) subjects. It the methods and criteria used in identifying brain
may be that internalizing rather than externalizing dysfunction, and in terms of differences in the subject
symptoms are more distinctively tied to brain dys- samples selected for study. For example, the preva-
function as the child grows older and encounters re- lence would appear to be rather low if one simply
peated failure and loss in self-esteem. The rela- used the presence of positive findings on a routine
tionship eventually may become blurred as other neurological examination as the basis for establishing
factors enter and play a more important determining neurological involvement. However, such an ap-
role in perpetuating the youngster's poor adjustment. proach would likely be associated with an under-
Moreover, this process may be accelerated in cases estimation of prevalence because normal neu-
with early histories of more severe disorders. This rological examinations are common even among
was suggested in a study by Tramontana, Hooper, children with documented histories of head injury,
and Nardolillo (in press) in which the presence of encephalitis, or epilepsy (Rutter, 1977).
neuropsychological deficits was found to be associ- The findings from the few studies that have in-
ated with more extensive behavior problems among corporated noninvasive neurodiagnostic methods
psychiatrically hospitalized boys, regardless of fac- such as computed tomography (CT) have been
tors such as IQ and SES. However, the relationship mixed. Much of the research has been with children
mainly applied to younger (8 to 11) as opposed to having autism or other major developmental hand-
older (12 to 16) subjects, and specifically involved icaps for whom enlarged ventricles and other struc-
internalizing rather than externalizing behavior tural deficits have been found in subgroups of the
problems. subjects examined (Campbell et al., 1982; Caparulo
et al.. 1981; Damasio et al.. 1980; Rosenbloom et study with a similar sample of subjects in which neu-
al., 1984). Reiss et al. (1983) likewise found ven- ropsychological results were compared with various
tricular enlargement in a controlled comparison of quantified indices of brain structure examined
CT scans for a mixed group of child psychiatric pa- through CT (Tramontana & Sherrets, 1985). Psychi-
tients. The results were of questionable gener- atric cases without suspected brain damage again
alizability, however, because their subjects also were found to show a high rate of neuropsychological
tended to be among the more impaired with respect to abnormality (at least 50%) when examined on either
psychiatric and developmental status, with about half the HRNB or the Children's Revision of the Luna-
of the group having a confirmed neurological disor- Nebraska Neuropsychological Battery (LNNB-C;
der and a third showing mild mental retardation. Golden, 1981). Impaired performance was more
In another study, CT scans were compared likely among boys, younger subjects, and those with
across four subgroups of subjects with childhood dis- more chronic psychiatric histories. Interestingly, im-
orders (Infantile Autism, Attention Deficit Disorder, paired performance was not associated significantly
Tourette's Syndrome, and Language Disorder) and a with IQ. The overall results of the two test batteries
control group of medical patients without docu- correlated quite highly, but it was the LNNB-C that
mented neurological disorder (Harcherik et al. corresponded more closely with CT scan results.
1985). No differences were found among the groups Specifically, impairment on the LNNB-C was asso-
with respect to ventricular volume, right-left ven- ciated with smaller ventricular size and less density
tricular ratios, asymmetries, or brain density. The variability, suggesting delayed brain maturation. It
study was very well done from a technical stand- also was associated with lesser regional densities,
point, but the interpretation of its results is compli- especially within the right cerebral hemisphere.
cated by several factors including: the groups were The absence of control subjects in the foregoing
not matched in age, and the neurological status and study does not permit one to conclude that the CT
level of functioning of subjects (including controls) results, although associated with neuropsychological
were poorly specified. abnormality, were themselves necessarily abnormal
In contrast, prevalence rates using neuro- according to any established normative standards.
psychological criteria tend to be comparatively high. Nonetheless, the findings were noteworthy in that the
For example, Tramontana, Sherrets, and Golden presence of neuropsychological deficits among the
( 1980) found a high rate of neuropsychological ab- psychiatric cases did correspond to variations in brain
normality in a mixed sample of child and adolescent structure, and were not merely the product of non-
psychiatric patients without known brain damage. neurological factors. This was a remarkable finding,
The subjects consisted of 20 hospitalized cases rang- especially in view of the restricted range of the sam-
ing from 9 to 15 years of age who had neither a ple, because of the exclusion of cases having docu-
history of brain damage nor positive findings on a mented neurological involvement.
routine neurological examination performed by the Taken together, the studies reviewed in this sec-
admitting psychiatrist. From a neuropsychological tion indicate that the question of prevalence is inex-
standpoint, these were "nonreferred" cases for tricably tied to the methods and criteria used in as-
whom brain dysfunction was not suspected. None- sessing brain dysfunction. Children with cerebral
theless, about 60% of the subjects showed at least palsy, epilepsy, and other obvious neurological con-
mild impairment (with 25% showing more definite ditions (as evidenced on a routine neurological exam)
impairment) according to the normative rules estab- probably comprise less than 5% of the total popula-
lished by Selz and Reitan (1979) on the Halstead- tion of children with psychiatric disorders (Rutter,
Reitan Neuropsychological Battery (HRNB). Im- 1977). The rate is uncertain, but obviously would be
paired performance on the HRNB was associated higher if one were to include children with clum-
with lower IQ, and was more prevalent among cases siness, language impairment, mental retardation, and
whose psychiatric disorders were of at least 2 years' learning disabilities (Gualtieri, Koriath, Van Bour-
duration and who had a lag of at least 2 years in gondieu, & Saleeby, 1983; Rutter et al., 1970) for
academic achievement. whom there is at least the suspicion of underlying
One may question the meaning of the neuro- brain damage. The rate is higher still if one further
psychological abnormalities found in the Tramon- includes children for whom brain damage is not sus-
tana et al. study, especially as to whether they indeed pected, but who nonetheless may show various neu-
reflected underlying brain anomalies that were ropsychological deficits when they are comprehen-
missed in a routine neurological examination or re- sively assessed. Although these deficits may have a
view of history. This was explored in a subsequent relationship with underlying structural factors (see
92 CHAPTERS
Tramontana & Sherrets, 1985}, they cannot be in- consisting of inattentiveness and defiance as an
terpreted as reflecting brain damage per se. Rather, eventual (albeit indirect) outcome. There also may be
they should be viewed as functional impediments, a compounded difficulty in those areas of perfor-
some of which may be tied to abnormalities in brain mance that have become anxiety-laden and aversive.
structure or maturation, which in any event may play Parents and teachers may come to view the child as
a role in the development of child psychiatric disor- lazy, apathetic, or otherwise difficult, and thereby
ders. As was noted before, the presence of neuropsy- generate expectations that would only serve to per-
chological deficits has been found to be associated petuate the existing problems. The latter represents a
with more extensive behavior problems among transactional effect, namely, the differential rein-
younger boys, regardless of factors such as IQ, SES, forcement elicited from significant others by the
and whether the deficits can be linked specifically brain-impaired child and his/her particular deficits.
with a history of brain injury (see Tramontana et al., Lastly, the effects on behavior are dynamic rather
in press). Neuropsychological deficits are important than static. Just as the primary symptoms of brain
in their own right, as they appear to comprise an dysfunction may change over time, so too they may
important index of increased psychiatric risk. vary in terms of their developmental significance and
the reactions that they elicit from others, including
the child. The pattern of behavioral disturbance itself
Relationship to Manifest Psychopathology may vary so that, for example, instead of hypersen-
sitivity, defiance, and misconduct, the child later
A number of mechanisms have been suggested may show apathy, withdrawal, and resignation.
whereby brain dysfunction may lead to psycho- Besides the issue of how brain dysfunction may
pathology, although evidence as to their relative con- lead to psychopathology in childhood, there also is
tributions is uncertain (Rutter, 1977, 1983). These the question of what form manifest symptoms may
include: (1) behavioral disruption that arises directly take. Earlier thinking (e.g., Bakwin & Bakwin,
from abnormal brain activity; (2) a heightened ex- 1966; Wender, 1971) suggested that the behavioral
posure to failure, frustration, and social stigma due to manifestations of cerebral dysfunction, whatever the
associated disabilities; (3) the possible effects of cause, were uniform, and comprised a rather dis-
brain damage on subsequent temperament and per- tinctive behavioral syndrome consisting of symp-
sonality development; (4) adverse family reactions toms such as hyperactivity, inattention, and im-
ranging from overprotection to scapegoating; (5} the pulsivity. However, there is little evidence of such a
child's own reaction to being handicapped and its behavioral stereotype for the brain-impaired child.
effects on his/her actual capacity to cope and com- Symptoms such as hyperactivity, inattention, and
pete; and (6) possible adverse effects from treatments impulsivity do not distinguish children with either
themselves (e.g., recurrent hospitalization) that may frank brain damage (see Brown et al., 1981; Rutter et
restrict normal activities and socialization. Thus, the al., 1970) or soft neurological signs (see Shaffer et
effects may be direct or indirect. They also may be al., 1983, 1985). This is not to say that such symp-
conceptualized as transactional and dynamic. toms are not common among brain-impaired chil-
Direct effects, for example, would be seen in dren-they are, but they also are common features of
the case of frontal lobe damage resulting in pro- psychiatric disorder in general, regardless of whether
nounced impulsivity and social disinhibition. Other neurological abnormality is present (Rutter, 1977;
examples include organically induced psychosis or Werry, 1972).
episodic aggressiveness that may arise from temporal One may argue that the relationship between
lobe epilepsy. In other cases, however, brain dys- brain dysfunction and psychopathology in childhood
function may play more of an indirect etiological is nonspecific (e.g., Boll & Barth, 1981). That is, the
role, one that essentially sets the stage for other fac- presence of brain dysfunction, regardless of its pat-
tors to come into play that, themselves, act to pro- tern or cause, may contribute nonspecifically to a
duce an emotional or behavioral disturbance and per- lowered adaptive capacity and a greater likelihood of
haps further aggravate existing functional difficulties exposure to adverse experiences. In this view, brain
(Tramontana, 1983). dysfunction operates indirectly by creating the func-
For example, brain dysfunction may give rise to tional deficits that make successful adjustment more
learning disabilities that, in turn, render the child difficult for the child. Any of a variety of behavioral
more likely to encounter frustration and failure upon and emotional problems may result, with the dis-
entry into school. This may lead to a conduct disorder tribution of specific symptoms being similar to what
is seen generally among children with psychiatric return to the question of specificity, i.e., the extent to
disorders. which different types and localization of brain dys-
There is some support for this position. In the function are associated with specific patterns of psy-
Isle of Wight study (Rutter et al., 1970), children chopathology, and vice versa.
with brain damage showed a heterogeneous range of
psychiatric disorders with no specific features. Ex-
cept for cases falling at the extreme of incapacity, the Findings in Selected Categories of
risk was greater in children with more severe injuries,
seizures, and lower IQ. Also, apart from the possible
Child Psychopathology
relationship between frontal lobe dysfunction and
gross social disinhibition, Brown etal. (1981) found This section provides a summary of neu-
no psychiatric symptoms that were specific to chil- rological and neuropsychological findings with re-
dren with closed head injuries. From a different per- spect to psychotic disorders in childhood (including
spective, Tramontana and Hooper (1987) found that Infantile Autism), Attention Deficit Disorder, con-
groups of adolescents with either conduct disorder or duct disorders, and affective disorders. We also will
major depression were virtually identical in their pat- examine briefly the findings in an assortment of other
tern of neuropsychological functioning. Thus, al- conditions, including Tourette's Syndrome.
though these represented two very different types of
psychopathology (each falling at opposite ends of a Psychotic Disorders
continuum of externalizing and internalizing symp-
toms, respectively), there were no distinctive neu- Although the general evidence regarding
ropsychological features. organic involvement in childhood psychotic disor-
On the other hand, it was noted before that a ders is rather compelling (Omitz, 1983), the findings
history of soft neurological signs or the presence of are imprecise and obscured by complex issues sur-
neuropsychological impairment tended to be associ- rounding diagnostic definition. This broad category
ated specifically with internalizing behavior prob- includes conditions such as Pervasive Developmen-
lems consisting of symptoms such as anxiety, de- tal Disorder, Infantile Autism, and Childhood
pression, and withdrawal (Shaffer et al., 1985; Tra- Schizophrenia. Other suggested subcategories have
montana et al., in press). In addition to cognitive included developmental psychosis (Noll & Benedict,
deficits, children with physical disabilities secondary 1982), disintegrative psychosis (Rutter & Shaffer,
to brain damage are likely to show persistent prob- 1980), and hypotonic schizophrenia (Cantor, Pearce,
lems with social isolation, but problems with aggres- Pezzot-Pearce, & Evans, 1981). The relationships
sion are less likely to persist (see Breslau & Marshall, among these various subcategories are unclear and,
1985). Also, results from a study of children with as may be expected, differential diagnosis has tended
localized (penetrating) head injuries showed a signif- to be associated with poor reliability and validity
icant association between the presence of depression (Fein, Waterhouse, Lucci, & Snyder, 1985). By far,
and lesions ~pecifically involving right frontal and the bulk of research investigating neurological and
left posterior cerebral regions; this was true re- neuropsychological abnormalities in childhood psy-
gardless of the child's age, sex, and psychosocial chosis has focused on Infantile Autism, with a small-
factors (Rutter, 1983). No relationship was found, er number of studies describing their subjects as
however, between the site of injury and symptoms childhood schizophrenics.
such as hyperactivity, inattention, aggression, or
antisocial conduct. Thus, although we are not sug- Childhood Schizophrenia
gesting the existence of an alternative behavioral
stereotype, it may be that internalizing rather than Netley, Lockyer, and Greenbaum ( 1975) postu-
externalizing symptoms are more distinctively tied to lated that neurological involvement is a necessary
brain dysfunction in childhood, perhaps especially in antecedent for the development of childhood schizo-
terms of longer-range outcomes. There also is some phrenia. Children within this category have been
indication that specific behavioral features may vary found to show a greater frequency of neurological
according to the type and localization of injury. signs (Hertzig & Walker, 1975; Owens & Johnstone,
The following section provides a selective re- 1980), abnormal BEGs (Netley et al., 1975), histo-
view of neurodiagnostic findings in major categories ries of perinatal complications (Torrey, Hersh, &
of child psychopathology. With this, we then will McCabe, 1975), and, compared to other psychiatric
94 CHAPTERS
subjects, tend to show a greater degree of cognitive A number of studies have documented the pres-
impairment (Carter, Alpert, & Stewart, 1982). ence of structural abnormalities in autism, with some
A great deal of attention has been given to iden- of these specifically identifying left hemispheric, and
tifying the early developmental precursors of schizo- in some cases bilateral, defects particularly involving
phrenia in high-risk populations, such as the off- frontal and temporal regions (Gillberg & Svendsen,
spring of schizophrenic parents. These children have 1983; Hauser, DeLong, & Rosman, 1975; Maurer &
been found to show a greater frequency of non- Damasio, 1982). Others (Hier, LeMay, & Rosen-
specific neurological signs (Erlenmeyer-Kimling et berger, 1979) reported different patterns of mor-
al., 1982; Marcus, Hans, Mednick, Schulsinger, & phological asymmetry. In a review of the research
Michelson, 1985), although some investigators have literature, Hetzler and Griffin ( 1981) concluded that
cited mild discoordination and hyperactivity as oc- there was evidence of bilateral temporal lobe in-
curring most frequently (Rieder & Nichols, 1979). volvement in autism. DeLong (1978) instead sug-
Fish (1977), furthermore, reported three specific gested that there are two subtypes of autism: one with
types of neurological abnormality that distinguished primarily left hemispheric impairment and the other
infants at risk for schizophrenia: abnormally quiet with bilateral impairment.
state, ~isual-motor problems (particularly on bi- However, there have been disconfirming find-
manual tasks), and decreased vestibular respon- ings as well (see Harcherik et al., 1985). Although
siveness. CT scan abnormalities were found by Caparulo et al.
For the most part, the evidence regarding specif- (1981), no clear localizable pattern emerged. Other
ic neuropsychological features in childhood schizo- studies found no relationship between morphogotical
phrenia has been inconclusive. Whereas one study asymmetries and delayed language development
found that childhood schizophrenics differed from (Tsai, Jacoby, & Stewart, 1983; Tsai, Jacoby, Stew-
other psychiatric controls specifically in terms of Per- art, & Beisler, 1982), and in some studies no struc-
formance IQ (Carter et al., 1982), another study tural abnormality of any kind was found (Harcherik
found that it was Verbal IQ that distinguished chil- eta/., 1985; Prior, Tress, Hoffman, & Boldt, 1984).
dren at risk for schizophrenia from normal controls Lastly, Coleman, Romano, Lapham, and Simon
(Gruzelier, Mednick, & Schulsinger, 1979). Like- (1985) found no consistent differences in a post-
wise, no clear localizing patterns have been found mortem cell count of selected left hemispheric re-
with respect to neurostructural and electrophysiol- gions between an autistic adult and control subjects.
ogical findings. With respect to neurophysiological evidence, it
has been estimated that approximately 40 to 50% of
child autistics show abnormalities in their EEGs
Infantile Autism (Tsai, Tsai, & August, 1985). The abnormalities are
Infantile Autism is a behavioral syndrome typ- of a varied nature, but often may include excessive
ically defined by disturbed social and object rela- slow-wave activity and less alpha bilaterally (Cantor,
tions, poor communication and language abilities, Thatcher, Hrybyk, & Kaye, 1986). Among autistic
and difficulties in the modulation of sensory input. A children, the presence of a normal EEG appears to be
variety of etiologies have been proposed, including associated with a more favorable developmental
genetic factors (Levitas et al., 1983), pathological course and higheriQ (Small, 1975). Visual and au-
endorphin activity (Gillberg, Terenius, & Lonner- ditory evoked potentials also have been observed to
holm, 1985), and autoimmune abnormalities (War- be impaired in autistics, with visual processing ca-
ren, Margasetten, Pace, & Foster, 1986). However, pabilities tending to be more intact than auditory pro-
regardless of the specific anomaly or etiology that is cessing (Courchesne, Lincoln, Kilman, & Galam-
hypothesized, some form of brain impairment is bos, 1985; DeMyer, Hingtgen, & Jackson, 1981).
thought to be involved in nearly all cases (Damasio & Numerous neuropsychological aspects of au-
Maurer, 1978; Ornitz, 1983). tism have been reported. Children with autism have
Children with autism tend to have. a significant been found to have poor motor imitation abilities
prenatal or perinatal history and show a high rate of (Jones & Prior, 1985), disproportionate impairment
soft neurological signs (Jones & Prior, 1985). Kagan in sequential processing abilities (Tanguay, 1984),
(1981) found two or more signs suggestive of neu- and, as a group, IQs that are significantly lower than
rological involvement in over 94% of his autistic normals, but comparatively higher than mentally re-
sample. Garreau et al. (1984) further noted that the tarded children (Kagan, 1981). The cognitive pro-
presence of neurological impairment was associated files of autistic children can be rather varied; indeed,
with an earlier onset of autistic features. using clustering techniques, Fein, Waterhouse, Luc-
ci, & Snyder (1985) differentiated five subgroups of showed more deviant language development, a se-
autistic children on the basis of their cognitive vere comprehension deficit, and deficits in the social
profiles. usage of language. Although related to childhood
Many of the neuropsychological studies have language disorders, the communication deficits in
been directed toward investigating the presence of autistic children are qualitatively different from those
lateralized deficits in autistic children. The findings seen in developmental dysphasia or acquired ap-
have included a reversal of ear advantage for speech hasia. Specifically, autistic children are deficient in
sounds (left ear rather than right) on dichotic listening symbolic-representation abilities necessary for lan-
tasks (Blackstock, 1978; James & Barry, 1983; Prior guage development (Ferrari, 1982), show an im-
& Bradshaw, 1979); increased prevalence rates of poverishment in verbal mediation and gestural
left and mixed handedness of about 20 and 34%, communication (Cohen, Caparulo, & Shaywitz,
respectively (Soper et al., 1986); and performance 1976), and, in echolalic autistics, there is an inap-
profiles on neuropsychological test batteries sug- propriate use and modulation of expressive-intona-
gestive of predominantly left hemispheric dysfunctional speech (Simon, 1975).
tion (Applebaum, Egel, Koegel, & Imhoff, 1979; Tager-Flusberg (1981) argued that whereas au-
Dawson, 1983; Hoffman & Prior, 1982). In a recent tistic children show a normal but slower developmen-
study by Dawson, Finley, Phillips, and Galpert tal course with respect to phonological and syntac-
(1986), there was strong evidence of an atypical pat- tical skills, semantic and pragmatic language
tern of hemispheric specialization, with about 70% of development may be particularly deviant. Prizant
autistic children showing right hemisphere domi- (1982) further argued that the ritualized patterns and
nance for speech. highly rigid behaviors of verbal autistic children are
However, the results of some studies have sug- directly related to their limitations in cognitive and
gested a more complex picture. Fein, Waterhouse, linguistic processing. Like Tanguay (1984), Prizant
Lucci, Rennington, and Humes (1985) found that, suggested that the peculiarities in autistic speech and
among autistic children, left-banders performed bet- language reflect an undue reliance on a simultaneous
ter than right-banders across a variety of tasks. How- rather than a sequential mode of cognitive pro-
ever, those with mixed handedness performed the cessing.
worst. This suggests that if there is early injury to the Thus, the research on autism provides a some-
left hemisphere, a reversal of handedness ultimately what varied picture with respect to neurological and
may be associated with a better compensatory devel- neuropsychological features. With the possible ex-
opment. In another study, Arnold and Schwartz ception of aberrations in language development and
(1983) found that autistic children did not demon- communication skills, there is little agreement as to
strate the same reversal of ear advantage for speech neurodevelopmental features that are necessarily
on dichotic listening demonstrated by children with characteristic of the disorder. Some children with
aphasia and other language disorders. These findings autism show significant anomalies in brain structure,
suggest that autism and language disorder are not whereas others do not. The same is true with respect
identical, and that language in autism may not be to neurophysiological and neuropsychological fea-
accommodated by the right hemisphere as is often tures. Although some children with autism show evi-
true in other cases of acquired left hemispheric inju- dence of lateralized dysfunction mainly involving the
ry. Kagan's (1981) analysis of speech behavior, left cerebral hemisphere, this by no means is a defin-
memory, and thought processes suggested that the ing characteristic of the syndrome (Fein, Humes,
presence of right hemisphere dysfunction in autism Kaplan, Lucci, & Waterhouse, 1984).
should be considered as well.
Regardless of the issue of lateralization, the
presence of disturbed language functions in autism is Attention Deficit Disorder
critical. Language problems are one of the primary
symptoms observed in autistic children (Rutter, This syndrome has had a long and controversial
1978), and the degree of language impairment ap- history. Nonetheless, it remains one of the most com-
pears to be strongly predictive of the child's prog- monly diagnosed child psychiatric disorders (Mat-
nosis (Rutter, Greenfield, & Lockyer, 1967; Wing, tison eta/., 1986). The term Attention Deficit Disor-
1971). Bartak, Rutter, and Cox (1975) postulated der (ADD) replaced earlier terms such as
that a language disability probably constitutes a nec- hyperkinetic reaction and hyperactivity due to the
essary condition for the development of this behav- central role that deficits in attention were thought to
ioral syndrome. They observed that autistic children play in the disorder [Diagnostic and Statistical Man-
96 CHAPTERS
ual-ll/, (DSM-111), American Psychiatric Associa- with ADD children have failed to identify focal neu-
tion, 1980]. DSM-Ill actually describes two global rophysiological features (Grunewald, Grunewald, &
subtypes of the disorder-ADD with and without Rasche, 1975; Mikkelsen, Brown, Minichiello, Mil-
hyperactivity. However, whereas many studies have lican, & Rapoport, 1982; Montagu, 1975), a recent
documented the presence of deficits in selective and study of regional cerebral blood flow patterns dem-
sustained attention in ADD children (Brown & onstrated lower perfusion rates in the frontal regions
Wynne, 1984; Douglas, 1983), it has been proposed of some ADD children (Lou, Henriksen, & Bruhn,
that ADD without hyperactivity be deleted as a diag- 1984). Also, in a well-designed study, Chelune, Fer-
nostic category in the forthcoming revision of DSM- guson, Koon, & Dickey (1986) were able to dis-
Ill because of its ambiguous nature (Barkley, 1986a). tinguish ADD children from age- and IQ-matched
ADD has often been linked with minimal brain normals with 85% accuracy using tests such as the
dysfunction (MBD) because of purported behavioral Wisconsin Card Sorting Test, a measure commonly
similarities between children with ADD and those thought to be sensitive to adult frontal lobe dysfunc-
with documented brain damage (Strauss & Lehtinen, tion. They also demonstrated that, among the ADD
1947). However, problems in documenting the pres- children, medication response with psychostimulants
ence of underlying brain dysfunction (e.g., Rutter, was poorer for those showing a greater degree of
1983; Taylor, 1983) have led to a more descriptive neuropsychological impairment. This finding is con-
approach in conceptualizing the disorder. Children sistent with the observations of Rapoport et al.
with ADD have been characterized as showing inat- ( 1980) who found that even normal children show
tention, impulsivity, and overactivity (Douglas, improved performance with psychostimulant medi-
1980, 1983); deficits in self-directed instruction cation. It may be that a positive medication response
(Kendall & Broswell, 1985); poor self-regulation of is dependent upon relatively intact frontal lobes, and
arousal, particularly in meeting environmental de- that the presence of more severe frontal lobe pa-
mands (Douglas, 1983); and deficiencies in rule-gov- thology would tend to be associated with a poor med-
erned behavior (Barkley, 1981a,b). A number of in- ication response. This is a fruitful area for further
vestigators have questioned whether ADD truly inquiry.
represents a valid syndrome (Rubinstein & Brown,
1984; Rutter & Taylor, 1978), given the hetero-
geneity of its behavioral manifestations (Halperin, Conduct Disorders
Gittelman, Klein, & Rudel, 1984; Johnson, 1981)
and the difficulties in distinguishing it from conduct Research in this broad category of child psycho-
disorders more generally (Delamater & Lahey, pathology has been beset with a number of problems.
1983). First, as a diagnosis, it pertains to a very hetero-
Given the debates surrounding the validity and geneous range of disturbances in which the man-
diagnostic criteria comprising this disorder, it is not ifestation of socially unacceptable behavior is the
surprising that the search for a neurological basis to primary common feature. Second, the bulk of re-
ADD has presented confusing (Taylor, 1985), and search has focused on adolescents, particularly the
often undifferentiated findings (Levine, Busch, & juvenile offender. If one excludes children with
Aufseeser, 1982). A number of theories have been ADD, little is known with respect to the neurological
proposed, but the exact neuropathology of attentional and neuropsychological features of conduct disorders
disturbances in children remains poorly understood manifested at early ages. Third, youngsters with con-
(Mesulam, 1981). To date, the evidence seems to be duct disorders have a higher risk for accidental head
strongest with respect to implicating frontal lobe dys- injury (Lewis & Shanok, 1977; Lewis, Pincus, &
function in the increased distractibility and impulsive Glaser, 1979; Pincus & Tucker, 1978); thus, al-
orienting reactions to irrelevant stimuli seen in ADD though they may show neurological abnormalities on
children (Passier, Isaac, & Hynd, 1986; Stuss & Ben- examination, these may bear no direct relationship to
ton, 1984; Zambelli, Stamm, Maitinsky, & Loiselle, the initial conduct disorder. This problem obviously
1977). Various specific patterns of localization have is compounded by the emphasis on studying older as
been proposed, including frontal regions anterior and opposed to younger conduct-disordered subjects.
medial to the precentral motor cortex (Mattes, 1980), With these limitations in mind, the findings for this
as well as frontolimbic pathways (Lou et al., 1984; general category of psychopathology are summa-
Newlin & Tramontana, 1980). rized below.
The evidence with respect to localization has A number of studies have reported abnormal
been mixed but promising. Whereas EEG studies neurological findings in youngsters with conduct dis-
orders (Elliott, 1982; Korhonen & Sillanpaa, 1976; Further investigations into the pattern of neu-
Krynicki, 1978; Woods & Eby, 1982). Elec- ropsychological deficits in conduct disorders have
trophysiological studies (Coble eta/., 1984; Elliott, produced mixed results. Berman and Siegal (1976)
1982; Krynicki, 1978; Luchins, 1983) have found found that delinquents performed more poorly than
EEG sleep abnormalities, specifically in the ex- normal controls on virtually every task of the HRNB.
pression of slow-wave (delta) activity (Coble et al., Whereas prominent deficits were observed in tasks
1984); seizure activity that may contribute to recur- requiring verbal mediation, concept formation, and
rent and unprovoked rage attacks (Elliott, 1982); and perceptual organization, only minimal difficulties
in some cases, frontal lobe paroxysmal activity, par- were found in memory and gross motor coordination.
ticularly in conduct-disordered adolescents with a Brickman, McManus, Grapentine, and Alessi (1984)
significant history of assaultive behavior (Krynicki, found that more violent youth tended to show more
1978). The latter finding bears some relationship to impairment on the LNNB than their nonviolent coun-
the work of Woods and Eby (1982) and Pontius and terparts, with Expressive Speech and Memory being
Ruttiger (1976) who postulated a delay in the devel- the distinguishing summary scales. This was true
opment of normal inhibitory mechanisms (i.e., front- with respect to both male and female offenders.
al lobe functions) in repetitively aggressive young- These findings were similar to the results of earlier
sters. Children with conduct disorders have been studies by Lewis, Shanok, and Pincus (1982) and
reported to show a higher incidence of episodes of Voorhees (1981). However, in controlling for the
disturbed consciousness and, as already noted, to presence of psychosis and a history of neurological
suffer more head injuries than other children (see disorder, Tarter, Hegedus, Alterman, and Katz-Gar-
Lewis & Shanok, 1977; Lewis et al., 1979; Pincus & tis (1983) failed to find differences in neuropsychol-
Tucker, 1978). However, they have not been found ogical, intellectual, and psychoeducational perfor-
to differ from normal controls in terms of perinatal mance across groups of adolescent offenders
problems, except for more frequently being small for differing with respect to their type of offense (i.e.,
gestational age (McGee, Silva, & Williams, 1984). violent, nonviolent, sexual).
These findings further serve to suggest that the neu- The previously noted problems limit the gener-
rological features in many of these children may post- alizations that one can make with respect to this cate-
date the initial onset of their conduct disorders. gory of child psychopathology. It is probably fair to
Conduct-disordered youngsters have been found say that, as a group, youngsters with conduct disor-
to have a high rate of learning disabilities (Cannon & ders tend to have more limited verbal abilities and a
Compton, 1980; Robbins, Beck, Pries, Jacobs, & heightened rate of neurological signs (these, howev-
Smith, 1983; Zinkus & Gottlieb, 1978), as well as er, may arise secondarily as consequences of their
more generalized problems with language perfor- behavior disorders). With the possible exception of
mance (Funk & Ruppert, 1984; Stellern, Marlowe, cases with prominent histories of repetitive, as-
Jacobs, & Cossairt, 1985; Wardell & Yeudall, 1980). saultive behavior, the specific role of neurological
This appears to apply to both nonincarcerated (Rob- factors in conduct disorders remains unclear.
bins et al., 1983) as well as incarcerated (Cannon &
Compton, 1980) populations. These findings suggest
that the presence of cognitive impairments, perhaps Affective Disorders
particularly of a verbal nature, places the youngster at
risk for acting out impulsively when placed in frustrat- MacAuslan (1975) reported that depressed chil-
ing or provocative social situations. The degree of dren have an increased frequency of neurological soft
impulsivity per se is unrelated to either the type or the signs when compared to normal controls. Converse-
number of crimes committed by delinquent youth ly, as was noted earlier, adolescents with early soft
(Oas, 1985). Rather, it may be that the presence of signs were more likely to have a psychiatric disorder
faulty capacities in verbal reasoning and judgment, characterized by symptoms such as anxiety, with-
along with impulsivity, is a necessary ingredient in the drawal, and depression (Shaffer et al., 1985). Simi-
production of chronic antisocial conduct. Thus, al- larly, social isolation rather than aggression is more
though unrelated to the degree of impulsivity, the likely to be a persistent problem in children with
presence of at least a 15-point inferiority in Verbal IQ physical disabilities secondary to brain damage (see
versus Performance IQ on the Wechsler Intelligence Breslau & Marshall, 1985). Moreover, internalizing
Scale for Children-Revised (WISC-R) has been rather than externalizing symptoms have been found
found to be predictive of recidivism in adjudicated to be more clearly tied to neuropsychological impair-
white delinquent boys (Haynes & Bensch, 1981). ment in psychiatrically hospitalized boys (Tramon-
98 CHAPTERS
tana et al., in press). Also, apart from gross social Comprehension, Block Design, and Coding, as well
disinhibition, it will be recalled that depression was as on the Matching Familiar Figures Test, the Cate-
the only psychiatric symptom that bore any specific gory Test of the HRNB, and the Visual Reception
relationship to lesion localization in the series of Subtest of the Illinois Test of Psycholinguistic Abili-
studies on head injury by Rutter and his colleagues ties. Although the localizing significance of this pat-
(Rutter, 1983). Thus, depression and other distur- tern of results is uncertain, two children in the study
bances in affect appear to be important features of the were reported to have had a mild left-sided hemi-
brain-impaired child, perhaps especially in terms of paresis, which also improved subsequent to anti-
long-range outcomes. depressant treatment. The latter finding, if repli-
Much of the neuropsychological investigation cated, would constitute more convincing evidence of
into childhood depression has focused specifically on improvement in lateralized dysfunction.
the question of lateralization of dysfunction. Re- A number of electrophysiological studies have
search demonstrating the specialized role of the right been reported as well. Rochford, Weinapple, and
cerebral hemisphere in the processing of human emo- Goldstein ( 1981) found greater EEG variance in the
tion and affective cues, along with reports of right right hemisphere than in the left in a heterogeneous
hemispheric dysfunction in adults suffering from de- group of depressed adolescents. This pattern was dis-
pression (Tucker, 1980), prompted inquiries into the tinct from that of normal controls, who demonstrated
existence of such relationships in children. A number about equal hemispheric variance, and from adoles-
of studies have reported impaired nonverbal abilities cents with paranoid symptomatology, who exhibited
relative to verbal abilities in children with depres- greater variance in the left hemisphere. However,
sion. For example, Kaslow, Rehm, and Siegel Knott, Waters, Lapierre, and Gray (1985) found no
(1984) found that higher scores on the Children's evidence of specific hemispheric abnormalities in a
Depression Inventory (CDI) were associated with comparison of EEG patterns and auditory-evoked po-
poorer performance on the WISC-R subtests of Block tentials in matched pairs of siblings discordant for
Design, Coding, and Digit Span in a mixed group of affective disorder. They did find that the bipolar
childhood depressives. No significant relationships group spent less time in EEG alpha, suggesting a
were found for WISC-R Vocabulary or the Trail- hyperarousal of the nervous system in this form of
Making Test of the HRNB. Blumberg and Izard affective disorder. EEG abnormalities in REM sleep
( 1985) found a similar pattern of results using the latencies also have been described in depressed ado-
Peabody Picture Vocabulary Test and WISC-R lescents, although this finding has not been docu-
Block Design, with the CDI again serving as the mented in prepubescent children (Mendlewicz, Hoff-
index of depression. In both studies, girls were found man, Kerkhofs, & Linkowski, 1984).
to perform more poorly than boys on Block Design. Sackeim, Decina, and Malitz (1982) reviewed
Children of bipolar probands likewise have been much of the earlier literature pertaining to functional
found to show a disproportionate inferiority in Per- brain asymmetry and affective disorders. They con-
formance IQ relative to Verbal IQ when compared to cluded that affective disorders, particularly unipolar
normal controls (Decina et al., 1983). However, the depression, tend to be associated with right hemi-
fact that left-handedness was overrepresented in their spheric cognitive dysfunction and/or electrophysiol-
sample of children at risk for affective disorder would ogical overactivation. In contrast, bipolar patients
tend to argue against an inference of right hemi- may evidence right- or left-sided hemispheric hyper-
spheric dysfunction. More generally, the findings in activation depending on whether the individual is
the preceding studies constitute very weak evidence experiencing a depressive (right hemisphere) or man-
of lateralized right hemispheric dysfunction. The ob- .ic (left hemisphere) episode. These assertions will
tained pattern of results simply may reflect the differ- require further validation with child and adolescent
ential sensitivity of performance measures to the ef- subjects.
fects of depressed concentration and motor speed.
Several studies have reported improvements on Other Disorders
neuropsychological measures suggestive of both
right hemispheric and frontal lobe dysfunction subse- Although not specifically a psychiatric disorder,
quent to treatment with antidepressant medication Tourette's Syndrome is included here because of its
(Brumback, Staton, & Wilson, 1980; Staton, bizarre behavioral presentation, particularly in ex-
Wilson, & Brumback, 1981; Wilson & Staton, treme cases, and the heightened psychiatric vul-
1984). Specifically, Staton et al. found that remis- nerability of the afflicted child. It is a rare disorder
sion of melancholic symptoms was associated with characterized by facial, body, and vocal tics, with
improved performance on WISC-R Similarities, about 50% of the cases demonstrating coprolalia
(Woodrow, 1974), and approximately 20-25% ex- ries of child psychopathology. For example, we saw
hibiting imitative gestures and copropraxia (Shapiro, evidence suggestive of left hemispheric dysfunction
Shapiro, & Wayne, 1973). These symptoms vary in in disorders as dissimilar as Infantile Autism and
intensity, with an exacerbation typically being noted Conduct Disorder; frontal lobe dysfunction was re-
during times of stress (Woodrow, 1974). The spec- ported in one study or another for almost all of the
ific etiology of this disorder is unknown, although categories of disturbance considered. Clearly, there
current thinking suggests that it is a neurological dis- is wider symptomatic variation across the different
order (Devinsky, 1983) with a major neu- categories of child psychopathology than the lo-
rophysiological component (Glaze, Frost, & Janko- calization findings would suggest. With the neu-
vic, 1983; Tanner, Goetz, & Klawans, 1982). Some rodiagnostic findings overlapping to such an extent,
have suggested that it mainly involves subcortical these hardly could be used to provide a satisfactory
impairment secondary to a neurochemical distur- explanation for the different forms of psycho-
bance, and that the disorder follows a progressive pathology manifested. Although this lack of specific-
course (Bornstein, King, & Carroll, 1983). How- ity may be an artifact of our limited ''windows'' into
ever, neither epidemiological work (Lees, the brain, it does support the view of a largely non-
Robertson, Trimble, & Murray, 1984) nor serial specific, indirect relationship between brain dysfunc-
neuropsychological assessments performed over a 5- tion and psychopathology in childhood.
year period (Newman, Barth, & Zillmer, 1986) have Undoubtedly, the picture was blurred by dif-
confirmed the presence of a degenerative process. ferences in subject samples and the methods used in
The presence of attentional difficulties often ob- identifying brain dysfunction across studies. Incon-
served in these patients has led some investigators to sistencies in the use of diagnostic terminology and
hypothesize a relationship with ADD, particularly criteria obviously served to confuse the picture when
for those ADD children who show motor tics as a side considering a particular disorder. We should not ex-
effect of psychostimulant medication (Comings & pect the neurodiagnostic findings to be any more co-
Comings, 1984). hesive than the particular behavioral syndrome or
At present, no consistent pattern of neurological category of disturbance to which they refer.
or neuropsychological deficits has emerged that char- Confusion also seems to have resulted from a
acterizes the disorder. Whereas some studies (Fer- faulty application of neuropsychological inference in
rari, Matthews, & Barabas, 1984; Incagnoli &Kane, a number of studies. It is one thing to use neuropsy-
1983; Sutherland, Kolb, Schoel, Whishow, & chological test data in making inferences regarding
Davies, 1982) have identified specific impairments lesion localization for cases with documented brain
(especially involving visual-spatial and visual- damage; however, even here issues such as cerebral
motor abilities), others have suggested a more het- plasticity and individual differences in compensatory
erogeneous picture (Joschko & Rourke, 1982). The development can obscure specific brain-behavior re-
interested reader is referred to Barkley ( 1986b) for a lationships (e.g., Bigler & Naugle, 1985; Rourke et
critical review of the research on Tourette's Syn- al., 1983). In any event, one is certainly on rather
drome in children. weak ground in making such inferences on cases for
Although inconclusive, the reader also may whom there is no corroborating evidence as to the
wish to refer to an assortment of studies examining presence or localization of injury. A relatively low
neurological/ neuropsychological abnormalities in Verbal IQ is not necessarily associated with left
children and adolescents with Conversion Reaction hemispheric impairment, nor is impulsivity neces-
(Regan & LaBarbera, 1984), Borderline Personality sarily a sign of frontal lobe dysfunction. Although
(Palombo & Feigon, 1984; Smith, Bemporad, & such results may have localizing significance, they
Hanson, 1982), and Obsessive-Compulsive Disor- easily can be attributed to nonneurological factors as
der(Behar eta/., 1984; Rapoport, Elkins, & Langer, well. Unfortunately, too many investigators have of-
1981). fered interpretations of localized dysfunction solely
on the basis of this kind of weak evidence.
More rigorous applications of reliable diag-
nostic criteria, together with a multimethod ap-
Implications for Research and proach (Tramontana, 1983) that incorporates recent
Practice advances in neurodiagnostic technology (including
magnetic resonance imaging, positron emission to-
Based on the preceding review, there appears to mography, and topographic EEG mapping), cer-
be little evidence of specificity in the type or pattern tainly will help to advance our knowledge in this
of brain dysfunction associated with different catego- area. This promises to be an exciting line of research
100 CHAPTER 5
offering fresh insights into the neuropathology of sus disturbance versus delay in the neuropsychologi-
child psychiatric disorders. However, more is cal results of psychiatrically disordered children. The
needed-especially research that focuses on issues standard application of neuropsychological methods
of prevention and treatment. appears to be associated with a greater likelihood of
The existing research has documented the false-positive errors in diagnosis with this popula-
heightened risk for psychopathology in the child with tion. This is because a psychiatric disturbance in
brain dysfunction. Emphasis should be given to gain- childhood or adolescence, in the absence of brain
ing a better understanding of what factors might cur- damage, may itself produce significant impairment
tail that risk, and thereby maximize outcomes. At on many neuropsychological tests. Impaired perfor-
present, the natural history of behavioral distur- mance could result from the disruptive effects of anx-
bances secondary to brain dysfunction is poorly un- iety, depression, or psychogenically based problems
derstood. There is some indication that the rela- with impulse control and attention. Such conditions
tionship may weaken or grow more indirect over may not only disrupt present performance, but also
time, as other factors perhaps come to assume a more could have impeded the past attainment of various
important determining role in maintaining problem skills that are prerequisite to age-appropriate perfor-
behaviors (Dorman, 1982; Tramontana et al., in mance in many of the areas that are assessed. It is just
press). The nature of behavioral disturbances also as undesirable to overdiagnose brain dysfunction as it
may show some convergence over time, with symp- is to overlook it when it does exist. This has led some
toms such as withdrawal and depression being among authors (e.g., Tramontana, 1983) to argue for the use
the more common outcomes associated with a history of more conservative detection criteria when apply-
of chronic handicap (Breslau & Marshall, 1985; ing neuropsychological methods in a child psychi-
Shaffer et al., 1985). It is important to know more atric population. Neuropsychological inferences re-
precisely how this process unfolds so that it might be garding the presence of brain dysfunction should
redirected more positively, if not prevented. The never be based solely on defective levels of perfor-
whole issue of diff~rential treatment responsiveness mance, but also should be supported by other features
as a function of neuropsychological factors certainly in the neuropsychological results.
warrants further exploration, especially with respect Following this line of thinking, and opera-
to some of the promising findings that have been tionalizing decision-rules based on Reitan's (1974)
reported in the areas of ADD (Chelune et al., 1986) four methods of inference (i.e., level of perfor-
and childhood depression (Staton et al., 1981). mance, pattern of performance, pathognomonic
Rather than localization of dysfunction per se, great- signs, and right-left differences), Tramontana and
er emphasis should be given to examining the Hooper (1987) were able to distinguish psychi-
therapeutic and prognostic significance of different atrically hospitalized adolescents with and without
profiles of functional deficits, with the emphasis documented brain damage on the basis of their neu-
being onfunctional systems. ropsychological results. Using the LNNB, they
The implications for clinical practice are sim- found that the rate of overall correct classification
ilar. Accurate detection of the functional deficits and was improved, with false-positive errors correspon-
behavioral liabilities in the brain-impaired child is the dingly reduced, when diagnosing brain impairment
first step in limiting the risk for the later development was based on the subject meeting criteria on at least
or exacerbation of psychopathology. The acronym two of the detection methods examined. This resulted
"ITEM-ize" seems to capture the essence of the in a 76% rate of overall correct classification, which
strategy, i.e., identify, treat early, and thereby mini- was a substantial improvement over the results ob-
mize the development of secondary disturbances. tained with the standard cutoff on the battery.
The neuropsychologist can play an important role in There has also been some work examining the
this regard. Of all the professions that deal with use of brief screening procedures in identifying child
brain-impaired children, the neuropsychologist psychiatric cases who would likely show significant
should be uniquely qualified not only in identifying abnormalities on a comprehensive neuropsychologi-
primary deficits, but in treating secondary emotional cal assessment. Capitalizing on the variance shared
and behavioral disturbances that may arise. by measures such as the WISC-R and Aphasia
Issues surrounding valid neuropsychological di- Screening Test with standard batteries such as the
agnosis with this population have been discussed HRNB and LNNB (Tramontana, Klee, & Boyd,
elsewhere (Tramontana, 1983), and thus will not be 1984; Wolf & Tramontana, 1982), Tramontana and
elaborated here. Briefly, the major interpretive prob- Boyd ( 1986) derived a regression formula for pre-
lem involves distinguishing the effects of deficit ver- dicting neuropsychological abnormality in child psy-
chiatric referrals on the basis of such screening pro- Bigler, E. D., & Naugle, R. I. (1985). Case studies in cerebral
cedures. Although not a replacement for a full plasticity. International Journal of Clinical Neuropsychol-
neuropsychological assessment, this may help aid ogy, 7, 12-23.
clinicians in identifying cases for whom a compre- Blackstock, E. (1978). Cerebral asymmetry and the development
hensive neuropsychological assessment is indicated. of early infantile autism. Journal of Autism and Childhood
Schizophrenia, 8, 339-353.
Overall, the neuropsychology of child psycho-
Blumberg, S., & Izard, C. (1985). Affective and cognitive charac-
pathology represents an important and challenging teristics of depression in 10 and 11 year old children. Journal
aspect of the broader field of child neuropsychology. of Personality and School Psychology, 49, 194-202.
It is a complex area of investigation for the researcher (Abstract)
and clinician alike, as there are many confounding Boll, T., & Barth, J. (1981). Neuropsychology of brain damage in
factors that can obscure the study of brain-behavior children. InS. B. Filskov & T. J. Boll (Eds.), Handbook of
relationships in child psychopathology. Our discus- clinical neuropsychology (pp. 418-452). New York: Wiley.
sion of a number of these hopefully has given the Bomstein, R. A., King, G., & Carroll, A. (1983). Neuropsycho-
reader an appreciation for the complexity of the top- logical abnormalities in Gilles de Ia Tourette's syndrome.
ic. However, it is not only a field with problems, but Journal of Nervous and Mental Disease, 17, 497-502.
Breslau, N., & Marshall,l. A. (1985). Psychological disturbance
one with prospects as well. The work to date certainly
in children with physical disabilities: Continuity and change
has served to highlight promising areas for inquiry in a 5-year follow-up. Journal of Abnormal Child Psychol-
and intervention in which the child neuropsycholo- ogy, 13, 199-216.
gist can play an important contributing role. Brickman, A., McManus, M., Grapentine, W., & Alessi, N.
(1984). Neuropsychological assessment of seriously delin-
quent adolescents. Journal ofthe American Academy ofChild
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6
Neuropsychological Sequelae of
Chronic Medical Disorders
RICHARD A. BERG AND JOHN C. LINTON
Introduction nothing in the human body functions in total indepen-

dence, there can be no single causal mechanism.
In the past, neuropsychologists were largely con- Easily acknowledged on one level, this concept is
cerned with the evaluation and study of neurological both pervasive and essential to the understanding of
conditions that result in impairment in intellectual brain-body relationships.
functioning. The vast majority of both clinical work In the assessment of a child with medical prob-
and published research was done with adults. By lems, however, it is important that clinicians consid-
comparison, child clinical neuropsychology is still in er multiple causes for any noted neuropsychological
its infancy. Both clinicians and researchers who have dysfunction. Additionally, psychiatric and social
worked with children have tended to focus their ener- problems may impact on a child's behavior and over-
gies largely on the brain itself and have viewed most all functioning. The determination of the presence
problems of concern to them as occurring within the and severity of any brain effects thus requires knowl-
brain or some other portion of the central nervous edge of the possible contribution of a variety of fac-
system (CNS). However, child neuropsychologists tors including the disease itself, those organ systems
are becoming increasingly involved in the evaluation directly and indirectly affected, the specific phase of
of individuals who suffer from diseases that may af- the illness, any current medical treatment, premorbid
fect any part of the body. personality, the coping capacity of the child, and the
Although the brain and other parts of the body child's estimated functional level prior to the illness.
are separate in terms of anatomy, they function as an In many disease conditions, the cognitive se-
integrated whole. Thus, when other organ systems quelae only have been assumed due to clinically re-
are affected by a disease process, the brain in general, ported mental or behavioral changes of some children
and cognitive functioning in particular, also may be- with the disease. There has been comparatively little
come impaired. This impairment may result from research on the neuropsychological effects of indi-
damage to brain tissue from the disease itself, or viduals suffering from a great many nonneurological
alternatively, brain dysfunction may occur as a sec- diseases. Even when CNS effects are reported as
ondary effect of a disease process elsewhere in the possible or frequent, there is little understanding of
body. For instance, the failure of other organ systems the specific types of cognitive deficits likely to occur
to provide nutrients to the brain may result in dimin- with differing disease processes, and even less is
ished cognitive functioning. The notion of multiply known about recovery patterns or residual effects.
interactive systems is primary to the discussion of . In this chapter we will discuss the functioning of
diseases and conditions presented in this chapter. As each major organ system in the body and the ways in
which its malfunction may potentially impact on
brain functioning. Additionally, we will attempt to
RICHARD A. BERG AND JOHN C. LINTON Depart- pull together the comparatively little research that has
ment of Behavioral Medicine and Psychiatry, West Virginia Uni- been done on disease processes specific to an organ
versity Medical Center-Charleston Division, Charleston, West system and the neuropsychological effects that have
Virginia 25326. been reported in the literature. As the reader will
107
108 CHAPTER 6
note, in a number of cases specific neuropsycho- Infections of the CNS

logical data is not available. In those instances,
clinical symptomatology that implicates possible The effects of encephalitis on the developing
neuropsychological dysfunction will be presented. brain have been of interest since the outbreak of epi-
demic encephalitis following World War I, which
resulted in high mortality among children and a high
The Brain and CNS frequency of subsequent psychiatric morbidity
(Graham, 1983). Ebaugh (1923), Kennedy (1924),
Basic brain structure and function are reviewed and Strecker (1929) all reported studies of children
in other sections of this book. We are concerned here who had been followed for a number of years after the
with the function of the brain in relation to other body initial acute illness. The acute phase of encephalitis
processes. The brain has unusual energy require- was characterized by sleepiness, fever, and other
ments. Although it comprises only about 2% of total signs of localized CNS involvement, which was fol-
body weight, it receives roughly 15% of cardiac out- lowed by a gradual onset of a number of significant
put, and accounts for 20% of the body's oxygen con- personality changes. Ebaugh (1923) reported a wide
sumption (Freedman, Kaplan, & Sadock, 1976). As range of behavioral and emotional sequelae that in-
a consequence of this high energy demand, brain volved insomnia with nocturnal agitation, affective
cells are extremely sensitive to alterations in their disorders of the depressive type, hysterical reaction,
energy supply, mainly oxygen and glucose. Even and unwarranted fearfulness as well as mental
mild energy deficits can impair the function and in- retardation.
tegrity of brain cells (Ariel & Strider, 1983). Since the 1920s, reports of epidemic encepha-
In the normally functioning brain, energy is ob- litis and subsequent behavioral sequelae have been
tained through a process of oxidation of glucose to sporadic and Graham (1983) noted that encephalitis
carbon dioxide and water. The energy is then expend- is now generally considered a rare cause of childhood
ed in the transportation of various compounds across cognitive disturbance. Levy (1959) described 100
cell membranes and for the synthesis of other cell children with hyperkinetic and antisocial behavior
constituents. Because oxygen and glucose are trans- disorders to whom he ascribed the cause as encepha-
ported to brain cells by blood, an adequate cerebral litis. However, since that study, doubt has been
blood flow is essential for brain metabolism. Addi- raised as to the actual etiology of the disorders man-
tionally, adequate availability of nutrients is depen- ifested by these children. Sabatino and Cramblett
dent upon proper functioning of the digestive system. ( 1968) reported that 14 children who had contracted
When parts of the brain are damaged, other documented cases of California encephalitis virus be-
organ systems may or may not be disrupted depend- tween the ages of 5 and 14 years demonstrated au-
ing upon which portion(s) of the brain is involved. If, ditory perceptual deficits as well as unspecified defi-
for example, damage occurs to cortical areas, gener- cits in visual perception. A variety of emotional
ally only an individual's cognitive and sensorimotor disorders were also reported including nervousness,
skills are affected. Subcortical damage may disrupt hyperactivity, restlessness, and disruptive behavior
the automatic functioning of other systems, however, together with learning problems.
such as heart rate, blood pressure regulation, Meningitic infections also must be considered
breathing, hormonal balance, water regulation, or when discussing potential adverse effects of CNS
immune response. Such disruption can lead to further infections. One of the most comprehensive studies to
disability and potentially to more damage to the date, however, has not revealed any significant cog-
brain. nitive deficits in children (Lawson, Metcalfe, &
If peripheral nerves are damaged, only the area Pampiglione, 1965). Ninety-nine children whose in-
served by those nerves typically demonstrates im- fections had been contracted between the ages of 2
pairment. However, if a major organ system is in- months and 15 years were followed for I to 8 years
volved, it may begin to function improperly, creating after recovery from the illness. No significant de-
imbalances in other systems that may, in tum, impact clines in intellectual functioning were noted nor were
on brain functioning. Thus, it appears that all parts of any specific cognitive deficits identified. There was,
the body in some way contribute to maintaining brain however, some suggestion that those children who
functioning and vice versa, as a disturbance in one had nonbacterial infections were more likely to show
system is highly likely to lead to a disruption learning difficulties than those who had contracted
elsewhere. bacterial illnesses. About 21% of the children dem-
NEUROPSYCHOLOGICAL SEQUELAE OF CHRONIC DISORDERS 109
onstrated EEG abnormalities; however, there was no tomas. Studies suggest that the 5-year survival rate is
correlation between EEG findings and intellectual, between 40 and 75%, and 30 and 50% after 10 years
behavioral, or learning deficits. A smaller-scale (Bloom, Wallace, & Henk, 1969; Hope-Stone,
study on 18 children with meningitis found that the 1970). In one study, 18 of 22 survivors were reported
only adverse sequelae occurred in the few children to be without serious deficits (Bloom et al., 1969).
who had had seizures in the acute phase of the disease Two children of those followed were found to have
(Fee, Mariss, Kardash, Reite, & Seitz, 1970). partial disability, and two others demonstrated sig-
nificant intellectual deterioration. It is noteworthy
that the two children who demonstrated intellectual
Brain Tumors decline were those who were diagnosed at the youn-
gest ages (11 and 15 months). These findings with
After malignancies of the blood-forming tissues respect to age are similar to those reported in some
such as leukemia, brain tumors are the most common studies of children with leukemia comparing early
type of malignancy in children (Graham, 1983). It and later diagnosed children: children diagnosed at
has been calculated that there are approximately 600 an early age appeared to be more at risk for the devel-
new cases in the United States annually (Till, 1975). opment of cognitive dysfunction (Eiser, 1979; Mead-
Approximately 60% of childhood brain tumors occur ows et at., 1981). (Further discussion about the ef-
in the subtemporal part of the brain, and of these most fects of leukemia and its treatment can be found later
are either medulloblastomas or cerebellar astro- in this chapter.) Matson and Crigler (1969) studied
cytomas. The remainder consist of subtentorial tu- children treated for craniopharyngioma and found no
mors or tumors of the brain stem and adjacent struc- particular psychological or behavioral problems even
tures. About 3% of brain tumors are metastatic, in though the survivors were frequently partially sight-
marked contrast to that found in adults. Surprisingly, ed and required hormone replacement therapy. Sys-
it is unusual for children with brain tumors to present tematic studies of a child's neuropsychological status
with symptoms of intellectual decline or behavioral following treatment for a brain malignancy are quite
change (Graham, 1983). Headache and vomiting are rare and clearly are needed. Much of the current liter-
the most common present symptoms, and although ature also notes the need for further research on the
there may be some accompanying irritability, this effects of brain tumors, particularly to determine
does not typically lead to any diagnostic confusion whether those survivors who do not manifest directly
(Till, 1975). There is one distinct exception to this, observable deficits show deficits of a far less obvious
however-gliomas in the pontine area. Malignancies nature.
in this brain region generally present with what are
described as striking personality changes (Arseni &
Goldenberg, 1959; Cairns, 1950; Lassman & Ar- Neuromuscular Diseases
jona, 1967). Characteristically, the symptom pattern
seen involves a period of withdrawal, apathy, and There are a variety of neuromuscular diseases
lethargy followed by aggression, hyperactivity, tem- that afflict children and it is beyond the scope of this
per tantrums, and physical violence. These tumors chapter to detail the effects of each on the cognitive
usually occur between the ages of3 and 13 years. The functioning of children. One disease entity, Duch-
course of this tumor may last several years and the enne muscular dystrophy (DMD), will be offered as a
outcome is generally fatal despite treatment with ra- possible model for the effects such diseases can have
diation therapy. Other types of brain stem tumor are on the developing brain. It is important to note that
likely to present with gait disturbance and symptoms the sequelae of such diseases tend to have variable
such as squint indicating cranial nerve involvement, identifiable effects depending on a wide variety of
but behavioral changes involving lethargy, irri- factors including age at diagnosis, age at testing, and
tability, inability to concentrate, enuresis, and sleep so on.
disturbance also have been known to occur (Panitch DMD is a hereditary disease causing pro-
& Berg, 1970). gressive muscular weakness and degeneration of
The prognosis for brain malignancies in chil- skeletal muscle tissue. Its course generally includes
dren is poor at best, despite the use of the best avail- confinement to a wheelchair by age 11 and death in
able treatments such as surgery and irradiation. The the late teens. It affects males almost exclusively.
clearest information is available concerning the most Many studies of intellectual functioning in DMD pa-
common brain tumor in children-medullobla s- tients have reported diminished or retarded intellec-
110 CHAPTER 6
tual development, supporting the position of Duch- rebral hemorrhages, and blindness have been re-
enne in 1872 (Dubowitz, 1979). The group IQ score ported in severe cases (Aita, 1964). Preliminary re-
generally averages about 85, one standard deviation search conducted with children diagnosed as having
below the mean of the general population (Dubowitz, sickle cell disease indicated that the overall intellec-
1977; Karagan, 1979). tual capabilities of these children were lower than
Although there is support for the notion of intel- those of an age- and sex-matched group of black
lectual impairment in DMD patients, there is no com- children (Berg & Wilimas, 1983). In this pilot pro-
mon consensus of this in the research literature. ject, the Wechsler Intelligence Scale for Children-
Some have reported a decline in intellectual perfor- Revised (WISC-R) and the children's version of the
mance (e.g., Black, 1973; Florek & Karolak, 1977) Luria-Nebraska Neuropsychological Battery were
whereas others have found no significant differences administered both to a group of 30 black children
in longitudinal studies (e.g., Cohen, Molnar, & Taft, with the disease who had not undergone hyper-
1968; Worden & Vignos, 1%2). transfusion of packed red cells and to a similar group
A recent study attempted to clarify the picture of black children without the disease who had been
somewhat by studying 14 younger and 11 older chil- selected based on age and sex. In all cases, children
dren with DMD. It was found that younger children with the disease performed significantly more poorly
with DMD performed more poorly on tasks requiring on all IQ measures. No significant differences on the
some language and attentional-organizational skills, Luria-Nebraska tests were found although the results
but not on visual-motor tasks. The older group had were reported as following the same direction as that
generally higher IQ levels in the average range and found on the WISC-R.
the younger group had low-average IQ scores (Sol-
lee, Latham, Kindlon, & Bresnan, 1985). These au-
thors noted that individuals with DMD do not appear Polycythemia Vera
to suffer from fixed, global cognitive deficits.
Just as an abnormal decrease in erythrocytes can
Rather, deficits appear to vary at different ages with
lead to abnormal cognitive status, the converse is also
no specific patterning evident to date.
true. An abnormal increase in red blood cell produc-
tion in the bone marrow (polycythemia vera) can
cause erythrocytes to clump together, creating a sit-
Blood and Circulatory System uation that slows blood flow and impedes circulation.
Despite the fact that in this condition there is an ade-
The primary function of the blood system is that quate oxygen supply, there is difficulty in breathing
of a carrier and delivery service of transporting oxy- and the individual may become cyanotic. Brain func-
gen from the lungs to tissues and returning carbon tioning may become lowered due to insufficient cir-
dioxide, conveying metabolites to tissues, and re- culation or blockage of a cerebral blood vessel. Aita
turning waste products for disposal. It has other ( 1964) discussed a number of commonly reported
important functions such as maintaining water con- neurological symptoms in diseases that result in ex-
tent of the tissues, harboring the body's defense cells, cess erythrocytes. These include headaches, dizzi-
carrying hormones that regulate a variety of body ness, visual and hearing difficulties, and paras-
functions, and helping to maintain and regulate body thesias. Children who tend to hemorrhage easily may
temperature. A disruption either in the blood or with- show more focal deficits such as aphasia and hemi-
in the circulatory system can directly impact on brain paresis, or they may exhibit a progressing demen-
functioning. tialike condition as more and more cerebral tissue is
destroyed by repeated hemorrhaging (Aita, 1964;
Ariel & Strider, 1983).
Anemia
Anemia, or an abnormal decrease in red blood Excessive Increases or Decreases in Platelets
cells, can produce variable CNS effects. Erythro-
cytes (red blood cells) contain hemoglobin, which A severe reduction in the number of platelets or
carries oxygen, and any unusual decrease in the defects in coagulation factors in the blood may result
number of these cells can result in an overall lowering in spontaneous bleeding. This can be a primary dis-
of brain functioning due to cerebral hypoxia (defi- ease (e.g., thrombocytopenia purpura) or it can de-
ciency in oxygen supply). Convulsions, diffuse velop secondarily to another disease process such as
organic brain syndromes, focal vascular lesions, ce- leukemia (discussed below), toxic chemical ex-
posure, irradiation, infection, or massive blood of lymphoblasts (one type of white blood cell) in the
transfusion. If such bleeding occurs within the brain, bone marrow results in acute lymphocytic leukemia
it may be single or multiple, small or large, and may (ALL). ALL is perhaps the most prevalent form of
resemble a focal stroke (Aita, 1964). The cognitive malignancy in children and the one that has been the
sequelae of such an incident can be tremendously most heavily researched with respect to the effects of
varied depending on the location and size of the hem- the disease and its treatment. This is because the
orrhage and can range from comparatively minor to therapy for the disease has become so effective that
pervasive with the patient existing in a vegetative long-term disease-free survival can be expected in at
state (Walton, 1977). In the more minor occurrences least 50% of patients (Bowman, 1981; Mauer, 1980).
of such bleeding, temporary general confusion, par- Survival of these children has permitted an increasing
esis, and convulsions can be seen (Heron, Hutchin- emphasis on the late sequelae of ALL and its treat-
son, Boyd, & Aber, 1974). ment. Treatments for other childhood malignancies
Matoth, Zaizov, and Frankel (1971) reported have not been quite so effective. Thus, research into
that 20 children with chronic thrombocytopenia had the cognitive sequelae has been highly restricted. The
been found to have learning and behaviorial prob- research investigating the long-term effects of ALL
lems when compared with patients with other medi- and its treatment may, however, be used as an at least
cal disorders. Their study, which used the WISC, temporary model for the effects of other malignant
Bender Visual-Motor Gestalt, and Human Figure disease processes.
Drawing tests, revealed no statistical differences be- A complicating factor in the study of the neuro-
tween the two groups on any of the tests, however. It psychological functioning of children with ALL lies
was noted that over two-thirds of the group of chil- in the standard treatment regimen for the disease.
dren with thrombocytopenia exhibited ''soft'' neu- Common treatment involves the intrathecal and intra-
rological signs of minimal brain dysfunction. Over venous administration of a neurotoxic medication,
half of this group also demonstrated mild, diffuse methotrexate. Coupled with this is the administration
EEG abnormalities. To date, there has been no long- of at least 1800-2400 rads of cranial irradiation,
term follow-up of such groups to determine if noted which is done prophylactically in an attempt to de-
behavioral or cognitive abnormalities persist into stroy those leukemic cells that may have migrated to
adulthood. the brain. Some recent reports have suggested that
An excessive increase in the number of platelets cranial irradiation may not be necessary in the treat-
can result in the formation of a thrombus and subse- ment of what is referred to as "standard-risk" leuke-
quent blockage of a blood vessel. Tissue supplied by mia and that such prophylactic measures need only be
the blocked vessel will then receive an insufficient employed with ''high-risk'' patients whose disease is
supply of blood, and an ischemic condition wherein diagnosed at a more advanced stage and is more like-
the tissue starves may result. If the tissue dies or is ly to have invaded the CNS (Copeland, Pfefferbaum,
damaged, an infarction is the result. Thrombus for- Aetcher, Jaffee, & Culbert, 1982). In any event, it
mation anywhere in the body can be serious because becomes clear that it is very difficult, if not impossi-
of the high tendency for the thrombus to pass through ble, to assess the effects of the disease alone in such
the heart and be carried to the lungs or brain. When instances.
cerebral blood vessels become blocked and an infarc- Despite the fact that a good deal of research has
tion occurs, deficits in cognitive functioning can oc- been conducted on the effects of ALL, the actual
cur (Walton, 1977). If the blocked vessel supplied a effects of the disease still tend to be inconsistent.
small area of the brain, the cognitive sequelae will Eiser and Lansdown (1977) and Goff, Anderson, and
generally resemble those seen with a fairly discrete Cooper (1980) found that when leukemic children
cerebral lesion. Where the blocked cerebral vessel who had received CNS irradiation were evaluated,
supplied a larger region of the brain, pervasive defi- significant deficits emerged. This was particularly
cits can result. true if the disease was diagnosed and treated prior to
the age of 5 years. Deficits included declines in over-
all intellectual abilities as well as a pattern of distrac-
Leukemia tibility and memory deficits. Other investigators
have noted deficits involving IQ declines (Meadows
Leukemia is a disease in which there is an un- et al., 1981) and motor speed deficits (Eiser, 1978).
controlled multiplication of certain white blood cells In contrast, several investigators have found
resulting in their accumulation in large numbers that the disease and its treatment lead to no docu-
(LODAT, 1981). An abnormal growth and division mented dysfunction (Obetz et al .. 1979; Ivnik, Col-
112 CHAPTER 6
ligan, Obetz, & Smithson, 1981). A longitudinal lationships among the various endocrine glands.
study in which a group of leukemic children were Hormones are exceedingly powerful agents, and in
followed from original diagnosis and treatJ;IIent for a some instances their activities cover practically the
period of at least 3 years found no specific patterns of entire body. In most cases, they interact normally and
deficits or any IQ declines (Berget a!., 1983). How- well. Production of hormones is usually regulated by
ever, almost half of the children had performance the bodily requirements for each, and when this need
patterns suggestive of the presence of mild, specific is met, production is decreased or antihormones are
learning dysfunction when performance patterns released.
were analyzed individually rather than as a group. Uncontrolled excesses or insufficiencies of
Copeland eta!. ( 1982) suggested that the cranial glandular secretion are responsible for a variety of
irradiation is the principal factor leading to cognitive disorders of development and metabolism, most
dysfunction in children with ALL. In a carefully con- of which have implications for the integrity of the
trolled investigation, two groups of children treated brain. One such disorder-diabetes mellitus-has
for leukemia were evaluated. One group received the received a great deal of attention by neuropsycholo-
standard treatment including prophylactic cranial ir- gists of late.
radiation and the other group received no irradiation.
The former group were found to perform signifi-
cantly worse on a number of neuropsychological Diabetes Mellitus
measures including generally lower IQ scores and
poorer nonverbal memory. Significant differences Diabetes mellitus is a disease complex resulting
were also found on the Wechsler Information, Sim- from abnormalities in carbohydrate metabolism, due
ilarities, Arithmetic, Block Design, and Object As- to insufficient production of insulin in the pancreas.
sembly subtests. Because of this lack of insulin, diabetics have chron-
In general, the research conducted to date indi- ically high blood glucose levels (hyperglycemia),
cates that there is likely a higher than normal chance and excrete a great deal of unmetabolized sugar as
that any type of treatment for leukemia and/ or the well as many salts and minerals essential to health.
disease itself is potentially detrimental to a child's Diabetes mellitus is a heterogeneous group of disor-
neuropsychological development. Research into ders rather than a single disease, and its exact cause is
these effects is currently ongoing in a large number of unknown (Miller & Sperling, 1986).
facilities and is attempting to delineate more specifi- However, two general classifications of di-
cally the areas of functioning that may be affected as abetes are common. Both forms have the potential to
well as the influences of various types of treatment injure large and small blood vessels, leading to dete-
for childhood malignancies. rioration of peripheral and autonomic nerves, the car-
diovascular system, the eyes, and the kidneys (Cirillo
et al., 1984; Pfeifer et al., 1984). As such, diabetics
are at increased risk for heart disease, stroke, kidney
Endocrine System dysfunction, blindness, and peripheral neuropathy.
Adult onset, also known as type II or non-in-
The endocrine or ductless gland system is pri- sulin-dependent, diabetes mellitus (NIDDM) is the
marily involved in the production of hormones for most common, accounting for over 90% of all diabet-
correlating and regulating bodily processes. Such ics, and affecting about 5 million adults in the United
glands include: the pituitary, which lies in a depres- States. Occurring typically in overweight individuals
sion of the sphenoid bone between the roof of the past the age of 40, the onset is subtle, and diagnosis is
mouth and the hypothalamus; the pineal, which is often made secondary to problems with the vascular
just posterior to the pituitary; the adrenals, which are system. NIDDM is characterized by diminished but
attached to the top of each kidney; the thyroid, lo- not absent secretion of insulin by the pancreas. Treat-
cated in front of the trachea just below the voice box; ment is usually by diet change and the use of medica-
the parathyroids, which are embedded in the thyroid; tion for the stimulation of insulin production; ex-
the thymus, found near the lower part of the trachea; ogenous insulin is not necessary.
the pancreas, found in the curvature between the Juvenile onset, also known as type I or insulin-
stomach and small intestine; the ovaries, located near dependent, diabetes mellitis (IDDM) is a common
the uterus; and the testes, suspended in the scrotum. chronic disease estimated to affect 150,000 children
Study of this system reveals complex interre- and adolescents (Cerreto & Travis, 1984) and
400,000 adults (Carter Center, 1985) in the United socioeconomic status, and the attempt to experimen-
States. Males and females are equally affected, and tally relate specific diabetic characteristics such as
peak presentation is seen at the time of puberty, al- age of onset and duration of illness to outcome (Ack,
though IDDM is diagnosed from early childhood Miller, & Weil, 1961).
through early adulthood (Miller & Sperling, 1986). One important global finding from such work
In IDDM the pancreas stops producing insulin was that age of onset seemed to be an important
entirely. Presentation of symptoms is usually clear variable, with those diagnosed as diabetic before the
and dramatic, with polyuria, polydipsia, polyphagia, age of 5 having average IQs l 0 points lower than their
and rapid weight loss over a period of about 1 month. siblings. A trend was also seen suggesting an inverse
If untreated, severe hyperglycemia can lead to keto- relationship between number of hypoglycemic sei-
acidosis, diabetic coma, and death. This previously zures experienced and measured intelligence.
fatal disorder was converted to a manageable chronic Thus, although no clear evidence of specific
disease after 1922 with the availability of exogenous neurobehavioral dysfunction in diabetic children
insulin (Johnson & Rosenbloom, 1982). emerged, researchers were made aware that there
For the youngster with lOOM, management of may be some neurobehavioral differences between
near-normal metabolism involves constant monitor- diabetic and normal children, and that the age of
ing of bodily systems and daily insulin injections. onset and the number of hypoglycemic seizures noted
Insulin needs vary with nutrition, exercise, physical in the history may relate to the extent of this dif-
health, and emotional state. As mentioned, insuffi- ference (Ryan & Morrow, 1987a).
cient insulin can lead to dangerous hyperglycemia. Because global measures of intelligence were
Conversely, too much insulin or too little food, used in that series of studies, differences between
or an imbalance of food, exercise, and insulin can diabetics and controls could not be assigned to specif-
result in a marked decrease in blood sugar (hypo- ic structural or operational changes in the brain.
glycemia). Hypoglycemia can progress from an in- However, a series of EEG studies did fmd a signifi-
sulin reaction, with mental confusion and anxiety, to cantly higher number of clinically abnormal EEGs in
hypoglycemic seizures, to insulin coma (Miller & a group of diabetic children as compared to age-
Sperling, 1986). This metabolic seesaw may have matched normal controls, further finding that the var-
important implications not only for the psychological iable most related to this EEG difference was the
adjustment, but also for the brain of the diabetic number of severe hypoglycemic episodes (Eeg-
youngster. Olofsson & Peterson, 1966), orthenumberofsevere
Extensive investigation of neuropsychological episodes of both hypoglycemia and hyperglycemia
functioning in lOOM is currently being carried out by (Haumont, Dorchy, & Pelc, 1979).
at least three research teams, namely those of Ryan and Morrow (1987b) posited that this IQ
Christopher Ryan at the University of Pittsburgh; and EEG evidence seemed to demonstrate that dia-
Joanne Rovet at the Hospital for Sick Children in betic children and adolescents showed a greater ten-
Toronto; and Clarissa Holmes at the University dency than their nondiabetic age mates to have mild,
of Iowa. diffuse brain dysfunction, and that multiple episodes
An excellent review of this area is that by Ryan of severe hypoglycemia were in some fashion re-
and Morrow (1987a). Discussing the history of responsible for the development of this ''diabetic en-
search in this area, they point out that early on, di- cephalopathy.'' They noted with some surprise that
abetes per se was thought to be benign with respect to although these findings fmnly established a basis for
impact on brain functioning, the only connection further investigation of this diabetes-related organic
thought to be secondary to involvement of renal or syndrome, such research essentially dried up for no
cardiovascular disease in older patients who had the apparent reason during the 1970s, in favor of studies
disease for many years. of the psychosocial aspects of diabetes (see Cerreto &
A series of studies from the 1930s through the Travis, 1984).
1960s challenged this notion by comparing the intel- Given these early findings, and the fact that a
ligence of diabetic children with general norms, in medical colleague found a high incidence of school
sum yielding results that were equivocal. Although difficulty in his diabetic patients, Ryan and his asso-
the findings were inconclusive, two important meth- ciates at the Children's Hospital in Pittsburgh began a
odological innovations were introduced in these se- series of neurobehavioral studies to reassess the de-
ries. These were the use of nondiabetic siblings con- gree to which diabetic youngsters are at risk to devel-
trols to control for effect of family influences and op cognitive deficits secondary to CNS defects.
114 CHAPTER 6
The goal of their series of studies was to de- matched controls over time, and further that cog-
scribe particular neuropsychological difficulties nitive and achievement test findings in this group
found in this population, and to relate these problems were best predicted by measures of school atten-
if possible to specific variables associated with each dance.
case. Based upon previous findings and some prelim- Therefore, perhaps like most chronically ill
inary work, they focused on the examination of age at youngsters, diabetics miss a significant amount of
onset, duration of disease, and degree of metabolic school (Gortmaker & Sappenfield, 1984), and this
control as they related to cognitive functioning, attendance problem may reduce their ability to mas-
which was measured by neuropsychological testing. ter classroom-related learning, or crystallized intel-
To test the notion that both age at which diabetes ligence. Thus, longer duration of diabetes would lead
mellitus is diagnosed and duration of the disease are to greater attendance problems, and more difficulty
potent variables, Ryan, Vega, and Drash (1985) ad- in school.
ministered a comprehensive neuropsychological bat- Ryan, Vega, and Drash (1985) and Ryan and
tery to 125 randomly selected diabetic adolescents, Morrow (1987), on the other hand, suggested that the
all of whom had been diabetic for at least 3 years, but findings regarding age of onset and performance on
ranged in their age of onset from 2 months to 14 tasks assessing fluid intelligence may be due to struc-
years. They divided their subjects into an "early tural or functional disturbances in the brain. This
onset" group (diagnosed before age 5, n = 46), a mild brain damage may develop from multiple epi-
"later onset" group (diagnosed after age 5, n = 79), sodes of severe hypoglycemia and resultant hypo-
and a sibling control group (n = 83). glycemic seizures early in life.
A factor analysis of the cognitive measures used There is some evidence (Temand, Go, Gerich,
in their testing battery generated five clusters of tests, & Haymond, 1982) that younger diabetics are more
namely general intelligence, visuospatial processes, sensitive to the effects of insulin, and therefore have
learning and memory, attention and school achieve- more reactive hypoglycemic seizures. This is con-
ment, and mental and motor speed. Statistical analy- sistent with the finding of Ryan, Vega, and Drash
ses found significant differences between early and ( 1985) that early onset diabetics had more of a history
late onset subjects on all five clusters. Further, cut- of hypoglycemic seizures.
ting scores of two standard deviations below the con- In general, the work of Ryan and colleagues
trol mean were assigned to each of the 20 tests that suggests that cognitive deficits in diabetics can be
discriminated early from late onset subjects, with at seen as early as age 10. Rovet and her colleagues in
least three such low scores necessary to be seen as Toronto have undertaken the study of even younger
"impaired." On the basis of these rules, 24% of the diabetic patients, in an effort to further examine neu-
early onset were seen as impaired, whereas only 6% robehavioral findings in this group. Rovet, Ehrlich,
of both the late onset and controls met impairment and Hoppe ( 1988) administered an extensive series of
criteria. neuropsychological tests to a diabetic sample includ-
Further analysis of these data suggested that age ing children as young as 6. They divided the sample
at onset and disease duration differentially affected into 27 early onset (pre-age 4), 24 later onset (post-
the testing results. Age at onset appeared to predict age 4), and 30 sibling controls.
results of tests measuring .. fluid intelligence," de- In contrast to Ryan's studies, they found no dif-
scribed by the authors as adaptive abilities used to ferences among the three groups on intelligence or
process relatively unfamiliar information in novel achievement, actually finding that diabetics outper-
ways, such as scanning and identification of visual formed controls on tasks measuring verbal ability.
stimuli. Duration of illness seemed more able to pre- However, they found some interesting results related
dict performance on tests tapping ''crystallized intel- to gender. Early onset girls performed less well on
ligence," defined as the use of well-practiced skills spatial tasks and had a lower performance IQ than
depending largely on stored knowledge, such as later onset or control girls, but this finding did not
reading and spelling skills, and sequencing ability. hold for the boys. These early onset girls also had
Regarding the differential effects of duration more academic problems, including failed grades
and age at onset, there is some evidence to indicate and special education placement, than the other
that the relationship between duration and groups.
crystallized intelligence can be accounted for by the A multiple regression analysis for each sex sep-
fact that school attendance is a factor in both. arately found that for both genders taken together, the
Ryan, Longstreet, and Morrow (1985) found best predictor of verbal performance was so-
that diabetics missed significantly more school than cioeconomic status; for girls only, the best predictor
of spatial performance was age at onset; and again for teristic personality style that may account for some of
both genders, the best predictor of spatial perfor- this psychomotor task performance difference,
mance was seizures before the age of 5. Rovet (per- which will be addressed briefly below. In general, it
sonal communication, February 9, 1988) is currently appears that early onset diabetes produces mild brain
conducting a prospective study, following newly di- dysfunction as measured on cognitive tests, but no
agnosed diabetic children to better examine at what such findings were evident in this later onset group.
point neurobehavioral deficits are evidenced, rather Another variable to receive research attention is
than depending on retrospective study. that of degree of metabolic control. As mentioned
Other interesting results regarding gender and earlier, poor metabolic control implies a tendency to
age at onset include those of Ryan and Morrow hyperglycemia, which is implicated in the risk for
(1987b), who found that early onset diabetic adoles- disorders of the vasculature, both large and small
cent girls had significantly poorer self-esteem, as vessels, and hypoglycemia, which has been shown to
measured by the Piers-Harris subscales of Physical have clearly deleterious effects on the brain. The
Appearance and Anxiety, than did early onset boys, work by the teams of Ryan and Rovetdoes not show a
later onset boys and girls, and controls. However, the relationship between degree of metabolic control and
extent to which this represents a result of greater cognition in children and adolescents.
cognitive deficit, bodily changes differentially expe- However, work by Holmes and her team at Iowa
rienced by girls over time, or a unique coping reac- suggests that a recent history of poor metabolic con-
tion in the face of chronic illness is undetermined. trol may increase the risk of mild neuropsychological
Ryan and Morrow (1987b) summarized this lit- disturbances in young adults. Holmes (1986) com-
erature by stating that both their and Rovet's teams pared two matched groups of diabetic men in their
have found age of onset of diabetes to be an important early 20s, one classified as in "good" and the other
risk factor for the development of significant neu- in ''poor'' control as measured by tested hemoglobin
rological deficits in both children and adolescents. A1C levels. This test measures the relative degree of
They speculated that this strong association between metabolic control, or avoidance of blood glucose ex-
diabetes early in life and brain dysfunction may be tremes, over the preceding 3 months.
accounted for by two different phenomena, namely In her study, Holmes found that the poor control
that the brain of a young child is very sensitive to the group had lower scores on the Information and Vo-
deleterious effects of any sort of metabolic insult, and cabulary subtests of the WAIS, and also did worse on
that this sensitivity may be greater in females; or that reaction time tasks. Ryan and Morrow (1987) sug-
the young child has a heightened responsivity to ingested caution in interpreting this finding, as meta-
sulin, and thus has more hypoglycemic seizures, with bolic control was only measured for the 3 months
resultant increase in damage to the brain. before testing. They speculated that perhaps if these
These findings seem to be consistent with in- subjects were out of control as children, they may
creasing evidence that the time from birth to 5 years have attended poorly, and now retrieve poorly as
may constitute a "critical period" for the develop- adults.
ment of serious brain dysfunction from a variety of In a typical day the blood glucose level of a
causes with a number of outcomes. diabetic child may vary widely, being dependent
It is worthy of note that even though early onset upon food, insulin dose, and exercise (Miller & Sper-
is viewed as an important variable, diabetes appears ling, 1986). Cerebral metabolism depends upon the
to affect performance even in those who are diag- ability of serum glucose to circulate freely in the
nosed later in life (Franceschi et al., 1984). Ryan, brain. Because little glucose is stored in the brain,
Vega, Longstreet, and Drash ( 1984) tested 40 diabet- when its supply has been compromised there is a lag
ic adolescents (aged 12-19) who were classified as time before fatty acids are utilized as a backup source
late onset (diagnosed at 5-12), and a group of 40 (Holmes, Koepke, Thompson, Gyves, & Weydert,
matched nondiabetic controls using a neuropsychol- 1984).
ogical battery and critical flicker fusion. Temporary change in cerebral functioning
They found that all subjects performed within might therefore be possible at the time of testing,
normal limits, but that the diabetic sample had verbal perhaps affecting psychomotor tasks if not global
IQs lower than controls (which may be related to the intelligence. In a series of studies (Holmes, Hayford,
duration effects and school attendance noted above), Gonzalez, & Weydert, 1983; Holmes et al., 1984;
but also did less well on psychomotor tasks, per- Holmes, Koepke, & Thompson, in press) Holmes
forming more slowly than controls. It has been hy- and her colleagues inspected the acute neuropsychol-
pothesized that diabetics may develop a charac- ogical consequences of deviant blood glucose levels.
116 CHAPTER6
By use of an automatic insulin/ glucose infusion tail. However, they admit that this is more a matter of
system, they were able to stabilize young diabetics clinical lore than evidence.
for extended periods at one of three blood glucose In summary, it is clear that over the past 7 years
levels: hypoglycemia (55-60 mg/dl); euglycemia a good deal of progress has occurred in understanding
(110 mg/dl); or hyperglycemia (300 mg/dl). All sub- the neuropsychological correlates of insulin-depen-
jects were tested in all three conditions, using a bal- dent juvenile onset diabetes in children and adults.
anced design in which neither experimenter nor sub- Specific neurobehavioral impairments have been
ject knew in which level the subject was. identified, as have several diabetes-related variables
They found that relative to euglycemia, subjects that appear to be important risk factors for the devel-
tended to perform more slowly in the hypoglycemic opment of such impairments.
state on a variety of tasks involving simple mental Ryan and Morrow (l987a) reiterated that age at
calculation and word production, as well as respond- onset of IDDM is a most potent variable, with those
ing in choice reaction time situations. A tendency diagnosed before the age of 5 to be much more likely
was noted for subjects to perform in a similar fashion to show evidence of cognitive impairment than those
in the hyperglycemic state. with onset later than age 5. They suggested that this
Ryan and Morrow (l987a) summarized such re- diabetic encephalopathy yields deficits in a wide se-
search by stating that the hypoglycemic state reduces lection of cognitive domains, with performance dis-
efficiency and increases response time on brief tasks. rupted on measures of attention, learning, memory,
They further speculated about the possibly more problem-solving, visuospatial, and visuomotor ef-
dramatic effects that this state might produce on ficiency.
more lengthy tasks under conditions of greater fa- Thus, some early onset diabetics have lower IQs
tigue, a situation that may have occurred during pre- than their siblings or nondiabetic peers. But not all
viously described measurements of cognitive func- early onset diabetics have diminished intellectual
tioning in diabetics by use of neuropsychological functioning, and in fact most do not.
testing. However, evidence from both electrophysiolog-
Finally, there has been some question as to the ical and neuropsychological measures suggests that
relative contribution of nonorganic variables to per- those who have had multiple episodes of serious hy-
formance on measures of neurobehavioral function- poglycemia early in life are likely to be impaired on a
ing. A number of studies have commented upon be- wide range of tasks. These findings imply clearly that
havior and personality styles among diabetics. Some because young children are quite insulin sensitive,
have stressed problems in the family (Lancet Edi- keeping an excessively tight metabolic control (rigid-
torial, 1980; Winter, 1982) and school (Weitzman, ly preventing hyperglycemia) may increase the risk
1984), whereas others have focused upon IDDM as a of starting serious and perhaps debilitating hypo-
risk factor in certain clinical syndromes such as eat- glycemic episodes in these patients.
ing disorders appearing in adolescent females Most diabetic children and adults are late onset,
(Daneman, Johnson, & Garfinkel, 1985). and show relatively subtle impairments. When de-
Still other authors have tried to conceptualize tected, they tend to appear on difficult informa-
the effects of diabetes as the child and adolescent tion-processing tasks requiring the subject to com-
attempts to cope with normal developmental tasks at plete novel assignments as rapidly as possible. The
different cognitive stages (Johnson & Rosenbloom, slowness noted may be involuntary (reflective of a
1982; Cerreto & Travis, 1984). Some of the self- transient hypoglycemic state) or voluntary (due to
esteem problems found in early onset diabetic learned caution in the face of decision-making situ-
females may be of interest here. ations).
Research in this area of diabetic personality It is also possible that information-processing
functioning has been fraught with methodological mechanisms in this population may be disrupted by a
problems, and at least one study (Skenazy & Bigler, complex biochemical disturbance, resulting from a
1985) found that diabetics are no more poorly ad- long history of poor metabolic control. And finally,
justed than other chronic disease groups, and further performance may be impaired due to increased ab-
that degree of psychological adjustment was not pre- sences from school, with related academic problems.
dictive of performance on a battery of neuropsychol- All of these hypotheses are grist for the research
ogical tests. Ryan and Morrow (l987b) commented mill, for at this time there is no strong evidence that
that they have observed a "cautiousness" in their extensive structural damage to the brain is directly
young diabetic patients, perhaps reflecting the causative of the subtle deficits sometimes found in
youngsters' daily need for constant attention to de- patients with late onset IDDM.
Respiratory System recognized for centuries, there is currently no com-

monly agreed upon definition of the syndrome, nor
The respiratory system is comprised of the up- any. consensus with regard to whether asthma is pri-
per airway, including the nose, pharynx, larynx, and marily a medical or a psychological disorder (Creer,
epiglottis; the lower airway, including the trachea, 1982). A great deal has been written about the onset
the primary or main bronchi, the segmental bronchi, of asthma from several psychological perspectives,
and bronchioles; and the lungs, located within the notably psychoanalytic and behavioral (Sadler,
thoracic cavity on either side of the heart. 1982), and a variety of psychological interventions
The exchange of gases provided by this system have been presented to deal with this condition
is vital to the brain. The cardiovascular system's (King, 1980).
function is to supply oxygen to body tissues via cir- Basically, asthma is a bronchial disorder char-
culating blood. The blood also removes carbon diox- acterized by airway obstruction that is intermittent,
ide produced by metabolism, and transports this variable, and reversible. The lung pathology may
waste product to the lungs. Here the carbon diox- occur in the central or larger airways, and the pe-
ide is replaced by oxygen, and the newly oxygenated ripheral or smaller airways. Obstruction of these
blood is recirculated to the tissues, including the bronchial airways may be due to smooth muscle con-
brain. striction, swelling of tissue, swelling of the mucosa,
A network of airways provides the pathway for and dried mucus plugs (Chai, 1975; King, 1980).
the transport and exchange of oxygen and carbon The one common denominator is a peculiar hyper-
dioxide. Under normal circumstances, by inhalation reactivity of the airways, whether to physical, chem-
the upper airway provides air for the lower airway, ical, pharmacologic, or immunologic stimuli
where it is conducted through smaller and smaller (Sadler, 1982).
pathway branches in each lung field. The final The clinical symptoms present as spasms of dif-
branches of bronchioles (terminal respiratory bron- ficult breathing, coughing, and wheezing, with the
chioles) end in clusters of alveoli, or air-filled sacs. attacks lasting from several minutes to several hours,
Thus, the working area of the lung is a network of air although in a condition known as "status asth-
tubes and blood vessels, through which blood ulti- maticus" obstruction may last for days or weeks.
mately reaches the alveoli, which are the primary Attacks can vary along a continuum of severity from
structures for the exchange of carbon dioxide and very mild to very severe, the latter increasing the risk
oxygen (Luckman & Sorenson, 1980). Given that the of brain damage or even death (Bierman, Pierson,
need for oxygen by the brain is so great, a significant Shapiro, & Simons, 1975).
disruption in the functioning of the respiratory sys- Although the notion that cerebral anoxia sec-
tem may have negative cerebral consequences. ondary to bronchial asthma attacks may lead to neu-
robehavioral deficits seems to be defensible and stim-
ulating, very little solid research has been conducted
Bronchial Asthma in this area.
Dunleavy and Baade (1980) stated that there
Asthma is the most common chronic disease of have been a number of studies reporting on the adap-
childhood, estimated to occur in 5% of adults and tive behaviors of asthmatic children, particularly as
children in the United States, over 10 million people, applied to the classroom situation. Most are spec-
of whom over 2 million are under the age of 16. The ulative, whereby observed maladaptive behaviors
onset of asthma is usually within the first 5 years, and learning problems are assumed to be related to
although it can occur at any age. A more favorable organic damage, which is further assumed to be a
prognosis appears to be related to an early onset, result of transient hypoxia accompanying their severe
unless significant asthma attacks begin before the age asthmatic attacks.
of 2 (King, 1980). In an effort to make use of assessment instru-
Asthma accounts for nearly one-fourth of all ments better designed to detect brain-behavior rela-
days absent from school by children, and it ranks tionships, Dunleavy & Baade (1980) evaluated a
~ird ~~ong all chronic illnesses as a cause of physi- sample of asthmatic children using the Halstead Neu-
ctan vtstts (Sadler, 1982). It also contributes greatly ropsychological Test Battery for Children. Their goal
to acute visits to emergency rooms, days in the hospi- was to identify patterns of neurobehavioral deficit
tal, and problems related to psychosocial adjustment characteristic of severely asthmatic children 9 to 14
(Rubin et al., 1986). years of age.
Although the symptoms of asthma have been Nineteen severely asthmatic subjects and 19
118 CHAPTER 6
matched nonasthmatic controls who had no history of March 21, 1986) and his research team at the Na-
organic damage were administered the Halstead Bat- tional Jewish Hospital in Denver have recently com-
tery. Significantly poorer test performance was noted pleted a 3-year study of the effects of antiasthma
for the asthmatic group, with eight Halstead Battery drugs such as steroids on information retention in
tests showing most difference between the groups. asthmatic children. Their preliminary analyses sug-
Three of these tests, Trail Making, Tactual Perfor- gested that the use of such medications has no notice-
mance, and WISC Mazes, were more sensitive than able effect on retention in reading and writing, but
the others in discriminating asthmatic from non- quite significant effects on the automatic memory
asthmatic subjects. The authors concluded that the required for retention of math skills.
primary deficits of impaired asthmatic children are in In summary, limited research has demonstrated
visualizing and remembering spatial configurations, that some severely asthmatic children exhibit very
in incidental memory, and in planning and executing mild to mild brain-damage-like behaviors, that cer-
visual and tactile motor tasks. tain such behaviors are more likely to be seen than
Using both a classification battery, developed others, and that these deficits can be predicted to a
from four of the eight Halstead Battery tests that degree by previous episodes of loss of consciousness
showed greatest discrimination between groups, and cyanosis. Other research has suggested that such
and blind clinical analysis, Dunleavy and Baade findings are consistent not only with the assumption
(1980) identified 7 of the 19 asthmatics (35%) as of underlying change in cerebral structure or func-
impaired, whereas only one of the controls was so tion, but also as an iatrogenic effect of antiasthma
labeled. drugs over time.
They further compared the test score means of
the seven neuropsychologically impaired asthmatic Cystic Fibrosis
children with the Halstead Battery test score means of
9- to 14-year-old brain-damaged (cerebral tumor, Cystic fibrosis (CF) is the most commonly seen
traumatic injury, inflammatory disease) group stud- lethal genetic syndrome of infants, children, and
ied by Boll (1974). Their asthmatic sample per- young adults. It is most prevalent in Caucasian
formed better than did the Boll sample, in line with youngsters, with one case of CF in every 1500-2000
the clinical assessment of very mild to mild brain live births; it is much less common in black and Ori-
damage for the asthmatic children in their.study. ental populations. Inheritance appears to be by an
The authors also mentioned that five of their autosomal recessive gene, suggesting a specific bio-
asthmatic subjects reported that they had experienced chemical defect, but no single, unifying hypothesis
periods of unconsciousness and had "turned blue" exists at this time to account for the pathogenesis of
during their attacks. Of these five, four were classi- CF (Matthews & Drotar, 1984).
fied by their Halstead scores as impaired. This find- CF is a very complex condition affecting a wide
ing was thought to add credence to the notion that loss variety of bodily functions. It causes abnormalities in
of consciousness and cyanosis, which occurs during the exocrine gland network, pancreas, liver, gas-
some severe asthmatic attacks, can contribute to later trointestinal tract, reproductive system, and es-
occurrence of organic dysfunction. pecially in the respiratory system. Chronic obstruc-
Suess and Chai (1981) suggested the conclu- tive pulmonary problems seem to account for the
sions of Dunleavy and Baade were premature, be- majority of morbidity and mortality in the CF patient.
cause the possibility of similar performance deficits In the past, children with CF simply died young.
as a function of antiasthma medications was not taken But the introduction of the sweat test in 1954 permit-
into account. In essence, the treatment and not the ted early diagnosis, and coupled with newer treat-
disease, may account for the obtained neu- ment regimens, children with this disease are now
robehavioral deficits. Dunleavy (1981) responded surviving fairly well into late adolescence, young
that in their sample they found no relationship be- adulthood, and in some cases into early mid-life
tween drug use, as obtained from detailed medical (Taussig & Landau, 1986). A tremendous adjust-
history, and neuropsychological test performance. ment to the disease is required because it requires
Further, he reported that of the seven children classi- lifetime care, a great deal of medicine, a strict diet, a
fied as impaired, only three were receiving anti- mechanical apparatus to assist breathing, daily pos-
asthma medication, and of the 12 asthmatic children tural drainage and breathing exercises, and living in
who showed no evidence of performance deficit, constant danger of respiratory infections.
seven were receiving such medication. Individuals with CF are prone to such infec-
However, Chai (personal communication, tions, and their breathing is often altered as a result of
increased airway resistance. Some of the issues dis- adjustments that cause the heart to work harder to
cussed above with asthmatics regarding decreased compensate for these changes, resulting in further
cerebral oxygenation and its effect on cortical integ- damage. A compromised heart eventually leads to a
rity may be germane here, although symptoms seem compromised brain. Although the brain will still re-
to be less severe. ceive a greater share of materials needed by the body,
CF is not seen as a disease that directly affects prolonged cardiac dysfunction will ultimately lower
the brain. In fact, Breslau (1985) and Breslau and the amount available to brain cells. Insufficient oxy-
Marshall ( 1985), in studies of psychiatric disorders in gen and nutrients are likely to produce results of dif-
children with physical disabilities, used CF subjects fuse neuropsychological dysfunction in children with
as non-brain-involved chronic disease controls. They cardiovascular disease or irregularities (Cravioto &
found that healthy and CF subjects, previously diag- Arrieta, 1983). The child is likely to have cognitive
nosed as troubled, improved in their mentation and deficits in a wide variety of functions, although these
psychological adjustment over a 5-year period, may be mild unless damage to the heart (or reduction
whereas brain-damaged subjects showed no such of blood flow) has been severe. Many of the cog-
improvement. nitive deficits in individuals with cardiac problems
However, Matthews and Drotar (1984) sug- may not even be noticed because of the concern over
gested that CF children express some of their diffi- other more attention-demanding physical symptoms.
culty in adjusting to this multisystem disease by the Mild deficits that are noticeable are often temporary
development of learning problems in school. As is and tend to be viewed with less concern (Ariel &
seen with other chronic diseases, these learning prob- Strider, 1983).
lems may in fact be symptomatic of psychological When circulation to the heart itself is blocked
difficulties, absenteeism, and decreased sensory and tissue is damaged (''heart attack''), there is often
stimulation; however, they may also be due to mild an extreme drop in blood pressure. This may produce
neurobehavioral deficits. Currently, no research spe- symptoms of dizziness or massive changes in mental
cifically addresses this issue in children with CF. functioning such as delirium or dementia. The lack of
oxygen to brain tissue may produce focal deficits
such as aphasia, sensorimotor disturbances, or visual
Cardiovascular System difficulties (Rowland, 1984). Such effects can be
either temporary or permanent. A cerebral hemor-
The main functions of the cardiovascular system rhage may occur from the increased pressure and
are to pump blood through the body, to pick up and destruction of cerebral blood vessels, producing ei-
deliver fluids, gases, chemicals, and nutritive sub- ther diffuse or focal effects that tend to be more per-
stances, and to increase or decrease blood flow in manent (Rowland, 1984). Because these deficits are
response to activity levels of the body. The car- generally more disrupting to the child's ability to
diovascular system is composed of the heart, large function, they are more likely to lead to a concern to
arteries and veins, smaller arterioles and venules, and the child, parent(s), and/or physician, and are often
the capillaries. The manner of blood flow and its the symptoms that lead to requests for evaluation. H
regulation are crucial factors to be considered in dis- such diseases progress slowly, then compensation
cussing cardiovascular functioning and the effects of usually occurs and the child may appear to have nor-
dysfunction. mal cognitive functioning. This is particularly true
Blood traveling through vessels exerts different for children as the developing brain tends to be some-
pressures and moves at different speeds according to what more amenable to recovery of function than the
the size of the vessel. The cardiovascular system acts more mature adult brain. It must be cautioned, how-
to maintain a relatively constant and limited range of ever, that there is a growing body of literature to
pressures and blood flow velocities within the ves- suggest that the developing brain may not be as
sels. Any increase in friction, such as occurs with "plastic" as once was thought (Golden, 1981).
blockages, narrowing, or roughness along the vessel Another outcome of cardiac disease may be the
walls, increases the workload of the system and can development of bacterial endocarditis, an infection
lead to failure. of cardiac tissue wherein bacteria collect in damaged
valves or in the pericardia} sacs. In addition to creat-
CNS Effects ing inflammation and edema, bacteria may spread to
other parts of the body by means of blood circulation.
Disease or malfunction anywhere in the car- If the brain is entered, the result is usually a septic
diovascular system tends to initiate a vicious cycle of embolism (a blockage creating infection in that area),
120 CHAPTER 6
widespread meningitis, or development of a focal vealed more abnormalities after cardiac surgery than
brain abscess (Rowland, 1984). Neuropsychological prior to the surgical procedure. He further noted that
effects can be quite variable, ranging from focal defi- if the patient's EEG does not return to normal within
cits that resemble an adult stroke to a diffuse enceph- 3 to 4 weeks after surgery, the likelihood of cerebral
alopathy (widespread inflammation). The variations damage having occurred is quite high. Studies using
possible make it a quite difficult condition to accu- neuropsychological instruments have found that
rately diagnose. In such instances, it has been sug- signs of cerebral dysfunction prior to surgery place
gested that evaluation be conducted on a follow-up the child at even higher risk for the development of
basis to determine if additional damage has occurred later cerebrovascular problems as well as at a higher
or to assess the extent and severity of residual impair- risk for death during the surgical procedure (Kil-
ment (Ariel & Strider, 1983; Golden, 1981). patrick, Miller, Allan, & Lee, 1975).
The development of hemorrhages in the brain In the adult literature, there have been a number
from hypertensive destruction of vessels also proof investigations conducted on patients who have un-
duces variable effects. Although hypertension in dergone surgery for occlusions or narrowing of the
children is comparatively rare, it occurs with enough internal carotid arteries. Such patients are often so
frequency to merit some discussion. Hemorrhages diagnosed because they experience transient ische-
typically result in focal deficits, but these can be mic attacks with such symptoms as dizziness, memo-
singular or multiple. Mild or severe disruption of ry loss or disorientation, mild speech problems, visu-
cognitive functional systems can result depending on al changes, or mild sensorimotor deficits. If
where bleeding occurs (Walton, 1977). Acute hyper- untreated, a cerebral stroke is likely (Thompson, Pat-
tensive encephalopathy may produce massive edema man, & Talkington, 1978).
and pressure effects leading to severe diffuse deficits, To date, little such work has been conducted
convulsions, decerebrate rigidity, coma, or death with children, and therefore, inferences must be
from cerebral hemorrhage. drawn from the adult literature. Those studies that
Hypotension, or low blood pressure, generally have been done with adults to determine if surgical
has only mild or unnoticeable effects on brain func- intervention improves or changes cognitive status
tioning (Ariel & Strider, 1983); however, it can pro- have reported mixed findings. Several studies have
duce diffuse impairment of moderate to severe de- reported significant improvement (e.g. , Bornstein,
grees as well. Children may complain of amnesia, Benoit, & Trites, 1981; Goldstein, Kleinknecht, &
excessive fatigue, fainting, convulsions, or loss of Gallo, 1970; Owens et al., 1975) whereas a similar
specific cognitive abilities, all of which indicate that number of investigations have found either no im-
ischemia to brain tissue has likely occurred (Gold, provement or deterioration in function occurs (e.g.,
1984). As such sequelae are variable and often fluc- Drake, Baker, Blumenkrantz, & Dahlgren. 1968;
tuating, the diagnosis of brain dysfunction or perma- Murphy & Maccubbin, 1966). One relatively recent
nent impairment is a difficult one to make. study concluded that any reported performance in-
Cardiovascular difficulties also can modify crease was likely a function of test-retest practice
blood constituents, producing brain ischemia be- effects and not true improvement in functioning
cause of the alteration in blood flow or inability of (Matarazzo, Matarazzo, Gallo, & Weins, 1979). De-
erythrocytes to carry oxygen. Many such problems spite the large number of studies on adults, the issue
may first be labeled as "psychiatric" or emotional still appears to be highly controversial.
disorders, because the child exhibits depressive Children with similar cardiovascular dysfunc-
symptoms or confusion as the first symptoms (Tay- tion, therefore, may suffer from much the same
lor, 1979). forms of dysfunction; however, there remains the
Surgery for cardiovascular problems also car- caveat that one is dealing with a developing brain. As
ries a certain risk. Circulation of blood to the brain the brain appears to develop functional capacity dur-
may become impaired while the patient is connected ing development, early damage may impede this de-
to a heart-lung machine. Thrombosis, embolism, velopment. Damage incurred at later ages may result
anoxia, or toxic/allergic reactions to anesthesia or in a loss of established functional capabilities. How-
injected medications may occur. Infections can de- ever, it is generally felt that the prognosis for recov-
velop that spread to the brain, or the heart may simply ery of cognitive function or reacquisition oflost func-
fail to regain its normal rhythm after surgery. All of tions depends primarily on an interactive effect of a
these may lead to cognitive deficits of varying degree number of variables including type, location, and
and location (Ariel & Strider, 1983). extent of the damage, to name a few (Rourke, Bak-
Brobeck (1979) reported that EEG tracings re- ker, Fisk, & Strang, 1983).
Finally, in cases of cardiovascular system ab- tern, any disruption of it can disrupt water and elec-
normality or malfunction that has led to cognitive trolyte balance within the body, which in tum can
impairment, personality changes such as depression, increase pressure on the capillary system, shut down
irritability, anxiety, and so on may occur with some blood flow, and eventually result in death.
frequency (Lishman, 1978). These changes often are
noticed before actual intellectual deficits appear and
may be attributed to the child's inability to adjust to Disorders of the Connective Tissue System
the illness. In some cases, the changes may be the
Connective tissue refers to fibrous tissue that
sequelae of damage to brain tissue and this possibility
provides support for holding cells together and forms
needs to be fully explored.
a protective covering around the body and internal
organs. Connective tissue cells are found everywhere
in the body, but large amounts of them are found in
Lymphatic and Connective Tissue bones and joint tissues. The connective tissue system
Systems is composed of ligaments, tendons, cartilage, skin,
blood vessels, internal membrane linings, and sheath
The lymphatic system, often referred to as the coverings of organs and muscles. They also con-
immune system, is similar to the blood and car- stitute a large portion of organs such as the eyes,
diovascular systems in its structure, but differs great- lungs, heart, kidneys, and liver (American Rheu-
ly in function. Its primary purposes are to defend the matism Association Committee, 1973).
body against invasion by injurious agents, to gather Disorders of the connective tissue can be inher-
and destroy worn-out cells, and to produce anti- ited or acquired. The genetic maladies are com-
bodies. It also stores extra red blood cells and pro- paratively rare and are beyond the scope of this
duces hormones that help to regulate the develop- chapter. Acquired conditions generally include rheu-
ment of new red blood cells. The lymph system is matoid arthritis, systemic lupus erythematosus,
composed of the spleen, lymph vessels and nodes, progressive systemic sclerosis, polymyositis, der-
and defensive cells (Rowland, 1984). matomyositis, Sjogren's syndrome, amyloidosis,
various form of vasculitis, and rheumatic fever. Al-
though different in terms of severity and the age
Spleen groups that can be affected, these diseases all display
features associated with inflammation and destruc-
The spleen is the main storage center for new red tion or alteration of connective tissue. Common
cells and the destruction center for old ones. It also symptoms include fatigue, fever, muscular weak-
makes some types of white cells (the lymphocytes). ness, joint swelling and pain, skin lesions, gastroin-
In emergency situations, large numbers of red cells testinal erosions with hemorrhages, peripheral vas-
are dumped into the bloodstream to ensure adequate cular dysfunctions, neuropathies, and blood cell
oxygen supply. disorders such as anemia and thrombocytopenia. The
course of the illness may vary greatly from individual
to individual, with periods of both remission and
Lymph Vessels exacerbation, a chronic mild illness, severe and
The lymph system has its own vessel system that rapidly progressing deterioration, or fluctuations be-
drains fluid from the tissue spaces. These vessels tween mild and severe episodes. Some children with
form into larger ducts that eventually merge into the these diseases may become severely disabled due to
blood. Along the vessels are lymph nodes, which act crippling joint deformities or loss of function in a
to help prevent large particles or foreign bodies from major organ system, such as the kidneys. Initial
entering the bloodstream. Lymph cells in the nodes symptoms can mimic many other diseases because
are generally effective in eliminating most foreign they are so variable, and thus are difficult to diagnose
bodies with the exception of viruses. Lymph ducts in many instances (Gilroy & Meyer, 1975).
and nodes are found almost everywhere in the body
except in the CNS. The lymph capillary system is CNS Effects
placed in such a manner so that virtually all materials
that enter the body through the skin or mucosa must Comprehensive research on the neuropsychol-
first pass through the lymphatic system. As the ogical effects of diseases of lymph and connective
lymph system is in essence a dumping/disposal sys- tissue systems in children is minimal, at best. The
122 CHAPTER 6
medical literature indicates that the effects on the function the provision of the body with fluids, nu-
brain and CNS tend to be variable and generally un- trients, and electrolytes. It is lined with secreting
predictable (Gilroy & Meyer, 1975; Rutter, 1983; cells and glands, and has accessory organs, all of
Walton, 1977). The small vessel inflammation and which contribute to this function of providing the
destruction that can occur in many of these diseases body with that which it needs to function. A second
can produce focal ischemic lesions in many organs, function is to dispose of the waste residues from the
causing them to malfunction and reduce their support digestive process (Luckman & Sorenson, 1980).
to the brain. Vessels in the brain may also be af- Some of the important parts of this system are
fected, although pathological studies have been in- the stomach, the small bowel, the colon, the rectum,
consistent in confirming this with most disease types and the anus. A variety of chronic diseases interfere
with the exception of giant cell arteritis, a condition with the function of the GI tract, yielding psychologi-
rarely found in children (American Rheumatism As- cal as well as physical problems (Whitehead &
sociation Committee, 1973). Hypertension is a fre- Bosmajian, 1982; Reinhart, 1982; Raymer, Wein-
quent outcome of these diseases the effects of which inger, & Hamilton, 1984).
were described above. Compression or ischemia may
result in peripheral neuropathy, with sensory or
motor losses in digits or limbs (Graham, 1983). Dif- Inflammatory Bowel Disease
fuse or focal cerebral infections may occur as a result
of the suppression of immune responses from drugs Ulcerative colitis and Crohn's disease are usu-
taken during treatment. ally considered together as inflammatory bowel dis-
Although evidence of the disease process in the ease. The cause of both is unknown, and the clinical
brain itself has not yet been confirmed, studies have symptoms presented are similar, including severe
indicated the presence of immune complexes associ- cramps and discharge of mucus and blood. Pediatric
ated with connective tissue and lymphatic system presentations often mimic a number of other condi-
disease processes in the choroid plexus of the brain tions, including idiopathic growth failure, before a
(Atkins, Kondon, Quismorio, & Friou, 1982; diagnosis is made (Kelts & Grand, 1980).
Bresnihan et al., 1979; Winfield, Lobo, & Singer, Both diseases are serious and potentially life-
1978). Psychoses, depression, and mental confusion threatening, and often necessitate surgery as well as a
have frequently been reported as sequelae of these variety of other medical and psychological treat-
conditions. Reactions to corticosteroids, antihyper- ments. Further, the risk of cancer of the bowel is
tensives, antidiuretics, anti-inflammatory agents, greatly increased in such patients. Although inflam-
and other medication used for treatment have been matory bowel disease is usually thought of as a syn-
found to produce changes in emotional or mental drome of young adults, cases are found in all age
state, although it is difficult to separate this from the groups. The greatest incidence is in adolescence, al-
effects of the disease itself. though 15% of all cases occur in those below the age
CNS effects have been most often reported with of 15, and this proportion seems to be on the rise
systemic lupus erythematosus (Ariel & Strider, (Hagenah, Harrigan, & Campbell, 1984).
1983). The reported sequelae include emotional dis- A number of extraintestinal manifestations of
orders, convulsions, choreiform movements, and ce- irritable bowel disease exist, including disorders of
rebrovascular accidents with focal neurological defi- the liver and biliary tract, skin lesions, joint swelling,
cits. These usually occur in children with highly and later arthritis. But perhaps most important from a
active and severe disease. In the early stages oflupus, neuropsychological point of view is the retardation in
the CNS effects may be mild and transient, or may so growth seen in 15 to 30% of these children. This
resemble a psychiatric disorder that the patient is manifestation often precedes the diagnosis of the dis-
treated as such (Bennett, Bong, & Spargo, 1978; ease, and may be independent of severity of symp-
Hughes, 1979). toms or use of steroids in treatment. Some commonly
cited reasons for this growth failure are malabsorp-
tion, intestinal protein loss, abnormal hormonal re-
sponse, anorexia, and undernutrition (Kelts &
Gastrointestinal System Grand, 1980).
Although the implications of this retarded
The gastrointestinal or digestive system extends growth for the brain have not been addressed, it
from the mouth to the anus, and has as its principal would appear that loss of needed nutrition, particu-
larly in early childhood, may have a deleterious ef- alysis. It is important to note that there is typically a
fect on cerebral development. However, no studies to time lag between dialysis treatment and subsequent
date have found specific neurobehavioral problems improvement or deterioration of the child's behavior
in children with inflammatory bowel disease. or mental status changes. Performance on tests of
visual-motor speed and accuracy was found to be
best 24 hours after treatment (Lewis, O'Neil, Dust-
man, & Beck, 1980).
Renal System Despite the clear necessity of the dialysis pro-
cedure, it too has its complications. It is now well
The kidneys are bean-shaped organs located recognized that an encephalopathy referred to as di-
against the posterior wall of the abdomen. Their prin- alysis disequilibrium syndrome may be a conse-
cipal function is to assist in the maintenance of water quence of the procedure (Marshall, 1979). This syn-
balance, blood pH level, and electrolyte balance. The drome has a characteristic course involving
functional unit of the kidney is the nephron, which is intermittent slowing of speech with stuttering and
a mass of filter tubes. Green (1978) estimated there to word-finding difficulties, which tends to develop
be approximately I million nephron units in each over a period of 2 to 3 months. Symptoms appear to
kidney. be more prominent either during or immediately
Blood goes to the kidneys directly from the aorta after dialysis (Ariel & Strider, 1983). These speech
by way of the renal arteries. The latter divide into a difficulties progress to problems in the production of
net of capillaries shaped as a tiny ball. This ball of sentences, and myoclonus and dyspraxic move-
capillaries is called the glomerulus. The blood re- ments occur. Additionally, severe memory loss,
turns from the kidneys via the renal vein. Blood flow concentration problems, and, at times, psychoticlike
is slowed as it goes through the glomerulus, which behavior can develop in children. Other symp-
allows water ions and smaller molecules to diffuse tomatology appears toward the end of a dialysis
through a "filtration system" of sorts in which un- treatment and may subside over several hours, but
wanted material is passed on to the bladder. Other the confusion, when it appears, may persist for sev-
substances are returned to the blood for further use. eral days (Ariel & Strider, 1983). Evidence suggests
Kidney damage is referred to as nephrosis. In- that electrolyte imbalance and edema of the brain
fections of the kidney system (nephritis) may impair may cause the disequilibrium syndrome (Raskjn &
the functioning of the kidneys. When kidney function Fishman, 1976).
is impaired and urine production is reduced, the There is also a dialysis dementia that may be
waste products typically excreted are retained in the seen in those undergoing long-term dialysis (Alfrey
body and can lead to potentially fatal disorders. Gen- et al., 1972; Mahurkar, Dhar, & Salta, 1973). Al-
erally, when kidney malfunction occurs, dialysis is though noted primarily in adults, dialysis dementia
used to either augment or replace the filtration aspect has been found to occur in children. It is charac-
of kidney function. terized first by a disturbance in speech, with facial
Severe psychological as well as neuropsycho- grimacing, convulsions, and eventually dementia.
logical complications are known to arise from di- The symptoms occur initially during the dialysis pro-
alysis. Depression is common, both as a function of cess and tend to clear after a period of time, but
the kidney dysfunction as well as the stress of the eventually the remission no longer occurs and the
procedure on the patient. The patient may then be syndrome continues on its course. To date, no suc-
unable or unwilling to follow the necessary medical cessful treatment has been found (Ariel & Strider,
regimen, which can further exacerbate the disease. 1983).
Other findings, however, show that symptoms and Subdural hematomas have been reported in di-
behavior can be related to interference with CNS alysis patients (Talalla, Halbrook, Barbour, &
functioning (Marshall, 1979). Kurze, 1970). Two explanations have been offered
It has been well documented that uremia results for this. Many patients undergoing dialysis are given
in severely impaired cognitive functioning (Ariel & anticoagulant drugs so that the shunts implanted in
Strider, 1983). Characteristic symptoms such as the arm can remain free from thrombosis. Addi-
sluggish mentation, lethargy, anorexia, nausea and tionally, patients with kidney failure are subject to
vomiting, tremor, sleepiness, or convulsions have abnormal bleeding. The symptoms may look similar
been widely reported (Ginn, 1975; Raskin & Fish- to dialysis equilibrium and are often difficult to dif-
man, 1"976). These symptoms are relieved by di- ferentiate clinically. However, worsening or per-
124 CHAPTER 6
sistence of symptoms between dialysis treatments chiatric problems in mixed connective tissue disease. Ameri-
may signal the presence of a hematoma as opposed to can Journal of Medicine, 65, 955-962.
the disequilibrium syndrome. Evaluation of neuro- Berg, R. A., Ch'ien, L. T., Bowman, W. P., Ochs,J., Lancaster,
psychological functioning in such children can aid in W., Goff, J. R., & Anderson, H. R., Jr. (1983). The neuro-
documenting functional level. psychological effects of acute lymphocytic leukemia and its
treatment-A three year report: Intellectual functioning and
Assessment of mental status and neuropsycho-
academic achievement. International Journal of Clinical
logical functioning in children with uremia can pro-
Neuropsychology, 5, 9-13.
vide useful diagnostic treatment recommendations. Berg, R. A., & Wilimas, J. J. (1983. May). Sickle cell disease and
Obtaining good baseline measures early in the diag- neuropsychological function. Paper presented at the Mid-
nosis of renal disease will allow for more valid as- South Conference on Human Neuropsychology, Memphis,
sessment of any later occurring deterioration as well Tennessee.
as response to dialysis treatment when initiated (Ariel Bierman, C., Pierson, W., Shapiro, G., & Simons, E. (1975).
& Strider, 1983). The timing of the assessment of Brain damage from asthma in children. Journal of Allergy
dialysis patients must be considered as the cognitive and Clinical Immunology, 55, 126.
functioning of individuals tends to fluctuate greatly at Black, F~ W. ( 1973). Intellectual ability as related to age and stage
of disease in muscular dystrophy: A brief note. Journal of
periods in the dialysis regimen, yielding different
Psychology, 84, 333-334.
performance patterns. Bloom, H. J. G., Wallace, E. N. K., & Henk, J. M. (1969). The
Ryan, Souheaver, and DeWolf (1981) reported treatment and prognosis of medulloblastoma in childhood.
comparative neuropsychological assessments on American Journal of Roentgenology, /05, 43-62.
chronic hemodialysis patients, undialyzed uremic Boll, T. J. (1974). Behavioral correlates of cerebral damage in
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Bowman, W. P. (1981). Childhood acute lymphocytic leukemia:
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(1985). Neuropsychological impairment in Duchenne mus- Winfield, J. B., Lobo, P.l., & Singer, A. (1978). Significance of
cular dystrophy. Journal of Clinical and Experimental Neu- anti-lymphocyte antibodies in systemic lupus erythematosus.
ropsychology, 7, 486-496. Anhritis and Rheumatism, 21, 215-216.
Strecker, E. (1929). Behaviour problems in encephalitis. Archives Winter, R. J. (1982). Special problems of the child with diabetes.
of Neurology and Psychiatry, 21, 137-144. Comprehensive Therapy, 8, 7-13.
Suess, W. M., & Chai, H. (1981). Neuropsychological correlates Worden, D. K., & Vignos, P. J. (1962). Intellectual function in
of asthma: Brain damage or drug effects? Journal ofConsult- childhood muscular dystrophy. Pediatrics, 29. 968-9n.
ing and Clinical Psychology, 49, 135-136.
7
Neuropsychological Bases of Common

Learning and Behavior Problems in
Children
MARION J. SELZ AND SHERYL L. WILSON
One of the few consistencies found in the literature on general term into learning disabilities and hyper-
learning disabilities is that there is little agreement kinesis (or hyperactivity). Research and clinical ob-
about the meaning, behavioral correlates, or etiology servation have found that some children are affected
of this term. There is even dispute over whether it is by the so-called pure form of learning disability,
an homogeneous or a heterogeneous diagnostic entity whereas other children are affected by the so-called
(e.g., Fisk & Rourke, 1983; Goldman, Thibert, & pure form of hyperactivity. But there are some chil-
Rourke, 1979; Pirozzola & Campanella, 1981; Sat- dren who are affected by both disorders and still oth-
terfield, Cantwell, & Satterfield, 1974). Within the ers who have specific deficits that do not appropri-
literature, "learning disability" has often been used ately fit within a general label of "learning
synonymously with hyperactivity, attention deficit disability.'' In an attempt to account for the diversity
disorder, minimal brain dysfunction, and minimal within both hyperactivity and learning disability,
brain damage, as well as specific learning disorders. Denckla ( 1979) devised a clinical inferential system
This has further supported the idea that there is a that identifies ten common syndromes.
single phenomenon that manifests itself in these vari- Perhaps the most current and widely used clas-
ous forms. The tendency toward a unitary view of sification system is the American Psychiatric Asso-
learning disabilities is most likely the result of almost ciation's third edition of the Diagnostic and Statis-
a century of research that has been primarily confined tical Manual of Mental Disorders (DSM-III) (1980).
to developmental reading disorders (Pirozzola & Within this system, learning disabilities are present-
Campanella, 1981). More recently, increasing atten- ed as specific, but not exclusive, developmental
tion has been given to the possibility that these sepa- disorders, whereas hyperactivity is subsumed under
rate terms may be describing subgroups subsumed a separate category, Attention Deficit Dis-
under this general clinical category (Pirozzola, 1979; order (ADD).
Rourke, 1975; Satz & Morris, 1981). The relationship between neuropsychological
An early attempt to classify the diverse symp- deficits and learning disabilities will be reviewed in
toms found in the general category "learning dis- this chapter. First, the early models and research that
ability" was proposed by Peters, Romine, and initially demonstrated the neuropsychological basis
Dyckman (1975). They simply divided the entire of learning disabilities will be briefly discussed. Sec-
range of childhood disturbances encompassed by the ond, the view that the concept of "learning dis-
ability" is comprised of various subgroups that can
be differentiated on the basis of specific neuropsy-
MARION J. SELZ Rehabilitation Psychology, St. Mary's chological deficits will be presented. Third, behav-
Hospital, Tucson, Arizona 85703. SHERYL L. ioral disorders, emphasizing ADD, will be dis-
WILSON Department of Psychology, University of Ari- cussed, within the framework of Luria's functional
zona, Tucson, Arizona 85721. systems of the brain model.
129
130 CHAPTER 7
Reitan's Theoretical Model and (9-14) was based on seven of Halstead's original ten
Original Work measures (three were not retained because Reitan's
1955 validational research found that these tests did
not reliably discriminate between brain-damaged and
Interest in brain-behavior relationships, from control subjects). Other tests were added or new ones
both experimental and clinical points of view, is not a developed (particularly for the younger children's
recent development in psychology. However, formal battery), in accordance with Reitan's conceptual
assessment techniques concerning evaluation of the framework (Reitan, 1980).
status of brain functions in individual persons have a According to this framework, a comprehensive
rather recent history, dating back only approximately neuropsychological test battery must meet three cri-
50 years. Perhaps the best known American pioneer teria: first, the battery must be comprehensive in that
in the study of human brain-behavior relationships is the full range of abilities subserved by the brain must
Ward Halstead (1908-1969). Based on naturalistic be measured; second, the battery must include tests
observation, Halstead developed a battery of behav- that are sensitive to general or overall brain functions
ioral indicators designed to differentiate individuals as well as tests capable of detecting deficits in partic-
with cerebral damage from those without such ular parts of the brain; and third, the tests must be
damage (Halstead, 1947). He recognized that brain technically designed to be amenable to valid neuro-
damage in its various forms can affect sensory, cen- psychological inference and interpretation based on
tral processing, or motor functions, and so included the four methods of inference, as described by Reitan
measures of these three stages of the behavioral cycle (1967), Reitan and Davison (1974), and Reitan and
in his original battery. Heineman (1968).
Ralph Reitan, who began his neuropsychologi- In regard to meeting the first two criteria, the
cal research in Halstead's laboratory, went on to de- batteries developed by Reitan currently contain mea-
velop a research approach oriented essentially toward sures of abstraction and concept formation, visual-
systematic subdivision of the term brain damage (Re- spatial and spatial-kinesthetic problem solving, at-
itan, 1975). He understood the potential contribution tention and discrimination, memory, language skills,
of a standardized battery approach, which served as and sensory-perceptual and motor skills. By these
the basis of his research. Reitan's first study utilizing measures, the broad range of abilities as well as spe-
this approach compared the results obtained with cific areas responsible for particular functions are
Halstead's tests by a group of 50 subjects with docu- thought to be tapped. The third criterion, application
mented cerebral damage or dysfunction with a group of the four methods of inference, is perhaps one of
of 50 subjects who showed no past or present signs or Reitan's most important contributions to the field of
symptoms of cerebral damage or dysfunction. The neuropsychology because it provides a means for val-
results showed "striking" differences between the id interpretation of the test batteries. (For a detailed
two groups (Reitan, 1955). Reitan (1955) concluded description of the four methods of inference, as well
that "Halstead's battery was sufficiently sensitive to as their application to the neuropsychological study
the effects of organic brain damage to provide an of learning disabilities, see Selz, 1981.)
objective and quantitative basis for detailed study of
relationships between brain function and behavior''
(p. 8).
Reitan's work in this area resulted in a modifica- Early Developmental
tion and expansion of Halstead's original battery, Neuropsychological Studies
which is now known as the Halstead-Reitan Neuro-
psychological Test Battery. This is appropriate for In the refinement and validational research, as
adults and adolescents 15 years and older. During the mentioned previously, Reitan initially demonstrated
1960s, Reitan and his colleagues at the Indiana Uni- that the neuropsychological test battery was able to
versity Medical Center expanded their work to in- differentiate between adult subjects with and without
clude children (Reed, Reitan, & Kl~ve, 1965; Re- brain lesions (Reitan, 1955). Subsequent studies re-
itan, 1964; Reitan & KI0ve, 1968). This resulted in lated test findings using the adult battery to such
the development of two batteries for children: the conditions as site of lesion, causal effects, age of
Halstead Neuropsychological Test Battery for Chil- onset, premorbid condition, and severity and extent
dren (ages 9-14) and the Reitan-Indiana Neuropsy- of lesion (Doehring & Reitan, 1962; Reitan, 1958;
chological Test Battery for Children (ages 5-8). The Reitan & Davison, 1974; Reitan & Fitzhugh, 1971).
adult battery as well as the battery for older children Some of the issues addressed by these early adult
BASES OF COMMON LEARNING AND BEHAVIOR PROBLEMS 131
studies, for example, whether the neuropsychologi- able to classify subjects according to group mem-
cal approach could differentiate between normal sub- bership with 70-80% accuracy.
jects and brain-damaged subjects, could also be ap- These studies demonstrate that groups of brain-
plied to children, but questions unique to children damaged children consistently achieve lower scores
began to emerge. The first such issues were: Does than age-matched controls on the neuropsychological
cerebral damage to developing abilities in children and Wechsler measures. Significant group dif-
have effects similar to damage to acquired abilities in ferences, however, do not automatically translate
adults? And, are there neuropsychological deficits in into clinical applications. For example, the fact that
children who have negative neurological findings, three motor tasks differentiated normal from brain-
but whose behavior is in some ways similar to that of damaged children (Boll & Reitan, 1970) does not
children with structural brain damage? The research suggest that these measures would comprise an ade-
pertinent to these issues will be briefly reviewed, as quate brain-damage test. For an accurate and com-
the answers to these initial questions were necessary prehensive diagnosis of a child's problems, the full
before the more sophisticated questions pertaining to battery and utilization of the four methods of in-
learning disabilities could be formulated. ference are necessary.
In 1965, Reed et al. matched 50 brain-damaged The question concerning the possible difference
children between the ages of I 0 and 14 years with 50 between the effects of brain damage on developing
normally functioning controls and compared the per- abilities in children and those to acquire abilities in
formance of each pair on 27 measures from the adults was initially raised by the results of the Reed et
Wechsler-Bellevue Scale and the neuropsychologi- al. (1965) study. Several subsequent studies at-
cal battery. This analysis found that the brain- tempted to further explore this issue. In 1965,
damaged subjects were most frequently impaired in Fitzhugh and Fitzhugh compared 30 pairs of subjects
language functions. Because brain damage in adults between 15 and 29 years of age on 22 measures from
tends to markedly impair adaptive and problem-solv- the Wechsler scales and from the neuropsychological
ing abilities rather than language skills, these initial battery for adults. In one group, all subjects had sus-
results suggested that brain damage sustained in tained brain damage before age 10; in the other
childhood may have a different effect than brain group, all subjects had sustained brain damage after
damage sustained in adulthood. In a replication and age 12. The latter group achieved higher mean scores
extension of this study, Boll (1974) found compara- on all 22 measures. The differences between the
ble results, supporting the validity of the Wechsler groups were significant on several Wechsler perfor-
scales and neuropsychological measures as tests for mance scales, the Traii Making Test, Part A, and
brain damage in older children. TPT-Memory. These results suggest that greater im-
Boll and Reitan ( 1970) found significant dif- pairment of abilities occurs with early onset than with
ferences on the performance of motor and sensory- late onset of brain damage. This indicates that the
perceptual tasks when they compared a sample of longer a person has a normal brain, the more time
brain-damaged children with a control sample. Spe- there is to acquire information and skills.
cifically, one measure of sensory-perceptual func- Further support for these conclusions was pro-
tion (Tactile Finger Localization) and three measures vided in 1966 by Reed and Fitzhugh in a study com-
of motor functions (Finger Tapping Test, Tactual paring four groups of brain-damaged patients with
Performance Test, and Grip Strength Test) were able age-matched controls. The brain-damaged groups
to differentiate between the two groups. consisted of older children with mild brain damage;
In regard to the younger children's battery, older children with moderate brain damage; adults
Reitan ( 1964) compared 29 brain-damaged children with recent, mild brain damage; and adults with long-
between 5 and 8 years of age with 29 controls on the standing moderate brain damage. Results indicated
Wechsler Intelligence Scale for Children (WISC) and that the controls performed at a higher level than the
neuropsychological measures. He found significant brain-damaged groups, and that the mildly impaired
differences between the groups on all but one of 41 groups were superior to the moderately impaired
measures (the insignificant comparison involved grip groups.
strength using the dominant hand). Consistent with The most important aspect of the findings, how-
the results found by Reed eta/. ( 1965), the measures ever, related to the patterns of deficits within the
of verbal functions frequently showed the largest groups. The two groups of brain-damaged children
group differences. In an earlier study utilizing the differed from the controls most strikingly on mea-
same groups of subjects, Reitan (1971) found that sures of language and symbolic skills. The dif-
motor and sensory-perceptual measures alone were ferences between the normal and brain-damaged
132 CHAPTER 7
children were smaller on the Tactual Performance described as having mainly behavioral problems in
Test, Finger Tapping, and Category Test. Similarly the classroom. The test results were subjected to two
the moderately impaired adults showed their greatest types of analysis: an analysis of variance supple-
impairment on language-related tests. But the mildly mented by t tests, and a blind overall judgment of
impaired adults had a different pattern. They differed whether each child appeared to have normal, mildly
from their control groups primarily on measures of impaired, or abnormal brain functions. Using statis-
immediate problem-solving ability such as the Cate- tical methods to analyze the level of performance, the
gory Test, Tactual Performance Test-Time, and authors found that the normal subjects generally
Wechsler Block Design. achieved the best scores and the brain-damaged sub-
The results of this study are somewhat difficult jects the lowest scores, with the two MBD groups
to interpret, as severity of cerebral impairment was usually scoring in between. The brain-damaged
confounded with age of onset in the adult samples. groups consistently performed significantly more
However, the consistency of findings across several poorly than the other three groups, but the differences
studies suggests that brain damage in young children between the two MBD groups and the control sub-
impairs their ability to acquire knowledge in the man- jects generally failed to reach significance. The blind
ner that knowledge is presented in the schools, and judgment analysis achieved finer distinctions be-
thus the skills emphasized in the school years-lan- tween the groups. Using only the test protocols,
guage and symbolic skill-show some of the greatest Reitan identified 64% of the normal children as hav-
deficits. In contrast, if brain damage occurs in ing normal brain functions, approximately 85% of
adulthood after a normal childhood and adolescence, the MBD subjects as having mildly impaired brain
language and acquired knowledge are usually spared functions (averaging the two groups), and 96% of the
(with the exception of cases of damage to the lan- brain-damaged children as having abnormal brain
guage areas in the brain) and deficits appear primarily functions.
in adaptive and problem-solving ability. Finally, in research designed to specifically ad-
Once the validation studies began providing evi- dress the neuropsychological difference between
dence that the neuropsychological analysis could normal, learning-disabled, and brain-damaged chil-
successfully differentiate between brain-damaged dren in the 9- to 14-year age groups, Selz (1977)
children and normal children, researchers began ap- found significant differences between these three
plying this method to other childhood disorders. One groups. Using analysis of variance on three summary
area that seemed particularly appropriate was that of IQ scores and 10 neuropsychological measures, there
learning disabilities. One of the first studies designed were significant differences between the groups be-
to test this method of analysis was conducted by yond the .01 level on II of the 13 measures, and a
Doehring in 1968. He compared 39 boys between the significant difference beyond the .015 level on one
ages of 10 and 14 who were retarded in reading but measure.. The t-test comparisons indicated that the
otherwise normal, with a control group of 39 boys learning-disabled subjects performed in a relatively
with normal reading skills. Doehring found that the normal manner on measures with a strong motor
normal readers were significantly superior to the re- component. The performance of the disabled learners
tarded readers on 62 out of 103 measures, and that the resembled that of the brain-damaged subjects on tests
pattern of deficit included visual and verbal impair- with strong cognitive or attentional demands. A dis-
ment. The retarded readers were superior to the nor- criminant analysis that utilized the 13 measures clas-
mal readers on several measures using somesthetic sified subjects according to group membership with
input. Two experienced neuropsychologists gave 80% accuracy. The 20% classification errors tended
subjects blind ratings of ''no cerebral dysfunction'' to be in the direction of classifying subjects as less
or ''definite cerebral dysfunction. '' The trend for the impaired than their group membership implied, for
judges to rate the normal subjects as having no cere- example, assigning a learning-disabled subject to the
bral impairment and the retarded readers as having control category (Selz & Reitan, 1979).
definite cerebral impairment was significant.
Reitan and Boll (1973) evaluated the neuropsy-
chological correlates of minimal brain dysfunction Refinements in the Study of Learning
(MBD) in children 5 to 8 years of age. Their study Disability
included four groups of approximately 25 children
each. The categories were normal; brain-damaged; Once the evidence supporting the ability to dif-
MBD children whose primary referral was due to ferentiate learning-disabled children from normal
academic problems; and MBD children who were children using neuropsychological analysis was
found, researchers began developing new applica- period, 24 NR and 20 RR subjects from the original
tions for this method of assessment. Just as Reitan groups participated in the retesting.
had begun his career by developing an approach to One of the important deviations of this study
aid in systematic subdivision of the term brain from previous work in the area was Rourke's deci-
damage, the most recent application of neuropsycho- sion to include only subjects with Full Scale WISC
logical methods centers upon attempting to subdivide scores between 91 and 117. Rourke defended this
learning disabilities into discrete categories. The next decision on the basis that it would be reasonable to
section of this chapter will focus on the research from assume that "dull" and "bright" children would
the Neuropsychology Laboratory of Windsor West- differ markedly on a large number of variables, rather
em Hospital Centre, one of the major laboratories than just on reading ability, and that the results of this
involved in this effort. This work was chosen for its investigation were intended to apply to groups of
comprehensive treatment of learning disabilities, and "average" children.
is an example of the work being done in several dif- The overall results of this study showed that in
ferent settings. general, the children in the RR group were further
One of the Neuropsychology Laboratory's ma- behind the children in the NR group at the time of the
jor contributors to research utilizing neuropsycho- final assessment than they had been initially. This
logical assessment of children with learning dis- was attributed to the fact that most of the NRs made
abilities is Byron Rourke, who has provided evidence more than 4 years of progress in reading over the 4-
supporting the division of learning disabled into dis- year period, whereas the PRs made less than 2 years'
tinct subgroups. He has also provided the rationale progress. Several subjects originally classified as RR
for these distinctions, in that the classifications pro- made significant advances in reading performance
vide information pertinent to both prognosis and re- during this 4-year period, but it was found that there
habilitation. Rourke's work will be presented in three were variables that reliably differentiated between
parts: reading disorders, spelling disorders, and these RRs and those who made little if any progress.
arithmetic disorders. This investigation provided important meth-
odological support for the utilization of Reitan's four
methods of inference (level of performance, dif-
Reading Disability: Analysis and ference scores, comparisons of performance on the
Remediation two sides of the body, and pathognomic signs).
These plus developmental analyses provided impor-
Initially, Rourke began his research program tant information that may not have been available
based on the theoretical question of whether it was were such rigorous methods not practiced.
the case that some or all of the deficits exhibited by Another issue addressed in this investigation by
children who are classified as "learning disabled" Rourke was the relative merits of the positions in the
are the result of cerebral impairment (Rourke, 1975). controversy between the "developmental lag"
The investigation of this question led to the utiliza- model and the "deficit" model. Satz and Van
tion of neuropsychological assessment as well as the Nostrand (1972) had postulated an underlying "lag
implementation of Reitan's four methods of in- mechanism'' in brain maturation that they thought
ference. The first important application of this meth- forecast the later onset of dyslexia. Based on this,
od of investigation was a 4-year longitudinal study of they conceptualized dyslexia within the framework
reading disability. Due to its importance as an early of a developmental model rather than that of 3 ''defi-
demonstration of the use of neuropsychological cit'' model. They suggested that the underlying lag in
methodology in the study of learning-disabled chil- brain maturation causes a delay in the rate of acquisi-
dren, this work will be presented in some detail. tion of developmental skilJs rather than a loss or im-
In the initial phase of the investigation, there pairment in these skills.
were 30 subjects in the normal-reading (NR) group The "deficit" model, supported by Doehring
and 29 subjects in the retarded-reading (RR) group. (1968), Reed (1968), and Reitan (1964), suggests
Subjects were assigned to their respective groups that there is some sort of cerebral dysfunction under-
based on their performance on two subtests of the lying the acquisition of age-appropriate reading
Metropolitan Achievement Test (MAT). Subjects skills. The "deficit" view differs from the "devel-
were matched for age; their ages were between 7 opmental lag" position in that there is no necessary
years, 2 months and 8 years, 4 months. The study expectation that the children who suffer from the
included testing at intervals of2 years, 3 years, and 4 deficit(s) will ever catch up with their normal age
years after the initial assessment. By the final testing mates in those skills that are required for age-appro-
134 CHAPTER 7
priate reading, but is similar to the "developmental restricted distributions of initial MAT subtest scores.
lag" view in that it also predicts a less than age- Also to be considered are the restricted age span and
appropriate level of reading performance throughout fairly small number of measures chosen for com-
the elementary school years. The "deficit" position parison (Rourke, 1976b).
supports the possibility that children will exhibit a The final study to be discussed in this section
deficit in the cerebral structures or systems that sub- constitutes Rourke's first attempt to design a study
serve some of the abilities necessary for reading, but specifically to identify subgroups of reading-disabled
allows for adaptation and/ or compensation for the children (Petrauskas & Rourke, 1979). The study
deficits in question. Drawing from the work of Luria used a multivariate classification procedure (Q-type
( 1966) and Wepman ( 1964), the possibility of enlist- factor analysis) similar to that employed by Doehring
ing other neuronal structures or systems that in the and Hoschko (1977). The sample was comprised of
ordinary course of events would not subserve these 150 children between 7 and 8 years of age. There
abilities is entertained. were 133 RRs chosen from a clinic population and 27
In order for Rourke to relate this investigation to NRs who were tested in the original longitudinal
the assessment of these two positions, seven develop- investigation.
mental lag-deficit paradigms were constructed. Then The results indicated three types of RRs that
the results of Satz, Friel, and Rudegair' s ( 1974) study could be differentiated from NRs and one another.
as well as Rourke's (1975) longitudinal study were Following is a brief description of each subtype (in-
compared in the light of these paradigms (Rourke, cluding the subtype containing the NRs).
1976a). In general, it was found that there was some
support for the "developmental lag" position in the
case of fairly simple, early-emerging abilities. Spe-
Subtype 1
cifically, the position presented by Satz and Van Subtype I could be characterized as having rela-
Nostrand (1972) postulates a particular lag in the tively well-developed visual-spatial and eye-hand
development of the left cerebral hemisphere. Both coordination skills; average or near-average tactile-
Rourke's ( 1975) study as well as Staz and colleagues' kinesthetic abilities, abstract reasoning, and nonver-
(1974) study lent support to the notion that dysfunc- bal concept foirnation; near-average word definition
tion of the left cerebral hemisphere is particularly ability; mildly impaired word-blending ability, im-
involved in the genesis of reading retardation. How- mediate memory for digits, and store of general in-
ever, Rourke did not find that RRs, as a group, formation; and moderate to severe impairment in ver-
eventually "caught up" in those abilities thought to bal fluency and sentence memory.
subserve the reading function, nor did they "catch
up" in the ability to read. Thus, the weight of the
evidence of Rourke's ( 1975) study favors a "deficit" Subtype 2
rather than a "developmental lag" position.
Another study that grew out of this longitudinal Subtype 2 could be characterized as having
investigation used measures of reading, spelling, and average or near-average kinesthetic, psychomotor,
psychometric intelligence as well as the Underlining visual-spatial constructional and word-defining abil-
Test (Doehring, 1968), in an attempt to determine ities, and nonverbal problem-solving and abstract
their relative predictive accuracy for both the NR reasoning skills within a context that provides imme-
group and the RR group (Rourke & Orr, 1977). The diate positive and negative feedback; borderline to
results indicated that performance on the Underlining mildly impaired immediate memory for digits and
Test was the best predictor of eventual achievement other "sequencing" skills, store of general informa-
levels in reading and spelling when compared to the tion, sound-blending verbal fluency, and concept
other tests used (i.e., reading, spelling. and psycho- formation when substantial verbal coding is required
metric intelligence). It was also found that the Under- and/or when no positive and negative feedback is
lining Test was particularly sensitive with the RRs, provided; and moderate to severe impairment in fin-
providing accurate predictions about the substantial ger recognition, immediate visual-spatial memory,
gains in reading by the one subgroup of RRs. and memory for sentences.
Although the results of this study were exciting,
Rourke and Orr ( 1977) advised caution in the draw- Subtype 3
ing of clinical inferences (including prognosis) for
individual cases. This caution was necessary because Subtype 3 could by characterized as having
of the restricted range of IQs and the truncated and average or near-average finger recognition (left
hand), kinesthetic, visual-spatial constructional, vo- In regard to specific remediation recommenda-

cabulary and sound-blending abilities, and nonverbal tions, at this time there seem to be very little avail-
concrete formation within a context of immediate able. It is stressed that the nature of the deficit deter-
positive and negative feedback; borderline to mildly mines the remedial teaching methods (Aaron, 1981 ),
impaired finger recognition (right hand), immediate which has led to a lack of any systematic approach.
memory for digits, eye-hand coordination under This is in part due to the lack of information pertain-
speeded conditions, store of general information, and ing to the different types of deficits that are man-
nonverbal abstraction and the shifting of set without ifested as reading disability. The work of Rourke is
the benefit of positive and negative feedback; mild to an attempt to understand these diverse deficits. How-
moderate impairment in verbal fluency, sentence ever, as he has stated, the research focused on devel-
memory, and immediate visual-spatial memory; and opment of remedial programs has just begun (Rourke
moderate to severe impairment in concept formation & Strang, 1983). At this time the basic approach is to
that involved substantial verbal coding. differentiate between children who respond to pho-
netic approaches and those who respond to whole
Subtype 4 word approaches (Aaron, Grantham, & Campbell,
1978). This is very similar to the remedial approach
Subtype 4 could be characterized as having to spelling disability, which will be detailed in the
average or above-average finger recognition, kines- next section.
thetic, sequencing, eye-hand coordination, visual-
spatial constructional, visual memory, auditory-ver-
bal receptive, and concept-formation abilities. Spelling Disability: Analysis and
The results of the Petrauskas and Rourke ( 1979) Remediation
study illustrated the complex nature of the neuropsy-
chological dimensions of the groups of clinical disor- Several studies conducted by Rourke and his
ders known primarily as "reading disability." At the colleagues have attempted to analyze spelling errors
very least, this analysis provided evidence indicating from the point of view of their degree of phonetic
that reading-disabled children do not constitute a ho- accuracy. The impetus for this line of research
mogeneous group. It is also clear that deficiencies in emerged from clinical practice with learning-dis-
psycholinguistic skills play a major role in reading abled children and research evidence derived from
difficulties at this age level. Further work (Fisk & studies of adults with well-documented lesions (e.g.,
Rourke, 1978) found that psycholinguistic dis- Kinsbourne & Warrington, 1963; Rourke, 1976c).
abilities are also the source of major problems for Both sources have found consistent evidence indicat-
different subtypes of learning-disabled children ranging the relative "intactness" of children (and adults)
ing from 9 to 14 years of age. whose misspelling was essentially phonetically accu-
These results provide important clinical applica- rate (e.g., gelusy for the word jealousy). This is con-
tions. If the various subtypes of reading disability trasted to misspellings that are phonetically inaccu-
have various etiologies, then perhaps reading-dis- rate (e.g., htvowe for jealousy). In particular,
abled children will respond differentially to various research has documented that adults with lesions of
forms of teaching and intervention. Investigations the so-called "language areas" of the left cerebral
designed to address this issue are needed and are part hemisphere exhibit a tendency to spell in a phonet-
of Rourke's ongoing research strategy (Rourke & ically inaccurate way (e.g., Kinsboume & War-
Strang, 1983). Also, Rourke and his colleagues have rington, 1963). Rourke began a line of research based
been able to provide speculations regarding the like- on these findings that was designed to investigate the
lihood of dysfunction maximally involving different existence of two types of spelling disability.
systems, suggesting a relationship between the left In the first study (Burgher & Rourke, 1976), the
temporal lobe and reading disability associated with spelling production of the subjects from the longitu-
subtype I; a relationship between the left temporo- dinal investigation of reading retardation (Rourke,
parieto-occipital area and reading disability associ- 1975) was examined. It was found that RRs had sig-
ated with subtype 2; and a relationship between the nificantly fewer phonetically accurate spelling errors
left frontal lobe and reading disability associated with than NRs. Also, there was a "leveling off' in the
subtype 3 (Rourke & Strang, 1983). Of course, these degree of phonetic accuracy of the misspellings after
attempts at localization are only speculative at this the second year of testing (i.e., ages 9-10).
time, but they provide a basis for further validation The next study (Sweeney & Rourke, 1978) was
and research. cross-sectional in nature and was based on two
136 CHAPTER 7
groups of studies. The first group of studies was con- suits of this study indicated that whereas PI spellers
ducted by Newcombe (1969) and Nelson and War- were significantly inferior to NS in their logical-
rington (1974) and found a positive relationship grammatical reasoning, PA spellers were not in-
between spelling retardation characterized by pho- ferior. This led Sweeney et at. (1978) to pose two
netically inaccurate errors and a general impairment non-mutually exclusive possibilities: (I) that younger
in language functioning. The second group was con- PI spellers are deficient in the ability to benefit from
ducted by Boder (1973) and demonstrated a positive formal instruction in rules by which different forms-
relationship between spelling performances charac- of symbolic information are processed; and (2) that
terized by an excess of phonetic accuracy and poor PI spellers have difficulty in processing language that
memory for how words looked. can be viewed as somewhat more complex than
The subjects for the study conducted by Sween- everyday conversation.
ey and Rourke (1978) were children at age levels In general, these studies indicate the heuristic
corresponding to grades four and eight. There were value of a qualitative analysis of the spelling errors of
three groups, one a control group consisting of nor- children if the nature of the underlying deficiencies of
mal spellers (NS) and two experimental groups of spelling retardation is to be explicated. Also, it is
disabled spellers. One of the experimental groups clear that the age at which children were tested was a
consisted of phonetically inaccurate (PI) spellers; the very important consideration with respect to the rela-
other was composed of phonetically accurate (PA) tionship between degree of phonetic accuracy of mis-
spellers. spellings and performance on the dependent vari-
It was found that the PI spellers were inferior to ables (Rourke, 1978).
the PA spellers and the NS on most measures of Sweeney and Rourke (1985) formulated an ex-
psycholinguistic ability at the older (grade eight) age tensive remedial program that will be presented here
level. Upon closer examination, it was discovered in brief (for further detail, refer to the original
that the PA spellers performed at levels similar to source).
those of NS on tests in which the correct responses The limited ability of PI spellers to carry out
could be brief, single-word answers, whereas the PI specific operations on linguistic information (e.g. ,
spellers were inferior to both the PA spellers and the phonemic segmentation) suggests that this subtype
NS. In contrast, the levels of performance of PA of disabled spellers would encounter significant dif-
spellers could not be distinguished from those of PI ficulty in learning the rudiments of applying such
spellers and were inferior to NS on those measures operations to specific verbal information, including
that required a fairly complex formulation of an an- single words, through conventional classroom in-
swer to a question, and when the correct answer struction. Also, these children would have difficul-
could not be determined exclusively by utilizing the ties in generalizing from conventional instruction to
information contained in the question itself. Sweeney new verbal information, including unfamiliar
and Rourke ( 1978) concluded that the older PA spell- words. Therefore, it may be appropriate to provide
ers experienced significant difficulty in associating PI spellers with the opportunity to "operate" exces-
spoken language with the analysis of visual-spatial sively on each word to be learned (e.g., by syn-
information; in relating the verbal information pro- thesizing repeatedly the individual speech sounds of
vided with other information; and encoding relatively the words presented in sequence, and by segmenting
complex word strings in response to verbal informa- repeatedly the phonemic composition of the word
tion provided. presented orally). Once these operations can be car-
Returning to the younger group, it was found ried out efficiently on a particular word, it would
that the arithmetic subtest of the Wide Range probably also be beneficial to develop the ability to
Achievement Test (WRAT) differentiated the three read the word "by sight" in order to promote fluen-
groups, with the PI spellers exhibiting the poorest cy in reading. If concentrated training in the applica-
performance. This suggested that one important defi- tion of these basic operations on unfamiliar words
ciency in the PI spellers at this age level might be their does not improve performance, then it would be rea-
ability to benefit from formal instruction in the use of sonable to restrict instruction to intensive develop-
rules and, consequently, in logical-grammatical rea- ment of a sight word reading strategy.
soning. This prompted further analysis of these sub- Sweeney and Rourke ( 1985) proposed the uti-
jects at the fourth grade level (Sweeney, McCabe, & lization of remedial methods involving intense visual
Rourke, 1978) in which the subjects' performance on analysis to aid the PA spellers. They refered to the
the Logico-Grarnmatical Sentence Comprehension "right hemisphere strategies" proposed by Bakker,
Test (Wiig & Semel, 1974) was compared. There- Moerland, and Goekoop-Hoefkens (1981), which
consist of (l) development of a sight word strategy; Arithmetic Disability: Analysis and
(2) an attempt to increase the salience of the visual- Remediation
spatial features of word configurations, particularly
for unfamiliar words and words with low phoneme- There is a notable lack of research pertaining
grapheme correspondence; and (3) encouragement of specifically to arithmetic disability as compared to
visualization of the graphic features of words to be studies of retarded reading and spelling (Rourke,
spelled and to attend to disregarding how the word 1978). One reason for this may be the lack of educa-
looks. tional concern due to the emphasis in Western
Other strategies that may benefit PA spellers culture on reading and spelling (Rourke & Strang,
include flashcard exercises, activities that require I983). The fact that arithmetic is often viewed as a
recognition of words in tachistoscopic presentations type of language activity (e.g., the Arithmetic sub-
that gradually decrease in exposure time, and exer- test of the WISC-R is considered part of the verbal
cises requiring simultaneous reading aloud with an scale) may also contribute to the neglect of this area
instructor who gradually decreases his/her input to of learning. Rourke and his colleagues at the Neuro-
promote independent oral reading. It may also be psychology Laboratory have conducted important
beneficial to have the child, while blindfolded, si- work in this area.
multaneously trace the spatial features of relatively The first of these important studies was that of
unfamiliar words made from sandpaper, while re- Rourke and Finlayson ( I978) who attempted to deter-
peating the words, and then to write these words out mine if children who exhibited arithmetic retardation
correctly, again while repeating the words orally. within the context of differing patterns of reading and
This may serve to increase the salience of the phys- spelling performances would also exhibit differing
ical forms of word configurations (Sweeney & patterns of brain-related abilities. For this study, chil-
Rourke, 1985). dren between the ages of 9 and I4 who had been
Both PI and PA spellers demonstrated difficulty classified as learning disabled were divided into three
in assimilating verbal information and in making groups on the basis of their patterns of performance in
generalizations from this information. This may be reading and spelling tasks relative to their perfor-
addressed by multisensory teaching in conjunction mance in arithmetic. The children in Group 1 were
with dramatization. Although this method would uniformly deficient in reading, spelling, and arith-
provide some overlap in the teaching aids for both PI metic. The children in Group 2 exhibited signifi-
and PA spellers, it should be stressed that the empha- cantly better performance in arithmetic (which was
sis for each group is quite different. Specifically, still below age expectation) relative to reading and
although both groups have demonstrated receptive spelling. The children in Group 3 exhibited normal
language difficulties, the deficiencies of the PI spell- reading and spelling but marked impairment in arith-
ers focus on their inability to carry out very basic, metic. Also, Groups 2 and 3 did not differ in their
receptive linguistic operations. In contrast, the PA level of arithmetic performance, although they were
spellers have difficulty in associating the spoken superior to the Group I in arithmetic performance.
word with an analysis of visual-spatial information, The three groups were equated for age and Full Scale
relating verbal information provided with existing IQ on the WISC. There were 16 dependent measures
information, and encoding relatively complex word that provided the basis of comparison.
strings in response to verbal information provided Analysis of the three groups' performance on
(Sweeney & Rourke, 1985). the dependent measures found: (I) the performance
Investigating the development of linguistic and of Groups 1 and 2 were superior to Group 3 on mea-
cognitive abilities in children who exhibit qualita- sures of visual-perceptual and visual-spatial abili-
tively distinct spelling disorders would seem to be a ties, and (2) Group 3 performed at a superior level to
natural course to follow in delineating underlying Groups 1 and 2 on measures of verbal and auditory-
deficiencies, with a view to the formulation of a spe- perceptual abilities. These results were interpreted as
cific plan of remediation. It should be emphasized, being consistent with the view that the children in
however, that the patterns of abilities and deficits Group 3 may have a relatively dysfunctional right
emerging from the studies reviewed and the associ- cerebral hemisphere, and that children in Groups 1
ated remedial strategies presented, are not considered and 2 were suffering from the adverse effects of a
exhaustive. Replications of these studies and addi- relatively dysfunctional left cerebral hemisphere
tional investigations geared to specifying further the (Rourke & Finlayson, I978). Of particular interest
nature of the deficits related to different types of within this context was the fact that the two groups
spelling disorders would certainly be warranted. who had been equated for deficient arithmetic perfor-
138 CHAPTER 7
mance (i.e., Groups 2 and 3) exhibited vastly differ- Arithmetic subtest, in an attempt to gain further in-
ent performances on verbal and visual-spatial tasks. sight into this neglected disability. The results and
These differences were clearly related to their pat- implications of this approach will not be discussed
terns of reading, spelling, and arithmetic, rather than here; the reader is referred to Strang and Rourke
being limited to only their arithmetic performance. (1985) for a detailed description.
A second study pertaining to this question was Of particular importance from a psychoeduca-
conducted shortly after the first by Rourke and Strang tional standpoint is the pattern of results that emerged
(1978), utilizing level of performance comparisons in these studies in the case of the children with out-
as well as comparison of performance on the two standing or "specific" deficiencies in arithmetic
sides of the body to determine differences between (Group 3). It is clear that these children exhibited a
the three groups of children from the first study number of adaptive deficiencies that should render
(Rourke & Finlayson, 1978). Rourke and Strang them the focus of more serious concern than had been
(1978) were specifically interested in the ability of the case. It is quite probable that they are not seen as
motor, psychomotor, and tactile-perceptual tests to in need of early help with their scholastic career be-
differentiate between the two groups, and they found cause they read and spell at normal levels. Also, it
that there were no significant differences evident on may be the case that specific deficiencies in arith-
the simple motor tasks. However, on more complex metic are thought by many to result from socioemo-
psychomotor measures as well as on a composite tional disturbances, genetic predispositions, or moti-
tactile-perceptual measure, the children in Group 3 vational shortcomings, which are not within the
exhibited marked impairment. Finally, there was evi- normal province of educational intervention and are
dence consistent with the view that Group 3 children often thought to "pass with time" (Rourke, 1978).
were suffering from the adverse effects of a relatively And this may very well be the case in some instances.
dysfunctional right cerebral hemisphere within the However, it is also clear that at least a subset of such
context of satisfactory left hemispheric functioning. children would appear to have a number of signifi-
Opposed to this was the evidence that Group 2 chil- cant brain-related deficiencies that can and should be
dren exhibited indications that would be consistent recognized and dealt with early in their academic
with the opposite pattern of hemispheric integrity. career.
A third study (Strang & Rourke, 1983) using the Strang and Rourke (1985) presented two princi-
same children from Groups 2 and 3 compared their ples that underlie the arithmetic difficulties of chil-
performance on the Halstead Category Test (Reitan dren who exhibit neuropsychological arithmetic dif-
& Davison, 1974). This investigation found that chil- ficulties similar to Group 3 children. First, it must be
dren in Group 3 made significantly more errors on the considered that mechanical arithmetic should be
test. Also, whereas the level of performance of the made as much a verbal task as possible. Second, the
Group 2 children was age appropriate on this nonver- teaching of such children must be highly systematic
bal problem-solving task, Group 3 children's perfor- and rather concrete, sometimes requiring physical
mance was approximately one standard deviation be- aids to illustrate mathematical concepts (for a more
low the mean. Specifically, these children had partic- detailed treatment of this issue, refer to Strang &
ular difficulty on the subtests requiring "high-order" Rourke, 1985).
visual-spatial analysis. The striking differences between the two groups
The overall consistency of these three studies that were equated for level of performance in arith-
(Rourke & Finlayson, 1978; Rourke & Strang, 1978; metic calculations (i.e., Groups 2 and 3) should also
Strang & Rourke, 1983) is striking. All three studies serve as a note of caution regarding the composition
indicated that learning-disabled children who are bet- of learning-disabled groups of children for study.
ter on the Arithmetic subtest of the WRAT compared Had subjects from Groups 2 and 3 been combined to
to the Reading and Spelling subtests (i.e., Group 2) form a group retarded in arithmetic for comparison
performed poorly on tests thought to tap abilities pri- with a normal control group or other learning-dis-
marily subserved by the left cerebral hemisphere. abled children, it is clear that the differences evident
Children whose only deficit appeared on the Arith- between these two groups would simply have been
metic subtest of the WRAT, with Reading and Spell- cancelled. The important conclusion that emerges
ing within normal limits (i.e., Group 3), did poorly from this type of analysis is that it is no longer accept-
on measures of abilities thought to be subserved pri- able within the field of development or learning dis-
marily by the right hemisphere. Rourke and his col- abilities to constitute groups of children for study
leagues have conducted qualitative analyses on the solely on the basis of their levels of performance on
performance of Group 3 children on the WRAT academic tasks. One must at least be prepared to
designate qualitatively distinct types of reading or ated with speech and reading in normal individuals as
arithmetic disabilities, if such exist, before launching measured by more invasive techniques such as so-
into a measurement of the supposed correlates of dium Amytal testing (Wada & Rasmussen, 1960) and
these problems. Failure to do so may not only pose regional cerebral blood flow (rCBF) (Lassen, lngvar,
severe and unnecessary limitations on the conclu- & Skinhoj, 1978).
sions that can be drawn from such studies, it may also Another electrophysiological procedure often
increase the probability that Qlatantly false "find- used to investigate the basis of learning disability has
ings" will be generated and propagated (Strang & been evoked potential (EP). This procedure has en-
Rourke, 1985). countered the same type of difficulties encountered
by the EEG studies, but the difficulties have similarly
6een somewhat ameliorated by the BEAM technique
(Duffy et al., 1979). Further refinement of this pro-
Electrophysiological Correlates of cedure has resulted in the finding that brain stem
Learning Disability evoked responses (BSER) appear to be a viable elec-
trophysiological procedure to assess learning dis-
A relatively new approach to the study of learnability (Obrzut, Wilson, Lord, & Caraveo, in press).
ing disabilities is from a neurobiological perspective, Until recently, auditory brain stem responses have
which supports the neuropsychological etiology of been evoked by the binaural presentation of a brief,
some childhood learning disorders (Gaddes, 1980, discrete sound stimulus and recording of the poly-
1981; Hynd & Cohen, 1983; Obrzut & Hynd, 1983; phasic change in the electrical activity of the brain
Geschwind & Galaburda, 1985). Electrophysiolog- stem during the first 10 msec following the stimulus.
ical and neuropathological evidence is accumulating These BSERs are thought to be the far-field reflection
that supports the existence of the clinical syndrome, of sequential electrical events at successively higher
"learning disability." Although this line of investi- levels of the brain stem auditory pathway.
gation is beginning to provide some gross differentia- Recent refinement in this approach involved
tion within this syndrome (i.e., language versus spa- presenting the auditory stimulus monaurally to the
tial difficulties), the research is unable at this time to left or right ear, and determining any asymmetry in
provide the fine distinctions found in the neuropsy- the BSER that occurs in response to the monaural
chological research. stimulus. To date only a few attempts to assess learn-
One of the current methods in this line of re- ing-disabled populations via this procedure have
search has focused on developing and refining elec- been made and these reveal a marked symmetry in
trophysiological procedures to investigate the basis neurologically normal persons and characteristic
of learning disabilities. Initial work in this area used asymmetry in a special population (stutterers)
EEG data as indices of cortical dysfunction. Major (Decker & Howe, 1981). The limited research in
difficulties encountered have been concerned with evoked responses in learning-disabled populations
the interpretation of the temporal and spatial rela- has focused upon abnormalities in laterality or asym-
tionship of vast arrays of electrode patterns in on- metry in the cerebral cortex. This rather gross ap-
going brain activity. To deal with this problem, proach has not yet provided any useful diagnostic
Duffy, Burchfield, and Lombroso (1979) developed taxonomy for the various subtypes of learning dis-
the brain electrical activity mapping (BEAM) tech- ability, including disabilities involving confusion in
nique, which can summarize, reduce, and visually the processing of auditory information.
display spectral, spatial, and temporal information of There are a number of other electrophysiolog-
brain activity from 20 different scalp locations. This ical techniques available for the study of the brain,
information is then statistically compared to a control e.g., computerized axial tomography (CAT), mag-
group (Torello & Duffy, 1985). netic resonance (MR) imaging, and positron emis-
The BEAM recording technique has demon- sion tomography (PET) scans. These tools may be
strated diagnostic utility within a well-defined popu- considered invasive because of the potential for ex-
lation of dyslexics, finding that dyslexia is a neu- posure to radiation. In addition, these techniques re-
rophysiological problem with topographically quire that a state-dependent condition (e.g., same
specific brain areas of dysfunction (Duffy, Denckla, state cognitive task) exist for approximately 30 min
Bartels, & Sandini, 1980). Discrete brain areas were to provide time for the radioactively labeled glucose
identified in the "pure" dyslexic subjects as being compound to enter the metabolically activated cells
significantly different from the age-matched control for detection by the sensors (Torello & Duffy, 1985).
subjects. These areas have been classically associ- For these reasons, the research focusing on learning
140 CHAPTER 7
disabilities has not used these methods. As can be language and right dominance for spatial processing
imagined, it would be difficult to justify the use of is somehow arrested in the dyslexic, resulting in in-
these invasive methods with a normal population, as creased symmetry. Further. there has been a connec-
well as children with difficulties discernible by less tion between learning disabilities and non-right-
dangerous methods. handedness (Geshwind & Behan, 1982). But as the
Although the emphasis of the electrophysiolog- authors noted, the findings in these studies do not
ical research has been on differentiating normal imply that non-right-handedness causes learning dis-
learners from disabled learners, other research has abilities. Rather, non-right-handedness is simply a
focused upon studying the developmental process of marker of an alteration in dominance. Geschwind
the brain. Specifically, it has been found that investi- and Galaburda (1985) further stated that there is a
gation into the asymmetrical development of the strong genetic component associated with learning
brain may lead to new hypotheses concerning the disabilities, which is sex-limited (a gene is expressed
etiology of learning disabilities (Geschwind & Ga- less often in one sex). They proposed that learning
laburda, 1985). disorders are more common in males because of
In their recent review, Geschwind and Galabur- some male-related factor in development, possibly
da ( 1985) presented evidence for the following: ( 1) testosterone (e.g., Dorner, 1980; Gorski, Harlan, &
anatomic asymmetry of the brain; (2) asymmetry of Jacobson, 1980; Pfaff, 1966; MacLusky & Naftolin,
the fetal brain; (3) male-female differences in the 1981; McEwen, 1981; Raisman & Field, 1973).
brain; (4) laterality in developmental disorders; (5) When one considers the consequences of these spec-
abnormal cytoarchitecture in childhood dyslexia; (6) ulations, it would appear that learning disorders may
patterns of maturation of the brain; (7) cell death in not be preventable, making the need for greater un-
the developing brain; (8) reorganization of the brain derstanding of the etiology as it pertains to remedia-
after intrauterine lesions; (9) hormonal influences on tion even more important.
brain structures; (10) genetic studies of handedness;
(11) chemical asymmetry of the brain; (12) evolution
of asymmetry; (13) associations of left-handedness;
and (14) relationships of laterality to special talents. Attention Deficit Disorder (ADD)
As can be seen from this list, the review by Ge-
schwind and Galaburda (1985) was quite comprehen- Within the neuropsychological literature, ADD
sive. It is not our intention to attempt a summary of is considered the major behavioral disorder in child-
the fmdings; our discussion will be limited to those hood (Goldman, Thibert, & Rourke, 1979). The
findings dealing directly with developmental disor- DSM-lll includes under ADD the childhood disor-
ders and childhood dyslexia. The interested reader is ders that have previously been labeled hyperactivity,
referred to the original article for greater detail. hyperkinesis, minimal brain dysfunction, minimal
Geschwind and Galaburda ( 1985) postulated brain damage, minimal cerebral dysfunction, and
that the brain abnormalities in dyslexia are develop- minor cerebral dysfunction. The clinical signs of
mental in nature and can be attributed to alterations in ADD are developmentally inappropriate inattention,
the cortex and connectionally related subcortical excessive overactivity, and impulsivity. The DSM-
structures resulting from disturbances in neuronal 111 identifies two subtypes of ADD, one with and one
migration and assembly. Further, they stated it is without hyperactivity. The DSM-lll also provides a
likely that in some individuals the postulated slowing third category that reflects the findings that in most
of the rate of migration ofneurons to the left cortex is cases, hyperactivity decreases markedly or disap-
even more marked than in the normal state; this ex- pears after pubescence without a comparable reduc-
cessive delay can lead to lateralized developmental tion in either inattention or impulsivity (ADD, Re-
arrest and malformation, thus leading to childhood sidual Type).
dyslexia and possibly to other developmental disor- The cause of ADD may be brain damage, psy-
ders. This hypothesis is based on the case studies of chosocial frustrations, or a mixture of the two (Pir-
five patients (Drake, 1968; Galaburda, 1983; Ga- ozzola & Campanella, 1981). Although the scope of
laburda & Eidelberg, 1982; Galaburda & Kemper, neuropsychology includes differential diagnoses be~
1979). tween the different causes, the major contribution of
As can be seen, the emphasis of this type of neuropsychology probably lies in its ability to ex-
research is finding the neurological basis for learning plain the disorder in terms of brain-behavior rela-
disabilities. At this time, it appears that the normal tionships. In order to do this, both the developmental
asymmetrical development with left dominance for processes of the brain and the differences between the
fully mature brain (adult) and the maturing brain this disorder, hyperactivity, has received a great deal
(child) must be considered. of scientific attention. It has been hypothesized that
hyperactivity may result from two separate mecha-
nisms (Satterfield, Cantwell, & Satterfield, 1974). In
Developmental Processes the frrst, the child is "underaroused," which implies
that the reticular system is not producing sufficient
Gontrary to a notion once widely held, the brain cortical arousal or is not allowing enough stimuli
is not fully developed at birth (Boll & Barth, 1981). through to maintain cortical arousal. This induces a
In fact, research now supports the model of a devel- state of "sensory deprivation," a situation that is
opmental process that begins at conception and may highly aversive if prolonged. In response, the child
end as early as 12-15 years of age or as late as the will attempt to generate additional input and arousal
mid-20s. Therefore, neuropsychological evaluation in the only manner available, generally motor move-
needs to identify not only what skills should be pre- ments, including vocalizations. The opposite of the
sent at what age, but also at what ages what skills are underaroused child is the overaroused child. In this
appropriately or pathologically absent. Further, the case, the difficulty appears to be in the ftltering sys-
brain does not mature in a vacuum, but is the result of tem, which fails to screen stimuli, thereby flooding
its interaction with the child's environment. At pre- the cortex with an excess of information. The child
sent, no one-to-one relationship has been established becomes stimulus bound, unable to focus on any one
between periods of physical growth in the brain and thing. However, the behavior is very similar to the
psychological maturation (Golden, 1981). Although underaroused child in that this child is unable to sit
this may appear to make generalizations about the quietly for any length of time, which also increases
relationship between children's behavior and their the activity level of the child.
brain integrity extremely difficult, by combining a Drug studies have provided evidence supporting
developmental model with a theory of how the sys- this hypothesis of two separate forms of hyperac-
tems within the brain function, the neuropsychologist tivity. It has been found that approximately 70% of
can successfully diagnose behavior disorders such as children displaying hyperactive behavior respond
ADD and hypothesize the neurological causes. positively to stimulant medication, and 30% either
One well-formulated theory of how the develop- show little improvement or actually become worse
ing brain forms higher mental processes has been (Knights& Viets, 1975; Satterfield eta/., 1974). The
proposed by Luria (1964). He conceptualized the explanation offered for these results is that hyperac-
brain as composed of three complex functional sys- tive children who respond best to stimulant medica-
tems, and that the brain's functions "may suffer as a tion are those who have low CNS arousal levels be-
result of the destruction of any link which is a part of fore treatment. Satterfield et al. (1974) hypothesized
the structure of a complex functional system" (p. that associated with low CNS arousal levels there is
11). A brief description of Luria's theory will provide insufficient CNS inhibitory control over motor func-
an understanding of how injury to the brain, and in tion and that CNS arousal and inhibition vary to-
particular to the reticular activating system (RAS), gether. Consistent with this, it was found that the
may produce the diverse syndrome now classified as children who responded well to stimulant medication
ADD. had the greatest amount of restlessness as reported by
Luria (1964) conceptualized the functional sys- school teachers and had excessive movement-gener-
tems of the brain as consisting of three units. The first ated EEG artifacts in the laboratory. Satterfield et al.
unit is designated the arousal unit, which consists of (1974) cited animal neurophysiological studies in
those parts of the brain identified as the RAS. This which stimulation effects at the reticular formation
system is a collection of diffuse intertwined struc- both increased cortical arousal and enhanced the inhi-
tures that act to raise or lower cortical arousal as well bition of sensory signals at synapses in the sensory
as filtering sensory input, especially from those pathways. All of this appears to indicate that a major-
senses that are always "on" (tactile/kinesthetic and ity of children manifest hyperactive behavior due to
auditory). This prevents the cortex from being low CNS arousal and insufficient inhibitory control
flooded with constant, irrelevant stimuli, which can over motor outflow and sensory input due to RAS
interfere with cognitive processing. It is now consid- dysfunction. The remaining children may already be
ered that the arousal unit is the most -important ele- overaroused, which explains the ineffectiveness of
ment in the development of normal attention. stimulant drug treatment, and is also related to a
Injury to the RAS during the prenatal or per- problem in the RAS.
inatal period may result in ADD. One symptom of The second unit discussed by Luria is the most
142 CHAPTER 7
widely and frequently researched area of the brain skills, usually through the loss of the ability to effec-
(Reynolds, 1981). This unit is responsible for most tively integrate across two or three sensory modal-
early learning skills as well as higher-order cognitive ities.
information processing. According to Luria's con- Luria postulated that "the third block of the
ceptualization, the second unit is subdivided into brain, comprising the frontal lobes is involved in the
three types of areas: primary, secondary, and terti- formation of intentions and programs for behavior''
ary. The primary areas act as sensory reception (1970, p. 68). This unit, which is labeled the out-
areas-input is received on a general "point-to- put/planning unit, is also conceptualized as consist-
point" basis from the appropriate sensory area. ing of primary, secondary, and tertiary areas. The
There are three primary areas, each devoted to a spe- primary area of this unit is the motor output area of
cific sense. The primary auditory area is in the tem- the brain. Signals are sent from this area, through the
poral lobe; the primary visual area is in the occipital motor tracts of the brain, to the specific muscles
lobe; and the primary tactile/kinesthetic area is in the needed to perform any given behavior. The second-
parietal lobe. ary area is responsible for organizing the sequence of
The secondary areas analyze and integrate the motor acts. The tertiary area of the output/planning
information from the primary areas. It is thought that unit represents the highest level of development and
the secondary areas of the sensory input unit process is, in many ways, dramatically different from the
information sequentially, which allows the brain to primary and secondary areas in terms of functions.
be aware of stimulus change and to link events tem- The tasks of the tertiary area are planning, decision-
porally. Also, there is more specialization in the role making, evaluation, temporal continuity, impulse
of the hemispheres at the secondary level. For most and emotional control, focusing of attention, and
individuals, the left hemisphere predominates in the cognitive flexibility. As the frontal lobes develop,
analysis of verbal material, and the right hemisphere they assume dominance over the arousal unit of the
predominates in the analysis of nonverbal material. brain. Thus, at about puberty, many symptoms of
However, this is also a developmental process and reticular system dysfunction may disappear as the
careful consideration of the skills required of the tertiary areas achieve behavioral dominance. This
functional system must be recognized. For example, provides an explanation for the clinical observation
the earliest stages of reading require the recognition that hyperactivity associated with ADD often disap-
of unfamiliar shapes, a task that is primarily done in pears at or around puberty.
the right hemisphere. However, once the letter is Injuries to the frontal lobes prior to adolescence
learned, it becomes a verbal symbol primarily de- are virtually impossible to detect behaviorally. Chil-
tected by the left hemisphere (Golden, 1981). dren may show "symptoms" associated with frontal
The tertiary level of the sensory input unit, lo- lobe dysfunction (e.g., irritability, hyperemo-
cated primarily in and around the parietal lobe, is tionality, impulsiveness, rage), but these are usually
responsible for cross-modality integration. This area the result of injury to the arousal unit during the
plays a primary role in many of the tasks commonly neonatal period or the limbic system thereafter. Such
subsumed under "intelligence." For example, au- symptoms may or may not improve when frontal lobe
ditory-visual integration is necessary for reading, development occurs depending upon the integrity of
whereas auditory-tactile integration is necessary for the frontal lobes themselves. Therefore, prediction of
writing. Arithmetic, as well as body location in space adolescent hyperactivity based on early childhood
and visual-spatial skills, depends upon visual-tac- behavior is very difficult without definite neu-
tile integration. Further hemispheric differentiation ropathological information. For that matter, even the
of tasks also occurs at this level. The left hemisphere absence of ADD in childhood, implying an intact
is responsible for grammar, syntax, and other lan- RAS, does not necessarily preclude the possibility of
guage-related skills, as well as the understanding of behavioral difficulties in adolescence if some form of
arithmetic symbols and processes. The right hemi- insult has occurred.
sphere is responsible for the visual-spatial rela- In general, although the concept that attentional
tionship of parts, the spatial nature of arithmetic difficulties may interfere with cognitive processes
(e.g., "borrowing" or "carrying over"), verbal- has been recognized for several decades, it is only
spatial skills, facial recognition, recognition of emo- within the last 10-15 years that ADD has been differ-
tional (nonverbal) facial and postural reactions, and entiated from learning disabilities. This new perspec-
analysis of unusual or unknown pictures. Injuries to tive seems to be a direct result of the advances within
the tertiary area, depending on location and severity, neuropsychological research. Not only has neuropsy-
can lead to loss or impairment of any of the above chology provided the tools for differential diagnosis
of specific learning disabilities and attentional defi- Burgher, P., & Rourke, B. P. (1976). A comparison of the phonet-
cits, but it has also provided the means to differenti- ic accuracy of spelling errors of normal and retarded read-
ate the causes of these disabilities (environmental ers; A four year follow-up. Unpublished study, University of
versus physiological). This then allows for both valid Windsor.
prediction of behavior based upon brain integrity and Decker, T. N., & Howe, S. W. (1981). Auditory tract asymmetry
in brain stem electrical responses during binaural stimulation.
appropriate intervention procedures.
Journal of the Acoustical Society of America, 69, 1084-
1090.
Denckla, M. B. (1979). Childhood learning disabilities. In K.
Conclusions Heilman & E. Valenstein (Eds.), Clinical neuropsychology.
New York: Oxford University Press.
Doehring, D. G. (1968). Patterns of impairment in specific read-
At this time it seems that there is enough mount-
ing disability. Bloomington: Indiana University Press.
ing evidence to support the neuropsychological basis Doehring, D. G., & Hoschko, I. (1977). Classification of reading
of learning disability. As the most recent research has problems by the Q-technique offactor analysis. Cortex, 13,
found, this can no longer be considered a homoge- 281-294.
neous entity, but must be regarded as a category com- Doehring, D. G., & Reitan, R. M. (1962). Concept attainment of
prised of various deficits and etiologies. Therefore, human adults with lateralized cerebral lesions. Perceptual
the area of remediation needs to recognize these dif- Motor Skills, 14, 27-33.
ferences and provide appropriate approaches. At this Dorner, G. (1980). Sexual differentiation of the brain. Vitamins
time, research has just begun to address this need. Of and Hormones, 381, 325-385.
particular concern should be the question of how the Drake, W. E. (1968). Clinical and pathological findings in a child
with a developmental learning disability. Journal ofLearning
field of neuropsychology can make this emerging
Disability, I, 9-25.
information available to educators and clinicians so Duffy, F. H., Burchfield, J. L., & Lombroso, C. T. (1979). Brain
that appropriate interventions are provided for the electrical activity mapping (BEAM): A method for extending
learning-disabled child. the clinical utility of EEG and evoked potential data. Annals
of Neurology, 5, 309-321.
Duffy, F. H., Denckla, M. B., Bartels, P. H., & Sandini, G.
(1980). Dyslexia: Regional differences in brain electrical ac-
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8
Measurement and Statistical Problems

in Neuropsychological Assessment of
Children
CECIL R. REYNOLDS
The field of neuropsychology as practiced clinically impromptu, bedside examination and discussions
has been driven in large part by the development and with soldiers with head injury; Sperry and his stu-
application of standardized diagnostic procedures dents followed and observed a series of ''split-brain''
that are more sensitive than medical examinations to patients going about their daily activities, even to the
changes in behavior, in particular higher cognitive point of observing some as they dressed themselves
processes, as related to brain function. The tech- and while engaged in leisure activities with others.
niques and methods so derived have led to major Major advances have occurred because of the
conceptual and theoretical advances in the under- sheer clinical acumen of these individuals. Many
standing of normal and abnormal patterns of brain- clinical neuropsychologists continue to evaluate pa-
behavior relationships. Despite the apparent utility of tients quite profitably on the basis of observation and
many of the neuropsychological tests discussed in informal assessment. Others have devoted them-
this volume, their psychometric properties leave selves to more purely actuarial approaches to clinical
much to be desired. Much of their utility comes from work and research (e.g., Reitan, Rourke, and Satz).
the clinical acumen and experience of their users and Most clinicians engage the complementarity of the
developers, a situation that has, historically, made two approaches, a modus operandi that has made
clinical neuropsychology more difficult to teach than neuropsychologists more and more accepted and
should be the case. In fact, much oftoday's practice contributing members to medical staff in teaching
and yesterday's theoretical advances in clinical neu- hospitals and clinics. Clearly, clinical neuropsychol-
ropsychology stem from intense and insightful obser- ogy has been successful in earning its riches in medi-
vation of brain-damaged individuals by such astute cine and in psychology largely due to the combina-
observers as Ward Halstead, A. R. Luria, Hans Teu- tion of empirical research and clinical acumen in the
ber, Karl Pribram, Roger Sperry, and others. These field. Neuropsychological techniques have infil-
superstars of clinical neuropsychology were state-of- trated assessment in special and remedial education
the-art researchers (though the state-of-the-art was as well (e.g., Hynd, 1981).
often crude) to be sure, but their greatest inspirations At the same time, many of the practices in neu-
came from their constant monitoring and informal ropsychology, clinical and research, have been crit-
interactions with the behavior of persons suffering icized extensively from inside (e.g., Parsons & Pri-
from a variety of neurological trauma and disease. gatano, 1978; Reynolds, 1982; Willson & Reynolds,
Halstead roamed the halls of Otho S. S. Sprague 1982) and outside the discipl!ne (e.g., Coles, 1978;
making notes as he observed behavior among brain- Sandoval, 1981) for a lack of attention to certain
damaged individuals; Luria gained great insights into principles of research design in the field and the
brain function with his rather informal, sometimes failure to incorporate the many advances in psycho-
metric methods of the past 25 years. To be sure, our
research methods and statistical tools have improved
CECIL R. REYNOLDS Department of Educational Psy- greatly since Halstead's early work; yet our ability
chology, Texas A&M University, College Station, Texas 77843. (or our inclination) to apply them uniformly or to our
147
148 CHAPTER 8
best advantage certainly has not kept pace with the around measurement problems evident in the neuro-
growth in our clinical acumen and with theoretical psychological literature, the resolution of which
advances in the field. Neuropsychologists have could enhance progress in research and practice in the
shown an increasing interest in the educational prob- field. The solutions are neither novel nor unknown
lems of children categorized as learning disabled as nor are the problems restricted to neuropsychology.
well, bringing neuropsychological methods to bear A number of difficulties in present practice are appar-
on the recurring questions of neuropsychological ently the result of either a lack of psychometric so-
dysfunction within this population. Clinical neuro- phistication among those in the field, an ignoring of
psychological assessment of educational disorders certain well-known measurement principles, or some
such as learning disability offers a prime opportunity combination of these two reasons. The following dis-
to meld theory and clinical acumen with good psy- cussion will present several examples of what may be
chometric practice, but has not, apparently, come seen as a lack of sophistication in or attention to
about. measurement issues in neuropsychology and propose
The failure to reach this coalescence in clinical alternative procedures. Rather than employ a single
neuropsychology has serious implications for the battery or procedure as an example throughout, a
credibility and, ultimately perhaps, the survival of variety were chosen to illustrate the widespread
the clinical application of neuropsychological princi- nature of the problem and not to appear to be ''pick-
ples in medical and educational settings. Perhaps it is ing on" any specific application. A series of statis-
because of the youth of the field or its placement tical issues related to diagnostic research problems is
primarily in the medical setting, where good research next presented along with recommendations for im-
design and statistical methods have only recently proving this line of research as well.
been discovered, that has retarded coalescence. Lest this work appear too negative, it is worth
Problems of statistical methods and design in noting that neuropsychology has emerged as a major
test development in clinical neuropsychology have field within psychology and that the procedures cri-
been noted with increasing frequency (e.g., Reyn- tiqued herein have been and remain useful in clinical
olds, 1982, 1986). In reviewing the Halstead-Reitan and research domains. The clinical acumen, insight,
Neuropsychological Test Battery (HRNB), Dean and dedication of the practitioners who use these
(1985) remarked that the "manual for the HRNB scales are considerable and are not being questioned.
lacks the basic psychometric documentation needed Indeed, they have moved the field substantially in
in interpretation. Moreover, interpretations are more many ways. Nevertheless, the fact remains that our
dependent on the psychologist's knowledge and methods and techniques could be better-by follow-
clinical acumen than reported psychometric proper- ing some well-known, widely accepted methods.
ties for the battery'' (p. 645). The other major battery
in the discipline, the Luria-Nebraska Neuropsycho-
logical Battery (LNNB), fares no better; as Adams
(1985) remarked, "the methodological errors com- Normative Data and Standardization
mitted in the construction of the test [the LNNB] are Samples
both numerous and substantive" (p. 879). Other
scales in common use by clinicians are equally The systematic development and presentation of
guilty. The normative data for the Benton Test of normative data has received far too little attention in
Facial Recognition, Mirsky's Continuous Perfor- neuropsychology. Perhaps this is due to the rather
mance Test, Purdue Pegboard Test, the Wide Range tedious, mundane nature of such tasks, but, nev-
Achievement Test, and numerous other measures ertheless, the lack of good normative data in neuro-
used in neuropsychological testing are far below con- psychology is a distinct handicap to the field. Cer-
temporary standards. It is a monument to the clinical tainly one encounters reports of "normative data" in
acumen and tenacity of clinical neuropsychologists, the professional literature. However, these reports
and perhaps also the insensitivity of many medical either are typically based on very small samples
practitioners to behavioral changes, that the field has (some even as small asN = 10 at yearly age intervals)
survived and in fact prospered over the last 50 years. or do not employ normal individuals. Too much of
The issues to be delineated in the following our neuropsychological data are based on impaired
pages deal primarily with pragmatic concerns that individuals; we do not know enough about how nor-
affect the clinical practice of neuropsychology in pa- mal individuals respond to most neuropsychological
tient care certainly, but also the study of brain-be- tests. The latter issue is more serious clinically than
havior relationships. These issues principally revolve most clinicians realize because in addition to the
NEUROPSYCHOLOGICAL ASSESSMENT OF CHILDREN 149
other problems it creates, it results in a lack of items {Kaufman & Kaufman, 1983) is an excellent model
with sufficient difficulty for assessment of premor- of the development of normative data. Good standar-
bidly high functioning individuals with less than dization samples provide a reliable standard against
massive neurological trauma. Most of the children which to judge the performance of others and have
with premorbid IQs or I 30 or more who suffer gener- additional benefits including at least the following:
al cerebral trauma but lose only 20 to 25 IQ points or {1) communications between researchers, {2) train-
less can easily go undetected in neuropsychological ing of clinical neuropsychologists, and (3) the defla-
testing, i.e., they can appear normal and go untreated tion and exposure of a variety of clinical myths. After
or even lose existing services once these levels have a brief discussion of the first two of these benefits, I
been reached in the case of initial massive trauma. will tum to a more extensive presentation of the
Without adequate normative data drawn from "myth deflation advantage."
large-scale samplings of the population, the clinician Communication among researchers is a difficult
and the researcher are also unable to assess the effects and expensive task but a necessary one; indeed, it is
of demographic variables such as race or ethnicity, in communication among us that the foundation of
gender, and socioeconomic status on neuropsycho- the "community of scholars" must lie. It would cer-
logical test performance. Demographic variables do tainly enhance the clarity of research communica-
have a significant influence on test performance on tions in the field if a good normative reference sample
any number of tasks. Often, neuropsychologists ig- were available against which research samples could
nore such factors during test interpretation or believe be contrasted {provided other appropriate demo-
that because brain function is being evaluated, demographic variables were adequately controlled). The
graphic variables may be irrelevant. Systematic ef- development of scaled scores for neuropsychological
fects of many demographic variables have been noted tests based on such a sample would simplify matters
on numerous tasks as illustrated by even simple tasks as well. The issue of training also is ultimately one of
like Coding and Digit Symbol (some of the most communication. The presence of normative data
sensitive of all the Wechsler tasks to neurological would make learning easier. Although the accuracy
trauma) from the Wechsler Scales where females of the statement is not known, it has often been said
(both black and white) consistently outscore males. that when asked about how to become a good clinical
Whether using a level of performance or an ipsative neuropsychologist, Ralph Reitan replied, "Work in
profile analysis, ignorance of such robust findings the field for 30 years.'' Although this would probably
could mislead the clinician. Very little research has work, much of this time would be spent in developing
considered the influence of demographic variables on a set of "clinical norms" in one's own mind about
more strictly neuropsychological test results and how normal and various groups of impaired indi-
some of the primary books in the field do not discuss viduals perform on such tests as the HRNB. This is
the issue or its relationship to diagnosis (e.g., Gold- necessary because of the lack of a standardization
en, 1981). For such tests as the Wechsler scales, the sample for such scales as the HRNB and the Bader
major studies of demographic influence on scores Test of Reading-Spelling Patterns (a scale clearly
have occurred as a function of research involving the intended to assess developmental phenomena), and
standardization samples of these instruments (see the less than adequate sample for such popular scales
Reynolds & K~tufman, 1986, for a review). The as the LNNB. The transmission of the knowledge and
failure to provide good, stratified samples in the de- the clinical skills of neuropsychology could be great-
velopment and standardization of neuropsycholog- ly enhanced by the presence of accurate, high-quality
ical tests has been a major inhibiting factor in efforts normative data.
to understand demographic influences. Norms also have the advantage of allowing us to
Other writers have reached similar conclusions. evaluate certain aspects of the "clinical mythology"
The manual for the HRNB contains no standardiza- of assessment. For some time, statistically signifi-
tion or normative data, yet age and other demograph- cant Verbal-Performance IQ differences on the
ic variables are correlated with the test results. This Wechsler Scales were believed {and, unfortunately,
greatly complicates test interpretation for individuals still are by many) to be indicative of brain damage,
(Dean, 1985). neurological dysfunction, or almost certainly a learn-
By good normative data, reference is made to ing disability if a child were involved. From the stan-
the application of stratified, random sampling tech- dardization sample of the WISC-R, Kaufman
niques now common, and applied to such tests as the ( 1976a) developed normative data for the frequency
WISC-R, the McCarthy Scales, and the K-ABC. In- of occurrence of these differences. Prior to reporting
deed, the recent standardization of the K-ABC these data, he took an infonnal poll of clinicians
150 CHAPTER 8
asking what they believed, on the basis of their Piotrowski, 1978; Reynolds, 1979a; Reynolds,
clinical experience, the typical Verbal-Performance Hartlage, & Haak, 1980), the range of subtest scores,
IQ difference would be for normal children. The re- i.e., highest minus lowest subtest score (Kaufman,
sponse indicated a belief that other than small dif- 1976b; Tabachnick, 1979), and the "number of de-
ferences were considered unusual. A 3- or 4-point viant signs" or number of subtests deviating signifi-
difference was the typical response. Differences of cantly from the mean of all subtests (Kaufman,
15 points have long been thought to be clinically 1976b). Range of subtest scores in particular has at-
significant and have been used (e.g., Dean, 1978) to tracted substantial attention as a potential technique
document the presence of a learning disability. with which normals and different pathological
Actual analyses of the frequency of occurrence groups could be distinguished. Although some prior
of Verbal-Performance differences by Kaufman research has found statistically significant dif-
(l976a) with the 2200 normally functioning children ferences between diagnostic groups on this scatter
in the WlSC-R standardization sample revealed a index, other studies, such as Thompson (1980), have
very different picture. The average difference was not. Even in those studies where significant dif-
more than 9 points, with 12-point differences (the ferences in Wechsler subtest scatter have been found
difference required for significance at p = 0.05) oc- across groups of normal, brain-damaged, emo-
curring with one of three children, and 15-point dif- tionally disturbed, and other categories of child psy-
ferences (p = .01) occurring with one of four chil- chopathology, the small actual differences and re-
dren. This should not have been surprising as this is sulting substantial overlap of distributions have
essentially the same distribution of difference scores made scatter indexes such as the range of little diag-
that was reported 20 years earlier for the WISC, but nostic utility. As such results become more widely
that had gone largely ignored until Kaufman pub- known, the search for more sensitive, sophisti-
lished his analyses of the WISC-R standardization cated indexes of scatter has broadened and statis-
sample. Note that the availability of a proper standar- tics such as the profile variance technique (Plake,
dization sample made the investigation possible Reynolds, & Gutkin, 1981) have been devel-
at all. oped.
This again points to the need to develop good Selz and Reitan ( 1979) presented another
normative data from which to evaluate one's clinical Wechsler scatter index that seemed to facilitate the
insights. Below is given an example of another re- accurate diagnosis of neurological dysfunction when
cently developed index of neurological dysfunction combined with other perceptual and neurological
that was not normed until very recently, as an exam- tests. Specifically, scatter was calculated by subtract-
ple of how one goes about developing and reporting ing the lowest subtest score from the highest subtest
such data. score and dividing the result by the mean of all sub-
tests (i.e., it is calculated as the range/mean). Selz
and Reitan reported three levels of diagnostic criteria
in their study. A scatter index calculated with this
Gutkin and Reynolds' (1980) technique that equaled or exceeded 1.0 was taken as
Norming of the Selz and Reitan Index a mild indication of neurological dysfunction. A
of Neurological Dysfunction scatter index that equaled 1.4 was interpreted as
being consistent with the existence of a ''probable''
During the last several decades, hundreds of neurological problem. A scatter index equaling or
attempts have been made to develop diagnostically exceeding 1.76 (rounded to 1.8 for the Gutkin &
useful patterns based upon Wechsler subtest scores Reynolds, 1980, study) was viewed as part of a
(Matarazzo, 1972). In general, these attempts have symptom complex indicating definite neurological
not been successful (Kaufman, 1979; Sattler, 1974). impairment.
A variety of scatter indexes have been developed and One of the most common shortcomings in the
investigated as potentially useful diagnostic indica- Wechsler scatter pattern body of research has been
tors for exceptionality. The Wechsler scales, andes- the failure of investigators to validate the abnormality
pecially the Wechsler Intelligence Scale for Chil- of various diagnostic indicants with a normal popula-
dren-Revised (WISC-R) (Wechsler, 1974), have tion. Often, seemingly abnormal levels of subtest
been extensively investigated with regard to utility of scatter have been found to be quite common among
scatter indexes in diagnosis. Scatter indexes from the normal individuals (Field, 1959; Kaufman, 1976a,b;
WISC-R that have been investigated include Verbal- Reynolds, 1979a) prompting the Gutkin and Rey-
Performance IQ discrepancies (Kaufman, 1976a; nolds (1980) study.
The subjects for their investigation were the TABLE 1. Means and Standard
white (N = 1868) and black (N = 305) children from Deviations for Scatter Index Using
the WISC-R standardization sample of 2200 chil- 10 Subtests
dren. The characteristics of these children are de-
scribed in great detail elsewhere (Wechsler, 1974). It FSIO Whites Blacks Totals
is noteworthy, however, that these groups accurately
reflect the 1980 United States census and are thus <8.5
Mean 0.98 1.01 0.99
excellent, nationally representative samples of nor-
S.D. 0.36 0.38 0.37
mal white and black children. The sample of 2200
85-115
was chosen to be a stratified random sample of chil- Mean 0.64 0.70 0.65
dren of the United States with sample stratification S.D. 0.23 0.23 0.23
occurring by age (20 at each year between 6! and >115
16}), race, sex, geographic region of residence in the Mean 0.51 0.62 0.51
United States, urban versus rural residence, and so- S.D. 0.16 0.20 0.16
cioeconomic status (as determined by occupation of Totals
the head of household). Mean 0.65 0.84 0.68
As per the procedure separately described by S.D. 0.27 0.35 0.29
Selz and Reitan (1979), a scatter index was calcu-
lated for each subject by subtracting his/her lowest
subtest score from his/her highest subtest score and never differed from each other by more than 0.04,
dividing the result by his/her mean subtest score. subsequent data analyses were broken out only ac-
This calculation was performed for both the 10 regu- cording to subject race and FSIQ. Means, standard
larly administered subtests and the 12 total subtests deviations, and the percentage of subjects equaling or
comprising the WISC-R. A series of one-way exceeding each Selz and Reitan (1979) diagnostic
ANOV As was calculated to determine if subtest scat- criterion as found by Gutkin and Reynolds ( 1980) are
ter varied as a function of the demographic and intel- represented according to subject race and FSIQ cate-
lectual characteristics of subjects, for the stratifica- gory in Tables 1-5.
tion variables are known to be differentially related to As indicated by the data analysis, the utility of
overall performance on the various IQ scales (Reyn- the Selz and Reitan (1979) scatter index varies with
olds & Gutkin, 1979). Socioeconomic status is typ- the level of criteria employed and the characteristics
ically related to level of performance on cognitive of the subjects examined. The most stringent criteri-
tests, whereas race has its greatest impact on pattern on (i.e., scatter index equal to or greater than 1.8)
of performance (Reynolds, 1981a). Specifically, appears to set a standard that is almost ~ever reached
subjects were grouped according to age (less than 10, in the normal population except for 2-5% of the
10-12, greater than 12), sex (male, female), race subjects in the lowest IQ group.
(white, black), place of residence (urban or rural),
and Full-Scale IQ (FSIQ) (less than 85, 85-115, and
greater than ll5). Because Kaufman (1976b) found TABLE 2. Means and Standard
significant differences in Verbal-Performance IQ Deviations for Scatter Index Using
scatter as a function of FSIQ, one-way ANOVAs 12 Subtests
yielding significant results were further examined
with a covariance analysis with FSIQ serving as the FSIO Whites Blacks Totals
covariate. Demographic variables that yielded signif-
icant results with covariance analysis were used to <85
Mean 1.07 1.10 1.09
segregate the study's data.
S.D. 0.35 0.37 0.35
Analysis of variance on the dimensions of place 85-115
of residence, sex, FSIQ, occupation of the head of Mean 0.71 0.78 0.72
household, age, and race revealed significant dif- S.D. 0.23 0.22 0.23
ferences for the latter four variables. Using the FSIQ >115
as a covariate resulted in nonsignificant differences Mean 0.58 0.70 0.58
for occupation of the head of household, but statis- S.D. 0.17 0.14 0.17
tically significant differences remained for the di- Totals
mensions of age and race. Because further examina- Mean 0.72 0.93 0.76
tion revealed that the means at the different age levels S.D. 0.27 0.34 0.29
152 CHAPTER 8
TABLE 3. Percentage of Subjects TABLE 5. Percentage of Subjects

Equaling or Exceeding Scatter Equaling or Exceeding Scatter
Index of 1.0 Index of 1.8
10 subtests 12 subtests 10 subtests 12 subtests
FSIO Whites Blacks Whites Blacks FSIO Whites Blacks Whites Blacks
<85 49 55 62 64 <85 4 3 2 5
85-115 9 15 14 21 85-115 0 0 0 0
>115 0 0 2 0 >115 0 0 0 0
Using the second most stringent criterion (i.e., evidenced on the Selz and Reitan index between
scatter index equals or exceeds 1.4) also yields satis- blacks and whites, with the former group consistently
factory results with all but the lowest IQ group. As showing higher index scores (see Tables 1 and 2)
with the highest criterion, normal subjects with IQs across the entire IQ range. Even smaller, but statis-
of 85 and above virtually never equal or exceed the tically significant, differences were found as a func-
Selz and Reitan index of 1.4. It is noteworthy, how- tion of the children's age. No consistent pattern
ever, that both black and white subjects in the lowest emerged in regard to this variable, although the youn-
IQ group do exceed the 1.4 criterion at a rate that calls gest group most often evidenced the highest Selz and
into question the validity of this index for this particu- Reitan index scores.
lar group, unless one assumes a rather high incidence However, the overall data from the Gutkin and
of neurological impairment in children with IQs be- Reynolds ( 1980) study indicate that the utility of the
low 85, even though most of these children were Selz and Reitan index varies substantially according
functioning normally. to subject characteristics, especially FSIQ. As point-
The most lenient of the Selz and Reitan criteria ed out by Selz and Reitan, their scatter index is in
(i.e., scatter index equals or exceeds 1.0) appears to need of cross-validation with other samples before
completely lack validity with the lowest IQ group. the clinician can use it with confidence. The presen-
Depending upon whether one uses 10 or 12 subtests tation of normative data in the detail presented here
and whether the subjects were white or black, be- will be necessary for such batteries as the HRNB and
tween 49 and 64% of the sample exceeded the 1.0 LNNB if we are to advance not only the study of
cutoff. Clearly, the use of this standard with this brain-behavior relationships in the normally func-
group of normal children would lead to an unaccept- tioning human brain but the clinical acumen of the
able number of false-positives. The middle IQ group neuropsychologist as well.
also meets or exceed the 1.0 criteria in numbers that Designing and conducting a normative study on
call the validity of the index into serious question. such a large scale as to be useful is time-consuming
Only with the highest IQ group was the 1.0 standard and quite expensive. Few and far between are the
sufficiently infrequent. times when money is available for the wholesale as-
Although the differences are not highly pro- sessment of normally functioning individuals. Neu-
nounced, statistically significant differences were ropsychologists must move actively to seek federal
funding for normative studies, and test publishing
houses must become convinced of the viability of
TABLE 4. Percentage of Subjects neuropsychological test construction projects. Major
Equaling or Exceeding Scatter publishing houses have been responsive to the needs
Index of 1.4 of psychology in some instances resulting in large
investments in test construction projects such as the
10 subtests 12 subtests Wechsler Scales. Clinical neuropsychologists must
demand that neuropsychological tests meet the same
FSIO Whites Blacks Whites Blacks psychometric standards as many other scales and
move toward the development and norming of such
<85 12 18 21 23 scales. Nowhere is this more needed generally than in
85-115 I I I 0
>115 0 0 0 0
neuropsychology and child neuropsychology in
particular.
alents produced by the child. Both test-retest reports

Reliability of Neuropsychological of reliability are based on wide age spans; for Read-
Measures ing Level an r 12 of 0.98 is reported for ages 6-9,
and 0.96 for ages 10-15. These rs are inflated to an
Reliability may be the single most influential of unknown degree by the correlation of Reading Level
psychometric concepts because of its relationship to with age. The use of a wide age range with rs based
all other psychometric characteristics. It is the foun- on raw scores or other age-related scores such as
dation of validity, and classical psychometric theory grade equivalents and age equivalents is a common
is known as reliability theory. The problem of relia- method of exaggerating the observed reliability of
bility, particularly of internal consistency reliability test scores. When corrected for the confounding with
such as represented in Cronbach 's alpha and the vari- age, which is certainly correlated to some substantial
ous Kuder-Richardson formulas, has not been well degree with Reading Level, these reliabilities are far
attended in clinical neuropsychology. Observed test less impressive. The original r 12 for correctly spelled
score variance can be divided into two components, known words is but 0.64 for ages 6-9 and 0.84 for
true score variance and error variance. Only true ages 10-15. For Good Phonetic Equivalents, the val-
score variance is "real," systematic, and related to ues are 0.89 and 0.85. After correction for spurious
true differences among individuals. Only true score correlations with age, it would be surprising to find
variance can be shared or related between two vari- these reliabilities within any commonly accepted
ables; thus, we see that the criterion-related validity range for diagnosing individual cases. Also, the Ns
of any test is restricted as a function of the square root are extremely small (ages 6-9, N = 27; ages 10-15,
of the product of the reliabilities of the two measures N = 23) for making any decision about the stability of
(i.e., (rxxryy)l). Reliability of neuropsychological scores on the Boder. The long-term rs were 0.81 for
measures is an area that has received attention in the Reading Level, 0.62 for spelling, and 0. 79 for Good
literature as an area of special need (e.g., Parsons & Phonetic Equivalents, values that were cleary un-
Prigatano, 1978; Reynolds, 1982). Reliability of acceptable for individual cases, but based only on N
neuropsychological measures is equally important to = 14, an unacceptable sample size in any case.
individual diagnosis and to research, as reliability Internal consistency (corrected split-half) relia-
will influence the likelihood that any experimental or bility estimates are reported for 46 cases randomly
treatment effects will be detected. In short, reliability selected (by Boder & Jarrico's description) from
is the foundation on which validity, the most impor- Roder's private patient files. If truly random, the age
tant of measurement concepts, is built. Nonetheless, range of these 46 children is 6 to 18 years. This
even in the research literature, reliability data are tremendous age range greatly inflates internal con-
seldom presented and the most frequently used of the sistency estimates and is unacceptable for assessing
various batteries, the HRNB, does not even have a reliability (Willson & Reynolds, in press). Though
discussion of reliability in its manual. Reliability of considerably inflated, the values were 0.97 for Read-
the LNNB is reported but is based on highly hetero- ing Level, 0.82 for spelling (known words),
geneous groups, across a too wide age span, and is and 0. 92 for Good Phonetic Equivalents. The degree
likely spuriously inflated. The BoderTest of Reading of spurious inflation is indeterminate.
Spelling Patterns, developed by a pediatric neu- The errors made in the estimation of the reliabil-
rologist as a neuropsychological measure of educa- ity of the Boder Test are serious but are all too com-
tional deficits, provides a good example of how not to mon, not only in neuropsychology but in several
assess reliability of neuropsychological measures, al- areas of testing (e.g., see Reynolds, 1983). Lack of
though the authors must be acknowledged for at least attention to standard psychometric methods seems all
attending to the issue. too rampant in clinical neuropsychology and is re-
In studying the reliability of the Boder Test, tarding developments in the field. One other piece of
Boder and Jarrico ( 1982) reported on several aspects relevant data is reported in the Boder Test manual's
of reliability. Test-retest (represented as r 12) or sta- reliability section-the agreement on diagnosis of
bility of scores is reported for 2-month and 1-year one of three reading disorders for the two testings
intervals. The sample size for the 2-month study was with the test-retest reliability samples. Chi-square
50 and for the long-term study, N was 14. Three tests were used, appropriately, to evaluate changes in
aspects of the test (the Boder not actually being divid- classification across testings, yet even these results
ed into subtests) were evaluated, those yielding are interpreted improperly. According to Boder and
scores for Reading Level, Correctly Spelled Known Jarrico (1982, p. 95), when the chi-square is evalu-
Words, and the number of Good Phonetic Equiv- ated, "a significant result shows high agreement be-
154 CHAPTER 8
tween the classifications at the two testings. ' ' Rather, tion methods are not in great agreement. Dichotic
the significant chi-squares only show a statistically listening and split-visual field methods are both very
significant relationship between the two classifica- unreliable from a purely psychometric perspective.
tions; that is, the two sets of classifications were not The reliabilities reported (albeit infrequently) in the
independent. The actual number of children given the literature are seldom better than 0. 5 to 0. 65. The re-
same classification on each testing was not reported liability problems here possibly lie with the tech-
and is necessary for a more proper interpretation of niques themselves but a more likely problem seems
these results. The reliability of the Boder Test re- to be the stimulus materials, i.e., the test that is pre-
mains an open question specifically as does the relia- sented through these methods. The proper applica-
bility of the most popular of neuropsychological tests tion of traditional psychometric methods in the con-
generally. At first glance, this seems attributable to struction of tests to be presented through these
the lack of presence of the major test publishers in methods would undoubtedly enhance the reliability
neuropsychology. The HRNB is essentially an in- of these techniques. Increases in the reliability of
house production of Reitan; the Boder Test is pub- neuropsychological measures could increase the dis-
lished by Grune & Stratton and is their only test criminability of the tests in studies of differential
product. The LNNB, on the other hand, is produced diagnosis as well. Error variance cannot contribute to
by Western Psychological Services, one of the 10 the general problem of distinguishing among clinical
largest test publishers in the country. Tests such as groups, although, as reviewed later in this chapter,
the revision of the Wechsler Memory Scale by the error variance can contribute spuriously in single
Psychological Corporation and the Kaufman Assess- studies without internal replication. Although in-
ment Battery for Children (American Guidance Ser- creasing reliability will most certainly not alleviate
vice), put out by the major houses involved in the all of the interpretive problems existing in this liter-
development and publication of individually admin- ature, it is better not to base arguments over the in-
istered tests, fare much better in the appraisal of their terpretation of data on what is essentially error vari-
reliability and their corresponding methods of es- ance and little else.
timation. Authors are ultimately responsible for the
psychometric care used in devising their tests, and
closer attention to the details of reliability seems
clearly necessary. Scaling Problems in
Because the validity of a test is restricted as a Neuropsychological Testing
function of the square root of the product of the relia-
bility coefficients of the test and the criterion [i.e., Children are in a constant state of development
the theoretical limit placed on a test's validity coeffi- and change in many ways but perhaps most dramat-
cient is equal to (rxxryy)i]' one method of improving ically in their neurological and higher cortical devel-
the validity of existing neuropsychological tests then opment. Children are acquiring knowledge at the
obviously is to work toward enhancing the reliability most rapid pace of their lifetime and their reasoning
of these scales. Too frequently, neuropsychologists processes and insights into their learning grow in a
rely on the "clinical" nature of certain tests and dramatic manner. All are nevertheless moving at an
procedures to the extent that such important concepts uneven pace. Consequently, the scaling of any tests
as reliability are overlooked. or measurement devices designed to aid the assess-
Reliability of our testing and assessment pro- ment of brain-behavior relations is crucial. This is
cedures is equally important to research in neuropsy- true regardless of whether one takes a "key ap-
chology. The most direct implication of reliability for proach," looks simply at level of function, or as-
research is in the detection of experimental effects. sesses profiles of performance. The scaling of neu-
As reliability decreases, so does the likelihood that a ropsychological tests has been sporadic, with some
significant effect will be found in any experimental or scaled well, some poorly, and a significant number
clinical treatment. Marcel Kinsbourne has made ref- not at all. Even when scaling is handled well from a
erence to just this problem in consistently detecting technical perspective, the quality of the standardiza-
hemispheric differences on certain tasks under a tion sample providing the estimates of population
specified set of conditions ( 1981 , personal commu- parameters from which standard scores are subse-
nication). As anyone acquainted with the neuropsy- quently determined will influence the utility of the
chology literature will be quick to recognize, there- derived scores.
sults of research employing dichotic listening pro- Raw scores, e.g., the number correct, a time to
cedures and tachistoscopic split-visual field presenta- completion, or a number of errors, are problematic
but common. The HRNB does not provide any trans- The GE, i.e., RL, of the BTRSP is based on the
formed scores. Without standard score transforma- grade level at which the words from the reading lists
tion, it is difficult to make any meaningful com- of the Boder are estimated to be introduced into the
parisons of scores. The dominant approaches to curriculum, and assumes that half of the children
interpretation of the HRNB include assessing levels master these words for reading and spelling. True
of performance and contrasting performance among GEs are based on actual student knowledge of the
the various tasks. Raw scores cannot be compared or curriculum content as reflected in mean scores on
assessed directly for a variety of reasons, the most achievement tests. When content is introduced and
potent being the lack of comparability of the raw when it is actually mastered by 50% of the pupils may
score distributions among the tasks of the battery and not be closely related. Actual performance must be
for any one task across age. As Dean (1985) noted, in assessed.
reviewing the HRNB, "without standard score trans- GEs as a score on which to base decisions about
formation data, it is difficult to make any meaningful individual pupils have serious deficiencies that have
comparison between scores on individual tests" (p. been presented in detail in a variety of sources (e.g.,
645). The use of raw scores is not necessarily wrong Angoff, 1971; Reynolds, 1981a, 1982; Thorndike &
and is typically superior to the use of inaccurate score Hagen, 1977). Though frequently treated as a stan-
transformations. Appropriate use of raw scores does dard score, GEs are not standard scores, and attempts
require extensive work and numerous calculations on to standardize them (Burns, 1982) have been largely
the part of the person interpreting the test scores. The unsuccessful (Reynolds & Willson, 1983); and in-
LNNB provides standardized or scaled scores in the deed the true meaning of the GE is often distorted if
form of the familiar T-score (mean = 50, standard understood at all. Most of the problems with GEs can
deviation = 10) although the scaling is questionable be traced to one of two factors, or both: (1) GEs are
due to the shape of the distributions obtained and the calculated independent of the dispersion or distribu-
sample used in their derivation. Other attempts to tion of scores about the mean, and (2) the regression
scale neuropsychological measures have been made of the age, grade, and raw score is nonlinear, and
but use inappropriate scales, particularly age or grade varies across subject matter within grade as well as
equivalents (GEs). Neuropsychological reports, across grade within subject matter or content areas
even textbook examples, often contain performance (AEs have analogous problems). Essentially, this
reported in GEs. The BoderTest can again provide an tells us the GEs are on an ordinal scale of measure-
illustration of some of the problems with scaling as ment and not an interval scale as so frequently in-
practiced in clinical neuropsychology. terpreted. This makes many common uses of GEs
The Boder Test does not actually provide any entirely inappropriate.
type of standard score although the test's authors treat Boder and Jarrico (1982, p. 5) defined signifi-
the various scores as though they are standardized or cant reading retardation as performance two years
scaled scores. The Boder Test provides a Reading below grade level for age according to the Boder Test
Level (RL) (analogous to aGE), a Reading Quotient RL. Other diagnoses are dependent upon the RL and
(RQ), and a Reading Age (RA). Without adequate its discrepancy with expected level of performance as
normative data, which the Boder does not possess, well. The "two years" criterion for a reading disor-
these scores are not very meaningful. Even if care- der has been a common ground for diagnosis for
fully normed, using state-of-the-art methods, these some time and only recently abandoned (see also
scores have serious limitations and should be used Reynolds, 1984). The use of GE scores at a constant
with extreme caution if at all and never as the featured discrepancy level irrespective of actual grade place-
scores for any contemporary scale, neuropsycholog- ment produces considerable irregularity for diag-
ical or otherwise. nosis, however. The distortions in interpreting dis-
crepancies between GE scores and grade placement
RLandRA are readily apparent in Table 6, which was developed
from data available in the norms or technical manuals
The RL and RA of the BTRSP have similar of the Wide Range Achievement Test (WRAT), Pea-
problems. RL has the greatest difficulties even if body Individual Achievement Test (PlAT), Wood-
calculated on the basis of good normative data, so the cock Reading Mastery Test (WRMT), and the Stan-
RL (the Boder Test's analogue of aGE) will be fea- ford Diagnostic Reading Test (SORT). As is typical
tured here. Given the interdependence of the RL and ofGE scores, some occasional interpolation was nec-
the RA as calculated on the Boder Test, their prob- essary to derive the exact values in Table 6. It is
lems are almost identical. apparent, however, that a third grader who reads
156 CHAPTER 8
TABLE 6. Standard Scores Corresponding to Performance "Two Years below Grade Level
for Age" on Four Major Reading Testsa
Standard scoresb
Two years Wide Range Stanford

Grade below Achievement Peabody Individual Woodcock Reading Diagnostic
placement placement Test Achievement Test" Mastery Testd Reading Teste
1.5 Pk.5 65
2.5 K.5 72
3.5 1.5 69 64 64
4.5 2.5 73 75 77 64
5.5 3.5 84 85 85 77
6.5 4.5 88 88 91 91
7.5 5.5 86 89 94 92
8.5 6.5 87 91 94 93
9.5 7.5 90 93 96 95
10.5 8.5 85 93 95 95
11.5 9.5 85 93 95 92
12.5 10.5 85 95 95 92
a Adapted from Reynolds ( 1981 a).

bAll standard scores have been converted for ease of comparison to a common scale having a mean of I00 and a standard deviation of 15.
<Reading Comprehension subtest only.
d"fotal test.
"two years below grade level for age" has a much standard score values corresponding to two years be-
more severe problem than say a seventh or eighth low grade level for age after about grade 7 or 8. In
grader reading two years below grade level. In fact, a fact, GEs have almost no meaning at this level, for
twelfth grader with an IQ of 90 on a Wechsler scale reading instruction typically stops by high school and
and reading two years below grade level for age has GEs are really only representing extrapolations from
no reading problem at all, but rather reads at a level earlier grades. An excellent example of the difficulty
slightly higher than what might be expected. Stan- in interpreting GEs beyond about grade 10 has been
dard scores are by far the more accurate representa- provided by Thorndike and Hagen ( 1977) using an
tion of an individual's achievement level than GEs analogy with AEs. Height can be expressed in AEs
because they are based not only on the mean at a just as reading can be expressed in GEs. However,
given level but also on the distribution of scores about although it might be helpful to describe a tall first-
the mean. Thus, in the case of deviation standard grader as having the height of an 8}-year-old, how
scores, such as the Wechsler IQs, the relationship does one then characterize the 5' 10" 14-year-old
between standard scores is constant across age, and female, for at no age does the mean height of females
there are no excuses for the failure to provide such equal 5' 10"? Because the average reading level in the
scores. Certainly the Boder Test provides no ra- population changes very little after junior high
tionale for the lack of standard scores or even the school, GEs at these ages become virtually nonsen
preference forGEs. Neither do most clinical neuro- sical, with large fluctuations in GEs sometimes re-
psychologists have an adequate rationale for consulting from a raw score difference of 2 or 3 points on
tinued use of AEs and GEs in reports or in their a 100-item test.
application to profile analysis. 2. GEs assume that the rate of learning is con-
GEs are also inappropriate for use in any other stant throughout the school year and that there is no
sort of discrepancy analysis of an individual's test gain or loss during summer vacation.
performance or key or profile analyses for the follow- 3. As partially noted above, GEs involve an
ing reasons: excess of extrapolation, especially at the upper and
1. The growth curve between age and achieve- lower ends of the scale. However, because tests aie
ment in basic academic subjects flattens out at upper not administered during each month of the school
grade levels. This can also be observed in Table 6 year, scores between the testing intervals (often a full
where it is seen that there is very little change in year) must be interpolated on the assumption of con-
stant growth rates. Interpolation between extrapo- standard score as thought by many. It is conceptually
lated values on an assumption of constant growth the antiquated notion of a ratio IQ that was aban-
rates is at best a highly perilous activity. The assump- doned many years ago in favor of more refined stan-
tion underlying score derivations on the Boder Test dard score systems. The standard deviation of the
that each word read correctly represents 2 months of first version of the RQ will almost certainly range
academic achievement is even more perilous, and from at least 10 to 29, leading to the confusing (and
most likely cannot be substantiated. For the Boder unaccounted for in the Boder Test's diagnostic sys-
Test, this adds to the error and the unfounded as- tem) state wherein, depending upon age, RQs of 80
sumptions already present in properly derived GEs, and 90 represent the same overall level of perfor-
which the RL of the Boder Test is not. Popular mance at different ages. The actual range of standard
achievement tests in neuropsychology have similar deviations could be larger or smaller; whichever it
problems. The front of the protocol for the WRAT, turns out to be is less important than the fact that the
for example, notes that standard scores only and not standard deviation will not be constant across age and
the so-called grade rating (the WRAT's GE) should that the standard deviation at any age is unknown.
be used for interpretive purposes. Use of either of the two alternative formulas
4. Different academic subjects are acquired at given below for calculating the RQ is even more
different rates and the variations in performance dif- problematic. These formulas 2
fer from one content area to another. As a conse-
quence, "two years below grade level for age" may 2RA
be a much more serious deficiency in mathematics RQ = MA + CA X 100 (l)
than, say, in reading comprehension. The degree of
academic deficit in Reading versus Spelling, as on 3RA
RQ = X 100 (2)
the BoderTest, denoted by the "two years" marker, MA + CA + Grade Age
will differ as well.
5. GEs exaggerate small differences in perfor- are quite similar to expectancy formulas proposed by
mance between individuals and for a single indi- the U.S. Office of Education (1976) in their attempt
vidual across tests. Some test authors (e.g., Jastak & to define severe discrepancies between aptitude and
Jastak, 1978) even provide a caution on test record . achievement. Commentary on such formulas has
forms that standard scores only, and not GEs, should shown them to be grossly inadequate for use in any
be used for comparison purposes. kind of normative reporting or discrepancy analysis
(e.g., Algozzine, Forgnone, Mercer, & Trifiletti,
RQ 1979; Cone & Wilson, 1981; Danielson & Bauer,
1978; Hanna, Dyck, & Holen, 1979), and far more
The Boder Test also provides an RQ calculated sophisticated approaches are needed (Reynolds,
in accordance with one of three formulas offered in 1984). The standard deviation of the scores derived
the Boder Manual, with the choice of derivation from these formulas will also vary and is unknown.
given to the examiner. Giving a choice of three for- The same number of children will not be identified at
mulas to the examiners is problematic in itself. each IQ level or each age level using the BTRSP
Though some general guidelines are provided con- classification rules. There is no established validity
cerning when to use each formula, the choice is left to for either formula; they are only intuitive in their
the examiner, and it is entirely probable that, faced appeal.
with a similar or even identical set of scores, different Given the problems of age- and grade-based
examiners will arrive at different RQs; the same ex- equivalency scores and the amount of severe crit-
aminer may well fall to the same plight over time, icism they have received in the literature, it is diffi-
being inconsistent in the choice of formulas given a cult to imagine a justification for their use in place of
common set of circumstances. However, this is one standard scores. Certainly standard scores should be
of the more minor problems with the Boder Test RQ. provided at a minimum with AEs and GEs and related
The RQ is derived from a faulty score to begin with, derived scores (e.g., RQ) provided as supplementary
the RA, as noted in the previous section. The RQ, 1 as if at all. Because AEs and GEs are representing only
calculated to be (RA/CA) x 100, will not have a ordinal scale data (and thus cannot be averaged or
constant standard deviation across age and is not a otherwise manipulated with any confidence except
1CA, Chronological age. 2 MA, Mental age.

158 CHAPTER 8
under special conditions), it is particularly important tion across age. By standard scores is meant scores of
that these scores not be used for comparative pur- the Wechsler Deviation IQ genre, referred to more
poses. Standard scores could not be reported for the properly as age-corrected deviation scaled scores.
Boder Test because there are no normative data on This designation is used because the mean and the
which to base these calculations. standard deviation of the scaled score distribution are
reset or rescaled periodically, typically every 2 to 4
months at preschool ages and every 4 to 6 months
Ratios and Quotients therea_fter until the adult years when much larger age
groupmgs may be used. Standard scores of the devia-
Probably the best known of all scores to the
tion IQ type have the same percentile rank across age,
layperson is the ratio IQ, originated for use with the
for they are based not only on the mean but the vari-
Binet scales early in this century. As every introduc-
ability in scores about the mean at each age level. For
tory psychology course student knows, IQ = (Mental
example, a score that falls two-thirds of a grade level
Age/Chronological Age) x 100. This forms the ratio
below the average grade level has a different percen-
or quotient from which the designation IQ was de-
tile rank at every age.
rived. Such ratios or quotients have numerous psy-
Standard s~ores are more accurate and precise.
chometric problems and are no longer used by the
When constructmg tables for the conversion of raw
major test publishers but do persist in certain areas of
sc~res into standard scores, interpolation of scores to
neuropsychology, even to the point of developing
amve at an exact score point is typically not neces-
ratios of "hold" to "don't hold" subtests for es-
timating premorbid functioning. Such ratios are non- s_ary '.whereas t?e opposite is true of GEs. Extrapola-
tiOn ts also typtcally not necessary for scores within
sensical for most interpretive purposes, however,
three standard deviations of the mean, which ac-
and lead primarily to confusion. Although they may
counts for more than 99% of all scores encountered.
be used to rank individuals who take a common test
Standard scores are on an equal interval scale in
no comparisons beyond rank on the common mea~
many cases (see Gordon, 1984), making profile anal-
sure ar~ possible-including profile analysis or any
ysis possible across subtests of a common scale. Ip-
compansons across tests. The so-called ratio IQ is a
sative analysis of performance only makes mathe-
l"l!tio. of ?umbers with radically different underlying
matical sense with an interval or higher scale of
dtstnbuttons and mathematical properties. Chrono-
meas~rement. Score comparisons among different
logical age is a ratio scale of measurement. Mental
battenes or subparts of different measuring devices
ag~ is on an ordinal s~ale of measurement. Creating a
are also possible provided the reliability of each mea-
l"l!tto of two such dtsparate scales is a conceptual
sure is known and, for some purposes, the correlation
mghtmare of some proportion. The standard devia-
between the various pairs of scores must also be
tion of the distribution of such ratios will also vary
across age. The 1937 Stanford-Binet Intelligence known. If ~e ~li~bility coefficients are comparable,
the score dtstnbuttons are normal, and the percentile
Scale, which yielded such a ratio IQ, showed a stan-
rank of scores is known, Table 7 can be used to place
?ard deviation that ranged from about 9 to 32 depend-
scores on a commonly expressed metric, i.e., a scale
mg upon the age of the individual assessed. The fa-
having the same mean and standard deviation. The
miliar standard deviation of 16 used then, and now,
choic~ of s~dard score scales is often arbitrary but is
by the Binet Scales, was the average standard devia-
sometimes dtctated by the standard deviation of the
tion across ages 2 years to about 16 years. Gross
raw score distribution, such that the score points
inaccuracies of interpretation are facilitated by such
should not be artificially spread over too many stan-
scales and they are not standard or scaled scores in
d~d score points nor should too many raw score
any sense of contemporary uses of these terms. Vari-
pomts be collapsed into a single scaled score point.
ous ratio scores and quotients such as the early IQ
Such problems are usually avoided by the choice of
remain in use in neuropsychological assessment but
an appropriate scale and finding a suitable scale is
do not possess the properties of standard scores that
easy_en~ugh that it is seldom a serious problem in the
make the latter so useful in all areas of testing and
apphcatton of scaled scores to most practical prob-
assessment.
lems of assessment. There are few instances when
other score systems are superior to scaled scores, and
Standard or Scaled Scores methods are now available for the use of scaled
scores even at the most extreme points in the distribu-
The primary advantage of standardized or scal- tions of intelligence, achievement, and other special
ed scores lies in the comparability of score interpreta- abilities (e.g., see Reynolds & Clark, 1985, 1986).
TABLE 7. Conversion of Standard Scores Based on Several Scales to a Commonly

Expressed Metric
X=O X=-100 X= 100 X= 100 X=500 X= 50 X= 50 X=36 X= 10 Percentile
S.D.= I S.D.= 15 S.D.= 16 S.D.= 20 S.D.= 100 S.D.= 10 S.D.= IS S.D.=6 S.D.=3 rank
2.6 139 142 152 760 76 89 52 18 >99

2.4 136 138 148 740 74 86 51 17 99
2.2 133 135 144 720 72 83 49 17 99
2.0 130 132 140 700 70 80 48 16 98
1.8 127 129 136 680 68 77 47 15 96
1.6 124 126 132 660 66 74 46 15 95
1.4 121 122 128 640 64 71 44 14 92
1.2 118 119 124 620 62 68 43 14 88
1.0 115 116 120 600 60 65 42 13 84
0.8 112 113 116 580 58 62 41 12 79
0.6 109 110 112 560 56 59 40 12 73
0.4 106 106 108 540 54 56 38 II 66
0.2 103 103 104 520 52 53 37 II 58
0.0 100 100 100 500 50 so 36 10 so
-0.2 97 97 96 480 48 47 35 9 42
-0.4 94 94 92 460 46 44 34 9 34
-0.6 91 90 88 440 44 41 33 8 27
-0.8 88 87 84 420 42 38 31 8 21
-1.0 85 84 80 400 40 35 30 7 16
-1.2 82 81 76 380 38 32 29 6 12
-1.4 79 78 72 360 36 29 28 6 8
-1.6 76 74 68 340 34 26 26 5 5
-1.8 73 71 64 320 32 23 25 5 4
-2.0 70 68 60 300 30 20 24 4 2
-2.2 67 65 56 280 28 17 23 3
-2.4 64 62 52 260 26 14 21 3
-2.6 61 58 48 240 24 II 20 2 <I
methodological and statistical problems in clinical

Differential Diagnosis: Determining neuropsychology-one that, oddly enough, is nearly
Membership in Clinical Populations the opposite of the preceding discussions. In differ-
ential diagnosis, rather than being naive about the
One of the major problems of psychologists in underlying psychometrics or scaling, the tendency
professional practice has historically been that of dif- has been to perform analyses that are too sophisti-
ferential diagnosis of mental disorders. In the area of cated for the data.
clinical neuropsychology, differential diagnosis has To their credit, researchers have, over the last
been of particular importance. As Golden (1981) decade, brought to bear the most sophisticated statis-
pointed out, one of the major areas of research in tical methodologies directly on the problem of diag-
clinical neuropsychology has had as its purpose the nosis and classification of mental disorders in the
development of clinical tests and procedures to dif- form of various multivariate analytical techniques. In
ferentiate reliably between brain-injured and neu- the quest to provide accurate diagnosis of neu-
rologically intact individuals and to separate brain- rological disturbances, a large set of behaviors is
injured groups into subsamples according to loca- typically assessed. Rourke (1975), in discussing
tion, cause, time of onset, and, in some cases, prog- more than two decades of research in differential
nosis. Many neuropsychologists still earn a consider- diagnosis, indicated that children referred to his labo-
able portion of their "keep" differentiating organic ratory are typically administered "the WISC, the
from nonorganic psychiatric referrals and evaluating Peabody Picture Vocabulary Test, the Halstead Neu-
the nature and extent of lesions for the neurology ropsychological Test Battery for Children, the Reitan
service. This does bring out another major area of Indiana Neuropsychological Test Battery, the Wide
160 CHAPTER 8
Range Achievement Test, an examination for senso- A second consideration in prediction occurs
ry-perceptual disturbances, the Klove-Mathews when the prediction used a strategy for selecting a
Motor Steadiness Battery, and a number of other tests small number of variables from a much larger initial
for receptive and expressive language abilities'' (p. set of variables (e.g., Purisch, Golden, & Hammeke,
912). Multivariate classification techniques are very 1979). In the same, some correlations underestimate
powerful in the determination of group membership. the population value and others overestimate it. In
Unfortunately, with such a large set of variables, stepwise regression or discriminant procedures and
small numbers of subjects can all be grouped and related multivariate methods, the overestimates are
classified purely on the basis of random or chance always chosen. When a large number of predictors is
variation that takes maximum advantage of corre- available, stepwise procedures maximize the chance
lated error variances. Thus, the need for large num- of selecting random or near-random predictors.
bers of subjects in such research is a crucial one. These are variables that do not predict well in the
In the study of clinical disorders, however, one population but by chance correlate highly with the
is frequently limited to relatively small samples of outcome in the particular sample being used.
design. Although most researchers acknowledge this The degree of decrease in R 2 from sample to
difficulty, few realize the devastating effects of sub- population can be estimated. The most commonly
ject/variable ratios approaching I on the gener- used estimate is from Wherry ( 1932; see also Lord &
alizability of studies of differential diagnosis. This is Novick, 1968, p. 286) and is
not to say that excellent studies have not been done.
Studies of discriminability by Satz and his colleagues R~ = 1 - (1 - R2)(N- 1)/(N- K- 1) (3)
(e.g., Satz & Friel, 1974; Satz, Taylor, Friel, &
Fletcher, 1978) use large numbers of variables but N is the number of observations, K the number of
have considerable subject populations. LargeN stud- predictors, R 2 the observed squared multiple correla-
ies of clinical populations are the exception rather tion between outcome and predictors, and R~ the pop-
than the rule. Willson and Reynolds ( 1982) evaluated ulation squared multiple correlation. This formula
the effects of small samples on the validity of re- holds for either multiple regression or discriminant
search attempting to discriminate among clinical dis- analysis.
orders on the basis of neuropsychological test perfor- Formula (3) has been widely cited. A review by
mance and have reported on many of the statistical Cattin ( 1980) suggested that for small Nand large K,
problems that seem to plague the area. another approximation should be used:
R2 = (N-K-3) p4 + p2
(4)
Some Statistical Considerations (N-2K-2) p 2 + K
In predicting group membership from a set of where

variables (e.g., neuropsychological test scores) there
are several considerations. First, procedures that use N-3
samples of the target populations involve sampling p2 =I- N-K-1 (1-R2)
error in the estimation of the relationships being ex- [ 20 - R 2 ) 8(1 - R2 ) 2 ]
amined. This means that results are expected to fluc- 1+ N-K-1 + (N-K+1)(N-K+3)
tuate from sample to sample due to the random dif-
ferences inherent in the samples. The usual measure Although R2 is biased, the amount of bias is on the
of prediction is the squared multiple correlation (R 2). order of .01-0.02 for N = 60 and K =50.
In applying results of a particular sample to a second Of special interest is the case where there are
sample, R2 is expected to decrease because correla- more predictors than people. In equation (4), the
tion is a maximizing operation-R2 was made as big shrunken R2 may become negative or greater than
as possible for the first sample capitalizing on corre- 1.0. What this really means is that mathematically
lated error variances whenever possible. It is unlikely with more predictors than observations of the out-
the same fit of the data will occur in a second sample. come, there is no unique solution to a best prediction.
Thus, rules for classification derived from a particu- In discriminant analysis this may result in perfect
lar sample cannot necessarily be expected to gener- classification entirely at random by the predictors.
alize to any other sample without a cross-validation Mathematically, this results from having more pa-
effort to demonstrate such an effect. rameters to estimate than data points. Either one is
forced to make enough side conditions to constrain analysis is so seldom applied by clinical researchers.
the solution or one accepts a solution that results from The omission is significant in that. although re-
a particular order of entering predictors. As it is searchers in neuropsychology may not be familiar
mathematically impossible to estimate all regression with or do not apply this technique for other reasons,
coefficients, there will be it may be quite useful in discriminating among sever-
al populations.
K_ K!
N- N!(N-K!) The Willson and Reynolds Examples of
Classification Problems
different solutions that would provide perfect classi-
fication but would not generalize to any other sam- To illustrate the problems !hat can be created by
ples. In particular, it may be quite likely to find a these statistical considerations, Willson and Reyn-
solution that maximizes R2 based entirely on chance olds (1982) examined all articles in three journals
correlations if there are enough correlations from (Psychology in the Schools, Journal of Consulting
which to choose. and Clinical Psychology, and Clinical Neuropsy-
Even when there are fewer predictors than sub- chology) for the years 1979-1981. They selected
jects, the shrunken R2 estimate will rapidly approach studies that used test batteries, socioeconomic or de-
zero as the number of predictors becomes a signifi- mographic variables, or a combination of these vari-
cant proportion of the number of subjects. When ables to predict clinical group membership and that
small samples of subjects are involved, as with many could help illustrate the difficulties of such work.
neuropsychological studies, the use of a large Nine studies were found.
number of tests as predictors frequently fulftlls this The studies are listed in Table 8 (from Willson
condition. & Reynolds, 1982). Also listed are sample sizes (N),
Multiple regression and discriminant analysis total number of predictors used in stepwise pro-
have been discussed interchangeably to this point, cedures (KT), and number of predictors used in the
but some distinctions need to be made about them. final or discriminant equation (KF). In one case, RF
Formally, they are identical in two-group prediction, was determined indirectly through a 2 x 2 classifica-
e.g., brain-damaged versus non-brain-damaged. For tion table that was reported in the studies. The
more than two groups, discriminant analysis must be tetrachoric correlation was computed and squared
used. There have been a number of different classifi- (see Glass, 1978, for a discussion of estimating cor-
cation rules proposed using discriminant analysis. relation effects).
These pertain to assumptions about prior proba- Table 8 lists several other statistics that repre-
bilities for population composition and about homo- sent estimated values of R~ and their significance via
geneity of within-group covariances. In any case the their associated F-statistic. The statistic At repre-
R of relationship between predictor and between sents the estimated R shrunken by equation (3) to
group distance is computed. It is a canonical correla- account for all the predictors originally considered.
tion (see Cooley & Lohnes, 1971, p. 249). Because Because in no study was the overall Rt
reported for
there may be more than one discriminant function, all predictors, it was necessary to use the R~ based on
there will be a canonical R for each. Their squares do the final regression. Thus, Rt underestimated the
not necessarily add together to get a total R2, as there shrunken R~ to some degree. Its upper bound is given
may be redundancy between functions (Cooley & by R~ the shrunken estimate based on the number of
Lohnes, 1971, p. 170), but their squared sum is the predictors actually used. This is an overestimate of
maximum possible R 2 This may be useful as a liberal the actual shrunken R2.
estimate because if it can be shown that fl.2 is near A second set of ~tatistics was calculated from
zero, there is no need to estimate the stu~ys R2, the nine studies to estimate loss of classification
because it will produce an even smaller estimate power due to shrinkage and is presented in Table 9.
A2
of RP. For the reported R~ and the Rt the t-statistic equiv-
For two groups, multiple regression and dis- alent was computed according to
criminant analysis yield the same results. For more R2JK ] 112
than two groups, the canonical R2 is still useful as an [ (5)
t = (l-R2 )/(N-K-1)
approximation to a multiple regression R2. This in-
terpretation can be a useful one but is rare in clinical Although most studies had only two groups, in
neuropsychology. as multiple group discriminant Selz and Reitan (1979), the t-statistic was based on a
162 CHAPTERS
TABLE 8. Summaries of Prediction Studies from Three Special Population Journals

Sample Total number Number of R~
2 2
Study size of predictors predictors used (reported) RT RF
Dean (1978) 120 14 4 0.25* 0.09 0.21*

Selz & Reitan (1979)" 75 37 37 0.57 0.57 0.57
Wallbrown, Vance, & Pritchard (1979) 200 8 3 0.19* 0.13 0.17*
Purisch, Golden, & Hammeke (1979) (a) 100 282 40 1.00* ()b ()b
(b) 100 14 14 0.88* 0.84* 0.84*
Taylor & Imivey (1980) (a) 30 16 5 0.44* 0.00 0.26
(b) 30 3 I 0.08 0.00 0.05
(c) 30 16 5 0.30 0.00 0.10
(d) 30 3 1 0.14* 0.02 0.12
(e) 30 16 2 0.25* 0.00 0.22*
(f) 30 2 1 0.11 0.03 0.09
Dunleavy, Hansen, & Baade (1981) 24 37 3 0.82* ()b 0.79*
Fuller & Goh (1981) 80 22 12 0.38* 0.05 0.19
Golden, Moses, Graber, & Berg (1981) (a) 60 11 2 0.55* 0.37* 0.54*
(b) 120 11 2 0.68* 0.62* 0.68*
Malloy & Webster (1981)'" (a) 36 14 14 0.57 0.57 0.57
(b) 36 14 14 0.94*d 0.94* 0.94*
"Trinomial classification table was reported; it was converted to a binomial (normal versus brain-damaged or ID) and the tetrachoric ~lation
computed, wbich was squared to obtain R~. Because it was based on a praliction equation from another study, no shrinkage was expected.
bAn R2 of 0.00 is expected in an ovenletermined system, in wbich there are more predictors than subjects. Perfect classification is always possible.
Binomial classification was reported. The tetrachoric com:lation was computed as in footnote a.
"The R2 values were estimated from a misclassification rate of 20% with 36 subjects. Although actual study was trinomial, the R2 represents the equivalent
for binomial classification for ease of computing.
*p < 0.05.
reduction of three groups to two (nonnal versus ab- subject/variable ratios and proper cross-validation
normal). Then, an effect size was computed, becomes immediately obvious in considering the re-
sults summarized in Tables 8 and 9. Interested pro-
(6) fessionals must consider with special care the predic-
tion rules generated from those studies when R
as defined by Glass (1978). This statistic is the dropped to nonsignificance.
number of standard deviations separating the two In examining the misclassification rates (see
groups. Finally, the percentile point under the normal Table 9), there is a change from about one-third ex-
curve for halfthe effect is presented. This is the point pected in the original studies (35%) to almost half
that minimizes misclassification assuming equal cost (44%) using the corrected values, the chance rates
for either false-positive or false-negative errors, and under no knowledge, and very unimpressive when
the equal population base rates. contrasted against base rates in referral populations.
Of the 17 R~ obtainable from the studies, 12 This is not surprising given the considerable decline
were initially significant. After correcting the in effect sizes shown in Table 9.
shriilkage, only 4 were significant as Ri-, and 8 as R~. It must be reiterated that the shrinkage occurs in
Thus, half the results reported in these studies are research in which correlation maximizing procedures
attributable to chance large correlations. Under the have been used: stepwise multiple regression, step-
most optimistic of circumstances, the upper limit of wise discriminant analysis, and canonical correla-
shrinkage R2 estimate shows a mean R2 of 0. 37 ver- tion. The R2 does not shrink in a fixed variable study
sus a mean obtained R 2 value of 0.48 for all studies in which all variables are included and in which order
considered. The lower bound estimate of the is unimportant (balanced ANOVA design) or in
shrunken R 2 yields even more pessimistic results, which order is predetermined (path analysis design,
demonstrating a mean value of but 0.25. The chance causal model design). Diagnosis seeks to find the
variation that can appear on the surface to be reliable best empirical discriminators, but it is most subject to
discrimination with powerful multivariate techniques chance.
is thus rather considerable. The importance of large The shrunken estimate of R2 and the expected
TABLE 9. Expected Misclassifications from Nine Studies

Estimated effect" Two-population %
size for two misclassification
t-equivalent for populations for for
'2 z z z z z
RF RT Rr RT RF RT
Dean (1978) 2.76 0.86 0.50 0.16 39% 47%

Purisch, Golden, & Hammeke (1979) (a) 0 0 0 0 50% 50%
(b) 6.27 6.27 1.25 1.25 27% 27%
Selz & Reitan ( 1979)h 1.15 1.15 0.27 0.27 45% 45%
Wallbrown, Vance, & Pritchard (1979) 3.12 1.89 0.44 0.27 41% 45%
Taylor & Imivey (1980) (a) 1.69<" 0.00 0.62 0.00 38% 50%
(b) 1.21c 0.00 0.44 0.00 41% 50%
(c) 0.13c 0.00 0.27 0.00 45% 50%
(d) 1.95c 0.42 0.71 0.15 36% 47%
(e) 2.84C 0.00 0.73 0.00 36% 50%
(f) 1.16C 0.65 0.64 0.24 37% 45%
Dunleavy, Hansen, & Baade (1981) 5.01 0 2.05 0 16% 50%
Fuller & Goh ( 1981) 1.14 0.37 0.25 0.06 45% 49%
Golden, Moses, Graber, & Berg (1981) (a) 5.78 1.61 1.49 0.42 23% 42%
(b) 11.15 4.00 2.04 0.73 15% 36%
Malloy & Webster (1981)b (a) 1.19 1.19 0.40 0.40 42% 42%
(b) 5.04 5.04 1.68 1.68 20% 20%
Mean 3.11 1.38 0.81 0.33 35% 44%
aEffect = t(lln, + l/n2 ) 112 (Glass, 1978).

hNo shrinkage occurred.
single group statistics; effects were computed as if for two groups. Single group results are smaller than reported here.
misclassification rate are part of the technique of Should prediction studies be cross-validated pri-
cross-validation. Cross-validation requires two inde- or to publication? Is it the responsibility of the re-
pendent samples. Ideally both are drawn indepen- searcher to provide this evidence? If actuarial rules
dently from the same population. Often a single sam- for diagnosis are used, the obvious answer is yes.
ple is split into two halves. In either case the Even in more purely clinical decision-making, the
regression is computed on one sample and the repeatability of one's results from a referral pool can-
weights applied to the scores of the second popula- not be ignored. The Selz and Reitan ( 1979) research
tion to predict the outcome or group membership as is an example where this procedure was followed,
appropriate. The R 2 is a one-sample estimate of the with quite credible results. The application of such a
R 2 in the nonvalidation sample, but it is not nearly so prediction rule to new populations requires new
convincing. First, it is a statistic itself that may vary; cross-validation, however. To those who argue it is
second, it uses information from one sample, not difficult to obtain subjects in rare disorder catego-
nearly as good as that available from two samples. In ries-hold the results until a second population is
clinical samples theN is typically so small that split- sampled. There will be no real loss to the discipline.
ting it is not a good idea. The regression weights and On the contrary, there will be a net gain, for only the
R 2 will become even more changeable as the sub- cross-validated results will achieve publication.
ject/variable ratio is halved. This leaves two-sample Given the sometimes harsh attacks on the application
cross-validation. Samples should be drawn from the of clinical neuropsychological techniques (e.g.,
same population initially. There may also be consid- Coles, 1978; Sandoval, 1981) to the rehabilitation of
erable value in determining the generalizability of the learning and related problems, it certainly behooves
results to other populations in an effort to improve the researchers to be careful in deciding when research is
clinical utility of the classification rules. These are ready to report. The external validity of one's "find-
separate problems; the sampling procedure in the first ings" must be clear.
case is obvious and has been discussed. Sampling in Cross-validation, when it is presented as evi-
the second case will be dictated by the specific design dence for the consistency of results in one popula-
of the study. tion, does not provide evidence for generalizability to
164 CHAPTER 8
other populations. This can be done by additional approaches. Roffe and Bryant (1979), in a study of
studies. There is no reason to believe the regression profile reliability for the McCarthy Scales, used the
weights that discriminate two groups will discrimi- Pearson correlation. This approach is problematic
nate either from a third. This point is not restrictive to from several perspectives. If the Pearson correlation
prediction studies but occurs in all behavioral is employed, profiles must first be "standardized" as
research. described by Nunnally (1978). However, even under
A related issue should be obvious and of great these circumstances, the Pearson correlation is likely
significance to the practicing clinician in neuropsy- to be inaccurate, for it does not consider level, disper-
chology and other subdisciplines involved in differ- sion, shape, and accentuation of the various profiles.
ential diagnosis. When actuarial rules for the diag- Several very powerful techniques have been devel-
nosis of psychological and neuropsychological oped that accurately determine the similarity of pro-
disorders appear in refereed professional journals, files, including D 2 (Cronbach & Gieser, 1953; Os-
those in applied settings, especially those keeping good & Suci, 1952) and the coefficient of pattern
closest to current developments in the field, may feel similarity, rP (Cattell, 1966). These two approaches
very confident in applying such rules in diagnosis and in particular are accurate, sophisticated measures of
in the development of treatment plans. Clearly, the profile similarity and should be employed whenever
Willson and Reynolds ( 1982) results show that in the possible.
absence of proper cross-validation, many diagnoses
or classifications may be made on the basis of random
relationships. This constitutes an unacceptable situa-
tion for all involved, but especially for the patient and Summary
his/her physician.
It has become customary over the years to end
reports of research with cautionary statements and
Profile Reliability call for further research. If diagnostic or classifica-
tion studies with small samples and large numbers of
A related problem when multiple scores are variables employing powerful, sophisticated multi-
being used in classification or individual diagnoses variate classification techniques are to continue to
and decision-making is the reliability of the set of appear without concurrent cross-validation, and mul-
scores for each individual considered. Perhaps sta- tivariate profiles are to be considered, much stronger
bility is a better conceptualization, as the question is cautions are needed to avoid the inadvertent leading
whether (or how much) the profile of scores, taken as of the diagnostician into potential malpractice. The
a whole, would change and whether this change most obvious, and the most sound solution is not to
would affect clinical decision-making. Stability of publish such small-N studies without concurrent rep-
profiles over at least very short periods of time lication, and not to rely on profiles with unknown
(largely depending upon the clinical disorder under stability in differential diagnosis research or clinical
investigation) needs investigation and yet has gone practice.
largely ignored. The problems of such research, Many problems related to measurement and sta-
which may at first seem simple, are difficult ones, but tistics in clinical neuropsychological research and in
can be solved. clinical diagnosis have been reviewed here. Many
The most difficult problem is that of differential other problems exist but a substantial portion of these
practice effects among the various scales that go into difficulties can be resolved by avoiding the problems
making up the score profile. This introduces meth- noted in this chapter. By so doing, other, now fuzzy,
odological artifacts that require statistical control issues, methodological, statistical, and clinical,
through estimation of regression effects for each part should be brought into a sharper focus and new prob-
of the battery prior to comparing the two profiles lems can be identified. The failure to resolve basic
obtained-in such a case, only the second profile measurement issues in clinical neuropsychological
should be corrected. Following this set of correc- research can do nothing except restrain progress in
tions, profile stability or reliability can then be as- the field at a time when sophisticated technology is
sessed. Profile reliability is essentially a multivariate experiencing explosive growth all around us. Major
problem and thus requires a multivariate solution. A publishers must be persuaded to enter the field in a
variety of statistical approaches may be used and the big way and users of neuropsychological tests must
specific purpose of the study may dictate different demand quality instrumentation.
research. In L. Shulman (Ed.), Review ofResearch in Educa-

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9
Models of Inference in Evaluating

Brain-Behavior Relationships in
Children
EILEEN B. FENNELL AND RUSSELL M. BAUER
Introduction goal, we will first describe basic issues in clinical

inference as they relate to child neuropsychology. In
Neuropsychologists generally measure behavior as a doing so, we will outline a ''hypothesis-testing'' ap-
means for making inferences about brain function. proach to neuropsychological assessment that bor-
Regardless of whether such measurement takes place rows from classical methods of inductive inference.
in the clinic or the laboratory, the basic process is the Finally, we will articulate some of the basic models
same: behavioral and cognitive performances that are of inference of particular relevance to child neurop-
readily observable "stand in," as it were, for the less sychological assessment.
observable ''brain states'' they are thought to reflect.
Once measurement is completed, the quantitative
and qualitative relationships among such perfor- Basic Issues in Clinical Inference
mances are assembled according to certain rules in
order to make probabilistic statements about brain
function. The rules that are applied in the given case Clinical-Inferential Methods
depend on the inferential model one uses in relating
behavioral performance to brain function. This basic ''Inference'' refers to the process of arriving at a
process characterizes all of neuropsychology, tran- conclusion by reasoning from evidence. Inferences
scends theoretical persuasion, and, in fact, is a funda- generally take place according to organized systems
mental aspect of the clinical-inferential method in of rules that stipulate (a) the kind of evidence on
general. which conclusions can be drawn, (b) the kinds of
It may seem trivial to point this out because conclusions that are possible given certain evidence,
making inferences about brain functioning from be- and (c) a set of logical connections between evidence
havioral data is so much a part of the neuropsycho- and conclusions. In child neuropsychology, the per-
logical approach. However, because such inferences formance of the child on cognitive or neuropsycho-
are so routinely made, it is important not only to logical tests is the "evidence" on which inferences
articulate the various levels at which they play a part about brain functioning are based. It is assumed that
in our thinking, but also to understand the specific the ''conclusions'' of interest are couched in terms of
theoretical assumptions on which they are based. The some aspect of brain function that is not directly ob-
goal of this chapter is to describe major inferential servable by the neuropsychologist. In general, we do
models that relate behavior to brain function in the not observe or measure ''functions''; we see only the
child neuropsychology area. In working toward this behavioral indicators of spared and impaired brain
functions. Thus, for example, we make inferences
about language function on the basis of performance
EILEEN B. FENNELL AND RUSSELL M. on tests of language ability; we may infer that there is
BAUER Department of Clinical and Health Psychology, Uni- some disturbance in brain-based attentional mecha-
versity of Florida, Gainesville, Florida 32610 nisms when the child cannot stay on task, repeat
167
168 CHAPTER 9
digits, or shows inconsistent performance across a set ic merits of this hypothesis, and its ability to explain
of homogeneous test items. core features of autism, are not at issue. What is
In what follows, we presume that there are com- important, however, is that the hypothesis was de-
plex differences between children and adults in terms rived by starting with observable signs and symptoms
ofhow brain pathology leads to neuropsychological and by inferring from them a possible functional
and behavioral deficits. Thus, the meaning or utility anatomy.
of a behavioral "sign" that has been well-validated
with adults may be different when that sign is applied
to child neuropsychology cases (Rourke, 1983; Levels of Inference
Aetcher & Taylor, 1984). Similarly, the predictive
value of knowing that a patient has had a specific Up to this point, we have discussed clinical in-
brain insult may critically depend on the age at which ference as if it were a simple process of reasoning
the damage was incurred (Woods & Teuber, 1973; from neuropsychological test performance to brain
Rasmussen & Milner, 1977). function. In fact, there are several types of inference
Despite the fact that the behavioral effects of the involved here, each of which exists at a different
brain disease are complexly dependent on such fac- level of analysis. For purposes of discussion, consid-
tors as age and stage of development, we believe that er a 5-year-old male child who has received a closed
one fruitful approach to understanding childhood head injury in a vehicular accident. He is given a
neuropsychological data is the classical inferential battery of neuropsychological tests including assess-
method commonly used in adult neurology (Adams ment of intellectual ability, memory, language, visu-
& Victor, 1977). Briefly, this method involves the al and auditory perception, attentional ability, and
collection of clinical data in terms of signs (e.g., sensorimotor skill. Results indicate low average in-
neuropsychological impairments) and symptoms tellectual ability, attentional and recent memory
(clinical complaints). These findings are then corre- problems, and poor beginning reading skills. We are
lated with similar signs and symptoms occurring in asked to relate the child's current status to the recent
neurological disorders in which the underlying anat- head injury and to assist in educational planning.
omy is known. By making analogy with these better There are three basic levels of analysis involved in
known disorders, and by reasoning from anatomic utilizing our test data to answer such questions. At
data, the findings in an individual case can be in- the first level, we are concerned with the degree to
terpreted in terms of some pathophysiological which the behavior elicited by the test battery is rep-
mechanism. resentative of the domain of behavior that would have
This particular approach can be used with the been elicited given unlimited testing time (Cronbach,
individual case or can form the framework of a gener- Rajaratnam, & Gieser, 1963). The basic issue here is
al conceptualization of a disorder that is as yet poorly whether our test findings are generalizable to other
understood. An excellent example is seen in a neu- settings or conditions. At the second level of analy-
robehavioral model of autism (Damasio & Maurer, sis, we are interested in the specific meaning of each
1978; Maurer & Damasio, 1982). These authors ob- of the test findings. Each test finding might have a
served various abnormalities in a group of autistic formal statistical (actuarial; see Wiggins, 1973) rela-
children, including disturbances of motility (stereo- tionship with a specific form of brain impairment or
typed movements, abnormal posturing and gait), at- may suggest a qualitative feature seen in other known
tention (unpredictable response to sensory stimuli, brain disease (Adams & Victor, 1977). In either
gaze aversion), communication (mutism, use and event, we are inferring what the outcome of each test
comprehension of nonverbal signs), and social be- means in terms of some nontest behavior or variable.
havior (poor cooperative play, failure to initiate so- This is a process that Holt ( 1968) termed primary
cial interaction). They related each of these signs and iriference. Thus, we make inferences regarding the
symptoms to findings in specific acquired neu- status of verbal memory ability (and its constituent
rological diseases (e.g., basal ganglia disease, ac- variables) by individually noting performance on
quired mutism from mesial frontal lobe lesions) in tests to which this ability contributes. At the third
which the pathogenesis and localization were more level, we are concerned with integrating the diverse
firmly established. On the basis of this analysis, they test findings to arrive at a general interpretation or
proposed a specific neuroanatomy for autism, which conceptualization of their meaning. We are con-
included the mesolimbic cortex (mesial temporal and cerned here with the degree to which the pattern of
frontal lobes), the neostriatum, and the anterior and spared and impaired abilities suggests a specific neu-
medial thalamic nuclei. For our purposes, the specif- ropsychological mechanism that can best account for
EVALUATING BRAIN-BEHAVIOR RELATIONSHIPS 169
the test findings and the clinical complaints. Holt ment approach. Regardless of whether one adopts a
( 1968) indicated that this level "quantitative" or a "qualitative" approach, or some
mixture of the two, an important concern is the man-
demands a knowledge of the range of expectable syn-
ner in which clinical data contribute to hypotheses
dromes, what their constituent variables are, and some
means of measuring the strength of each variable. By about the nature of the child's neuropsychological
drawing on this knowledge and on his [sic] knowledge status.
of theory, the diagnostician puts together his primary In this section, we outline a general approach to
inferences and in an act of secondary inference locates forming and testing hypotheses derived from neuro-
the subject with reference to diagnostic syndromes. (p. psychological test data that seems equally well suited
15) to both quantitative and qualitative models. This ap-
proach is based on our belief that there is no funda-
It is important to note that the specific inferences
mental distinction between scientific and clinical hy-
the clinician makes at each of these three levels will
potheses. That is, we believe that the same inferential
differ depending on the purpose and targets of assess-
processes one uses in the research laboratory for dis-
ment and will at least in part be related to the assump-
tinguishing between viable and invalid scientific hy-
tions the clinician makes about the relationship be-
potheses can be used in deriving and testing clinical
tween test behavior and brain function. Such
hypotheses (see also Landy, 1986, who takes a hy-
differences are most apparent at the second and third
pothesis-testing approach to the process of test val-
levels. For example, clinicians who favor an actu-
idation). Our approach is based on a model of induc-
arial or statistical approach to test interpretation will
tive inference outlined by Platt (1964), a model that
be most concerned with the formal quantitative rela-
abounds in the physical sciences, particularly mo-
tionships between test signs and specific forms of
lecular biology and high-energy physics. Platt called
neuropsychological impairment. Those who favor
his approach strong inference because its systematic
qualitative approaches might be more interested in
application seems related to rapid scientific advance
demonstrating the presence of one or more "pathog-
in the fields that utilize its strengths. It is based pri-
nomic signs'' that are considered crucial indicators of
marily on disconjirmatory logic (Popper, 1959) and
functional impairment. In either case, an attempt is
consists mainly of the sequential evaluation of hy-
made to relate the pattern of test findings to pre-
potheses that survive disconfirmation in experimen-
viously available data on children with head injuries.
tal (clinical) test. Strong inference consists of the
The quantitative clinician may attempt to determine
systematic application of the following steps:
the degree to which other children with documented
head injuries obtained the same or similar clinical
a. Devising alternative hypotheses
profile. The qualitative clinician might focus efforts
b. Devising "crucial experiments" with alter-
on determining the degree to which this child is sim-
native possible outcomes, each of which will
ilar to other head-injured children in terms of the
exclude one of the alternative hypotheses
specific neurobehavioral mechanisms that can best
c. Carrying out "clean" experiments
account for their neuropsychological deficit pattern.
d. Recycling the procedure with surviving
In actual practice, the responsible clinician fre-
hypotheses
quently uses a mixture of actuarial and clinical meth-
ods in making inferences from test data (Meehl,
These four steps are recognizable to all neuropsycho-
1957; Lezak, 1983).
logists as the basic elements of inductive inference.
The difference, however, is in the systematic, formal
Fundamentals of Hypothesis Formation: The application of all of these steps to every clinical
Logic of Strong Inference problem.
We will illustrate the utility of this approach by
In the previous section we briefly considered describing a series of simple "experiments" de-
three levels at which inferences about brain function signed to determine more precisely the nature of a
may be made from test performances. The specific specific neuropsychological deficit. As an example,
nature and content of such inferences will depend in assume we have a child who performs poorly on
large part on the assumptions the clinician makes WISC-R Block Design and assume that we have rea-
about the relationship between test behavior and son to believe from the medical history that a signifi-
brain function. That is, inferential processes in neu- cant neuropsychological factor is involved. Because
ropsychological assessment are inextricably related Block Design measures more than one ability, a
to the theoretical or conceptual basis of one's assess- question of some relevance might be to determine
170 CHAPTER 9
more specifically the nature of the child's failure. On this makes the clinician an additional source of vari-
an a priori basis, the Block Design test can be ance in test interpretation, which some (e.g.,
thought of as tapping motor, visuoperceptual, visu- Rourke, Bakker, Fisk, & Strang, 1983) find some-
omotor, constructional, and problem-solving abili- what undesirable, we believe that the "cognitive ac-
ties. A strong inference approach to isolating the rea- tivity of the clinician" is an integral and inevitable
son(s) for a deficit in Block Design would proceed aspect of neuropsychological test interpretation. This
first by devising a series of tests that systematically issue has received little systematic attention within
eliminate one or more of these constituent abilities neuropsychology, though some guidance is available
and then observing the resulting effects on perfor- from the contemporary application of the Brunswick
mance. Assuming relatively good control over diffi- Lens Model (Brunswick, 1956) to the practice of
culty level, performance on Block Design could be psychodiagnosis (Hammond, Hursch, & Todd,
contrasted with performance on visuoperceptual 1964; Hursch, Hammond, & Hursch, 1964; Meehl,
tasks without motor demands (e.g., form discrimina- 1960; Wiggins, 1973).
tion, visual synthesis). The relative role of visu- The basic idea is that inference in neuropsychol-
omotor versus motor abilities could be assessed by ogy is not only dependent on the specific relationship
contrasting performance on motor tests not requiring among test signs and brain function (so-called criteri-
visual tracking (e.g., fmger tapping, fine finger on-oriented validity), but also on the manner in
movements) with tasks with high visuomotor de- which the neuropsychologist uses such test signs in
mands (e.g., drawing, visual reaching, grooved peg- arriving at interpretive statements. There are two
board), and so on. By a systematic approach that basic issues involved here. First is the degree to
involves the ruling out of alternative hypotheses for which the clinician accurately uses the test results to
the Block Design performance, attention is gradually arrive at a clinical diagnosis. This issue can be under-
directed toward surviving hypotheses. For example, stood if one assumes that the separate test perfor-
a pattern of good performance on visual, problem- mances function as variables that, separately and in
solving, and motor tasks would tend to rule these combination, predict some criterion (e.g., brain
abilities out as explanations, leaving the hypothesis function). The intercorrelations among test perfor-
that it was the visuomotor or constructional aspect of mances, and their individual relationships to the cri-
Block Design that specifically gave rise to the poor terion, determine the relative importance (weighting)
performance. It is our view that almost any complex each performance has in predicting the criterion. In
behavior can be broken down in this way so that more an ideal setting, the neuropsychologist utilizes the
precise hypotheses about performance deficits can be various test performances in a manner that accurately
achieved. reflects the separate and combined relationship such
The most important point is that a strong in- performances actually have with the criterion. In this
ference approach, with its emphasis on disconfirma- ideal world, the clinician's inferences directly reflect
tion, is quite different from the logic typically used in the empirical validities of the various test perfor-
traditional approaches to neuropsychological testing. mances vis-a-vis the criterion; the test performances
Traditional approaches typically utilize a pattern of that bear stronger relationships with the criterion are
test performances (e.g., lateralized motor or sensory given more weight than are those that correlate less
findings, poor nonverbal memory performance) as highly. However, in actual clinical practice, the
confirmatory evidence for a particular hypothesis. clinician may not have precise knowledge of the pre-
This is the fundamental assumption underlying the dictive relationship between test performance and
so-called "sign" approach. Our view is that al- criterion. What might result from this situation is a
though this approach may result in correct in- method of combining test performances that does not
ferences, it does so inefficiently and at the risk that accurately reflect their predictive validity with re-
alternative explanations for a test sign or perfor- spect to the criterion. In this case, it becomes impor-
mance have not been entirely ruled out. tant to distinguish empirical validity (the statistical
relationship that exists between predictor variables
and criterion) and cue utilization (the relationship
Qinical Judgment in Neuropsychology between test performance and the inferences made by
the clinician) (see Wiggins, 1973, p. 157).
We have implied in the previous section that the A second issue is the manner in which test re-
theoretical model the clinician espouses will be an sults are combined to arrive at a clinical conclusion.
important factor governing the kinds of inferences Do neuropsychologist& combine test findings in the
made about neuropsychological test data. Although linear fashion implied by multiple regression ac-
counts of empirical validity, or do they adopt a more Models of Inference in Child

complex, nonlinear method of combining data in
which certain test scores are viewed as a priori more Neuropsychology
important than others? An example of a nonlinear
approach to test score interpretation is the use of the As Tarter and Edwards (1986) noted, clinical
''pathognomic sign'' approach in neuropsychology. neuropsychological assessment is descriptive, cor-
Pathognomic signs are performances that are seen relational, and inferential rather than explanatory,
rarely, if ever, in persons with normal brain function. causal, and direct. Neuropsychological procedures
When they do appear, therefore, they more than like- provide descriptive information regarding behavior
ly suggest some brain impairment. For example, the in both normal children and neurologically impaired
appearance of aphasia is regarded as a pathognomic children. This description of behavior on standard-
sign of left hemisphere impairment. In terms of this ized and formal observations (tests) is then correlated
discussion, pathognomic signs could be weighted with suspected or known pathological lesions derived
very heavily and could form the basis of the clinical from other tests (concurrent validity) in order to en-
judgment even in the absence of other supportive able the neuropsychologist to: ( 1) infer the presence
clinical evidence. In this situation, the clinician could or absence of brain pathology from test signs (pri-
elect, perhaps unwisely, to ignore the relationships mary inference) or (2) classify the individual child
among other test performances and the criteria if according to test and historical variables into some
pathognomic signs are present. classification group (e.g., brain injured, learning dis-
abled, attention deficit disordered) by a process of
secondary inference. Although the inferential pro-
Summary cess may be similar in adult and child neuropsychol-
In discussing these basic issues, our purpose has ogy, major differences exist in the context of that
not been to argue for one or another approach to process.
interpretation, but rather to articulate the processes
entering into the inferential process in child neuro- The Inferential Context of Child
psychology. Our view is that it is important to be Neuropsychology
explicitly aware of the crucial role such processes
play in making sense out of neuropsychological test Several recent texts devoted to child or develop-
data. In large part, the concepts that are invoked to mental neuropsychology emphasize the critical dif-
explain neuropsychological test performances (e.g., ferences in the neuropsychological organization and
attention, memory capacity) are unobservable and functioning of children as compared to adults
must be inferred from overt behavior. Whether one (Rourke et al., 1983; Spreen, Tupper, Risser, Tuok-
elects to deal at the individual test level or at the level ko, & Edgell, 1984; Hartlage & Telzrow, 1986).
of pattern analysis, the same basic inferential pro- Furthermore, as the analytic focus for the child
cesses are involved. In this section, we have pur- neuropsychologist is on a developing brain, inferen-
posely emphasized the context, rather than the con- tial processes regarding brain function must rest on
tent, of inductive inference in the clinical setting. As models that account for differences in development at
we have stated, this is important because the inferen- different ages (Segalowitz & Gruber, 1977; Vander
tial method is such a fundamental aspect of the neu- Vlugt, 1979; Dean, 1986) rather than rely on the
ropsychological approach. We have outlined a strong fixed models of adult brain functions and pathologies
inference model that, for us, is a useful way of con- (Lezak, 1983; Heilman & Valenstein, 1985). In addi-
ceptualizing the process of hypothesis formation and tion, unlike adult neuropsychology, child neuropsy-
hypothesis testing in child neuropsychology. Finally, chology is still in need of basic descriptions of the
we have attempted to point out some of the general neuropsychological effects of developmental and ac-
issues involved when a clinician attempts to derive quired pathologies of childhood (Boll & Barth, 1981;
meaningful interpretations of multiple test perfor- Boll, 1983; Menkes, 1985; Netley & Rovet, 1983;
mances. With these broad issues as a background, the Pirozzolo, Campanella, Christensen, & Lawson-
specific nature and content of the inferences made by Kerr, 1981; Rutter, 1983; Spreen et al., 1984) as well
the neuropsychologist will in large part depend on the as with regard to understanding the role of individual
level of data analysis and on the conceptual model differences in affecting the descriptive and inferential
that governs the assessment approach. We now tum processes in child neuropsychology (Bakker, 1984;
to a discussion of the major inferential models of Bolter & Long, 1985; Clark, 1984; Rourke &
relevance to the child neuropsychologist. Adams, 1984; Dean, 1986). Finally, only recently
172 CHAPTER 9
has an emphasis been placed on the discriminative terpretation of large numbers of clinical groups can
validity of various test signs and historical indicators be gathered (Tarter & Edwards, 1986; Hartlage &
of certain subgroups of childhood disorders such as Telzrow, 1986). However, a fixed battery approach,
learning disabilities (Rourke, 1981; Rourke, Fisk, & particularly one that is empirically rather than the-
Strang, 1986; Morris, Blashfield, & Satz, 1986) or oretically based, may not be designed to assess age-
minimal brain dysfunctions (Denck1a, 1979; Satz & related differences sensitively in problem-solving be-
Fletcher, 1980; Ross & Ross, 1982; Chadwick & haviors because the emphasis is often on quantitative
Rutter, 1983). To the extent that the content of neu- discrimination. Frequently educational and other ex-
ropsychological knowledge of the developing brain periential variables are not treated in the content of
is still emerging, primary and secondary inference in the battery itself and often the battery may not be
child neuropsychology is affected by maturational capable of addressing specific referral questions such
and experiential variables to a more significant as prescription of remediation programs for a devel-
degree than is typically assumed in adult neuropsy- opmental impairment. Finally, many fixed batteries
chology. At the same time, methods of assessing suffer from dependence on the match between the
neuropsychological functioning in children were his- validation and cross-validation samples and the base
torically rooted in the work on adult assessment (ln- rate of clinical problems in the sample in which it is
cagnoli, Goldstein, & Golden, 1986). It is not sur- applied. Thus, for example, batteries developed at a
prising, therefore, to find that there are many hospital-based referral clinic may or may not be as
clinicians who have approached child neuropsychol- capable of detecting cognitive disorders in a school-
ogy with techniques of assessment and models of based or psychiatry inpatient setting.
inference that were borrowed from adult batteries or In the flexible battery approach, a core set of
with "scaled-down" versions of adult tests, there- standardized tests are administered to which are add-
sults of which form the data for their clinical in- ed a selected set of additional tests designed to en-
ferences (Boll & Barth, 1981; Boll, 1983; Rourke et hance examination for specific referral questions
al., 1983). (Rourke et a/., 1986) or as problem behaviors
are elucidated from the core battery (Hartlage &
Telzrow, 1986). Like the fixed battery, such an ap-
Assessment Methods in Child proach may be empirically derived or theoretically
Neuropsychology based or some mixture of the two such as when a
screening battery, empirically derived, is followed
Broadly speaking, assessment approaches in by a theoretically based complement of tests de-
child neuropsychology can be classified into three signed to test the best fit to a syndrome type. The
major types: a fixed battery approach, a flexible bat- advantage of such a flexible battery is the ability of
tery approach, and an individualized or patient-cen- the neuropsychologist to employ both a nomothetic
tered approach. In the fixed battery approach, the as well as an ideographic approach to child assess-
same set of tests, designed to tap a very broad spec- ment in order to allow for evaluation of broad dimen-
trum of functions and abilities, is administered to sions of behaviors as well as specific subcomponents
each child regardless of the referral question. This of an ability or symptom related to a specific referral
approach (reviewed in more detail in a subsequent question.
chapter by Golden) may be either empirically or the- In the individualized or patient-centered ap-
oretically based. In the former instance, the test bat- proach to assessment (Goodglass, 1986), the set of
tery is selected according to its ability to separate test procedures employed is driven by two interacting
groups and is typified by the work of Reitan and his factors: the referral question that includes the child's
associates. Theoretically based batteries, in contrast, history and presenting symptoms and the test perfor-
are founded upon a theory of development as it re- mance (successes and failures) itself (Luria, 1973;
lates to rather broad or narrow dimensions of behav- Christensen, 1975). More than any other approach,
ior and is typified by the Florida Longitudinal Project the patient-centered assessment requires that the
Battery (Satz & Morris, 1981). Fixed batteries may clinician have substantial clinical knowledge of the
also include formal decision rules for clinical in- specific as well as nonspecific effects of brain lesions
terpretation (Rourke, 1981; Rourke et al.. 1986). on brain development and neuropsychological func-
The major advantages of a fixed battery approach are tioning. The patient-centered approach has, as a pri-
the breadth and depth of functions assessed, the nor- mary goal, the isolation of a specific neurobehavioral
mative data bases frequently provided, and the ease mechanism to account for the pattern of test findings.
with which a systematic data base for clinical in- In this sense, the logic underlying this approach is
most easily adapted for use in the strong inference ual dexterity), preferred performance (e.g., handed-
model outlined earlier. ness), or accuracy of performance on sensory or
A number of lesion-related factors have been motor tasks (e.g., tactile form discrimination).
shown to have a differential impact on the developing Transfer of learning from one side to the other may
brain including: age at time of insult (e.g., prenatal also be compared (e.g., dominant versus nondomi-
versus adolescence), type of lesion (e.g., vascular nant hand time to complete Tactual Performance
versus infectious), site oflesion (e.g., primary versus Test, Reitan & Davison, 1974). In this analysis, dif-
association cortex), and etiology (e.g., anoxia versus ferential performance between the sides of the body
trauma). As yet, however, detailed descriptions of or in transfer of learning is the basis for inferring
the neuropsychological functions and organization of differential functional integrity at the level of the
behaviors in many children with development or ac- brain (Reitan & Davison, 1974).
quired neuropathologies are not yet available. As a The fourth approach, the longitudinal ap-
result, the highly clinical-inferential approach of the proach, compares performance on a battery of tests
patient-centered battery is infrequently seen in over time. In this approach, pretest versus posttest
practice. comparisons can be made of the effects of a known
acquired lesion (e.g., surgical excision of an epilep-
tic lesion), of the effects of recovery or restoration of
Quantitative Inferences in Child function following an acquired lesion (e.g., recovery
~europsychology of memory functions subsequent to head trauma), or
of the effects of a treatment intervention (e.g., phar-
There are four major inferential approaches that macological therapy for attention deficit disorder
focus on quantitative aspects of performance in child with hyperactivity).
neuropsychological assessment. These interpretive In all these quantitative approaches, the reliabil-
approaches derive primarily from the fixed battery ity and validity of the interpretations made rest on the
methods in clinical assessment outlined by Reitan data base available. Although normative data con-
and others and focus on: (I) level of performance, (2) tinue to be developed, there is still a paucity of data
differential score patterns, (3) comparisons between about the neuropsychological performance of various
sides of the body, and (4) comparisons of perfor- childhood neurologic disorders as well as a paucity of
manceacrosstime(Boll, 1983;Rourkeetal., 1986). longitudinal studies of these clinical groups against
In the level ofperformance approach, the child's which normal versus abnormal inferences can be
performance on a variety of measures is individually derived.
compared to normative data available for age-
matched normal subjects or for selected clinical com-
parison subgroups (Satz & Morris, 1981; Spreen et Qualitative Inferences in Child
al., 1984). Oneriskofthis approach is a high number ~europsychology
of false-positive errors due to the large number of
factors (e.g., psychiatric disturbance) besides brain Reflecting the emphasis of American psychol-
dysfunction that can lead to poor performance. ogy on a psychometric approach, it is an unfortunate
The differential score or panern approach eval- truth that only recently have developmental neu-
uates an individual's set of performances on a battery rologists begun to collect data on the qualitative as-
of tests and may compare relative strengths or weak- pects of performance in both normal and abnormal
nesses in the total performance or may attempt to development and attempted to relate these findings to
match a pattern or profile of scores to a clinical sub- neurologic models of brain development and to cog-
type. This is frequently done in the learning dis- nitive development (Fletcher & Taylor, 1984; Waber
abilities literature. This latter inferential approach is & Holmes, 1985). The focus of this approach is the
often difficult due to the fact that all measures do not emphasis on the qualitative features of performance
equally allow for a comparison between the idealized (''how" a test is performed) rather than solely on the
referrant group and the individual case (Morris, quantitative features of performance ("what" is
Blashfield, & Satz, I 986) or due to the absence of a achieved). By examining these qualitative features of
well-defined ideal subtype to which the individual performance, inferences are derived about the pro-
case is compared (Boll, 1983). cesses involved in executing a given behavioral task.
Comparisons between sides of the body may be These processes are then related to the differential
made on the basis of speed of performance (e.g., functions of the right or left cerebral hemispheres or
finger tapping rate), skill of performance (e.g., man- to other subcortical functional processes (Van der
174 CHAPTER 9
Vlugt, 1979). To some degree, this approach has also description of brain pathology in adults. Although it
been applied to an analysis of errors in performance, has been argued that the type and locus of childhood
for example, among different subgroups of learning- brain pathologies often do not lead to a picture of
disabled children (Hynd, Obrzut, Hayes, & Becker, focal deficits (Boll & Barth, 1981; Boll, 1983),
1986) and to understanding the neurobehavioral defi- wherever possible, appropriate neurological and neu-
cits of autistic children (Damasio & Maurer, 1978). rodiagnostic criteria must be utilized to assess the
To some extent, this qualitative approach also under- sensitivity of behavioral tests to brain pathology.
lies the pathognomic sign approach in models of de- The similar-skills fallacy focuses on the belief
velopmental delay versus deficit (Hartlage & that tests developed and normed on adult subjects
Telzrow, 1986), in the analysis of "soft" versus measure the same abilities in children. Thus, for ex-
"hard" neurologic signs among learning-disabled ample, age norms that step down from adult age
children (Denckla, 1979; Shafer, Shaffer, O'Con- groups to younger children have been published for
nor, & Stokman, 1983; Shaffer, O'Connor, Shafer, such widely used adult measures as the Wechsler
& Prupis, 1983), and in the search for behavioral Memory Scale (Ivinskis, Allen, & Shaw, 1971). In
signs of "organicity" such as rotations in drawings this example, it is assumed that children process
(Boll, 1983). In this latter context, the neuropsychol- these task demands in a fashion similar to adult sub-
ogist infers that the presence of the ''sign'' indicates jects, despite clear evidence of age-based differences
the presence of brain damage or brain dysfunction. in the capacity and processes of verbal memory in
As Rourke et al. (1983) pointed out, however, the children (Kail, 1984). Other major differences be-
risk of relying upon this approach is the likelihood of tween children and adults are widely recognized in
increasing false-negative errors, for the absence of such important behavioral domains as language
sign is interpreted to reflect the absence of pathology. (Segalowitz, 1983), right hemisphere functions
In fact, it is now recognized that behavioral signs of (Witelson, 1977) and early versus later acquired
brain pathology are age-related and may appear, dis- reading skills and the role of the right versus the left
appear, and reappear at different stages of develop- hemisphere (Bakker, 1984).
ment due to the late versus early effects of a lesion as The special-sign fallacy occurs when neuropsy-
well as the capacity of the developing brain to adapt chologists utilize specific test behaviors (e.g., rota-
and to compensate for brain pathology (Stein, Rosen, tions in drawings) as signs of brain pathology or infer
& Butters, 1974; Boll, 1983). Finally, as noted with from the presence of minor, accompanying or corre-
regard to quantitative inference, qualitative inference lated signs that the major pathology from which these
also depends on carefully documented empirical data signs derive is present. A variant of this same fallacy
relating qualitative aspects of performance to normal occurs throug)J the overreliance on analogies be-
and abnormal development, which are still not wide- tween signs of CNS pathology in adults and the as-
ly available to clinical practitioners (Spreen et al. , sumption that such signs must also mean CNS pa-
1984). thology in children. As Fletcher and Taylor (1984)
and Boll (1983) noted, there is very little evidence
that similar behavioral pathologies seen in adults and
Inferential Fallacies in Child children reflect similar etiologies. We do not want to
Neuropsychology imply that lessons learned from adult neurology
should not be applied to children-only that they
Fletcher and Taylor (1984) pointed out a must be applied with caution. The major advantage
number of inferential fallacies about the relationship of such application would be to generate new hypoth-
between a child's test performance and the integrity eses capable of being put to subsequent disconfir-
of that child's brain. These fallacies include: (1) the matory trials.
differential-sensitivity fallacy, (2) the similar-skills Finally, the brain-behllvior isomorphism fal-
fallacy, (3) the special-sign fallacy, and (4) the lacy consists of mistaking dysfunction on behavioral
brain-behavior isomorphism fallacy. tests as prima facie evidence of brain dysfunction.
In the differential-sensitivity fallacy, it is as- Instead, there is a need to document that behavioral
sumed that neuropsychological test findings associ- dysfunction observed on a. test is related to brain
ated with brain lesions in adults will be useful signs of pathologies and not to other sources of variability
brain disease in children. Instead, Fletcher and Tay- such as experiential, socioeducational, or emotional
lor ( 1984) argued that one must document that a par- factors. As Fletcher and Taylor ( 1984) noted, there is
ticular measure is a sensitive neurobehavioral mea- no simple relationship between the degree or extent
sure in children whether or not it is helpful in the of brain involvement and the degree of behavioral
disorder among children with brain pathology. This The context of the primary or secondary inferen-
fallacy is often embedded in the language employed tial process in child neuropsychology is influenced
by the child neuropsychologist such that descriptions by several critical factors that include: the lack of a
of behavioral dysfunctions are equated inferentially consistently employed neurologic model of brain de-
to etiology (developmental delay) or to diagnosis velopment to relate to behavioral data; the differen-
(brain damage) (Hartlage & Telzrow, 1986). tial effects of lesions according to age at insult; type
Boll ( 1983) cautioned against several other per- and etiology of lesion on a developing brain; the need
sistent myths in the field of child neuropsychology. for better descriptive data on a wide variety of clinical
One myth suggests that there are certain predictable populations in developmental neuropathologies; and
characteristics of brain-damaged children rather than the need for better specification of quantitative as
recognizing that the overriding effect of brain well as qualitative aspects of normal and abnormal
damage upon psychological functioning is to in- behavior. In the absence of substantive knowledge of
crease the variability of behavior. A second myth the influence of such critical factors, inferential mod-
asserts that brain damage in children causes charac- els in child neuropsychology are still primarily de-
teristic hyperactive motor behavior rather than recog- scriptive in nature. The beginning emergence of an
nizing that changes in simple, complex, and inte- integration of description and adequate neuropsycho-
grated motor skills may occur in many but not all logic tests (Freides, 1985) with classification
neurologic disorders, including psychiatric/be- schemes should facilitate prescriptions for remedia-
havioral disorders without evidence of neurologic tion and better understanding of the effects of inter-
abnormality. vention on the remediation of neurobehavioral defi-
Still another myth asserts that perceptual dys- cits resulting from neurologic pathologies in infancy,
functions are the major difficulties produced by brain childhood, and adolescence.
damage in children rather than recognizing that no
single pattern of neuropsychological deficits is char-
acteristic of brain damage in children. One final myth
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Wechsler Memory Scale norms to lower age groups. Journal Rourke, B. P., Fisk, J. L., & Strang, J.D. (1986). Neuropsycho-
of Clinical Psychology, 26, 354-357. logical assessment of children: A treatment oriented ap-
Kail, R. (1984). The development of memory in children. San proach. New York: Guilford Press.
Francisco: Freeman. Rutter, M. (Ed.). (1983). Developmental neuropsychiatry. New
Landy, F. J. (1986). Stamp collecting versus science: Validation York: Guilford Press.
as hypothesis testing. American Psychologist, 41, ll83- Satz, P., & Fletcher, J. M. (1980). Minimal brain dysfunction: An
ll92. appraisal of research concepts and methods. In H. E. Rie & E.
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the point of view of behavioral neurology. Journal of Autism chological and cognitive processes in reading (pp. 109-
and Developmental Disorders, 12, 2ll-221. 141). New York: Academic Press.
Segalowitz, S. (Ed.). (I 983). Language functions and brain orga- batteries. In T. Incagnoli, G. Goldstein, & C. J. Golden
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Segalowitz, S. J., & Gruber, F. A. (Eds.). (1977). Language teries (pp. 135-153). New York: Plenum Press.
development and neurological theory. New York: Academic Vander Vlugt, H. (1979). Aspects of normal and abnormal neu-
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(1983). Hard thoughts on neurological soft signs. In M. Rut- Waber, D.P., & Holmes, J. M. (1985). Assessing children's copy
ter (Ed.), Developmental neuropsychiatry (pp. 133-143). of productions of the Rey-Osterrieth complex figure. Jour-
New York: Guilford Press. nal of Clinical and Experimental Psychology, 7, 264-280.
Shaffer, D., O'Connor, P. A., Shafer, S. Q., &Prupis, S. (1983). Wiggins, J. S. (1973). Personality and prediction: Principles of
Neurologic "soft signs": Their origins and significance for personality assessment. Reading, MA: Addison-Wesley.
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try (pp. 144-163). New York: Guilford Press. terhernisphere plasticity: An empirical and theoretical re-
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(1984). Human developmental neuropsychology. New York: development and neurological theory (pp. 213-287). New
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Stein, D. G., Rosen, J. F., & Butters, N. (Eds.). (1974). Plasticity Woods, B. T., & Teuber, H. L. (1973). Early onset of comple-
and recovery offunction in the central nervous system. New mentary specialization of cerebral hemispheres in man.
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Tarter, R. E., & Edwards, K. L. (1986). Neuropsychological 113-117.
II
Neuropsychological Diagnosis
10
Halstead-Reitan Neuropsychological
Test Batteries for Children
NANCY L. NUSSBAUM AND ERIN D. BIGLER
The purpose of this chapter is to review the children's dardize a battery of measures to assess various as-
version of the Halstead-Reitan neuropsychological pects of brain functioning in children. The major
test batteries for children. The Halstead-Reitan Neu- theoretical basis of the Halstead-Reitan and the
ropsychological Test Battery for Children 9 to 14 Reitan-lndiana is the proposition that behavior has
years of age (Reitan & Davison, 1974) and the an organic basis. Thus, performance on behavioral
Reitan-Indiana Test Battery for Children ages 5 measures can be used to assess brain functioning.
through 8 (Reitan, 1969) are two children's batteries Obviously, in order to infer brain functioning based
based on the adult version of the Halstead-Reitan on behavioral measures, it was necessary to validate
(Reitan & Wolfsun, 1985). These two batteries will . these measures on children with known brain
be discussed in terms of their development and valid- damage.
ity. This discussion will be followed by a description
of the measures, their administration, scoring, and
the functional domains they are purported to mea- Validation Studies
sure. Finally, the interpretation of test results ob-
tained from the Halstead-Reitan and the Reitan-In- The validation of the Halstead-Reitan for chil-
diana will be discussed. dren was first reported by Reed, Reitan, and Klove
The Halstead-Reitan Neuropsychological Test (1965) for 9- to 15-year-old children with known
Battery for Older Children (9 to 14) and the Reitan- brain damage, and by Klonoff, Robinson, and
Indiana Neuropsychological Test Battery for Young- Thompson (1969) for 5- to 9-year-old children.
er Children (5 to 8) are two of the most commonly These studies demonstrated the validity of using neu-
used neuropsychological test batteries for children. ropsychological variables from the Halstead-Reitan
These batteries were developed by Ralph Reitan to differentiate brain-damaged from non-brain-
based on the adult version of the Halstead-Reitan damaged children. Subsequently, numerous studies
Neuropsychological Test Battery (Halstead, 1947; have shown the discriminant validity of the
Reitan & Davison, 1974; Reitan & Wolfsun, 1985). Halstead-Reitan and the Reitan-Indiana in separat-
The children's batteries include modifications and a ing children with known brain damage from non-
downward extension of the adult Halstead-Reitan, brain-damaged children (Boll, 1974; Reitan, 1974;
as well as the addition of some supplementary mea- Selz, 1981; Selz & Reitan, 1979a,b). For example,
sures not included in the adult version (see Table 1). Boll (1974) matched 27 brain-damaged children with
The reason for the development of the 27 normal children on the basis of age, sex, race, and
Halstead-Reitan and the Reitan-Indiana was to stan- handedness. Significantly poorer performance by the
brain-damaged group was reported for finger oscilla-
tion (dominant and nondominant), the tactual perfor-
NANCYL. NUSSBAUM Learning Diagnostic Center/ Aus- mance test (dominant, nondominant, and both
tin Neurological Clinic, Austin, Texas 78705. ERIN 0. hands), finger recognition (dominant), fingertip
BIGLER Department of Psychology, University ofTexas at number writing (dominant and nondominant), Sea-
Austin, Austin, Texas 78712; and Austin Neurological Clinic, shore Rhythm Test, and Speech Sounds Perception
Austin, Texas 78705. Test. Similar results were found by Reitan ( 1974) in a
181
182 CHAPTER 10
TABLE 1. Subtests of the Halstead-Reitan

Neuropsychological Test Batteries for Children
Halstead battery<' Reitan-Indiana battery<'
(9-14 years) (5-8 years)
Category test Category test

Tactual performance test Tactual perfonnance test
Fingertapping test Fingertapping test
Speech sounds perception test
Seashore rhythm test
Trail-making test, A & B Marching test
Sttength of grip test Sttength of grip test
Sensory perceptual exam Sensory perceptual exam
Tactile fmger localization test Tactile finger localization test
Fingertip number writing test Fingertip symbol writing test
Tactile fonn recognition test Tactile form recognition test
Aphasia screening test Aphasia screening test
Color form test
Progressive figures test
Matching pictures test
Target test
Matching figures and matching V's test
Drawing of star and concentric squares
"The Wechsler Intelligence Scale for Olildren-Rcvised (Wechsler, 1974), the Wide
Rallge Ac:bievemellt Test-Revised (Jastak & Wilkinson, 1984), and the Lateral Domi-
nance Test (Harris, 1947) are often included in the comprehensive neuropsychological
evaluation of children.
study with children aged 5 to 8, matched for age and memory, visuospatial abilities, visuomotor abilities,
sex. Furthermore, in a study of children with ques- conceptual processing, sequential processing, and
tionable rather than defmite neurological impair- language functioning. Therefore, although the
ment, it was found that a neuropsychological test Reitan-lndiana and the Halstead-Reitan are often
battery correctly identified the presence or absence of used in the evaluation of organic dysfunction in chil-
~pairment, even when the initial subjective clinical dren, they also have a great deal of clinical utility as
impressions did not suggest deficits (Tsushima & measures of behavioral competencies in children. In
Towne, 1977). Also, in a recent study (Nici & regard to this use of the Reitan-Indiana and the
Reitan, 1986) using intellectual, achievement, and Halstead-Reitan to assess behavioral functioning,
neuropsychological measures, it was found that mea- Fletcher and Taylor (1984) proposed that the great-
sures of motor functioning and general neuropsycho- est clinical utility of these instruments is in their
logical abilities were the best discriminators of 9- to usefulness in defining the ability structure of the
14-year-old brain-damaged children versus non- child. They argued that the widest clinical applica-
brain-damaged children. tion of the children's neuropsychological batteries is
It should be added that although the Reitan- related to the clinical sensitivity of these measures to
lndiana and the Halstead-Reitan were originally de- the child's behavioral strengths and weaknesses.
veloped to assess brain damage in children, they In summary, as can be seen from the previous
also have been used extensively to evaluate various discussion, the Reitan-Indiana and the Halstead-
aspects of purely behavioral functioning. As such, Reitan have a wide variety of clinical applications.
in general clinical practice, the assessment of func- These test batteries can be useful in the behavioral
tional aspects of behavior may be the most widely assessment of children with known brain damage, as
used application of these measures. Through the use well as in the evaluation of the ability structure of the
of the Reitan-Indiana and the Halstead-Reitan, a child without known brain damage. In the next sec-
great deal of information can be obtained concerning tion, types of behaviors measured, the administration
certain aspects of sensory functioning, motor abili- and scoring of the Halstead-Reitan and the Reitan-
ties, auditory processing, attention, spatial abilities, Indiana will be discussed in greater detail.
HALSTEAD-REITAN TEST BATTERIES 183
Subtests from the Halstead-Reitan Domain Measured. The tactual performance

Neuropsychological Test Battery for test is a measure of tactile, motor, spatial, and memo-
ry functioning.
Children Ages 9 through 14
Nonnative data for the measures included in the Fingertapping Test
Halstead-Reitan have been developed by Spreen and Description. This test requires a child to tap a
Gaddes (1969) and Knights and Norwood (1980).* mounted key as quickly as possible with the index
See Tables 2 and 3 for an example of a raw score finger of the dominant and nondominant hand. Five
conversion table, in which raw scores are converted trials are given for each hand.
to standard scores (X= 100, S.D. = 15) using nor-
mative data. Scoring. The child's raw score is the average of
the five scores from the dominant and nondominant
hand.
Category Test
Domain Measured. This task is a measure of
Description. This test includes 168 items pre- fine motor speed and coordination.
sented visually to the child. The child must respond
by selecting a number ( 1, 2, 3, or 4) that corresponds
with the visual stimulus. Feedback is given on each Speech Sounds Perception Test
item regarding the correctness or incorrectness of the Description. On this test, the child must dis-
response. criminate nonsense words presented on a tape record-
Scoring. The child's raw score is the total er. The child is given four choices to select from and
number of errors made. Normative data are also must underline the correct stimulus.
available for each of the six subtests of the category Scoring. The child's raw score is the total
test (Knights & Norwood, 1980). number of items correct out of 30.
Domain Measured. The category test is a mea- Domain Measured. Auditory discrimination,
sure of concept formation. The child must abstract sound-symbol matching, and attentional abilities are
principles related to number concepts, spatial posi- assessed on this task.
tion, and unusualness of the stimuli. There is also a
memory component involved in the last subtest of
this measure. Seashore Rhythm Test
Description. The child is presented pairs of
Tactual Performance Test rhythms on a tape recorder and must discriminate
whether they are the same or different.
Description. On this test, the child is required
to complete a six-figure formboard while blind- Scoring. The child's raw score is the total
folded. The test is carried out first with the dominant number of items correct out of 30.
hand, then the nondominant hand, and finally with Domain Measured. This test is a measure of
both hands. Next, the board is removed and the child nonverbal auditory perception, attention, and
is asked to draw from memory the shapes and their concentration.
correct locations.
Scoring. The child's raw score is the amount of Trails A
time taken with the dominant, nondominant, and
both hands. The total time is the sum of the trials with Description. On this test, the child must con-
the dominant, nondominant, and both hands. Also, nect circles containing the numbers 1 through 15 as
the memory raw score is the total number of blocks quickly as possible.
recalled, and the location raw score is the number of Scoring. The child's raw score is the number of
blocks reproduced in their correct locations. seconds taken to complete the task, and the number
of errors made.
*Address for nonnative data: Dr. Robert M. Knights Psychologi- Domain Measured. This task includes compo-
cal Consultants, Inc., 52 Hopewell Ave., Ottawa, Ontario K15 nents measuring visual perception, motor speed, se-
2Y8, Canada ($6.50). quential skills, and symbol recognition.
184 CHAPTER tO
TABLE 2. Finger Oscillation-Dominant Handa

Electric tapper Manual tapper
Age'> 6 7 8 9 10 II 12
x 30.9 33.6 37.9 34.3 37.7 38.9 41.3
S.D. 3.27 3.93 5.45 4.37 4.98 5.51 5.47
Raw score
20
21 55
22 59 56 56 58
23 64 60 59 61 56 57
68 63 62 65 59 60
24
73 67 64 68 62 63
*
55
25
26 78 71 67 72 65 65 58
27 82 15 70 75 68 68 61
28 87 79 73 78 71 71 64
29 91 82 76 82 74 73 66
30 96 86 78 85 71 16 69
31 too 90 81 89 80 79 72
32 lOS 94 84 92 83 81 74
33 110 98 87 96 86 84 71
34 114 102 89 99 89 87 80
35 119 lOS 92 102 92 89 83
36 123 109 95 106 95 92 85
37 128 113 98 109 98 95 88
38 133 117 100 113 101 98 91
39 137 121 103 116 104 100 94
40 142 124 106 120 107 103 96
41 146 128 109 123 110 106 99
42 151 132 111 126 ll3 108 102
136 114 130 116 lll lOS
43 **
44 140 117 133 119 ll4 107
45 144 120 137 122 116 110
46 122 140 125 119 113
47 125 144 128 122 116
48 128 131 125 118
49 131 134 127 121
so 133 137 130 124
51 136 140 132 126
52 139 143 135 129
53 141 137 132
S4 144 141 135
55 143 137
56 ** ** ** ** 140
57 143
58
59 ** ** ** ** **
60 ** **
Standard sans (X = 100, S.D. IS) were c:alculated based on the normative data devel-
oped by S}IRell and Gaddes (1969). standard score greater than three standard deviations
below lbe mean; , standard scote greater than three standard deviations above lbe mean.
six- to eight-year-old norms are for lbe electric fin&ertappet; 9- to 12-year-old norms are for
lbe manual fingertapper.
TABLE 3. Right Hand0

Fingertip symbol writing Fingertip number writing
Age 5 6 7 8 9 10 11 12 13 14
X errors 6.00 3.50 2.70 2.05 4.36 3.25 2.75 2.00 0.50 0.50
S.D. 3.00 2.50 2.00 1.50 3.73 3.01 2.00 1.00 o.ss 0.40
Raw score
0 130 121 120 121 117 116 121 130 113 119
I 125 115 113 lll 113 111 113 115 86 81
2 120 109 105 101 109 106 106 100 59
3 115 103 98 91 105 101 98 85
4 110 97 90 81 101 96 91 70
5 105 91 83 71 97 91 83 55
6 100 85 75 61 93 86 76
7 95 79 68 90 81 68
8 90 73 60 86 76 61
9 85 67 82 71
10 80 61
** 78 66
11 75 55 74 61 **
12 70 70. 56 *"'
13 65 66
14 60 62
IS 55 58
Standard sco~ (X = 100, S.D. = 1') were calculated based on tbe normative data deY!'loped by Knights and
Norwood (1980). ** standanl ~greater diaD duee standanl deviations below tbe mean.
Trails B Sensory Perceptual Exam

Description. This test requires the child to con- Tactile, auditory, and visual perception are
nect alternating letters (A to G) and numbers (l to 8). measured by this task.
Scoring. As in Trails A, the child's raw score is Tactile Perception. The child is asked to close
the number of seconds taken to complete the task, the eyes and to report whether the right hand, left
and the number of errors made. hand, right face, or left face is being lightly touched.
Following unilateral trials to determine whether the
Domain Measured. Trails B also measures vi- child can perceive
sual perception, motor speed, sequencing skills, and unilateral stimulation, bilateral tri-
symbol recognition. It also is a measure of simul- als are randomly interspersed with unilateral trials.
taneous processing and cognitive flexibility. Bilateral trials include the stimulation of both hands
and contralateral stimulation of the hand and face, the
so-called double simultaneous stimulation (DSS)
Strength of Grip Test procedure. (In addition, we have found it useful to
include ipsilateral hand/face trials. This appears to
Description. The child's grip strength is mea- require more sensitive tactile discrimination.)
sured using a dynamometer adjusted for hand size.
Three alternating trials are allowed for the dominant Scoring. A raw score for each body side is cal-
and nondominant hand. culated by summing the total number of errors made
on unilateral and bilateral trials. (Ipsilateral errors are
Scoring. A mean raw score is obtained for each not included in this raw score when converting raw
hand. scores to standard scores.)
Domain Measured. Differential hand strength Domain Measured. Differential tactile percep-
is assessed by this measure. tion is measured by this task.
186 CHAPTER 10
Auditory Perception. The examiner lightly Tactile Form Recognition Test

rubs his/her fingers together by the child's right ear,
left ear, or both ears. The child is asked to close his Description. The child places a hand through
eyes and to report where the sound is coming from. an opening in a board, and the examiner places either
Following unilateral trials to determine whether the a small cross, triangle, square, or circle in the child's
child can perceive unilateral stimuli, bilateral trials hand without the child seeing what object has been
are randomly interspersed with unilateral trials. Bi- placed there. The child must then point to the correct
lateral stimulation constitutes the DSS procedure for object on the board with the other hand. The task is
auditory stimulation. carried out two times with each hand.
Scoring. A raw score for each ear is calculated Scoring. The raw score is the sum of errors
by summing the total number of errors made on uni- made with each hand, and the number of seconds
lateral and bilateral trials. taken to identify the object with the right and the left
hand.
Visual Perception. The child's visual fields are
tested by quadrant. Then the child is asked to report Domain Measured. This test is a measure of
peripheral, unilateral, and bilateral single move- attention, tactile perception, and reaction time for
ments by the examiner at eye level, above eye level, each body side.
and below eye level. Bilateral stimulation constitutes
the DSS procedure for visual stimulation. Aphasia Screening Test
Scoring. A raw score for the right and left visu- Description. This test includes 32 items requir-
al fields are calculated by summing the total number ing naming, copying, spelling, reading, writing, re-
of errors made on unilateral and bilateral trials. peating, verbal comprehension, and right/left
Domain Measured. Differential visual percep- discrimination.
tion in the right and left visual fields is measured by Scoring. Selz and Reitan (l979b) developed a
this task. scoring system for the items from the Aphasia
Screening Test.
Tactile Finger Localization Test Domain Measured. The Aphasia Screening
Test is a useful screening measure for dyspraxia (both
Description. With the child observing, the ex-
spelling and constructional), dysnomia, dysgraphia,
aminer numbers the child's fingers. The child must
dyslexia, dyscalculia, ideational dyspraxia, ex-
then close the eyes and report the number of the
pressive aphasia, receptive aphasia, dysarticulation,
finger being stimulated. visual dysgnosia, auditory dysgnosia, and right/left
Scoring. The raw score is the sum of the errors disorientation.
made on each hand.
Domain Measured. This test is a measure of
tactile perception, tactile localization, and attention Subtests from the Reitan-Indiana
for each body side. Neuropsychological Test Battery for
Children 5 through 8
Fingertip Number Writing Test
The Reitan-lndiana (Reitan, 1969) is a down-
Description. The child watches while the ex- ward extension of the Halstead-Reitan Neuropsy-
aminer traces the numbers 3, 4, 5, and 6 on the palm chological Test Battery (see Reitan & Wolfsun,
of the child's hand. The child is then asked to close 1985) developed for children 5 to 8 years of age. The
the eyes and report the number written in a set order modifications discussed below were necessary be-
on the fingertips of the right and left hands. cause of the developmental differences found be-
Scoring. The raw score is the sum of the errors tween younger and older children (Reitan &
made on each hand. Davison, 1974; Boll, 1981). In addition, as in the
older children's battery, normative data for measures
Domain Measured. Aspects of complex tactile included in the Reitan-Indiana have been developed
perception and concentration are assessed by this task by Spreen and Gaddes ( 1969) and Knights and Nor-
for each body side. wood (1980).
Category Tests Sensory Perceptual Exam (SPE). The tactile

and auditory tasks of the SPE remain unchanged.
Description. The number of test items was re- Only a minor modification of the visual task has been
duced to 80 items in five categories. On the first
made requiring that visual stimulation be presented at
subtest the child is required to identify colors by se-
eye level only. In addition, if the young child has
lecting a corresponding lever. The following four
difficulty verbally reporting the body part touched or
subtests involve principles of size, shape, color, or
the side of stimulation (i.e., right, left), they are
memory.
allowed to point to or raise their hand on the side of
Scoring. (See the previous description of scor- stimulation.
ing for the Category Test.)
Tactile Finger Localization. The procedure for
Domain Measured. Nonverbal reasoning, this task remains unchanged from the older children's
learning, memory, and concept formation are as- battery.
sessed by this task.
Fingertip Symbol Writing. This task is very
similar to the Fingertip Number Writing Test from
Tactual Performance Test the older children's battery. The child is required to
close the eyes and report which symbols (X's and
Description. The same six-figure formboard O's) are written on the child's fingertips. (See the
employed in the older children's battery is used on
older children's battery for a description of the scor-
this test, but the board is presented horizontally. (See
ing procedure and the domain measured.)
the previous discussion of the tactual performance
test for a more detailed description of the task, the Tactile Form Recognition. The procedure for
scoring, and the abilities measured.) this task remains unchanged from the older children's
battery.
Fingertapping Test
Description. The same procedure is used with Aphasia Screening Test
younger children, as was described for older chil- Description. Some items were deleted or sim-
dren, except an electric fingertapping device is used plified for the younger children. Items included in
to compensate for the younger child's poorer fine this test require the child to write, copy simple geo-
motor coordination. (The scoring and domain mea- metric figures, identify pictures, read letters and sim-
sured are the same as described previously,) ple words, carry out simple mathematical functions,
identify body parts, and identify right/left body side.
Speedt Sounds Perception Test, Seashore Scoring. Knights and Norwood ( 1979) devel-
Rhythm Test, Trails A and B oped a scoring system for the younger children's ver-
sion of the Aphasia Screening Test.
These tests were omitted in the younger chil-
dren's battery. Domain Measured. This is a screening instru-
ment for constructional dyspraxia, dysgraphia, dys-
Marching Test lexia, dysnomia, dyscalculia, right/left disorienta-
tion, receptive aphasia, expressive aphasia, visual
Description. On the Marching Test the child is dysgnosia, and body dysgnosia.
required to follow a sequence of circles connected by
lines up a page, by touching each circle as quickly as
possible. Color Form Test
Scoring. The raw score is the number of errors Description. A board is presented with differ-
and time taken to complete the task. ent colored geometric shapes. The child must alter-
nate between touching shapes and colors selectively
Domain Measured. This test is a measure of attending to one aspect of the stimulus (e.g., color),
upper extremity gross motor functioning and while ignoring the other (e.g., shape).
coordination.
Scoring. The child's raw score is the total
Strength of Grip. This test remains unchanged number of errors made and the amount of time taken
from the older children's battery. to complete the task.
188 CHAPTER 10
Domain Measured. This test is a measure of Scoring. The raw score is the number of errors
attention, ability to inhibit, visual sequencing, cog- and time taken to complete the task.
nitive flexibility, and upper extremity gross motor
coordination. Domain Measured. This test is a measure of
visual perception and reaction time.
Progressive Figures Test

Drawing of Star and Concentric Squares
Description. The child is presented a sheet of
paper on which are printed eight large geometric Description. The child must copy figures of
shapes (e.g., circle), with a smaller shape (e.g., varying complexity.
square) inside. The child must use the small inside Scoring. The raw score is the number of errors
figure as a cue for moving to the outside shape of the and time taken to complete the task.
next figure.
Scoring. The child's raw score is the total visual perception, fine motor coordination, and con-
number of errors made and the amount of time taken structional praxis.
to complete the task.
Domain Measured. This test measures visual
perception, motor speed, cognitive flexibility, atten- Interpretation of Children's
tion, and concentration. Performance on Neuropsychological
Batteries
Matching Pictures Test
In the past, a number of approaches have been
Description. The child must match pictures be- applied to the interpretation of children's perfor-
ginning with identical pictures and progressing to mance on neuropsychological tasks (Reitan &
matching pictures from more general categories. Davison, 1974; Selz, 1981; Rourke, Bakker, Fisk, &
Scoring. The raw score is the total correct out Strang, 1983; Fletcher & Taylor, 1984; Teeter,
of a possible 19. 1986). These various approaches and their limita-
tions will be discussed below.
visual discrimination, reasoning, and categorizing
skills. Level of Performance
In this approach, the child's level of perfor-
Target Test mance on neuropsychological measures is compared
Description. The child is shown an 18-inch to normative data, such as the norms developed by
card with nine dots printed on it, and is given a sheet Spreen and Gaddes (1969), and Knights and Nor-
with the same dot configuration. The examiner taps wood (1980). If the child's performance falls signifi-
out a design on the stimulus card and the child must cantly below (e.g., two standard deviations below
draw the design on the response sheet. the mean) what would be expected for their age, then
a deficit is diagnosed in the particular area measured
Scoring. The raw score is the number of items by the neuropsychological task. For example, on the
correct. fmgertapping test, the mean performance for a 9-
Domain Measured. Visual/spatial memory is year-old is 34.3 (S.D. = 4.37) (Spreen & Gaddes,
1969) for the dominant hand. Using the level of per-
measured by this task.
formance approach, if a 9-year-old obtained a score
of25, their fine motor speed with the dominant hand
Matching Figures and Matching V's Test
would be interpreted as impaired.
Description. On the Matching Figures Test the There are a number of disadvantages to relying
child must match figures printed on blocks with fig- solely on this method for the interpretation of chil-
ures printed on a card. The figures become pro- dren's neuropsychological test performance. First,
gressively more complex. The matching V's task re- because of the large variability in normal children's
quires the child to match V's that vary in the width of performance on neuropsychological measures, it is
the angle. often difficult to interpret the individual child's
scores. For example, the mean performance for an 8- Test, but who performs poorly on the constructional
year-old on the Tactual Performance Test (dominant tasks of the Aphasia Screening Test and poorly on the
hand) is 5. 71 minutes but the standard deviation of 6 Tactual Performance Test Memory and Locations
minutes is greater than the mean (Knights & Nor- subtests, may be interpreted as having adequate au-
wood, 1980)! If a two-standard deviation cutoff is ditory processing, but deficits in the area of nonver-
adhered to for interpreting a deficient level of perfor- bal, visual/spatial functioning.
mance on this task, the child would be required to This approach is of limited use in the interpreta-
continue for over 17 minutes in order to diagnose tion of neuropsychological performance of very
impaired performance. Another problem that is en- young children and children with severe disabilities
countered when using only the level of performance (Rourke et al., 1983). However, it has been used
to interpret children's neuropsychological perfor- quite extensively in the subgrouping of children with
mance is the tendency to yield a large number of learning disabilities (Rourke, 1984; Nussbaum &
false-positives. This is largely because so many fac- Bigler, 1986).
tors other than impairment can negatively influence
the child's performance (e.g., motivation, attention,
Comparison of Right and Left Body Sides
frustration tolerance) (Rourke et at., 1983).
This approach compares the relative perfor-
Pathognomonic Signs mance of one body side to the other on motor and
sensory-perceptual tasks. For example, a large dis-
The pathognomonic signs (e.g., hemiplegia, crepancy between the right (dominant) and the left
aphasia, hemisensory deficit) approach refers to the (nondominant) hand on the fingertapping test, with
identification of specific deficits that are not com- the right-hand score less than the left-hand score,
monly seen in normal individuals. For example, ar- may indicate impairment in left-hemisphere func-
ticulation errors on the Aphasia Screening Test could tioning. However, once again, because of the wide
be interpreted as an aphasic "sign." Again, one of variability in the performance of normal children,
the limitations of this approach would be the large discrepancies between performance on the right and
variability seen in the normal population. For exam- left body sides may often be difficult to interpret for
ple, because of the wide variation in the development the individual child. This is especially true of the
oflanguage abilities in children, it is often quite diffi- younger child.
cult to interpret specific errors made by the individual
child. There may be a tendency to interpret as abnor- Multiple Inferential Approach
mal an isolated error made by the child.
Conversely, it has also been found that the sole Boll (1974, 1981) proposed a multiple inferen-
use of the pathognomonic signs approach has a tential approach to the interpretation of children's neuro-
dency to yield a large number of false-negatives. For psychological performance because of the limitations
example, Boll (1974) found that 26 of 35 children of the isolated use of the approaches discussed pre-
with known brain damage were misclassified as nor- viously. In the multiple inferential method, the com-
mal when the sign approach was used to classify plimentary use of level of performance, pathog-
subjects. One reason for this is that such conditions as nomonic signs, pattern analysis, and right/left
infantile hemiplegia may show considerable plas- comparisons is employed in the interpretation of
ticity and recovery of function (see Bigler & Naugle, neuropsychological performance. This approach
1985), and their neuropsychological test perfor- minimizes the limitations that are encountered when
mance may not conform with what would be ex- these methods are used in isolation.
pected with a more recently acquired brain lesion.
Rules Approach
Patterns of Performance
The rules approach developed by Selz and
In this approach, the relationship among perfor- Reitan ( 1979b) also combines a number of inferential
mance on neuropsychological measures is examined. methods in the interpretation of children's neuropsy-
If large discrepancies are noted, then strengths and chological performance. The rules are based ori the
weaknesses are interpreted. For example, a child four methods of inference discussed earlier: level of
who does very well on the Speech Sounds Perception performance, pathognomonic signs, pattern analy-
Test and the verbal items from the Aphasia Screening sis, and right/left differences.
190 CHAPTER 10
The rules were initially developed and validated Summary

as an objective system for classifying children as
normal, learning disabled, or brain damaged. They In summary, the Halstead-Reitan and the
consist of a four-point scoring system in which 37 Reitan-Indiana were developed by Reitan (Reitan &
aspects of neuropsychological performance are rated Davison, 1974) based on the adult version of the
on a scale from 0 (normal to excellent performance) Halstead-Reitan Neuropsychological Battery (Rei-
to 3 (very abnormal performance). For example, a tan & Wolfsun, 1985). Since the initial modifications
child who made nine or more errors on the Tactile of the Halstead-Reitan Neuropsychological Battery,
Finger Recognition task would receive a score of 3 a great deal of work has been done in the developing
(impaired) using the rules system. In summary, the normative data (Spreen & Gaddes, 1969; Knights &
rules approach is an attempt at providing an objective Norwood, 1980) and interpretive models (Fletcher &
system to measure the degree of impairment in the Taylor, 1984; Obrzut & Hynd, 1986) for the chil-
neuropsychological performance of children. dren's neuropsychological batteries. In this chapter
the various measures included in the Halstead-Re-
itan and the Reitan-Indiana were reviewed. A de-
Functional Organizational Approach scription of each measure was given, as well as a
brief discussion of scoring and domains measured by
The functional organizational approach is an-
the various tests. Finally, a number of approaches to
other method that has been proposed for the in-
the interpretation of children's neuropsychological
terpretation of children's neuropsychological perfor-
performance were reviewed.
mance (Fletcher & Taylor, 1984). In this model,
three variables are taken into consideration: (1) the
manifest form of the disability [e.g., the impulsive
behavior of the child with attention deficit disorder References
(ADD)]; (2) the behavioral and cognitive correlates
of the manifest disability (e.g., performance on neu- Bigler, E. D., & Naugle, R. I. (1985). Case studies in cerebral
ropsychological measures with an attentional compo- plasticity. Clinical Neuropsychology, 7, 12-23.
Boll, T. J. (1974). Behavioral correlates of cerebral damage in
nent); (3) the biological substrate underlying the
children age 9-14. In R. M. Reitan & L.A. Davison (Eds.),
covariance of the first two variables (e.g., neu- Clinical neuropsychology: Current suztus and applications.
rochemical imbalance, structural abnormality, lag in Washington, DC: Winston.
cortical maturation). Boll, T. J. (1981). The Halstead-Reitan neuropsychological bat-
This model avoids the tenuous inference in- tery. InS. Filskov & T. J. Boll (Eds.), Handbook of clinical
volved in the interpretation of direct brain-behavior neuropsychology. New York: Wiley-Interscience.
relationships in children using behavioral data. Fletcher, J. M., & Taylor, H. G. (1984). Neuropsychological
Rather, the biological or neurological substrate is approaches to children: Towards a developmental neuropsy-
seen as influencing the manifest disability by impos- chology. Journal of Clinical Neuropsychology, 6(1), 39-56.
ing limits on the basic behavioral competences of the Halstead, W. C. (1947). Brain and intelligence: A quantitative
study of the frontal lobes. Chicago: University of Chicago
child. Additional moderator variables, such as the
Press.
family system and the educational setting, are also Harris, A. J. (1947). Ha"is test of lateral dominance, manual of
taken into consideration. directions for administration and interpretation. New York:
Furthermore, the relationship between perfor- Psychological Corporation.
mance on neuropsychological measures and the man- Jastak, S., & Wilkinson, G. J. (1984). The Wide Range Achieve-
ifest disability is not seen as causal but instead as ment Test-Revised. Wilmington, DE: Jastak.
correlational. Thus, performance on neuropsycho- Klonoff, H., Robinson, J. C., & Thompson, G. (1969). Acute and
logical measures is used to clarify various functional chronic brain syndromes in children. Developmental Medi-
aspects of the child's manifest disability. For exam- cine and Child Neurology, 11. 198-213.
Knights, R. M., & Norwood, J. A. (1979). Neuropsychological
ple, the ADD child's performance on neuropsycho-
test battery for children: Exmniner' s manual. Ottawa:
logical measures can help to determine the degree of
Knights Psychological Consultants.
cognitive impulsivity present in the disorder. In this Knights, R. M., & Norwood, J. A. (1980). Revised smooth nor-
example the functional aspects of the child's perfor- motive dauz on the neuropsychological test battery for chil-
mance would be stressed in the interpretation of the dren. Ottawa: Knights Psychological Consultants.
neuropsychological data. Also the importance of in- Nici, J., & Reitan, R. M. (1986). Patterns of neuropsychological
terpreting neuropsychological data in a developmen- abilities in brain-disordered versus normal children. Journal
tal context is emphasized in this model. of Consulting and Clinical Psychology, 54, 542-545.
Nussbaum, N. L., & Bigler, E. D. (1986). Neuropsychological Child neuropsychology: An introduction to theory, research
and behavioral profiles of empirically derived subgroups of and clinical practice. New York: Guilford Press.
learning disabled children. International Journal of Clinical Selz, M. (1981). Halstead-Reitan neuropsychological test battery
Neuropsychology, 8, 82-89. for children. In G. W. Hynd&J. E. Obrzut(Eds.),Neuropsy-
Obrzut,J. E., &.Hynd, G. W. (Eds.). (1986). Child neuropsychol- chological assessment and the school-age child: Issues and
ogy (Vol. II). New York: Academic Press. procedures. New York: Grone & Stratton.
Reed, H. B. C., Reitan, R. M., & Klove, H. (1965). Influence of Selz, M., & Reitan, R. M. (1979a). Neuropsychological test per-
cerebral lesions on psychological test performances of older formance of normal, learning-disabled and brain-damaged
children. Journal of Consulting Psychology, 29, 247- older children. Journal ofNervous and Mental Disease, 167,
251. 298-302.
Reitan, R. M. ( 1969). Manual for administration of neuropsycho- Selz, M., & Reitan, R. M. (1979b). Rules for neuropsychological
logical test batteries for adults and children. Indianapolis, diagnosis: Classification of brain function in older children.
IN: Author. Journal of Consulting and Clinical Psychowgy, 47, 258-
Reitan, R. M. (1974). Psychological effects of cerebral lesions in 264.
children of early school age. In R. M. Reitan & L. A. Davison Spreen, 0., & Gaddes, W. (1969). Developmental norms for fif.
(Eds.), Clinical neuropsychology: Current status and ap- teen neuropsychological tests for ages 6 to 15. Conex, 5,
plications. Washington, DC: Winston. 171-191.
Reitan, R. M., & Davison, L. A. (Eds.). (1974). Clinical neuro- Teeter, P. A. (1986). Standard neuropsychological batteries for
psychology: Current status and applications. Washington, children. InJ. E. Obrzut&G. W. Hynd (Eds.), Child neuro-
DC: Winston. psychology (Vol. II). New York: Academic Press.
Reitan, R., & Wolfsun, D. (1985). The Halstead-Reitan neuro- Tsushima, W. T., & Towne, W. S. (1977). Neuropsychological
psychological test battery: Theory and clinical interpretll- abilities of young children with questionable brain disorders..
tion. Tuscon, AZ: Neuropsychology Press. Journal of Consulting and Clinical Psychology, 45, 757-
Rourke, B. P. (Ed.). (1984). Subtype analysis of learning dis- 762.
abilities. New York: Guilford Press. Wechsler, D. (1974). Wechsler Intelligence Scale for Children-
Rourke, B. P., Bakker, D. J., Fisk, J. L., ~Strang, J.D. (1983). Revised. New York: Psychological Corporation.
11
The Nebraska Neuropsychological

Children's Battery
CHARLES]. GOLDEN
The Nebraska Neuropsychological the adult battery. It was also found that those items in
Children's Batteries: Current Status general corresponded to those that one would expect
from Luria's theories on brain development. It was
and Applications also found that below age 8, drastic changes were
needed in the battery content to have a useful test.
For the past 7 years, researchers at the University of Thus, it was initially decided to develop a test down
Nebraska and elsewhere have been attempting to de- to age 8.
velop objective neuropsychological test batteries for Similarly, it was found that 13- and 14-year-
children that draw on some of the ideas and tech- olds could perform perfectly normally on the adult
niques employed by A. R. Luria. Development of the battery (which was originally intended to extend
children's battery was heavily influenced by the ear- down to age 15). At the 12-year-old level, children
lier development of the adult Luria-Nebraska Neu- began to show difficulties with the adult battery (al-
ropsychological Battery (LNNB) as well as the work though above-average 12-year-olds can also perform
done by Lawrence Majovski. perfectly normally). Thus, it was decided that the
Research on the battery has been discussed in adult battery could be used down to age 13 and that
the literature (e.g., Plaisted, Gustavson, Wilkening, the new children's battery should aim at ages 8 to 12.
& Golden, 1983) as well as the test manual (Golden, A battery for younger children was postponed until
1986) in great detail, and therefore the present chap- completion of this work and is described in the last
ter will focus primarily on a more important issue: the section of this chapter.
interpretive strategies used with the battery. Specifi- Items were deleted from the adult battery that
cally, the present chapter will look at several issues: appeared to be too difficult for initial normative
(I) the process of development of the battery; (2) a youngsters in this age range. When possible, similar
description of the battery with a brief review of cur- but easier items were substituted. We were also privi-
rent research; (3) methods of interpreting the test leged to consult with Dr. Lawrence Majovski who
battery; and (4) current research studies aimed at im- was working on developing a qualitative approach to
proving the test battery and extending its usefulness the assessment of children based on his studies with
to lower ages. Luria. We were able to adapt and add several addi-
tional items and areas of examination to the test from
Development of the Battery his suggestions. This initial work consisted of three
successive versions of the test, which were evaluated
The original development of the battery was be- on groups of normal and impaired children until the
gun by administering the adult LNNB to children fourth and published version was completed.
from ages 5 to 12. It was discovered that children 8
and up could do a majority of the procedures used in
Description of the Battery
CHARLES J. GOLDEN Departments of Psychology. So- The final version of the children's battery con-
ciology, and Anthropology, Drexel University, Philadelphia, sisted of 11 basic scales, just as the adult battery
Pennsylvania 19104. does, and 149 procedures. However, most of these
193
194 CHAPTER 11
procedures consist of numerous items so that the ac- ically selected testing in areas in which more infor-
tual number of items exceeds 500. Administration mation is needed after examining the LNNB perfor-
time takes about 1! to 3 hours depending on levels of mance, and by using qualitative observations to
cooperation and levels of impairment. enrich the data generated by quantitative analysis
This version was given to 125 children. The alone.
group consisted of 25 normal children at each of five Although we will describe the test scales in
age levels: 8, 9, 10, 11, and 12. Performance norms somewhat greater detail later, we present a synopsis
were developed on each procedure and scale based on of the scales here for those readers not familiar with
the performance of this group. The first task was the the child or adult battery.
development of scale scores for each item. It was Scale Cl (Motor): This scale is designed to mea-
decided to have different scale scores for each age sure basic fine motor speed, unilateral and bilateral
group on each item so that scores for a given indi- coordination, imitation skills, verbal control of
vidual could be directly compared. For each pro- motor movements, and construction skills.
cedure, a score of 0 was set to mean a performance Scale C2 (Rhythm): Items on this scale evaluate
within one standard deviation of the mean score for the children's ability to make simple tonal discrimi-
the age group. A score of 1 represented a perfor- nations, maintain a melodic pattern in singing, count-
mance between one and two standard deviations being tones, and reproduction of rhythmic patterns.
low the mean, and a score of 2 represented scores Scale C3 (Tactile): This scale assesses tactile
more than two standard deviations below the mean. sensitivity through localization of stimuli, two-point
Each item of the test was assigned to 1 of the 11 discrimination, pinprick and pressure sensation,
basic scales. Originally, this was done on the basis of movement detection, and stereognostic skills.
our experience with the adult battery and on our the- Scale C4 (Visual): Items evaluate visual recog-
oretical belief of where items should load. From this nition skills, identification of altered pictures,
assignment, scale raw scores were calculated by closure, and the use of spatial relationships.
adding up the scaled score on each procedure to yield Scale C5 (Receptive): This examines the ability
a total raw score. Procedures were then correlated to discriminate phonemes, analyze simple sounds
with each of the raw scores to ensure that procedures and words, and follow increasingly complex
correlated highest with the scale they were assigned instructions.
to, so that items could be reorganized when nec- Scale C6 (Expressive): This scale examines the
essary. ability to pronounce words and sounds properly, rep-
After final scale assignments were determined, etition of sentences, naming, automatic speech, and
scale T scores were generated by first calculating the the use of complex expressive structures.
means and standard deviations of each of the original Scale C7 (Writing): These items measure basic
125 normal subjects. An ANOV A for each scale copying skills, the ability to analyze letter sequence,
score by age indicated no significant differences be- the ability to write from dictation, and the ability to
tween the scale mean scores for each age group, and spell.
F tests indicated no significant differences among Scale C8 (Reading): This scale evaluates basic
group variances. As a result, the conversion of scale reading recognition skills as well as sound synthesis.
raw scores to T scores was done on the basis of all125 Scale C9 (Arithmetic): The items assess basic
subjects rather than for each age group alone. arithmetic skills from number recognition through
Each of the 11 scales is multifactorial in struc- multiplication and simple algebra.
ture. This was done for several reasons. First, each Scale CIO (Memory): This scale measures
scale was conceived not as covering a specific skill short-term verbal and nonverbal memory with and
but rather as a domain of skills in a given area (such as without interference.
motor function). Second, this allowed the test to Scale Cll (Intelligence): This scale is com-
yield stable test scores (which is related to the number prised of items similar to the Wechsler Intelligence
of items on the scale as well as the individual sta- Scale for Children (WISC) Picture Arrangement,
bilities of the items) with fewer items in each skill Picture Completion, Vocabulary, Comprehension,
area. This has the positive effect of allowing for a Arithmetic, and Similarities subtest items. Other
broader coverage of skills in a reasonable period of items measure basic ability to generalize and make
time. This has the drawback, however, of not cover- deductions from data.
ing any one area in as much detail as possible. This is In addition to the basic scales, the 149 items
remedied by simply following the LNNB with specif- were factor analyzed in a population of 719 brain-
THE NEBRASKA NEUROPSYCHOLOGICAL CHILDREN'S BATTERY 195
damaged and notmal children. The resulting factors Interpretation

were impressive in that few of the factor scales used
items from multiple scales, suggesting that item Of prime importance with any test battery are
placement was essentially correct. Some factor the methods of interpreting the battery. This is es-
scales simply repeated what the regular scales al- pecially important with the LNNB-CR for many be-
ready yielded, whereas some failed to achieve rea- cause the process is often different from the pro-
sonable stability. Those scales that were both stable cedures used with other tests. In interpreting the
and yielded new information were kept for further LNNB-CR, little confidence is placed in formal in-
study. terpretations of elevations on individual scales. A
A second analysis involved the factor analysis major reason for this is that these are clearly not
of each scale alone. Many of the resultant factors homogeneous scales with many items intended to
duplicated factors found in the first analysis and were measure just one ability but rather a domain of abili-
discarded, as were factors that were insufficiently ties. As a result, a single interpretation of an eleva-
stable. At the end of this process, II additional scales tion on any particular scale would be ludicrous and
were derived, 2 of which were cross scale factors and possibly lead to obscure diagnostic errors. Thus, pat-
9 of which were intrascale. For each of these 11 tern analysis of the scales and items, combined with a
scales, T scores were derived on the basis of the qualitative analysis of the test performance, is the
performance of 240 normal children in the overall major approach to interpreting scale profiles.
sample.
The 11 factors were briefly described as: (1)
academic achievement, the largest cross scale factor Levels of Interpretation
including reading, writing, arithmetic, and ex-
pressive items; (2) spatial organization, the second When interpreting the LNNB-CR, or other sim-
major cross scale factor; (3) purposeful unspeeded ilar batteries, it is important to be aware that the many
movement; (4) motor speed; (5) drawing quality; (6) levels on which the battery can be interpreted depend
drawing time; (7) rhythm perception and reproduc- on the needs, as well as the skill and knowledge, of
tion; (8) basic tactile function; (9) basic receptive the user.
language skills; (10) repetition; and (11) abstract ver- The first level is primarily concerned with ascer-
bal skills. taining whether significant brain injury exists in a
At present, other scales are also in the process of given child as a screening procedure to differentiate
development, including scales to measure left and neuropsychological from other possible disorders.
right hemisphere sensorimotor function and scales This level is not appropriate with children for whom
for the analysis of chronicity of disorders. However, there has been known significant brain injury, as the
there are no localization scales planned for the chil- question is clearly unnecessary at that point. Rather,
dren's battery as with the adult battery because this level of interpretation is used most often when
localized lesions do not generally cause consistent there may have been a brain injury, in screening chil-
deficits in children due to the interaction of develop- dren for a possible cause of unusual behavior, or
mental processes with brain development and the when there has been a brain injury to which there are
time and location of the injury. attributed no "significant" effects on neurological
For those readers interested in the details of gen- examination.
eral research on the battery, the test manual (Golden, This level is used most often by individuals who
1986) offers the most complete and detailed account are not neuropsychologists and is the level most fre-
of this work. Other reviews may be found in Plaisted quently discussed and taught in programs and in-
eta/. (1983). In general, research has examined the ternships in clinical, school, and counseling psychol-
ability of the test to discriminate between brain- ogy. When there is a high likelihood of brain damage
damaged and normal subjects (with hit rates of about in cases screened in this manner, it is imperative that
86%), and other studies have examined correlations the child be referred for a more sophisticated evalua-
between the LNNB and such tests as the PIAT and the tion of the data. On the other hand, because most
WISC-R. As reported in the test manual, this work children are seen initially by nonneuropsychologists,
has generally confirmed the validity of the LNNB this level of practice is quite important in the screen-
scales. Other work has evaluated the effectiveness of ing to determine which children should be referred
the test with such groups as children who are learning for further evaluation.
disabled or who have epilepsy. The second level of interpretation involves sim-
196 CHAPTER 11
pie description of what the child can and cannot do, when working with children where localization is
without drawing any conclusions or reaching any in- problematical.
tegrative statements.
The third level of interpretation takes the second
level to the next logical step: identification of the Identifying Brain Damage
probable underlying causes of the child's overall be-
havior. This step requires extensive understanding of Use of the Critical Level
the various brain-behavior relationships. The in-
terpretation process generally evolves from a the- Adjusting for Age. The first step in identifying
oretical orientation of how the brain functions and the when a profile is statistically abnormal and likely to
ways in which information is processed through the be indicative of brain damage is based on establishing
central nervous system. a valid critical level for the child. The critical level
Finally, the fourth level of interpretation in- represents the highest LNNB-CR score that can be
volves the integration of all findings and conclusions considered normal for the battery. In contrast to some
into a description of how the brain of the individual is other tests, this cutoff level is variable with the
functioning. This is a difficult task in most cases, LNNB-CR, and is adjusted for age.
because the result of brain damage is affected by a The computerized scoring program for the
variety of factors including: (1) the combination of LNNB-CR calculates the critical level. If the hand-
areas injured; (2) when the injury occurred; (3) the scoring version of Form I is used, the critical level
degree to which alternate functional systems are may be calculated using the following formula:
available or are later formed (spontaneously or
through training); (4) the kind of injury; (5) the emo- Critical level= 82.02- (0.14 x age in months)
tional reaction of the child; (6) the adequacy of the
examination situation; (7) the stimuli presented; (8) Identifying Deviant Scores. Once the critical
the time of day the testing was done; (9) the organiza- level has been established, determining the proba-
tion of the brain before brain injury; ( 10) the nature of bility of brain damage is relatively simple. The
brain dominance in the individual; and (11) the pres- number of scales on the battery that exceed the crit-
ence of subcortical or peripheral impairment. In addi- icallevel is counted, yielding the number of abnor-
tion, any conclusions can be complicated by a myriad mal scores. The scores that are considered at this
of factors that can radically alter one's decisions. point are the basic clinical scales (Cl through Cll).
In many cases, the last level of interpretation In general, three or more scores above the critical
concerns the understanding of basic underlying defi- level are thought to be indicative of brain damage,
cits rather than simply determining location. In gen- whereas zero or only one elevated scale suggests the
eral, localization is useful not so much because of a probable absence of brain damage. If the critical
need to know exactly where the lesion is but because level has been chosen correctly, the accuracy of this
it may allow the generation of hypotheses about the decision is about 75 to 85% of all cases.
child's problems and future that can be subsequently In addition to the problems in setting the educa-
evaluated and related to known patterns of recovery tional level in some cases, there are also important
in specific disorders. These hypotheses can be tested exceptions to the rules for determining the presence
by observation of the child's behavior.lt is this level or absence of brain damage. There are cases that have
that is ultimately important; to know where a lesion is two scale elevations. In such cases, the profile is
but to be wrong about its effects is useless. It is much tentatively considered borderline.
more useful to understand the effects and implica- Before labeling anyone as brain damaged, even
tions of the injury and to be concerned less about their in a relatively straightforward case, one should care-
anatomical localization. In most cases, lesion lo- fully consider the effects of such a diagnosis on the
calization is only an intermediate step useful in hy- individual. Such persons or their protocols should
pothesis generation. generally be referred to an experienced neuropsycho-
It should be noted, however, that lesion lo- logist for diagnosis. In any case, any diagnosis of
calization and description is useful in itself in some brain damage in a profile should be qualified to re-
cases. Primary among these are legal cases in which flect the neuropsychological sophistication of the
it is essential to know whether a given deficit or person using the test; as noted earlier, use of neuro-
deficit pattern can reasonably be related to a given psychological tests does not make one a neuropsy-
injury or injuries. These conclusions should be left to chologist. It is much safer to avoid diagnoses in re-
expert neuropsychologists. This is especially true ports as much as possible and to use the finding of
possible brain dysfunction as a reason for further reflect residual damage. It is important to notice these
referral of the protocol to an interpreter with more factors, as they are often useful in explaining specific
expertise. problems the child may be having that were not
noticed before the damage occurred, as well as in
designing specific rehabilitation training.
Interpreting Scale Patterns Another important aspect is the location of the
damage. Brain damage in each hemisphere is ex-
Factors Affecting Scale Interpretation pressed very differently on the pattern of scores, as is
brain damage in different locations within a single
It is important to recognize that injuries in any hemisphere. In general, the LNNB-CR is more sen-
part of the brain can potentially affect the scores on sitive to the disruptive effects of left hemisphere
any of the scales of the battery. This is due to the lesions.
relatively homogeneous content of the scales with The cause of the brain dysfunction also repre-
respect to secondary skills that are measured in con- sents a major problem with respect to the battery's
junction with the primary skill as denoted by the scale results. Brain dysfunction may be caused by a wide
label. Despite this caution, hypotheses may be gener- range of problems: from overt structural damage to
ated from individual scales and overall patterns of metabolic disorders and idiopathic problems that
scores if proper caution is used in recognizing the have no clear genesis. In general, those disorders that
wide ranges of factors that affect the neuropsycho- destroy brain tissue cause much more damage to the
logical performance on a given scale. brain and therefore cause more highly significant de-
For example, a child may have such severe ex- viations on the LNNB-CR battery. Disorders such as
pressive language problems that any item that re- idiopathic epilepsy, which may not have a clear
quires any verbal response, no matter how simple, structural focus or clear cause, may cause relatively
may be missed. Similarly, severe receptive language little damage.
problems may make it impossible to adequately com- A final consideration is the premorbid level of
municate instructions to the child. Although the ad- the individual. Specifically, an individual with high-
ministrative procedures attempt to minimize the ef- er skills prior to a given brain injury will have higher
fects of these disorders, in some cases it is not. skills afterward than would a person with overall
possible to eliminate these factors. lower initial cognitive skills; the person with higher
Similarly, children with severe peripheral defi- cognitive skills can more easily reorganize brain
cits or brain stem injuries may appear to have more function to adapt to the loss in specific areas. An
severe cognitive injuries than are actually present. individual who is extremely intelligent prior to an
These problems are unfortunately common to all injury may show only motor and sensory signs with
standardized tests. To an extent, the identification of relatively few cognitive deficits in the abnormal
these factors through the qualitative scoring is possi- range even after a significant injury, because the per-
ble, although interpretation of these indices is not as son's skills have simply been reduced from above-
well established as for the quantitative scores. ' average to average. In these cases, one must be sen-
Other factors that cause changes in scale eleva- sitive again to the pattern of items missed by the child
tions as well as overall patterns include a wide variety that may indicate brain dysfunction. One obvious
of neurological factors. One of the most important problem with children is that we may not have an idea
factors is the duration of the brain disorder, and of what the "premorbid" level was.
whether or not it is still present. In general, the acute For the reasons discussed above, interpretation
disorders, i.e., those that are continuing, will affect of the LNNB-CR typically focuses more on scale
LNNB-CR scores much more significantly than will patterns and on intrascale variability than on in-
disorders from which the child has had 3 to 6 months terpretation of scale elevations per se. Scale patterns
or more to recover. have the advantage of allowing the user to make de-
The size of the lesion must be considered along ductions about the reason a given scale was impaired.
with the question of chronicity. In individuals with For example, in profiles in which CS (Receptive
disorders that resolve themselves without structural Speech) is the highest score, one can hypothesize that
damage to the brain, LNNB-CR scores will return deficits on other scales may be attributed to the loss in
essentially to normal, reflecting the child's recovery receptive skilJs. As with any other procedure, this
of all major skills. The examiner should nevertheless leads only to hypotheses, but can offer valuable in-
be alert to specific items, even on normal scales, that sights in attempting to understand the child's basic
the child may fail to adequately perform and that may underlying deficits. The major patterns on the
198 CHAPTER 11
LNNB-CR are discussed below in the context of the injuries to the right hemisphere or to the left parietal
highest scale among the basic clinical scales. area. Drawings that are accurate but done slowly may
simply reflect motor dysfunction of the dominant
Developmental Issues in Interpretation. hand and the opposite cerebral hemisphere (or, some-
Another substantial problem in interpretation is the
times, compulsiveness).
role of developmental issues. There are several major
Because of the nature of the items on the C I
problems that must be recognized when the test is
scale, it tends to be sensitive to many different types
interpreted. All of these problems stem from the fact
of brain dysfunction. Primary sensitivity is to sec-
that children's brains are not fully developed until tions of the posterior frontal lobe, but lesions of the
midway in their teenage years. Thus, there is a dif-
temporal and parietal lobes, as well as the anterior
ference in what brain skills can be affected at given
frontal lobe, will also cause significant elevations in
ages and in the long-term impact of such injuries
the score. However, extreme elevations (scores ex-
when the injury occurs at different developmental
ceeding SOT) will usually only be caused by lesions
stages. It is not the purpose of this chapter to review
in the motor system.
theories of brain development, but such issues must
Elevations on the C 1 scale are best interpreted in
be considered in the interpretation of any child neuro-
comparison to elevations on C3 (Tactile Functions).
psychology battery.
When Cl is elevated but C3 is not, this is suggestive
In the context of these theoretical concerns, one
of difficulties with motor tasks. This comparison can
can approach the interpretation of the LNNB-CR (or
be very useful in initially localizing a deficit in the
any other neuropsychological test for children). The
anterior-posterior dimension. Clients displaying
focus of such interpretation should not be localiza-
pure parietal lobe dysfunction will rarely achieve a
tion, but rather a detailed analysis of the major defi-
Cl score above 60T, although specific items involv-
cits that underlie the child's function. Such in-
ing kinesthetic feedback will be most frequently
terpretations must take into account the factors
missed. On examination, the items on the battery will
discussed in this chapter and not solely rely on face
usually show a clear pattern in these posterior injuries
valid interpretations of item content and one's sup-
that is highly effective in localizing a given disorder.
position of what an item measures. One must be alert
When both of these scales (C1 and C3) are high-
to how the child performs the items (whether the
ly elevated, generalized impairment of motor and
answer is right or wrong) and integrate this informa-
sensory areas is suggested, but this is often in the
tion with knowledge about developmental stages.
context of diffuse deficits. If only these four scales
Even more so than in adults, children's behavior after
are affected, then peripheral disorders affecting
brain injury can be unpredictable and must be consid-
motor and sensory skills need to be considered, as
ered as its own case study.
well as the possibility of subcortical diseases.
Even with these limitations, one can examine
scale patterns to generate hypotheses. Each hypoth- Cl (Rhythm). The C2 scale is much more sim-
esis that is generated must be tested against the actual ply organized than the C1 scale. Item 35 involves the
patterns of items in the scales and the qualitative data analyses of groups of tones. The child must compare
on how the items were performed. The scale pattern two groups of tones, saying whether one is higher or
serves to only generate hypotheses. lower. Items 36 through 38 require the child tore-
produce tones. Whereas the initial items involve the
Clinical Scales perception of tonal qualities, these latter items in-
volve the expression of tonal relationships.
Cl (Motor Functions). The Cl scale is one of Items 39 through 40 involve the evaluation of
the most complex scales on the LNNB-CR. A wide acoustic signals. The child must identify the number
variety of motor skills reflect both right and left hemi- of beeps in groups of sounds. The last two items in
sphere performance. The first three items involve the C2 scale deal with the perception and reproduc-
simple movements of the hands. These items are es- tion of rhythm. Item 41 measures the ability of the
pecially sensitive to disorders in or near the posterior child to reproduce rhythmic patterns. This item re-
frontal lobe. In many cases, evidence of lateralized quires both the perception of rhythmic patterns and
motor disorders may be detected by examining the the reproduction of sounds, usually using the domi-
raw scores on these items. nant hand. The item can be missed by individuals
Items 21 through 32 assess construction dys- with deficits in either hemisphere. Item 42 asks the
praxia. Items that are performed very poorly often child to make a series of rhythms from verbal com-
reflect severe spatial disorganization characteristic of mands. The combination of verbal and rhythmic con-
tent on this item also makes it sensitive to injuries in naming and identification tasks while causing less
either hemisphere. difficulty in purely spatial tasks. When the deficit is
Of all the basic clinical scales, C2 is the most purely spatial, such as in proftles with C3 and C4
sensitive to disorders of attention and concentration. (Visual Functions) elevations, the injury is likely to
When giving these items to such individuals, it is be right parietal-occipital, although this pattern may
often useful for the examiner to stop the administra- also reflect subcortical involvement of one or both
tion between the stimuli in each item and not go on to hemispheres. When naming is strongly involved, left
the next item until the individual's attention has been parietal deficits should be considered. All such hy-
secured. Because there are usually only two choices pothesized localizations assume a normally dominant
in each item, items cannot be repeated. Conse- left hemisphere. Such patterns can be changed signif-
quently, it is important to ensure that the first admin- icantly by mixed or right hemisphere dominance for
istration is carried out as accurately as possible. speech.
When elevations of the C2 scale are the highest
C4 (Visual Functions). The C4 scale evaluates
in the proftle, they are most often associated with
right hemisphere injuries that are usually more ante- a range of visual functions. Items 59 and 60 ask the
child to identify objects by viewing either an object
rior than post~rior. This is especially true when the
highest scales are some combination of C2, C9 itself or a picture of an object. The person need not
(Arithmetic), and CIO (Memory). However, this identify the object by name but rather can describe
same pattern may be seen in left anterior lesions as function or indicate recognition in other ways. De-
well, although in those cases it is accompanied by at spite this, naming must be considered a component of
least subtle, if not gross, deficits in some form of these items. If the child is not able to do these items,
later items on the battery that are more sensitive to
verbal skills. When the C2 deficit is combined with
C4 (Visual Functions) scale elevation, then the lesion right hemisphere function may be missed simply be-
may be either anterior or posterior, with a more pos- cause of left hemisphere involvement. Thus, in-
terior lesion being more likely with higher elevations terpretation of the scale must depend on the child's
onC4. performance on the simple, initial items.
Later items require a great deal more visual-
C3 (Tactile Functions). Items 43 through 56 spatial perception than do these first two items, al-
involve different levels of cutaneous sensation. Indi- though naming is still required. Item 61 presents pic-
viduals must identify where they are touched, how tures that are difficult to perceive. Item 62 presents
hard they are touched, and so forth. Injuries to the objects that overlap one another and that the child
anterior parietal area will cause significant elevations with poor visual-spatial skills has difficulty identify-
on this scale as will injuries to the middle parietal ing. Item 63 examines the ability to determine that
areas that Luria (1973) designated as the "secondary two figures are mirror-image versions of one another.
area'' of the parietal lobe. Individuals with damage in Item 64 is a modification of items from the Raven
and around the angular gyrus may have particular Progressive Matrices (Raven, 1960). It is also a
problems with verbal/tactile items. The last two strong measure of visual-spatial organization and
items on the C3 scale involve the stereognostic per- right hemisphere function. Item 65 involves spatial
ception. Individuals with old injuries to the parietal rotation without any speech components. Individuals
lobe on either side may have difficulty meeting the may point to the correct answer or circle it as neces-
time requirements. sary (or say it if this is not possible). Poor perfor-
Proftles with highest scores on the C3 scale are mance on this task is suggestive of impairment of
interpreted in conjunction with the relative standings visual-spatial skills.
on the Cl scale. If C3 is greatly elevated over Cl, Proftles in which the C4 scale is .highest, in
then this points to a posterior lesion. This generally combination with any secondary scale, generally re-
remains true even when the C I scale equals the C3 flect impairment in the right hemisphere or the oc-
scale, especially if the Cl deficits arise from con- cipital areas of the left hemisphere. The C4 scale can
struction difficulty and sequencing rather than motor be elevated in other left hemisphere injuries, but
paralysis. rarely will it be the highest scale overall. In right
Deficits may be due to an inability to concen- hemisphere injuries, deficits on only more complex
trate, which should also result in inconsistent behav- visual tasks suggest either a mild parietal involve-
ior, or to an inability to integrate and identify all ment or injury to anterior areas. These lesions are
stimuli. In the latter case, the deficit will have a usually accompanied by elevation on the Cl scale
similar effect but will also show up as a rule in other suggestive of right hemisphere lesions. Subcortical
200 CHAPTER 11
lesions that interfere with visual processing can also multiple infections requiring tubes or infections that
cause patterns suggestive of right hemisphere injury, caused partial or complete deafness. In these chil-
as can severe peripheral visual problems. dren, language abnormalities may simply be due to
an inadequate chance to develop the relevant skills.
CS (Receptive Speech). C5 items evaluate the Similar problems arise from backgrounds with inade-
ability of the child to understand receptive speech, quate verbal stimulation. It is very difficult to differ-
from simple phonemic analysis to the understanding entiate between deficits due to a poor premorbid his-
of complex sentences with inverted English gram- tory and those due solely to brain damage.
mar. Items 66 through 71 concern the understanding
of simple phonemes. For items 66 through 70, the C6 (Expressive Speech). The C6 scale eval-
individual hears simple phonemes and must then re- uates the individual's ability to repeat simple
peat or write them. It is important to note if indi- phonemes and words and to generate automatic as
viduals are able to either say or write phonemes but well as more complex speech forms. Initial items
not to do both. simply require the repetition of sounds or words spo-
Item 71 tests the ability to understand phonemes ken by the examiner. Beginning with item 89, the
spoken at different levels of pitch. It is not unusual child must repeat the same list of words and sounds
for individuals with significant damage in the right by reading them rather than hearing them. If an indi-
temporal area to miss this item. Items 72 through 77 vidual is able to pass either one of these sections,
involve the understanding of simple words and sen- significant expressive speech deficits are not present.
tences. The child must do relatively simple tasks of For example, the individual who is able to read but
naming, pointing, and identifying, and must define not to receive auditory information will be able to do
simple words. The intent of these items is simply to the second section. Inversely, the child who is unable
ensure that the child is hearing correctly and in- to read will be able to do only the first section. There-
terpreting correctly what is said to him or her. fore, one must carefully examine the pattern of an-
Beginning with item 78 and continuing through swers to see if the errors are confined to one modality
the end of this scale to item 83, the individual is given or the other.
increasingly more difficult instructions. These items Beginning with item 93, the child must repeat
assess the child's ability to understand and to perform increasingly more difficult sentences. Item 94 exam-
or answer as requested. All these items can be af- ines the ability to name from a description rather than
fected by damage to the left hemisphere, but several from a visual presentation of the object. Items 95
items can also be affected by right hemisphere dys- through 98 ask individuals to count and say the days
function. For example, item 79 requires some spatial of the week, first forward then backward, all a form
orientation on the part of the child. If the child ap- of automatic speech. Items 99 through 104 evaluate
pears to understand the sentence but disrupts the spa- the ability to produce speech spontaneously under
tial requests made, the possibility of right hemisphere three conditions: after looking at a picture, after hear-
dysfunction must be suspected. ing a story, and after being given a topic to discuss. If
When this scale is highest, as well as signifi- other items on this scale are performed without diffi-
cantly elevated above the critical level by at least 15 culty, and yet the child experiences problems with
points, deficits are usually associated with left hemi- these items, there is the possibility of low intel-
sphere injury. Lesser elevations, caused by difficulty ligence. The final section involves complex systems
with the more complex items, can appear as the high- of grammatical expression; the child must fill in
est scale in right anterior injuries. This can be es- words that are missing in a sentence or make up a
pecially true in mild elevation combinations of C5 sentence from words that are given to the child.
and C 10 (Memory), C5 and C2 (Rhythm), C5 and C4 In general, C6 scores are sensitive to injuries in
(Visual Functions), or C5, C11 (Intellectual Pro- the left hemisphere only. It is rare to see a high C6
cesses), and C9 (Arithmetic). In the most significant score in individuals with unilateral right hemisphere
elevations, however, left hemisphere involvement is injuries. Exceptions to this are individuals who had
generally indicated. difficulty reading prior to their injury, or whose dis-
An important caveat in evaluating speech in orders have somehow interfered with auditory per-
children without a history of normal language ception or have had generalized effects (e.g., pres-
achievement is differentiating between problems due sure effects from a tumor). However, examination of
to environment and nonneurological physical factors the patterns of the items on the battery can easily
and those due to brain-based deficits. One common eliminate these possibilities. In the absence of these
problem is the child with hearing difficulties due to types of conditions, elevation on the C6 scale, es-
pecially above a score of70T, is almost always indic- which the writing itself is motorically intact but spa-
ative of a left hemisphere injury. tially disrupted (at large angles to the horizontal, or
Very mild C6 elevations may be associated with where words are written over one another) may re-
right hemisphere lesions, with the major errors oc- flect injuries to the right (or spatially dominant)
curring in the last items of the scale (spontaneous hemisphere.
speech, sequencing, and fill-in items). One assump-
tion underlying interpretation of all the language CB (Reading). The C8 scale closely parallels
scales is that the child was originally fluent in En- the C7 scale. The child is asked to generate sounds
glish, as all of the current research is based on native- from letters that the examiner reads aloud. This. gen-
born speakers. erally measures the ability of the child to show inte-
gration of letters and auditory analysis functions of
the temporal and parietal areas of the left hemisphere.
C7 (Writing). The C7 scale evaluates the abil-
The child is then asked to name simple letters, read
ity to analyze words phonetically in English and then
simple sounds, and read simple words and letter com-
to do copying of increasing difficulty. Initially, chil-
binations that have meaning. Finally, the child must
dren are asked to copy simple letters, then combina-
read entire sentences as well as paragraphs. If the
tions of letters and words, and then write their first
and last names. They are then asked to write sounds, child is able to read simple words but not entire sen-
tences or paragraphs, possible injuries include disor-
words, and phrases from dictation.
ders of visual scanning that make it impossible for the
In general, disorders of writing localize to the
child to grasp more than one word at a time.
temporal-parietal-occ ipital area, especially in and
Generally, deficits on the C8 scale, in a child
around the angular gyrus of the left hemisphere.
However, specific disorders may indicate problems who could read prior to an injury, are almost always
in other areas. For example, the ability to write from associated with a left hemisphere injury, usually pos-
written material but not from auditory material sug- terior. The exceptions to this are deficits that occur
gests a specific lesion in the temporal lobe. Con- because of spatial disruption (inability to follow a
versely, the ability to write from dictation but not line, which shows most clearly in the paragraph read-
from written material suggests a lesion in the oc- ing) or neglect of the left side (which should be cor-
cipital or occipital-parietal areas of the cerebral rected by the examiner if the test is administered
correctly). Both suggest right hemisphere dysfunc-
cortex.
If the child is, in general, able to write but has tion. However, we are not justified in making such
difficulty forming letters and changing from one let- conclusions in an individual who never was able to
ter to another, there could be a problem in kinesthetic read unless there is other evidence to confirm a given
feedback in which the child mixes up letters that are injury.
formed by similar motor movements. If the child is C9 (Arithmetic). The C9 scale is the most sen-
simply unable to write at all due to paralysis, this, of sitive of all the LNNB-CR scales to educational defi-
course, is suggestive of a lesion in the motor strip cits. Even in normally educated individuals, this is
area of the posterior frontal lobe. Finally, if the child the scale most likely to appear in a severely patholog-
writes at an angle to the page, suggesting some spa- ical range when there is, in fact, no damage.
tial problems, and has no other writing disorders, this This scale starts with the child simply writing
can be related to right hemisphere dysfunction. Lack down numbers from dictation in both Arabic and
of the abiJity to read or write one's name is often Roman numerals. Several items have been employed
indicative of a general dementia or, in some cases, a to identify the spatial dysfunctions that are possible.
disorder of automatic writing that may occur with The child is asked to write 17 and 71 , 69 and 96.
injuries in both hemispheres. Thereafter, the scale requires the person write down
Motor writing errors are generally associated numbers of increasing complexity. As numbers be-
with the hemisphere opposite the child's normal writ- come more complex, it is possible to see if the child
ing hand, although care must be taken in injuries that places the numbers in the correct sequence, again
cause the child to change writing hands. In these looking for possible spatial deficits that can be caused
cases, writing may remain poor but reflects an injury by right hemisphere or left occipital-parietal dys-
in the ipsilateral hemisphere. Motor writing prob- function. In the next section, the child is asked to
lems may arise simply as a result of motor problems compare numbers, an operation that is basic to the
reflecting the functions of the motor areas of the left occipital-parietal area. In items 124 and 125, the
brain, but may also arise in injuries involving kines- child is asked to do simple arithmetic problems.
thetic and tactile feedback. Motor writing deficits in These are problems that most individuals can proba-
202 CHAPTER 11
bly do from memory. The last item is the presentation subtest of the Wechsler Adult Intelligence Scale
of serial 3's. (WAIS). Performance in this area is further evaluated
The C9 scale appears to be potentially sensitive by items 144 through 146, in which the child must
to lesions in all parts of the brain, as well as to preex- find the logical relationships between specific objects
isting deficits common to about 20% or more of the and the groups to which they belong. The last items
normal population whose performance is well below on the scale, items 147 through 149, involve simple
grade level expectations. arithmetic problems very similar to those seen on the
C10 (Memory). The CIO scale is basically in- WISC-R Arithmetic subtest.
Overall, the C11 scale is highly sensitive to dis-
volved with short-term memory functions. The first
orders in both hemispheres but is most sensitive to
items on C I 0 look at the ability of the child to memo-
disorders in the left hemisphere. Injuries in the par-
rize a list of seven simple words and to predict his or
ietal lobes will cause maximum dysfunction. The
her performance. Items 129 through 131 involve im-
determination of laterality, however, must be made
mediate sensory trace recall. The items test word
by investigating specific items to judge whether those
memory and visual memory.
initial items that are right hemisphere oriented sug-
Items 132 and 133 involve simple verbal memo-
gest adequate visual interpretation skills. If these
ry under two conditions of interference. Several diffi-
skills appear to be intact, then the scale is likely to be
culties in short-term memory are seen in these items.
reflecting a left hemisphere dysfunction alone. If
Finally, item 135 is a measure of the individual's
these are the only items missed on the scale, the
ability to associate the verbal stimulus with a picture.
possibility of isolated right frontal dysfunction must
This item can be interfered with by either left or right
be seriously considered.
hemisphere dysfunction and is sensitive to high-level
The Cll scale score correlates about 0. 7 with
disturbances in memory skills.
WISC-R Full Scale IQ. However, this scale, because
Overall, the C 10 scale is most sensitive to verbal
of its greater flexibility in administration, may yield
dysfunction because of its importance in a majority of
higher IQ estimates in individuals with impairment in
the items. However, nonverbal dysfunction caused
expressive or receptive speech skills. Although the
by right hemisphere lesions will show up in a moder-
scale can reflect impairment in either hemisphere, a
ately elevated CIO score of about 60T, with a pattern
high elevation combined with C2 (Rhythm), C4 (Vi-
of missing the nonverbal items. It is always important
sual Functions), CIO (Memory), and C9 (Arithmetic)
to look at the pattern of the items missed before ven-
generally points to right hemisphere dysfunction,
turing the hypothesis of a possible etiology.
whereas elevations combined with C6 (Expressive
C11 (Intellectual Processes). The items in Cll Speech), C8 (Reading), and C7 (Writing) indicate
should be differentiated from items in a standard in- left hemisphere damage.
telligence test. All the items on this scale have been
selected because they are able to discriminate be-
tween brain-damaged and normal subjects. Thus, Qualitative Analysis
rather than giving a level of intelligence that can be
associated with a child's learning history, the items The LNNB-CR lends itself to a qualitative anal-
tend to give a functional intellectual level. ysis along with the quantitative analysis discussed in
Initial items in the scale involve the understand- this chapter. The consideration of the qualitative fac-
ing of thematic pictures. The first item asks the child tors becomes the next step in the diagnostic process.
to interpret a picture in his or her own words; items Here, the interest is not in whether a child got a
137 and 138 ask the individual to put pictures into a certain score on a certain item but rather how that
series that makes sense, similar to the items in Picture score was achieved. One of the great advantages of
Arrangement. Item 139 asks the child to tell what is this battery (inherent in its design as well as in the
comical or absurd about certain pictures. Deficits of administration and testing-the-limits techniques sug-
visual scanning can also be seen in individuals who gested) is that the same test procedures lend them-
are not able to appreciate the complexity of a picture selves to both quantitative and qualitative analyses.
and who, thus, tend to focus on one area. Item 140 Although it is possible to interpret the battery from
requires the child interpret a story. Items 141 and 142 only one method or the other, the use of only one
ask for similarities. Item 141 involves simple concept technique does not take full advantage of the pos-
formations and definitions; items 142 and 143 call for sibilities within the battery nor does it yield the max-
comparisons and differences between objects in imum amount of useful information in any given
much the same way as do items on the Similarities case. The two approaches complement one another
and allow the user of the LNNB-CR to enjoy the best which to approach later supervised clinical experi-
of both methods, avoiding that continuing, yet ulti- ence. A standard examination such as the LNNB-
mately futile, argument over which approach is better CR, which allows the observation of the same basic
or which approach should be employed. behaviors across many diagnostic groups, is also an
In scoring qualitative errors, there is a wide aid in making these clinical observations.
range of possibilities aimed at gaining a better under- It is very important that the clinician learn to
standing of the .. why" behind a child's error. observe and record the child's approach to the items,
Qualitative analysis can also aid in the evaluations of especially if that approach differs from those seen in
responses that are correct in terms of the quantitative the normal child. (The examiner must have adequate
scoring but still unusual, such as the child who reads experience with normals to make this comparison.)
a word on the C8 scale but stutters in pronouncing it, This should be done even if the examiner does not
or the child who can describe an object and its uses on understand the meaning of the behavior or its signifi-
the C4 scale but is unable to give its name. cance. Sometimes the significance becomes clear
The disadvantage of qualitative inferences is the after the quantitative analysis is completed, or it may
lack of formal scoring criteria and reliability across become clear upon consultation with one's super-
examiners. At present, there is no way in which such visor or a consultant. By doing this on a systematic
problems can be completely eliminated, but there are basis, the user will begin to appreciate the meaning of
ways in which such problems can be minimized. The the child's behavior and to develop the ability to
Qualitative Scoring Summary allows the user to perform such analyses independently.
score over 60 categories of qualitative observations After a qualitative analysis has been made, it
that can be made during administration of the battery. should be integrated with the quantitative analysis. It
Although this could be cumbersome in a child is our strong belief that neither form of data is inher-
who is severely impaired, it is quite useful in the child ently .. superior" in any given case. In some cases,
who shows mild to moderate damage, or who is ap- the qualitative data help to explain inconsistencies
parently showing no damage at all, in identifying a that cannot be resolved in the quantitative results. In
specific deficit that may have neuropsychological other cases, the quantitative data suggest an alternate
implications. These categories are not exhaustive by approach to an observation that clears up the in-
any means, but do represent the areas we have found terpretation of a qualitative aspect of behavior. Only
to be the most useful and reliable. The presence of when the two sets of data have been integrated has a
such a scoring system does not, however, eliminate fully effective initial evaluation been completed.
the need for intelligent observation on the part of the
user, nor the need for neuropsychological knowledge
to interpret this information. Prior History
It should be clear from the previous description
that there are a number of major complexities with a Even at this point, there still remains another
qualitative system and these have generally inhibited step in the diagnostic process-the reconciliation of
the development of such systems in the past or caused the conclusions of the above techniques with the his-
them to be quite unreliable across examiners. It is tory. This can be done in two ways: (I) knowing the
expected that the details for each qualitative item history when the case begins and considering it
scoring will allow this system to be somewhat more throughout the diagnostic process, or (2) analyzing
rigid but also more reliable. the case with a minimum of information and check-
Interpretation of qualitative information on ing the detailed history afterward. (Doing any case
more than a behavioral level is quite difficult. At completely blindly is not recommended.) Both tech-
present, all information on such interpretations is niques have their drawbacks. If too much history is
largely unsystematized in the sense that different known, one may be so biased that the inconsistencies
clinicians or researchers use different definitions and between the history and data are overlooked or
different theoretical frameworks. deemed unimportant.
At present, learning to properly observe and in- Historical information and the conclusions
terpret the qualitative aspects of behavior is done made available by others prior to the neuropsycho-
through clinical experience with children and the logical assessment may be right or wrong. A lesion
reading of such experiences reported in specific cases may exist as reported, or may not. The child's devel-
by clinicians such as Luria. An academic understand- opmental history may be accurate or may contain
ing of the qualitative aspects of behavior through serious errors. The relative accuracy of information
reading and classes yields a basic framework from does depend on the source of that information as well
204 CHAFfER 11
as its nature. In all cases, however, it is important to pencil version and a version primarily given by com-
double-check all such information. puter under the supervision of a technician or psy-
Consequently, our bias suggests working from a chologist. The computer version has the advantage of
basic history for important aspects that concern the ensuring that the test materials are given properly and
validity of testing. In the evaluation process, we treat timed properly, freeing the examiner to do more ob-
conclusions from the data as simply hypotheses to be servation and analysis of the patient's performance.
confirmed or discarded. This leaves the clinician It is expected that the new version will be released for
more flexibility to take his or her data seriously and to general use in about 3 years.
learn from those data all that is possible. If, at the
end, discrepancies are found between history and
neuropsychological findings, the clinician should in-
vestigate the history and the findings for errors that Conclusions
may cause this discrepancy, and look for conditions
outside neuropsychology that may have affected one The Luria-Nebraska Children's Battery is a test
or the other source of data. that evaluates a wide range of skills aimed at assess-
ing the neuropsychological competence of children
New Research Approaches between the ages of 8 and 12. The battery offers a
variety of quantitative and qualitative scores by
At present, we are in the development of a new which to detail the performance of children and to
battery that represents a substantial expansion of the integrate that performance with historical data. The
old one. The new battery has been expanded to more battery has been shown to be highly successful in
heavily cover areas not well involved in Luria's origi- diagnosis, but does need to be supplemented by other
nal examination: more complex and detailed analysis tests when detailed analysis of single areas is neces-
of visual-spatial functions, more detailed analysis of sary or preferable. The battery lends itself to in-
various aspects of aphasia, reading comprehension, terpretation on a variety of levels. Thus, it can be
motor writing, complex memory functions, and useful to people with varying backgrounds providing
higher intellectual skills. The new test combines caveats on use are followed carefully.
items from both the children's and adult Luna-Ne- In the long run, the battery represents an initial
braska battery along with new items. A factor analy- test that will be expanded and improved with each
sis of the items as a whole yielded 37 scales, which version. This is based on the philosophy of the author
form the basis of the new test. Internally, these scales that there is never a perfect test battery, and that
are more like the factor scales, representing purer and change of current tests on the basis of research is both
more specific abilities. necessary and desirable.
The test differs in that instead of giving every
item, items are given on the basis of the individual's
abilities (as with the Stanford-Binet, for example).
Within each area patients may get only very difficult, References
very easy, or moderately hard items depending on
their performance. This allows the test to contain Golden, C. J. (1986). Manual for the Luria-Nebraslw Neuropsy-
chological Battery: Childrens Revision. Los Angeles: WPS.
items suitable from ages 3 through adulthood, and Plaisted, J. R., Gustavson, J. L., Wilkening, G. N., &Golden, C.
applicable to wide ranges of performance in brain- J. (1983). The Luria-Nebraska Neuropsychological Bat-
injured individuals. The giving of only a part of the tery-Childrens Revision: Theory and current research find-
item pool allows for a reasonable testing time (2 to 3 ings. Journal of Clinical Child Psychology, 12, 13-21.
hours). Raven, J. C. (1960). Guide to the Standard Progressive Matrices.
The test will come in two versions, a paper and London: Lewis.
12
Applications of the Kaufman

Assessment Battery for Children
(K-ABC) in Neuropsychological
Assessment
CECIL R. REYNOLDS, RANDY W. KAMPHAUS,
AND BECKY L. ROSENTHAL
The Kaufman Assessment Battery for Children (K- was project director for development of the WISC-R
ABC) (Kaufman & Kaufman, 1983a) is a recently and the McCarthy Scales, tasks to which he was well
published, individually administered clinical test of suited because of his studies at Columbia under the
intelligence and achievement designed specifically tutelage of the psychometrician Robert L. Thorn-
for use with children from 2i to 121 years of age. The dike. Subsequently, Kaufman's (1975) article on the
K-ABC was developed from a theoretical framework factor analysis of the WISC-R standardization sam-
that to a large degree reflects a coalescence of the ple (still one of the most cited articles in WISC-R
work of Luria and Vygotsky and American re- research) provided an important reminder to clini-
searchers with interests in cerebral specialization as cians that, as was the case with the old WISC, the
interpreted and integrated by Alan and Nadeen Kauf- updated WISC-R produced three factors. Hence, it is
man. The K-ABC is thus of interest to clinical neu- not always possible to interpret the verbal and perfor-
ropsychologists. This chapter will review the the- mance IQs of the WISC-R as unitary dimensions. A
oretical framework of the K-ABC, provide an possibly more legendary article by Kaufman (1976)
overview of the test, its methods of development and cautioned psychologists against overinterpreting ver-
standardization, its technical properties, and describe bal and performance IQ discrepancies that were quite
its conceptual and empirical relationship to neuro- common in the general population.
psychology. Additionally, techniques for rehabilita- Alan and Nadeen Kaufman's first book,
tion of academic disturbances will be introduced as Clinical Evaluation of Young Children with the Mc-
viewed from the K-ABC model. Carthy Scales ( 1977), provided a logical framework
The previous work of the K-ABC authors, Alan and summary of major research findings for what was
S. and Nadeen L. Kaufman, is well known in the area at the time a new, and somewhat unique, measure of
of intellectual assessment. Alan Kaufman had a ma- intelligence. PriortotheK-ABC, however, Kaufman
jor impact on the assessment of children's intel- was probably best known for his text Intelligent Test-
ligence long before the K-ABC. As a Research Asso- ing with the WISC-R (l979a). Anastasi (1982) says of
ciate at The Psychological Corporation, Kaufman Kaufman's book that the
most important feature of [Kaufman's] approach is that
it calls for individualized interpretations of test perfor-
CECIL R. REYNOLDS Department of Educational mance, in contrast to the uniform application of any
Psychology, Texas A&M University, College Station, one type of pattern analysis . . . . The basic approach
Texas 77843. RANDY W. KAMPHAUS AND described by Kaufman undoubtedly represents a major
BECKY L. ROSENTHAL Department of Educational Psy- contribution to the clinical use of intelligence tests. (p.
chology, University of Georgia, Athens, Georgia 30602. 466)
205
206 CHAPTER 12
Throughout his writings, however, one detects a tual schemes of the functional organization of the
sense of dissatisfaction with many aspects of existing brain are probably the most comprehensive currently
intelligence tests. In an article published in the Jour-
available" (Adams, 1985, p. 878). Much of Luria's
nal of Research and Development in Education work grew from earlier writings of Sechenov (trans-
(1979b), Kaufman set the stage for the development lation, 1965) and Vygotsky (translation, 1978). Ma-
of the K-ABC. In that article, he maintained that jovski (1984), who studied with Luria in Russia for
individual intelligence testing had been remarkably several years near the end of Luria's life, evaluated
resistant to change, despite advances related to the the K-ABC regarding its relevance to Luria's ap-
understanding of intelligence in fields such as psy- proach with children and to child neuropsychology in
chology and neurology. Kaufman argued that sub- general, and gave the scale high marks.
stantive theoretical advances in intelligence research Luria defmed mental processes in term of two
had gone unheeded in the conservative test-publish- sharply delineated groups, following Sechenov's
ing industry and that the field lacked any true innova- suggestions. The first is the integration of elements
tions since the work of Binet around the turn of the into simultaneous groups. He further qualified
century. In developing his intelligent testing philoso- Sechenov's original meaning, indicating that simul-
phy (an outgrowth of Wesman's (1968) intelligent taneous processing meant the synthesis of successive
testing approach), Kaufman gave great emphasis to elements (arriving one after the other) into simul-
the need for theory-driven assessment and interpreta- taneous spatial schemes whereas successive process- .
tion of children's intelligence and adherence topsy- ing meant the synthesis of separate elements into
chometric theory (Reynolds, 1987). Kaufman successive series. The latter qualifications are crucial
( 1979b) then set the stage for the emphasis of theory in seeing the match of the various subtests of the K-
in the development of the K-ABC. The Kaufmans' ABC mental processing scales to this processing
emphasis on assessing intelligence from a strong the- dichotomy.
oretical base is one characteristic of the K-ABC that, In the K-ABC the Kaufmans define these pro-
perhaps more than anything else, distinguishes it cesses in a manner similar to Luria and provide a
from its predecessors; it is the derivation of that theo-.
standardized assessment of these functions. Simul-
ry that creates much of interest to the neuropsycholo- taneous processing here refers to the mental ability of
gist. the child to integrate input simultaneously to solve a
problem correctly. Simultaneous processing fre-
quently involves spatial, analogic, or organizational
abilities (Kaufman & Kaufman, 1983b) as well as
Theoretical Framework problems solved through the application of visual
imagery. The Triangles subtest on the K-ABC (an
The K-ABC intelligence scales are based on a
analogue of Wechsler's Block Design task) is a pro-
model of sequential and simultaneous information
totypical measure of simultaneous processing. To
processing. The theoretical underpinnings of the pro-
solve these items correctly, one must mentally inte-
cessing model were gleaned from a convergence of
grate the components of the design to "see" the
research and theory in a variety of areas including
whole. Such a task seems to match up nicely with
both neuropsychology and cognitive psychology.
Luria's qualifying statement of synthesis of separate
The neuropsychological theory employed by the
elements (each triangle) into spatial schemes (the
Kaufmans was distilled from two lines: the informa-
larger pattern of triangles, which may form squares,
tion processing approach of Luria (e.g., Luria, 1966)
rectangles, or larger triangles). Whether the tasks are
and the cerebral specialization work done by Sperry
spatial or analogic in nature, the unifying charac-
(1968, 1974), Bogen (1969), Kinsboume (1975),
teristic of simultaneous processing is the mental syn-
and Wada, Clarke, and Hamm (1975).
thesis of the stimuli to solve the problem, indepen-
dent of the sensory modality of the input or the
Lurian Theories output.
Sequential processing, on the other hand, em-
Luria's theory was of paramount importance in phasizes the arrangement of stimuli in sequential or
the formulation of the Kaufmans' approach to assess- serial order for successful problem solving. In every
ing intelligence with the K-ABC. This seems only instance, each stimulus is linearly or temporally re-
appropriate given the stature of Luria's theory. "Al- lated to the previous one (Kaufman & Kaufman,
exander R. Luria's theory of higher cortical function- 1983b) creating a form of serial interdependence
ing has received international acclaim. His concep- within the stimulus. The K-ABC includes sequential
K-ABC 207
processing subtests that tap a variety of modalities. man, & Kamphaus, 1985). This scale contains mea-
The Hand Movements subtest involves visual input sures of what have been identified traditionally as
and a motor response; the Number Recall subtest verbal intelligence, general information, and ac-
involves auditory input with a response involving the quired school skills. Keeping in mind that it is not
auditory output channel only; Word Order involves possible to separate entirely what you know (achieve-
the visual channel for input and an auditory response. ment) from how well you think (intelligence), the
Therefore, the mode of presentation or mode of re- Kaufmans attempted to differentiate the two vari-
sponse is not what determines the scale placement of ables better than traditional measures of intelligence
a task, but rather it is the mental processing demands had. From a clinical neuropsychological standpoint,
of the task that are important (Kaufman & Kaufman, the K-ABC allows one to assess information process-
1983b). By providing systematic variation of ing skills without as much contamination from prior
modality of input and modality of response, the K- learning. Measurement of children's academic skills,
ABC provides a clinical vehicle for locating intact however, is a traditional component of comprehen-
complex functional systems as well as specifying sive neuropsychological assessment. The inclusion
where any potential breakdown may have occurred in of the Achievement Scale in the K-ABC affords the
a faulty functional system. Qualitative evaluation of opportunity to observe the application of processing
a child's performance on the K-ABC can be most skills to complex learning tasks, assess functional
useful in such instances and can lead to beneficial academic levels, and estimate long-term memory
rehabilitation plans. ability. For a thorough review of interpretation of the
No one with an intact brain uses only a single K-ABC Achievement Scale, see Kamphaus and
type of information processing to solve problems. Reynolds (1987).
These two methods of information processing are Majovski (1984) noted the high degree of "fit"
constantly interacting (even in the so-called split- between Luria's theory and the K-ABC and recom-
brain following commissurotomy, the two hemi- mended that the test be used as an integral part of the
spheres of the brain often "whisper" to each other neuropsychological battery for children. The K-ABC
even if they cannot talk), though one approach will is not, under any circumstance, a complete or sub-
usually take a lead role in processing. Which method stitute battery for a comprehensive neuropsychologi-
of processing takes the lead role can change accord- cal assessment; it is a good complement to nearly any
ing to the demands of the problem or, as is the case choice of neuropsychological instruments. Majovski
with some individuals, persist across problem type found the K-ABC particularly useful in contrasting
(i.e., forming what Das, Kirby, and Jarman (1979) problem-solving skills with acquisition of facts and
refer to as habitual modes of processing). In fact, any in evaluating how a child solves a particular problem.
problem can be solved through either method of pro-
cessing. In most cases, one method is clearly superior
to another. It is the latter case that makes the K-ABC Cerebral Specialization Theories
a valuable tool-the two mental processing scales
are primarily, not exclusively, measures of sequen- Support for use of the K-ABC in the context of
tial or simultaneous processing. Pure scales, i.e., neuropsychological assessment also comes from a
scales measuring only one process, do not exist. variety of sources in cerebral specialization research.
Careful observation of a child's performance, which In a comprehensive review of research concerning
should be the order of the day during any evaluation, the lateralization of human brain functions, Dean
will be particularly important to any neuropsycholog- (1984) concluded that the K-ABC was well suited to
ical assessment or neuropsychological interpretation clinical use and in research with children. Research
of K-ABC test results; observation in many cases will evidence to be reviewed in a subsequent section pro-
be a primary source of information regarding which vides additional but still tentative support for Dean's
mental processes a child invoked on any given task, conclusion.
regardless of its scale. It has been proposed that sequential and simul-
An equally important component of the K-ABC taneous processing are lateralized to the left and right
is the Achievement Scale. This scale measures abili- hemispheres, respectively (e.g., Reynolds, 1981b;
ties that serve to complement the intelligence scales. Sperry, 1974; Sperry, Gazzaniga, & Bogen, 1969).
Performance on the achievement scales is viewed as Many other dichotomies have been suggested. The
an estimate of children's success in the application of most prominent of these are displayed in Table I.
their mental processing skills to the acquisition of Some find research on cerebral specialization diffi-
knowledge from the environment (Kaufman, Kauf- cult to coalesce. Indeed, the many seeming contra-
208 CHAPTER12
TABLE 1. Definitions of the Two Types of Mental Processing That Underlie the K-ABC
Intelligence Scales from the K-ABC Manual and from Several Theoretical Perspectives"
Source Labels for process Defmitions
K-ABC: Kaufman & Kaufman Sequential Places a premium on the serial or temporal order of stimuli
(1983a) when solving problems.
Simultaneous Demands a gestalt-like, frequently spatial, integration of stim-
uli to solve problems with maximum efficiency.
Celebral Specialization: Nebes Analytic/propositional/ Sequentially analyzes input, abstracting out the relevant details
(1974) (summarizing model left hemisphere to which it associates verbal symbols in order to more effi-
of Bogen, Levy-Agresti, ciently manipulate and store the data.
and Speny)
Synthetic/appositional/ Organize and treat data in terms of complex wholes, being in
right hemisphere effect a synthesizer with a predisposition for viewing the total
rather than the parts.
Luria/Das: Das, Kirby, & Jar- Successive Processing of information in a serial order. The important dis-
man (1979) tinction between this type of information processing and si-
multaneous processing is that in successive processing the
system is not totally surveyable at any point in time. Rather,
a system of cues consecutively activates the components.
Simultaneous The synthesis of separate elements into groups, these groups
often taking on spatial overtones. The essential nature of this
sort of processing is that any portion of the result is .at once
surveyable without dependence upon its position in the
whole.
Cognitive Psychology: Neisser Sequential/serial Viewed as a constructive process, it constructs only one thing at
(1967) a time. The very definition of 'rational' and 'logical' also
suggest that each idea, image, or action is sensibly related to
the preceding one, making an appearance only as it becomes
necessary for the aim in view.
A spatially serial activity is one which analyzes only a part of
the input field at any given moment ... On the other band,
sequential refers to the manner in which a process is orga-
nized; it is appropriate when the analysis consists of suc-
cessive, intem:lated steps.
Parallel/multiple Carries out many activities simultaneously, or at least indepen-
dently.
From Kaufman (1984). Reprinted with permission.
dictions in the results of cerebral specialization stud- Goldstein, Jaynes, & Krauthamer, 1977; Kina-
ies have prompted at least one leading researcher to bourne, 1978; Schwartz, Davidson, & Maer, 1975;
remark thus: .. (To] say that the field of hemispheric Segalowitz & Gruber, 1977). One will fmd in the
specialization is in a state of disarray and that the literature a large number of studies of hemispheric
results are difficult to interpret is an understatement. specialization attempting to provide anatomical lo-
The field can best be characterized as chaotic'' calization of performance on specific, yet higher-
(Tomlinson-Keasey & Clarkson-Smith, 1980, p. 1). order, complex tasks. Much of the confusion in the
On the other hand, reviews by Dean (1984) and Rey- literature stems from the apparently conflicting data
nolds (1981b) have noted some consistencies, as dis- of many of these studies. However, the dynamic
played in. Table 1. functional localization principle of Luria, and knowl-
For the vast majority of individuals, the left ce- edge that any specific task potentially can be per-
rebral hemisphere appears to be specialized for lin- formed through any of the brain's processing modes,
guistic, propositional, serial, and analytic tasks and should give some insight into the conflicting results
the right hemisphere for more nonverbal, apposi- that appear in the literature. In this regard, it is most
tional, synthetic, and holistic tasks (Bever, 1975; important to remember that cerebral hemispheric
Bogen, 1969; Gazzaniga, 1970; Hamad, Doty, asymmetries of function are process-specific and not
K-ABC 209
stimulus-specific. Shure and Halstead (1959) noted psychological assessment as to any other area of
early in this line of research that manipulation of clinical evaluation.
stimuli was at the root of hemispheric differences, a Das et al. ( 1979) do not agree that simultaneous
notion that is well supported by current empirical and successive processing are represented in the right
research (e.g., Ornstein, Johnstone, Herron, & and left hemispheres, respectively, but rather believe
Swencionis, 1980) and thought (e.g., Reynolds, that each mode of processing is prominently repre-
198Ib). The confusion of the content and sensory sented in both hemispheres. According to Bever's
modality through which stimuli are presented with (1975) line of reasoning, this is an impossible state of
the process by which they are manipulated, particu- affairs in the normally functioning human brain. Ad-
larly in the secondary and tertiary regions of each ditionally, the hemispheric-lateralization literature is
lobe of the neocortex, seems to be at the root of the consistent with the notion of a successive-processing
chaos. How information is manipulated while in the left hemisphere and simultaneous-processing right
brain is not dependent on its modality of presentation hemisphere relationship. Das et al. (1979) have de-
and not necessarily on its content, though the latter veloped their theory exclusively on the basis of group
may certainly be influential. The variation in content data, yet they attempt to discredit hemispheric later-
and method of presentation of the tasks that make up alization of cognitive processing by calling upon an-
the three scales of the K-ABC allow one to tease ecdotal individual case data. Hardly anyone would
out any modality or content effects that might nev- contend that hemispheric specialization for cognitive
ertheless occur for a specific child, though clearly processing is the same in every individual. However,
the emphasis of the K-ABC is on process, not con- this seems to be the requisite state of affairs for Das et
tent. al. to accept the hypothesis of lateralization of simul-
A review of Table 1 reveals that a process-ori- taneous and successive processing. This hardly
ented explanation provides an organizing principle seems necessary. The sheer weight of evidence at
superior to a focus on content. The "content-driven" present (cited later in this chapter) indicates that, for
attempts at explaining hemispheric differences fail to the vast majority of individuals, the lateralization of
recognize the possibilities for processing any given simultaneous and successive processes is to the right
set of stimuli or particular content in a variety of and left hemispheres, respectively.
processing modes. Bever (1975) emphasized this Children may also form habitual modes of infor-
point and elaborated on two modes of information mation processing that detract from their efficiency
processing that are of interest here due to their sim- in learning new material or in solving novel problems
ilarity to simultaneous and successive cognitive (Reynolds, 1981b). This would be one explanation of
processes. large sequential-simultaneo us score differences that
According to Bever (1975), cerebral asymme- should also be explored, perhaps through protocol
tries of function result from two fundamental later- analysis or some related technique during a testing of
alized processes: holistic and analytic processing. the limits type of procedure. Children who attempt to
Lateralization of these two methods of information solve sequential tasks using simultaneous processing
processing is incompatible and cannot coexist in the approaches or vice versa are likely to have academic
same physical space. Analytic processing appears as well as behavioral problems. n any event, a prob-
analogous to successive processing and is lateralized, lem is evident when this occurs, one that needs more
in most individuals, to the left hemisphere. Holistic detailed study for the individual child in order to
processing is analogous to simultaneous processing explain the reason for this persistent approach. Nor-
and is typically lateralized to the right hemisphere. mally functioning individuals appear to be able to use
The K-ABC also taps most of the functions the two modes of information processing separately
identified by Dean ( 1984) in his review of the cere- or in conjunction with one another or possibly shift at
bral specialization literature, with the exceptions of will depending on the type of information to be pro-
depth, haptic, and melodic perceptions. These skills cessed (Gazzaniga, 1974, 1975), though such deci-
are assessed by other traditional neuropsychological sions are more likely to be made at an unconscious
batteries, although such tasks are virtually nonexis- level in interaction between the stimuli to be pro-
tent for the very young child. Careful observation cessed and the child's preference for a processing
may still provide insight into neuropsychological approach. At.the highest level of function, the two
processing deficits especially if one pays particular modes of processing operate in a complementary
attention to the manner in which errors are made. manner, achieving maximal interhemispheric inte-
Qualitative and quantitative data are complementary, gration of processing or, in Bogen, Dezure, Ten-
not interchangeable; the intelligent testing philoso- outen, and Marsh's (1972) terminology, "cerebral
phy of Kaufman (1979b) is just as crucial to neuro- complementarity.'' For example, right hemisphere
210 CHAPTER 12
function (simultaneous processing) is important in pantomime and that are responded to motorically), to
contributing to letter and word recognition during the assess the intelligence of children with speech or lan-
formative stages of learning to read. It is a more guage handicaps, of hearing-impaired children, and
complex function handled primarily through suc- of those who do not speak English. It is particularly
cessive processing in the intermediate learning stage, useful as part of the assessment of children suspected
due to its linguistic nature. Highly skilled readers of aphasia and certain of the apraxias. However, the
who have mastered the component skills of reading, Nonverbal scale is useful as an estimate of general
making it an automatic function, demonstrate exten- intellectual level only and cannot be subdivided into
sive use of both processes in reading (Cummins & Sequential or Simultaneous Processing scales.
Das, I977). All of the K-ABC global scales (Sequential Pro-
When first learning to read, successive process- cessing, Simultaneous Processing, Mental Process-
ing is most important and many children with diffi- ing Composite, Achievement, and Nonverbal) yield
culties in learning to read have problems with suc- standard scores, with a mean of IOO and standard
cessive processing (Cummins & Das, I977). This is deviation of I5, to provide a commonly understood
also consistent with the findings of higher Wechsler metric and to permit comparisons of mental process-
performance than verbal IQ in most groups of reading with achievement for children suspected of learn-
ing-disabled children. Performance IQ is almost cer- ing disabilities. Furthermore, use of this metric al-
tainly more closely related to the simultaneous pro- lows for easy comparison of the K-ABC global scales
cessing of information than to successive processing to other major tests of intelligence and to popular
whereas the converse relationship holds for the ver- individually administered tests of academic achieve-
bal IQ, the latter being a language task as is reading.ment, provided that the standardization samples are
Most (though certainly not all) young children with comparable (see Reynolds, I984). The availability of
reading and related language problems have greater age-corrected deviation scaled scores for all intrain-
difficulty with sequential processing (Kamphaus & dividual score comparisons offers another advantage
Reynolds, 1987). to the neuropsychologist. The use of other equiv-
The traditional verbal-nonverbal distinction be- alent-type scores, such as age or grade equivalents,
tween the two hemispheres, although in part accu- has long been a problem for interpretation of tests in
rate, is likely an overcharacterization and simplifica-child clinical neuropsychology (see Reynolds,
tion of hemispheric differences (Dean, I984). I98Ia, 1984). Standard scores are clearly the most
Hemispheric differences seem more related to the appropriate mechanism for score comparison and the
method by which information is processed than to the analysis of fluctuations in individual performance,
specific modality of presentation (Brown & Hecaen, one of the hallmarks of current (and past) neuropsy-
1976; Dean, 1984; Reynolds, 1981b). The K-ABC chological approaches to test interpretation. .
seems to be the best available measure of intelligence The K-ABC is comprised of 16 subtests, not all
to quantify this bimodal functioning. Although spe- of which are administered to any age group. Children
cific neural substrates related to K-ABC performance aged 2! are given 7 subtests, age 3 receives 9 sub-
remain to be detailed, the scale appears useful as a tests, ages 4 and 5 receive II subtests (but not pre-
tool to gain insight into the relative efficacy of the cisely the same set of tasks, due to developmental and
two hemispheres. neuropsychological processing changes), age 6 re-
ceives I2 subtests, and the peak of 13 subtests is
given to those aged 7 through 121. Also, attempting
to be sensitive to children's development, testing
An Overview of the Scales time ranges from about 30 minutes for 2!-year-olds to
1 hour 20 minutes (including the Achievement scale)
The intelligence scales of the K-ABC consist of for 7- to 12!-year-olds. The Mental Processing sub-
subtests that are combined to form scales of Sequen- tests yield standard scores with a mean of 10 and
tial Processing, Simultaneous Processing, and the standard deviation of 3, modeled after the familiar
Mental Processing Composite, a summary score re- Wechsler scaled score. Achievement subtests, on the
flective of the sequential and simultaneous scales. On other hand, yield standard scores with a mean of tOO
the separate Achievement scale, subtests are com- and a standard deviation of 15, which permits direct
bined to form a global Achievement score. The K- comparisons of the mental processing global scales
ABC also includes a special short form of the Mental with individual achievement areas. Kamphaus and
Processing Composite, known as the Nonverbal Reynolds ( I987) have developed a new organization
scale (comprised of tasks that can be administered in of the K-ABC subtests into a more traditional system
K-ABC 211
that allows derivation of a verbal IQ and a Reading Mental Processing Scale

Composite in addition to a Global Composite IQ and Sequential Processing Scale
the typical K-ABC scales. Those who prefer a Hand Movements (ages 2Yz-12Vz years)*
Wechsler-type approach to test data may find this Imitating a series of hand movements in the same
reorganization of interest. The Kaufmans have orga- sequence as the examiner performed them
Number Recall (ages 2Vz-12Vz)
nized the K-ABC as shown in Figure l.
Repeating a series of digits in the same sequence as
the examiner said them
Word Order (ages 4-12Y2)
Administration and Scoring Touching a series of pictures in the same sequence
as they were named by the examiner, with
Administration and scoring procedures for the more difficult items employing a color-inter-
K-ABC are available in the K-ABC Administration ference task
and Scoring Manual (Kaufman & Kaufman, 1983a). Simultaneous Processing Scale
One important aspect of K-ABC administration that Magic Window (ages 2Vz-4)
deserves special mention, however, is the notion of Identifying a picture that the examiner exposes by
teaching items. The first three items of each mental moving it past a narrow slit or "window,"
making the picture only partially visible at any
processing subtest (the sample and the first two items
one time
appropriate for a child's age group) are designated as Face Recognition (ages 2Vz-4)*
teaching items. On these items the examiner is re- Selecting from a group photograph the one or two
quired to teach the task if the child fails on the first faces that were exposed briefly in the preced-
attempt at solving the item. By "teaching the tas'k" it ing photograph
is meant that the examiner is allowed the flexibility to Gestalt Closure (ages 2Vz-12Vz)
use alternate wording, gestures, physical guidance, Naming the object or scene pictured in a partially
or even a language other than English to communi- completed "inblot" drawing
cate the task demands to the child. The examiner is Triangles (ages 4-12Vz)*
not allowed to teach the child a specific strategy for Assembling several identical triangles into an ab-
stract pattern that matches a model
solving the problem, however. This built-in flexibil-
Matrix Analogies (ages 5-12Vz)*
ity is particularly helpful to preschoolers, minority- Selecting the picture or abstract design that best
group children, and exceptional children, who some- completes a visual analogy
times perform poorly on a task in a traditional IQ test, Spatial Memory (ages 5-12Vz)*
not because of a lack of ability, but because of an Recalling the placement of pictures on a page that
inability to understand the instructions given. Ka- was exposed briefly
ufman and Kaufman ( l983b) discuss the concept of Photo Series (ages 6-12Vz)*
teaching items in greater detail and note, as is evident Placing photographs of an event in chronological
from Table 3(later in this chapter), that this built-in order.
flexibility has not adversely affected the reliability of Achievement Subtests
the K-ABC. Expressive Vocabulary (ages 2Vz-4)
Naming the object pictured in a photograph
The extensive use of sample practice and teach- Faces & Places (ages 2Vz-12Vz)
ing items on the K-ABC helps to ensure that the Naming the well-known person, fictional character,
various subtests actually measure what they were or place pictured in a photograph or illustra-
intended to measure. Many intelligence tests contain tion
basic language concepts, such as "next," "same," Arithmetic (ages 3-12Vz)
"alike," "opposite," "backwards," and "after," Answering a question that requires knowledge of
that less than half of children in kindergarten and a math concepts or the manipulation of num-
significant number of primary-grade children do not bers
understand (Kaufman, 1978). Thus, a child may per- Riddles (ages 3-12Vzl
form poorly on a test because of a very specific lan- Naming the object or concept described by a list of
three characteristics
guage deficit, despite the fact that the test was
Reading/Decoding (ages 5-12Vz)
intended to measure psychomotor speed, memory, Naming letters and reading words
spatial ability, or some other intellectual ability. Vio- Reading/Understanding (ages 7-12Vz)
lations of standardized procedure to explain the di- Acting out commands given in written sentences
rections to children make the obtained scores essen-
tially unusable, as the amount and direction of error FIGURE 1. K-ABC subtests. Asterisks denote subtests that also
introduced through such procedures are unknown make up the nonverbal scale.
212 CHAPTER 12
and are not constant across children (or across exam- metrically most sophisticated nonverbal scale pres-
in~rs). Because the K-ABC was standardized by ently available. Several features of the K-ABC also
usmg the sample and teaching items to ensure the make it a very attractive scale for use in evaluating
child's understanding of the task, influences on per- very low-functioning adolescents. Reynolds and
formance are built into the normative data and the Clark ( 1985) described_ a useful approach to applying
error introduced is included in the standard errors of the K-ABC (and certam other tests) to this difficult
measurement reported in the K-ABC Interpretive population; a special record form is available from
Manual (Kaufman & Kaufman, 1983b). the publisher of the K-ABC for this procedure and
The K-ABC basal and ceiling rules, referred to several other special, newly derived scales.
as starting and stopping points in the K-ABC Admin-
istration and Scoring Manual (Kaufman & Ka-
ufman, 1983a), are also somewhat different from Standardization
those of many existing intelligence tests. The first
Th~ K-ABC was standardized on a sample of
rule_ for administering the K-ABC subtests is very
2000 children, using primarily 1980 U.S. Census
straightforward: examiners are instructed to start and
stop testing at the items designated as starting and figure_s. Th~ sample was s~atified by age, sex, geo-
graphic regiOn, race/ethmc group, parental educa-
~topping points for the child's age group. The set of
tional attainment (used as a measure of so-
Items between the starting and stopping points are,
cioeconomic status (SES)), community size and
therefore, designed based on standardization data, to
represent a full range of difficulty for the child's age educational placement (regular class placeme~ ver-
group. The first basal and ceiling rule is very straight- s_us plac~ment in a variety of programs for excep-
tional children). Educational placement is an infre-
forward, but it is also rigid. Hence, several supple-
mental rules are given to allow examiners to find quently used stratification variable. Typically,
exceptional children are excluded from the standar-
items of appropriate difficulty for children at the ends
of the distribution of ability. The K-ABC also incor- dization samples for individually administered tests.
An attempt was made to include representative pro-
porates a very simple discontinue rule, one that is the
P?rtions of learning-disabled, mentally retarded,
same for all K-ABC subtests.
gifted and talented, and other special populations in
As noted earlier, the Nonverbal scale is intended
~e standardiza~on sample according to data pro-
for use with children for whom administration of the
vided by the National Center for Education Statistics
regular K-ABC (and virtually all other well-normed,
and the U.S. Office of Civil Rights. An overview of
standardized measures of intelligence) would be in-
the K-ABC standardization sample, indicating its
appropriate: those who are hearing impaired, have
match to the U.S. Census data for the variables of
speech or language disorders, other communication
gCC?graphic region, race/ethnic group, parental edu-
handicaps, or are limited English proficient. The
cation, and community size, is presented in Table 2.
Nonverbal scale yields a global estimate of intel-
O~e~l: the mat~h is quite good, although high-SES
ligence; however, a method for profile interpretation
mmonties (specifically blacks and Hispanics) were
of subtest scaled scores is offered in the K-ABC In-
statistically significantly oversampled. The real ef-
terpretive Manual (Kaufman & Kaufman, 1983b).
fect was small, however, resulting in an overestima-
Most well-normed intelligence tests that are applica-
tion of black and Hispanic populations' total scores
ble to communications-handicapped children are
by around two points on the Mental Processing Com-
very narrow and give a quite limited view of these
posite (overestimation here referring to the mean
children's intelligence (e.g., the Columbia Mental
scores of these groups had their representation in the
Maturity Scale). Although the K-ABC Nonverbal
standardization sample been a perfect match to the
scale has limitations in this regard, of those tests of
1980 U.S. Census Bureau statistics).
mental ability with adequate technical/psychometric
characteristics the K-ABC Nonverbal scale provides
the broadest sampling of abilities. This breadth of Reliability
assessment should enhance studies of these children
and their development. The lack of adequately nor- Split-half reliability coefficients for the K-ABC
med scales with any breadth of assessment has been a global scales ranged from 0.86 to 0.93 (mean
hindrance not only to clinical assessment of children = 0.90) for preschool children, and from 0.89
with communication disorders but also to research in to 0.97 (mean = 0.93) for children aged 5 to 12!.
the area (Reynolds & Clark, 1983). The Nonverbal Mean internal consistency reliability coefficients for
scale of the K-ABC is the best-normed, psycho- the global scales and the subtests are shown in Table
K-ABC 213
TABLE 2. Representation of the K-ABC Standardization Sample (Ages 2% through 12%)

by Geographic Region, Race/Ethnic Group, Parental Education, and Community Size
K-ABC
sample K-ABC sample
Stratification U.S. population Stratification U.S. population
variable N % (%) variable N % (%)
Region Race or ethnic group

East 401 20.0 20.3 White 1,450 72.5 73.1
North Central 565 28.2 26.5 Total minorities 550 27.5 26.8
South 628 31.4 34.0 Black 3ll 15.6 14.5
West 406 20.3 19.2 Hispanic 157 7.8 9.1
Native Ameri- 82 4.1 3.2
can, Asian,
or Pacific
Islander
Parental education Community size
Less than high school 384 19.2 2l.l Central city 579 28.9 27.9
High school education 813 40.6 4l.l Suburb or small 876 43.8 43.8
Some college 413 20.6 19.8 town
College degree 390 19.5 18.0 Rural area 545 27.2 28.3
3. A test-retest reliability study was conducted with Validity

246 children retested after a 2- to 4-week interval
(mean interval 17 days). The results of this study The K-ABC Interpretive Manual (Kaufman &
showed good estimates of stability that improved Kaufman, 1983b) includes the results of 43 validity
with increasing age. For the Mental Processing Com- studies, an impressive amount of prepublication re-
posite, coefficients of .83, .88, and .93 were ob- search that is all too uncommon in test manuals.
tained for the Achievement scale at each age group. Studies were conducted on aspects of construct, con-
Further details of the test-retest study can be found current, and predictive validity. In addition, several
on pp. 81-84 of the K-ABC Interpretive Manual (Ka- of the studies were conducted with samples of excep-
ufman & Kaufman, 1983b). tional children, including samples classified as hear-
The test-retest reliabilitY coefficients for the ing impaired, physically impaired, gifted, mentally
global scales, and to a lesser extent the internal con- retarded, and learning disabled.
sistency (split-half) coefficients, show a clear devel- Topics considered under construct validity in-
opmental trend, with coefficients for the preschool clude developmental changes, internal consistency,
ages being smaller than those for the school-age factor analysis, and convergent and divergent rela-
range. This trend is consistent with the known vari- tionships with other measures. Of particular interest
ability over time that characterizes preschool chil- are the data on factor analysis and correlations given
dren's standardized test performance in general. in detail in the K-ABC manuals and elsewhere (e.g.,
As shown in Table 3, the reliability coefficients Kamphaus & Reynolds, 1987; Reynolds, 1984); only
of the K-ABC subtests typically meet or exceed those a synopsis of the findings in the K-ABC Interpretive
for comparable intelligence tests with (Kaufman & Manual is given here. A recent book by Kamphaus
Kaufman, l983b) subtest reliabilities ranging and Reynolds ( 1987) details a wealth of K-ABC va-
from 0.72 to 0.89 for preschool children and from lidity data. Serious K-ABC users are referred to that
0. 71 to 0. 92 for school-age children. Test-retest co- volume for a book-length treatment of K-ABC re-
efficients for the subtests given in the K-ABC In- search data and clinical findings.
terpretive Manual (Kaufman & Kaufman, l983b) Several prepublication factor analytic studies
show the same predictable developmental trend iden- were conducted with early research editions of the K-
tified for the global scales, and are consistent with the ABC (Kaufman, Kaufman, Kamphaus, & Naglieri,
values for such traditional intelligence scales as the 1982; Naglieri, Kaufman, Kaufman, & Kamphaus,
various Wechsler Scales and the McCarthy Scales. 1981). In addition, Kamphaus, Kaufman, and Kauf-
214 CHAPTER 12
TABLE 3. Average Reliability Coefficients for the K-ABC

Scales and Subtestsa
Preschool children School-age children
(ages 2!1 through 4) (ages 5 through 12!1)
N = 500 N = 1500
Scale or subtest mean r across age mean r across age
Global scalesb
Sequential processing 0.90 0.89
Simultaneous processing 0.86 0.93
Mental processing composite 0.91 0.94
Achievement 0.93 0.97
Nonverbal 0.87 0.93
Mental processing subtestsc
Magic window 0.72
Face recognition 0.77
Hand movements 0.78 0.76
Gestalt closure 0.72 0.71
Number recall 0.88 0.81
Triangles 0.89 0.84
Word order 0.84 0.82
Matrix analogies 0.85
Spatial memory 0.80
Photo series 0.82
Achievement subtestsc
Expressive vocabulary 0.85
Faces & places 0.77 0.84
Arithmetic 0.87 0.87
Riddles 0.83 0.86
Reading/decoding 0.92
Reading/understanding 0.91
The values shown for preschool children are the mean coefficients for three age groups (2~. 3,
and 4), and the values shown for school-age children are the mean coefficients for eight age
groups.
bComposite score reliability coefficients were computed based on Guilford's (1954) formula.
cAll coefficients for the subtests were derived using the split-half method and corrected by the
Spearman-Brown formula.
man (1982) factor analyzed the published edition of ly suspect, as they are being developed after the fact
the K-ABC using the 2000 children from the standar- in a manner reminiscent of Monday morning quarter-
dization sample. All of these exploratory studies sup- backing and not from a prior theoretical base, as did
port the division of the intelligence scales into the the Kaufmans. The subtests of the Achievement scale
Sequential and Simultaneous Processing scales. An do show their largest loadings on a separate, clearly
overview of the findings from the Kamphaus et al. identifiable factor, as Kaufman and Kaufman
(1982) study is presented in Table 4. (1983a) proposed, yet each shows large secondary
Subsequent confirmatory factor analytic re- and tertiary loadings on the two mental processing
search provides strong support for the two-factor se- factors. Though some would interpret the Achieve-
quential and simultaneous processing model (Will- ment scale as a good measure of verbal intelligence or
son, Reynolds, Chatman, & Kaufman, 1985) but is perhaps even "g" (e.g., Keith, 1985), this seems ill
less enthusiastic in support of a distinct Achievement advised as it involves so many assumptions regarding
scale. Hence, it is possible to find a better mathe- equal opportunity to acquire certain knowledge and
matical fit to the subtest's structure when the is, in addition, extremely inferential, relying pri-
Achievement scale subtests are included; however, marily upon acquired factual knowledge rather than
the psychological meaning of such structures is high- the manipulation of information to solve a problem.
K-ABC 215
TABLE 4. Mean Sequential/Simultaneous Factor Loadings for Preschool

and School-Age Childrena
School-age (ages 5 through
Preschool (ages 2~ through 4) 12~)
Scale Sequential Simultaneous Sequential Simultaneous
Sequential processing
Hand movements 0.60 0.19 0.37 0.43
Number recall 0.64 0.28 0.77 0.15
Word order 0.69 0.32 0.75 0.26
Simultaneous processing
Magic window 0.21 0.63
Face recognition 0.28 0.40
Gestalt closure 0.23 0.59 0.08 0.53
Triangles 0.36 0.47 0.20 0.72
Matrix analogies 0.30 0.57
Spatial memory 0.24 0.60
Photo series 0.26 0.69
a Factor loadings were obtained by principal factor analysis with varimax rotation. Factor loadings of 0.35 and above are
italicized.
Of particular interest to various clinicians is the Relationship of Individual Subtests to

relationship of the K-ABC to the WISC-R. Numer- Neuropsychology
ous studies involving the K-ABC and WISC-R are
reported in the K-ABC Interpretive Manual (Kauf- Although the simultaneous/ sequential process-
man & Kaufman, 1983b). In a study of 182 children ing dichotomy was the most important factor in sub-
enrolled in regular classrooms, the Mental Process- test selection, many of the separate subtests of the
ing Composite (MPC) correlated 0. 70 with WISC-R K-ABC resemble traditional tasks in neuropsycho-
Full-Scale IQ (FSIQ). Hence, the K-ABC Mental logical assessment. Kaufman, O'Neal, Avant, and
Processing scales and the WISC-R share a 49% over- Long (1987) summarized these similarities. Luria
lap in variance. These findings indicate that the K- used tasks similar to Hand Movements and Word
ABC does bear a substantial relationship to the wide- Order to assess motor conditions and higher cortical
ly used WISC-R; yet these data also indicate that the functions of the left temporal lobe. Number Recall
K-ABC is hardly a duplicate of the WISC-R, but and Matrix Analogies are generally considered
rather possesses its own unique contribution to the marker tests for sequential and simultaneous pro-
field of intelligence measurement. Also of interest in cessing, respectively. These tasks are also included
this sample is the standard score difference between in a Luria-based successive-simultaneous test bat-
the MPC and FSIQ. The K-ABC, based on 1980 tery. Tasks like Gestalt Closure have long been ac-
U.S. Census data, was shown to be about 3 points cepted as measures of simultaneous processing and
tougher (mean MPC = 113.6) than the WISC-R right hemisphere processing. Research with tests
(mean FSIQ = 116.7), based on a sample of 182 similar to Face Recognition and Face & Places is
children from regular classes (Kaufman & Kaufman, continuing in an effort to establish the localization
1983b). and lateralization for the recognition of familiar and
Kamphaus and Reynolds (1987) found that the unfamiliar faces. Finally, Kaufman et al. (1987)
K-ABC norms are a couple of points tougher than noted that Triangles is an adaptation of Kohs' s
older tests such as the 1972 Stanford-Binet. The one Block Design test (Kohs, 1927). A version of the
exception to this rule is the McCarthy Scales where block design test is included in all of the Wechsler
no consistent pattern has emerged. The K-ABC Scales and in Goldstein's tests for brain damage
norms are also quite similar to those for tests normed (Goldstein, 1948). Knowledge of the background of
in the 1980s such as the Stanford-Binet Fourth these tasks adds to the clinician's interpretation of
Edition. the K-ABC at the subtest level. Further investigation
216 CHAPTER 12
of the localization value and developmental progres- SEQ -0.64, MPC -0.64, Nonverbal -0.51, ACH
sion of these tasks as presented in the K-ABC is -0.26). Correlations with the LNNB-CR are nega-
certainly warranted. tive in direction because high scores on the LNNB-
CR are indicative of increasingly high levels of pa-
thology, i.e., the LNNB-CR is scored negatively, not
Specific Neuropsychological Research positively as are most mental tests such as the K-
on the K-ABC ABC. In a stepwise multiple regression, from three to
five LNNB-CR scales were required to maximize the
prediction of each of the K-ABC scales. The pattern
The amount of neuropsychological research de-
of relationships is much as one would anticipate.
voted to the K-ABC is limited at present, but the few
Results of these analyses are shown in Table 5. After
studies available are generally supportive of its role
the intelligence scale, the visual and the motor scales
in adding useful information to general neuropsycho-
contributed the greatest to the prediction of the Si-
logical batteries. Studies relating the K-ABC to the
multaneous scale; for the Sequential scale, following
child forms of the Halstead-Reitan Neuropsycholog-
intelligence, the Rhythm and the Receptive Speech
ical Battery are noticeably absent from the literature
scales were the best predictors of performance. The
and are certainly needed. Such studies are a neces-
MPC and K-ABC Nonverbal scales showed the same
sary component of any comprehensive assessment of
pattern as the Simultaneous scale, and not surprising-
utility of the K-ABC to determine how it precisely
ly because these scales overlap so much with the
fits into the neuropsychological assessment process.
Simultaneous scale. The K-ABC ACH scales corre-
Several studies are available relating the K-ABC to
lated from -.50 to -.58 with the school-related
the Lucia-Nebraska Neuropsychological Battery-
scales of the LNNB-CR (e.g., Expressive Language,
Children's Revision (LNNB-CR) and several have
Reading). In the multiple regression, academic skiJJs
compared the K-ABC and WISC-R with relatively
well-defined samples of neurologically impaired
children. Other studies have looked at the K-ABC
alone with neurologically impaired children. TABLE 5. Multiple Correlations
between Subtest Standard Scores
on the Luria-Nebraska
Correlation with the Luna-Nebraska Scales Neuropsychological Battery-
Children's Revision (Predictors)
Of particular importance to understanding how and K-ABC Global Scale Standard
the K-ABC might contribute to neuropsychology, Scores (Criteria) (N = 46) 8
clinically as well as in the research setting, will be
understanding how the K-ABC is related to existing Luria-Nebraska
neuropsychological scales. To be useful in neuropsy- K-ABC scale Predictor R
chological assessment, the K-ABC should be related
to existing measures, but not so closely that its use is Sequential processing Intelligence 0.582
merely redundant with preexisting scales. Although Rhythm 0.656
no data are available relating the K-ABC to the Receptive speech 0.677
Halstead-Reitan techniques, several studies have Motor 0.694
Tactile 0.714
been reported comparing the K-ABC with the
Simulataneous processing Intelligence 0.521
LNNB-CR. The first such report was by Snyder,
Visual 0.641
Leark, Golden, Grove, and Allison (1983). Motor 0.694
Synder et al. ( 1983) evaluated 46 elementary Mental processing Intelligence 0.638
school children (ages 8 to 12!) who had been referred composite Motor 0.697
for a variety of learning difficulties. All children Visual 0.733
were administered the K-ABC, WISC-R, and Achievement Arithmetic 0.579
LNNB-CR as described in Golden (1978). Correla- Receptive speech 0.620
tions between the K-ABC and LNNB-CR ranged Writing 0.655
from -0.01 (LNNB-CR Writing scale with K-ABC Memory 0.679
Nonverbal Intelligence 0.499
Simultaneous) to -0.64 (LNNB-CR Intelligence
Visual 0.608
with K-ABC Sequential and MPC). The LNNB-CR Motor 0.669
Intelligence scale correlated highest of all LNNB-CR
scales with the K-ABC global scales (SIM -0.54, Adapled from Snyder et al. (1983).
K-ABC 217
again dominated prediction of the ACH scales. The interesting patterns emerge here. The LNNB-CR
K-ABC mental processing scales also were related subscales that are known to be the most sensitive to
significantly to each WISC-R IQ in this study; cor- brain impairment (Pathognomonic and Intellectual)
relations ranged from 0.35 between SEQ and PIQ are clearly the most closely related to performance on
to 0. 72 between the MPC and FSIQ and the Nonver- all of the K-ABC global scales in the Leark et al.
bal and FSIQ. The K-ABC ACH scale correlated study. However, there is very little overlap in item
0.66 with FSIQ, 0.77 with VIQ, but only 0.28 with content from these scales to the K-ABC and yet the
PIQ. After examining the overall pattern of correla- K-ABC seems sensitive to deficits in cortical func-
tions in the study, Snyder et al. concluded that the tioning, at least at the level of the higher information
relationships revealed were "basically consistent" processing functions of the brain. The SEQ-SIM
with the model of intelligence on which the K-ABC distinction and the separate Achievement scale of the
was based and the theoretical perspective of Luria in K-ABC receive support from the pattern of correla-
particular. Snyder et al. also concluded that the K- tions in Table 6 as well. The school-related subscales
ABC provides additional information, beyond the of the LNNB-CR correlate considerably higher with
WISC-R and LNNB-CR, that should be useful to the the K-ABC ACH scale than with the mental process-
clinical neuropsychologist. We agree. The pattern of ing scales. Clear differentiations occur elsewhere as
correlations as well as the magnitude of correlations well. When evaluating correlations with the LNNB-
is encouraging. The K-ABC is clearly related to chil- CR Rhythm scale, one sees that the SEQ scale is
dren's neuropsychological function as determined by significantly related to the Rhythm scale (r
the LNNB-CR, but not so much so that K-ABC = -0.40) whereas the SIM scale is not (r = -0.13).
scores are simply redundant with other neuropsycho- A similar pattern is observed for the LNNB-CR Re-
logical test results; the K-ABC apparently has some- ceptive Speech scale. Additionally, the K-ABC Non-
thing to add. Another recent study supports this verbal scale is more highly correlated with the
conclusion. LNNB-CR Motor scale than is any other K-ABC
In a similar study with a larger sample (65 chil- scale. The Nonverbal and the SIM scales are more
dren), Leark, Snyder, Grove, and Golden (1983) closely related to the LNNB-CR Visual scale than is
provide more detailed information. Table 6 displays the SEQ scale. Most of these relationships are intu-
the correlation matrix between the K-ABC global itively obvious but their actual occurrence, especially
scales and the subscales of the LNNB-CR. Several given the moderate magnitude of the relationships, is
TABLE 6. Correlations between K-ABC Global Scales and Luria-

Nebraska Neuropsychological Battery-Children's Revision
Summary Scales (N = 65)0
Correlation with K-ABC global scale
Luria-Nebraska Sequential Simultaneous

scale processing processing MPC Achievement Nonverbal
Motor -0.382 -0.424 -0.456 -0.242 -0.481

Rhythm -0.405 -0.132 -0.282 -0.370 -0.199
Tactile -O.ll5 -0.320 -0.270 -0.221 -0.321
Visual -0.252 -0.498 -0.461 -0.192 -0.489
Receptive -0.515 -0.355 -0.482 -0.600 -0.427
Expressive -0.323 -0.154 -0.260 -0.614 -0.259
Writing -0.324 -0.144 -0.248 -0.539 -0.246
Reading -0.210 -0.060 -0.066 -0.618 -0.012
Arithmetic -0.307 -0.152 -0.258 -0.607 -0.202
Memory -0.471 -0.300 -0.427 -0.629 -0.356
Intelligence -0.567 -0.570 -0.645 -0.439 -0.599
Pathognomic -0.598 -0.469 -0.606 -0.649 -0.656
Left -0.171 -0.379 -0.335 -0.222 -0.352
Right -0.075 -0.319 -0.244 -0.091 -0.301
"Adapted from Leark et at. (1983).

218 CHAPTER 12
certainly encouraging with respect to potential con- showed the higher Spatial and Simultaneous scores.
tributions of the K-ABC to neuropsychological as- Results with dyseidetic children are less clear on this
sessment and research. point, most likely due to the small number of reading-
disabled children showing this particular problem.
The results of these two studies, considered in con-
Relationships with Other cert, though ambiguous with regard to the WISC-R,
Neuropsychological and Neurological Test provide support for the use of the K-ABC in evaluat-
Results ing children with neuropsychologically related read-
ing problems.
Several early studies have related the K-ABC to Hooper and Hynd ( 1985) also examined the util-
other neuropsychologically based scales and to hard ity of using the K-ABC in differential diagnosis of
evidence of neurological impairment. Much more is developmental dyslexia according to Boder's sub-
needed but progress is evident in these few studies. types. Their sample consisted of 30 normal readers
Telzrow, Redmond, and Zimmerman (1984) and 87 reading-disabled students (two or more grade
examined test score patterns of children classified levels below their grade placement). On the basis of
into Boder's three subtypes of dyslexia-dysphonet- the Boder Reading-Spelling Pattern test, 32 of the
ics, dyseidetics, and mixed. Telzrow et al. attempted reading-disabled students were classified as "non-
to determine whether the WISC-R or the K-ABC specific'' (significantly low achievement in reading,
would be more closely aligned with Boder's neuro- but reading and spelling pattern typical of normal
psychological classification of reading disorders. readers), and 55 were classified as dyslexics. Of the
WlSC-R scores were grouped into Bannatyne's four dyslexics, 30 were classified as dysphonetics, 5 as
categories of neuropsychological functions, as these dyseidetics, and 20 as alexics. Evaluation of the per-
groupings (Verbal Conceptualization, Sequencing, formance of all of these children on the K-ABC indi-
Spatial, and Acquired Knowledge) seem most clearly cated the discriminatory value of the Sequential Pro-
related to various schemes for regrouping the cessing scale but not the Simultaneous Processing
Wechsler subtests to Boder's diagnostic categories. scale in terms of Boder's subtypes. Normal readers
These children could not be differentiated on the scored significantly higher than all of the reading-
basis of their Bannatyne patterns on the WISC-R. disabled subtypes on the Sequential Processing scale.
Boder' s subtypes were randomly distributed across Sequential/simultaneous discrepancies, however,
Bannatyne's suggested patterns. On the K-ABC a did not discriminate between the subtypes of dyslex-
significant relationship (p < 0. 01) occurred between ia. The small number of dyseidetics in the study may
Boder classification and the pattern of Sequential- have contributed to this outcome. When combined
Simultaneous score differences on the K-ABC. In with the results ofTelzrow et al. (1985), Hooper and
particular, Boder' s dysphonetic dyslexics were far Hynd's results provide support for the simultaneous
more likely to display a SIM greater than SEQ pattern > sequential pattern in dyslexia (particularly dys-
than were the other diagnostic groups. Though phonetic subtype) but the importance of the simul-
Telzrow et al. used a small sample (N = 23) the taneous < sequential pattern in dyslexia (as it may
results are impressive with large effect sizes. The apply to dyseidetics) is much less clear. Hooper and
pattern of K-ABC results was precisely in keeping Hynd note, "It would be of interest to examine the
with predictions of underlying neuropsychological discriminant validity of the K-ABC with empirically,
deficits in Boder's classification scheme. A follow- as opposed to clinically, derived subgroups of devel-
up study with a second sample showed similar results opmental dyslexia."
with one major difference (Telzrow, Century, Har- In a conceptually related work, Dietzen ( 1986),
ris, & Redmond, 1985). using dichotic listening tasks to assess hemispheric
In the latter study, 27 children with reading dis- specialization, found a positive correlation between
orders were compared according to their perfor- the K-ABC simultaneous processing scores and
mance on the WISC-R and the K-ABC,just as in the hemispheric specialization for nonverbal processing
previous study. In the Telzrow et al. ( 1985) work, for 75 children of low SES. Dietzen reported a signif-
considerable consistency was found among the icant positive relationship between sequential pro-
K-ABC, WISC-R, and the Boder results. Three- cessing on the K-ABC and degree of hemispheric
quarters of the dyslexic children who displayed a specialization for verbal information in this same
Bannatyne WISC-R pattern of Spatial greater than sample.
Sequential also showed a K-ABC pattern of Simul- Additional studies have added to our knowledge
taneous greater than Sequential scores. In each case, through the use of physical evidence of neurological
it was the dysphonetic reading-disabled children who damage and relating it to K-ABC results. Morris and
K-ABC 219
Bigler (1985) investigated whether the K-ABC SEQ ings. The two children with right-hemisphere find-
and SIM scales can be related to left and right hemi- ings were non-right-banders. Of the six children with
sphere functioning and whether the K-ABC is better significantly lower simultaneous scores, four showed
able to indicate neuropsychological deficits than the right hemisphere findings. Of the two with left hemi-
WISC-R. In this study, 79 children ages 6 to 12 years sphere findings, one was left-handed and the other
were administered the WISC-R, the K-ABC, and had primarily left occipital findings with some visual
several neuropsychological measures of left and right impairment" (Shapiro & Dotan, 1985, p. 6). The K-
hemisphere functioning. Neurological data, includ- ABC Simultaneous scale should always show con-
ing EEGs and CAT scans, were also available. Neu- siderable impairment for children with visual
ropsychological test scores were collapsed into two problems.
composite scores for each subject, right hemisphere Even with the small sample size available, high-
(RH) and left hemisphere (LF). Twenty-five children ly significant (p < 0.005) relationships occurred be-
who were right-handed and neurologically impaired tween left-brain focal findings and lower sequential
were divided into three groups according to their K- than simultaneous scores and focal right-brain prob-
ABC scores: SIM >SEQ, SEQ> SIM, and SIM = lems and lower simultaneous than sequential scores.
SEQ. A one-way MANOVA revealed a significant Shapiro and Dotan noted that the relationship was
difference among these groups on the RH and LH stronger for males than for females. They concluded
scores (p < 0.05) but not for WISC-R groups using in part that ''the lack of relationship of ver-
VIQ-PIQ differences for classification (p = 0.41). bal/performance discrepancies on the Wechsler tests
Further analyses revealed that the key to undertand- to neurological findings may reflect the lack of ho-
ing these differences was the inability of the WISC-R mogeneity of function in those scales as compared to
to detect RH dysfunction. Whereas both scales the K-ABC" (p. 7). These results and the subsequent
seemed to pick up LH dysfunction, only the K-ABC conclusions are clearly in accordance with the results
could diagnose RH problems at a statistically signifi- of Morris and Bigler and the two studies by Telzrow
cant level. These results also are consistent with lat- et al.
eralization of sequential and simultaneous processing Taken as a whole, empirical results available
of the left and right hemispheres, respectively, giving thus far are impressive in their support of the poten-
evidence also consistent with the findings of Leark et tial of the K-ABC in contributing to the tasks of the
al. (1983). neuropsychologist. Not only does the K-ABC model
Shapiro and Dotan ( 1985) provided a replication appear useful, but the psychometric integrity of the
of sorts of the Morris and Bigler ( 1985) study, though K-ABC lends the scale to other theoretical ap-
their sample size (N = 27) makes statistical com- proaches, thus avoiding the fate of the inadequately
parisons less relevant. The pattern of Shapiro and developed ITPA. The K-ABC seems to be related,
Dotan's results is most interesting, however. These even at this early stage in its career, to neuropsycho-
researchers compared two groups of children with logical functioning both theoretically and em-
neurological impairment defined as focal versus non- pirically. The moderate but consistent relationships
focal on the K-ABC and on the Wechsler Scales. All with other neuropsychological batteries bode well for
had neurological exams and most had EEGs orCAT its use, indicating that it does provide additional or at
scans, or both. Two groups were formed. The non- least distinctive information. It also seems more
focal group was determined to be children with nor- closely related to recent neuropsychological models
mal exams with the exception of soft neurological of higher cognitive processes than the Wechsler se-
signs that were not unilateral in nature. Most of these ries. The Wechsler series is much more researched at
13 children were diagnosed as ADD, LD, BD, or this point, however, and we should proceed cau-
developmental delay. The 14 children in the focal tiously with the K-ABC; existing data are very prom-
group had lateralized deficits on the neurological ising and dictate that research should continue full
exam and a focal abnormality on the EEG or struc- speed ahead.
tural damage on the CAT scan. The nonfocal group
contained 10 males and 3 females (a typical occur-
rence) and the focal group, 7 males and 7 females. Of
particular interest here, Verbal-Performance IQ dif- Clinical Neuropsychological
ferences on the Wechsler Scales were not related to Applications of the K-ABC
the presence of focal neurological findings. "How-
ever, ... , one finds that of the eight children with The general field of clinical neuropsychology is
significantly lower sequential than simultaneous seen by many as a set of tests and related techniques
scores, six had predominantly left hemisphere find- for relating observed, quantifiable behavior to the
220 CHAPTER 12
integrity of an individual's functional neurological tirely on trial-and-error experience and more or Jess
organization and structure. The efficacy of these shooting in the dark whenever encountering a child
techniques in the diagnosis and remediation of learn- with a set of behavioral nuances and test scores not
ing disturbances has been well documented over the previously seen.
last decade (e.g., Bradley, Battin, & Sutter, 1979; The neuropsychological approach proffered
Gaddes, 1981; Golden, 1978; Hartlage, 1982; here and by the K-ABC generally is one that matches
Hartlage & Reynolds, 1981; Knight & Bakker, 1980; up cognitive neuropsychological strengths with
Reitan & Davison, 1974; Rourke & Orr, 1977). It is methods of presenting and acquiring information that
not surprising, then, that many individuals believe rely most heavily on these strengths. Neuropsycho-
that to become a successfully functioning clinical logical strengths in a child's ability spectrum may be
neuropsychologist, it is only necessary to master the in traditional areas of ability like linguistic process-
technical skills involved in the administration and ing or in a particular cognitive/learning style. Cog-
scoring of tests like the Halstead-Reitan Neuropsy- nitive and/ or learning styles are now being more fully
chological Test Battery. Such thinking is a gross explored but seem almost certainly to be tied strongly
oversimplification of the profession and function of to the underlying neuropsychological integrity, de-
clinical neuropsychology. velopment, and preferences of the individual (Guyer
Much more than being a set of techniques, the & Friedman, 1975; Reynolds, 1980, 198lb).
principal tool of neuropsychology is the paradigm it Of course, merely detecting cerebral dysfunc-
offers for viewing and interpreting individual test tion (or minimal brain dysfunction or minimal brain
data. Without the provision of a strong paradigm, damage) is not a very useful exercise from an educa-
clinical neuropsychology could not have progressed tional or rehabilitative perspective. It is the accurate
to the point of applicability and generalizability that description of the dysfunction (an integral part of
has emerged today. As with other areas and sub- diagnosis) leading to an educational program to en-
specialties of psychology, several competing para- hance the child's acquisition of skills in a subject
digms and theories exist in clinical neuropsychol- matter area that is of significance. The K-ABC and
ogy, and any one of these may be the most the WISC-R provide excellent instruments for deter-
appropriate for interpreting data for any single child mining a baseline standard of general mental ability
(e.g., Ayers, 1974; Das et al., 1979; Luria, 1966; against which to compare other, more specific scales,
Pribram, 1971; Reynolds, 1981b; Tarnopol & Tar- during the process of ipsative test score interpreta-
nopol, 1977; Wittrock, 1980). It is thus crucial to tion. The multidimensional scaling of these tests also
achieve an understanding of the various neuropsy- makes them amenable to a variety of neuropsycho-
chological models of higher-order human informa- logical interpretive strategies (Hartlage, 1982; Ka-
tion processing in order to be effective in translating ufman, 1979a) despite the K-ABC's reliance on
test results into meaningful educational programs, Luria's approach. As Hartlage (1982) has discussed,
i.e., teasing out the aptitude x treatment interaction one can compare the functional integrity of the left
for a single individual. The relationship of the K- and right temporal lobes through the Similarities ver-
ABC to a particular neuropsychological model, sus Picture Arrangement contrast, or left and right
Vygotsky's Zones of Proximal Development, will parietal lobe function by contrasting the child's per-
be explored in some detail later in this chapter. formance on Arithmetic and Block Design. Knowing
Contemporary neuropsychological theories of that Arithmetic significantly exceeds Block Design
the intellect and its function are presented in a or even that the child's left parietal lobe function
number of sources (e.g., Das et al., 1979; Kolb & presents as superior to right parietal lobe function is
Whishaw, 1985; Luria, 1966; Pribram, 1971; Reyn- of little import in and of itself. Rather, the inferences
olds, 1981b; Wittrock, 1980) and will not be re- that can be drawn from such a finding are the impor-
viewed further here. Well-grounded, empirically tant focal point of the evaluation, and can be turned
evaluated theoretical models of neurological function toward the design of educational programs.
enable one to make specific predictions about how Certain cognitive skills tend to cluster together
children will perform under a given set of learning within an individual's overall functional level. Neu-
circumstances. Of course, one will not always be ropsychological and certain other approaches to as-
correct; but a good theory from which to work allows sessment allow one to make inferences about skills
the psychologist to narrow down the number of alter- that have not actually been evaluated by knowing the
native hypotheses (methods of remediation) consid- correlates of these skills. Look-say, whole word,
erably. Without a viable set of theories, one would be configurational approaches to reading seem to be
a completely stimulus-bound technician relying en- moderated much more by the posterior right parietal
KABC 221
lobe in coordination with sections of the right oc- fined, as it should be, and not restricted to school
cipital and temporal lobes than in the left hemisphere learning). The first rejected theory centers on the
counterparts of these structures. Knowing that these assumption that processes of child development are
structures in the right hemisphere function more ef- independent of learning, which is considered an ex-
fectively (efficiently or at a higher level) thus gives ternal process, not an activity involved in develop-
rise to the designation of a method for teaching read- ment. Accordingly, learning uses the achievements
ing to the child in question that can capitalize on the of development in acquisition of new knowledge
identified neuropsychological strengths. Addition- rather than providing impetus for modifying the
ally, there is no reason why behavioral methods can- course of development. Vygotsky classified Piage-
not be employed as motivational strategies in such tian theory under this theoretical rubric. The second
programs. The neuropsychological interpretation of rejected approach are theories assuming that learning
many common psychological tests can generate good is development, approaches that reduce development
hypotheses for choosing a particular method of in- to a simple accumulation of all possible responses by
struction, and operant psychology or one of its vari- the child. The third rejected theoretical proposition is
ants can assist in promoting the student's interest in based on a combination of the two prior positions, in
and learning through the specified method. which development is based on two different but re-
The K-ABC, designed with such approaches in lated processes, maturation, which depends upon the
mind, a priori, should help in such models. It can development of the central nervous system, and
also offer information on the intact nature of a variety learning, also considered here as a developmental
of processes for young children that are poorly tapped process. In this apparently reciprocal relationship,
by most existing scales. Extensions of tasks such as maturation makes new learning possible, which then
Hand Movements, Word Order, and Spatial Memory stimulates and pushes forward the maturation pro-
can be useful tools rather than methods of testing. cess. The latter is the approach that led educators in
Attention seems to be to the area of cognitive re- the past to conclude that the study of certain subjects
habilitation of deficit skills most influenced by cog- (e.g., Latin) was of great value for mental develop-
nitive retraining and such an addition of teaching ment. Vygotsky framed the concepts of ZPD to pro-
tasks can prove useful. The K-ABC is a nice fit to vide a more adequate view of the relationship be-
Reynolds' ( 1981 b) approach, an approach recently tween learning and development. This concept can
elaborated and integrated with cognitive and behav- lead us to better cognitive retraining and rehabilita-
ioral models (Reynolds, 1986). tion programs for children who have resisted more
traditional approaches.
In determining and using ZPDs, two develop-
Vygotsky's Zones of Proximal Development mental levels must first be established. The first is the
child's current, actual level of development. Vygot-
Vygotsky (translation, 1978) has offered an- sky viewed this level as that already completed as a
other neuropsychologically related concept that may result of previous developmental cycles. This is a
be amenable to assessment with the K-ABC, with level determined by rigidly administered, standard-
some modification in the standardized administration ized measures of intelligence and achievement. It is
procedures. Vygotsky espoused what continues to be the level determined by what children can do on their
a widely held ''truth'' even today as regards chil- own. The second level of development to determine
dren's learning. "A well known and empirically esis the level the child can achieve if an adult or more
tablished fact is that learning should be matched in advanced, accomplished peer provides help through
some manner with the child's developmental level'' demonstration, asking leading questions, or actual
(Vygotsky, 1978, p. 85). Hunt (1961) in his now- collaboration leading the child to discover the an-
classic volume concurred and conceptualized this swer. It is the difference between these two levels
concept in part as the "problem of the match." Al- that is important to use here, and that difference is the
though true for normally developing children, such a ZPD. ZPD is ''the distance between actual develop-
inatch may be absolutely crucial for promoting the mental level as determined by independent problem
development of children with an immature or trau- solving and the level of potential development as
matized central nervous system. determined through problem solving under adult
In formulating the concept of zones of proximal guidance or in collaboration with more capable
development (ZPD), Vygotsky rejected what he con- peers" (Vygotsky, 1978, p. 86). The upper limit of
sidered to be the three primary alternative develop- the ZPD today becomes the actual developmental
mental theories of learning (learning broadly de- level of tomorrow. The fundamental principles of
222 CHAPTER 12
ZPD are the basis for the approaches taken by Feuer- ever a child misses an item when adminis-
stein, Haywood, Campione, and others to cognitive tered under standardized conditions. Give
assessment and cognitive training though some key credit for the item as above, i.e., whenever
differences exist (see Reynolds, 1986, for a brief you can lead the child to the correct re-
review). sponse, but do not assign credit when you
In neuropsychological work in particular, it can must demonstrate or recite the correct
be of help to apply this principle in rehabilitation response.
efforts and the K-ABC is structured in such a way as 4. Continue administration of each subtest until
to give the best available assessment of the ZPD. the child fails to obtain credit on two con-
Typically, the ZPD is determined by contrasting secutive items (a ceiling we have estimated
scores on the same test under standardized versus to be appropriate based on the growth curves
nonstandardized limit-testing procedures. The re- of the various mental processing subtests and
quirement of initial testing under standardized pro- the length of time available for testing) when
cedures confounds the latter. The use of two different assistance has been provided by the
tests is confounded by differences in normative sam- examiner.
ples and other technical differences between the 5. Compute the raw and scaled scores for the
scales (e.g., see Reynolds, 1984, 1985, for discus- mental processing subtests and the MPC just
sions of these problems). The structure of the K-ABC as though a standardized administration had
offers a good solution to these problems. been conducted.
The first developmental level, independent
problem solving, can be determined from administra- This procedure obviously does not allow one to
tion of the K-ABC Achievement scale or preferably report standard scores for the MPC or other K-ABC
from the more restricted Verbal Intelligence scale mental processing scales. The Verbal Intelligence
described in the recent text, Clinical and Research scale (Kamphaus & Reynolds, 1987) or Achieve-
Applications of the K-ABC (Kamphaus & Reynolds, ment scale can be reported as needed, however. The
1987), the latter being more appropriate in this in- difference between the MPC, as derived above, and
stance because it does invoke considerable reasoning the Verbal or Achievement scale approximates the
skills and is so much akin to Cattell's concept of child's ZPD, and is thus easily quantified for research
crystallized intelligence. The second level of devel- purposes. On a more practical level, it provides rela-
opment can be ascertained perhaps more accurately tively clear guidance in developing short-term and
with the K-ABC Mental Processing scales than with intermediate goals for cognitive rehabilitation pro-
any other currently available technique, but only grams. The next step in the developmental process is
through the use of a nonstandard administration. revealed through assessment of the ZPD, the near
To assess the second developmental level, ad- point in development. In cognitive retraining it is
minister the K-ABC mental processing subtests using certainly important to know which skills are most
the following procedures: likely to be responsive to rehabilitation efforts at spe-
cific points in the retraining process. Again the ZPD
I. Begin all children with the sample item just provides clues. Individual subtests as well as sub-
as directed for the standardized adminis- scales of the MPC can be contrasted with the regular-
tration. ly obtained Verbal Intelligence Composite or
2. Use the teaching item of the K-ABC as in- Achievement scale score to ascertain areas needing
structed with the following exception. If the greater attention or even in the evaluative process to
child determines the solution to the problem determine what progress has been made and in what
with help or simple repetition, then give areas. Given the uneven nature of progress in devel-
credit for successful completion of the item. opment and cognitive rehabilitation, the latter can be
If you must give the child the correct answer useful in determining where next to focus re-
rather than lead him or her to develop a cor- habilitative efforts.
rect response, do not assign passing credit. The assessment can be repeated periodically as
Under these conditions it is permissible to well. By this conceptualization, we are constantly
give strategies and practice trials on subtests seeking to move children forward to a level that is
that are heavily memory dependent such as within their reach by constantly reassessing the
Hand Movements or Number Recall. child's reach so that we continue the "match" (a Ia
3. After the sample and teaching items, con- Hunt, 1961) between development and learning.
tinue to use the teaching procedures when- This can be a useful guide for learning-disabled chil-
K-ABC 223
dren and mentally retarded children as well and is in the educational program, so that the interface be-
certainly not restricted to children with neuro- tween cognitive strengths (rather than weaknesses)
psychological problems, and is an approach that determined from the assessment and the intervention
seems, at least at this stage, similar to approaches strategy is the cornerstone of meaningfulness for the
proposed by Haywood and Switzky (1986). entire diagnostic-interventi on process. Placed in the
language of Luria's neuropsychological model of in-
telligence, it is necessary to locate an intact complex
Implications for Educational functional system capable of taking over and moder-
Rehabilitation ating the learning process needed to acquire the aca-
demic skills in question.
One of the goals for the K -ABC was to develop a The K-ABC philosophy is reflected in the at-
children's intelligence test that yields scores that can titude that the best remedial program for a child who
provide guidance to educational interventions (Kauf- cannot read is to teach the child to read, but to do so
man & Kaufman, 1983b). Chapter 7 of the K-ABC using methods and materials optimally related to the
Interpretive Manual provides a framework for educa- child's best information processing skills. The focus
tional intervention. is clearly on direct instruction in the child's area of
academic deficit allowing children to exploit their
The Kaufmans support a strength model of re-
mediation as opposed to deficit-centered ability train- perference for processing in a particular way. The
ing models (approaches focusing on the remediation structure of the K-ABC provides theoretical guidance
of underlying cognitive processing deficiencies to this admittedly muddy area of educational research
rather than the specific behavioral deficit), which and practice, guidance that is sorely needed (see
have permeated much of past and present special Reynolds, 1981b), and guidance that is focused on
education practice. Findings in neurology, genetics, instruction, not peripheral activities.
and related areas have repeatedly suggested major The K-ABC provides a clear model for using
limitations of the deficit model (e.g., Adams & Vic- neuropsychological data and theories to make in-
tor, 1977; Hartlage, 1975; Hartlage & Givens, 1981; ferences regarding important aptitudes for the indi-
Hartlage & Hartlage, 1973a,b, 1978). Viewed from vidual Ieamer. A model for matching neuropsycho-
contemporary neuropsychological models, the defi- logical aptitudes to treatment approaches that is
cit approach to remediation is doomed to failure, as it nicely complemented by the K-ABC has been pre-
takes damaged or dysfunctional areas of the brain and sented by Hartlage and Telzrow (1983). Their model
focuses training specifically on these areas. Not only teaches ''circumvention'' of dysfunctional areas of
does knowledge of neurology predict failure for such the brain to develop compensatory (not remedial)
efforts (Kolb & Whishaw, 1985), evaluations of skills and then to capitalize on the child's strengths.
tht;!ltl approaches have found them to be quite ineffec- Hartlage and Telzrow's approach is very much in line
tual in the remediation or learning protJiems (e.g., with thE K-ABC phila~mphy and may be useful pllf-
Glass & Robbins, 1967; Levine, Brooks, & ticularly to the neuropsychologist in designing re-
Shonkoff, 1980). One need not embrace localiza- habilitation approaches from K-ABC results, thus
tionist approaches to the diagnosis and descriptive expanding the potential utility of the K-ABC in
etiology of learning problems, however, in order to clinical application in neuropsychology.
employ the neuropsychological model. Most current
neuropsychological models do not subscribe to strict
localizationist approaches, but rather employ dynam- Summary
ic localization concepts similar to that of Luria ( 1966,
1970). The paramount discovery thus far, however, We have much to learn about the neurological
is that deficit approaches to remediation do not seem substrates of the K-ABC. Yet for a scale so young,
to be very effective. Such approaches have been crit- there is a great deal of support for the continued use
icized as being potentially harmful to the child as well and exploration of the K-ABC as a tool in the psycho-
(Hartlage & Reynolds, 1981). logical and educational assessment of children. Very
A more meaningful, efficacious approach to a much remains to be done. As the years progress, we
child's learning problems is provided by adopting a are confident that the K-ABC will continue to show
strength model of remediation. The strength model is evidence of utility in helping neuropsychologists
based on abilities that are sufficiently intact so as to gain a better picture of children's brain-behavior re-
subserve the successful accomplishment of the steps lationships, leading to improved rehabilitation pro-
224 CHAPTER 12
grams. We must, of course, keep in mind the tenuous Gazzaniga, M. S. (1975). Recent research on hemispheric later-
nature of localization in the 2! to 12! group (see alization of the human brain: Review of the split brain. UCLA
Wilkening, this volume), the age group addressed by Educator, 17, 9-12.
the K-ABC, but also one of the most perplexing and Glass, G. F., & Robbins, M.P. (1967). A critique of experiments
on the role of neurological organization in reading perfor-
demanding age groups of all those encountered by the
mance. Reading Research Quarterly, 3, 5-52.
clinical neuropsychologist.
Golden, C. J. (1978). Diagnosis and rehabilitation in clinical
neuropsychology. Springfield, IL: Thomas.
Goldstein, K. (1948). After effects of bnun injuries in wars: Their
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The Kaufman Assessment Battery for Children (K-ABC). In address to the Utah State University Conference on Brain
C. S. Newmark (Ed.), Major Psychological Assessment In- Research and Teaching, Logan.
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Kaufman, A. S., Kaufman, N. L., Kamphaus, R. W., &Naglieri, level for age'' as a diagnostic criterion for reading disorders.
J. A. (1982). Sequential and simultaneous factors at ages 3- Journal of School Psychology, 19, 350-358.
12!: Developmental changes in neuropsychological dimen- Reynolds, C. R. ( 1981 b). Neuropsychological assessment and the
sions. Clinical Neuropsychology, 4, 74-81. habilitation of learning: Considerations in the search for the
Kaufman, A. S., O'Neal, M. R., Avant, A. H., & Long, S. W. aptitude x treatment interaction. School Psychology Review,
( 1987). Introduction to the Kaufman Assessment Battery for 343-349.
Children (K-ABC) for pediatric neuroclinicians. Journal of Reynolds, C. R. (1982), The importance of norms and other psy-
Child Neurology, 2, 3-16. chometric concepts to assessment in clinical neuropsychol-
Keith, T. z. (1985). Questioning of the K-ABC: What does it ogy. In R.N. Malatesha & L. C. Hartlage (Eds.), Neuropsy-
measure? School Psychology Review, 14, 9-20. chology and cognition (Vol. II). The Hague: Nijhoff.
Kinsbourne, M. (1975). Cerebral dominance,leaming, and cogni- Reynolds, C. R. (1984). Critical measurement issues in learning
tion. In H. R. Myklebust (Ed.), Progress in learning dis- disabilities. Journal of Special Education, 18, 451-476.
abilities. New York: Grune & Stratton.. Reynolds, C. R. (1986). Transactional models of intellectual de-
Kinsboume, M. (1978). Biological determinants of functional velopment, yes. Deficit models of process remediation, no.
bisymmetry and asymmetry. In M. Kinsbourne (Ed.), Asym- School Psychology Review, 15, 256-260.
metrical function of the brain. London: Cambridge Univer- Reynolds, C. R. (1987). Intelligent testing. In C. R. Reynolds &
sity Press. L. Mann (Eds.), Encyclopedia of special education. New
Knight, R. M., & Bakker, D. J. (1980). Treatment of hyperactive York: Wiley-Interscience.
and learning disordered children: Cu"ent research. Bal- Reynolds, C. R., & Clark, J. H. (Eds.). (1983). Assessment and
timore: University Park Press. programming for children with low incidence handicaps.
Kohs, S. C. (1927). Intelligence measurement. New York: New York: Plenum Press.
Macmillan. Reynolds, C. R., & Clark, J. H. (1985). Profile analysis of stan-
Kolb, B., & Whishaw, I. Q. (1985). Fundamentals of human dardized intelligence test performance of very low function-
neuropsychology (2nd ed.). San Francisco: Freeman. ing individuals. Journal of School Psychology, 23, 277-
Leark, R. A., Snyder, T., Grove, T., & Golden, C. I. (1983, 283.
August). Comparison of the K-ABC and standardized neu- Rourke, B. P., & Orr, R. R. ( 1977). Prediction of the reading and
ropsychological batteries: Preliminary results. Paper pre- spelling performances of normal and retarded readers: A four-
226 CHAPTER 12
age follow-up. JounuJI of Abnormal Child Psychology, 5, W. Beuyn (Eds.), Handbook of clinical neurology. New
9-20. York: Wiley-Interscience.
Schwartz, G. E., Davidson, R. J., & Mear, F. (1975). Right Tarnopol, L., & Tarnopol, M. (1977). Introduction to neuropsy-
hemisphere lateralization for emotion in the human brain: chology. In L. Tarnopol & M. Tarnopol (Eds.), Brain/unc-
Interactions with cognition. Science, 190, 286-288. tion and reading disabilities. Baltimore: University Park
Sechenov, I. (1965). Reflexes of the brain. Cambridge, MA: MIT Press.
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Segalowitz, S. J., & Gruber, F. A. (Eds.). (1977). Language April). Relationship between neuropsychological processing
development and neurological theory. New York: Academic models and dyslexia subtypes. Paper presented at the National
Press. Association of School Psychologists, Las Vegas.
Shapiro, E. G., & Dolan, N. (1985, October). Neurologicalfind- Telzrow, C., Redmond, C., & Zimmerman, B. (1984, October).
ings and the KmiftrumAssessment BaJteryfor Children. Paper Dyslexic subtypes: A comparison of the Bannatyne, Bader,
presented at the National Association ofNeuropsychologists, and Kaufman models. Paper presented at the aMual meeting
Philadelphia. of the National Academy of Neuropsychologists, San Diego.
Shure, G. H., &Halstead, W. C. (1959). Cerebrallateralizationof Tomlinson-Keasey, C., & Clarkson-Smith, L. (1980, February).
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andApplied, 72, (12). ed at the meeting of the International Neuropsychological
Snyder, T. J., Leark, R. A., Golden, C. J., Grove, T., & Allison, Society, San Francisco.
R. (1983, March). CorrelationsoftheK-ABC, WJSC-R. and Vygotsky, L. S. (1978). Mind in society (M. Cole, V. John-
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Sperry, R. W., Gazzaniga, M. S., & Bogen, J. E. (1969). In- Journal of School Psychology, 23, 216-269.
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Syndromes of hemispheric discoMection. In P. Vinken & G. Academic Press.
13
Neuropsychological Applications of
Common Educational and
Psychological Tests
CATHY F. TELZROW
There are two major orientations to neuropsychologi- (I 985) made a distinction between neuro-
cal assessment. The first, best exemplified by Reitan psychologists who hypothesize from a central ner-
(1979), Rourke (1981; Rourke, Bakker, Fisk, & vous system (CNS) impairment orientation to chil-
Strang, 1983), and the Luria-Nebraska school dren's behavior and those who reason the other way,
(Golden, 1981; Gustavson et al., 1984), employs a developing hypotheses about children's neuro-
standardized battery of tasks designed to identify psychological functioning from careful, systematic
brain impairment. Typically, an invariant battery of behavioral observations. A flexible neuropsycholog-
identical tasks is utilized for all subjects regardless of ical assessment approach that employs traditional ed-
the presenting problem or the history of the child. ucational and psychological tests appears more con-
The second approach to neuropsychological assess- sistent with the latter orientation, which Fletcher and
ment of children favors the use of a flexible combina- his colleagues (1985; Taylor et al., 1984) argue is
tion of traditional psychological and educational better suited to the unique developmental charac-
tests. The composition of this battery varies depend- teristics of children.
ing upon a number of child variables, including the To illustrate the differences between these two
age, history, functioning level, and presenting prob- orientations, consider that many of the tasks on stan-
lem of the particular child. dardized batteries are not appropriate for young
Although the neuropsychological battery ap- children with significant impairment or those with
proach to assessment is important historically be- specific sensory deficits. Administration of a
cause of its major contributions to the understanding Halstead-Reitan or a Luria-Nebraska Children's
of brain-behavior relationships, its application with Battery thus results in much missing data, and it may
children may not be appropriate in all instances. Crit- not be possible to derive meaningful information
icisms of the standardized battery approaches have about the neuropsychological abilities of such chil-
focused on the time and cost requirements (Gold- dren from these techniques. In contrast, use of a flex-
stein, 1984; Hartlage & Telzrow, 1986; Slomka & ible battery of developmental and psychological tests
Tarter, 1984; Sutter & Battin, 1984), the redundancy permits the clinician to select tasks appropriate to the
of procedures in some cases, and the cursory ap- functioning levels and response limitations of the
praisal of functions in others (Goldstein, 1984; child, resulting in a more complete assessment of
Hartlage & Telzrow, 1986; Slomka & Tarter, 1984; neuropsychological strengths and weaknesses. In ad-
Taylor, Fletcher, & Satz, 1984). Perhaps of greater dition, this procedure provides a description of the
import, however, is the theoretical orientation such neuropsychological assets of children, rather than
an approach presumes and its sometimes question- emphasizing the diagnosis and localization of brain
able validity with pediatric populations. Fletcher impairment, for which standardized batteries have
been noted. As a result of this delineation of residual
CATHY F. TELZROW Cuyahoga Special Education Ser- neuropsychological strengths, the flexible battery ap-
vice Center, Maple Heights, Ohio 44137. proach translates more directly into educational and
227
228 CHAPTER 13
vocational interventions, a major goal of neuro- functioning relative to the normative population, as
psychological assessment (Dean, 1986; Klesges, well as analysis of intraindividual strengths and
Fisher, Pheley, Boschee, & Vasey, 1984; Telzrow, weaknesses in cognitive processing. A general level
1985a). Finally, because this orientation employs of performance score is important as a means of mak-
traditional educational and psychological tests that ing predictions about expected achievement levels
are more familiar to school personnel, the flexible for children with developmental problems, and in
battery approach to neuropsychological assessment determining loss of function for children with ac-
is more directly applicable to school settings. Be- quired impairment. It also serves as an important
cause schools provide valuable rehabilitation oppor- baseline for the interpretation of other data. Howev-
tunities for children with neuropsychological impair- er, this type of assessment alone is not sufficient, for
ment, the ease with which assessment data can be a general cognitive ability score may be misleading,
transferred into these settings is critical. in that unique neuropsychological deficits may con-
This chapter describes the standardized test tribute to a decrement in overall performance (refer to
components of a flexible neuropsychological assess- the Stanford-Binet scores of R.G. in Figure 3 to
ment approach, including major variables to consider illustrate this point). For this reason, analysis of indi-
in the selection and interpretation of traditional mea- vidual cognitive processing strengths and weak-
sures. The scope of this chapter necessitates limiting nesses is critical.
discussion to psychological and educational tests. In performing such analyses, Kaufman (1979),
However, in clinical practice, the author typically Reynolds (1981), and others have stressed the impor-
utilizes other sources of data, including a detailed tance of ipsative or intraindividual comparisons, for
history, observation, and selected neuropsychologi- instance, comparing an individual's pattern of sub-
cal tasks, such as finger tapping and measures of test or scaled scores with his or her own mean perfor-
sensory-perceptual functioning. For a more complete mance. Conducting profile analyses with this degree
treatment of the integration of these multiple data of precision minimizes such interpretive errors as
sources, the reader is referred to Hartlage and assuming chance variability reflects significant pro-
Telzrow (1986). cessing differences.
Various ability scales conceptualize cognitive
processes differently. Some of these scales were de-
Major Areas of Function and veloped from theoretical models of intelligence
(e.g., Stanford-Binet Intelligence Scale, 4th Ed.;
Associated Tests Thorndike, Hagen, & Sattler, 1986). Others were
formulated from theoretical constructs, with em-
The major neuropsychologically relevant be- pirical (i.e., factor analytic) rationale for the assign-
haviors in children that can be tapped by traditional ment of tasks to specific scales (e.g., Kaufman
educational and psychological tests include cognitive Assessment Battery for Children; Kaufman & Kauf-
ability (with additional analysis of information pro- man, 1983). The following cognitive ability scales
cessing patterns), academic achievement, language have been found to be of value in conducting neuro-
and motor skills, and social-emotional behavior. A psychological evaluations of children.
description of each of these functions, together with
its relevance for neuropsychological assessment of
children, follows in this section. Included within the Bayley Scales of Infant Development (Bayley,
discussion of each area are specific measures that
1969)
have demonstrated utility for assessing such func-
tions. Attempts were made to include only instru- Standardized scores for mental and motor abil-
ments with sound psychometric properties that are in ity can be derived from the Bayley Scales for infants
fairly general use in educational and clinical practice. and toddlers up to 30 months old. Age equivalent
scores can be computed for older children function-
Cognitive Functioning ing at these developmental levels. The Bayley is ap-
propriate for children with a wide variety of develop-
Cognitive functioning encompasses intelligence mental problems. However, because of its heavy
and more specific components of information pro- visual demands, it is not considered an appropriate
cessing, such as memory, visuospatial processing, instrument for children with visual impairments. As
and linguistic ability. Assessment of cognitive func- is true with most infant scales, there is a heavy re-
tioning includes determination of overall level of liance on motor skills.
APPLICATIONS OF EDUCATIONAL AND PSYCHOLOGICAL TESTS 229
Use of the Bayley in its traditional format pro- (Bracken, 1985; Keith, 1985). Other critiques, par-
vides a comparison of children's mental and motor ticularly those conducted by persons with clinical
performance. Although this is of some value for orientations (Kaufman, 1984), have been somewhat
young children with significant motor impairment more optimistic about the scale's contribution to neu-
(e.g., hypotonic children or those with cerebral pal- ropsychological assessment of children (e.g., Ger-
sy), several of the mental scale items require motor man, 1983; Majovski, 1984; Telzrow, 1984).
responses; hence, the separation is not pure. Reuter, After nearly three years of use with children
Stancin, and Craig (1981) developed an extremely with a wide variety of developmental and acquired
useful scoring adaptation for the Bayley that permits problems, it is the author's opinion that the K-ABC is
the derivation of developmental age scores for five of mixed value in the neuropsychological assessment
domains: cognitive, language, social, fine motor, of children. For selected children, the hypothetical
and gross motor. Use of the Kent Scoring Adaptation profile (e.g., Sequential > Simultaneous, or vice
of the Bayley Scales of Infant Development provides versa) predicted from history or other test data proves
a systematic analysis of individual strengths and true. For other children, however, the anticipated
weaknesses. It has been found particularly useful by pattern is not demonstrated (e.g., see case of J.G. in
the author in differentiating among developmental Figure 2), and thus far common elements or predictor
language disorders, autistic syndromes with disor- variables in populations for whom the model works
dered language, and mental retardation in young chil- and those for whom it does not have not been identi-
dren. Children with severe expressive language syn- fied fully.
drome, as described by Rapin and Allen (1983), tend Investigations of the K-ABC and other psycho-
to have scores on the language domain depressed metric tests for reading-disabled children have re-
relative to the other domains. Those with childhood vealed predicted patterns, suggesting some construct
autism tend to have unique depressions in the lan- validity for the K-ABC Mental Processing scale. For
guage and social domains, as well as deficits on sev- example, dyslexic children who demonstrate a V < P
eral of the cognitive items, although they may do profile on the Wechsler Intelligence Scale for Chil-
quite well on the form boards and other tasks with dren-Revised (WISC-R; Wechsler, 1974) have
heavy visuospatial loading. Mentally retarded chil- been reported to have a Sequential < Simultaneous
dren, though deficient in all areas, are not uniquely split on the K-ABC (Stoiber, Bracken, & Gissal,
low on language and social domains; in fact, these 1983; Telzrow, Century, Harris, & Redmond,
may represent relative strengths for this population. 1985). Comparison of reading-disabled children's K-
ABC scores with their cognitive factor scores on the
WISC-R 1 derived from recategorization of subtests
Kaufman Assessment Battery for Children using the procedures outlined by Bannatyne (1974),
(K-ABC; Kaufman & Kaufman, 1983) also demonstrated expected similarities (e.g., WISC-
R sequential factor based on Arithmetic, Digit Span,
The K-ABC is a measure of intellectual ability and Coding subtests was similar to the K-ABC Se-
and achievement. The cognitive processing portion quential score) (Telzrow et al., 1985). Furthermore,
of the K-ABC will be discussed in this section, with relationships between the K-ABC and subtypes of
the achievement scale described subsequently. The reading disorders have been demonstrated, again in a
K-ABC was designed from a theoretical model inte- direction predicted by the K-ABC's theoretical
grating data and hypotheses from cognitive psychol- model (i.e., dysphonetic dyslexic has Simultaneous
ogy, cerebral specialization research, and clinical >Sequential profile) (Telzrow et al., 1985).
neuropsychology (Kamphaus & Reynolds, 1984). There are a number of cases, however, in which
Drawing heavily from the Luria school and the work the predicted profile on the K-ABC is not demon-
of followers of this model, Kaufman and Kaufman strated. In a study of left- and right-hemiplegic chil-
attempted to develop a measure of intellectual ability dren, Lewandowski and DeRienzo (1985) reported
that divides information processing into sequential the presence of the anticipated Sequential > Simul-
and simultaneous types. The well-standardized taneous pattern for left-hemiplegic children, but not
scale, released with an impressive number of validity the corollary for the right-hemiplegic group. Hooper
studies, nevertheless encountered sharp criticism and Hynd (1985) analyzed the K-ABC's relationship
from those who found fault with the authors' the- to the Boder Test of Reading-Spelling Patterns
oretical model of intelligence (Goetz & Hall, 1984; (Boder & Janico, 1982), and found the K-ABC dif-
Sternberg, 1984) and with the empirical support for ferentiated dyslexic from normal readers but did not
the Sequential and Simultaneous processing scales distinguish among dyslexic subtypes. In the author's
230 CHAPTER 13
experience, children who show significant V > P drocephalus demonstrate a visuospatial weakness
patterns on the WISC-R frequently do not reflect (Spiegler,-Baron, Hammock, & McCullough, 1985),
comparable Sequential > Spatial profiles on the K- presumably associated with right lateralized shunt
ABC. In addition, youngsters for whom there is other insertion (Batshaw & Perret, 1981; Hartlage &
evidence of substantial language impairment often Telzrow, 1986). The case ofD.S., shown in Figure
may not have a Mental Processing Composite (MPC) I, illustrates the dichotomy of scores between two
that is significantly lower than the Nonverbal Score factors, one apparently a linguistic, sequential factor,
on the K-ABC. There appear to be a couple of possi- and a second visuospatial factor. D. S. , a young boy
ble explanations for these inconsistencies. with a shunt, demonstrates perceptual deficits on the
First, decisions about the assignment of the K- Gestalt Closure, Triangles, and Spatial Memory sub-
ABC subtests to the Sequential and Simultaneous tests. However, his superior verbal reasoning skills
scales, respectively, were made largely on the basis produced a score well above average on the Matrix
of factor analysis. These analyses sometimes re- Analogies subtest. Similarly, his mastery of oral lan-
vealed that specific subtests (e.g., Hand Movements, guage skills resulted in superior scores on the Ex-
Matrix Analogies, Photo Series) were not factorially pressive Vocabulary and Riddles tasks, although his
pure throughout the age span of the K-ABC. In fact, visuospatial deficits have made early learning of let-
the authors pointed out (Kaufman & Kaufman, 1983) ter and number symbols more difficult.
that Hand Movements, assigned to the Sequential These examples were used to illustrate the fact
scale, actually has substantial loading on the Simul- that the Sequential and Simultaneous scales do not
taneous factor at certain ages as well, a finding that appear to be pure factors. The Simultaneous scale, in
may describe developmental variability in cognitive particular, seems to be an amalgam of perceptual
processing (Kaufman, Kaufman, Kamphaus, & processing, more equivalent to the WISC-R Perfor-
Naglieri, 1982). As a result of this lack of factor mance scale, or, particularly, Bannatyne' s spatial
discreteness, derived scores sometimes are a little factor from this scale (Picture Completion, Block
difficult to interpret. Design, and Object Assembly) and subtests with
The overlap between the K-ABC Sequential and more sequential loading (e.g., Matrix Analogies,
Simultaneous scales can be demonstrated by examin- Photo Series).
ing the learning-disabled (LD) profile reported for Other hypotheses for the sometimes inconsis-
this instrument. The K-ABC manual describes an LD tent pattern of scores on the K-ABC relative to other
profile as one where the Simultaneous scale is common cognitive scales have been proposed. Keith
slightly higher than the Sequential scale, where Ge- (1985) questioned the K-ABC's sequential versus si-
stalt Closure represents the highest subtest score, multaneous constructs, and suggested the two identi-
where Sequential scores, in general, are lower rela-
tive to the other scores, and where Riddles, a subtest
on the Achievement scale that has the highest simul- Kaufman Assessment Battery for Children
taneous loading, is the highest achievement subtest.
It is the author's experience that this profile often Sequential ss Simultaneous ss
does prove to be true for LD children. However, one
Hand Movements 11 Gestalt Closure 6
observation that has been made concerns the distribu-
Number Recall 15 Triangles 6
tion of subtest scores throughout the Simultaneous Word Order 9 Matrix Analogies 12
scale. There often seems to be a dichotomy between Spatial Memory 4
subtests with high perceptual content (Gestalt
Closure, Triangles, and Spatial Memory), and those Sequential Simultaneous
Processing = 110 7 Processing = 80 7
with greater sequential processing potential (Matrix
Analogies, Photo Series). For many LD children, the Mental Processing Composite = 92 6
latter tend to be lower than the items with more visu-
ospatial demands. As a result, the total Simultaneous Subtest ss
score is depressed, resulting in only a slight dif-
Faces & Places 109 11
ference, or perhaps none at all, between the two men-
Arithmetic 87 8
tal processing scales. Riddles 124 10
This unusual distribution of subtest scores also Reading/Decoding 93 6
can be demonstrated by examining profiles of chil-
dren with spina bifida who have had ventriculo-per- FIGURE I. D.S.: Spina bifida with ventriculo-peritoneal shunt.
itoneal shunts inserted. As a rule, children with by- CA. 5-3.
fied factors (with slightly different subtest loadings) on visual perceptual skills are made; hence, the test is
perhaps more accurately are identified as verbal not considered appropriate for children who may
memory and nonverbal reasoning scales. Bracken have visual impairments, or those who may have
(1985) suggested the Kaufmans' "sequential" tasks perceptual difficulties as a result of neurological
lack cognitive complexity and instead are tasks of trauma.
short-term memory. Obrzut, Obrzut, and Shaw's In the author's experience, the Leiter is particu-
(1984) finding that the K-ABC Sequential score did larly useful in the assessment of children who have
not correlate at significant levels with the WISC-R significant language impairments. This may be true
Verbal IQ suggests these two scales are measuring of deaf or hard of hearing children, those with devel-
somewhat discrete skills. In the author's experience, opmentallanguage disorders, or those with atypical
the subtests on the K-ABC represent extremely novel developmental syndromes such as autism (Shah &
tasks for children. As a result, some youngsters, par- Holmes, 1985). Use of the Leiter in conjunction with
ticularly those who are very young or who come from other carefully selected psychological tests can as-
disadvantaged backgrounds, may not respond well to sist the clinician in making a differential diagnosis
such unfamiliar tasks (e.g., Hand Movements). among these types of disorders.
Also, there appears to be a heavy short-term memory In young deaf or hearing-impaired children, the
demand on the K-ABC. Because many children with author frequently uses the Leiter together with an-
neuropsychological impairment have memory dys- other age-appropriate verbal measure of cognitive
functions, this variable may impact children's perfor- ability (e.g., the Bayley in children below age 2i, the
mance on the scale. . Binet or the Wechsler in older children). By compar-
In summary, the K-ABC is a relatively recent ing performance across the two measures, it is possi-
scale of cognitive ability that purports to tap sequen- ble to determine whether the hearing loss represents a
tial and simultaneous processing abilities. The de- discrete impairment, or is one component of more
gree to which the scale succeeds has been debated, pervasive problems. Children with hearing impair-
although the recency of the battery suggests consider- ment alone, especially congenitally deaf children,
ably more research needs to be conducted before any tend to score within normal limits or often above on
definitive conclusions about its applicability with the Leiter (as the Leiter tends to inflate cognitive
neuropsychologically impaired children can be scores at the early ages), while scoring much lower
drawn (see Reynolds, Kamphaus, & Rosenthal, this on tasks with greater language demands. Develop-
volume). From clinical experience, the author has mental performance on other tasks (e.g., motor tasks
found the K-ABC Mental Processing scale to be of or items sensitive to nonverbal mental milestones)
mixed value in the assessment of children with a tends to be age-appropriate, although for pre-
variety of developmental and acquired problems. schoolers some self-care skills (e.g. , toileting, dress-
ing) may be slightly delayed because of the com-
munication requirements essential for such skill ac-
Leiter International Performance Scale (Leiter, quisition.
1969) When used in conjunction with verbal scales of
cognitive ability, the Leiter is helpful in identifying
The inclusion of the Leiter in this discussion of children with specific communication disorders who
cognitive measures represents a compromise. Al- may have adequate nonverbal cognitive skills (Elbert
though this instrument does not possess the same & Willis, 1984). As with the hearing-handicapped
degree of psychometric sophistication demonstrated children described above, this population tends to
by the other measures described in the chapter, it score within normal limits on the Leiter, while per-
nevertheless is included because of its unique proper- forming quite poorly on any language tasks, such as
ties and the author's experience that it can be of picture naming. The case of J.G. (Figure 2) illus-
important clinical value in the assessment of children trates the Leiter and K-ABC scores of a hyperlexic
with neuropsychological impairment. child with a pervasive oral language deficit. Separat-
The Leiter is a nonverbal scale of cognitive abil- ing children such as J. G. who have specific language
ity that requires no language in either the administra- disorders from those with more pervasive disorders
tion or the subject's response. It relies on the use of such as autism may be possible through use of the
perceptual tasks, graduating from rather pure percep- Leiter, together with such instruments as the K-ABC
tual matching tasks at the early ages to items of great- Achievement scale, and measures of communicative
er abstract reasoning and concept formation at the intent and social responsiveness (Telzrow, 1985b).
upper levels. Throughout the test, extensive demands In the author's experience, children whose failure to
232 CHAPTER 13
Kaufman Assessment Battery for Children McCarthy Scales of Children's Abilities (MSCA;
McCarthy, 1972)
Sequential ss Simultaneous ss
The MSCA is a measure of cognitive ability
Hand Movements 7 Gestalt Closure 7 designed for use with children aged 2! to 8!. This
Number Recall 8 Triangles 8 scale conceptualizes cognitive processing into five
Word Order 7 Matrix Analogies 9
scales on the basis of a theoretical model derived
Spatial Memory 5
from the author's clinical experiences. The Verbal,
Sequential Simultaneous Perceptual-Performance, and Quantitative scales are
Processing = 83 7 Processing = 81 7 discrete in content, and combine to derive a total
Mental Processing Composite = 80 6 score or General Cognitive Index (GCI). Two addi-
tional scales, Memory and Motor, are obtained from
Nonverbal Score = 81 7
subtests that either are totally separate from or over-
Subtest ss lap with the other scales. Factor analysis of a portion
of the standardization sample supports the existence
Expressive Vocabulary 68 9 of a general cognitive factor, Memory, and Motor
Faces & Places 74 11 components across all ages (McCarthy, 1972).
Arithmetic 107 8 Cross-validation studies support the existence of in-
Riddles 76 10 dependent Verbal, Perceptual-Performance, and
Reading/Decoding 144 6 Motor factors as well (Naglieri, Kaufman, & Har-
Reading/Understanding Age equivalent = 7-6 rison, 1981). Another study of 300 6- to 8~-year-old
children demonstrated support for the general (GCI),
Leiter International Performance Scale
CA =5-2
Verbal, and Motor factors, but questioned the in-
MA =5-3 terpretation of the Memory, Perceptual-Perfor-
10 = 102 mance, and Quantitative scales for this population
(Keith & Bolen, 1980). Other evidence suggests that
Soder Test of Reading-Spelling Patterns interpretation of a discrete Quantitative scale may be
Reading Quotient= 135 problematic for preschool children (Kaufman & Ka-
Known Words = 80% ufman, 1977) and for school children with GCis in
Unknown Words = 20% the lowest 16th percentile (Naglieri et al., 1981).
FIGURE 2. J.G.: Severe expressive communication disorder
In the author's experience, the MSCA is most
with hyperlexia. CA, 5-2. useful in the assessment of mildly impaired children
ages 4 and older. Younger children and those with
more pervasive handicaps, such as those with signifi-
develop speech is associated with an expressive syn- cant communication disorders or attention deficits,
drome or even auditory-verbal agnosia (Rapin & have not been found to perform optimally on this
Allen, 1983) tend to perform consistently on all long, demanding scale. Furthermore, the MSCA
Leiter items up to their general level of nonverbal may not have sufficient floor to derive valid scores
cognitive ability. In contrast, autistic children dem- for moderately retarded children (Beckett, Reuter, &
onstrate a much more variable performance pattern, Stancin, 1984). For the assessment of suspected
and tend to fail even early Leiter items requiring learning disabilities, however, or other kinds of mild
social experience (e.g., Picture Completion at Year handicaps, the McCarthy may provide a relevant
3, Genus and Clothing at Year 5). Pure perceptual analysis of strengths and weaknesses, particularly in
tasks, however, may be passed by autistic children light of the separate Memory and Motor scales. Early
beyond their chronological age levels. investigations of the MSCA reported significantly
In summary, the Leiter is less than adequate lower GCis for LD than for non-LD populations
psychometrically. However, its unique task demands (Gob & Simons, 1980). Furthermore, Gob and Si-
make it a useful clinical tool for evaluating the non- mons (1980) reported an absence of distinctive pat-
verbal cognitive ability of children. When used in tern or scatter characteristics on the MSCA for LD
conjunction with other measures, it can provide groups, and clinicians should be mindful of the sig-
useful information in performing differential diag- nificant scatter demonstrated by populations of nor-
noses among mental retardation, specific language mal children (Kaufman, 1976). No significant scatter
disorders, and atypical developmental syndromes differences were found between "at-risk" pre-
such as childhood autism. schoolers and the MSCA standardization sample
(Prasse, Siewert, & Ellison, 1983), although a great- split on the Wechsler, for example, tend to have a
er proportion of at-risk children showed scatter great- significant Verbal Reasoning < Abstract/Visual
er than or equal to 21 points. Prasse et al. (1983) Reasoning difference on the Binet. The Quantitative
suggested that the MSCA, particularly the Motor scale, early experience suggests, is less precise,
Scale, may contribute to the identification of neu- probably because of the extensive language demands
rologically compromised 4-year-old children. on the Quantitative subtest of this scale. Similarly,
children with a Verbal Reasoning< Abstract/Visual
Reasoning profile (e.g., see scores ofR.G. in Figure
Stanford-Binet Intelligence Scale-Fourth Edition 3) may have a significant difference between Short-
(Binet; Thorndike et al., /986) Term Memory subtests that are sensitive to spatial as
opposed to temporal memory.
The recent revision of the Stanford-Binet was The author's early impressions are that the
viewed by most as long overdue, given there had fourth edition may not be as useful as its predecessor
been few changes in individual items since Terman for evaluating the general cognitive ability of young
and Merrill's 1937 edition (Sattler, 1982). The fourth delayed children, a group for whom the 1960/1972
edition represents a significant departure from pre- version was used frequently. Although it is at this
vious versions, and, although validity data are just writing an impression based on a limited sample, the
beginning to be accumulated, early impressions are fourth edition seems not to have adequate floor for
that the latest Binet has the potential for significant this population.
contributions to the neuropsychological assessment
of children.
The fourth edition was developed from a the- Wechsler Inteiiigence Scale for Children-Revised
oretical model relying heavily on g or general cog- (WISC-R; Wechsler, 1974)
nitive ability. The work of Cattell and others is used
to conceptualize intelligence as comprising fluid and The WISC-R has been perhaps the most widely
crystallized abilities, as well as a memory compo- used measure of intellectual ability, and has been
nent. The four major scales on the fourth edition are incorporated into the Reitan neuropsychological bat-
Verbal Reasoning and Quantitative Reasoning (pre- tery for older children (Selz, 1981; Selz & Reitan,
sumably indices of crystallized ability), Ab- 1979). Because of its excellent psychometric proper-
stract/Visual Reasoning (theoretically a measure of ties and the plethora of validity data on this instru-
fluid ability), and Short-Term Memory. A composite ment, the WISC-R probably remains the measure of
or partial composite score can be derived from any choice in the assessment of children's cognitive
combination of area scores. strengths and weaknesses.
Results of preliminary factor analyses con- The Verbal-Performance dichotomy employed
ducted during the preparation of the technical manual in the WISC-R often is useful in demonstrating
for the fourth edition indicated the presence of a unique deficits in either linguistic or perceptual
strong g factor throughout, as well as a verbal reason- skills. Verbal-Performance splits have been identi-
ing component across all ages. A short-term memory fied in a number of populations of children with neu-
factor was identified at all but preschool ages, al- ropsychological impairment, including those with
though items sensitive to spatial memory (e.g., the learning disabilities (V < P or V > P, depending on
Bead Memory subtest) were not correlated with the subtype; Rourke, 1983), Turner's syndrome (V > P;
other subtests on this scale (Memory for Digits, Lewandowski, Costenbader, & Richman, 1985;
Memory for Sentences, Memory for Objects), which McGlone, 1985), hydrocephalus (V > P; Spiegler et
appear to be more sensitive to temporal memory. al., 1985), and children with Duchenne's dystrophy
Evidence for the Quantitative and Abstract/Visual (V < P; Leibowitz & Dubowitz, 1981). Children
Reasoning scales were inconsistent across the ages with diffuse neuropsychological impairment such as
analyzed. attention deficit disorder (ADD) have been reported
Additional validity data on the revised Binet are to exhibit unique deficits on the Arithmetic, Digit
not available at this writing, hence the following im- Span, Coding triad on the WISC-R (Lufi & Cohen,
pressions should be considered tentative. In limited 1985). Ownby and Matthews (1985) suggested that
clinical use the author has found the fourth edition to this so-called "third factor" on the WISC-R is a
reveal patterns of neuropsychological strengths and complex cognitive index that may be associated with
weaknesses that are consistent with data from other, the ability to change mental set and to sustain atten-
proven measures. Children who demonstrate a V < P tion during higher cognitive tasks. Such abilities ap-
234 CHAPTER 13
Stanford-Binet Intelligence Scale: Fourth Edition
Verbal Reasoning ss . Abstract/Visual Reasoning ss

Vocabulary 26 Pattern Analysis 52 (est., no ceiling)
Comprehension 29 Copying 48 (est., no ceiling)
Absurdities 34 Matrices 48
Verbal Reasoning SAS = 54 Abstract/Visual Reasoning SAS = 98 est.
Quantitative Reasoning ss Short-Term Memory ss

Quantitative 36 Bead Memory 47
Memory for Sentences 24
Quantitative Reasoning SAS = 72 Short-Term Memory SAS = 66

Test Composite = 69
FIGURE 3. R.G.: Severe expressive communication disorder with autism. CA, 17-0.
pear to share common characteristics with the plan- weaknesses of individual children. Of particular sig-
ning and integrative functions attributed to the frontal nificance for describing subtypes of LD children are
cortex (Goodglass & Kaplan, 1979). the relative scores on Bannatyne's sequential (com-
In general, WISC-R profiles such as those just prising WISC-R Arithmetic, Coding, and Digit Span
described are most tenable for populations of chil- subtests) and spatial (formed by Picture Completion,
dren with developmental problems. For children with Block Design, and Object Assembly subtests) fac-
acquired impairments, particularly those dating from tors. Populations of LD children have been reported
an early age, even lateralized insults may not trans- to demonstrate a spatial > sequential pattern on the
late into the hypothesized V-P split. Although such WISC-R (Bannatyne, 1978; Zingale & Smith, 1978).
children appear to have relative sparing of presum- More recent investigations suggest this pattern may
ably lateralized functions, a generalized decrement be revealed most often in reading-disabled subtypes
in intellectual ability may be evidenced (Aram, (Fischer, Wenck, Schurr, & Ellen, 1985; Rugel,
Ekelman, Rose, & Whitaker, 1985; Lewandowski & 1974; Stoiber et al., 1983; Telzrow, Century, Red-
DeRienzo, 1985; Satz, 1985; Wilkening & Berg, mond, Whitaker, & Zimmerman, 1983). Individual
1985). Hence, specific impairment (e.g., depressed subject characteristics, particularly IQ and gender,
Verbal IQ subsequent to an early left lateralized trau- may relate to the cognitive patterns demonstrated on
ma) appears to give way to more generalized losses. the Bannatyne recategorization of the WISC-R
One exception to this rule may be children with ac- (Fischer et al., 1985).
quired severe head injuries, who have been reported
to show a significant deficit on Performance but not
Verbal IQ relative to those with mild to moderate Woodcock Johnson Psychoeducational Battery:
injuries (Bawden, Knights, & Winogron, 1985). Tests of Cognitive Ability (W]PB-TCA; Woodcock
Other studies also suggest that Performance IQ is & Johnson, 1977)
especially vulnerable to the effects of head injuries
(Berger-Gross & Shackelford, 1984; Chadwick, Rut- The WJPB-TCA, although not a measure of in-
ter, Brown, Shaffer, & Traub, 1981). This V > P tellectual ability comparable to the WISC-R or the
pattern appears to be associated with greater sen- Binet (Hessler, 1982), nevertheless may prove to be
sitivity of the Performance Scale's tasks to brain im- of value in the appraisal of children's neuropsycho-
pairment rather than to locus of brain injury. logical strengths and weaknesses. The WJPB-TCA is
In addition to interpretation of the separate Ver- divided into four major cluster scores: Verbal Abil-
bal-Performance scales on the WISC-R, many clini- ity, Reasoning, Memory, and Visual-Perceptual
cians find that analysis of four cognitive factors pro- Speed. Two of the clusters-Verbal Ability and Rea-
posed by Bannatyne (1974) contributes to soning-use suppressor variables in the derivation of
understanding the neuropsychological strengths and the cluster scores. Suppressor variables are nega-
tively weighted subtests designed to homogenize the The Visual-Perceptual Speed cluster of the
two clusters so they are "purer" measures of verbal WJPB-TCA is somewhat unique among cognitive
and reasoning ability. Individuals who score high on measures, and may offer potential for identifying
the main subtests within a cluster are presumed to neuropsychological deficits in this area, particularly
have lower scores on the suppressor variable, and those associated with conditions such as Tourette's
vice versa. To the degree this theoretical premise syndrome or performance decrements attributed to
does not hold true for a given child, the cluster score specific medications. Such a measure of performance
may under- or overestimate that individual's perfor- may have implications for vocational planning as
mance on specific subtests (Breen, 1985). Score ar- well. The Memory cluster on the WJPB-TCA com-
tifacts also may occur for children whose scores fall prises a limited sample of short-term auditory memo-
at either end of the distribution (Kampwirth, 1983). ry, and hence clinicians should be cautious about
In any of these cases, computation of individual sub- overinterpreting these results. However, weaknesses
test scores is recommended (Hessler, 1982; Marston in this area may be demonstrated by ADD or LD
& Ysseldyke, 1980), although clinicians should be populations.
mindful of the fact that standard errors of measure-
.ment are higher for subtest than for cluster scores.
Hessler ( 1982) identified three major profiles on Academic Achievement
the WJPB-TCA. The first, which has been associated
with learning disabilities involving reading and spell- Establishing levels of academic achievement is
ing, is characterized by a low Verbal Ability cluster important for determining the presence of specific
learning disabilities and loss of function following a
score relative to the Reasoning cluster score. A sec-
specific trauma, as well as for helping to plan and
ond profile is the reverse, with a low Reasoning clus-
monitor specific interventions. This section de-
ter score compared to Verbal Ability. Such children
scribes psychometrically sound measures of aca-
may have adequate skills in the language areas such
demic achievement, including both comprehensive
as reading and spelling, although they may exhibit
arithmetic problems. A third type of pattern, which achievement batteries and individual measures.
has been associated with diffuse neuropsychological
impairment such as may be observed in children with K-ABC (Kaufman & Kaufman, 1983)
attention deficits, is characterized by low scores on
the Memory and Visual-Perceptual Speed areas rela- As noted above, in addition to its mental pro-
tive to the other two cluster scores. cessing scale, the K-ABC also includes a comprehen-
Critics of the WJPB-TCA suggest the entire bat- sive achievement battery. As such, it is the only
tery is verbally loaded, and thus tends to be biased published instrument that provides both intellectual
against youngsters with weaker language abilities ability and achievement data on the same standar-
(Phelps, Rosso, & Falasco, 1985). Although the dization population. (Although this claim is made for
Reasoning cluster score of the scale appears upon the WJPB, many experts dispute the fact that the
initial examination to be sensitive to nonverbal cog- WJPB-TCA is a measure of intellectual ability in the
nitive ability, comparison of this cluster score and its traditional sense.) The K-ABC provides standard
two main subtests (Analysis-Synthesis and Concept scores for these subtests: Expressive Vocabulary
Formation) with the WISC-R and the Halstead Cate- (ages 2-6 through 4-11 only), Faces & Places (a
gory Test did not support this hypothesis (Harr & measure of general information), Arithmetic, Rid-
Telzrow, 1986). The WJPB-TCA Reasoning cluster dles (an index oflistening integration ability), Read-
score was shown to be correlated at significant levels ing/Decoding (ages 5 and up), and Reading/ Under-
with both the WISC-R Verbal and Performance IQ standing (ages 7 and up).
scores, and in fact showed higher correlations with In the author's experience, the K-ABC achieve-
the WISC-R sequential than spatial subtests. The ment scale is useful in generating and supporting
Analysis-Synthesis subtest, in particular, shared sub- hypotheses about a variety of neuropsychological
stantial variance with the WISC-R Verbal IQ (r problems in children. The following patterns on this
= 0. 72). This analysis revealed virtually no rela- scale have been identified. Youngsters with learning
tionship between the WJPB-TCA Reasoning cluster disabilities, as noted above, tend to have highest
or its subtests and scores on the Category Test. Harr scores on the Riddles subtest. Because this is a listen-
and Telzrow concluded that the Reasoning cluster of ing task, and LD children often have problems in this
the WJPB-TCA does not appear to be sensitive to area, such a pattern may seem incongruous. Howev-
nonverbal cognitive ability. er, items on the Riddles subtest may be repeated, and
236 CHAPTER 13
the heavy simultaneous (i.e., integrative) emphasis tive to Mathematics and Knowledge. Such a profile,
on this task seems to favor the strengths of these typically observed in youngsters with language-
youngsters. In contrast, Arithmetic and, particularly, based learning disorders affecting reading and writ-
the Reading subtests may be depressed for LD popu- ten language, is consistent with the low Verbal Abil-
lations. Young children with severe communication ity-high Reasoning pattern on the cognitive portion
disorders tend to score poorly on the Expressive Vo- of the WJPB. Mathematics learning disabilities are
cabulary, Faces & Places, and Riddles subtests, al- reflected in a significantly weak performance on the
thpugh their scores on Arithmetic and the Read- Mathematics cluster. Such students are reported to
ing/Decoding subtests may be more within normal have a cognitive profile characterized by a high Ver-
limits at early ages, due to the high visuospatial con- bal Ability cluster score relative to the Reasoning
tent in early number and letter recognition. The K- cluster score. Two other achievement profiles on the
ABC is particularly useful in identifying preschool WJPB-TA are described by Hessler (1982). The first,
hyperlexic children, whose scores may be at ceiling observed in children whose incidental learning abili-
levels on the Reading/Decoding subtest and above ties are adequate despite unique deficits in formal
average on the Reading/Understanding subtest learning, is reflected in low scores in Reading, Math-
(given the gestural response mode and early single- ematics, and Written Language clusters relative to
word items), despite significant deficiencies on Ex- the Knowledge cluster. Finally, students may obtain
pressive Vocabulary, Faces & Places, and Riddles low scores on all four of the WJPB-TA clusters. Pre-
(Telzrow, 1985b) (seecaseofJ.G. inFigure2). Chil- sumably, such students have significant neuropsy-
dren with unique visuospatial deficits tend to have an chological impairment, such as may be observed in
opposite pattern on the K-ABC Achievement scale,. mental retardation or pervasive learning disabilities.
and may exhibit deficits on Arithmetic and Reading
tasks that rely on visuospatial skills, although tasks
sensitive to oral language (i.e., Expressive Vocabu- Boder Test of Reading-Spelling Patterns (Boder &
lary, Faces & Places, and Riddles) are preserved (see ]arrico, 1982)
case of D.S. in Figure 1).
Inclusion of the Boder, as with the Leiter, de-
scribed earlier, represents a compromise of psycho-
W]PB: Tests of Achievement (W]PB-TA; metric imprecision and clinical utility. Although
Woodcock & Johnson, 1977) criticized because of its psychometric weaknesses
(Reynolds, 1984), the Boder has nevertheless been
The WJPB-T A derives cluster scores in four found to be of value in clinical practice (Hiltebeitel,
achievement areas: reading, mathematics, written 1985; Nockleby & Galbraith, 1984; Telzrow et al.,
language, and knowledge (comprising social studies, 1983). This instrument, developed by pediatric neu-
science, and humanities subtests). Cluster scores are rologist Elena Boder after extensive observation of
not differentially weighted for variable intracluster the reading and spelling habits of dyslexic children,
subtest performance; hence, a significant difference is designed to identify the presence and type of neu-
between individual subtests comprising a cluster rologically based reading disorder. The scale uses
score may result in the cluster score's misrepresent- graded word lists, balanced for phonetically regular
ing those separate abilities. In such cases, separate and irregular words, and individual spelling lists that
scores should be derived for the individual subtests are prepared for each subject based on reading perfor-
(Hessler, 1982; Marston &Ysseldyke, 1980). This mance. Three criteria (reading quotient, percent
may occur, for example, for children with certain known words spelled correctly, percent unknown
types of learning disabilities who perform adequately words spelled as good phonic equivalents) are used to
on rote arithmetic tasks despite limited ability to ap- categorize children into these reading types: normal
ply arithmetic concepts. In this instance the total reader, dysphonetic dyslexic, dyseidetic dyslexic,
mathematics cluster score would underestimate com- mixed dyslexic, dyslexic reader with an unspecified
putation skills and overestimate the score on the Ap- pattern, and a nonspecific reading disorder with a
plied Problems subtest. normal reading/spelling pattern.
Hessler's ( 1982) description of the cognitive In clinical use, the dyslexic reading types identi-
profiles on the WJPB-TCA has corollaries on the fied by the Boder have been demonstrated to exhibit
achievement portion of the battery. One pattern re- predicted profiles on the WISC-R (Telzrow et al.,
ported for LD children is characterized by low scores 1983), finger tapping (Telzrow et al., 1983), and the
o_n the Reading and Written Language clusters rela- K-ABC (Telzrow et at., 1985). For example, chil-
dren whose reading is characterized by the poor cians to determine whether a given subtest score on
sound-symbol associations and sound blending the TOLD-Pis significantly higher or lower than the
weaknesses typical of Boder' s auditory phonetic dys- individual's own mean performance. Analysis of
lexia tend to show a lower Verbal than Performance unique strengths and weaknesses in this fashion
WISC-R IQ and demonstrate a spatial strength on might lead to hypotheses about language deficits af-
Bannatyne's factors. Auditory phonetic dyslexics fecting phonological, semantic, or syntactic lan-
have been hypothesized to have a left hemisphere guage systems (Elbert & Willis, 1984). Significantly
dysgenesis (e.g., Rourke, 1983), and a finger tap- poor performance on the Word Discrimination or
ping profile suggestive of such a pattern frequently is Word Articulation subtest may suggest a pho-
observed. Such children also have been reported to nological disturbance, whereas low scores on Gram-
exhibit a Sequential < Simultaneous profile on the matic Understanding and Grammatic Completion
K~ABC (Telzrow et al., 1985). This profile on the tasks may be associated with disruption of the syntac-
WISC-R, K-ABC, and Boder is depicted in the case tic language systems. Semantic skills presumably are
study of S. W. at the conclusion of this chapter. reflected by scores on the Oral and Picture Vocabu-
In the author's experience, use of the Boder with lary subtests.
beginning readers requires a special caution. Young-
sters who are just beginning to read and spell often Peabody Picture Vocabulary Test-Revised
find sound-symbol associations difficult. Hence,
(PPVT-R; Dunn & Dunn, 1981)
their reading-spelling patterns, if scored strictly on
the bases of the rules prescribed by Boder and Jarrico The PPVT-R is a test of receptive vocabulary
(1982), may be consistent with the authors' descrip- appropriate for individuals aged 2! to 50. The multi-
tion of a dyslexic reader. However, frequently such ple-choice pictoral format may utilize a pointing, oral
children may be exhibiting a normal stage of reading (i.e., indication by letter designation), or yes/no re-
development rather than a specific deficit (e.g., sponse, so it is possible to adapt the test for brain-
Bradley, 1983). Other data should be considered to injured persons who have significant upper extremity
help differentiate between neuropsychological dys- involvement.
function and a failure of acquisition. The PPVT-R can contribute to neuropsycholog-
ical evaluation of children in a number of ways. In
Oral and Written Language Skills normal individuals, PPVT-R scores are moderately
correlated with intelligence (median correlation with
The broad area of oral and written language major tests in the mid 0.60s; Dunn & Dunn, 1981).
skills is diverse and complex, and cannot be treated Hence, major discrepancies between measured IQ
comprehensively in this chapter. However, psychol- and PPVT-R scores might suggest neuropsycholo-
ogists working with preschool and school-aged chil- gical weaknesses in general language capacity or in-
dren should be able to identify signs of specific com- adequate incidental learning opportunities. Such
munication deficits of a neuropsychological origin as comparisons should be made in light of the average
distinct from impoverished language as a result of mean score differences reported between the PPVT-
poor language models or generally depressed cog- R and cognitive scales (Bracken & Prasse, 1984).
nitive ability. This section describes traditional tests Comparison of PPVT-R scores with performance on
of oral and written language that might be used for nonlanguage tests such as the Beery has been sug-
this purpose. gested as a means of developing hypotheses about
neuropsychological strengths and weaknesses
(Hartlage, 1981; Satz & Fletcher, 1982).
Test of Language Development (TOLD; Hammill
& Newcomer, 1982, 1984)
Test of Written Language (TOWL; Hammill &
The TOLD, which is published in primary Larsen, 1978)
(TOLD-P) and intermediate (TOLD-I) versions, is
designed as a screening measure of children's recep- The TOWL is one of the few standardized, nor-
tive and expressive language skilJs. ProfiJe analysis mative measures available to assess the written lan-
using ipsative comparison techniques might be used guage skills of younger children. The instrument was
to determine whether a given youngster exhibits standardized using 1602 (for scaled score norms) or
unique weaknesses on individual subtests. Reynolds 1712 (for grade equivalent score norms) children
( 1983) developed a helpful table that enables clini- aged 8! to approximately 14!. The TOWL provides a
238 CHAPTER 13
balanced assessment of written language mechanics The test authors (Hammill et al., 1980) advo-
(spelling, grammar, and punctuation) and creative cate the use of ipsative interpretation, particularly
components (thematic maturity, vocabulary, and using composite scores, and suggest as a guideline
thought units). A written language quotient, or stan- that differences of more than one standard deviation
dardized age score, is derived from the five principal from the individual's own mean scores may reflect
subtests; scores for Thought Units and Handwriting significant intraindividual variability. Hence, analy-
areas are reported separately. sis of the relationship among composite scores may
In the author's experience, use of the TOWL reveal generalized language deficits or specific im-
may be particularly helpful in identifying dys- pairment in written language areas such as reading
graphia, especially of the type occurring without dys- and writing.
lexia. For such children, unique weaknesses in spell-
ing and handwriting may be identified, although their
performance on other TOWL subtests may be age-
Motor/Visual Motor Skills
appropriate or above. Assessment of motor skills is important as an
indication of general neurodevelopmental delay in
The Token Test for Children (DiSimoni, 1978) young children, or as a sign of unique motor deficien-
cy exclusive of cognitive functioning (e.g., in some
As DiSimoni indicates in the manual accom- cases of cerebral palsy or musculardystrophy). Visu-
panying this instrument, the title "Token Test" has al motor performance can be used to establish a base-
become a generic, in that there are numerous versions line for nonverbal cognitive skills, as well as an index
and adaptations from the original instrument de- of discrete abilities in this area. Specific measures
scribed by DeRenzi and Vignolo in 1962. The Di- sensitive to motor and visual motor performance are
Simoni form of the Token Test is essentially Noll's described in this section.
adaptation of the measure, standardized on 1304 chil-
dren aged 3 to 12! without known language or learn- Physical Dexterity Tasks-System of
ing problems (DiSimoni, 1978). When used appro- Multicultural, Pluralistic Assessment (SOMPA;
priately, the Token Test can provide helpful data Mercer & Lewis, 1978)
regarding the ability of children to follow oral direc-
tions, to understand basic language concepts, and to These tasks, designed for children aged 5-12,
integrate verbal information. It has been reported su- are purported to identify neuropsychologically rele-
perior to teacher judgment in identifying preschool vant motor behaviors. The tasks are divided into six
children with receptive language difficulties (DiSim- areas: ambulation, equilibrium, placement, fine
oni & Mucha, 1982). When scores on this task are motor sequencing, finger-tongue dexterity, and in-
compared with performance on nonverbal measures voluntary movement. Risk status is based on the per-
of mental development for young children, some hy- formance of the normative sample and age, as most
potheses can be generated about the child's relative of the tasks are significantly age-related.
strengths and weaknesses in neuropsychological The SOMPA Physical Dexterity tasks are of the
processing. type frequently used to identify "soft neurological
signs" in children (Gaddes, 1985; Spreen, Tupper,
Test of Adolescent Language (TOAL; Hammill, Risser, Tuokko, & Edgell, 1984). Such signs have
been associated with a variety of neuropsychological
Brown, Larsen, & Wiederholt, 1980) deficits, including hyperactivity, subnormal IQ, and
The TOAL is one of the few empirical, na- behavior problems (Shaffer, O'Connor, Shafer, &
tionally standardized scales of adolescents' oral and Prupis, 1983). However, false-positives are com-
written language abilities. Although it is a long, diffi- monly identified, so cautious interpretation of chil-
cult test, and many clinicians have reported anec- dren's performance on such tasks is warranted.
dotally that it identifies far too many false-positives,
it probably remains the language measure of choice Developmental Test of Visual Motor Integration
for adolescents. The test comprises eight subtests (VMI or Beery; Beery, 1982)
designed to survey in comprehensive fashion seman-
tic and syntactic aspects of written and oral language The Beery is a form-copying task appropriate
via both receptive and expressive modes. Ten differ- for children aged 2 and older; a developmental ceil-
ent composite scores can be derived from various ing occurs at approximately age 13, and scores are
combinations of subtests. not provided above this level. Performance on this
test provides a good estimate of general developmen- been significantly correlated with achievement.
tal level in younger children (Routh, 1984), as draw- Traits such as persistence and adaptability have been
ings of geometric designs and human figures tend to reported to be the best temperament predictors of
be highly correlated with age. Children with unique achievement (Martin & Holbrook, 1985). In a meta-
deficits in motor or visual perceptual skills (e.g., analysis of a wide variety of kindergarten and first
children with cerebral palsy or a late acquired left grade predictors, including IQ, language skills, soft
hemiparesis) would represent an exception to this neurological signs, and behavioral characteristics,
rule. The VMI has been reported to be a valid predic- Hom and Packard (1985) found that social behavioral
tor of future academic performance in kindergarten- traits such as attention/distractibility were among the
age children, and there is evidence that it is particu- best predictors of subsequent school achievement.
larly related to subsequent mathematics achievement Furthermore, findings suggest that a behavioral
(Klein, 1978). Such a pattern between visuospatial checklist is superior to children's cognitive or neu-
skills, as reflected in VMI scores, and arithmetic ropsychological performance in identifying brain
achievement is consistent with the observations of damage confirmed by CAT scan (Klesges & Fisher,
Rourke and his colleagues (Rourke & Finlayson, 1981).
1978; Rourke & Strang, 1983). Other studies have shown a relationship be-
Use of the Beery in conjunction with nonmotor tween neuropsychological functioning and social be-
tasks of visual perception can help delineate specific havior. For example, Gill and Lueger (1985) re-
neuropsychological skills. Youngsters who perform ported that adolescents with conduct disorders
poorly on the Beery and the WISC-R Coding subtest, perform poorly on neuropsychological tasks sen-
and yet score within normal limits on the Picture sitive to frontal lobe functions. Other support for the
Completion, Object Assembly, and Block Design role of the frontal lobes in mediating behavior comes
subtests on the WISC-R may exhibit discrete motor from Slomka, Tarter, and Hegedus (1984), who de-
impairment. Conversely, children who show described attention variables such as distractibility and
pressed scores on all these tasks may have a gener- hyperactivity as dramatically apparent in a case of an
alized visuospatial deficit regardless of response adolescent with agenesis of the frontal lobes. Similar
format. behavior problems were reported for an 11-year-old
girl with frontal lobe dysfunction subsequent to sur-
gery (McKay et al., 1985).
Motor Scales of Selected Batteries Because all human behavior-be it cognitive,
perceptual, or social-arises from the central ner-
In addition to the two specific measures men-
tioned above, a number of developmental instru- vous system (Gaddes, 1985), consideration of only
ments, particularly those designed for young chil- some of these elements (e.g., only cognitive or
dren, include motor scales. Examples include the achievement variables) may result in an incomplete
Bayley and McCarthy scales, described above, and description of neuropsychological abilities. Chil-
others such as the Vineland Adaptive Behavior Scale dren's social-emotional behavior constitutes an
(Sparrow, Balla, & Cicchetti, 1984) and the Battelle important variable on which they are judged; thus,
Developmental Inventory (Newborg, Stock, Wnek, comprehensive assessment of such behavior in chil-
Guidubaldi, & Svinicki, 1984). dren is especially critical. This section describes psy-
chometrically sound empirical measures of social-
emotional behavior.
Social-Emotional Behavior
Clinicians are becoming increasingly aware of Child Behavior Checklist (CBCL) (Achenbach &
the behavioral sequelae of neuropsychological dys- Edelbrock, 1983)
function on social and interpersonal skills. One indi-
cation of the focus on neuropsychological aspects of The CBCL is available in parent-report (ages 4-
behavior is evidenced by studies of children's tem- 16), teacher-report (ages 6-16), direct observation
perament (Martin, 1983; Rothbart & Posner, 1985). (ages 4-16), and self-report (ages 11-18) formats.
A variety of temperament characteristics, including Factor analysis of the parent-report scales of 2300
activity level, degree of responsiveness, and general children was used to cluster items into several scales
mood, have been associated with individual dif- sensitive to both internalizing and externalizing di-
ferences in neuropsychological functioning. Teacher mensions. Similar analyses were conducted for the
ratings of children's temperament, presumably ge- teacher-report form for 1800 children (McConaughy,
netically influenced behavioral characteristics, have 1985). Profiles of specific populations have been
240 CHAPTER 13
identified on the CBCL, including delinquent, ADD significant developmental delays requiring selection
with hyperactivity, and a subtype characterized by of an instrument designed for chronologically young-
significant aggressiveness that is elevated on the De- er populations. The author has utilized the Bayley,
pressed, Social Withdrawal, and the Aggressive for example, in assessing autistic children as old as
scales (Achenbach & Edelbrock, 1983). Further 18 years. This procedure is preferable to selecting an
analysis has suggested the teacher form of the CBCL age-appropriate instrument with insufficient floor to
may help distinguish between subtypes of ADD (with describe the neuropsychological functioning of a
and without hyperactivity) (Edelbrock, Costello, & given individual.
Kessler, 1984). Others have found that LD children A second variable to consider when selecting
may be elevated on various of the CBCL scales, al- instruments within each of the areas of function con-
though especially on the hyperactivity scale (Mc- cerns the response format of the test and specific
Conaughy & Ritter, 1986). Many of the items on this handicaps of the child that may be inconsistent with
scale are sensitive to attention deficits, poor impulse these. To illustrate, tests of receptive language that
control, and deficient interpersonal skills associated require a pointing response (e.g., the Token Test for
with neuropsychological deficits in children. Children) may be inappropriate for youngsters with
impaired use of upper extremities. A distinction
should be made between nonessential task demands
Revised Behavior Problem Checklist (RBPC; Quay and tests of specific neuropsychological abilities.
& Peterson, 1979) The example of the Token Test illustrates non-essen-
tial task demands; that is, a pointing response is not
The RBPC is a recent revision and expansion of
essential to the evaluation of language understand-
its predecessor, the Behavior Problem Checklist.
ing. Consideration of the child's specific skills in
Factor-analytic studies of the behavior problems of
relation to non-essential task demands is necessary in
special populations (including psychiatric inpatients
order to obtain an accurate description of the child's
and outpatients, LD students, and developmentally
neuropsychological abilities. It would be inaccurate,
disabled children) produced six scales: Conduct Dis-
for example, to conclude that a child's receptive lan-
order, Socialized Aggression, Attention Problems-
guage skills were deficient because of his or her in-
Immaturity, Anxiety-Withdrawal, Psychotic Be-
ability to point and manipulate tokens. However, it
havior, and Motor Excess. The scales have been
would not be inappropriate to administer a test of
reported to differentiate between normal and clinic
motor ability to the child, for such a measure
samples of children (Quay, 1983). In addition, con-
would-quite appropriately-describe the signifi-
struct validity for several of the RBPC's scales is
cant motor limitations of the individual (Willis,
reported in a comparison with DSM-ill categories
Culbertson, & Mertens, 1984).
(Quay, 1983). Concurrent validity for the RBPC has In addition to the child's age and non-essential
been demonstrated by high correlations with behav- task demands in light of specific impairments, a third
ioral observation data in various contexts (Lahey &
variable to consider when making test selections con-
Piacentini, 1985). The absence of representative na- cerns the validity of specific instruments for popula-
tional norms for this scale has been described as a tions of children with various neuropsychological
potential limitation to its clinical utility (Lahey & disorders. In the case of some of the measures de-
Piacentini, 1985). scribed, such validity h,as been demonstrated through
extensive investigation with children with a wide va-
riety of developmental and acquired disorders. For
Selecting Combinations of Tests others, the recent release of the instrument has not
made the accumulation of validity data possible, al-
When assessing the neuropsychological abili- though clinical experience with these instruments
ties of children, a comprehensive survey of behavior suggests that they may contribute to the description
is desirable. Hence, collecting data about all the of neuropsychological abilities in children.
functioning areas just described is recommended. A fourth variable to consider when selecting
The choice of specific tests within each area requires specific test instruments concerns the purpose of the
consideration of a number of child variables and test evaluation and the specific question(s) it is intended
characteristics. to answer. Clinicians in hospitals or rehabilitation
The first factor to consider is the age or develop- settings may be called upon to establish levels of loss
mental1evel of the child. Although the two are com- of function and to monitor recovery or, for degener-
parable in most children, some youngsters exhibit ative conditions, progressive deterioration. Psychol-
ogists working in educational settings must respond Wechsler Intelligence Scale for Children-Revised
to questions regarding the need for special program-
ming and adaptive equipment and the viability of Verbal ss Performance ss
certain interventions. Knowledge of the degree to
Information 6 Picture Completion 12
which specific instruments can help the psychologist
Similarities 9 Picture Arrangement 14
be responsive to such referral questions is a critical
Arithmetic 6 Block Design 14
ingredient in conducting neuropsychological eval- Vocabulary 9 Object Assembly 19
uations. Comprehension 7 Coding 6
Finally, choosing the standardized test compo- Digit Span 5
nents of a flexible battery of traditional educational
Verbal 10 = 84 Performance 10 = 121
and psychological tests should incorporate knowl-
edge of the test interactions and the ways in which Full Scale 10 = 99
scores from various instruments complement one an-
other and contribute to a description of the child's Kaufman Assessment Battery for Children
functioning. Such awareness is gleaned not only
from research data, but also from clinical practice Sequential Subtests ss Simultaneous Subtests ss
and experience in using diverse instruments with Hand Movements 9 Gestalt Closure 13
various populations of children. Number Recall 7 Triangles 11
Word Order 6 Matrix Analogies 6
Spatial Memory 7
7
Developing Hypotheses about Photo Series
Neuropsychological Functioning from Sequential Simultaneous

Score= 83 8 Score= 91 6
Combinations of Traditional Tests
Mental Processing Composite = 86 6
Several premises about neuropsychological or- Nonverbal Score = 86 6
ganization (e.g., lateralized abilities, a comparison
of developmental milestones and current perfor- Achievement Subtests ss
mance) can guide the clinician in developing hypoth-
eses relative to the nature, etiology, and chronicity of Faces & Places 96 8
observed neuropsychological deficits (e.g., Hartlage Arithmetic 79 8
& Telzrow, 1986). One example of the application of Riddles 89 9
Reading/Decoding 76 8
these guidelines is demonstrated by a neuro-
Reading/Understanding 77 8
psychological profile of specific dyslexia, charac-
terized by a significantly lower WISC-R Verbal than Soder Test of Reading-Spelling Patterns
Performance IQ; a Bannatyne factor pattern favoring Reading Quotient = 68
spatial skills; generally more efficient visuospatial Known Words = 40%
processing (e.g., on the Beery VMI) relative to lan- Unknown Words = 0%
guage ability (e.g., TOLD-I); and a dysphonetic
FIGURE 4. S.W.: Developmental dyslexia, auditory phonetic
reading-spelling pattern on the Boder Test (Telzrow
type. CA, 10-9.
et al., 1983). The test data shown for S. W. in Figure
4 illustrates such a profile.
Characteristic patterns of this sort have been
identified for various groups of children with neuro- possibly because of the influence of such moderating
psychological impairment, and as further study is variables as age, gender, and rehabilitation experi-
conducted on subtyping conditions such as learning ences. Individual differences are just that-indi-
disabilities (Rourke, 1985), head injuries (Rourke et vidual-and although it sometimes is possible to
al., 1983), and hyperlexia (McClure & Hynd, 1983), generalize across groups of children with known neu-
greater specificity of such profiles is anticipated. rological conditions, a more viable and useful ap-
However, sole reliance on known neuropsycholog- proach employs intraindividual profile analysis to
ical profiles is limiting, as such patterns have not identify neuropsychological strengths and weak-
been identified for all variations of impairment, and nesses (Reynolds, 1985).
those that have been described have been reported to When integrating data from traditional educa-
be unreliable when applied to groups of children, tional and psychological tests, the clinician utilizes
242 CHAPTER 13
identified intraindividual variability to provide a de- head injury in children: Intelligence and academic achieve-
scription of impaired neuropsychological functions ment. Paper presented at the International Neuropsycholog-
as well as residual assets. As noted early in this chap- ical Society, Houston.
ter, the flexible battery approach is less identified Boder, E., & Jarrico, S. (1982). The Boder Test of Reading-
with determining the presence and loci of brain im- Spelling Panerns, Manual. New York: Grone & Stratton.
Bracken, B. A. (1985). A critical review of the Kaufman Assess-
painnent as with a comprehensive behavioral de-
ment Battery for Children (K-ABC). School Psychology Re-
scription of how impaired abilities and residual view, 14, 21-36.
strengths affect routine functioning. For children, the Bracken, B. A., & Prasse, D.P. (1984). Peabody Picture Vocabu-
immediate outcomes of such a description should lary Test-Revised: An appraisal and review. School Psy-
include a prediction about the child's acquisition of chology Review, 13, 49-60.
new skills in specific areas (e.g., language, motor Bradley, L. (1983). The organization of visual, phonological, and
development), a discussion of implications for motor strategies and learning to read and to spell. In U. Kirk
school learning and activities of daily living (e.g., (Ed.), Neuropsychology of language, reading, and spelling
self-care skills, interpersonal behavior), and sug- (pp. 235-254). New York: Academic Press.
gestions about optimal intervention strategies Breen, M. J. (1985). The Woodcock-Johnson Tests of Cognitive
Ability: A comparison of two methods of cluster scale analy-
(Telzrow, 1985a). Such assessment data also can be sis for three learning disability subtypes. Journal of Psycho-
used to help adolescents select vocational options educational Assessment, 3, 167-174.
that are not contraindicated by their individual neu- Chadwick, 0., Rutter, M., Brown, E., Shaffer, D., & Traub, M.
ropsychological profiles (Hartlage & Telzrow, 1984, (1981 ). A prospective study of children with head injuries. II.
1986). Finally, because enjoyable leisure activities Cognitive sequelae. Psychological Medicine, 11, 49-61.
are critical for optimal personal adjustment, clini- Dean, R. S. (1986). Perspectives on the future of neuro-
cians may wish to counsel parents, children, and ado- psychological assessment. In B. S. Plake & J. C. Witt (Eds. ),
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garten Screening Battery. Odessa, FL: Psychological Assess- Hartlage & C. F. Telzrow (Eds.), Neuropsychological as-
ment Resources. pects of individual differences: A developmental perspective
Selz, M. (1981). Halstead-Reitan Neuropsychological Test Bat- (pp. 271-307). New York: Plenum Press.
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Neuropsychological assessment and the school-age child and interactive observation to differentiate pure hyperlexic
(pp. 195-235). New York: Grune & Stratton. syndromes from autism in preschool children. Paper present-
Selz, M., & Reitan, R. M. (1979). Rules for neuropsychological ed to the meeting of the National Academy of Neuro-
diagnosis: Classification of brain function in older children. psychologists, Philadelphia.
Journal of Consulting and Clinical Psychology; 47, 258- Telzrow, C. F., Century, E., Harris, B., & Redmond, C. (1985,
264. April). Relationship between neuropsychological processing
Shaffer, D., O'Connor, P. A., Shafer, S. Q., & Prupis, S. (1983). models and dyslexic subtypes. Paper presented to the meeting
Neurological "soft signs": Their origins and significance for of the National Association of School Psychologists, Las
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Shah, A., & Holmes, N. (1985). Brief report: The useoftbe Leiter Zimmerman, B. (1983). The Boder Test: Neuro-
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psychology(Vol. 2, pp. 109-137). New York: P1enumPress. scoring the fourth edition. Chicago: Riverside.
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14
Radiological Techniques in
Neuropsychological Assessment
ERIN D. BIGLER
Introduction techniques of that time (e.g., technetium brain scan,

pneumoencephalography, arteriography). Currently,
Since the introduction (in the early 1970s) of comput- in the post-CT scan era, where CT imaging is now
erized axial tomography (CT) scanning techniques commonplace, more precise lesion-localization rela-
(see review by Oldendorf, 1980), imaging of the tionships have been and are being established (Big-
brain has been revolutionized. Current CT imaging is ler, 1984; Kertesz, 1983). In fact, an era has now
capable of generating images that offer detailed de- been reached in which CT information, when avail-
pictions of the major anatomical structures of the able, should be routinely used in neuropsychologic
brain. Prior to the advent of the CT, only inferential diagnostics.
imaging methods were available. These procedures Historically, neuropsychologic diagnostic prac-
were not universally utilized because of their limited tice prided itself in its independence from other neu-
clinical efficacy (e.g., radioisotope scans could not rologic tests in the assessment of brain functioning
detect anything but the largest type of pathology such (see Lezak, 1983). In current practice, however, ig-
as a tumor) and morbidity risks with invasive pro- noring such CT information when available could
cedures (e.g., pneumoencephalography). Accord- greatly detract from the completeness of an evalua-
ingly, for a patient to undergo one of these pro- tion. This will become an even greater factor with
cedures, there had to be clear clinical justification, further improvements in neuroimaging. For exam-
and the neuroimages obtained were crude facsimiles ple, the new technique of magnetic resonance imag-
in comparison to today's standards. However, with ing (MRI) poses no radiation risks, provides an ex-
the current status of CT scanning the patient is at no ceptional image of anatomy (see Figure 1), and is
greater risk than for a routine X-ray procedure, the superior to CT images in depicting a number of un-
CT scan provides an excellent image of the brain, and derlying pathologic disorders. Thus, there will be a
as such has become a routine procedure performed on greater neuropsychology-brain imaging interface as
most patients, including infants and children, pre- brain-behavior relationships are pursued further.
senting with neurologic symptoms. With these factors in mind, this chapter has been
Clinical neuropsychology had its beginning in organized to present an overview of radiologic fea-
the pre-CT era. Prior to 1975, lesion-localization tures of CT and MRI across the major pathologic
studies were primarily based on neuropsychologic categories and the relationship of such findings with
inference, were dependent on findings from neu- neuropsychologic assessment. Normal brain anat-
rologic exam or direct inspection of the brain during omy will be presented first, followed by a review of
neurosurgery, or on the rather primitive imaging the major pathologic categories of childhood neu-
rologic disease and disorder. For further details con-
cerning the techniques behind CT and MRI, see
Buonanno (1984), Laffey, Mitchell, Teplick, and
ERIN D. BIGLER Department of Psychology, University Haskin (1976), Laffey, Oaks, Swami, Teplick, and
of Texas at Austin, Austin, Texas 78712; and Austin Neurological Haskin (1976), New and Scott (1975), and Oldendorf
Clinic, Austin, Texas 78705. (1980).
247
248 CHAPTER 14
FIGURE 1. (Left) MRI scan views in

the sagittal plane; (right) anatomic sec-
tions taken at a similar plane. Note the
clarity of the MRI sections and the pre-
cise anatomic detail that can be
achieved with this imaging technique.
RADIOLOGICAL TECHNIQUES IN NEUROPSYCHOLOGICAL ASSESSMENT 249
Normal Anatomy such as progressive leukodystrophy (see Figure 4)

and Huntington's chorea (see Figure 5), the degener-
Early in CT technology, out Of convention and ative pattern may appear initially to be focal.
standardization, increasing shades of white corre-
sponded with increased tissue density and increasing
shades of darkness corresponded with decreased
Neuropsychologic Findings
tissue density. According! y, as can be seen in the CT Although the correspondence between cortical
scans in Figure 2, the bone is white and the ven- degeneration seen on the CT and neuropsychologic
tricular system is dark, representing the range of den- outcome is not a one-to-one relationship (see Bigler,
sity seen in the cerebrum/cranial vault. Outside of the Hubler, Cullum, & Turkheimer, 1985), there may
brain and embedded in sinus cavities of the skull are be some relationship between areas of more focal
air pockets and these show an even Jesser degree of cerebral atrophy and corresponding neuropsycho-
density (i.e., the darkest area seen represents the den- logic deficits (e.g., left perisylvian atrophy may be
sity of air on an image; see Figure 2). As gray matter associated with a greater number of language symp-
is comprised of densely compacted cell bodies, the toms). However, with degenerative diseases, there
outer rim or mantle of the brain and internal nuclei will typically be nonspecific findings of neuro-
have a lighter appearance (see Figure 2). In contrast, psychologic impairment including decreasing intel-
white matter structures, which are less dense and lectual ability, diminishing motor function and ca-
typically represent white matter myelinated path- pacity, and a variety of problems in higher-order
ways, have a darker appearance (see Figure 2). A key language and integrative sensory-percept ual-motor
to interpretation of cr images is to examine for the functioning. It should also be noted that neuropsy-
normal distribution of white versus gray matter and chologic findings appear to be more sensitive to the
the general symmetry of the brain as depicted in Fig- progression ofdegenerative diseases than are many
ure 2. Sites of abnormal densities (whether hypo- or CT or MRI techniques (Bigler, 1988). Typically,
hyperdense) as well as marked asymmetries of brain detectable changes in progressive atrophy in degen-
development, typically signify underlying pathol-
ogy. The nature and type of cerebral pathology seen
erative disorders as seen by cr scan are met with
marked changes in neuropsychologic functioning.
with the major neurologic disorders of childhood will
be presented in the following sections.
Neoplasms
Degenerative Syndromes Neuroimaging Findings
Neuroimaging Findings Most tumors of the central nervous system can

be readily detected by a variety of neuroimaging
CT imaging of the brain in the normal indi- techniques. With CT scanning there is typically a
vidual, and particularly in children, shows either no noticeable density difference in and around the tu-
sulcal cleft or only a slight indentation (see Figure 2). mor site as well as some displacement of surround-
This is due to the closeness of the gyri in the normal ing structures (see Figures 6-10). Tumors can be
state, and in the absence of any significant sulcal characterized as intrinsic (deriving from brain cells,
distance a density change cannot be detected, and typically glial in nature) or extrinsic (originating in
thus the image shows no density difference across the bone or meninges). Typically, intrinsic tumors have
surface of the brain. However, in degenerative dis- a more destructive effect. Some tumors such as met-
eases affecting cortical neurons; there is a loss of astasizing neoplasms may have multiple sites.
neuronal density resulting in gyrai shrinking and sul-
cal cleft widening, which can be readily visualized in Neuropsychologic Findings
the CT image (see Figure 3). With cortical degenera-
tion, there is an actual volume loss in the amount of The nature and type of neuropsychologic deficit
neural tissue and a frequent secondary effect of this is associated with brain tumor depend on the location,
an enlargement of the ventricular system (hydro- size, and type of tumor. As depicted in Figure 6, the
cephalus ex vacuo). With progressive degenerative glioblastoma multiforme (grade IV astrocytoma)
diseases, the cortical atrophy pattern is typically dif- may develop into a very large tumor that will produce
fuse and generalized. However, in some disorders, widespread deficits and frequently hemisyndromes.
250 CHAPTER 14
S#l(~IUM 0' CQIIIII'V$

CALLOSUM
fiGURE 2. Cf scan views in the horizontal plane with corresponding diagrammatic representation of major anatomic structures. Note
the symmetry present throughout the major cerebral strucrures.
l"tTE,.HE-..[$#HfRIC
.-t----- !....:1..-'lt----- - - FISSUAE
'OSTt:RIOA FRO"tfA4.
~--~--T------- COAn
FIGURE 2. (Continued)
252 CHAPTER 14
FIGURE 3. Cortical atrophy in a case of progressive degenera-

tion. Note the excessive prominence of the sulci, which is a sign of
gyral shrinkage.
FIGURE 4. cr scan of focal white matter degeneration (leuko-

In addition to the direct effects of the tumor on brain dystrophy) in a 9-year-old male child. The patient presented ini-
tissue, secondary effects due to cerebral edema and tially with "learning problems," but rapid progression ensued. At
vascular compression as well as radiation and sur- the time of the Cf scan, pronounced deficits in all areas of higher
gical effects may produce widespread damage (see cortical functioning were present.
Figure 7).
uncommon sequela in (closed head injury) CHI and

Vascular Disorders will be discussed elsewhere. Infectious disease may
also produce occlusion due to the space-occupying
Neuroimaging Findings effects of the infection and/ or compression second-
ary to edema .. There is an increased risk of cerebral
The majority of childhood vascular disorders hemorrhage with premature delivery and this may
are associated with congenital anomalies or second-
ary to some disease or traumatic process. The com-
mon vascular disorders of adulthood (e.g., cerebral
arteriosclerosis, multi-infarct dementia) are only
rarely seen in childhood. The most common anoma-
lies are in the form of aneurysms and arteriovenous
malformations (AVMs). Aneurysms and A VMs
have a characteristic pattern on cr, particularly fol-
lowing the injection of contrast medium (a dye that
assists in visualizing the vascular components of the
brain; see Figure 11). A cerebrovascular accident
may take the form of hemorrhage or occlusion. The
pathology that may result from this is an area of focal
tissue loss associated with areas subserved by the FIGURE 5. cr scan in a patient with Huntington's chorea. Note
affected vascular system and frequently secondary the ventricular dilation of the anterior horns, which represents
effects due to the edema produced by the hemorrhage degeneration of the basal ganglia, and the presence of scattered
or infarction (see Figure 12). Hemorrhage is not an sulcal enlargement indicative of cortical atrophy.
b
.
......

I '
..
FIGURE 6. (a) cr scan of a glioblastoma multiforme (grade IV astrocytoma) of the right hemisphere. Note the extent of the tumor and
its spread into the left hemisphere. (b) This patient had classic features of a right hemisphere syndrome with left side neglect as depicted by
her copying (and absence of the left aspect) and positional placement of the Bender Visual Motor Gestalt figures.
FIGURE 7. cr scan of a 9-year-old female who had an astro- FIGURE 8. MRI scan in the coronal position depicting the pres-
cytoma removed from the mid-right temporal lobe. However, she ence of cerebellopontine angle tumor (dark, high-density mass
has had to undergo extensive chemotherapy and radiation therapy. about the size of a golf ball located in the cerebellum compressing
The cr shows generalized cortical atrophy and density loss in the brain stem). Note the anatomic detail that can be visualized
white matter regions. Such effects represent the secondary with MRI. Note also the distortion present in surrounding brain
iatrogenic effects of the cancer treatment. structures as a result of the expanding tumor.
254 CHAPTER 14
FIGURE 9. CT reveals an area of increased density in the posteri-

or left hemisphere, which turned out to be an ependymoma. This is FIGURE 10. MRI scan showing the location of a cerebral neo-
a tumor that develops from the lining of the ventricle (ependyma) plasm (oligodendroglioma) in the left temporal lobe in a 7-year-old
and occurs more frequently in children and adolescents than child. A partial left temporal lobectomy was undertaken to excise
adults. This child was thought to have developmental dyslexia, but the tumor. Presurgery, the child's WISC-R scores in intellectual
began having seizures, which prompted CT evaluation and the functioning were: VIQ = 87, PIQ = 93, FSIQ = 89. One year
discovery of the tumor. postsurgery, they were: VIQ =54, PIQ = 73, FSIQ = 61. Addi-
tionally, a marked receptive aphasia, ADD, and hyperactivity re-
sulted from the left temporal lobe damage.
take the form of an intraventricular bleed, which may

produce widespread damage.
With childhood cerebrovascular diseases in
which some anomaly is present coincidental with
brain development, the tissue around such an AVM
or aneurysm may be damaged in development, ancf
there may be a functional realignment or reorganiza-
tion (see Bigler & Naugle, 1984) by intact surround-
ing or homologous areas of the brain (see Figure
11). Thus, although focal damage may be seen on
the cr' if this damage was due to congenital vas-
cular anomaly or accident, damage in this area may
not fully correspond with what would be expected.
Thus, from the neuropsychologic perspective, one FIGURE 11. CT scan of a congenital AVM in the posterior left
has to be careful in such cases because of a tendency hemisphere. The AVM has been "enhanced" using a dye pro-
to overestimate the damaging effects of such an ear- cedure. Note the surrounding tissue loss seen as a decreased (i.e.,
dark) density. There is a bone defect present that represents an old
ly lesion by the degree of damage seen on the CT
surgical incision following a spontaneous rupture and subsequent
scan. In cases of vascular damage where a preexist-
surgical repair. This case also demonstrates the cerebral plasticity
ing anomaly was not present, the correspondence that may occur from congenital vascular disorders in that even
between areas of damage and neuropsychologic out- though the entire posterior left hemisphere has been affected, the
com~ is more clear (see Figure 12). The areas of patient displayed only minimal language impairment and that
damage and their corresponding neuropsychologic mainly in the area of reading. Otherwise, the patient had normal
features are presented in Figure 13. verbal intelligence (VIQ = 103) and language functioning.
FIGURE 12. The cr on the left depicts the acute effects of an intracerebral hemorrhage in the right frontal-temporal region secondary to
the rupture of a congenital aneurysm. The high-density (white) mass represents coagulated blood surrounded by edema (dark area). Also
note the compression of the ventricular system in the right hemisphere and the distortion across mid-line. The cr on the right shows the
chronic effects of such a hemorrhage. Note a large area of infarction (dark area) in the anterior temporal-posterior frontal region. Also
note the increased size of the right anterior hom of the lateral ventricular system. This is a sign of tissue loss in the adjacent frontal region.
Cranial Cerebral Trauma widespread tissue loss through compression and gen-
eralized infarction effects (see Figure 15). Also in
Neuroimaging Findings cases of severe CHI, even without significant hemor-
rhage, a diffuse atrophy may occur as a result of
Cranial cerebral trauma results in numerous cortical contusion effects, white matter shearing, and
damaging effects to the brain including contusions, subsequent neuronal loss (see Figure 17).
white matter shearing, traumatic infarction, edema,
hematoma, and subsequent compression effects, as Neuropsychologic Findings
well as a variety of biochemical derangements (King-
ston, 1985). CT scanning quite accurately depicts the Neuropsychologic sequelae associated with ce-
presence of most of these effects (see Figures 14- rebral trauma are related to both the focal as well as
18). However, the relationship between initial CT diffuse findings on CT. It should be kept in mind that
findings and outcome is quite specious and non- the postmortem studies have demonstrated that even
predictive. Thus, for determining the stable effects of in mild-moderate CHI cases, some degree of neu-
CHI on cognitive functioning, the CT or MRI scan ronal derangement may occur at the microscopic
that is done some 3 or more months following brain level that may not be detected by CT (Kingston,
injury will correspond best with the static, stable re- 1985). Thus, the correspondence between CT find-
sidual lesions seen with cerebral traumas. Impact ings and neuropsychologic outcome is not a one-to-
contusions, the area of previous hemorrhage, or lo- one relationship, yet the findings offocal atrophy or
calized edema may produce focal damaging effects encephalomalacia do tend to correspond more specif-
(see Figure 18). Severe edema may also produce ically with neuropsychologic outcome.
256 CHAPTER 14
FunctiOn Antenor Cerebral M1ddle Cerebral Pos.tenor Cerebral
IIIIotor Contralateral weakness or pa- Contralateral paralysis w1th Typically motor involvement
ralySIS. typically most affecting face and upper extrem1ty more not present except when proxi-
the distal lower extremity. affected than lower. mal artenes are affected; then
Rapid ahernating movements hemiba.llismus may result be
may be impaired or an inability cause of subthalamic nucleus
to maintain them. lesion. cranial nerve palsy. or
hemiparesis owing to involve-
ment of the corticospinal tract
as it passes down the brain
stem.
Sensory Absent or mild contralateral Depending on extent of in- If unilateral, then contralateral
tactile loss. volvement. there may be con- hemianopsia typically devel-
tralateral auditory, visual. and ops. Cortical blindness occurs
tactile sensory disturbance. if bilateral. Proximal occlusion
may affect the thalamus. pro-
ducing sensory disturbance.
pain, or both.
Language Impaired articulation or distur- With left hemisphere involve- If involves the left hemisphere.
bance in motor inertia may be ment may develop a Broca's, alexia without agraphia or
present. Wernicke's, global, or conduc- other aphasic symptoms may
tion aphasia depending on site occur.
and extent of involvement.
Praxis If anterior corpus callosum is Apraxia may occur with lesions Constructional apraxia with
affected, there may be left arm in either hemisphere. Con- right hemisphere involvement
apraxis. structional apraxia (in the may occur.
absence of aphasia) and
dressing apraxia are common
with right hemisphere
involvement.
Spatial-Perceptual Typically not affected. If right hemisphere is affected. If right hemisphere is affected.
varying degrees of impairment primarily visuospatial functions
may be present. will be impaired.
Memory Some disturbance in new With left hemisphere involve- Global amnesia may occur
memory may be present. ment greater tendency for dis that is either transient or per-
turbance in verbal memory: manent. Permanent short-term
with right hemisphere greater memory deficits may also
tendency for v1sual memory occur.
disturbance.
Gnosis Infrequently may display fea- With right hemisphere involve- Typically not affected.
tures of anosognosia (failure to ment. may have greater
appreciate loss of function). tendency to develop
topographagnosia (loss of
direction) as well as
anosognosia.
Behavior Frontal lobe syndrome may Impaired prosody if right hemi No particular behavioral syn-
develop with right hemisphere. sphere involved. drome is characteristic.
prosody may be affected.
FIGURE 13. cr depiction of functional deficit associated with locus of cerebral infarction.
FIGURE IS. Pronounced ventricular dilation (ventriculomegaly)
secondary to diffuse cerebral edema produced by cerebral trauma.
The top two scans depict diffuse edema as demonstrated by re-
duced ventricular size (Cf taken 2 days posttrauma). The bottom
FIGURE 14. Posttraumatic effects secondary to gunshot wound two scans were taken 2 months posttrauma and show severe dila-
to the posterior left cerebral hemisphere. Generalized encepha- tion of the entire ventricular system as well as infarction in the left
lomalacia and infarction are present in the entire posterior pole of frontal region.
the left cerebral hemisphere including the entire left occipital lobe
and posterior aspects of both the temporal and parietal lobes. Neu-
ropsychologically, the patient had the expected features of a right
visual field defect, dyslexia, and deficits in verbal comprehension.
FIGURE 16. Self-inflicted gunshot wound to the frontal region. Note the point of entry in the right frontal area with the bullet trajectory
passing obliquely from right to left. In this patient, a classic frontal lobe syndrome evolved with features of marked impulsivity, emotional
lability, and traumatic dementia (WISC-R results: VIQ = 73, PIQ =57, FSIQ = 63).
258 CHAPTER 14
Infectious Disorders
Neuroimaging Findings
The major problem with infection appears to
center on whether the damaging effects are focal ver-
sus generalized. Certain types of infectious processes
(i.e., abscesses) may produce focal cerebral effects
due to the direct invasion of the abscess and focal
effects of edema. This typically is well visualized on
CT as an increase in density associated with a mass
effect during the purulent stage and focal, necrotic
effects seen in the chronic. With meningitis and en-
cephalitis, the damaging effects tend to be dependent
upon how advanced the infection develops and
whether it is localized or generalized. The most
damaging effects, whether it be in meningitis or en-
cephalitis, occur with excessive cerebral swelling,
which may result in vascular occlusion and par-
FIGURE 17. Cortical atrophy as a result of severe closed head enchymal compression (see Figure 19).
injury. Note the prominence of cortical sulci. Such findings are
typically associated with some degree of nonspecific cognitive
dysfunction. This patient was an 18-year-old college freshman at Neuropsychologic Findings
the time of the injury. The Cf was taken 2 years postinjury and
neuropsychological studies indicated the expected nonspecific Neuropsychologic sequelae associated with ce-
dysfunction. Intellectual scores on the WAIS-R were: VIQ = 86, rebral infection depend upon whether the effects are
PIQ = 81, FSIQ = 82. Based on premorbidestimates these results focal or generalized and the effects of cerebral swell-
support a reduction of 15-20 points. ing. The outline presented under Vascular Disorders
FIGURE Ill. Local frontal pole atrophy in a case of traumatic encephalopathy secondary to closed head injury. The dark area that is
present across the bifrontal region represents cortical atrophy. Note also the greater prominence of the sylvian fissure bilaterally. This
patient was a 16-year-old honor student at the time of the accident. After the head injury, a traumatic change in personality and intellect
evolved (WISC-R results 9 months postinjury: VIQ = 87, PIQ = 78, FSIQ = 81).
holds true with infectious disorders in terms of focal correspond with what would be expected given the
effects. When the infectious process has been gener- physical examination findings (see Figure 21). In
alized and diffuse, then the neuropsychologic impair- mariy cases of congenital hemiplegia, the loss of neu-
ment is correspondingly nonspecific. ronal tissue corresponding with the contralateral
motor area is evident, but frequently, there is good
compensatory recovery of function by the intact
Anoxia hemisphere. Thus, one may overpredict the sequelae
given the size and extent of a lesion seen on CT
examination in the patient with congenital hemi-
Neuroimaging Findings plegia syndrome. This underscores the importance of
In terms of neuropsychologic assessment, CT neuropsychologic testing in establishing the level of
findings obtained approximately 3 or more months functioning.
following the acute anoxic injury are necessary to
establish the relationship between chronic structural Hydrocephalus
effects of this type of brain injury and cognitive im-
pairment. Typically, anoxic injury results in gener- On CT scanning the common feature of hydro-
alized, nonspecific damage that is typically depicted cephalus is the enlargement of the ventricular system
on the CT image in the form of generalized cortical (see Figure 22). The key in interpreting the neuropsy-
atrophy and secondary ventricular dilation (see Fig- chologic effects of hydrocephalus tends to be associ-
ure 20). ated with the degree of intactness of cortical tissue.
However, there are now several cases in the literature
of individuals with relatively normal intelligence de-
spite having severe hydrocephalus. Therefore, clini-
The typical neuropsychologic findings in chil- cal interpretation based only on CT findings needs to
dren with anoxic brain damage usually reflect some be done with caution.
degree of generalized impairment. Accordingly, in-
tellect and cognitive abilities are usually diminished Cortical Dysplasias
and may actually reflect marked declines in function-
ing. Language, motor, and sensory deficits may also In cortical dysplasia, there is a failure of neu-
be marked. Although CT scan abnormalities usually ronal growth or aberrant development. A host of ab-
stabilize by approximately 3-6 months after the normalities can be visualized on the CT, but the most
anoxic insult, cognitive improvement, particularly in common tends to be some type of asymmetry in cor-
children, may continue for up to 2 or more years after tical development or a significant density difference
the injury. or a gyral pattern irregularity (see Figure 23).
Mental Retardation
Congenital Anomalies/
Developmental Disorders In Down's syndrome, CT scan analysis typ-
ically demonstrates frontal and temporal lobe regions
Because of the complexity of the nervous sys- that are evidently small (see Figure 24). The re-
tem and its vulnerability during embryogenesis, nu- mainder of the gross anatomy is typically normal in
merous congenital malformations exist (Behan & appearance. In cases of idiopathic mental retarda-
Geschwind, 1985). The voluminous number of con- tion, frequently no specific abnormality may be evi-
genital anomalies far exceed the scope of this chap- dent (see Figure 25).
ter, but the more common cerebral abnormalities of
development are those seen in infantile hemiplegia,
Autism/Schizophrenia
hydrocephalus, and dysplasic cortical development.
Idiopathic mental retardation syndromes may also be Some children with autism or schizophrenia
included in this category. may display CT scan abnormalities, typically in the
form of ventricular dilation and/or presence of cor-
Infantile Hemiplegia tical atrophy (see Figure 26). These anatomic irreg-
ularities do not appear to represent any specific diag-
Frequently with infantile hemiplegia, there is an nostic category for these disorders, but it does appear
area of focal damage seen on the CT scan that does that the greater the degree of structural abnormality
260 CHAPTER 14
FIGURE 19. Acute-stage encepha-

litis is depicted in the cr films on the
left. Note the lack of definition in the
ventricular system, which is due to
massive cerebral edema. Chronic
postencephalitis effects are shown in
the cr films on the right with evi-
dence of generalized atrophy and ven-
tricular enlargement. Prior to the
brain infection, this 13-year-old male
was in a regular classroom setting
maintaining an average to above-
average GPA and had no history of
behavior disorder. However. follow-
ing this brain infection, the patient de-
veloped pronounced learning and be-
havior deficits. Intellectual studies
indicated the following WISC-R re-
sults: VIQ = 62, PIQ = 71, FSIQ =
64. Behaviorally, the child had prom-
inent attentional deficits associated
with poor impulse control.
RADIOLOGICAL TECHNIQUES IN NEUROPSYCHOL OGICAL ASSESSMENT 261
FIGURE 22. Severe hydrocephalus in a 6-year-old child with

FIGURE 20. Generalized cortical atrophy and ventricular dila- spina bifida. Note the marked destruction of the cortical mantle,
tion secondary to anoxic brain injury. particularly in posterior regions. Although mental retardation typ-
ically accompanies such cases of hydrocephalus, in some children
the mental retardation is not in proportion with what would be
expected given the degree of hydrocephalus (see Bigler & Naugle,
1984). In this case, the child's Weschler Preschool and Primary
Scales of Intelligence scores were as follows: VIQ = 75, PIQ =
66, FSIQ = 68. Also, despite essentially no remaining vital tissue
in the occipital region, the child could still visually process infor-
mation. This demonstrates the marked degree of cerebral plasticity
that may accompany some early brain insults.
present, the greater the degree of cognitive impair-

ment and the more resistant are the symptoms to any
treatment regimen (see Bigler, 1984).
Childhood Epilepsy
In some cases of epilepsy, the structural basis

may be visualized by CT scanning (see figure 27).
These are typically areas of focal abnormality and
likewise may correspond to focal neuropsychologic
findings.
Learning Disability
Although cr irregularities are not universally
FIGURE 21. cr scan of a patient with idiopathic congenital seen in learning-disabled children (see Denckla,
hemiplegic syndrome. As is readily seen, a large cystic area is LeMay, & Chapman, 1985), nor are there any CT
present adjacent to and communicating with the left lateral ven- abnormalities that are diagnostic of learning dis-
tricular system. This represents focal damage in the mid-frontal ability, there are cases in which a structural basis
region, consistent with contralateral paralysis. appears to be present. These typically take the fonn
262 CHAPTER 14
FIGURE 25. CT scan in a patient with idiopathic mental retarda-

tion. The scan is generally within normal limits, although the
ventricular system may be considered somewhat generous for a 17-
year-old. Despite the profound level of retardation, no gross ab-
normality is noted in general brain morphology.
FIGURE 23. Numerous congenital anomalies are present in this
cr scan of a 10-year-old female who presented with a history of
idiopathic mental retardation (WISC-R: VIQ = 59, PIQ = 55,
FSIQ = 53). No physical stigmata were present. cr demonstrates of cerebral asymmetries (see Figure 28) or more spe-
an agenesis of the corpus callosum, hemispheric asymmetry, and cific pathology in the posterior association cortical
dilated posterior horns of the lateral ventricles, particularly on the areas (see Figure 29).
left. Behaviorally, the child was hyperactive, impulsive, and with
shortened attention span in addition to the mild level of mental
retardation present. Birth Injury
A variety of cerebral damaging events may ac-
company a traumatic or problematic birth. These def-
icits may vary from focal to generalized effects (see
Figure 30).
FIGURE 24. cr scan of an adult (24-year-old) with Down's syn-

drome. The irregularity noted on cr scanning in the Down's syn-
drome patient is the diminished size of the frontal and temporal FIGURE 26. cr scan of an 11 -year-old autistic child. Note the
lobes. (Note the short distance from the rostral aspect of the ante- general enlargement of the ventricular system with particular en-
rior horns to the tip of the frontal poles, in comparison to the largement on the left. Such findings suggest that significant struc-
normal configuration shown in Figure 2.) tural abnormalities occur in some children with autism.
FIGURE 27. cr scan in a 14-year-old female with temporal lobe

epilepsy. Note the area of focal tissue loss in the right anterior
temporal region. This child had a history of significant learning
disability. FIGURE 29. Posterior hom dilation in a young adult patient with
a history of pronounced dyslexia. Such findings implicate proba-
ble dysplastic development in parietal and occipital areas typically
considered crucial for aspects of visual-verbal processing.
FIGURE 30. cr scan in a child who

had undergone a difficult labor and
who suffered respiratory and cardiac
failure. Thecr shows multiple areas
of infarction, namely in the occipital
region, bilaterally, agd in the left
frontal region. The child presented
FIGURE 28. Cerebral asymmetry that is sometimes observed in certain developmental and with hyperactivity, poor attention,
learning disorders. Note that the left cerebral hemisphere is distinctly smaller than the right. mild mental retardation, and cortical
Also note the ventricular asymmetry. blindness.
264 CHAPTER 14
References Denckla, M. B., LeMay, M., &Chapman, C. A. (1985). Few CT

scan abnormalities found even in neurologically impaired
learning disabled children. Journal of Learning Disabilities,
Behan, P., & Geschwind, N. ( 1985). Dyslexia, congenital anoma-
/8, 132-135.
lies and immune disorders: The role of the fetal environment. Kertesz, A. (1983). Localization in neuropsychology. New York:
Annals of the New York Academy of Sciences, 457, 13-18. Oxford University Press.
Bigler, E. D. (1984). Diagnostic clinical neuropsychology. Aus-
Kingston, W. J. (1985). Head injury. Seminars in Neurology. 5,
tin: University of Texas Press. 197-270.
Bigler, E. D. (1988). Neuropsychological and cr identification in Laffey, P. D., Mitchell, M. H., Teplick, J. G., & Haskin, M. E.
dementia. In H. A. Whitaker (Ed.), Neuropsychological (1976). Computerized tomography in clinical pediatrics.
Studies of Nonjocal Brain Injury. New York: Springer- Philadelphia: Medical Directions.
Verlag. Laffey, P. D., Oaks, W. W., Swami, R. K., Teplick, J. G., &
Bigler, E. D., Hubler, D. W., Cullum, C. M., & Turkheimer, E. Haskin, M. E. (1976). Computerized tomography in clinical
( 1985). Intellectual and memory impairment in dementia: Cf medicine. Philadelphia: Medical Directions.
volume correlations. Journal of Nervous and Mental Dis- Lezak, M. (1983). Neuropsychological assessment. New York:
ease, 173, 347-352. Oxford University Press.
Bigler, E. D., & Naugle, R. I. (1984). Case studies in cerebral New, P. F. J., & Scott, W. R. (1975). Computed tomography of
plasticity. International Journal of Clinical Neuropsychol- the brain and orbit. Baltimore: Williams & Wilkins.
ogy, 7, 12-23. Oldendorf, W. H. (1980). TheQuestforanlmageofBrain. New
Buonanno, F. S. (1984). Neurologic clinics (Vol. 2). Phila- York: Raven Press.
delphia: Saunders.
15
Psychophysiological Evaluation of
Children's Neuropsychological
Disorders
THALIA HARMONY
The objective of this chapter is to discuss those pro- clinical diagnostic procedure is not accurate in many
cedures that explore psychological processes by cases. Those investigators attempting to develop new
measuring different physiological variates. Study of procedures of evaluation with regard to patients with
brain electrical activity in humans allows the explora- well-defined neurological lesions have a fundamen-
tion of two fundamental levels of function, a very tal reference based in anatomopathological diagnosis
basic one, which gives information about the func- and surgical observation. However, in trying to de-
tional and anatomical integrity of the nervous sys- velop procedures for the study of the neuropsycho-
tem, and a second one, which explores higher cog- logical disorders of the children, clinical diagnosis
nitive activity. At the first level, it is possible to (which we know is not accurate in many cases) is
detect such localized lesions as an epileptogenic typically a very general symptomatic diagnosis.
focus or functional alterations of the sensory path- Many times we have no globally accepted reference
ways. Here, accumulated knowledge of brain elec- at all and thus do not know if the new procedure is any
trical activity is strong enough to have practical better than the usual diagnostic method.
clinical applications leading to differential diagnosis When developing new diagnostic procedures, a
and differential treatment. specific series of steps must be followed (Harmony,
In this chapter, studies of spontaneous EEG ac- 1984a). If it is an electrophysiological procedure, we
tivity and of evoked sensory potentials are reviewed. first identify and extract those electrophysiological
With regard to spontaneous EEG activity, two main features that are most directly related to the phe-
procedures will be analyzed: routine EEG visual in- nomenon we want to evaluate. This may be obtained
terpretation and frequency analysis of the EEG. Rou- by usual statistical procedures. However, diagnostic
tine EEG visual interpretation is a powerful tool for classification requires more than differentiating at a
the detection of paroxysmal activity and of special statistically significant level. The second step is the
types of patterns described in children. Frequency establishment of a decision rule for assigning a given
analysis of the EEG has been shown to be a precise subject to a diagnostic set. These sets may be known
method for evaluation of EEG maturation and EEG a priori or as a result of data analysis. A significant
background activity. problem in this process is that although we are look-
In neuropsychological disorders it is very im- ing for procedures to provide more objective and
portant to emphasize the following paradox: these more accurate diagnoses, the only means we have to
disorders are studied using new procedures the inten- define the groups among whom we look for elec-
tion of which is to obtain better methods for the diag- trophysiological differences are traditional pro-
nosis of such disorders, owing to the fact that the cedures known to be inadequate. Our answer to this
problem has been to examine the structure of the data
derived from our diagnostic procedures to see if there
THALIA HARMONY Neurosciences Research Program, are any statistically homogeneous groups and to de-
Iztacala School, National Autonomous University of Mexico, tect deviant values or outliers. If it is possible to relate
54030 Tlalnepantla, Mexico City, Mexico. new groups to some clinical characteristic, the prob-
265
266 CHAPTER 15
lem may be solved. In grouping analyses, many vari- visual inspection in the awake adult is abnormal.
ables must be considered. In the case of children, age Theta rhythm is the most frequent activity during
is the most important independent variable, and age- childhood. In children from 1 to 5 years old, theta
matched groups do not solve the problem. Satterfield rhythm of high amplitude is observed in posterior
and Braley (1977) were able to show that some mea- regions and is the dominant activity from age 4 to 6
sures of auditory evoked responses have a trend of years in central, temporal, and parieto-occipital re-
development in normal children that is different (op- gions. Alpha rhythm is most prominent in posterior
posite) from that in hyperkinetic children, and when regions under conditions of relaxation, with eyes
the total samples matched by age were compared no closed in awake adults. Infants between I and 2 years
significant differences were found. Age effect may old show brief periods of activity within the alpha
be removed by regression procedures as shown later. band. By age 5 years, a child's alpha rhythm be-
Sex is also an important variable. comes clearly discernible. From age 6 to 9, the EEG
Once the homogeneous groups have been deter- shows a mixture of frequencies within the alpha
mined, it is possible to proceed to the establishment range and lower. From age 10 to 13, the alpha rhythm
of a decision rule. If homogeneity is observed only is almost stabilized, with characteristics similar to
for normal children, then what proceeds is the cre- those observed in the adult. Beta activity is observed
ation of norms. Cross-validation of norms with new in 25% of awake children.
subjects will define the nature of the procedure. If Some special rhythms appear in normal chil-
many groups appear and they correspond to the origi- dren, although they are more frequently seen in chil-
nal groups, then a priori criteria and the new pro- dren with behavioral or cognitive alterations (Pe-
cedure are equivalent. If many groups appear and tersen, Sellden, & Eeg-Oiofsson, 1975). Among the
have no relation to the original groups, then it is rhythms that have these characteristics are the
necessary to analyze other converging variables such following:
as neuropsychological tests, pharmacological manip-
1. Slow posterior waves (Aird & Gastaut,
ulations, and the like.
1959), slow fused transients, or polyphasic
The state of the art in psychophysiological diag-
potentials (Petersen & Eeg-01ofsson, 1971)
nosis varies greatly depending on the procedure. For
are considered normal by several authors,
variates derived from frequency analysis of the EEG
although Cohn and Nardini ( 1958) reported
and for sensory evoked responses, norms exist and
this pattern to be related to personality disor-
deviant values can be identified. In relation to ERPs,
ders or aggressive social behavior, and to
only statistically significant differences between
disturbances in reading, writing, and adap-
healthy children and children with different types of
tive behavior (Cohn, 1958, 1961).
neuropsychological disorders are available. In this
chapter, consistent results obtained in homogeneous 2. Diffuse theta activity in drowsiness (hyp-
nagogic hypersynchrony or drowsy waves;
samples of children will be presented. Reviews of the
Kellaway & Fox, 1952) declines rapidly
field frequently mix papers on different topics under
from a maximal value at age 1 year to age 8-
one clinical item and therefore many contradictory
9 years, at which it appears only rarely.
results emerge. We discuss herein only those papers
3. Diffuse rhythmic 4- to 5-Hz activity with
in which selection of the sample was well explained
parieto-occipital maximum, is considered
and it was possible to find homogeneity in relation to
normal in young children, although it has
a sign or a deficit.
been associated with febrile convulsions and
may be considered a sign of predisposition to
convulsions (Doose, Gerken, & Volzke,
EEG Maturation and Abnormal EEG 1968).
Activity 4. 2.5- to 4.5-Hz slow posterior parieto-tem-
poral-occipital rhythm is typical of child-
hood, but after age 4 is rare. At high ampli-
Visual Interpretation tude, this type of slow posterior rhythm has
been correlated to paroxysmal activity at rest
EEG background activity is classified in four (Eeg-Oiofsson, Petersen, & Sellden, 1971).
frequency bands: delta(< 3.5 Hz), theta (4-7Hz),
alpha (8-13Hz), and beta(> 14Hz). Delta rhythm is Paroxysmal activity is defined as a group of
the dominant activity during the first 2 years of life waves that appear and disappear abruptly and is
but then tends to disappear. Delta activity detected by clearly distinguished from background activity by
PSYCHOPHYSIOLOGICAL EVALUATION 267
different frequency, morphology, and amplitude. fogS

Spikes, multispike complexes, sharp waves, spike
.: . ~
and slow wave complexes, and paroxysmal slow ... - --.
waves are recognized as the fundamental paroxysmal .
-~r.-
:: . :
patterns. In normal children, such activity is rarely I
observed (1.5-6%; Petersen et al., 1975). The in-

terpretation of Rolandic spikes has been controver- .----- -,
sial, for it has been observed that subjects with this ~ :e a. :~ . . .;
type of focus have a higher incidence of seizures and L-~~::---:;,!;:-;=----'
3.5 7.5 12.5 19
cerebral lesions. Hz
Other important and controversial aspects of FIGURE 1. Broadband analysis. Points represent the logarithm
EEG interpretation in children are the effects of hy- of the power spectrum for different frequencies. Bands delta,
perventilation. In normal children, spike and sharp theta, alpha, and beta are shown. It is possible to observe that the
wave paroxysmal activity has been reported in 0.3% approximation in some bands is not adequate.
of cases by Petersen and Eeg-Olofsson (1971), 2.3%
by Doose et al. (1968), and 0.5% by Gibbs, Gibbs,
and Lennox (1943). These are very low rates, but (1985) developed an EEG model derived from fre-
many electroencephalographists consider the obser- quency analysis. In this model two basic processes
vation of paroxysmal activity only during hyperven- are identified: the xi process characterized by a spec-
tilation to be normal. tral peak with its maximum located at zero frequency
Results for mental retardation, minimal brain and with a slow decrease in power at increasing fre-
dysfunction, and specific learning disabilities showed quencies, and the alpha process characterized by a
a significantly higher proportion of abnormal EEGs superimposed spectral peak on the xi process, which
than for normal children (Netchine & Lairy, 1975). is usually centered in the classical frequency range
The most frequent abnormalities are: high amount of circa 6-13 Hz; it may be absent, especially at lower
slow EEG activity, positive spikes, and paroxysmal ages and in frontal derivations. According to Pascual
spike and wave activities (Hughes, 1971; Lezny, et al. (1985), the appearance of the alpha process, its
Provasnik, Jirasek, & Komarek, 1977; Murdoch, growth in height and in peak frequency are charac-
1974; Becker, Velasco, Harmony, Marosi, & Land- teristic of EEG maturation. Figure 2 presents the dif-
azuri (1987). ferent measures derived from this model. Other mod-
els have been reviewed by Harmony (1984a).
Frequency Analysis
Maturation
If the EEG is considered as a mathematical func-
tion, it is possible to express its decomposition in a Matousek and Petersen ( 1973) performed a fre-
series of sine and cosine waves by Fourier analysis. quency analysis of a large sample of people from 1 to
These sine and cosine waves are harmonically relat-
ed, beginning with the fundamental frequency that
has a period equal to the sample length (if EEG ep- fogS
ochs of 2 sec are analyzed, the fundamental frequen-
cy will be 0.5 Hz with harmonics at 1.0, 1.5,
2.0, ... Hz). The component at each frequency can
be represented as the sum of a sine and a cosine wave
of that particular frequency. For each wave, three
measures will explain it completely: the frequency,
the amplitude, and the phase shift. If the sine and
cosine components of a particular frequency are
squared and added, the amount of power at that fre-
quency is obtained. Thus, the phase relationships are
FIGURE 2. The xi-alpha model of the EEG. Points represent the
lost and only the frequency components are obtained.
same spectrum as in Figure I. The solid line shows the approxima-
The most frequent application of Fourier analysis has tion by the model. Discontinuous lines illustrate the xi process (~)
been the computation of the power spectrum and the and the alpha process (a). Five measures derived from the model
calculation of the power for each frequency band, as are also shown: amplitude (A) and semibandwidth (B) of the xi and
shown in Figure l. Pascual, Valdes, and Alvarez alpha processes and position alpha (ll").
268 CHAPTER 15
21 years old. The analysis divided the EEG activity a marginal urban area of Mexico City with clear so-
into six frequency bands: &(1.5-3.5 Hz), 6 (3.5-7.5 cioeconomic and cultural handicaps, (4) 30 children
Hz), a 1 (7.5-9.5 Hz), a 2 (9.5-12.5 Hz), !3 1 (12.5- from a marginal urban area of the city of Toluca in
17.5 Hz), and !32 (17.5-25 Hz). The authors also Mexico, (5) 55 children from Caracas who belonged
obtained norms according to age by a multiple regres- to marginal and low socioeconomic classes, and (6)
sion analysis of several band parameters in order to 26 children from a middle class school of Caracas.
reach the highest possible correlation with age All children were healthy at the moment of the study,
(Matousek & Petersen, 1971). These regression had a normal IQ, and attended school regularly with-
equations could then be applied to any other EEG and out academic or behavioral problems. In groups (3),
the hypothetical age calculated (Friberg, Matousek, (4), and (5) children very frequently presented ante-
& Petersen, 1980). In cross-validation, John, Ahn, cedents of risk factors. Those children who had
Prichep, Trepetin, Brown, and Kaye (1980) com- grown up with adequate nutritional, sanitary, and
puted linear regression equations for each EEG band environmental conditions showed the same slopes as
and for each derivation in 306 healthy children from 6 children of the United States. Children nourished in
to 16 years old and compared the results obtained poor socioeconomic and sanitary environments, who
with those previously described by Matousek and frequently had pathological personal antecedents of
Petersen (1973). They found that the same equations risk factors associated to brain damage, showed ei-
described the EEG according to age in American and ther a slow maturation of the EEG characterized by
Swedish normal subjects. In a subsequent paper, smaller slopes of theta relative power or showed a
Ahn, Prichep, John, Baird, Trepetin, and Kaye great variance of EEG parameters with these param-
(1980) demonstrated that nonnally functioning chil- eters having no relation to age. We do not know if
dren from Barbados have an EEG that may be accu- these significant differences in EEG maturation have
rately predicted by previously described equations a functional correlate in relation to cognitive activity
for American children. In a rural population from at present or in the future, or if such deviations are a
Mexico, Harmony (1984b) observed that such equa- trace of the event from which the brain has recupe-
tions adequately described the EEG in central and rated without any physiological meaning at the mo-
frontotemporal derivations but that in parieto-oc- ment and in the future. We have moved a step for-
cipital regions the slope of the regression equations ward in the neurometric approach demonstrating that
did not fit. As she had recorded all the children from a healthy children that grew up in adequate environ-
small town and many of them had histories of brain ments in various countries have similar patterns of
damage, she attributed such a finding to the presence EEG maturation. However, there are other concur-
of slight brain dysfunction in some of the subjects, rent factors that should be taken into consideration.
which may produce less pronounced slopes or no In a subsequent paper, it was reported that be-
correlation with age of the different EEG bands in sides age, sex had an important effect in all bands in
parieto-occipital derivations. Alvarez, Valdes, and the posterior areas and in almost all derivations in the
Pascual (1987) validated the equations of John et al. theta and alpha bands. Risk alone had no effect, but
in a sample of 96 nonnal Cuban children. All of the important interactions between risk and sex were ob-
above-mentioned results were obtained with the served in the alpha band (Dfaz de Le6n, Harmony,
same bipolar derivations originally used by Marosi, Becker, and Alvarez, 1988).
Matousek and Petersen: C3Cz, C4Cz, F7T3, F8T4, In the computerized evaluation of EEG matura-
T3T5, T4T6, P301, and P402. tion it has been very important to the introduction of
However, the equations described by John et al. the concepts of maturational lag and developmental
( 1980) are useful only for children selected with strict deviation (John, Prichep, Ahn, Easton, Fridman, &
criteria of ''normality. '' Harmony, Alvarez, Pas- Kaye, 1983). The age at which the observed spec-
cual, Ramos, Marosi, Dfaz de Le6n, Valdes, and trum is within nonnal limits can be considered the
Becker ( 1988) compared the slopes of the regression apparent physiological age of the subject. The dif-
equations for delta, theta, alpha, and beta relative ference between the apparent physiological age and
power in six groups of children having different eco- the chronological age is defined as the maturational
nomic and psychosocial characteristics with the lag. If the observed values of the spectrum do not lie
slopes previously published by John et al. (1980). within normal limits at any age, then it is defined as
The groups studied were: (1) 96 cuban children se- displaying a developmental deviation. In other
lected with strict criteria of normality, (2) 28 children words, developmental deviation is present when the
from a middle class school of Mexico City selected EEG pattern is not similar to an EEG at any age.
with strict criteria of normality, (3) 28 children from Valdes, Biscay,. Pascual, Jimenez, and Alvarez
( 1985) introduced a more formal mathematical de- only two will be emphasized: (I) Age regression
scription of the developmental deviation. They de- equations were computed for univariate and multi-
fined the space of normal variation as the feature variate data in half of the control group using the
space spanned by normal individuals and the patho- second half for replication. (2) From univariate and
logical space as the complement of the normal multivariate data, the z score using the normative
space. They measured the Mahalanobis distance for regression equations was computed for each mea-
each subject within the normal space and within the surement of each child. This procedure ensures re-
pathological space. moval of the age effect and establishes a common
Concepts like these are very important from a metric of relative probability for each measurement
theoretical point of view, because they try to dis- across age. Children with specific learning dis-
criminate between immaturity and abnormality, two abilities showed greater 8 activity and lower a ac-
aspects that have long been debated in an attempt to tivity in parieto-occipital derivations than did normal
explain children's neuropsychological disorders. subjects. A discriminant function was computed, and
Clinical and related treatment implications are the independent replication of such function demon-
manifold. strated that 85% of normals and 65% of learning-
disabled children were adequately classified.
In the sample of children from suburban areas of
Children's Neuropsychological Disorders Mexico, in which all children had antecedents of risk
factors, Diaz de Le6n, Harmony, Marosi, Landazuri,
Satterfield, Schell, Backs, and Hidaka (1984), Becker, and Banuelos ( 1985) observed significant
in a cross-sectional and longitudinal study of hyper- differences between learning-disabled children and
active children, found that interactions between diag- control children, the former having more 6 and less a
nostic group and age were highly significant for all in parietal and occipital monopolar leads.
EEG frequency bands. Such interactions occurred Fein, Galin, Yingling, Johnstone, Davenport,
chiefly between the youngest group (6.8 years) and and Heron (1986) studied a selected group of 34 boys
the middle (8.3 years) group. Younger hyperactive (ages 9-13) with pure dyslexia and a sample of nor-
children had lower power in all bands than did normal mal children matched by age and sex. They found
controls. The middle and oldest hyperactive children that dyslexics had lower power in the high f3 band,
had higher power in ~ bands than did controls. ~ but were unable to demonstrate lower a and greater 8
differences in hyperkinetics have also been described or 6 levels in those children. As they studied age-
by Callaway, Halliday, and Naylor (1983). matched groups, it is possible that they did not find
Children with minimal brain damage (atten- significant differences in 8, 6, and a bands as have
tion deficits, hyperkinesis, and learning disorders) other authors because they did not remove the age
showed less a attenuation during active performance effect. As Satterfield eta/. (1984) emphasized, if the
of mental tasks (Fuller, 1977). In dyslexic children, developmental curves have different slopes in control
although visual scanning of the EEG showed no de- and experimental groups, differential effects may be
tectable abnormalities, differences in left parieto-oc- observed according to age, but if the whole sample is
cipital spectral values made possible a correct classi- analyzed and compared, then significant differences
fication of 87% of the children. Dyslexics had higher disappear.
relative 6 power than did normals and greater co- Gasser, Mocks, Lenard, Bacher, and Verleger
herence values within hemispheres during reading, (1983) reported that spectral parameters differenti-
whereas normal children showed greatest coherence ated between a group of 10- to 13-year-old mentally
between hemispheric homologous leads during read- retarded children and a matched (sex, age, and social
ing (Sklar, Hanley, & Simmons, 1973; Hanley & class) normal group. Larger 8 and 6 activities were
Sklar, 1976). Abundance of 6 activity in the left observed in the mentally retarded.
hemisphere during several eyes-open conditions in Alvarez, Ricardo, Valdes, and Pascual (1985)
dyslexics has been described by Rebert, Wexler, and compared a group of 63 mentally retarded children
Sproul (1978). (WISC IQ in the range 50-70) with an independent
John eta/. ( 1983) published results obtained for normal sample not used for the computation of EEG
a large sample of normal and learning-disabled chil- norms. All values were z scores to remove the age
dren following a strict evaluation and validation pro- effect. Impressive differences were observed for
cedure of different variates derived from EEG fre- broadband frequency analysis and for the xi-alpha
quency analysis. From a methodological point of model. Mentally retarded children were charac-
view, several aspects were taken into account, but terized by lower power in all bands compared to nor-
270 CHAPTER 15
mal children and higher 8 and 6 power. The most stimulus, but rather are associated with the subject's
important differences were observed in e left-right prior experience and current intentions and decisions
coherence. Computation of the maturational lag and and are more reflective of higher cognitive processes.
the distances in the normal and the pathological space Whereas exogenous components are always elicited
between the independent normal sample and the by external stimuli, endogenous components are
mentally retarded one showed that a great discrimina- nonobligatory responses to stimuli. The same phys-
tion may be obtained by the computation of the matu- ical stimulus sometimes will and sometimes will not
rational lag. Figure 3 illustrates the ROC (receiver elicit the component depending on the experimental
operating characteristics) curves for these three instructions. Moreover, endogenous components
global measures in the mentally retarded. The x axis could be elicited in the absence of a stimulus, if such
corresponds to the accumulated percentage of false- absence has an appropriate role in the subject's task
positives, and they axis to the accumulated percent- (Sutton, Tueting, Zubin, & John, 1967). Endoge-
age of hits. For 2.4% false-positives, 80.95% of hits nous components may be elicited with the same char-
were observed in the maturational lag. Such results acteristics even if the stimuli belong to different sen-
show how, on the basis of the EEG, it is possible to sory modalities but the role in the task is the same.
obtain accurate procedures for the evaluation of Variations in the task produce variations in the en-
many neuropsychological disorders of childhood. dogenous components. Research on ERP has been
directed toward identifying particular ERP compo-
nents as markers of specific stages of information
Electrophysiological Assessment of processing such as encoding, selecting, memorizing,
decision making, and so on (Donchin, Ritter, & Mc-
Cognitive Processing Callum, 1978; Hillyard & Kutas, 1983). Some of the
most widely studied endogenous components are the
Introduction Contingent Negative Variation (Walter, Cooper, Al-
dridge, McCallum, & Winter, 1964), the "process-
The waveform of ERPs is complex and extends ing negativity" (Naatiinen & Michie, 1979) or
several hundred milliseconds after stimulus presenta- "negative difference wave" (Hansen & Hillyard,
tion. The ''late'' potentials correspond to a variety of 1980), P300 (Sutton et al., 1967), and N400 (Kutas
processes that are invoked by the psychological de- & Hillyard, 1980). Before presenting the results ob-
mands of the situation rather than evoked by the pre- tained for various disorders, we shall describe briefly
sentation of the stimulus. These are the endogenous those endogenous components that have been studied
components. Their characteristics are related only in children's neuropsychological problems.
partially to the physical parameters of the evoking
Contingent Negative Variation (CNV)
hits ml
In assessing CNV, a conditional signal (S I) is
given, followed by a constant delay of l sec or more
ns.
before the second or imperative stimulus (S2) to
which the subject has to respond. After S 1, a slow
.5: ps negative potential in the interstimulus interval ap-
pears. ThisistheCNV. Walteretal. (1964)observed
that the buildup of CNV coincided with the learning
of stimulus-response association. The CNV thus ap-
peared to represent a fronto-cortical system involved
.5 f.p in the formation of sensorimotor expectancies. The
relation of CNV amplitude to learning varies as a
FIGURE 3. ROC curves derived from the comparison of the in- function of what is being learned. CNV amplitude
dependent normal sample and the group of mentally retarded chil-
increases during early acquisition; its duration and
dren by broadband analysis of the EEG. The x axis shows the
sustained amplitude depend upon the nature of the
accumulated percentage values of false-positives (f.p) and they
axis the accumulated percentage value of hits. ml, maturational
task. The tasks imposing the greatest cognitive de-
lag; ns, the Mahalanobis distance in the normal space; ps, the mands appear to sustain the CNV for the longest
Mahalonogis distance in the pathological space. (Courtesy of Al- period after initial acquisition. There is evidence sug-
varez et at.. 1985.) gesting that CNV amplitude is not simply propor-
tional to task difficulty, and this has been attributed to are not attended (Hillyard & Kutas; 1983). The term
the influence of stress and anxiety on the CNV. Peak channel has been used to refer to stimuli that share
CNV amplitude is not related to task difficulty; am- some simple cue characteristic such as position in
plitude is in the same range whether for Pavlovian space or tone.
conditioning or cognitive learning. These results are Because of the short latency of the so-called
compatible with either a motivation- or attention- processing negativity, Hillyard et al. (1973) pro-
based model of the role of CNV in learning. The posed that it was a sign of an early stage of selection
interest a subject has in a task might be unrelated to its that gives preferential access to stimuli belonging to
difficulty or complexity at the start of learning. In an attended "channel." According to this view,
later trials the CNV would tend to decrease in ampli- stimuli in unattended channels are rejected after a
tude as the task became less engaging or demanding, rapid initial analysis of their channel cues by a hy-
i.e., as the interest and motivation of the subject pothesized "filter" or "attenuator" mechanism,
waned. CNV has been associated with motivation, also known as "stimulus set" (Broadbent, 1971).
incentive, intentionality, expectancy, readiness, and Following this initial filtering, material in the at-
intense concentration (Donald, 1980; Glanzmann & tended channel is analyzed along more complex cog-
Froelich, 1984; Proulx & Picton, 1980; Tecce, Sav- nitive or semantic dimensions and is compared with
ignano-Bowman, &Meinbresse, 1976). stored information in memory. This subsequent
In a most general sense the CNV can be consid- mode of selection is also known as ''response set'' or
ered as a cortical change that occurs when an indi- "cognitive selection." Hillyard, Picton, and Regan
vidual's behavior is directed toward a planned action ( 1978) associated response set selections with the
in relation to a sequence of two or more events. The P300 component. In patients with lesions of the pre-
action can be an overt motor response, the inhibition frontal cortex, Knight, Hillyard, Woods, and Neville
of a motor response, or a decision. (1981) showed that although the cortex is not the
According to Marczynski (1978), the slow primary generator of the prominent auditory Nl 00
negative potentials are mediated by a concerted ac- wave or the auditory processing negativity, it modu-
tion of the cholinergic and catecholaminergic compo- lates the generators of those ERP components. Nd
nents of the ascending reticular activating system. and N I 00 are independent components: at a low rate
The cholinergic component depolarizes neuronal of stimulation, Nd may begin after NIOO. Increasing
dendrites, reduces the firing threshold of large popu- stimulation rate produced processing negativity with
lations of neurons in specific thalamic nuclei and shorter onset latencies while P300 latency is in-
cortex, and prolongs the discharge to increasing vol- creased (Hansen & Hillyard, 1984).
leys. Simultaneously the catecholaminergic compo-
nent appears to block the function of the GABAergic
P300
recurrent inhibitory circuits responsible for hyper-
polarization of large populations of neurons. Somjen P300 is an endogenous positive wave with a
( 1978) proposed that cholinergic input may activate latency of 300 msec or greater and is typically elicited
the sources of potassium, which in tum produces by rare target stimuli in a detection task. In selective
depolarization of neuroglial cells, thus causing sus- attention tasks, when the signal is correctly detected
tained extracellular currents. the ERP shows a large P300 component that does not
appear when the targets are missed. P300 also may be
Processing Negativity elicited when the signal is absent if this is a correct
report. That is, whether the decision is based on sig-
Selective attention to auditory stimuli elicits a nal presence or absence, P300 waves are enlarged for
broad negative ERP that begins 60 to 80 msec after more confident decisions and for Jess expected out-
the stimulus. This negative wave increases the ampli- comes. Because the auditory NIOO and P300 compo-
tude of the NIOO wave (Hansen & Hillyard, 1980). nents show parallel increases in amplitude and de-
For this reason the early attention effect was viewed creases in latency as a function of rated confidence of
as an augmentation of the evoked NIOO wave to at- signal detections, but P300 is also sensitive to
tended channel stimuli (Hillyard, Hink, Schwent, & whether or not the signal was correctly identified, it
Picton, 1973). This attention-related component can has been suggested that processing negativity is high-
be visualized and quantified as the negative "dif- ly correlated with "stimulus set" and P300 with "re-
ference wave" of the ERP to stimuli in an attended sponse set" (Hillyard et al., 1978). Thus, P300
channel minus the ERP to the same stimuli when they seems to be related to stimulus evaluation processes
272 CHAPTER 15
and independent of response selection and execution visual or auditory modality generate a frontally dis-
processes. P300 can be elicited in a variety of experi- tributed P300 complex that has been related to the
mental paradigms if the experimenter uses random orienting reflex (Courchesne, 1977). Patients with
alterations in stimulus parameters. However, P300 is prefrontal lesions showed no enhancement of the
not evoked solely by physical changes in stimulation: frontocentral P300 to unexpected novel stimuli,
undetected targets in a vigilance task do not elicit while the parietal P300 component to target stimuli
P300, and predictable changes in stimulus param- was normal (Knight, 1984).
eters do not elicit P300. In other words, occasional
changes in a physical aspect of an ongoing train of
stimuli may or may not be associated with P300 de- Developmental Changes of the Endogenous
pending on whether the subject knows in advance Components
when the change will take place. It is the activation of
a unique processor, a subroutine, with a specific At age 7 years, some endogenous components
function that is indicated by the appearance of P300. have characteristics similar to those observed in
This activity may be invoked for a variety of reasons adults; however, in general, those of children are
during the performance of different tasks but its role characterized by larger peak latencies and longer du-
in the sequence of information processing activities ration of ERPs. This observation has been related to a
invoked by the task is always the same (Donchin et delay in cognitive process in childhood compared
al., 1978). Any stimulus, once identified and cate- with adulthood. P300 to target visual or auditory
gorized, is thought to initiate two processes, one con- stimuli is of greater latency in smaller children
cerned with response selection, the other with what (Courchesne, 1977; Goodin, Squires, Henderson, &
might be called ''context updating,'' which depends Starr, 1978). However, there are also differences in
in tum on stimulus evaluation. If the unexpected hap- waveform and topographic distribution in some com-
pens, the model of the operating context must be ponents depending on task: Courchesne ( 1977) re-
revised. Donchin et al. (1978) hypothesized that this ported that rare nontarget stimuli elicited different
context revision process is manifested by P300. waves in children and in adults. In children, long
Johnson and Fedio (1984) considered that P300 am- latency, both negative (N410) and positive (P900),
plitude is affected by three variables: probability of was observed in frontal regions; in adults, rare stim-
target stimuli, task information, and equivocation. uli elicited N200 and P300. Differences in waveform
The first two are independent and may be combined and topographic distribution have been related to age
in a linear way. Both are modulated by equivocation, differences in the quality or mode of information
which is equal to the amount of missed information processing associated with differences in either brain
that occurs during the presentation of one stimulus. generator geometry or brain generator location
P300 has a broad centroparietal scalp distribu- (Friedman, Brown, Vaughan, Comblatt, & Erlen-
tion, which has led to inferences that it may be gener- meyer-Kimling, 1984a,b; Kok & Rooijakkers,
ated by a diffuse cortical source. However, a broad 1985). Neville, Kotas, and Schmidt (1984) also ob-
scalp distribution can also be produced by a subcor- served that ERPs from children aged 9-13 years were
tical source: Halgren, Squires, Wilson, Rohrbaugh, very different morphologically from ERPs from
Babb, and Crandall (1980) proposed that P300 was adults, even though they were recorded using the
generated in the hippocampus. However, Yingling same physical stimuli under the same task condi-
and Hosobuchi (1984) observed that rare auditory tions. Children's ERPs were characterized by a large
stimuli that were detected by the subject were accom- negativity around 400 msec, whereas adults were
panied by a prominent P300 component at the scalp, characterized by a positivity around the same time.
and by a negative activity at the subcortical sites with As they pointed out, synaptic development continues
the same latency as the scalp positivity. This is incon- at least until age 16, and it is likely that developmen-
sistent with a hippocampal generator for P300 but is tal changes in ERPs reflect both structural maturation
consistent with a generator in the thalamus or more and functional organization of neural systems during
dorsally located structures. Johnson and Fedio development. Moreover, ERPs apparently index the
( 1984) did not tind consistent asymmetries in the alterations of such neural development that occur
distribution of P300 that distinguish left from right when early experiences are abnormal. They investi-
temporal lobectomy in patients, proposing multiple gated deaf and hearing subjects with a paradigm that
P300 generators owing to the fact that the distribution would produce reliable language-related patterns of
of P300 has repeatedly been found to be task depen- intra- and interhemispheric specialization in hearing
dent. For example, unexpected novel stimuli in the subjects, by visual presentation in different visual
fields of words. A positive shift observed in ERPs er IV-V intervals than did controls. Wave V also
from the anterior left hemisphere in hearing subjects showed abnormally small latency increases at fast
was not seen in the deaf subjects. Additionally, the click rates. The group of mentally retarded of un-
negative peak in the right hemisphere ERPs from known origin. displayed shorter III-IV intervals and
deaf subjects was less pronounced in ERPs from longer IV- V intervals compared with controls. The
hearing subjects. From these results they concluded authors concluded that Down's syndrome is charac-
that altered early sensory and language experience of terized by an abnormal functioning of the auditory
the deaf subjects has changed the normal trajectory of brain stem pathway. Sohmer and Student (1978),
sensory and language-related processes, and that . studying a group of 10 children with psychomotor
these changes can be studied using the ERP retardation, found longer latencies of wave I and
technique. longer brain stem transmission times. In two chil-
Neville et al. (1984) proposed that, because our dren, waves IV and V were absent.
present understanding of the functional significance Goldman, Sohmer, Godfrey, and Manheim
and neural origins ofERPs is limited, developmental ( 1981) compared normal children of normal IQ val-
ERP studies should proceed in parallel with studies of ues with gifted children and with children with low
normal adults. Studies of development hold the IQs. They observed that retarded children had lower
promise of clarifying our understanding of those neu- amplitudes of the BAERs and higher amplitudes of
ral systems that subserve cognitive processes in nor- the long-latency AERs than did gifted children. The
mal children and adults, and the ways in which these unique common finding for those children with low
systems might be altered by early experience. IQs was that they were of low social class. The au-
thors concluded that sensory deprivation might be
the reason for such abnormalities of the auditory
Mental Retardation responses.
Finley, Faux, Hutcheson, and Amstutz (1985)
The possibility that ERPs may reflect neural studied the correlation between P300 latency and
substrates of intellectual capacity has engaged the cognitive impairment determined by the Halstead-
attention of many investigators. Chalke and Ertl Reitan neuropsychological battery test. They found
( 1965) were the first to report ERP correlates of intel- that children with abnormal evaluations, on the
ligence. They recorded visual evoked responses Halstead-Reitan showed greater P300 latencies than
(VERs) and found that less-intelligent subjects had did those with normal values on the neuropsychologi-
longer latencies. Rhodes, Dustman, and Beck ( 1969) cal test. They proposed that P300 might be used to
compared VERs in 10- and 11-year-old children with differentiate functional and organic cognitive
IQs ranging from 70 to 90 with those of children disorders.
whose IQs were between 120 and 140. They ob- In order to evaluate possible influences of dif-
served larger responses and higher ratios of right cen- ferences in intelligence on ERP' s relations to psy-
tral/left central VERs in bright children. chopathology, Shagass, Roemer, Straumanis, and
The finding of lower amplitude in dull children Josiassen (1981) compared high- and low-IQ psychi-
is not consistent with the results for Down's syn- atric patients with respect to different measures of
drome: these children have been reported to have a VERs, AERs, and somatosensory evoked responses
larger than normal amplitude of late components in (SSERs). Low-IQ patients had lower VER and AER
visual and somatosensory responses (Bigum, Dust- amplitudes. For SSERs, low-IQ patients had higher
man, & Beck, 1970) and in auditory evoked re- early (N60) and lower later (Pl85) waves than did
sponses (AERs) (Barnet & Lodge, 1967). This dis- high-IQ patients. The authors concluded that these
crepancy suggests that ERP deviations in Down's characteristics, although resembling deviations from
syndrome reflect processes other than those associ- normality reported for psychotics, could account for
ated with lower intelligence. Barnet and Ohlrich part, but by no means all, of the psychopathology-
( 1971) described a lack of evoked response decre- related ERP differences.
ment in Down's infants when studying the effect of Motor potentials to non cued movements showed
habituation on the AERs. Squires, Aine, Buchwald, a very different pattern in mentally retarded adoles-
Norman, and Galbraith (1980) reported a surprising cents and normals: a very prominent positive slow
result in their study of 16 adult patients with Down's wave, which according to Karrer, Warren, and Ruth
syndrome, 15 adult retarded subjects of unknown (1978) may reflect immaturity or impairment of sen-
etiology, and 15 normal adults: patients with Down's sorimotor development.
syndrome had shorter 1-11, III-IV intervals and long- The aforementioned results are difficult to in-
274 CHAPTER 15
terpret only on the basis of intelligence: the influence Many variables may explain such contradictory re-
of brain damage at the lower end of the IQ scale is sults: the intensity and frequency of stimulation used
possible. Low IQ scores and ERP abnormalities may vary from laboratory to laboratory, and some studies
both be the consequences of other causes not yet have not taken into account the sex effect in their
considered. samples nor risk factor effects that have been shown
to have a direct influence on BAERs. Therefore,
more experimental data are needed in order to deter-
Childhood Autism mine if autistic children have deficiencies in auditory
sensory processing.
From a neurophysiological point of view, stud- Cortical evoked responses in most studies have
ies on infantile autism have been conducted in order shown a smaller amplitude in autistic children than in
to show defects in information processing, defects in normal children (Lelord, Laffont, Jusseaume, &
mechanisms of orienting to novel stimulation, failure Stephant, 1973; Omitz, Tanguay, Lee, Ritvo,
in the devdopment of hemispheric specialization, Sivertsen, & Wilson, 1972; Small, De Myer, & Mil-
and maturational delay. Due to serious problems in stein, 1971).
obtaining the cooperation of these children, technical Martineau, Laffont, Bruneau, Roux, and Lelord
difficulties are frequent and for this reason some (1980) studied the ERP of 82 children with autistic
studies have been carried out during unmedicated behavior and/ or mental retardation and 43 normally
sleep. As in severely retarded children, it is often adapted children. Subjects were recorded during two
difficult to state the role played respectively by au- sessions of sound (S) and light (L) conditioning in
tism and by mental deficit. ERPs have been used in three stages: (1) habituation: sound alone; (2) condi-
an attempt to discover whether electrophysiological tioning: coupling SL; and (3) extinction: S alone after
data differ for emotional troubles and for cognitive SL series. Conditioning of ERP after coupling SL,
disturbances. which is expressed as an increase in the amplitude of
The study of BAERs in autistic children have sound ERP in the occipital area, was absent in men-
yielded contradictory results. Sohmer and Student tally retarded and weak in autistic children. In the
(1978) studied autistic children, children with mini- same group of children, subgrouping on the basis of
mal brain dysfunction, and children with psycho- clinical characteristics yielded three major groups:
motor retardation. They observed an increased laten- autism, mental retardation, and normal adaptation.
cy of all waves, including wave I, in all groups. In From an electrophysiological point of view, only two
order to avoid the effects of the possible presence of major groups were clearly defined: (l) few condi-
any conductive loss, they measured the transmission tioned ERPs with small amplitude, small uncondi-
time and obtained even more significantly increased tioned ERPs, and generalized conditioned and un-
differences between normal children and patient conditioned slow potentials, and (2) many
groups than with latencies alone. Although the re- conditioned ERPs, absence of generalized slow po-
sults per se do not clarify the question as to whether tentials, and many vertex slow potentials or CNV.
this functional deviation was due to a specific lesion From these results the authors concluded that ERP
of the auditory pathways or was a sign of diffuse helps to differentiate pathological groups from a nor-
brain damage, they concluded that a diffuse lesion mal group but is insufficient to distinguish the autistic
was the most probable explanation. Tanguay, Ed- from the mentally retarded.
wards, Buchwald, Schwafel, and Allen (1982) com- In a subsequent paper, Martineau, Garreau,
pared a group of autistic children with a control group Barthelemy, and Lelord (1984) measured amplitude
matched by age and sex and found only increased and latencies of peaks NlOO, P200, and P300 to S
latency of wave I to right ear stimulation with clicks alone and to paired stimuli in 18 normal and 15 au-
of 42 db in autistic children. Skoff, Mirsky, and tistic children. Latencies of AERs to S alone were
Turner (1980) and Rosenblum, Arick, King, Stubb, smaller in autistic children than in normal controls.
Young, & Pelson (1980) reported increased trans- P300 amplitude was also larger in the autistic group
mission times in autistic children, whereas Tanguay to S alone. Pairing S with L, latencies had few modi-
et al. (1982) did not find modifications in the trans- fications but the amplitude of all peaks increased in
mission times. Rumsey, Grimes, Pikus, Duara, and controls and diminished in autistic children. P300
Ismond (1984) did not find differences in BAER showed greater variability in autistic children. This
characteristics in their study of 25 children and adults finding agrees with that of Novick, Vaughan,
with pervasive developmental disorders, including Kurtzberg, and Simon (1980), who examined the
autism, versus 25 sex- and age-matched controls. standard deviation of the mean ERP in autistic chi!-
dren and found considerable variability. Callaway ries, designs, and quantification approaches gives
( 1975) related variability to thought disorders and support to the hypothesis that long-latency ERP com-
variable performance in schizophrenia. It also has ponents associated with cognitive processing could
been found that the urinary level of homovanillic prove valuable in determining the neurobiological
acid, one of the main derivatives of dopamine, is dysfunction or autism (Courchesne et al .. 1985). On
higher in autistic children than in controls, and that the other hand, Courchesne et al. did not find the
there is a negative correlation between homovanillic striking changes, in the AERs and VERs during non-
acid levels and amplitude of AERs and VERs in au- task conditions, that have been reported by others.
tistic and normal children. According to Garreau, Such differences may be due to the fact that autistic
Martineau, Barthelemy, and Lelord (1984), this sug- children may display a pattern of ERP abnormalities
gests a relationship between evoked potential charac- different from that of autistic adolescents and young
teristics and dopamine metabolism. adults.
Another approach to the study of infantile au-
tism has been that followed by Courchesne, Lincoln,
Kilman, and Galambos (1985) based on the clinical Childhood Schizophrenia
observation that autistic individuals do not orient to
novel information in a normal fashion. VERs and Strandburg, Marsh, Brown, Asarnow, and
AERs to stimuli requiring simple classification deci- Guthrie ( 1984) studied 10 schizophrenic children and
sions and ERPs to unexpected, novel information, 13 age-matched normal children lacking any positive
presented without forewarning to subjects, were ana- antecedent in their clinical history. ERPs were re-
lyzed in a group of I 0 nonretarded autistic subjects corded at midline frontal, central, and parietal re-
between 13 and 25 years old. Two conditions were gions and left and right frontotemporal and post-
studied in each session of AERs and VERs: no task erotemporal leads using short-circuited ear lobes as
condition, where children simply looked at or lis- reference during the performance of the Span Ap-
tened to these stimuli, and a task or performance prehension task (Span). This task was chosen be-
condition where they pressed a button at the occur- cause schizophrenic children and adults showed
rence of target stimuli intermixed with unexpected, impairment with regard to it (Asarnow & MacCrim-
novel stimuli and also with expected, familiar stim- mon, 1981). Subjects had to discriminate one or two
uli. In the task condition, auditory stimuli evoked letters from four different arrays of increasing diffi-
AERs of smaller amplitudes in autistic subjects to culty. A warning tone was presented 500 msec prior
novel sounds in vertex, to target (NHX>, P300), and to each array. The averaged epoch included this 500-
nontarget sounds (NIOO, P300) in frontal regions. In msec interval and I sec of activity following presen-
the visual modality the autistic group had smaller tation of the Span arrays. Schizophrenic children per-
VER amplitudes at the frontal sites to novels and formed worse than the normal children on each of the
targets. The results suggested: (1) nonretarded au- array types, but better than chance. Normal children
tistic subjects may have a limited capacity to process exhibited a long reaction time during the most diffi-
novel information-they are neither hypersensitive cult array relative to their performance in the easier
to novel information nor misperceive it as nonnovel condition. Schizophrenic children do not differ on
and insignificant; (2) classification of simple visual either condition. However, there were no significant
information may be less impaired than auditory; and differences in the reaction time between the two
(3) with the exception of only one latency difference, groups in any condition. The sequence of ERPs was:
visual and auditory ERP abnormalities do not seem to an initial auditory complex to the warning stimulus,
reflect maturational delay. followed by a preparatory CNV and then by the visu-
This study was performed in high-functioning al waves PIOO, Nl40, P200, and finally by several
autistic subjects to permit the analysis of the rela- late positive components. The following differences
tionship between neurophysiological variables and were found between the groups: The schizophrenic
information processing not confounded by mental re- group produced a small CNV that was slow to devel-
tardation, poor attention, poor cooperation, and low op and resolve, as well as diminished amplitudes for
performance capacity. The results supported the N100, P300, and slow components. This suggests
findings of Martineau et al. ( 1984) and Novick et al. that such children are impaired in their ability to regu-
( 1980) in relation to a decreased P300 to auditory late processes involved in the mobilization and direc-
stimuli in autistic subjects, which reflects that some tion of attention and the discrimination of target stim-
particular aspects of information processing are ab- uli. Significantly, the schizophrenic children did not
normal in autism. Such replicability across laborato- show progressive increases in N100 and slow-wave
276 CHAPTER 15
amplitudes in response to increases in array diffi- NIOO and P300 (Hiramatsu, Kameyama, Niwa,
culty, as was the case in normal children. ERPs of Saitoh, Rymar, & ltah, 1983; Roth, Pfefferbaum,
schizophrenic children were most aberrant in frontal Horvath, Berger, & Berts, 1980). At present, it ap-
leads, but lateralized deficits in the posterotemporal pears that all investigators agree that N 100 and P300
region were also seen: normal children had higher are of lower amplitude in schizophrenics, both to
VER amplitudes in the right hemisphere than the left. auditory and to visual stimuli. Lower amplitude of
The schizophrenic children did not show this later- P300 might be a genetic characteristic: In a study
alization and produced smaller responses at both employing syllable discrimination tasks in siblings of
leads. schizophrenic probands, Saitoh, Niwa, Hiramatsu,
The results of this study were very similar to Kameyama, Rymar, & Itoh (1984) reported that al-
what have been found in schizophrenic adults: the though siblings displayed increased amplitude of
CNV amplitude is lower in schizophrenic patients N100 according to the allocation of their attention
than in normal subjects, as has been reported by between two different channels, there was no aug-
many authors (Bachneff & Engelsmann, 1983; mentation of P300 to target stimuli. Mean amplitudes
Rizzo, Spadoro, Albani, & Morocutti, 1984; Timsit- of P300 for siblings were nearly equal to those for
Berthier, Mantanus, Ansseau, Doumont, & Legros, unmedicated schizophrenics, with these values in
1983; Van den Bosch, 1984). siblings being significantly smaller compared to
The second important difference observed in those of normal controls. Based on these results, it
schizophrenic children was the low amplitude of was concluded that abnormalities of P300 in siblings
NIOO and P300. In relation to these components, it may reflect a genetic predisposition to schizophrenia.
has been mentioned that they reflect stimulus set and From these studies it is possible to conclude on
response set, according to the theory of Broadbent the basis of ERPs that .schizophrenics are charac-
(1971 , 1977) who differentiated two levels of atten- terized by:
tional selectivity: stimulus set-selecting a channel
of information characterized by the same physical 1. Deficient ability to mobilize those processes
attribute; and response set-selecting those stimuli that underlie preparatory set demonstrated
requiring a particular response. In dichotic listening by the low amplitude of their CNV
tasks in which the subject has to focus attention and 2. Deficit in focusing attention or stimulus set
detect occasional targets among standard tones in one deficiency demonstrated by the failure to en-
ear and ignore all tones presented to the other ear, the hance N l 00 during selective attention
N 100 potential in normal subjects is larger for all 3. Deficits in the processes involved in the
tones in the attended ear, and P300 is larger only for identification of significant stimuli or re-
the detected targets. The relative amplitude dif- sponse set deficiency demonstrated by the
ference between the responses to attended and ig- low amplitude and insensitiveness to change
nored tones provides the measure of selective focus- of P300
ing on one auditory channel (stimulus set) and
In relation to the abnormalities described by
between the attended standard tones and targets, the Strandburg et al. in ERP hemispheric lateralization in
measure of response set selection. Using this para- schizophrenic children, the study of Hiramatsu et al.
digm, Baribeau-Braun, Picton, and Gosselin (1982) (1983) using auditory syllable discrimination tasks
found that theN 100 potential was significantly larger also supported this finding. Jutai, Gruzelier, Con-
for the controls than for the schizophrenics for the nolly, Manchanda, and Hirsch (1984) found abnor-
attended and for the ignored stimuli, but the NIOO mal patterns of hemispheric activation in schizo-
amplitude was significantly modulated by attention
phrenics. Such abnormalities may be capable of al-
only at fast rates of stimulation. The P300 component
tering both the normal reception and elaboration of
was significantly larger for controls than for schizo- visual and auditory information. Location of such
phrenics even when targets were detected accurately
abnormal activation in temporal areas may also have
and throughout the experimental manipulations.
implications for possible temporal lobe abnormalities
These results suggest that schizophrenics suffer from
in schizophrenia.
a general inefficiency in obtaining information from
significant stimuli. They are unable to organize and
maintain an effective strategy for processing infor- Hyperkinesis
mation, and this could result from an inability to
organize the processes in an optimal manner. Other The goals in studying ERPs in hyperkinetic chil-
authors have also observed decreased amplitudes of dren were to demonstrate a possible delay of the rna-
turation of the central nervous system or a low peractivity and peak V-VI (140-200) amplitude,
arousal level, which have been the hypotheses pro- and between therapeutic response and the attention-
posed to explain the behavioral disturbance and the inattention differences in mean peak latency of wave
improvement in behavior following drug treatment. V. This is the only report in the literature in which
Demonstration of homogeneous effects of ERPs smaller amplitude of VERs has been correlated with
in hyperkinetic children is difficult, as many appar- hyperkinesis.
ently contradictory results have been obtained. How- Callaway et al. ( 1983) recorded VERs to flashes
ever, upon detailed analysis of the .samples of chil- during passive and active conditions in hyperkinetic
dren studied, it is possible to note that in almost all and control children. In the active case, the subject
reviews on this aspect, the authors mixed the results pressed a microswitch for rare dim flashes embedded
obtained for learning disabilities with those for hy- in a series of brighter flashes to which VERs were
perkinesis. Thus, in this chapter both developmental averaged. In the passive case, there were no dim
abnormalities have been separated in an attempt to flashes. The authors reported group effects as well as
classify the results obtained. The term attentional interactions with age and condition. In relation to
deficit disorders has not been used because this clas- age, they observed greater amplitude of Nl60 with
sification appeared after the papers that will be increasing age, contrary to what has been reported
quoted. From a clinical approach, if hyperkinesis is elsewhere in the literature. Hyperkinetic children had
the more relevant sign, pharmacological treatment larger VERs, appearing more mature in this measure
will be recommended. If the learning deficit is pre- according to these authors. In normal children, N200
dominant, specific pedagogic rehabilitation will be latency increased with age, whereas hyperkinetics
indicated. However, in some children both symp- showed a decrease with age. Nl60, N200, and P230
toms are of equal relevance, and in these cases almost amplitudes were higher during the active task and in
all psychiatrists would recommend pharmacological all three measures hyperkinetics had larger ampli-
treatment and pedagogic training. With this in mind, tudes than did normals.
papers that emphasized hyperkinesis or drug treat- Michael, Klorman, Salzman, Borgstedt, and
ment have been grouped in this section. In next sec- Dainer ( 1981) measured the late positive components
tion, only studies that focused on learning disabilities (maximum amplitude in the 250-600 msec range) of
will be presented. VERs to the X and BX version of the Continuous
Buchsbaum and Wender (1973) recorded VERs Performance Test: the child was asked to watch a
to flashes of four different intensities in 24 children screen on which one of six letters was displayed. The
aged 6 to 12 years with minimal brain dysfunction child had to press a microswitch detecting the letter X
(MBD) and a matched control group of 48 children. first, and in the second part of the study the child had
The mean amplitude across intensities for N 140- to press the button upon presentation of the letter X if
P200 was higher in the experimental group. In addi- the preceding cue was B. Late positive components
tion, the normal group had a slower rate of increase of reflected the attentional demands of the task, as indi-
amplitude with increasing stimulus intensity. The cated by larger amplitudes evoked by targets than
MBD group had shorter latencies for PIOO-Nl40 and nontargets. The hyperactive children exhibited
P200. The normal maturation process appears to be smaller late positive components than did the normal
an increase in latency at low intensities and a de- peers, but the diagnostic differences were sharper
crease at high intensities. The amphetamine re- among younger children.
sponder group showed little change with age in either Prichep, Sutton, and Hakerem (1976) recorded
overall latency or latency-intensity change. In the long-latency AERs to clicks during a guessing para-
responder group, amphetamine produced larger la- digm under conditions of certainty and uncertainty:
tencies at low intensities. In contrast, in nonrespon- single and double clicks were presented randomly. In
ders the amphetamine effect was to reduce latencies the uncertain condition the subject guessed, prior to
at the lowest intensities and to prolong them at the each trial, whether a single or a double click would be
highest intensities, thus moving further in an abnor- presented. In the certain condition the subject was
mal direction. The authors concluded that the data told, prior to each trial, whether there would be a
supported the concept of a "maturational lag" in single or a double click. Differences between the
MBD children. These results were not replicated by normal and the hyperkinetic children were only ob-
Hall, Griffin, Moyer, Hopkins, and Rappaport served during the uncertain condition to the second
(1976), who did not find statistically significant dif- click. Hyperkinetics were characterized by: lower
ferences between groups. However, they found sig- amplitude of P 186, higher amplitude of N250, and an
nificant negative correlations between degree of hy- extremely large P300 during the certain condition.
278 CHAPTER 15
Because P300 would be expected to be relatively those of younger normal subjects. Such findings are
small under conditions of certainty (Sutton et al., more consistent with an aberrant than with a delayed
1967), the fact that hyperkinetics have larger P300 in maturational hypothesis.
the certain condition suggested that they were re- In Table I these results have been summarized
sponding inappropriately to task demands. Another in order to assist the following discussion. Taking
important observation was that there were no changes into consideration the opposite development of long-
in the AERs of hyperkinetics during either certain or latency AERs children, it is possibly to understand
uncertain conditions. why, in the study of sensory evoked responses (visual
The latter result is supported by evidence pre- or auditory) during passive conditions, the most fre-
sented by Loiselle, Stamm, Maitinsky, and Whipple quent observation was the absence of significant dif-
(1980), who studied the AERs to tone pips during a ferences (Hall et al., 1976; Loiselle et al., 1980;
selective attention task. Two independent dichot- Michael et at., 1981). If the range of age and the
ically presented series of pips at 800Hz to one ear and number of subjects are carefully observed, it clearly
1500Hz to the other ear with interspersed signal pips appears that as age has not been taken into account,
of 840 or 1150 Hz were delivered. The subject was the overall total differences between groups were not
instructed to listen to and count the number of signal significant possibly due to a masking of differential
pips to one ear and ignore those to the other ear. For effects of age. However, two papers did show higher
both groups the amplitudes of N100 were higher to amplitudes during passive conditions in hyperkinetic
the attended than to the nonattended channels. How- children (Buchsbaum & Wender, 1973; Callaway et
ever, the amplitude difference between these chan- al., 1983).
nels was substantial and significant only for the con- Experiments done during active conditions may
trol group. P300 waves were evaluated to the be classified as to those that emphasized ( l) the am-
attended signal tones and to the concurrent signals plitude of the first waves or (2) P300 or late positive
from the nonattended channel. Mean P300 ampli- components. Callaway et al. (1983) and Prichep et
tudes to the nonattended signals did not differ be- al. (1976) found higher amplitudes of the negative
tween groups. However, although both groups had waves in hyperkinetic children. But what is more
higher mean amplitudes to the attended than to the remarkable is the fact that there were no significant
nonattended signals, the amplitude difference was changes of amplitude during different conditions.
only significant for the controls. Also, P300 to at- P300 followed a contrary effect in normal and hyper-
tended signals was significantly greater for the con- kinetic children depending on the paradigm: it was
trol boys. abnormally high in certain conditions in hyper-
Using long-latency AERs to unattended clicks, kinetics (Prichep et al., 1976) and of lower amplitude
Satterfield and Braley ( 1977) demonstrated that age to targets (Loiselle et al., 1980), this effect be-
was an important factor when comparing normal and ing more clearly defined in younger hyperkinetics
hyperkinetic children: younger hyperactive children (Michael et al., 1981).
were found to have significantly smaller AER ampli- From the above discussion, it is possible to con-
tudes, and older hyperactive children had AER am- clude that hyperkinetic children are characterized by
plitudes larger than those of age-matched controls. an aberrant development of the central nervous sys-
Considering the total samples, there was no overall tem and by severe attentional defects at both the stim-
group difference. Recently, Satterfield et al. (1984) ulus and response sets.
reported a cross-sectional and longitudinal study of
age effects on a set of electrophysiological measures,
including AERs in hyperactive and normal children. Effect of Medication on the ERPs of Hyperkinetic
They showed that the amplitude decreased with age Children
among the controls, but increased among the hyper-
active subjects. The age by diagnostic group (hyper- Table 2 summarizes the most important effects
active/nonnal) interaction was significant for all am- of drug treatments in hyperkinetic children. It is ob-
plitude measures, and the youngest children (6.8 to vious that in ''responders,'' amphetamine and meth-
8.3 years) contributed most to the overall interaction. ylphenidate produced an improvement in ERP mea-
The authors concluded that their data did not fit a sures toward normalization. During passive condi-
delayed maturational model, because the youngest tions, modifications by drugs are not as clear as dur
hyperactive group had AER5 and BEG measures sim- ing active conditions. These results have great prac-
ilar to those of the older nonnal group, whereas the tical importance, because for the evaluation of such
oldest hyperactive group had measures more like drugs it is not necessary to wait for long periods. In
TABLE 1. Event-Related Potentials in Hyperkinetics

No. of No. of
Reference control hyperkinetic Age Stimuli Condition Lead Results
Buchsbaum 48 24 6-12 Photic Passive ~ MBD with higher amplitudes N140 P200.
&
Wender
(1973)
Hallet al. 9 10 6-ll Photic Passive cz No differences between groups.
(1976) 10 12
Callaway er 18 18 6-13 Photic Passive Cz, Pz Passive: hyperkinetics with higher Nl
al. (1983) Active amplitude.
Active: hypeddnetics with higher Nl N2 P2.
Age interaction.
Michael et 21 21 6-13 Photic Passive ~,Pz Active: hyperkinetics with smaller late
al. (1981) CPT-X Active positive components. Younger highest ef-
BX feet. Age interaction.
Prichep et 8 16 8-11 Single or Certain cz Certain: P300 higher in hyperlcinetics.
al. (1976) double Uncertain Uncertain: hyperkinetics with smaller P186
clicks and higher N2SO.
Hyperkinetics: No change certain versus un-
certain.
Loiselle et 15 12 12-14 Tone pips Unattended 4 Attended: hyperkinetics no significant ampli-
al. (1980) Attended tude increment of NIOO and P300.
Satterfield er 52 127 6-12 Clicks Unattended Differential effect according to age. Younger
al. (1984) hypeddnetics had smaller amplitudes and
older hyperkinetics had larger amplitudes
than nonnals.
Follow-up 48 51 Clicks Unattended Follow-up: Nonnals decreased amplitudes
with age, hyperkinetics increased ampli-
tudes with age.
two different sessions, one before treatment and the This finding was replicated in a second experiment
second one after a dose of the drug, it is possible to on twenty 9- to 15-year-old subjects. Preston,
reach conclusions about whether a particular child Guthrie, and Childs (1974) recorded VERs to flashes
will respond to pharmacological treatment. and the word "cat" in nine disabled readers aged 10
and in two control groups, one matched for age and
IQ and the other for reading level and IQ. They also
Dyslexia and Learning Disabilities found that N200 in the left parietal region was signifi-
cantly smaller in LD than in controls. They con-
Many papers have been dedicated to the study of cluded that as this finding could not be explained on
ERPs in learning disabilities (LD). Such studies have the basis of age, IQ, or reading level, it probably
tried to demonstrate perceptual deficits, abnor- represents a neurological concomitant of the disor-
malities on hemispheric specialization, and deficien- der. They were not able to exclude the possibility that
cies in temporal processing of verbal stimuli. disabled readers were simply less attentive to the
The first publications examined VERs. Conners stimuli.
(1971) recorded in parietal and occipital derivations Cohen ( 1980) studied 11 children with primary
VERs to flashes in twenty-seven 8- to 12-year-old dyslexia and a control group matched by sex, age,
"poor readers." He found a strong correlation be- and intelligence. He used a CNV paradigm on which
tween amplitude attenuation of wave N200 from left the strobe light was the warning signal followed by a
parietal derivation and severity of reading disability. 500-msec-duration tone that was terminated by the
280 CHAPTER 15
TABLE 2. Effect of Treatment on Event-Related Potentials

Reference Drug Stimuli Results
Buchsbaum & Wender Amphetamine Photic Responders: Amphetamine prolonged latencies at lower intensities
(1973)
Greenhill, Rieder, Lithium Photic Nonresponders: LC reduced both amplitude and latencies at lower intensity
Wender, Buchsbaum, carbonate
& Zahn (1973)
Saletu, Saletu, Simeon, Thioridazine Photic Responders to Td: Short latencies and smaller amplitudes 200-300 msec
Viamontes, & Itil before treatment. Td improves attention.
(1975) Amphetamine Responders to A: short latencies and higher amplitudes 80-100 msec before
treatment. A decreases hyperactivity.
Hall et al. (1976) Amphetamine Photic Responders: Lower amplitude and longer latency in inattention.
Prichep et al. (1976) Methyl- Clicks Responders: M produced higher differences in Pl86 between certain and
phenidate uncertain, higher amplitude of P186 and lower amplitude of N250
Michael et al. (1981) Methyl- Photic Amplitude of parietal late positive components enhanced by M
phenidate CPT-X
BX
Klorman, Salzman, Methyl- Photic Photic: M reduced amplitudes and prolonged latencies
Bauer, Coons, phenidate CPT-X CPT: M produced higher amplitudes of late positive components
Borgstedt, & Halpern BX
(1983)
Halliday, Callaway, & Methyl- Photic Effect of M varied according to age and experimental paradigm. Two types
Naylor (1983) phenidate of effects on ERP amplitude: monotonically changes with dose, interac-
lion dose-attention nonmonotonically. M speeds reaction time with011t
shortening ERP latencies.
Halliday, Callaway, & Methyl- Photic Responders: Amplitude NlP2 difference between M and placebo during
Rosenthal (1984) phenidate attending condition greater than 3 f.1.V
subject pressing a button. The two groups showed intercorrelations among the leads of each hemi-
differences between both amplitude and latency of sphere. The lowest correlations were obtained for the
VERs. The latencies of NlOO and P200 were longer early and late components of the control group to
in the dyslexic group. Cohen and Breslin (1984) word stimuli in the left hemisphere. Left hemisphere
compared the VERs to flashes and to verbal stimuli in intercorrelations were significantly lower than right
16 reading-impaired boys and 16 normal control boys hemisphere intercorrelations for VERs to words in
aged ll. The two groups had similar IQs and came the control group. Dyslexic children showed no sig-
from the same school classes. The authors corrobo- nificant differences between both hemispheres either
rated the finding of P200 increased latencies in the to flashes or to words. Cohen and Breslin proposed
dyslexic group both to flashes and to words. They that the early phase of information reception and pro-
also computed correlation coefficients between left cessing is represented bilaterally in the visual cortex
and right early, middle, and late components. Cor- with bilateral stimulation. This is followed by a peri-
relation coefficients were very high for flash stimuli od of information transfer to all of the association
in both groups in middle and late latency compo- areas of each hemisphere, lasting between 100 and
nents. Dyslexics have higher correlation coefficients 200 msec. Finally the information is recognized and
to words than to controls. According to these authors, registered by a brain area that is specialized for that
high interhemispheric correlation would imply that verbal process of template matching, usually a left
the hemispheres do the same things and low correla- hemisphere function. The failure of hemispheric spe-
tions would mean that contralateral positions on the cialization in even the early phase of target registra-
two hemispheres reflect different processes. To ana- tion and recognition is thought to be the functional
lyze the intrahemispheric specialization, they used disability in the specific dyslexic individual.
Shelburne ( 1978) studied nine boys aged 9 to 14 monds, and the letters b, d, p, and q-were recorded
with relatively pure reading disabilities. Visual stim- in all leads of the I 0/20 system. Similar results were
uli consisted of letters presented sequentially to form obtained with all visual stimuli. Significant dif-
consonant-vowel-consonant (CVC) trigrams. Each ferences between normals and verbal underachievers
trial consisted of the presentation of blank-CVC- were more marked on the left hemisphere in central
blank. eve formed either words or paired nonsense and parietal regions in the latency domains of 280-
syllables with the same first two letters as the word. 340 and 410-480 msec. Arithmetic underachievers
The child was instructed to observe the letters during showed more marked differences in right central and
each trial and to decide whether or not the eve was a parietal leads in the latency domains of 220-270 and
word. After the second blank the child pushed a tog- 310-380 msec. Mixed underachievers and normals
gle switch to the right (word) or left (nonsense sylla- were significantly different in the VERs in central,
ble). Immediate auditory feedback indicated whether parietal, occipital, and posterotemporal left hemi-
the response was correct (tone) or incorrect (buzzer). sphere around 220-260 msec of latency. As the read-
VERs for each position in the CVC trigram were ing- and arithmetic-specific disabilities showed most
averaged separately in central and parietal leads. In significant differences with respect to late compo-
previous experiments (Shelburne, 1973) normal chil- nents in the latency domain of 300 msec or later, and
dren who performed well on this problem-solving the mixed underachievers showed most significant
task showed greater positive amplitude of VERs from differences markedly earlier, at about 200 msec, Ahn
the third position stimuli than VERs from first and suggested that the first two groups suffered from a
second position stimuli. With the exception of one deficit largely related to cognitive processes and that
reading-disabled child, the reading disability chil- the mixed group suffered from a deficit more percep-
dren showed no significant VER differences. In con- tual in nature.
trast, 17 out of 20 normals tested previously showed Harmony and Di'az de Leon (1982, 1983) com-
significant VER differences. pared the VERs in three groups of children from a
VERs may also be obtained by presenting task- rural area: those with no academic problems, aca-
irrelevant visual stimuli while subjects perform some demic underachievers, and illiterate. Visual stimuli
task. This procedure is known as probe-ERP para- were a blank slide, a 7lines/inch grid, a 27lines/inch
digm. In these experiments it is assumed that a brain grid, and the letters b and d. Values of waveform and
region is less responsive to the probe stimulus when amplitude symmetry were very similar to those pre-
that region is engaged by the concurrent task. With viously reported in adults (Harmony, Ricardo,
this procedure, Johnstone, Galin, Fein, Yingling, Otero, Fernandez, & Valdes, 1973). Children with
Herron, and Marcus (1984) studied 34 controls and no academic problems showed a good response to the
32 dyslexic boys aged 10 to 12. VERs to flashed change of stimulation: VERs to patterns were of
checkerboards were recorded while the children per- higher amplitude in occipital areas compared to
formed silent and oral reading at two levels of diffi- VERs to flashes (Figure 4). VERs to the letters b and
culty. In all children for all four reading tasks, the d were different in parietal leads (Figure 5). In iilit-
right midtemporal VER was larger than at any other erate children and in academic underachievers, the
lead and the left midtemporal VER was smaller than changes of VERs to different stimuli were not so
at any other lead. Principal component analysis for apparent. However, the most important differences
both groups in the seven leads was computed. Eleven between the three groups were in the measurement of
factors accounted for 91% of total variance. Dyslex- variability within the evoked responses to the same
ics showed a significant amplitude decrease in the stimuli. Academic underachievers have greater vari-
positive components of 250-350 msec range while ability of VERs in parietal leads than controls, and
reading difficult material at bilateral central and par- illiterate children showed higher variability of VERs
ietal derivations. Normal readers showed no such in central and parietal areas. These results were in-
effect. terpreted as a dysfunction of the association parietal
Ahn ( 1977) sought to identify differential char- areas in academic underachievers and illiterate chil-
acteristics of groups of children with specific reading dren. Failure to have consistent VERs in central areas
disabilities (verbal underachievers), specific arith- in illiterate children may be related to a more severe
metic disabilities (arithmetic underachievers) and dysfunction of the unspecific systems related to at-
generalized learning disability (mixed under- tention. Such dysfunction may be produced by defi-
achievers), all with normal IQ. VERs to II different cits in early experience or sensory deprivation, for
visual stimuli-a blank slide, and 7 lines/inch grid, a these children belonged to severely culturally de-
27 lines/inch grid, large and small squares and dia- prived families.
282 CHAPTER 15
8 ?f work and scholarship of the parents, economic

f 71 mcome per capita, and conditions of the house. Pedi-
atric and neurological examinations showed that chil-
~ ~
dren were healthy at the time of the study, although a
c large group had personal antecedents of risk factors
associated with brain damage in both groups. The
power calculated as the sum of the square of the
amplitude values taking as reference the mean value
~J
along the 512-msec time epoch was measured for
0~ each VER. Also the left power/right power ratio and
~ the correlation coefficient were computed between
VERs from homologous leads. Power values were
transformed to logarithmic values and correlation co-
~fficie~ts to Fisher's Zr transform. Regression equa-
tions wtth age showed that left occipital power values
FIGURE 4. Visual evoked responses to flash and to 7 lines/inch to both stimuli, right occipital and left posterotem-
grid in a nonnal child. Observe the change in occipital (0) regions. poral VERs to pattern have a significant negative
correlation with age in control subjects. Older chil-
dren have smaller power values. This result agrees
In another study, Harmony, Marosi, Diaz de with other observations (Celesia & Daly, 1977). For
Le6n, Becker, and Landazuri (1984) recorded VERs measurements correlated with age, z values for each
to blank and to a checkerboard pattern in left and right child were computed eliminating age effects. Those
central, parietal, occipital, and posterotemporal not directly correlated with age were directly com-
leads using linked ear lobes as reference. Children pared by Student's t test. LD children had higher
between 7 and 13 years old were selected from a large power values in right posterotemporal lead to both
sample according to a test developed to analyze read- stimuli than did control subjects, and a smaller
ing and spelling difficulties. Those children who read left/right power ratio in posterotemporal areas (Fig-
and write according to their age and grade at school ures 6,7). The smallest VERs were recorded in left
composed the control group. Children with great dif- posterotemporal areas in both controls and LD to
ficulties in reading and spelling were assigned to the either fl~h or checkerboard. Therefore, we have ob-
LD group. Children with specific sensory distur- served, as did Johnstone et al. (1984), larger VERs in
bances such as visual refraction problems or hypo- right than in left posterotemporal areas in passive
acusia, behavioral problems, or borderline or low IQ conditions. LD children had lower correlation coeffi-
were omitted. All children had a normal IQ (WISC). cients than controls in parietal leads. Figure 8 pres-
Socioeconomic level was evaluated according to type ents an example.
A discriminant analysis using the standardized
values (corrected by age) of power, power ratio, and
correlation coefficients for pattern VERs showed a
b d significant discrimination between controls and LD.
However, when risk factors were taken into account,
p~ ~
controls with antecedents and LD without anteced-
ents were more abundant among the misclassified
subjects. Therefore, in order to determine whether
dependent variables other than learning disabilities
were affecting the results, we did a multiple regres-
0~
sion analysis. Independent variates considered were
sex, age, risk factors, socioeconomic status, and ped-
agogic evaluation. It was corroborated that power of
VERs clearly decreased with age. It was also ob-
served that girls had lower power than boys. Low
socioeconomic status, antecedents of risk factors,
FIGURE 5. Visual evoked responses to letters band din a nonnal and the presence of LD were associated with a decre-
child. Occipital (0) VERs do not change, but parietal (P) VERs are ment of VERs power in parietal areas. These results
of different wavefonn. showed the complex interactions that exist between
4000 FLASH PATTERN
-CONTROLS
[')ilL D
2000
O.,L----
FIGURE 6. Mean power of left (T5) and right (T6) posterotemporal leads ofVERs to flash and to a checkerboard in control and learning-
disabled (LD) children.
different factors on simple measures of ERPs (Har-

mony, Becker, Marosi, Landazuri, Baiiuelos, Diaz
de Leon, and Hinojosa, 1985). They also put a note
15 of caution in interpreting results provided by ERPs.
o1 At the present moment we are proceeding the analy-
sis in order to know more about the interactions of
such factors. Depression of VERs in parietal areas
has been considered a sign of visual processing deft-
15 cits, as mentioned earlier. The fact that so-
o2 cioeconomic and risk factors produce a decrement in
these areas poses a new question in relation to the
possibility that such factors may have a causal rela-
tionship with visual processing deficits.
15 The observation that in all children right post-
tS erotemporal VERs were larger than left posterotem-
poral responses, and that in LD children this dif-
ference is still more apparent due to larger right
temporal responses, is very difficult to explain.
15 Strandburg et al. (1984) using the same leads found
t6 the same in normal children, whereas in schizo-
phrenics the contrary was observed. Johnstone et al.
( 1984) also described this asymmetry in normal and
dyslexic children. These authors reported that right
FIGURE 7. VERs to a checkerboard pattern in an LD child. Ob- temporal predominance was not observed when
serve the high amplitude of the VER in posterotemporal right (T6) using checkerboards covering the central fields out to
region. 6 even in task-relevant experiments. Therefore, the
284 CHAPTER 15
IO 1168 1336 fJ 68 13 3 6
FIGURE 8. (Left) VERs to flash and (right) VERs to a checkerboard pattern in an LD child. It is possible to observe the wavef.onn
asymmetry in parietal leads (p3, p4).
characteristic to find larger right temporal VERs is with normal readers, disabled readers showed signif-
that stimulation should be given to the periphery of icantly lower amplitude of AERs recorded in the right
the retina. Such large potentials may be related to hemisphere (T4-Pz) during both tasks. Disabled
those described by Srebro ( 1985) using the Laplacian readers also showed significantly higher amplitude of
visual potential when upper field stimuli were used. left responses (T3-Pz) during the letter sounds con-
He associated this large potential to functions like dition. For both conditions the reading-disabled sub-
spatial orientation and identification of some at- jects showed significantly lower amplitudes of right
tributes of the stimuli. If correct, this finding may be than left hemisphere AERs. Task-related strategies
important from a physiopathological point of view. did not differ between groups. The pattern of AER
Lower power of VERs in parietal and occipital amplitude asymmetry found for disabled readers,
regions was observed in children with more severe which was opposite to that found for normal readers,
antecedents of risk factors. It has been reported that suggests that the same reading-related task activated
some risk factors such as perinatal asphyxia or higher different cerebral processes in the two groups
concentrations of heavy metals in children produce studied.
smaller VERs, though it is likely that this factor is Fried, Tanguay, Boder, Doubleday, and Green-
influencing the VERs. site (1981) also were interested in lateralization of
Long-latency AERs to pairs of tone pips used as AERs in dyslexic children. Stimuli were voiced
probe stimuli during two visual conditions were re- words do and go and strummed chords A7 and D7,
corded by Shucard, Cummins, and McGee (1984) in randomly arranged. Control subjects showed greater
a selected sample of 30 strongly right-handed male waveform differences between AERs to words and
disabled readers and 30 normal subjects. The entire chords in the left hemisphere. Developmental dys-
alphabet was displayed; during one condition the lexic children were divided into dysphonetic (great
subjects have to press a button upon viewing a letter difficulty in reading and spelling words phonetically)
with a long "e" sound (letter sounds condition), and and dyseidetic (difficulty in recognizing written
during the second condition subjects have to identify words) groups. The former group showed greater
letters having either closed circular shape or only differences to words and chords in the AERs of the
straight lines (letter shapes condition). Compared right hemisphere; in the latter group the greatest dif-
ferences were found in the left hemisphere, as in as suggesting that the reading-disabled child pro-
control subjects. cesses sensory information at a slower rate than does
The latter two studies are coincident in the dem- the normal child, which may be indicative of a neural
onstration that the right hemisphere of disabled read- deficiency.
ers (or at least a subgroup of them) is activated during Cohen (1980) reported larger CNV in controls
language processing, either if stimulus is presented than in dyslexics. However, the reaction time was the
as speech stimulus or in a condition that involves same for both groups and for this reason he concluded
visual-phonemic transfer. As we have already re- that the deficit observed in VERs and CNV was more
viewed for VERs, it has been possible to find a lack related to a neurophysiological dysfunction in visual
of activation in the left hemisphere of disabled read- information processing.
ers when they have to process words (Cohen & Fenelon ( 1978) recorded CNV s from frontal and
Breslin, 1984; Shelburne, 1978). parietal sites over both hemispheres of problem and
Deficits in selective and sustained attention normal readers during several stimulation condi-
have also been studied with ERPs in LD children. tions. Reading-disabled children showed CNVs of
Sobotka and May ( 1977) recorded VERs during a smaller amplitude in left parietal area. Assessment of
detection task on which subjects were required to intra- and interhemispheric symmetry of waveforms
respond to dim flashes occurring in a train of brighter was done by computation of correlation coefficients.
flashes. VERs were averaged for brighter flashes. Right hemisphere responses were more highly corre-
Dyslexics showed higher amplitudes ofPlNl waves lated in the disabled readers than in the normal group
than did normal children, and a slower reaction time in the visual stimulation conditions, but not when
to attended stimuli. The authors concluded that be- auditory stimuli were used.
cause dsylexic boys showed higher amplitudes of A brief review of BAERs in children with learn-
VERs to unattended stimuli, this may be due to an ing problems will now be presented.
attentional deficit. The results obtained were exactly It was mentioned in relation to mental retarda-
contrary to those of Conners ( 1971 ), Johnstone et al. tion and autism that Sohmer and Student ( 1978) re-
(1984), and Preston et al. (1974). VERs to the X and corded BAERs in several groups of children includ-
BX version of the Continuous Performance Test had ing a group with MBD. They observed longer
smaller late positive components (250-600 msec) in latencies and transmission time in MBD children
the dyslexic children as compared with a normal than in the normal group. However, the authors did
group (Dainer et al., 1981). not give detailed characteristics for this group. Gold-
Musso and Harter ( 1978) compared normal chil- man et al. (1981) observed smaller amplitudes of
dren and children with reading disabilities attributed waves I to V of BAERs in borderline children or
to visual and auditory perceptual problems. The sub- children with poor scholastic achievement. The de-
jects' abilities were assessed in a visual discrimina- creased response amplitudes of compound action po-
tion attentional task that consisted of flashing a warn- tentials and evoked auditory responses were in-
ing stimulus followed after 1100 msec by one or two terpreted as a decrease in the number of responding
randomly presented flashes, a relevant or an irrele- units. The common factor shared by these children
vant stimulus. For a correct response, the subject was was lower socioeconomic-cultural status. Because
given a token; for a mistake, the subject lost a token this background is often associated with such factors
and negative feedback was given immediately in the as slight undernourishment of the mother during her
form of a loud click. The effect of selective attention childhood, early marriage and pregnancy, high fre-
to relevant and irrelevant stimuli was measuted by quency of pregnancy, and limited prenatal and
finding the difference in amplitude of the VERs to the postnatal care of the children, the authors proposed
second stimulus when it was relevant or irrelevant. that these factors could lead to mild forms of MBD.
The reading-disabled children with visual problems They also considered that the retarded children hav-
showed greater relevant-irrelevant differentiation in ing been raised in restricted, culturally deprived, and
their VERs than did normals, which suggested that nonstimulating environments may also develop sim-
they were selectively attending more than the other ilar changes in neuronal function expressed as de-
group in order to compensate for their deficiency. creased response amplitudes. Children with speech
However, latency of P300 component was larger in and language disorders exhibited amplitudes for
children with visual than with auditory problems, waves I, III, and V smaller than those of the normal
who in tum had latencies longer than those of normal group, with no change in latency (Mason & Mellor,
children. These latency differences were interpreted 1984). Two explanations were suggested for this
286 CHAPTER 15
finding: an abnormal functioning of the auditory sys- important factor to be taken into account
tem due to deprivation of normal speech and lan- when defining norms.
guage development, or differences in the electrical
conductivity of the tissue in children with language
disorders.
From this review on BAERs it appears clear that
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Shelburne, S. A. (1978). Visual evoked potentials to language Allen, V. (1982). Auditory brainstem evoked responses in
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(Ed.), Multidisciplinary perspectives in event-related brain 180.
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16
Techniques of Localization in Child

Neuropsychology
GRETA N. WILKENING
The ability to relate constellations of neuro- in the adult population, but must also account for the
psychological deficit and strength to localized struc- research suggesting that there is an interaction be-
tural brain damage has been a major achievement in tween lesion localization and age at time of injury
the endeavor to understand how the brain functions that mediates where in the brain cognitive and per-
and to increase the utility of behavioral tools for un- ceptual processes occur subsequent to early brain
derstanding clinical problems. The majority of re- damage (Fedio & Mir8ky, 1969).
search dealing with localization has involved the Techniques for lesion localization in children
study of adults with pathological changes of the are intimately related to the research addressing the
brain. Less information is available regarding lo- possibility of plasticity and equipotentiality in the
calized deficits in children. Satz and Bullard-Bates young brain. For example, if children who sustain
(1981), for example, point to the relative paucity of early lateralized brain damage rarely show long-term
studies concerning acquired childhood aphasia in unilateral sensory deficits (e.g., plasticity of func-
contrast to numerous studies examining aphasia, and tion), then the failure to identify lateralized sensory
the effect of varying lesion localizations, in the adult findings cannot be interpreted as consistent with lack
population. This relative inequality reflects a number of lateralized damage. Similarly, if language disor-
of factors including the types of lesions typically ac- ders are as common secondary to early right as early
quired by children, how they differ from lesions ac- left hemisphere lesions (e.g. , equipotentiality), then
quired by adults, and the relatively greater difficulty the presence of a language disorder cannot be in-
involved in assessing and understanding a develop- terpreted as strongly indicative of a left hemisphere
ing organism (Boll & Barth, 1981). lesion, as would be interpreted in an adult. Adequate
Given the limited data regarding localization of appreciation of the current research on equipoten-
function in children, it is tempting to assume that the tiality and plasticity is essential in understanding both
integration of structure and function in the child's the limitations and the possibilities for lesion lo-
brain is identical to what has been described in the calization in the younger age group.
adult brain, and to utilize similar techniques for aid-
ing in diagnosis, localization, understanding dis-
abilities, and suggesting remediation. There is, how- Equipotentiality and Plasticity in the
ever, abundant evidence that functional localization
within the child's brain may be different from the Young Brain
relationship seen in the adult brain although the mag-
nitude of this difference is disputed. Techniques for There has been abundant discussion and debate
localization in children must be based not only on an about whether the young brain is equipotential (i.e.,
awareness of lateralized and intrahemispheric pat- are all parts of the brain uniformly competent to sup-
terns of presentation, such as those so important in port specific functions, such as language?) and
understanding the effects of structural brain damage whether it is more plastic than the adult brain (does it
recover more readily than the adult brain from similar
injuries?). Perhaps the easiest group of patients to use
GRETAN. WILKENING DepartmentofNeurology, The to discuss the equipotentiality hypothesis are those
Children's Hospital, Denver, Colorado 80218. who have had hemispherectomies (St. James-Rob-
291
292 CHAPTER 16
erts, 1979, 1981). This group of patients allows us to supports basic visual spatial skills, it is unable to
assess whether either hemisphere can support, with sustain right hemisphere functions that generally de-
equal success, language and other functions thought velop in the second decade of life.
to have lateralized representation within the adult In summary, neuropsychological test data sug-
brain. gest that the two hemispheres are not equipotential.
In a series of studies evaluating individuals who Although language develops in the isolated right
received hemispherectomies prior to 6 months of hemisphere, comprehension and production, both
age, who have normal intelligence and eventually written and oral, show subtle disturbances. Similar-
adequate school performance, Dennis and her co- ly, the isolated left hemisphere, although capable of
workers convincingly demonstrated that language basic directional and visual spatial perception, can-
can be supported in the isolated right hemisphere not as easily mediate complex visual spatial deci-
(e.g., Dennis & Kohn, 1975). Children who received sions. The pattern is similar to what is seen in adults
early left hemispherectomies, so that we know that who sustain later focal brain damage, although it
language is supported by an isolated right hemi- clearly represents not only an attenuated pattern, but
sphere, learn to speak and understand language at a a different pattern (Dennis & Kohn, 1974). Other
level sufficient for everyday discourse. Nev- data supporting the idea that the two hemispheres are
ertheless, when compared to individuals who had not equipotential even at birth included structural
early right hemispherectomies, those with early left (Geschwind & Galaburda, 1985) and physiological
hemispherectomies show subtle language disorders (Witelson, 1977) differences between the hemi-
as evidenced by differences in the rate of develop- spheres that exist from birth, or from very early in
ment of certain language skills, the time taken to life.
complete tasks of syntactic understanding (Dennis & If the brain is not equipotential, i.e., specific
Kohn, 1975), and differences in proficiency in un- areas are neuroanatomically designed to support spe-
derstanding complex syntax (Dennis & Whitaker, cific functions, how do children with early lesions
1977). Syntactic deficits are evident in a variety of acquire functions that should have been mediated by
contexts including production, repetition, com- damaged areas? It has been suggested that the young
prehension, awareness of anomalies, and judgment brain has greater plasticity, that functional re-
of word relationships (Dennis & Whitaker, 1976). organization is possible, with recommitment of neu-
The written language of patients with an isolated ral tissue to .compensate for damaged brain (Chelune
right hemisphere reflects a similar configuration & Edwards, 1981). Recommitment is thought possi-
(Dennis, Lovett, & Weigel-Crump, 1981). Indi- ble only when the neural substrate that is to substitute
viduals with early left hemidecortectomies learn to for damaged brain is not yet consistently supporting
read and spell, however, the type of errors they make other cortical functions (Finger & Stein, 1982). If
suggests that the isolated right hemisphere does not recommitment can occur, there must be a timeline
have access to higher-order linguistic rules. For ex- that would help us to understand at what ages the
ample, when asked to assess if a string ofletters could process of anomalous localization of function is pos-
be a word (e.g. , is the order and grouping of letters in sible, and when these changes are no longer viable,
nonwords permissible in the English language?) the with damage that may occur producing behavioral
left hemidecorticate subjects are less sensitive to the patterns more similar to what is seen in the adult
linguistically probable sequence ofletters in English. population.
Less information is available about the develop- Unfortunately, there is no firmly demonstrated
ment of ''right hemisphere skills'' in the isolated left or consistently agreed upon timeline to describe
hemisphere. Kohn and Dennis (1974) reported that when functional reorganization in humans is possible
both right and left hemidecorticate subjects perform (Hecaen, 1976). The largest set of data pertains to
competently on tasks of personal spatial organiza- recovery of function in childhood aphasia, but even
tion, and identification of fragmented visual stimuli here the time constraints are unclear with authors
in overlapping figures. However, the right hemi- variously citing from 2 years to puberty as the point
decorticates (e.g., an isolated left hemisphere) have beyond which reorganization is impossible (Satz &
significant difficulties on tasks requiring the use of Bullard-Bates, 1981).
spatial organization skills in more complex test situa- In considering the issue of plasticity and recom-
tions. For example, the isolated left hemisphere per- mitment and the research regarding children's recov-
forms less competently than the isolated right hemi- ery, it must be remembered that there are alternative
sphere on tasks such as mazes. Kohn and Dennis hypotheses explaining why children recover from
concluded that although the isolated left hemisphere brain damage differently than do adults (Finger &
TECHNIQUES OF LOCALIZATION 293
Stein, 1982; Chelune & Edwards, 1981). In fact, remembered that children more rarely than adults,
there is some evidence that functional reorganiza- present with acute, progressive, and focal cortical
tion, such as displacement of language to the right disorders such as those disorders that produce the
hemisphere, is relatively rare (Milner, 1974 ). Addi- specific patterns seen in adulthood (Reitan, 1972).
tionally, there are other researchers who maintain This reflects both the type of injuries and illnesses
that differential age effects reflect only meth- most common in children, and the fact that the period
odological error, not biological reality (St. James- between injury and evaluation is often much longer in
Roberts, 1979, 1981). children. For all these reasons, localization of func-
An important issue in considering localization tion in children can be a perilous and difficult
of function in children are the data suggesting that the enterprise.
most pronounced and consistent sequela of early Given that children with early focal brain injury
brain damage is a general decline in intellectual func- sometimes manifest a pattern of focal-looking defi-
tion (Milner, 1969; Reitan, 1974; Rutter, 1982). cits, what can be said about how to make sense of the
Even in those studies that demonstrate that the pattern data regarding a specific child? A review of the liter-
of perceptual and cognitive disabilities in early focal ature clearly demonstrates that there have been few
acquired lesions is similar to what is seen in adults, attempts to discuss techniques for localization in
there is an overall decrement in measured intel- child neuropsychology and only rare descriptions of
ligence when compared to controls (Aram, Kelman, specific patterns of deficit that are secondary to focal
Rose, & Whitaker, 1985). Woods (1980), for exam- injuries in children. There are numerous studies
ple, compared children with early unilateral (evident (e.g., Dennis, 1977;Pennington, VanDoornink, Mc-
prior to 1 year of age) or late unilateral (evident after Cabe, & McCabe, 1985) that have looked at groups
the first year of age; right hemisphere damage mean of children with nonfocal brain damage (at least at the
age of onset 6.4 years, left hemisphere damage mean structural level) and suggested that the patterns of
age of onset 5. 7 years) damage to the performance of cognitive and perceptual deficiencies are similar to
their closest in age sibling. Both the early right and adults with lesions in specific areas. Similarly, many
early left hemisphere-damaged groups differed from studies have discussed children with no known
their sibling controls on verbal and performance IQ. damage, but who have learning disabilities, and re-
The late left group differed significantly from their lated their pattern of disturbance to what is seen in
sibling controls on both verbal and performance IQ. adults with focal injuries (e.g., developmental
The late right group differed at a significant level Gerstmann's syndrome). There are far less data,
only on performance IQ. Rutter (1982) similarly however, discussing specific syndromes in children
found an age effect, with early localized lesions more with known focal lesions. In the next section, the data
likely to produce a decrement on tests of intellectual that are available will be discussed in terms of func-
functioning. tions rather than in terms of specific brain areas.
Despite the paucity of consistent data, and the Subsequent to that, several cases including analysis
many questions that remain unanswered, some con- of localized deficits will be presented.
clusions are possible that may serve as a guide in
clinical practice. It seems that there are consistent
patterns that emerge, even when young children sus-
tain brain damage, with left hemisphere lesions pro- Motor Functions
ducing disturbances in higher-level linguistic func--
tions including language-based academic skills, and Assessment of motor skills has been a standard
right hemisphere lesions producing subtle difficulties part of neuropsychological evaluation. Traditional
in the organization of extrapersonal space. These def- forms of assessment include evaluation of motor
icits are both le:;;s striking and less consistent than speed (e.g., the Finger Tapping or Finger Oscilla-
what is seen in adults who sustain similar injuries tions Test), dexterity (e.g., the Grooved Pegboard
(Rutter, 1982; McFie, 1961). The specific deficits Test), and strength. These measures are useful in
are often superimposed on a pattern of an overall localization if they are suggestive of unusual
decrement in measured intelligence. The patterns left/right differences.
that emerge seem to change with age so that the older There have been a number of studies evaluating
a child when sustaining a focal injury, the more likely the normal level of difference between hand perfor~
he or she is to present with a pattern that is similar to mance at different ages (Spreen & Gaddes, 1969;
brain-behavior relationships as they are manifested Denckla, 1973). Denckla (1973) noted that there ap-
in adults. In terms of clinical utility, it must also be pears to be a normal developmental sequence de-
294 CHAPTER 16
scribing the difference between hand performance on difference are one of the four means of inference used
repetitive tasks. In very young children, right-sided in neuropsychological diagnosis, lack of lateralized
(most often) functions are established first, with a motor deficits is not always consistent with the ab-
wide gap between left- and right-sided performance. sence of brain damage, nor with the absence of later-
Left-sided performance then increases rapidly so that alized brain damage, especially when a child is seen
although right-sided performance continues to be su- after a period of recovery. Certainly when lateralized
perior, the asymmetry is not as great. Annett (1970), motor deficits are clearly demonstrable, one's confi-
however, found no systematic change in the dif- dence in understanding the data is increased. Nev-
ference in performance between hands across ages. ertheless, the pattern of recovery seen in young chil-
Typically, the difference between hands in nor- dren must be remembered. Simple, more basic
mal children between 5 and 13 years of age has been functions recover better than more complex skills
reported to be 10-20% (Spreen & Gaddes, 1969; (Wilkening & Golden, 1982), so that often motor
Denckla, 1973). Differences between dominant and recovery will be quite good. Cortical lesions recover
nondominant hand performance greater than 20% better than subcortical lesions (Goldman, 1974) so
suggest a relative weakness in the nondominant that lateralized motor difficulties do not necessarily
hand. This would be consistent with damage to the suggest that consistent cognitive deficiencies will be
hemisphere contralateral to the nondominant hand. seen.
Differences between hands that are less than ex- During evaluation of motor functions, qualita-
pected suggest poorer than normal performance of tive observations are possible, and important. Mirror
the dominant hand. This could be indicative of movements are normal for the first decade of life.
damage to the dominant, most often left, hemi- Nevertheless, the consistent and lateralized presence
sphere. Conclusions must be cautious, within the of mirror movements (e.g., unintentional, uncon-
context of other data. There is some suggestion that scious movements of the hand that the child is not
in a normal population, the disparity between left and trying to move) may be suggestive of damage in the
right hand performance is less for young males than hemisphere ipsilateral to the hand unintentionally
for young females (Annett, 1970). moving (Woods & Teuber, 1978b).
There have been a number of studies indicating
congruence between hand performance in children
and other neuropsychological deficits presumed to
accompany lateralized dysfunction. When locus is
defined by the presence of hemiplegia (Annett, 1973; Deficits Tactile
Kiessling, Denckla, & Carlton, 1983; Kershner &
King, 1974), numerous studies have reported poorer Pathognomonic signs of brain damage such as
speech and language skills in children with right- consistent defects of simple sensory sensation, and
sided motor deficits than with left-sided motor dys- tactile extinctions are important diagnostically, and
function. Rourke, Yanni, MacDonald, and Young may be indicative of localized lesions. When demon-
(1973), studying learning-disabled children with pre- strated, the localization indicated is the same as that
sumed, but nondemonstrable, "cortical dysfunc- suggested by these symptoms in the adult population,
tion,'' found poorer right-handed motor performance for example, a lesion of the parietal lobe contralateral
in children with cognitive deficits presumed medi- to the neglected or insensitive side. Such signs are
ated by the left hemisphere (e.g., reading and spell- rarely seen in children, however, probably because
ing). The differential hand performance was seen children less often sustain focal lesions, and are most
only on more complex measures of motor perfor- often evaluated when the injury has become chronic.
mance (Grooved Pegboard), but not on measures of A sensory exam should be included in all neu-
simple motor function (as in finger tapping) (Rourke ropsychological batteries. Standard evaluations often
& Strang, 1978). This finding must be used with include assessment of tactile sensitivity, the presence
circumspection as it is based on consistency of neu- of finger agnosia, attention to double simultaneous
ropsychological deficits, not structural or physiologi- stimulation, graphesthesia, and stereognosis. The
cal evidence of brain lesions. stimuli used and the response mode required depend
When interpreting lateralizing motor deficits or upon the developmental level of the child being as-
the lack of such in clinical practice, several caveats sessed, and the child's status insofar as his or her
are warranted. Differences are interpretable only if ability to respond. Kinsbourne and Warrington
they are consistent across measures. Though neuro- (1962, 1963b) described a means of assessing "fin-
psychologists emphasize (Boll, 1981) that left-right ger sense" (topographic organization of tactile stim-
uli) so that adequate performance is not dependent multaneous stimulation) are rare (Rudel et at . 1974).
upon naming of fingers, a task often too difficult for Nici and Reitan ( 1986) reported that sensory tasks are
younger children. They found that by 6 years of age, ineffective in discriminating brain-damaged from
most of the children assessed were able to successful- normal children. Unlike adults with brain injury who
ly complete their tasks of finger differentiation and often have deficits in sensitivity, children rarely
could assess the spatial relationship between fingers. make errors of detection, though they do have com-
"Finger sense" is not the same as finger localization parable difficulty on higher-level integrative tasks.
as described by Benton (1955), but also may be relat-
ed to adequate function of the tertiary parietal areas.
In completing an assessment of tactile functions in
children, extreme care must be taken not to confuse Visual Perception
inattention with poor sensory performance.
Unilateral difficulties of simple tactile sensation As in the other modalities, pathognomonic signs
(touch sensation, increased two-point discrimina- of brain damage such as visual field defects are useful
tion, finger agnosia) are indicative of injury to the for diagnosis and topographic localization, but are
posterior portion of the contralateral hemisphere. infrequently seen in children, especially those with
Trouble with the more complex integrative tactile chronic lesions. Primary disturbances of visual func-
task of stereognosis is more difficult to lateralize. tioning have the same localizing significance in chil-
Unilateral deficits suggest injury to the parietal lobe dren as they would in adults. A left homonymous
of the contralateral hemisphere. Bilateral difficulties hemianopsia is characteristic of pathological changes
may, however, be indicative of severe right hemi- affecting the visual fibers of the right hemisphere,
sphere dysfunction, as the right hemisphere appears posterior to the optic chiasm. A right homonymous
dominant for tasks necessitating spatial problem hemianopsia suggests pathological changes in the left
solving in adults (Benton, Hamsher, Varney, & hemisphere. The quality of the hemianopsia, and the
Spreen, 1983; Rapin, 1982). There is some sug- accompanying neuropsychological changes vary ac-
gestion that the same pattern is true for children cording to whether the lesion is more anterior (e.g. ,
(Rudel, Teuber, & Twitchell, 1974). temporal) or more posterior (parietal or occipital)
The adult literature also suggests that bilateral (Martyn, 1975). A binasal hemianopsia requires in-
disorders of topographic organization of tactile stim- volvement of bilateral temporal visual fibers simul-
uli (e.g., difficulties with bilateral finger agnosia) taneously, and can be secondary to papilledema.
seen as part of Gerstmann' s syndrome are a conse- Bitemporal hemianopsias occur secondary to lesions
quence of lesions of the left angular gyrus (Strub & compromising the optic chiasm and are seen in chil-
Geschwind, 1983). Kinsboume and Warrington dren with pituitary tumors, though they occur most
( 1962) and Benson and Geschwind ( 1970) feel that often as a consequence of a craniopharyngioma or
although a developmental Gerstmann's variant ex- optic glioma (Martyn, 1975). Lesions of the primary
ists, no known localized pathology can be posited, occipital cortex are less common in children than in
despite the similarity to the adult symptoms. adults (The Ophthalmologic Staff of the Hospital for
Interpretation of localization based on the re- Sick Children, 1967), though they are seen. A re-
sults of a sensory exam must take into account the cently described, presumably genetic disorder,
chronicity of the condition, and whether the child has MELAS (mitochondrial encephalopathy, lactic acid-
sustained a known injury or is presumed to have a osis, and stroke-like episodes) (Pavlakis, Phillips,
developmental anomaly. The tactile consequences, Mauro, DeVivo, & Rowland, 1984), is notable for
for example, of congenital absence of the corpus cal- episodes of cortical blindness secondary to change in
losum, a developmental disorder in which in- the primary visual cortex.
terhemispheric transfer of information is limited, are Visual extinctions are rarer in children than in
different from what is seen in an adult whose corpus adults. When they are seen, visual extinctions are
callosum is surgically divided. Such children can suggestive of parietal neglect. Visual neglect may
complete tasks of intramanual transfer of information sometimes be observed when children are complet-
(Dennis, 1976). Similarly, early brain damage does ing the picture arrangement section of the WISC-R,
not have the effect of increasing the threshold for the reading section of the WRAT, or the Peabody
tactile stimuli so that errors by children with known, Picture Vocabulary Test. Neglect is manifest by con-
sometimes lateralized, brain damage on tasks assess- sistently missing items on one side of the page or
ing elementary sensory functions (two-point discrim- table. Informal cancellation tasks, for instance, hav-
ination, position sense, localization with double si- ing the child circle all the x 's on the page, can be used
296 CHAPTER 16
to identify visual field neglect. Obviously, such pat- mance on construction tasks, judging line orienta-
terns are important to identify for safety reasons, tion, and block design is seen.
even more so than for aiding in localization. Prosopagnosia can be informally evaluated
Visual agnosia in children has not been de- using family snapshots, and asking the children to
scribed in the literature, though it is seen clinically. identify family members. This will clearly demon-
In my practice, two cases of associative visual ag- strate the deficit. The Faces and Places section of the
nosia secondary to confirmed damage have been K-ABC can also be used. Colored chips often used in
identified. Associative visual agnosia is typified by Montessori classrooms, or paint chips may be used to
inability to assign meaning to what one observes de- assess color matching skills.
spite adequate visual perception (Alexander & Al- In our Neuropsychology Lab, one case of apper-
bert, 1983). In one case the bilateral occipital lesions ceptive agnosia has been identified. Apperceptive vi-
that have been described as producing agnosia in sual agnosia is identified when the inability to recog-
adults were demonstrable. In this child the lesion was nize objects is a consequence of deficits in basic
secondary to bilateral strokes, the pathological pro- visual perception (Alexander & Albert, 1983). The
cess often responsible for visual agnosia in adults. child had aCT-documented lesion in the right par-
Only unilateral (right hemispheric) structural damage ieto-occipital area. With this type of agnosia more
was demonstrable on Cf scan in the second child. basic deficits in perception are seen. The child was
The child had had herpes encephalitis, so that it is not able to name pictured objects, but also had diffi-
possible that bilateral lesions were present, though culty judging the orientation of lines, or matching
not seen on CT scan. Both children had accompany- faces or pictures. Performance on the Gestalt Closure
ing prosopagnosia, and central achromatopsia. They Section of the K-ABC was notably deficient. Identi-
were able to name colors in order to answer questions fication of objects was attempted by picking out a
(e.g., "What color is grass?") and performed ade- detail, and then guessing at what the whole might be.
quately on tasks such as the Ishihara plates, but were Though patterns of deficit similar to what is seen
unable to match colors or name the color of an object in adults with right parieto-occipital and bilateral oc-
they were shown. cipital damage are demonstrable, all the cases I have
Associative visual agnosia is demonstrable on reported reflect lesions acquired after 5 years of age.
the visual section of the Luria-Nebraska Neuro- Children with earlier acquired lesions do not gener-
psychological Battery (Golden, Hammeke, & Pu- ally demonstrate such circumscribed, specific defi-
risch, 1980). Such children cannot easily identify cits. Rudel and Teuber (1971), for example, found
pictured objects, especially when they are presented that children with early lesions had difficulty with a
with line drawings. They more easily identify real route-finding task of spatial orientation, regardless of
objects or photographs. Their performance on the the site of their lesion. The same task is differentially
Boston Naming Test may be disturbed. The naming sensitive to parietal lesions, particularly right-par-
errors they make reflect their visual deficits. For ex- ietal lesions in the adult population. All children with
ample, a pretzel may be called a worm, with correct early brain damage performed poorly on this task,
naming possible once the function (e.g., "It's some- their mean performance being poorer than children
thing you eat'') is described. I have found the Gestalt whose mean chronological age was less than the
Closure Section of the Kaufman Assessment Battery mean mental age of the brain-injured children. Of
for Children (K-ABC) (Kaufman & Kaufman, 1983) interest is that when the brain-injured group is divid-
to be helpful in understanding such children. Qualita- ed into two groups-those whose WISC Perfor-
tively, the examiner may also observe errors on the mance IQ was less than their Verbal IQ, and those
Picture Completion and Picture Arrangement sec- whose Verbal IQ was less than their Performance
tions of the WISC-R. These children are unable to IQ-the pattern is as one might anticipate based on
identify what is missing on Picture Completion be- adult performance. Poorer performance on the route-
cause they are not sure what the picture represents, finding task is more clearly associated with poorer
nor can they make sense of the order in Picture Ar- performance on Performance than on Verbal IQ.
rangement because they have no idea what the story This pattern of performance-a relative im-
is supposed to be about. Sometimes their inability to poverishment of Performance IQ compared to Verbal
recognize objects despite adequate perception is de- IQ-has frequently been reported in children with
monstrable on the Peabody Picture Vocabulary Test. right-sided brain injuries (Woods & Teuber, 1973;
Here their errors are secondary to visual errors, not Kershner & King, 1974; Annett, 1973; Fedio &
receptive language difficulties. Adequate perfor- Mirsky, 1969). It may be that what this represents is
an attenuated presentation, a less differentiated aphasia literature. There have been some recent at-
though similar version, of what is seen in the adult tempts to describe specific types of aphasia in chil-
population of individuals who have sustained right dren, and to relate these to specific areas of damage.
hemisphere lesions. Again, this conclusion must be This represents not only an attempt to increase our
tempered by other research that has found little asso- understanding of localization of function within the
ciation between Verbal and Performance discrepan- immature brain, but also an alteration in thinking
cies and site of lesion (Chadwick, Rutter, Thompson, about acquired childhood aphasia. In the past the
& Shaffer, 1981). Care also must be taken in in- disorder has typically been described as homoge-
terpretation because a number of studies have shown neous, regardless of intrahemispheric localization.
that Performance skills appear not to recover as well The traditional description of childhood aphasia
as Verbal skills secondary to diffuse lesions (Levin, included rapid onset followed by a period of mutism
Benton, & Grossman, 1982; Chadwick et al., 1981). or markedly decreased spontaneous language. Re-
What is useful clinically from this array of data is that ceptive language was said to be relatively more in-
when Performance IQ is lower than Verbal IQ, one tact. Jargon aphasia with increased fluency was said
might hypothesize that there are signs of right hemi- to not occur in children. Resolution of the aphasia
sphere damage, and the rest of the data must be con- typically has been reported to be good, with rapid
sidered with this in mind. Other evidence is clearly recovery. More recent reports suggest that there may
required, however, to corroborate and support such a be differences between aphasias associated with
contention. damage to specific brain areas even in children, and
that recovery may not be as rapid nor as complete as
has been previously reported, producing chronic pat-
terns of disability.
Language Skills Hecaen ( 1983) described differing presentations
of aphasia in children on the basis of more anterior
The study of language disorders in the adult versus more posterior localization. He found mutism
population has had a major impact on our understand- as the presenting symptom to be more common with
ing of how specific patterns of behavioral disorder frontal-Rolandic than temporal lesions, similar to the
reflect localized brain damage. There are multiple pattern seen in adults. Similarly, dysarthria was
schemes for classifying aphasia in adults and ongoing found to accompany 81% of the anterior lesions caus-
contention about the specific localization of various ing aphasia, but only 20% of the temporal lesions. In
forms of aphasia. Nevertheless, in adult neuropsy- general, within Hecaen's (1983) population, all lan-
chology one is fairly confident that acute acquired guage functions were more disturbed in the presence
language disorders suggest left hemisphere pa- of anterior left hemisphere lesions. When com-
thology. Similar conclusions may be possible in chil- prehension deficits were seen in aphasic children,
dren, though the pattern may be attenuated and less they were more likely to be associated with temporal
consistent. It certainly is more widely disputed. lobe disorders (Hecaen, 1976). Naming difficulties
Historically, there has been the contention that were found to have no localizing significance, sim-
acquired aphasia in children occurs as a consequence ilar to what is reported in the adult population.
of either left or right hemisphere lesions (Basser, Aram, Rose, Rekate, and Whitaker (1983) de-
1962). Recently, this notion has been strenuously scribed an acquired aphasia occurring secondary to a
disputed, and a number of reviews (Satz & Bullard- vascular lesion in the putamen, the anterior limb of
Bates, 1981; Carter, Hohenegger, & Satz, 1982; the internal capsule, and the lateral aspect of the head
Woods & Teuber, 1978a) rigorously demonstrate of the caudate. During the acute phase, the child had
that when only clearly confirmed localized cases are a nonfluent aphasia, marked by both phonemic and
considered, acquired aphasia in children, like apha- semantic paraphasias. (This is in contrast to Hecaen' s
sia in adults, is most likely to occur secondary to a left report (1976) that paraphasias are rare in childhood
hemisphere lesion. aphasia.) In the acute phase, difficulty with com-
Acquired aphasia in children would then sug- prehension was demonstrable, but no dysarthria was
gest that a pathological change to the left hemisphere present. Six and one-half months after onset, verbal
has occurred. This makes the assessment of acute language abilities had recovered completely, reading
problems relatively straightforward in terms of later- was normal, but spelling continued to be depressed.
alization, but does not address intrahemispheric dis- Ferro, Martins, Pinto, and Castro-Caldas ( 1982)
tinctions. These distinctions are pursued in the adult also reported on an aphasia that occurred secondary to
298 CHAPTER 16
a subcortical infarct (involving the internal capsule, and whether the child experienced a period of mutism
lenticular nucleus, and the insula). However, this or sparse language. Often this has been observed by
report is less useful because the child was left-handed, the parents as the child recovers, without it ever being
and the lesion right-sided. labeled "aphasia." Such information is useful in
Though the hallmark of acquired childhood making a topical diagnosis.
aphasia has been thought to be sparseness of overall The evaluation of language in children requires
output, Van Dongen, Loonen, and Van Dongen assessment of both its receptive and expressive com-
( 1985) reported the occurrence of fluent aphasias as- ponents. Adequate verbal IQ is not an indication of
sociated with cr-documented lesions of the left tem- normal language functioning, though the presence of
poral areas. In the three patients described, articula- a significant Verbal-Performance discrepancy with
tion was normal, with rapid rate of speech and normal Verbal lower than Performance is suggestive of lan-
prosody. Naming and repetition were disturbed, as guage difficulties. This is especially true when the
was comprehension. Paraphasias and neologisms Full Scale IQ is within the above-average range.
were prominent. Woods and Teuber (1978a) also de- Evaluation of expressive language includes as-
scribe a case of jargon aphasia secondary to a left sessment of repetition, naming, and complex verbal
hemisphere lesion, though the intrahemispheric lo- formulation. Naming deficits can be assessed in
calization is unknown. young children using the Stanford-Binet Intelligence
In my practice I have seen one child with a clear Scale or the K-ABC. There are norms available for
disturbance in phonemic discrimination and com- the Boston Naming Test as well. Norms for age-
prehension similar to what is seen in adults with flu- related changes in repetition of words and sentences
ent aphasias. cr and BEG results both suggested a are widely available. Complex verbal formulation
left anterior temporal disruption. In contradistinction can be observed on the WISC-R and in informal as-
to Van Dongen and colleagues' case, the lesion was sessment. Evaluation of receptive language must not
more anterior, and the child was dysfluent. Frequent be confined to understanding of words or simple sen-
paraphasias were present, however. tences. Informal assessment of receptive skills may
There is some suggestion that the specificity of fail to reveal profound difficulties in understanding
the language disorders seen in children secondary to complex syntactic structures, for in most informal
focal damage varies as a function of age of onset situations multiple cues are provided to aid in under-
(Hecaen, 1983). Some authors contend that younger standing. The Token Test, the Receptive Language
children, those .less than 10 years of age or so, are Scale of the Luna-Nebraska Neuropsychological
more likely to have the classic pattern (e.g., initial Battery, and other formal measures of receptive lan-
mutism with little comprehension deficit and rare guage functions are available. Care must be taken in
paraphasias), with older children demonstrating pat- interpreting localized damage when the only indica-
terns that are more consistent with aphasias seen in tion of left hemisphere disturbances is a language
the adult population (Satz & Bullard-Bates, 1981; disorder.
Alajouanine & Lhermitte, 1965). This pattern is not
reported by all authors. Similarly, there has been the
suggestion that the pattern of recovery differs across
ages, though again not all authors report this pattern Academic Skills
(Woods & Teuber, 1978a). Most authors agree that
even in the presence of good recovery of oral lan- As previously noted, difficulties with reading,
guage, children who have had left hemisphere lesions spelling, and arithmetic are frequent sequelae of left
with consequent aphasia are at great risk for ongoing hemisphere damage that is acquired in childhood.
academic deficits in mathematics and spelling, with This is true even in the absence of ongoing overt
reading difficulties often less extensive, but fre- language disorders. Hecaen (1976) reported that
quently seen (Hecaen, 1976, 1983; Alajouanine & arithmetic difficulties are the most frequent deficit,
Lhermitte, 1965). occurring in II of 15 cases in a population of children
Given more recent reports, it is clear that when who had acquired aphasia earlier in their childhood.
an evaluation reveals an acute language disturbance Woods and Carey (1978) reported ongoing spelling
in a right-handed child, the likelihood of a left hemi- difficulties in children with a clinically good recov-
sphere disturbance is high. In children with known ery from aphasia. Spelling difficulties were found
acquired lesions, it is often helpful, in taking the even in the group of children who sustained left hemi-
history, to ask about the child's pattern of recovery sphere lesions prior to l year of age, and who as a
group had no other signs of an ongoing aphasic dis- a nonfluent aphasia. Frontal alexia is thought to occur
turbance. Difficulties in acquiring spelling skills sub- with lesions of the anterior portion of the left hemi-
sequent to early left hemispherectomy were also re- sphere, with both cortical and subcortical involve-
ported by Dennis et al. (1981). In comparing ment (Benson, 1979).
individuals with early right and left hemidecortec- There is some evidence that children's failure to
tomies, they found that those with an isolated right acquire reading reflects pathology in the same lo-
hemisphere did not attend as automatically to graph- calizations implicated in adults with acquired ap-
eme-phoneme relationships, were Jess aware of the hasia. Duffy, Denckla, Bartels, and Sandini (1980)
valid letter sequences occurring within words, and reported group differences between dyslexic and nor-
more frequently violated orthographic rules. The iso- mal boys on topographically transformed evoked po-
lated right hemisphere, though able to read, acquires tential and EEG data. Differences were prominent in
this skill more slowly, does not perform as automati- the classical left temporal and parietal speech re-
cally, and is less able to exploit the linguistic struc- gions, bilateral frontal areas, and the left anterior
ture of a sentence in order to aid in fluent reading. lateral cortex. Similarly, Galaburda, Sherman,
Reading and spelling deficits were observed by Rosen, Aboitiz, and Geschwind ( 1985) reported au-
Chadwick et al. (1981) in a group of children with topsy findings of four men with developmental dys-
focal injuries to the left hemisphere occurring sec- lexia. All four revealed alterations in the usual asym-
ondary to depressed skull fractures with dural tears. metry of the brain (notably symmetric planum
As in other studies, academic deficits discriminated temporale rather than left larger than right) and devel-
children with left hemisphere injuries from those opmental abnormalities consisting of architectonic
with right hemisphere injuries, whereas other mea- dysplasias and neuronal ectopias. Though the devel-
sures, e.g., WISC scores, measures of verbal fluen- opmental abnormalities were bilaterally distributed,
cy, Matching Familiar Figures, left/right disorienta- they were predominantly located in the peri-Sylvian
tion, did not. classical speech areas of the left hemisphere. Though
Difficulty in acquiring academic skills second- the lack of normal asymmetry of the planum tem-
ary to earlier left hemisphere injuries is regularly porale occurs in 25% of the population, and develop-
reported. Acquired alexia in children is rarely re- mental anomalies occur in l 0% of the population, the
ported. In adults, acquired alexia occurs secondary to authors felt that it is Jess likely for both abnormalities
a variety of lesions. Alexia with agraphia, marked by to occur simultaneously by chance. They suggested
difficulty reading aloud as well as silently, and spell- that the pathogenetic process produces dyslexia only
ing deficits marked by better copying than writing to when it is significant enough to produce both types of
dictation, reflects damage to the parietal temporal developmental changes.
area of the left hemisphere (Benson, 1979; Green- Levine, Hier, and Calvanio (1981) reported one
blatt, 1983). Some degree of fluent aphasia is almost child who was unable to learn to read or write subse-
invariably associated with alexia with agraphia. Al- quent to an arteriovenous malformation producing a
exia without agraphia is notable though rare. This hemorrhage in, and subsequent removal of, the left
syndrome is marked by sustained ability to write in temporal lobe. No major disorder of intelligence or
the presence of very impaired reading skills. In fact, speech was present. The authors suggested that the
the patient is unable to read what he or she has just left temporal lobe may be involved in the acquisition
written. A right homonymous hemianopsia is an al- of written language skills. Galaburda et al. (1985)
most constant feature (Benson, 1979). This syn- reported five cases of dyslexia also associated with
drome occurs secondary to a lesion (most often a angiomatous abnormalities of the left posterior cor-
vascular accident) in the left medial inferior occipital tex, three left temporoparietal and two left temporal.
region with concurrent pathological changes to the Again, these cases represent failure to acquire written
splenum of the corpus callosum. Alexia secondary to language skills rather than loss of skills subsequent to
frontal lesions is also reported in the adult popula- focal damage.
tion. Frontal alexia is distinguishable by the patient's I have seen one clear case of isolated acquired
sustained ability to understand some written mate- alexia in a child in my clinical population. The young
rial. Patients can read many of the substantive words man, who was 14 years old when he lost his reading
in a sentence aloud or for comprehension but are skills, had recurrent abscesses of the left frontal and
unable to identify individual letters. Severe dys- left parietal occipital cortex. Alexia and agraphia
graphia is seen, with difficulty in copying as well as were present, unaccompanied by a right hemiparesis.
writing to dictation. It is most often accompanied by Language was notable for a marked dysnomia and a
300 CHAPTER 16
repetition disturbance. His speech was fluent with . in terms of failure to acquire skills rather than in
periodic paraphasias, but no neologisms. Under- terms of loss of previously acquired arithmetic
standing was disturbed. His alexia was profound, functions.
including inability to match letters written in differ- As previously noted, dyscalculia is frequently
ent types. He was unable to write to dictation. His reported as a long-term sequela of childhood aphasia,
alexia was secondary to the more posterior lesion, presumably reflecting left hemisphere damage. Dys-
and there has been little recovery. This case is re- calculia is one of the symptoms defining Develop-
ported in detail later in this chapter. mental Gerstmann's syndrome with acquired Gerst-
The fact that we most often see failure to devel- ruano's syndrome, which is thought to be a
op rather than loss of written language skills in chil- consequence of dominant angular gyrus deficits,
dren reflects our inability to assess skills that are not seen in adults.
yet firmly established. Young children are not sup- The localizing significance of arithmetic defi-
posed to know how to read or spell so we cannot cits is confused, however, by reports that develop-
possibly answer questions regarding the integrity of mental dyscalculia has been associated with other
these functions. Therefore, children only rarely can indications of right hemisphere disturbances. Rourke
be demonstrated to lose writing or reading skills; and his co-workers (Rourke Finlayson, 1975; Rourke
more frequently, they simply fail to develop. The & Strang, 1978; Strang & Rourke, 1985a,b) present-
implication of this (e.g., we are unable to assess ed evidence that specific difficulty in developing
skills not yet present) is apparent throughout child arithmetic skills with relatively better performance in
neuropsychology, and is particularly problematic in reading and spelling exists concurrently with a con-
thinking about localization of function. We can easi- stellation of deficits that distinguishes them from
ly establish that children who have had left hemi- children who perform relatively competently in arith-
sphere damage do not as easily learn to read as those metic but poorly in reading and spelling. Children
with no known damage or those with right hemi- with specific arithmetic deficits have particular diffi-
sphere involvement. But because children rarely culties with bilateral tactile perceptual and psycho-
have reading skills to lose, we cannot directly relate motor impairment (with left-sided performance more
the damage they sustain and subsequent loss of skill. impaired than right-sided performance) and impaired
Only rarely do we see disruption as an immediate visual spatial organizational skills. These children
consequence rather than a long-term sequela. often have an associated defect in social perception
Despite these limitations, the evidence that and judgment. This pattern is suggestive of difficul-
reading and spelling disorders are a consequence of ties with tasks mediated by the right hemisphere.
left hemisphere dysfunction is compelling. There is Rourke and his colleagues postulated that the failure
no evidence clearly implicating one area within the to have adequate sensory motor experience second-
left hemisphere. At a case report level, it appears ary to perceptual difficulties may account for the spe-
likely that the same areas that produce alexia in adults cific difficulty in acquiring arithmetic skills. It
may produce loss of reading skills or the failure to should be noted that although this research suggests
acquire reading skills in children. Rudel ( 1985) per- relative right hemisphere dysfunction in develop-
haps articulated this most clearly, noting that more mental dyscalculia, there is no evidence to suggest a
recent evidence suggests that children with develop- structural or focal lesion. Weintraub and Mesulam
mental dyslexia appear to have a basic disturbance in (1983) reported similar neuropsychological findings,
language processes suggestive of left hemisphere however, in adults with known right hemisphere
dysfunction. pathology.
Arithmetic skills, perhaps because they are so Clearly, dyscalculia or acalculia, because it rep-
complex, may be disrupted in adults as a conse- resents difficulty with a task that is so multifaceted
quence of either right or left hemisphere damage, or and complex, has limited localizing significance.
diffuse involvement. Calculation skills may be dis- The pattern of arithmetic, reading, and spelling defi-
rupted after damage to the tertiary areas of the domi- cits can be suggestive of laterality with all three skills
nant hemisphere (Luria, 1973). Written arithmetic often impaired in left hemisphere dysfunction, and
skills may be disrupted subsequent to posterior right arithmetic incongruously impaired with right hemi-
hemisphere damage presumably as a consequence of sphere dysfunction. Qualitative analysis of the errors
pervasive spatial confusion. There is little evidence made can be useful in understanding what part of the
regarding specific localizing implications of dys- arithmetic process is disordered, and hence sug-
calculia in children. As was the case with reading and gestive of localization. For example, if the child's
writing difficulties, deficits in arithmetic are reported performance is impaired because he or she cannot
read numbers, one might wonder about left hemi- en, 1981). As a later-myelinating area of the cortex
sphere disruption. This is particularly true if the dys- (Yakolev & Lecours, 1967), it has been suggested
calculia is seen in the context of dyslexia and dys- that it is impossible to observe functional deficits of
nomia. It should be emphasized, however, that the frontal cortex until the injured child has reached
dyscalculia has only limited localizing significance, adolescence. Some recent evidence suggests, how-
and must be interpreted in the context of the remain- ever, that performance on tasks presumably sensitive
ing battery (Strub & Geschwind, 1983). to frontal lobe functions in adults shows rather dra-
matic developmental changes prior to adolescence.
For example, on the Wisconsin Card Sorting Test
normal adult levels of performance are reached by
Executive Functions children by 10-12 years of age (Chelune & Baer,
1986). Passier, Isaac, and Hynd ( 1985) demonstrated
Executive functions-the ability to evaluate a that the verbal conflict and perseveration-eliciting
problem, plan a response, carry out that plan, and maneuvers used to demonstrate deficits in adults with
assess the adequacy of the response within the con- frontal damage fail to produce differential responses
text of the ongoing environment-are thought to be from control situations once children are about 10
subserved by the prefrontal cortex (Luria, 1973). years of age. This again suggests that "frontal
These functions are complex, rather subtle when op- skills'' mature through latency, but are demonstrable
erating effectively, and appear to mature with age. by about 10-12 years of age.
There have been vigorous disputes as to what con- There is some suggestion then that in children
stitutes a cognitive indication of prefrontal damage in who acquire specific focal frontal damage subse-
adults. Recent reviews suggest that formal neuropsy- quent to age 10, one should be able to demonstrate
chological testing, including performance on stan- impairments similar to what is seen in the adult popu-
dard tests of intelligence, is generally unaffected lation. It should be emphasized, however, that there
(Stuss & Benson, 1983). Performan~e on Trails B currently is no group empirical evidence indicating
may be somewhat slow (Jarvis & Barth, 1984) sec- that disproportional difficulties on, for example, the
ondary to mental inflexibility and difficulties with Wisconsin Card Sorting Test suggest structural
attention. Performance on the Wisconsin Card Sort- damage to the frontal cortices of children. The same
ing Test is grossly impaired with multiple persevera- statement is true for other tests thought to be sensitive
tions predominating (Robinson, Heaton, Lehman, & to frontal disorders in adults.
Stilson, 1980). There may be decreased verbal fluen- Clinically, the Wisconsin Card Sorting Test has
cy, and increased disinhibition on the Stroop Word been sensitive to damage to the prefrontal cortex in
Color Test (Stuss & Benson, 1983). Memory may be children even when such impairment is not seen on
disrupted by retroactive and proactive inhibition. other measures. Interpretation is greatly assisted and
Qualitatively, patients with damage to the pre- strengthened by concomitant findings, especially on-
frontal cortex demonstrate changes in personality going motor deficits. A note of caution, however:
functioning with both overexaggerated and apathetic difficulties on "frontal lobe tasks" are often seen
responses reported, often both seen in series (Mes- with more diffuse disorders in adults (Robinson et
ulam, 1986). Echopraxic responses to the environ- al., 1980) and I would anticipate the same might be
ment, i.e., responses that are a direct imitation on- true in children.
mediated by verbal knowledge (Luria, 1973), are
observed. Lhermitte (1986) and Lhermitte, Dillon,
and Serdaru ( 1986) described patients with damage
to the prefrontal cortex as being overly responsive to Memory
sensory stimuli (as processed by the parietal cortex)
because they lack the inhibition of inappropriate re- Research into memory deficits specific to a
sponses, which is normally provided by the frontal given modality has often emerged from the study of
cortex. Consequently, imitation of gestures even those with temporal lobe lesions and/ or temporal re-
when the patient is told that imitation is inappropriate sections for amelioration of uncontrolled seizures
is seen. Behavior increasingly is under control of (Milner, 1968). Current evidence suggests dissocia-
perceptions rather than autonomous self-regulation. tion between verbal and nonverbal memory with pa-
Self-appraisal is thought to be limited. tients with left temporal damage evidencing difficul-
There has been much discussion as to whether ties remembering verbal material and those with right
children can develop "frontal lobe" deficits (Gold- temporal damage experiencing difficulty in remem-
302 CHAPTER 16
bering visual information that cannot be easily ver- ically circumscribed patterns. As previously men-
bally encoded. These results have been repeatedly tioned, many of the disorders affecting children
demonstrated in adults. Butters (1984) and Squire (e.g., head injuries) damage the brain in a manner
( 1981, 1982) also demonstrated a differential pattern more likely to produce diffuse rather than focal inju-
of amnesia related to temporal versus diencephalic ries. All this being the case, why worry about lo-
damage. One such pattern is that individuals with calization of function in children?
temporal lobe damage demonstrate an abnormal rate At a heuristic level there are a number of reasons
of forgetting. Patients with diencephalic damage ap- why pursuing the possibility that there are circum-
pear to forget at a more normal rate. Other dimen- scribed psychological effects of focal injury in chil-
sions of memory as they relate to specific localized dren is important. Understanding the long-term im-
deficits in the adult population have been addressed. plications of early brain damage in terms of the issue
Not surprisingly, however, there has been little work of plasticity depends upon further elaboration of our
looking at specific memory deficits in children and understanding of focal damage and the factors medi-
relating these to focal impairment. ating its expression. Increased understanding of ac-
One exception is the study by Fedio and Mirsky quired focal effects may ultimately help us to under-
(1969). They compared the performance of four stand developmental brain pathology. For example,
groups of children: normals, children with gener- if specific right hemisphere damage produces visu-
alized three cycle per second spike and wave activity al/spatial deficits, and patients with Turner's syn-
on EEG, children with unilateral right hemispheric drome have a similar-appearing neuropsychological
epileptiform discharges on EEG, and children with profile, we may be able to begin to understand how
unilateral left hemispheric epileptiform discharges intrauterine and genetic disturbances affect brain de-
on EEG. In addition to an assessment of intellectual velopment. Using such an approach, Geschwind and
functions and attention, assessment of memory, both Galaburda ( 1985) theorized upon the emergence of
verbal and nonverbal and immediate as well as de- developmental dyslexia. Their theory is based upon a
layed, was completed. Although there were no sig- model of intrauterine differences with these dif-
nificant differences between the groups on length of ferences reflected in later lateralized effects. Lo-
memory span, there were moderately specific effects calization of function studies in children may also be
on measures of memory exceeding the subjects' basal useful because these should allow us to describe mu-
memory span (supra-span). Children with left tem- tually exclusive patterns of performance that typify
poral involvement demonstrated a flatter learning different disease states. A model for this in the adult
curve on a task of verbal learning than the remaining literature would be the dissociable memory deficits
groups. Children with right temporal involvement seen in diencephalic and temporal lobe patients.
had the lowest nonverbal supra-span. Delayed mem- Clinically, understanding focal brain-behavior
ory was also differentially impaired, with children relationships in children is of importance in structur-
with right temporal EEG abnormalities demonstrating an evaluation, providing counseling to families,
ing greater memory loss on a delayed reproduction of and assisting in the development of remediation strat-
the Rey-Osterrieth Figure than the remaining egies. Understanding of focal effects is helpful in the
groups, despite equivalent periods of exposure. process of evaluation. If we know a child has a spe-
These specific memory deficits were seen despite cific lesion, we can anticipate other associated defi-
normal performance on tasks of sustained attention. cits and use this to structure the evaluation (though it
should be clear that children often do not fit the antic-
ipated pattern, and a thorough, global evaluation fol-
lowed by subsequent finer testing of problematic
Reasons for Attempting areas is always recommended!). Knowledge of topo-
Neuropsychological Localization graphic brain-behavior relationships allows us to an-
ticipate associated deficits that should be looked for
Recent advances in neuroimaging (e.g., EEG, (e.g., if visual agnosia is identified, prosopagnosia
CAT scans, magnetic resonance imaging) provide should be anticipated). Counseling based on focal
noninvasive, relatively risk-free approaches to the brain-behavior relationships also utilizes the antici-
localization of structural brain lesions. Other mea- pated concurrence of patterns of disability. For ex-
sures (Brain Electrical Activity Mapping, Positron ample, children with visual-spatial disorders often
Emission Tomography, regional cerebral blood struggle terribly with learning long division. Coun-
flow) provide a means of assessing physiological ac- seling to help families and children anticipate and
tivity portrayed in a manner that reflects topograph- plan for such difficulties is helpful.
My focus during parent counseling is to help pattern may be useful in planning for a specific child.
parents see the difficulties their child has as part of The cases have been chosen to illustrate how the
one pattern that makes sense, not as a myriad of clinician might treat the data and are not representa-
distinct symptoms. For example, the hemi-neglect, tive of all patients seen in the practice of child neuro-
difficulty recognizing familiar people, and difficulty psychology.
drawing one mother identified are not three prob-
lems. Rather they are three facets of a unitary disor-
der. Such an approach supports families by decreas- Patient 1
ing anxiety, allowing them to plan for the future, and
helping them to make sense of the diversity of home F. U. is an 8-year 10-month-old female who was
observations. seen for a neuropsychological evaluation during hos-
Remediation strategies can be based upon a pitalization in an inpatient psychiatric unit. The hos-
knowledge of topographic brain-behavior rela- pitalization was evaluative in nature, with F. U. com-
tionships. This is true both for acquired focal lesions ing from and returning to a residential child care
and for deficits with no apparent etiological cause. facility. There were specific concerns regarding
Children with acquired lesions will have some recov- F.U. 's clinging, dependent behavior and her diffi-
ery of function but are often left with subtle deficits culty organizing herself in self-care routines. She
reflecting the focality of the initial damage. Remedial was seen as hyperactive.
strategies must be based upon compensatory ap- F. U. 's presentation was remarkable for her ea-
proaches. Such strategies can be developed using ger, enthusiastic approach to the evaluation. She re-
those functions known to be mediated by intact areas. membered the examiner's name, having read it from
For example, a child with a known acquired frontal the posted listing of appointments. On the walk to the
lesion who is unable to internally mediate responses exam room she stopped and checked printed signs,
to external events may have intact verbal skills. Such reading names to monitor her progress. The results of
a child can be taught to ''self-talk,'' to use intact her evaluation are presented in Table 1.
verbal skills to structure his or her own behavior. F. U. 's level of intellectual performance is at the
The use of known topographic brain-behavior lower end of the normal range. There are suggestions
relationships to aid in the remediation of develop- of both right and left hemisphere disruption, with
mental dysfunctions that present in a manner suggest- right-sided sensory and motor difficulties clearly pre-
ing focal pathology (e.g., language deficits seen in sent. Perhaps more outstanding, however, is her pro-
the presence of inability to acquire reading skills) is . found spatial disorganization and construction dys-
recommended by most authors, though the best strat- praxia. Though one might wonder if the spatial
egy given this information is controversial (Rudel, difficulties seen were another manifestation of her
1985). Most special educators advocate use of a left hemisphere impairment, the quality of her pro-
strength-based approach to remediation. Compen- ductions (see Figure 1) and her skillful language
satory strategies can be derived based upon using (good reading and spelling, no naming problems)
intact skills, or brain areas that are thought to be does not suggest that the left hemisphere difficulties
intact. explain the majority of her perceptual problems.
Clearly, the data 'available in child neuropsy- Qualitative and item assessment is revealing.
chology pertaining to topographic relationships are F. U. misses memory items requiring recollection of
scanty, and the factors mediating the long-term pre- visual material; however, she learns verbal material
sentation of focal injuries are not clear. Statements readily. Performance on tasks requiring recognition
regarding localization of function in children should of degraded pictures is notable for attention to de-
be made with circumspection. Often the best use of tails, with F.U. trying to identify the whole from
the data is to guide the psychologist in his or her observation of a part. Assessment of her performance
thinking, planning, and guidance of the family and reveals that in addition to the left hemisphere
other professionals, rather than attempting to clearly damage, evident in terms of right-sided sensory and
say "where" the damage is located. motor errors, there is also an indication of right pos-
terior dysfunction.
The clear identification of neuropsychological
Case Studies symptoms is particularly helpful in a child who has a
primary psychological or psychiatric diagnosis. It is
The following cases are included to demonstrate difficult to attribute F. U. 's lateralized sensory motor
how considering deficits as representative of a focal difficulties or the specific visual perceptual deficits to
304 CHAPTER 16
TABLE 1. Evaluation Results for F.U. (Right-

Handed Female Aged 8 Years 10 Months)
Stanford-Binet Intelligence Scale: 4th Edition
Verbal Reasoning Standard Age Score 74 !
Abstract-Visual Reasoning Standard Age 80 i
Score
Quantitative Standard Age Score 90
I
Short-Tenn Memory Standard Age Score 91 }
Composite Standard Age Score 81 i
Wide Range Achievement Test
Reading Standard Score 98
Spelling Standard Score 94
Arithmetic Standard Score 65
Gestalt Closure (Kaufman Assessment Battery for Children)
Scaled Score = 1
FlGURE 1. Rey-Osterrieth mme<hate reproduction.
Judgement of Line Orientation, Fonn V
2130 correct
Boston Naming Test
Given F.U.'s perceptual problems, a recon-
40 correct responses (X for age = 38)
sideration of her behavior is necessary. Might her
Trail-Making Test Fmger-Tapping Test clinging, dependent behavior relate to confusion
A = 19" RX = 20.2 about where she is, fear of getting lost, and difficulty
LX= 26.2 analyzing new and unusual situations? Indeed, inter-
Rey-Osterrieth Figure ventions aimed at helping F. U. to remain spatially
See Figure 1 organized; discussing where the group is going, look-
Luna-Nebraska Neuropsychological Battery-Children's Revised ing at maps, discussing what would be happening
T-Score prior to leaving the hospital, and allowing F.U. to
Motor ~ utilize her relatively more intact verbal skills (talking
Rhythm 72 about what to do if you get lost, rehearsing finding
Tactile 58 the store manager, and so on) decreased F.U. 's over-
Visual 79 reliance on adults. Similarly, she was aided in social
Receptive Language 71 relationships by establishing a photo album of impor-
Expressive Language 83 tant people that contained verbal labels. F.U. would
:!
Writing 53 use the book to help prepare herself for visits with
Reading
hospital staff (whose names she could almost always
Arithmetic
Memory 65 remember, but whose faces were less clear in her
Intellectual Processes 81 recollection). Labeling her dresser drawers with the
Pathognomonic 72 contentshelpedF.U. to remain organized. Similarly,
Left Sensory Motor 76 making a daily schedule dependent upon reading
Right Sensory Motor 47 words, not pictures of activities or reading a clock
- - - - - - - - - - - - - - - - - - - face, has assisted F.U. in maintaining independent
activity. F. U. 's difficulties suggest that recognition
and expression of affect may be an area of vul-
psychiatric dysfunction. Though F.U. has ongoing nerability for her at a neurological as well as at a
psychological difficulties, some of her ''disturbed'' psychological level. Therapeutic staff members have
behavior relates to her focal-appearing organic defi- worked with F. U. to assist her with affective recogni-
cits. These deficits appear to be chronic in nature. tion and expression.
There is no report of a recent change in performance.
Review of records reveals that F.U. was thought to Patient 2
have "mild cerebral palsy" as a toddler. A follow-up
neurological exam completed subsequent to the neu- K.N. was 15 years old at the time of evaluation.
ropsychological exam revealed some hyperactive During this evaluation he was hospitalized in a medi-
right-sided reflexes. ACT and MRI completed sub- cal inpatient unit for treatment of left hemisphere
sequent to this exam were both normal. abscesses that on CT scan were localized to the left
frontal and left parietal occipital areas. Despite solving abscesses, rather than to any secondary
known localized pathology, there were ongoing depression.
questions regarding cognitive and behavioral prob- K.N.'s protocol suggests that the left parietal
lems seen on the ward (e.g., depression versus occipital lesion has produced a Wemicke's-like
organicity, and questions about discharge planning).aphasia. There are signs of angular gyrus involve-
ment. The functional correlates included a marked
K.N. 's evaluation results are presented in Table
2. His presentation clearly demonstrates focal neu- repetition and comprehension disturbance. K.N. was
unable to understand complex grammatical struc-
ropsychological deficits, with K.N. 's perceptual and
cognitive difficulties exactly what one would have tures. Anomia was present and though some para-
phasic errors were seen, K.N.'s most common re-
predicted on the basis of anatomic localization. This
would suggest that the disturbances identified in his
sponse was to engage in circumlocution. Most
marked was the profound alexia with agraphia. K.N.
day-to-day functioning are closely related to the re-
was unable to easily match letters or words written in
TABLE 2. Evaluation Results for K.N. (Right- different styles. Numbers were misread as well.
Handed Male Aged 15 Years) Spelling errors included difficulty writing to dicta-
tion (e.g., wonche for once, nive for knife), as well as
Luna-Nebraska Neuropsychological errors in spontaneously generated material (e.g.,
Battery- pebl for people, wate for want).
Fonn 2 Left angular gyrus lesions often produce dys-
T-Score calculia. K.N. demonstrates clear calculation diffi-
Motor 37 culties. Mental arithmetic was mildly disturbed.
Rhythm 32 Written arithmetic was disrupted as well, with K.N.
Tactile 49 episodically confused in number recognition, reflect-
Visual 48 ing his left hemisphere deficits.
Receptive 78 Evidence of a language disturbance secondary
Expressive 86
Writing
to the posterior lesion was accompanied by both
79
Reading 85
qualitative and quantitative evidence of changes con-
Arithmetic 87 sistent with left frontal damage. Perseveration both
Memory 61 within and between tasks was seen, despite a rela-
Intellectual Processes 65 tively low level of perseverative responses on the
Left Frontal 75 Wisconsin Card Sorting Test. Some echopraxic re-
Left Sensory Motor 56 sponding was seen. K.N. was unable to persist at a
Left Parietal Occipital 76 task for a 10-second interval. He demonstrated clear
Left Temporal 64 problems in making accurate observations about ab-
Right Frontal 43 stract situations and was unable to easily generalize
Right Sensory Motor 57
from one situation to aid in understanding another.
Right Parietal Occipital 56
Right Temporal 67
His deficits are consistent with what has been de-
scribed in frontal lobe disorders (Luria, 1973). One
Category Test would anticipate these cognitive changes to be ac-
39 errors companied by the personality changes described in
Wisconsin Card Sorting frontal lobe disorders. Indeed, K.N. vacillated be-
13 perseverati ve responses tween irritable, hyperactive impulsive behavior and
Peabody Individual Achievement Test withdrawn apathy. Given the congruence of his cog-
Reading Recognition 2.6 grade level nitive and emotional presentation, and the locus of
Math 5. 3 grade level his lesions, one might best interpret K.N. 's presenta-
Spelling 2.7 grade level tion as secondary to the organic damage he has
Boston Diagnostic Aphasia Exam
sustained.
Reading Comprehension 2 correct/7 Discharge planning required careful coordina-
Matching words and tion with K.N. 's school. Frequent and intense speech
letters 8 correct/ 10 and language services were arranged. An individual
aide, to read for K.N. and to help him remain on task,
WISC-R (I month after current evaluation)
Verbal IQ 81
was provided. K.N.'s frontal symptomatology sug-
Perfonnance IQ 91 gests that social relationships might be endangered.
Full-Scale IQ 85 Consequently, psychotherapy to help K.N. cope with
this changed status and to learn new skills was ar-
306 CHAPTER 16
ranged. Intense education of school staff and family was invaluable in this project, as well as so many
was provided. others.
On follow-up exam, K.N.'s frontal symptoms
have resolved quite nicely though he continues to be
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17
Neuropsychological Sequelae of
Substance Abuse by Youths
ROBERT W. ELLIOTT
Drug- and alcohol abuse-related problems have been ior relationships. When drugs have been introduced
part of civilization since the ancient days, but it was into the brain, the specific purpose of the neuro-
not until the 1960s, when the counterculture became psychological evaluation can be to describe and mea-
a guiding force for the teen population, that society sure changes associated with altered cognitive func-
began to express widespread concern about adoles- tioning by investigating higher cortical functions,
cent use of drugs and alcohol. In 1975, a group of such as reasoning, memory, language, perception,
University of Michigan researchers began a longitu- and sensory-motor skills.
dinal series of studies to investigate the prevalence of Assessing youth is more complicated than as-
drug use by high school students (Johnston, O'Mal- sessing adults because of differences in emotional
ley, & Bachman, 1985). Although, by I985, John- development and brain development at different ages
ston et al. found that there had been a gradual decline and stages of development. During adolescence,
in the overall use of illicit drugs by the surveyed high there are spurts and plateaus in cognitive develop-
school seniors, nearly two-thirds had experimented ment; therefore, assessment of this dynamic and un-
with an illicit drug before graduation, and nearly half stable system should involve procedures and meth-
had used a drug other than marijuana. ods designed with these issues addressed (Rourke,
Children and adolescents, as well as young Bakker, Fish, & Strang, I983a-c).
adults, are populations rarely studied in drug abuse
research (Ivnik, I 986; Grant & Reed, I 985) although
this particular population is important because of is- Definitions
sues in brain development. It is during adolescence
that the higher-level cognitive attributes of planning, This chapter will focus primarily on the chronic
evaluation, flexibility, internalized behavioral con- effects of drugs. Chronic use implies the possibility
trols, higher-level abstracting skills, and ethical of long-tenn consequences after ingestion of the drug
awareness are developing (Golden, 1985). Use of has ceased (Ware, 1979). Acute effects are men-
drugs during this period could interfere with develop- tioned only when very few or no chronic effect stud-
ment of one or more of these attributes and have long- ies have been reported.
tenn ramifications for personality functions sub- "Drug dependence" and "addiction" are used
served by the frontal and prefrontal regions of the synonymously in this chapter. Both terms indicate a
neocortex. psychological and/or physical "need" for a particu-
lar substance (Parsons & Farr, 1981). "Tolerance"
Assessment of Youth indicates that increasingly larger doses are necessary
to achieve the same effects obtained with earlier use
The general purpose of a neuropsychological of the drug (Jaffe, I 975). "Withdrawal syndrome"
assessment is to describe and evaluate brain-behav- refers to the physical and psychological characteris-
tics observed in an individual when access to an ad-
ROBERT W. ELLIOTT Department of Special Education, dictive drug is reduced or terminated.
South Bay Union High School District, Redondo Beach, Califor- The research reviewed here has been. limited to
nia 90277. those studies investigating children, adolescents, and
311
312 CHAPTER 17
young adults, which herein will refer to individuals tremors, and deficits in gait and depth perception.
from birth through age 25 years. The researchers failed to establish a control group,
and no statistical data, description of the measures, or
information about the last use of marijuana was men-
tioned in this study.
Drug Classification Evidence of cerebral atrophy, including en-
larged left lateral ventricles, temporal lobe dilata-
There are a variety of classification schemes
tions, and damage to the region of the caudate nuclei
available that categorize drugs based on different cri-
and basal ganglia, was found by air encephalography
teria. Kiss in's ( 1977) system is one of only a few that
in lO male patients, average age 22 years, who had
are based on behavioral and central nervous sys-
smoked marijuana over a period of 3 to 11 years
tem consequences. He grossly divides psychoactive
(Campbell, Evans, Thompson, & Williams, 1971).
drugs into depressants, stimulants, and halluci-
Memory and concentration problems were evident in
nogens (Cepeda's chapter in this volume uses a more
most of the subjects. A serious flaw was introduced
detailed system). Parsons and Adams (1983) added
into this study when the authors failed to control for
inhalants to Kissin's classification system. No spe-
use of other drugs, because most of the subjects ad-
cific classification scheme was adopted for this re-
mitted to using other drugs. There was also no indica-
view because most of the specific drugs listed in these
tion as to when each subject had last used a drug.
systems have never been researched for long-term
Gleaton and Gowen (1985) hypothesized that
neuropsychological effects. Only drugs that have
because the marijuana cannabinoid chemicals re-
been the subject of more than one neuropsycholog-
mained in the body for weeks, there were subtle,
ical investigation are discussed.
long-term neurological effects, such as loss of short-
term memory, speech deficits, and symptoms con-
sistent with pre-senile dementia. They failed to sub-
Marijuana/Hashish stantiate their position with research findings.
A joint ARE/WHO scientific meeting report
Marijuana today is about 10 times more potent (Addiction Research Foundation, 1981) summarized
than the marijuana available 10 years ago. Hashish is many studies focused on the effects of cannabis. The
a refined form of marijuana, containing about 8% report noted that there was no evidence of residual
marijuana and about eight times the amount of A-9- brain damage, because computer-assisted tomo-
tetrahydrocannabinol (THC) found in most mari- graphic (CAT) scans of youthful cannabis users were
juana (Bell, 1985). Marijuana acts on the central asymptomatic.
nervous system as a depressant, although some re- Grant, Rochford, Fleming, and Stunkard ( 1973)
searchers (Kissin, 1977) treat it as a hallucinogen. studied 29 male medical students who had smoked
Over one-half of surveyed 1985 high school se- marijuana an average of three times a month regular-
niors admit to use of marijuana and/or hashish at ly for at least 3 years, and compared them against a
some time in theirlives (Johnston etal., 1985). Peak non-drug-using control group. The median age of
use is most prevalent in late adolescence (Schuckit, both the users and the controls was 23 years. The
1984, p. 123). Category Test, Tactual Performance Test (TPT), Ra-
Users report euphoria, a relaxed state, sleep- ven's Progressive Matrices, the Goal-Directed Serial
iness, heightened sexual arousal, hunger, decreased Alternation Test, and a special neurological exam
social interaction, short-term memory deficits, and were administered. The only significant difference
difficulty completing multiple-step tasks (Schuckit, between theusers and non users was on the TPT,
1984). Few studies report development of tolerance localization score. Although the researchers failed to
or physical dependence. find a number of significant differences, their sample
Kolansky and Moore (1971) examined the psy- was limited to bright, light to moderate users, who
chological and neurological performance of 38 psy- may have been well compensated.
chiatric patients, aged 13 to 24 years, all of whom Carlin and Trupin ( 1977) recruited a group of I0
smoked marijuana two or more times a week for well-educated subjects with an average age of 24
periods of more than 1 year. Although no standard- years. Candidates who had used any other recrea-
ized neurological exam was conducted, all of the tional drug I0 or more times, or who had suffered any
patients displayed limited attention span and im- neurological illness or injury, were excluded. The
paired cognition. Individuals who smoked marijuana subjects were asked to abstain from use of marijuana
four or five times a week displayed slurred speech, for 24 hours prior to administration of the Halstead
NEUROPSYCHOLOGICAL SEQUELAE OF SUBSTANCE ABUSE BY YOUTHS 313
Neuropsychological Battery. The only significant (p ylphenidate (Fischman et al., 1976; Martin, Sloan,
< 0.05) score difference between the users and non- Sapira, & Jasinski, 1976; Post, Weiss, Pert, & Uhde,
users was on the Trail Making Test, Part B, but sur- 1987; Trites, Sub, Offord, Neiman, & Preston,
prisingly, the user group performed better than the 1974). Thus, cocaine's powerful combination as a
nonuser group. local anesthetic and psychomotor stimulant makes its
Culver and King (1974) administered the effects difficult to interpret.
Halstead Neuropsychological Battery, WAIS, Trail The 11th annual University of Michigan high
Making Test, Laterality Discrimination Test, and se- school survey (U.S. Journal of Drug and Alcohol
lected tests from the Kit of Factor-Referenced Cog- Dependence, 1985, p. 4) revealed that adolescent
nitive Tests, to three groups of intact college seniors cocaine use was up in 1985 among males and females
(n = 84), aged 20 to 25 years. Group one were in most regions of the United States. The survey
LSD/mescaline users, the second group were mari- found that cocaine had been tried by 17.3% of the
juana/hashish users, and the third group served as seniors in the class of 1985, up from 16 .I% the pre-
controls. The marijuana/hashish users had used mar- vious year. This increase is alarming and has caused a
ijuana and/or hashish at least twice a month for at great deal of renewed search for preventive programs
least 12 months, and could be classified as light to (Elliott, 1987). An additional concern is the high
moderate users. The drug users agreed to abstain incidence of habitual use. Siegel (1984) completed a
from all drug use for the 7 days preceding testing. longitudinal study of 99 recreational users. He re-
There were no significant differences between the ported that 50% of these users maintained recrea-
marijuana/hashish users and the controls. tional use over a 10-year follow-up period. Of the
One study yielding positive physiological and remaining 50% who developed some degree of habit-
neuropsychological results with youthful marijuana ual use, 40% were "mild abusers" and 10% were
users (Campbell et al., 1971) was seriously flawed severe freebase users.
because most of the subjects used other drugs and Cocaine, an alkaloid derived from the mountain
also may have been manifesting acute rather than shrub Erythroxylon coca, is considered the most po-
chronic effects. Still, this study cannot be ignored. tent stimulant of natural origin. It can both incapaci-
Heath, Fitzgarrell, Fontana, and Garey ( 1980) found tate and excite neurons in the central and sympathetic
that exposure to THC, at doses commensurate with nervous systems (Maranto, 1985). Rosecran and
those used by human marijuana smokers, could result Spitz ( 1987) noted that cocaine could produce subtle
in changes in the limbic structure and endoplasmic imbalances in brain chemistry increasing the need for
reticulum and possibly produce nuclear inclusion more of the drug. Because cocaine is lipid soluble, it
bodies in rhesus monkeys. As suggested by Carlin reaches the brain quickly and stimulates production
(1986), deficits associated with marijuana use may of large amounts of dopamine, which may explain
be more subtle than can be detected by current meth- why use is so pleasurable (Estroff, 1985). The resul-
ods of assessment. Final conclusions cannot be tant high is short-lived, lasting only 10-30 minutes
drawn because most of the research generated to date (Elliott, 1987).
on marijuana has been flavored by methodological The issue of its addictiveness has been contro-
problems and biased sampling, but long-term effects versial since the 19th century (Rosecran & Spitz,
with chronic use seem highly probable (Fisher, 1987). As recently as 1982, Van Dyke and Byck
1987). noted in a Scientific American article that "The pat-
tern of behavior is comparable to that experienced by
many people with peanuts or potato chips. It may
interfere with other activities of the individual, but it
Cocaine may be a source of enjoyment as well" (p. 138).
Kaplan, Freedman, and Sadock (1980) noted that if
Cocaine has been separated from the other stim- " ... used no more than two or three times a week,
ulants in this chapter owing to its unique history, cocaine creates no serious problems" (p. 1621).
properties, increasing prevalence, public health Even in the American Psychiatric Association's diag-
threat, and addictive nature. Cocaine is defined as a nostic manual (DSM; APA, 1980), cocaine has a
potent local anesthetic but unlike other local anes- category for abuse but not for dependence (p. 173).
thetics such as procaine or lidocaine, cocaine is a The implication is that cocaine is a less serious addic-
powerful psychomotor stimulant that shares many of tive drug. The DSM-III Advisory Committee on Sub-
the behavioral and biochemical properties found in stance Abuse Disorders concluded that there was no
the psychomotor stimulants amphetamine and meth- evidence of withdrawal or tolerance, and thus no
314 CHAPTER 17
evidence of physiological addiction (Spitzer, not apply to cocaine. A new model of addictiveness is
Williams, & Skodal, 1980). Clinicians are now dis- necessary with cocaine.
covering tolerance and withdrawal features in free- The physical dangers connected with even a sin-
base and intravenous users (Gawin & Kleber, 1987; gle use of cocaine have been given wide coverage by
Spitz & Rosecran, 1987). the media during the last few years. Several well-
Although the long-term neuropsychological ef- known athletes have died suddenly after using co-
fects of both occasional and chronic cocaine use are caine. Athletes, in particular, may use this stimulant
unknown (Grant & Mohns, 1975), some data on neu- to mask fatigue, which can lead to injury and a gradu-
rological, physiological, and affective consequences al deterioration of performance ..
have been published (Adams & Durrell, 1984). Neuropsychological studies of chronic cocaine
Nunes and Rosecran (1987) noted many effects from use by young adults or adolescents have not been
chronic use including insomnia, hallucinations, para- attempted. Careful, controlled long~term studies of
noia, depression, lethargy, muscular twitches, trem- cocaine's effects on neuropsychological perfor-
ors, and muscular weakness. Elliott noted all of these mance are much needed at present, especially due to
effects and also convulsions in his clinical work with the widespread mythology surrounding use of co-
recovering adolescent cocaine users (Elliott, 1987). caine and beliefs in its enhancement of physical per-
Gawin and Kleber followed a group of 30 cocaine formance, alertness, and sexual response (Pope,
abusers seeking treatment over a period of months. 1987). EEG, brain imaging, and neuroendocrine
They found that many aftereffects of cocaine use techniques are available to document such changes
persisted for months and speculated that many subtle and have been used in much of the research focusing
effects might persist indefinitely (Gawin & Kleber, on drug addictions.
1986). Washton and Gold (1987) reported that 39%
of 500 cocaine users who had contacted the BOO-
COCAINE hotline claimed that they had suffered
cocaine-induced brain seizures with loss of con- Stimulants
sciousness. Reports of acute and short-term effects
are much more prevalent (Fischran & Schuster, After marijuana, the group of illicit drugs most
1981; Jones, 1984). Myers and Earnest (1984) noted widely used by teenagers are stimulants. Johnston et
that after three young adults (aged 20 to 25 years) al. (1985), in their annual survey of high school se-
injected 140-160 mg of cocaine, each sustained a niors, reported a use rate of 28%, the rate being
generalized convulsion. A neurological exam com- slightly higher for females than males.
pleted shortly thereafter, which included EEG and Stimulants can be grouped in three categories:
CT evaluations, was normal (Myers & Earnest, amphetamines, dextroamphetamines, and meth-
1984). amphetamines. Although the structure of each of
A few investigators have looked at the long- these synthetic drugs is different, each can produce
term consequences of chewing coca leaves by South similar, long-lasting cocaine-like effects. They differ
American Indians (Cagliotti, 1980; Negrete & Mur- primarily in their strength and duration of effect.
phy, 1967; Zapata-Ortiz, 1970). Although there were Stimulants act on the CNS by potentiating the effects
indications of deficits in attention, speed of respond- of norepinephrine, activating areas of the sympa-
ing, auditory and visual memory, and accuracy, the thetic nervous system (Young, Young, Klein, Klein,
deficits were subtle and the studies not well con- Klein, & Beyer, 1977). In toxic doses, stimulants
trolled. Occasionally, one comes across a statement produce stereotypic behaviors called punding
that cocaine may cause "brain damage" but these (Rylander, 1972), irritability, slurred speech, ataxia,
statements have not been validated in human studies tremor, paranoia, hallucinations, and death (Louria,
(Maranto, 1985). 1969; Holbrook, 1983a). Young students are fre-
Although the issue of addictiveness remains quently introduced to stimulants to fight fatigue and
controversial, the preponderance of findings from re- increase alertness during active periods.
cent research suggests that tolerance does exist. Although physical withdrawal symptoms are
Withdrawal signals are detectable on the EEG and in not evident when stimulants are suddenly discon-
sleep patterns, but the signals are weak compared to tinued, residual psychological effects may continue
the signals associated with withdrawal from barbitu- for several months (Holbrook, 1983a). Physical tol-
rates, alcohol, or opiates (Van Dyke & Byck, 1982). erance can develop in hours to days with continued
It may be that what we have come to believe are use, especially with .. speed" or methamphetamine
traditional withdrawal symptoms with most drugs do (Schuckit, 1984, p. 86).
Trites et al. (1974) evaluated the neuropsycho- other abused substances, such as glues, solvents, and
logical functioning of a group of average-IQ adoles- paint sprays (Callen, 1984), does not target a single
cents who were amphetamine users. Results of the organ system. Comstock and Comstock ( 1977) re-
Halstead-Reitan Neuropsychological Battery failed ported that nervous system, liver, and kidney injuries
to indicate brain dysfunction, the impairment index have been associated with toluene use. N-Hexane use
being 0.30. In a well-controlled study of chronic is clearly associated with polyneuropathy (Grant &
stimulant users, Grant, Adams, Carlin, and Rennick Reed, 1985). Gasoline vapor inhalation can cause
( 1977) were unable to find evidence of neuropsycho- motor neuronal degeneration, disorders of the hema-
logical impairment. topoietic system, and encephalopathy owing to the
A few researchers (Rylander, 1972; Connell, various additives such as TCP, lead, and benzene.
1966; Schuckit, 1984; Young et al., 1977; Louria, Aerosols frequently contained Freon, which can
1969) have suggested that the use of stimulants may cause hypercapnia, cardiac arrhythmia, renal tubular
damage the CNS, disrupting memory, concentration, necrosis, uremia, and sudden death (Wilde, 1975).
and abstract reasoning skills, but none of the re-
searchers presented corroborating evidence.
Glue Sniffing
Grant and Reed ( 1985) reviewed the available
Inhalants literature on the neuropsychological consequences of
toluene inhalation. They felt that although toluene
Inhalant abuse involves the voluntary inhalation had a fairly high margin of safety, evidence indicated
of the fumes from aerosols, anesthetics, or other sub- that long-term heavy use produced generalized cere-
stances in an effort to achieve an intoxicated state. bral atrophy and neuropsychological deficits.
The "high" is dose-related, cumulative over a short Allison and Jerrom (1984) compared the psy-
period of time, and may persist for periods ranging chological test performance of I 0 Scottish adoles-
from a few minutes to a few hours. Depression, seda- cents (mean age 15 years) who had inhaled solvents
tion, disorientation, coma, and death may result. for an average of 4i years against 10 matched control
Inhaling substances to enhance religious or my- subjects who had never inhaled solvents. The major
stical experiences goes back centuries (Berry, Heat- toxic component in the glue was toluene/acetone.
on, & Kirby, 1978). Sniffing glue to achieve intox- Intelligence, memory, and attention were assessed in
ication was virtually unknown in the United States both groups by means of the Vocabulary and Block
until about 1960 (Korman, Trimboli, & Semler, Design subtests of the WISC, the Wechsler Memory
1978). Soon thereafter, glue sniffing became epi- Scale (WMS), and the Paced Auditory Serial-Addi-
demic in many other countries. Solvents were attraction Task (PASAT). The results of this study indi-
tive because they were widely available, inexpen- cated weaker attention, verbal and visual memory,
sive, rapid in their ability to produce a "high," and and visuospatial problem-solving skills in long-term
they left the user with only a mild hangover (Cohen, users. Verbal abilities remained intact. Two crit-
1975). icisms were made regarding the design of this study.
Since 1981, inhalant use has been on the rise First, the test administrator was aware of the group
(Sharp & Korman, 1980). Johnston et al. (1985) assignment of each subject. Second, because of the
found that 19% of their high school seniors had used recency of the last use of solvents ( lO days to 6
inhalants sometime during their lives, with II% hav- weeks), acute rather than long-term consequences
ing used the drug in the previous year. In working may have been identified.
with inhalant-abusing youths, whom courts have More clear-cut findings were reported by Chan-
placed in treatment facilities, it has been reported that ner and Stanley (1983) in their examination of a 16-
Hispanics and blacks favored spray paint and Anglos year-old male who had begun to experience visual
favored gasoline. Young et a/. ( 1977) reported that hallucinations after inhaling a toluene/ acetone-based
inhalants seem to be used primarily by those between glue for 3 months. Four months after he had stopped
8 and 16 years. sniffing glue, a normal cr brain scan was recorded
Inhalants are diverse in their physiological, with a diffusely abnormal EEG and delayed visual
pharmacological, and behavioral effects, yet most evoked responses (VER). After 8 months, the hallu-
researchers tend to treat inhalants as a single class of cinations continued, the EEG was unchanged, and
drugs. Toluene, which may be the most widely the VERs were only minimally improved.
abused inhalant, either by itself or as an ingredient in Tsushima and Towne (1977) carried out an ex-
316 CHAPTER 17
tensive neuropsychological evaluation on a group of lead, as a causative agent, has been implicated in
20 ethnically mixed, paint-sniffing (primarily tolu- irreversible changes in cogntion (Ross, 1982).
ene-based) individuals (mean age of 18.5 years, Valpey, Sumi, Compass, and Goble (1978) dis-
range 11 to 24 years) from low-income housing pro- cussed an individual who began to inhale gasoline
jects. Although other drugs were used, paint fume and glue at the age of 13 years. Treatment for acute
inhalation was primary. They reported an average symptoms of gas sniffing began at the age of 17
use of 2. 3 cans of paint per day, for periods ranging years. One week after discontinuation of gas sniff-
from 2 to 13 years. A group of20 non-paint-sniffing ing, some skills improved. Nine months later, he was
individuals from the same neighborhood, matched readmitted after returning to gas sniffing. Tremors,
for age, education, and SES, served as a control bizarre behavior, poor time orientation, and deficits
group. The test battery, administered to both the ex- in recall of immediate and recent events were evi-
perimental and the control group, included the Finger dent. Two weeks after entering treatment, the trem-
Tapping Test, Seashore Rhythm Test, Trail Making ors subsided. Two years later, at the age of20 years,
Test, Grooved Pegboard Test, and Coding subtest of he was again treated for gasoline inhalation. The ear-
the WISC-R, Stroop Color and Word Test, Memory- lier symptoms returned and he became violent, suf-
For-Designs Test, and the Peabody Picture Vocabu- fered a convulsion, and developed symptoms of se-
lary Test. The data revealed significant differences vere dementia. Nine months later, he was again ad-
(2:: 0.05) between the sniffers and the controls on 11 mitted to the hospital, but died three days later. An
of the 13 measured variables, with sniffers exhibiting autopsy revealed mild cerebral cortical atrophy with
lower levels of performance on measures of motor ventricular dilation and patchy cerebellar atrophy.
speed, auditory discrimination, visuomotor function, The hippocampus, pons, thalamus, and pallidum
and memory. Limitations included the possibility of were all adversely impacted. As his serum lead con-
preexisting deficits in the sniffers, the admission by tent was markedly elevated on every admission, it
all of the sniffers that they had sniffed paint the day was suspected that tetraethyllead caused the demen-
before the assessment, imprecise paint-sniffing in- tia, ataxia, dysmetria, and dysarthria. Although the
formation, and lack of information about unknown researchers indicated that the patient had suffered
elements in the paint. chronic encephalopathy from sniffing gas, it was
In one of the earliest studies of glue sniffing, quite apparent that the patient did not stop sniffing
Massengale, Glaser, LeLievre, Dodds, and Klock gas for more than short periods of time following
(1963), evaluated 12 boys (aged lO to 16 years, me- each of his hospital discharges. Therefore, the effects
dian age 13 years)for cognitive function 12 hours to 7 could be more properly classified as acute rather than
days after their hist contact with glue. Toluene was chronic.
the major volatile component. Five tests were admin- Seshia, Rajani, Boeckx, and Chow's (1978)
istered, measuring attention, fine motor perfor- study supported the Valpey et al. (1978) study.
mances, detection of changes, design integration, They completed standard neurological examinations
and design recall. Despite inhalation of glue for peri- (EEG, Nerve Conduction Study, ECG, blood pro-
ods ranging from 1 to 42 months, there were no sig- file, X ray, and urine assay) on 50 Native Ameri-
nificant differences between the performance or cans, aged 4 to 20 years, who had _been referred to a
physical characteristics of the glue sniffers and a pediatric neurology service for evaluation and treat-
matched control group. ment following inhalation of leaded gasoline. Inha-
lation of gas vapors occurred for periods from 6
Gasoline Inhalation months in the youngest child to over 5 years in those
older than 12 years. Acute, but abnormal neu-
The inhalation of gasoline fumes for the purpose rological signs were apparent in 92% of the patients
of intoxication became a widespread problem follow- at day one. At 8 weeks, only one patient manifested
ing World War I (Lewis & Patterson, 1974). This fad residual neurological signs. This study suggested
quickly passed and was largely forgotten for a time. that although the acute neurological effects of gas-
In the 1950s, literature on the effects of gas sniffing oline vapor inhalation are acutely significant, over
began to reappear (Clinger & Johnson, 1951; Faucett time the adverse effects dissipate.
& Jensen, 1952), but the focus had changed from the
effects on adults to the effects on children. During the Multisolvent Inhalation
last few years, research on gas sniffing has focused
on children (Lewis & Patterson, 1974). Researchers Many investigators examining the effects of in-
have also been concerned about the effects of leaded halants have attempted to limit their research popula-
gasoline (Remington & Hoffman, 1984) because tion to youths who abuse only one type of solvent.
Other investigators have grouped their subjects to- in the preceding 2 years. The inhalant-abusing group
gether, regardless of the type of inhalants used. used an inhalant an average of over three times a day
Comstock (1977) evaluated 22 patients (mean for periods of time ranging from 1i to 17 years (aver-
age 17 years, range 13-26 years) who sought hospi- age 5.5 years). The control group was comprised of
tal treatment for solvent (toluene primarily) abuse. II subjects matched for age, sex. ethnicity. educa-
The patients had used inhalants an average of 4 tion, background, and use of substances other than
years (range 1-11 years). Twenty of the patients re- inhalants. The MMPI, WAIS, Category Test, TPT,
ported abuse of drugs as well as inhalants. The eval- Speech-Sounds Perception Test, Seashore Rhythm
uation process included EEG, EMG, nerve-muscle Test, Finger Tapping Test, Trail Making Test, Apha-
biopsy, and a general medical lab exam. The sic Screening Test, Spatial Relations, Reitan-Kl~ve
Halstead-Reitan was administered to two patients. Sensory-Perceptual Examination, Tactual Form Rec-
Despite heavy exposure to volatile solvents, the ognition, Grip Strength, Motor Steadiness Battery,
medical exam did not find CNS abnormalities. A Grooved Pegboard, Hole-Type Steadiness Test,
mental status exam identified "mental-grasp defi- Maze Coordination Test, and a modified Reitan Sto-
ciencies'' in 55% of the patients soon after their ad- ry Memory Test were administered to all subjects.
mission. Two weeks later, there was a clearing of The neuropsychological test scores were generally
these deficiencies. Of the two patients administered lower for the inhalant group than for the controls. The
the Halstead-Reitan, one scored in the pathological TPT, Tactual Form Recognition, Grip Strength,
range on a number of the subtests. The author hinted Maze Coordination, measures of learning efficiency,
at the possibility of residual impairment adversely memory score on the Story Memory Test, and both
affecting the ability of the patient to benefit from neuropsychological summary scores reached levels
''talking psychotherapy.'' The individual impaired of significance. Berry et al. concluded that inhalant
on the Halstead-Reitan remained impaired after 2 abuse caused impairment.
weeks. Limitations in this study included lack of a Korman et al. (1978) assessed 273 individuals
control group and failure to report on preexisting or (average age 21 years) seen in a psychiatric emergen-
contributing conditions. cy room over a 12-month period. With information
In a well-controlled study, Bigler ( 1979) per- obtained in a standardized psychiatric interview, the
formed extensive neuropsychological evaluations on researchers were able to establish three experimental
ten 16- to 19-year-olds (mean age 17.8 years) with a groups and one control group, all matched for sex,
history of chronic inhalant abuse (range 2-6 years). age, and ethnicity. The experimental groups consist-
The same testing was performed on three control ed of 37 inhalant users who used no other drugs, 54
groups matched for age, sex, and education. The inhalers who used other drugs, and 91 noninhalant
respective control groups ( 10 patients each) were: (a) multidrug users. Interview process ratings between
brain-damaged, (b) psychotic non-brain-damaged, the four groups on abstraction, insight, judgment,
and (c) non-brain-damaged/nonpsychotic patients. and other cognitive functions were more severely
Neuropsychological evaluations were begun about impaired for the inhalant groups than for the other
48 days after admission. They included administra- groups.
tion of theWAIS, Category Test, TPT, Rhythm Test, Noting the conflicting results with well-de-
Speech-Sounds Perception Test, Finger Oscillation, signed and -controlled studies, Korman, Matthews,
and Trail Making Test. The inhalant abuse group and Lovitt ( 1981) gathered 109 volunteer teenage
scored within the impaired range on most neuropsy- subjects for extensive neuropsychological testing.
chological measures and was similar to the brain- All of the subjects had used drugs but the range of use
damaged group in neuropsychological functioning. was unreported. Sixty-eight reported inhalants as
The nature of the neuropsychological deficits sug- their major drug of abuse, and 41 reported drugs
gested diffuse cerebral dysfunctioning. A factor that other than inhalants as their major drug of abuse. The
may have influenced the findings was medication Wechsler IQ test, most of the Halstead-Reitan
effects-7 of the I0 inhalant abusers were on a neu- Neuropsychological Battery, grip strength, motor
roleptic medication (Thorazine, Haldol, Cogentin, speed, and academic achivement measures were ad-
Mellaril, or Navane) of unreported dosage. ministered to all. Approximately 30% of the perfor-
In one of the most widely cited and carefully mance measures were completed with significantly
designed studies of inhalant abuse, Berry et al. lower levels of performance by the inhalant abusers
(1978) evaluated 37 inhalant-abusing youths (aver- than by the other drug abusers. Swprisingly, the
age age 18 years, range 14-29 years) who were re- more global and complex measures, such as the
ferred to a drug abuse treatment program. Sixty-two Wechsler IQ and academic measures, were most
percent were Hispanic, and they averaged five arrests clearly implicated, although both groups scored well
318 CHAPTER 17
below average. The authors concluded that inhalant B~ause of unexpected and unpleasant effects, it
abusers developed deficits in a wider range of cog- soon began to appear to new guises and in combina-
nitive areas than was previously known. Some caution with other drugs (Schuckit, 1984; Tong,
tion should be taken in interpreting the results of this Benowitz, Becker, Forni, & Boerner, 1975).
study as there was no drug-using control group, all of Although PCP is generally identified by users as
the abusers were multidrug users, the performances a hallucinogen, it cannot be accurately placed in any
of both groups were weak, and there was no mention single drug category. Most experts identify PCP as a
of the time elapsed since the last use of a drug. tranquilizer-anesthetic with hallucinogenic proper-
ties (Young et al., 1977).lts effects vary, depending
on the dosage, other drug involvements, age of the
Other Inhalants user, personality traits, route of administration, and
Acute physiological data and industrial ex- the physical setting. PCP increases the activity of the
posure results have been reported and compiled by brain dopamine system and interferes with the synap-
many different investigators for typewriter correction tic transmission between cells (Institute of Medicine,
fluid, deodorants, Pam, polishes, amyl nitrate, National Academy of Sciences, 1985; Schuckit,
nutmeg, chloroform, and ether (Chenoweth, 1977; 1984).
Lowry, 1979; Akesson, 1965; Lewis & Patterson, The use of PCP among adolescents declined be-
1974; Smialek, 1985), but none of these substances tween 1979 and 1981, but there has been little change
have been investigated neuropsychologically. since then. In the eighth annual High School Senior
The evidence is clear that inhalation of most, if Survey (Johnston et al., 1985), 5% of high scllool
not all, solvent fumes produces obvious acute CNS seniors admitted to use of PCP at some time in their
effects, including peripheral neuropathy. The issue is lives, with 1% admitting to use during the preceding
not as clear regarding long-term chronic effects. month.
Most of the available research indicates a clearing of Little is known about the neuropsychological
the nervous system over time when the primary effects of PCP, although clinical observations have
abused solvent is gasoline or glue. The evidence is indicated a progression from irritability to violence as
much more suggestive of permanent CNS impair- PCP use is continued (Fauman & Fauman, 1979).
ment when multiple solvents are inhaled. Such im- Mental health workers, friends of users, and users
pairment is apt to be general and most likely will themselves report decreased intellectual functioning
affect the complex, higher-order neuropsychological and confusion long after use of the drug has been
processes. discontinued (Ware, 1979; Schuckit, 1984).
Methodological problems and experimental ar- PCP produces dramatic changes in behavior,
tifacts complicate conclusions. Very few studies are memory, perception, and orientation. Because of
longitudinal and rarely is the issue of "presniffing" these effects, researchers have been concerned that
differences between experimental and control groups PCP use may result in permanent damage to the CNS,
addressed. Although multidrug users are identified as yet there has been very little formalized research
such, rarely are the types or extent of secondary drugs completed on neuropsychological sequelae of PCP
used by subjects fully identified. Although radi- abuse (Grant & Reed, 1985; Light, 1984).
ological investigations could add valuable diagnostic Ware (1979) compared the performance of eight
information, such techniques are rarely used in com- chronic PCP users to that of a group of eight multi-
bination with neuropsychological investigations to drug non-PCP users. The individuals [mean ages 19
confrrm or refute the presence of organic changes. and 20 years (range 16-35 years), respectively] were
inpatients at a state hospital, and were matched for
age, education, race, sex, current medication and
dosage level, and handedness. To ensure that they
Phencyclidine (PCP) were not showing acute effects of their drug abuse,
testing was not started until all of the subjects had
PCP was created by pharmacological research- been in the hospital a minimum of 3 weeks. The
ers as an animal anesthetic in 1956. In 1957, human Halstead-Reitan Neuropsychological Battery and
clinical trials were initiated, but the discovery of ad- WAIS were administered to all subjects. The PCP
verse side effects forced discontinuation of all human users performed worse than the multidrug users on
research by 1965. PCP made its appearance as a theWAIS Verbal IQ, Performance IQ, and Full Scale
"street drug" in 1966 in San Francisco, and was IQ, on the Information, Comprehension, Picture
marketed as the "PeCe Pill" (Reed & Kane, 1972). Completion, Block Design, and Object Assembly
subtests of the WAIS, and on the Speech-Sounds II had used drugs at least twice a week for at least 6
Perception test of the Halstead-Reitan Battery. The consecutive months but, on average, had not used
raters considered the PCP group to be more neuro- any drug during the 3-month period prior to testing.
psychologically impaired than the multidrug group, Each subject was given a standard neurological ex-
but the differences were not statistically significant. amination, EEG, and the WAIS and Halstead-
The researchers hinted at the possibility that chronic Reitan Battery. The only significant difference be-
users may experience more impairment in right than tween the groups was that the PCP/multidrug group
left hemispheric functions. Ware considered there- displayed more abnormal findings on Cranial Nerve
sults equivocal because the predrug intelligence lev- VIII measures. Crane concluded that PCP's long-
els were unknown and, though the data suggested term effects may not impair cortical functions, but
poorer performance by the PCP user group, much of may impair subcortical functions regulated by the
the data did not reach levels of statistical signifi- brain stem.
cance. Additionally, the study lacked a non-drug- In a five-part study of the effects of PCP on
using control group, the sample sizes were small, adolescent cognitive functioning, Light (1984) in-
half of the patients were on psychotropic medication, vestigated preexisting medical records and test re-
the two groups differed in IQ, a history of significant sults to determine whether multidrug/non-PCP,
alcohol consumption was apparent in most of the moderate PCP, and heavy PCP use correlated with
patients, and most of the patients had a non-drug- neuropsychological test results. In Study I, Light re-
related psychiatric disorder. Such problems are com- viewed medical records from 116 middle- to upper-
mon in this field, however. Additionally, the power socioeconomic-class 17-year-olds who had been as-
of random assignment and careful control of the sessed an average of 12 days after admission to a drug
abused drug are control methods obviously unavail- treatment facility. Each subject was administered the
able to the researcher. Shipley Institute of Living Scale, Reading subtest of
Carlin, Grant, Adams, and Reed (1979) ad- the Wide Range Achievement Test, Benton Visual
dressed the issue of chronic use of PCP by employing Retention Test, and MMPI. Although heavy PCP
a non-drug-using control group in their study. They users scored lower than the other groups on the
compared three groups of 13 recruited subjects on the Shipley, there was some question that the group had
Halstead-Reitan Battery, W AIS, and MMPl. Group not fully recovered from the acute effects of PCP by
I were persons who had taken PCP an average of 27 the time they were tested.
months (range 1 month to 27 years); Group II, per- In Study II, Light (1984) administered a neuro-
sons who had used a variety of drugs other than PCP, psychological battery to fifty-two 18- to 21-year-olds
but who had been drug-free for at least 3 weeks; who were classified as multidrug/non-PCP users,
Group III, a non-drug-using comparison group. The moderate PCP users, or heavy PCP users, matched
three groups (average age 25.9 years) were matched on age, race, sex, and medication. Multidrug/non-
for education, sex, and race. Both drug-using groups PCP and moderate PCP users were assessed after 4-6
displayed deficits in abstracting abilities and com- weeks of sobriety; heavy PCP users, after 149 days.
plex perceptual-motor skills, but these groups could Portions of the Halstead-Reitan Battery, two memo-
not be distinguished on the basis of the test results. ry items from the Luria-Nebraska Neuropsychologi-
Weaknesses in the study, including a small sample cal Battery, the Arithmetic subtest of the WRAT, and
size, reliance on self-reports for medical and drug use five subtests (Information, Comprehension, Picture
history, lack of external neurological criteria, higher Arrangement, Block Design, and Object Assembly)
IQ for the control group than the multidrug group, from the WAIS were administered. 'Only one
and a failure to control for the considerable amount of (Trails A) of the 27 neuropsychological variables was
ethanol ingested by both drug groups, militate significantly different across the three groups, and
against much of the results. this variable did not vary systematically with PCP
Crane (1984) evaluated the effects of chronic, use" (p. 82). Light was unable to match the subjects
long-term PCP ingestion on CNS functioning in ado- on a number of demographic variables, length of
lescents. Three groups of individuals were selected sobriety was much longer for the heavy PCP users,
from a residential treatment population and matched and the non-PCP group may have been more im-
for age (average age 16 years, range 15-20 years), paired due to problems associated with use of other
sex, ethnicity, and education. Group I comprised 10 drugs.
subjects with a history of multidrug and PCP use; The issue of the contribution of preexisting con-
Group II, I 0 multidrug users who had not used PCP; ditions to current levels of cognitive functioning in
Group Ill, 10 non-drug-using controls. Groups I and PCP/multidrug-using individuals was addressed by
320 CHAPTER 17
Light (1984) after he reviewed the school records of The control group included inexperienced LSD
37 of the 52 subjects in Study II. Light was able to users. If they used other drugs was not documented.
obtain four or five achievement/ intellectual test Of the 15 measures obtained, the LSD user group
scores on most subjects. The school test scores indi- displayed impaired functioning on the visuospatial
cated average or below-average functioning for all orientation and Trails A tests. There was also a
three groups compared to the general population. positive correlation between the number of LSD ex-
There were no significant differences among the periences and performance on Trails A and Raven
three groups. tests. There was no evidence of generalized neuro-
All researchers acknowledge that PCP has dra- psychological dysfunctioning. Biases in this study
matic acute effects on the CNS, but the effects vary that may have distorted the findings include a lack of
greatly among individuals. Dosage level appears to knowledge of premorbid levels of functioning and
be a critical element, heavy users developing more lack of awareness of the subject's alcohol and other
pathology than light users. Because the acute effects drug experiences.
of PCP linger for weeks, study of the chronic effects Wright and Hogan ( 1972) replicated the Cohen
of PCP has been difficult. Still, most of the available and Edwards (1969) study with forty 20-year-old
research with adolescents and young adults does indi- (age range 17-24 years) LSD users. The subjects had
cate neuropsychological impairment with chronic, used LSD an average of 29 times over a period of
long-term use. Motor performance skills appear to be from 4! to 27 months. None of the LSD users were
more adversely affected than verbal skills. judged acutely toxic at the time of testing, although 4
had used LSD the previous day. The Halstead-
Reitan Battery, Trail Making Test, WAIS, and an
aphasia test were administered. The LSD group per-
Lysergic Acid Diethylamide (LSD) formed better than the non-LSD group on the
Information subtest and worse on the Comprehension
The most recent data on the use of LSD by ado- subtest of the WAIS. There were no other significant
lescents indicate a decline over the last few years. In differences between the two groups. One reason why
1984, 8% of high school seniors reported use of LSD these findings may be at variance with those of Cohen
at some time in their lives. About 4% reported use and Edwards (1969) may be that the Wright and
during the previous year (Johnston et al., 1985). Hogan LSD users used LSD, on average, less than
Although LSD is classified as a hallucinogen, it half as many times as the Cohen and Edwards LSD
does not cause the user to hallucinate per se. Instead, users.
the user views the world in a distorted fashion or Cognitive and perceptual testing and EEG stud-
misinterprets sensory experiences. LSD's acute ef- ies were completed on 21 volunteers (average age 20
fects are variable and unpredictable. Flashbacks, re- years, range 15-27 years) who had ingested LSD an
ported to occur days or months after the initial dose, average of 65 times. None had ingested LSD for 48
are rare. LSD alters sensations, reasoning, percep- hours prior to testing. An auditory two-tone evoked
tion, and mood states. The drug primarily affects the potential showed no abnormalities, but the LSD users
visual cortex, limbic system, and reticular formation were uniquely sensitive to low-intensity stimulation
(Holbrook, 1983b). Physical dependence and with- on visually evoked potential procedures. Although
drawal do not occur, but tolerance quickly develops Blacker, Jones, Stone, and Pfefferbaum(1968) felt
and abates. that some of the EEG findings and behaviors dis-
Of all the hallucinogens, LSD has generated played by the LSD users were "suggestive of mini-
the more neuropsychological research. Because of mal brain damage" (p. 348), the evidence was not
LSD' s extreme psychopharmacological potency, conclusive. Several methodological problems were
various researchers have speculated that CNS apparent in this study. There was no matched control
damage might result from repeated exposure. group, all of the LSD users used other drugs as well,
Cohen and Edwards (1969) completed one of some of the subjects may have been experiencing an
the first studies of the effects of LSD on neuro- acute reaction to some drug at the time of testing, and
psychological functioning. They administered the the cognitive measures were nonstandardized.
Halstead-Reitan Battery, Raven's Progressive Ma- Acord (1972) gathered a group of forty 17- to
trices, and a spatial orientation test to two groups of 24-year-old (average age 20 years) military hospital
21-year-old volunteers matched for age, sex, and ed- inpatients and outpatients, of average intelligence,
ucation. The LSD user group had an average of 70 who had ingested LSD, MTA, STP, mescaline, or
LSD experiences and were known to use other drugs. psilocybin at least once. The Indiana Neuro-
psychological Battery and WAIS were administered. Neuropsychologists investigating the effects of
Using Halstead's cutoff scores (Halstead, 1947), LSD on adolescent and young adult development
Acord reported that scores on the Category Test and have generally used the same instrumentation. Al-
the Tactual Performance Test were in the brain- though most studies reported impaired neuro-
damaged range. There was no control group, no in- psychological performance with chronic use of LSD,
formation regarding the subjects' last exposure to the significant findings were inconsistent from study
drugs, past neurological and psychiatric history were to study probably because of preexisting differences
unknown, and, although different drugs were used, among the populations studied, length of use of LSD,
all of the drugs were grouped together as halluci- and time since last use of LSD. Most studies report-
nogens. ing significant findings suggest impairment in ab-
Acord and Barker (1973) expanded the 1972 stracting and speeded sequencing tasks, with overall
study by adding a control group. Subjects were levels of functioning remaining intact. Thus, it ap-
drawn from the same military hospital and matched pears that LSD has subtle, dosage-dependent effects
for intelligence and education. The experimental on the CNS when it is used chronically.
group of fifteen 21-year-old subjects had a history of
ingestion of LSD, MTA, STP, DMT, mescaline, or
psilocybin on at least one occasion. The fifteen 22-
year-old control had not used drugs. The Tactual Heroin
Performance Test (TPT) Localization Component,
Trails B, and Category Test were administed to all In the 1960s and 1970s, a young population of
subjects. The drug-using group performed signifi- addicts came to be recognized. Opium-rich Southeast
cantly less well than the non-drug-using group on the Asia had produced many addicts-American sol-
Category Test and the TPT Localization Component. diers returning home from Vietnam (Woolf, l983a).
The authors suggested the possibility of a causal rela- Between 1975 and 1981, the use of opiates (other
tionship between use of hallucinogens and brain than heroin) by high school seniors remained stable,
damage. as has opium use by high school seniors since 1980.
In a study comparing LSD I mescaline users and Of surveyed seniors, 9.7% report using an opiate
marijuana users against a control group with no histo- (other than heroin) at least once during their life,
ry of marijuana or LSD use, Culver and King (1974) whereas only 1.3% report having ever used heroin
administered the Halstead-Reitan Battery, WAIS, (Johnston et al., 1985).
Laterality Discrimination Test, three spatial-percep- Heroin is a narcotic analgesic of the opiate class.
tual tests from the Kit of Factor-Referenced Cog- It is a semisynthetic derivative of morphine but can
nitive Tests, and the MMPI. Matched triads of 28 be three times as potent as morphine (Young et al.,
subjects each were established from a group of bright 1977). Other opiate analgesics include opium, co-
20- to 25-year-old college seniors. The LSD and mar- deine, hydromorphone (Dilaudid), oxycodone (Per-
ijuana users were asked to stop using any drugs at codan), propoxyphene (Darvon), meperidine (De-
least 7 days before they were scheduled to be tested. merol), diphenoxylate (Lomotil), and pentazocine
LSD users scored significantly lower than the mari- (Talwin) (Schuckit, 1984). The actions of these
juana and control groups on the WAIS Performance drugs are homogeneous, tolerance develops rapidly,
and Full Scale IQ, Picture Completion subtest, Cube and all are extremely addictive.
Comparison Test, and the Trails A and B time scores. Heroin is generally injected into the body, but
A year later, Culver and King repeated the same can also be administered orally, snorted, or smoked.
testing on new subjects who were similar, in some Some addicts mix cocaine or amphetamines with her-
respects, to those in the first study. The second group oin, producing a mixture called "speedball." Con-
of triads were more closely matched on the WAIS. cerning autopsies on persons who have died of a
The only measures on which the LSD user group was heroin overdose, 60% show significant cerebral
significantly weaker than the marijuana and control edema (Parsons & Adams, 1983). Hill and Mikhad
groups were the Trails Band A plus B time scores. (1979) found significantly smaller sulci and ventri-
For the LSD user group, the only measure that cle/brain indexes in their study of adult heroin
reached statistical significance for both studies was abusers.
the Trail Making Test. Although the LSD user's Trail The only study examining the long-term cere-
Making Test time was slower than the marijuana and bral effects of heroin addiction on younger indi-
control groups' time, their performances were within viduals assessed performance on the Halstead-Re-
the normal range. itan Battery. Fields and Fullerton (1975) compared
322 CHAPTER 17
the performance levels of a group of heroin-addicted environmental features all affect the individual's re-
veterans with a brain-damaged group and a control action to the drug. Tolerance can quickly develop,
group without a history of brain damage or drug use. which makes barbiturates highly dangerous.
The three groups of 25 hospitalized subjects each Judd and Grant (1975) studied a group of 50
were matched for age, sex, and education. The hero- multidrug users who were heavy users of depres-
in and control groups were also matched on IQ. The sants, a group of 19 neurologically intact medical
heroin addicts had used heroin an average of almost 5 patients, and a group of 19 brain-damaged patients
years (range 1-10 years). The brain-damaged group (average ages 25, 24, and 22 years, respectively).
performed significantly worse on the Halstead-Re- Two to three weeks after admission to the hospital,
itan Battery than the heroin and control groups, the three groups were administered the Halstead-
whose scores were equivalent. Information regarding Reitan Battery, WAIS, and MMPI. Of the 18 multi-
premorbid history, use of alcohol, and extent of use drug users who also had a history of head injury, 9
of heroin was not provided. manifested neuropsychological abnormalities. The
Platt, Scura, and Hannon (1973) compared a drug users performed significantly worse than the
group of youthful incarcerated heroin addicts with a medical patients on 13 of 29 measures. Abstracting
group of nonaddicted controls with the Means-Ends ability, accuracy of perception, motor speed, nonver-
Problem Solving (MEPS) story completion tech- bal learning, and accuracy of perception were im-
nique. The MEPS measures how appropriately and paired functions in the drug user group. Although the
effectively an individual can resolve typical real-life investigators noted some limitations to their study,
problem situations. The 28 heroin addicts had a mini- they failed to address the issue of the age range of the
mum of a 2-year period of consistent addictive be- drug-using group (14 to 54 years). With such a wide
havior (mean 3.77 years). There were 31 nonad- range of ages, it is possible that more significant
dicted controls with no history of use of heroin. The results were canceled out, as it is known that there is
heroin addicts were about 22 years old and had 10.6 considerably more variability in performance levels
years of education. The control group averaged about of older adults compared to younger adults (Elliott,
20 years old and had 9.2 years of education. Results 1985).
indicated that the heroin addicts were less able to In summary, it appears that for some young peo-
generate solutions to problematic life situations. ple, use of sedatives and barbiturates over a long
Because of the absence of research on the long- period can lead to impaired neuropsychological func-
term effects of heroin addicition on brain-behavior tioning. Available research continues to use poor re-
relationships, it is not clear, at present, what effects search methods. Sample sizes are small, use of multi-
chronic heroin use has on neuropsychological func- pie drugs is not controlled in the research designs,
tions. Further study is required, particularly with her- premorbid abilities are unknown, and follow-up
oin-using individuals who are not using other drugs. studies rarely track a subject for more than 4 weeks.
Sedatives/Barbiturates Alcohol
Since the NIDA High School Senior Survey be- Alcohol is the most misused drug in the United
gan in 1975, the use of barbiturates and other seda- States today. It is by far the most widely used drug by
tives has been on the decline. In 1984, 9. 9% of high 12- to 17-year-olds (Nathan, 1983; Beyette, 1983).lt
school seniors reported using barbiturates and 13% is estimated that 6% of high school students drink on
reported use of sedatives at some point in their lives a daily basis (Beyette, 1983; Cohen, 1985). Johnston
(Johnson et al., 1985). et al. (1985) noted in their annual high school senior
Barbiturates are CNS depressants that vary in survey that 92.6% of the seniors had used alcohol at
duration of action. The fast-acting subclass is used to some time in their lives, and 67.2% had consumed
induce anesthesia (sodium pentothal), the short- to alcohol in the previous month. Since 1979, there has
immediate-acting subclass aids in sleep induction been no change in lifetime prevalence, although daily
(pentobaribtal), and the long-acting subclass is used use has declined.
to treat chronic conditions such as epilepsy (phe- Beer, wine, and distillates share the same active
nobarbital). Barbiturates depress the CNS and inter- ingredient-ethyl alcohol or ethanol, which is the
fere with synaptic functioning. Dosage, type of bar- intoxicant. Alcohol is a depressant that adversely af-
biturate, metabolism, use of other drugs, and fects most body systems, especially the CNS. De-
pressed reaction time, muscular incoordination the characteristic medical problems, such as cirrhosis
(American Academy of Pediatrics, 1984), agitation and pancreatitis associated with alcohol abuse, had
or depression, sensory impairment, and disinhibition not had enough time to develop.
(NIAAA, 1982) coma, and death occur with increas- The cognitive performance of young sober so-
ing dosage levels. cial drinkers was investigated by Hannon, Day,
Tolerance and physical and psychological de- Butler, Larson, and Casey (1983). The Shipley In-
pendence develop over time, with diagnosable alco- stitute of Living Scale, Wisconsin Card Sorting Test,
holism becoming established after 3 to 15 years of Digit Symbol Test, Trail Making Test, and TPT were
prolonged use (Young eta/., 1977). Damage to the administered to a group of 52 female and 40 male
CNS upon chronic use of alcohol has been well estab- college students (mean age 20.3 years). They were
lished. Nerve centers are destroyed (Board on Mental asked to refrain from taking any drug or consuming
Health and Behavioral Medicine of the Institute of alcohol for 24 hours prior to testing. The results indi-
Medicine, 1985), the lateral and third ventricles en- cated decreased neuropsychological performance
large (Wilkinson, 1985), there may be a marked re- with increased quantity of alcohol per occasion and
duction of cerebral blood flow (Tarter, 1980), sulci total lifetime consumption by both sexes. Women
widen, the gyri are narrowed (Callen, 1984), pe- appeared to be more adversely affected, neuro-
ripheral neuropathy develops (Schuckit, 1984), there psychologically, by social drinking than men.
can be a loss ofNissl substance (RNA), the substantia Hannon et al. ( 1985) replicated their 1983 study
nigra can be damaged, lesions can develop anywhere with a larger sample, a longer period of no alcohol
in the cerebral cortex or in the central brain struc- use, and a few changes in the tests administered.
tures, and generalized diffuse, nonspecific, atrophy There were I 03 female and 67 male co11ege students
can take place (Freund, 1985; Grant & Reed, 1985; (mean age 20.8 years). The Trail Making Test and
Eckhardt & Ryback, 1981). TPT were dropped from the test battery and Raven's
Functional deficits accompany CNS damage at- Advanced Progressive Matrices was added. Subjects
tributed to alcohol abuse, although age, drinking his- were asked to refrain from drinking any alcohol for 2
tory, use of other drugs, educational background, weeks prior to the testing. Although there was a pre-
socioeconomic status, ethnic background, and per- dicted negative relationship between quantity and
haps sex may modify behavioral and cognitive defi- cognitive variables for women, and three unpredicted
cits on neuropsychological instruments (Goldman, relationships for men, the correlations were weak and
1983). The majority of research studies of alcoholics conclusions speculative.
have been done with inpatients, abstinent 1 to 4 In the only published study investigating the
weeks (Grant & Reed, 1985). Investigations have role of age of drinking onset upon neuropsychologi-
revealed disturbances in abstracting ability, complex cal functioning, Portnoff (1982) administered the
perceptual motor skills, visual perceptual ca- WAIS, Shipley Institute of Living Scale, Wechsler
pabilities, learning capacity, visuospatial integra- Memory Scale, and an abbreviated version of the
tion, short- and long-term verbal and nonverbal Halstead-Reitan Battery to two groups of 10 chronic
memory, information processing rate, sequential or- alcoholics dichotomized by age of drinking onset.
ganization capabilities, visual search and scanning Portnoffhypothesized that differential onset of drink-
skills, concentration, perceptual analysis, synthesis, ing would be related to brain maturation and would
orientation, and sequencing skills, manual dexterity, be reflected in neuropsychological test results. The
memory functions, and acquisition of new informa- early onset group started drinking steadily at 14.1
tion (Wilkinson, 1985; Tarter & Edwards, 1985; years (range 12-18 years) and drank for an average
Eckhardt & Ryback, 1981; Grant & Reed, 1985). of 19.4 years. The later-onset group started drinking
Global intellectual capabilities and language skills steadily at 23.4 years (range 20-30 years) and drank
have not been implicated (Tarter & Ryan, 1983; for an average of 16.5 years. All of the subjects dis-
Eckhardt, Parker, Noble, Feldman, & Gottschalk, continued using all medication and had been alcohol-
1978; Parsons & Leber, 1982; Goldman, 1983). free for an average of 3. 8 weeks prior to testing. The
Although the study of the social and personality two groups were essentially similar in sex, educa-
effects of alcohol on children and adolescents has tion, race, and handedness. Significant differences
received considerable attention in recent years, there on the Shipley, Wechsler Memory Scale, Category
have been very few studies of the neuropsychological Test, Trails B, and Rhythm Test suggested that early
status of drinking children and teens (Tarter & Ed- onset alcoholics developed more impairment on mea-
wards, 1985). Defining alcohol abuse in these studies sures of abstraction, rhythm perception, visuospatial
of youthful drinkers was difficult because many of sequencing, verbal memory, and figural memory. It
324 CHAPTER 17
appeared that individuals who started drinking at an may be the most critical drug issue facing our youth
early age may have been more vulnerable to the ad- today (Gold eta/., 1985) because of the synergistic
verse neuropsychological effects of alcohol than in- effect of certain drug combinations. For instance, use
dividuals who started drinking at a later age. The of alcohol and depressants such as sleeping pills,
researchers did not review early school or medical hallucinogens, and stimulants may lead to a potentia-
records to control for premorbid developmental dif- tion of side effects (Schuckit, 1984). It has been
ferences between the two groups, the early onset shown that in today's Western society, there is a
drinkers had been drinking 3 years longer than the progression with respect to drug use. If a young per-
later-onset drinkers, and the sample sizes were very son who drinks and smokes elects to use other sub-
small. Thus, the findings of this study, although stances, the next choice will probably be marijuana,
strongly suggestive, were not conclusive. then a hallucinogen, depressant, or stimulant (Ham-
The very few studies focusing on the neuro- burg, Kraemer, & Jahnke, 1975).
psychological effects of alcohol on children have The most extensive study of multidrug abuse
suggested deficits in abstracting and problem-solving (Grant et al., 1978) investigated the neuropsycholog-
skills. Memory deficits have not been implicated, ical functioning of 151 25.5-year-old multidrug
although very few child studies have adequately test- users, 66 28.8-year-old psychiatric patients, and 59
ed memory functions. In child and adolescent alcohol 26.1-year-old non-drug-using, nonpatient volun-
use studies, longitudinal investigations are needed to teers. Each subject was given the Halstead-Reitan
pinpoint specific neuropsychological functions af- Battery, W AIS, a grooved pegboard test, and an
fected by alcohol use correlated with chronological MMPI. The multidrug users were evaluated between
age. 21 and 30 days after they enrolled in treatment.
Clinical evaluations of the protocols results in 37% of
the multidrug users, 26% of the psychiatric patients,
and 8% of the nonpatient group falling within the
Multidrug Abuse neuropsychologically impaired category. Age, edu-
cation, premorbid medical factors, and extensive use
Most members of today's society who misuse of depressants and opiates in the multidrug users, and
one drug tend to misuse at least one other drug as well extensive use of antipsychotic drugs in the psychi-
(Maddux, Hoppe, & Costello, 1986; Schuckit, 1984; atric group appeared to be related to neuropsycholog-
Parsons & Parr, 1981; Gold, Verebey, & Dackis, ical impairment. A factor analysis of the data re-
1985). Maddux et al. (1986) surveyed 133 senior vealed significantly weaker performance by the
medical students and found that most had abused multidrug users on general verbal intelligence, visu-
some type of psychoactive substance sometime be- al-motor, tactile-motor, and perceptual skills.
fore entering medical school. Most of those who had Three months later, 61% of the multi drug users,
used a drug reported use of more than one drug. In a 77% of the psychiatric patients, and 86% of the non-
survey of Army patients, over half of those reporting patient group were reevaluated. Only mild improve-
to a multidrug clinic reported use of three or more ment was noted in the multidrug group. Neuro-
different substances (Cook, Hostetter, & Ramsay, psychological impairment was found in 34% of the
1975). multidrug users, 27% of the psychiatric group, and
When two or more drugs are introduced into the 4% of the nonpatient group. Again, heavier use of
body, the potential for an interactive relationship ex- depressants and opiates, as well as premorbid illness
ists. This interactive effect may be additive, potenti- history and recent drug taking, was related to neuro-
ated, or inhibiting. An additive effect occurs when psychological impairment. The authors speculated
the effect of two or more drugs is greater than could that impairment associated with depressant and
be achieved by one drug, but no greater than addition opiate use may be enduring and that multidrug users
of the drug responses. Potentiation occurs when one may be deficient in verbally mediated problem-solv-
drug enhances the effect of another drug when the ing skills.
two are taken together. The combination of the drugs Ivnik (personal communication, February
may result in an effect that is greater than could be 1986) administered the WAIS-R or WISC-R, the
achieved by simple addition of the drugs. Inhibition arithmetic subtest of the WRAT, the reading section
occurs when one drug diminishes or reverses the ef- of the Woodcock-Johnson Psychoeducational Test
fect of another drug when the two drugs are taken Battery, the A YLT, and the MMPI to II 0 middle-
together (Woolf, 1983b). class, 13- to 19-year-olds (average 15.9 years) who
Some researchers believe that multidrug abuse were in treatment for drug abuse. The primary drugs
of abuse were marijuana and alcohol. Multidrug other area of cognitive functioning. The researchers
abuse ranged from I to 4 years, with wide variations assumed that the subjects were not using drugs during
in individual use. All testing was completed within testing because they were prisoners. Today, with our
I0 days after initial presentation. Test results failed to knowledge of the extensive use of drugs in the prison
identify evidence of significant cognitive dysfunc- system, such an assumption seems naive.
tion. Complications in this study included an absence The research findings on the effects of multi-
of a control group and a wide variation between sub- drug abuse in adolescents are mixed. A common
jects in extent of drug use. finding in studies of drug use in adolescent delin-
In an investigation of the neurological and neu- quents is deficient verbal IQ on the Wechsler scales
ropsychological consequences of PCP use by adoles- and a higher frequency of multidrug use than for
cents, Crane (1984) compared 20 PCP/multidrug nondelinquent drug users. The directionality of
(except inhalants) users, 10 multidrug users who had causation in this relationship remains open. Studies
not used PCP, and 10 nondrug users. The subjects, that have failed to find neuropsychological deficits
who were in a residential treatment facility, we~ seem to involve the youngest subjects, lack a control
between 15 and 20 years of age, and were matched group or, if there is a control group, the control group
for age, sex, and education. A neurological examina- is poorly matched with the experimental group. Stud-
tion, neuropsychological evaluation, and EEG were ies that have found a positive relationship between
administered to each subject. The subjects had been multidrug use and neuropsychological impairment
free of drugs an average of about 3 months at the time have tended to associate the impairment with use of
of testing. Although Crane was unable to identify any depressants and opiates. When impairmel)t was evi-
deficits in the multidrug user group, that group dif- denced, the primary systems affected included visu-
fered from the other two with respect to ethnicity and al, tactile, motor, perceptual skills, and verbally me-
may have experienced a greater degree of social, diated functions.
psychological, and intellectual development.
Neuropsychological impairment was found in a
group of young multidrug users who had been free of
drugs an average of 2 months. Grant, Mohns, Miller, Designer Drugs
and Reitan (1976) compared the performance levels
of a group of 22 male multidrug users (mean age 22 This short section deals with a group of sub-
years) in a residential drug treatment program against stances that have been created in the streets in an
the performance levels of a group of 19 medical and attempt to circumvent existing laws against produc-
19 neurological patients matched for age, education, tion and distribution of certain controlled drugs. The
and sex. At the time of testing, most subjects had term "designer drug" has been adopted by drug reg-
been drug-free for 2 months. The evaluation included ulation agencies and the media to describe a mind-
the Halstead-Reitan Battery, WAIS, and MMPI. altering substance that is a chemical variation of an-
About half of the multidrug users showed mild, gen- other substance already regulated under the federal
eralized neuropsychological impairment; 11 to 26% controlled substances act. The chemical variation is
of the medical patients and 84 to 89% of the neu- achieved by changing a few molecules of an existing
rological patients were judged as impaired. There illicit drug so that the resultant drug is modified
was no apparent association between impairment and enough molecularly to fall outside of existing regula-
the use of any specific drug. tions. Generally, designer drugs are hallucinogens or
In contrast, Bruhn and Maage (1975) were un- opiates. Because the quality controls in the labs that
able to identify any neuropsychological deficits asso- create these drugs are highly variable, the end prod-
ciated with heavy use of combinations of marijuana, uct may be ten times weaker or ten times stronger
hallucinogens, amphetamines, and opiates. Eighty- than the drug being copied.
seven Danish male prisoners (average age 23.1 One designer drug that has become popular with
years), matched for age and educatjon, were divided adolescents is known as Ecstasy, which is MDMA.
into four groups, ranging from no drug use to heavy The National Institute on Drug Abuse (Rusche,
use of four or more drugs. Each subject was given the 1986) reported that MDMA was closely related to
WAIS, Category Test, learning and memory tests, methamphetamine and methylene deoxyamphet-
Seashore Rhythm Test, Hidden Patterns Test, and a amine sulfate (MDA). Methamphetamine causes
reaction time test. There were no apparent dif- brain degeneration resulting in symptoms similar to
ferences between the groups in abstract reasoning, those seen in Parkinson's disease. MDA "induces
concentration, perception, learning capacity, or any prolonged serotonin neurochemical deficits by de-
326 CHAPTER 17
stroying serotonin nerve terminals'' (Leary, 1985). use. Individuals who use a drug tend to use more than
Such chemical reactions can adversely impact sleep, one drug (Parsons & Adams, 1983) and many of the
mood states, sensitivity to pain, and induce ag- drugs purchased on the streets by adolescents often
gressiveness. Animal lab studies suggest that even are impure and contain ingredients other than the
after a single dose of Ecstasy, serotonin cells in the presumed drug. Yet many researchers rely exclu-
brain may be harmed (Turkington, 1986). sively on the drug users' self-report of their drug use
No human studies have been reported, but the history; self-reports by drug users as to type and pu-
widespread popularity of designer drugs has caught rity of drug, although convenient to researchers,
the attention of the Drug Enforcement Administra- makes interpretation of results extremely difficult
tion(DEA). On July 1, 1985, theDEA madeMDMA and inaccurate and may be, in large part, responsible
a Schedule-One illicit drug like heroin, making it for the many seemingly contradictory findings in the
illegal to prescribe or possess it for other than autho- area.
rized research. The correct amount of drug used and duration of
drug usage need to be accurately recorded. Research
has shown that the type of drug, amount, and dura-
tion of use are all important elements when conduct-
Methodological Issues in Substance ing drug effect research (Korman, 1977). The type of
Abuse Research solvent involved, the medium or host agent for the
drug, and presence of toxic impurities further con-
When research findings from the field of alco- found research on the effects of street drugs.
holism and drug abuse research are evaluated, sever- Another methodological issue deals with alter-
al methodological considerations and pitfalls must be native explanations for significant research findings.
taken into account. One of the most important issues At times, positive research results on motor function
deals with selection of subjects. Those who use alco- tests may be a result of peripheral nerve damage
hol and drugs are apt to differ from the general popu- rather than CNS neuropathology. This is particularly
lation in ways that may have neuropsychological im- apparent in research with solvents. Yet few re-
plications. Some of these differences may predate searchers undertake nerve conduction studies, which
use of any mind-altering substance, and therefore could differentiate peripheral from CNS impair-
would have nothing to do with the adverse effects of ments.
any substance (Grant & Reed, 1985). Such dif- Sometimes, research findings may be signifi-
ferences could involve education, sociocultural and cant but the effect is obscured because the researcher
ethnic influences, nutrition, personality differences, has combined all drug-using group information under
and history of medically related neurological one category. Researchers who take drug use histo-
damage. Many research studies fail to match subjects ries find that most drug users use two or more drugs.
along these lines, thereby compromising the in- Although they continue to identify the subject by a
terpretation of the findings. primary drug, they fail to identify the secondary drug
Other methodological flaws in drug and alcohol and possible interactive effects.
research literature include a reliance upon retro-
spective studies, use of inappropriate and un-
matched control groups, lack of adequately sized ex-
perimental and control groups, reliance upon Summary
neurological or neuropsychological data-gathering
methods that have not yet been proved or reliable, Although there has been evidence of a general
and use of measures of central tendency, which as- decline in overall level of adolescent drug use during
sume a uniformity of impairment that may not exist the last few years, the decline has been gradual and
(Carlin, 1986). does not involve all drug classes. Use of marijuana,
There are two critical design features that, when amphetamines, methaqualone, barbiturates, tran-
ignored, can invalidate findings. First, many re- quilizers, and LSD has declined. Use of opiates, co-
searchers do not take into account how much time has caine, PCP, and alcohol has remained unchanged,
elapsed since the last use of drugs. In some studies, whereas that of inhalants has increased in the last few
subjects are tested just days after they last used a years. Johnston et al. (1985) reported that 62% of
drug, yet the researcher states, or implies, that chron- America's adolescents have used an illicit drug be-
ic drug use issues were addressed. A second issue fore leaving high school. Nearly half have used a
deals with the extent and nature of self-reported drug drug other than marijuana. One in twenty is consum-
ing alcohol on a daily basis, and almost 40% have had ings of impaired functioning, long-term conse-
five or more drinks on one occasion during the pre- quences are clearly evidenced for some and impli-
ceding 2 weeks. cated for many others. As Parsons and Farr (1981)
This level of drug use remains disturbingly noted, clinicians can always recall the "burned-out"
high and has implications for drug education and re- teen referral who was ''obviously'' brain-damaged
habilitation programs. If research can demonstrate and the literature is full of individual case studies of
that use of a drug adversely affects abstracting and severely impaired individuals whose diminished
conceptualization capabilities, then verbal, highly functioning was linked to drug usage. When groups
intellectualized therapeutic techniques may be of abusing individuals are studied, such dramatic
useless or less appropriate than behavioral condi- findings are not as apparent. Severely impaired indi-
tioning techniques. If perceptual motor, spatial, and viduals may represent the exception rather than the
sequencing skills are compromised, then a more di- rule.
dactic, verbal therapeutic approach may be appro- This review of the studies of the chronic effects
priate. Knowledge of the specific effects of certain of substance abuse on children, adolescents, and
drugs will allow the therapeutic team to intercede in young adults does not indicate consistent neuropsy-
family and environmental issues in a knowledgeable chological deficits associated with use of most sub-
manner. stances. Those substances most consistent in demon-
Definitive statements, offered by different in- strating chronic effects with the young include
vestigators, about the effects of different drugs or alcohol, depressants, and multiple drug use.
combinations of drugs upon the CNS of children, Most of the available research on the neuropsy-
adolescents, and young adults are difficult to summa- chological effects of substance abuse has been com-
rize, as there are substantial differences in outcomes, pleted on adult populations. Research with children
methodology, and implications from study to study. and adolescents involves controlling for a number of
A major problem in all drug research concerns confounding factors that are not as important in adult
causality. Did the drug cause the effect or did the research. Developmental changes involving brain
existence of the effect cause use of the drug? Another functioning, emotional development, age of onset of
major issue is the fact that nearly all drug users use drug use, and various environmental factors contrib-
more than one drug (especially alcohol). This makes ute to the relatively greater complexity involved in
it very difficult for an investigator to research the studying children and adolescents (Tramontana,
effects of a specific drug, as most users have not used 1983).
one drug exclusively. Future investigations of the neuropsychological
In research with adults, multidrug studies have sequelae of child and adolescent substance abuse
indicated that up to half of all drug users exhibit need to address the methodological issues noted ear-
neuropsychological deficits during the first few lier. The extent of drug use needs to be more sys-
weeks after discontinuation of drug taking. Although temically documented and verified by outside objec-
many users show signs of recovery 3 to 6 months tive sources. Sample sizes need to be enlarged and
later, residual impairment remains (Grant & Reed, careful matching is required in developing control
1985). groups. Longitudinal studies need to be developed
Research with adolescents is less damaging in that follow large groups of children before they start
its implications than research with adults. Although it taking drugs and monitor them through high school
is recognized by most researchers that extent of drug and possibly beyond. Only in this way can at-risk
use is an important factor, very few researchers have factors be identified. Last, the extent of alcohol use
attempted to assess the reliability of drug users' self- accompanying most drug abuse needs to be fully
reports. When severe use has been documented, even evaluated, as it is known that alcohol is usually the
with young individuals (Grant et al., 1976, 1977), first substance used by most individuals who have a
some CNS impairment is apparent. The younger history of drug abuse.
brain appears to be more resilient to the adverse ef-
fects of mild to moderate drug use, even over a period
of years. As the brain ages, it becomes increasingly
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III
Techniques of Intervention
18
Neuropsychological Models of
Learning Disabilities
Contribution to Remediation
CHE KAN LEONG
Introduction (Downing & Leong, 1982; Rutter, 1978). The ques-

tion of what constitutes significant discrepancy is a
The term model is defined by Kuhn (1970) as "the vexed one, although a lag of 24 months or more is
entire constellation of beliefs, values, techniques, usually taken as a yardstick to gauge "severe perfor-
and so on shared by the members of a given commu- mance deficit'' for these children.
nity. . . . It denotes one sort of element in that Neuropsychologically, the definition by Mattis
constellation, the concrete puzzle-solutions (1978) is a reasonable one:
which . . . can replace explicit rules as a basis for Dyslexia is a diagnosis of atypical reading develop-
the solution of the remaining puzzles of normal sci- ment as compared to other children of similar age,
ence" (p. 175). Furthermore, a paradigm or a model intelligence, instructional program, and socio-cultural
"need not, and in fact never does, explain all the opportunity which, without intervention, is expected to
facts with which it can be confronted" (p. 18). Based persist and is due to a well-defined defect in any one of
on these premises, the present chapter examines sev- sever.d specific higher cortical functions. (p. 54)
eral neuropsychological models of learning dis-
The differentiation between a given observable disor-
abilities and assesses their contribution to the re- der in dyslexics and in brain-damaged individuals is
mediation of learning-disabled children. In particu-
an important one but one not easily made. What must
lar, the emphasis is on neuropsychological models as
be delineated are: "atypical reading development,"
problem-solving approaches that may explain specif-
impairment in ''specific higher cortical functions,''
ic reading disabilities in children. These individuals
and whether or not such an impairment is a deficiency
or children with developmental dyslexia are those
amenable to remediation and not just a defect per se.
with severe difficulties with reading conceptualized
Although the presence of a specific disorder in a
as an internalized form of language.
critical process implies the presence of dyslexia, we
should also note the qualification by Mattis ( 1978)
that ''the absence of this specific defect does not
Focus on Developmental Dyslexia imply the absence of disordered reading" (p. 56).
Psychometrically, developmental dyslexia re-

fers to a heterogeneous group of reading disabilities
Dissociable Academic Skills
characterized by reading/spelling attainment signifi- There are several reasons for the narrower focus
cantly below the level predicted on the basis of the in this chapter on specific reading disabilities or de-
child's chronological age or measured intelligence velopmental dyslexia rather than on the umbrella
concept learning disabilities per se. One reason is
CHE KAN LEONG Department for the Education of Ex- that the connotation of learning disabilities is becom-
ceptional Children, University of Saskatchewan, Saskatoon, Sas- ing too broad, too diffuse, and that the children so
katchewan S7N OWO, Canada. designated are quite heterogeneous. Although the
335
336 CHAYTER 18
tenn may be a convenient label for the delivery of nonnal" learners and must add to our understanding
habilitation services, it needs to be redefined for of learning processes and remediation practices.
rigorous scientific studies (Leong, 1982, 1987). An- Similar views are evident in the appraisal of current
other reason is that related disabilities in reading and (to the late 1970s) advances in theory and research of
spelling, which are often subsumed under the same dyslexia (Benton & Pearl, 1978). The following sec-
omnibus term learning disabilities, are dissociable tions discuss indirect and direct approaches to ''train-
(Frith, 1978, 1979, 1980). ing the brain"; a model' based on Luria's (1966a,b,
Whereas there are obvious parallels between the 1973, 1977) simultaneous-successive syntheses and
processes of reading and spelling, proficiency or im- planning; and an emphasis on language access as an
pairment in the one subskill does not necessarily im- effective approach to remediation.
ply corresponding proficiency or impairment in the
other area. Reading and spelling are not reverse pro-
cesses. In children the use of rules for reading and for "Training the Brain": Indirect Approaches
spelling is distinguishable (Baron, Treiman, Wilf, &
Kellman, 1980) and can be markedly different Indirect approaches to 'training the brain'' gen-
(Bradley & Bryant, 1985). In developmental dyslex- erally involve some form of sensory-motor integra-
ia a speech-based deficiency may explain certain as- tion as a putative integration of the CNS at the
pects of reading and spelling difficulties, but not the subcortical level. In her reeducation program, Ayres
full range of results in a number of empirical studies ( 1972) suggested that learning is a fonn of movement
on reading and spelling disabilities. The 11- to 13- in response to a stimulus and that body-image devel-
year-old dyslexics studied by Frith (1978, 1979, opment relates to the assimilation of tactile-kines-
1980), who were poor in producing the conventional thetic stimuli. In other words, psychoeducational de-
spelling of words, were comparable to good spellers velopment of children with learning disorders must
in the spelling of dictated non words, but were poor at be seen as a successive integration of perception of
reading written nonwords. Parallel findings come stimulus, movement, conscious body-image and
from the patient R.G. observed by Beauvois and culminating in learning. The assumption that body-
Derouesne (1979, 1981). R.G. spelled each word by image concepts are the resultant of the different stim-
using phoneme-to-grapheme rules but his reading uli received in the brain via the sensory systems will
showed the opposite patterns. He read lexically and need to be further researched.
was very poor at reading nonlexically with graph- It is interesting to note that Ayres's reeducation
eme-phoneme correspondence rules. These various principle with its putative link to the CNS still has
findings of the differential use of linguistic structural considerable following in a number of European
codes and a general delay in accessing these codes countries. This is shown by the habilitative work of
suggest that ''spelling production might be viewed as the Swiss team of Affolter and Stricker (1980), and
being functionally distinct from reading" (Seymour the Thea Bugnet or the Bon Depart (good start) ap-
& Porpodas, 1980, p. 471). What needs to be further proach followed in Poland (see Duane & Leong,
explored is the nature and degree of these functional 1985). The Bon Depart approach emphasizes visual-
distinctiveness and relatedness of reading and spell- aural-motor activities involving the visual element
ing and their effects on children with specific reading (graphic symbols), the aural element (songs), and the
disabilities. motor element (harmonizing rhythmic movements
with graphic symbols and songs). The simultaneous
integration of visual-aural-motor activities aims at
making more efficient the visual, aural, and tactile-
Neuropsychological Models kinesthetic analyzers. In essence, the Bon Depart
approach is one of psychomotor rehabilitation com-
The focus of this chapter is thus on the neuro- bined with stimulation of psychomotor development.
psychological analysis of severe reading disabilities The actual habilitation involves: (l) motoric exer-
both for research and for habilitation purposes. The cises emphasizing relaxation and agility, (2) motor-
analysis is attempted not only in terms of brain-be- auditory exercises carried out to the tune of songs
havior relationship but also more in tenns of compo- sung by the children, and (3) motor-visual-auditory
nent processes of reading and the breakdown of these exercises that form the bulk of the activities.
processes. In this regard, we are reminded by Spreen It is claimed in these European countries that
( 1976) that neuropsychological models of learning this good-start approach appears to be effective not
disorders must encompass both "normal" and "ab- only with preschool children, but also with children
REMEDIATION 337
with dyslexia and dysgraphia. The eagerness with and to develop right ear dominance, some 'structur-
which the Ayres approach and its extension is fol- ing dynamics'' of listening and speech skills must be
lowed probably illustrates the goodness of fit be- established. This is done through the Tomatis listen-
tween the perceptual-motor match and what ing training program (LTP), which incorporates an
Cruickshank (1975, p. 272) termed the "psycho- "Electronic Ear" as the hardware or the main pro-
educational match.'' He also cautioned that these are gramming component.
instances where clinical practice coupled with the There are several stages in the habilitation, all
logic of the concept should provide a base for re- emphasizing auditory stimulation and auditory vocal
search and for linking theory with practice. exercises. First, the frequency of the acoustic signals
are filtered out through a gating mechanism in the
Electronic or Phonic Ear. The augmentation of high
"Training the Brain": Direct Approaches frequencies and attenuation of low frequencies and
the exaggeration of low frequencies and reduction of
high frequencies are meant to produce a positive
"Habilitation Movement"
therapeutic effect. Then listening to prefiltered
Direct "brain training" includes the well- sounds or to one's own filtered voice via almost in-
planned and systematic stimulation through the visu- stantaneous feedback through the Phonic Ear is said
al, auditory, and kinesthetic senses. One such ap- to train auditory discrimination. These two stages
proach is that of the "rehabilitation movement" of and the next one of the gradual attenuation of signal
Diller and associates (Weinberg, Piasetski, Diller, & intensity to the left ear all aim at restoring normal
Gordon, 1982). These researchers use visual half- listening development.
field training to help their patients to analyze and It should be noted that the Tomatis audio-
utilize more efficiently visual-spatial information. psycho-phonology is a supplementary form of hab-
Their techniques, however, are geared primarily for ilitation. It is intended as a complement to a strong
adults and are focused on the visual modality. academic program and is not meant to be used on its
own. This LTP seems to have attracted some follow-
ing and there have been claims made about its
Tomatis's Audio-Psycho-Phonology Habilitation efficacy in helping dyslexics. Although some shad-
and "Dysmetric Dyslexia" owy evidence of short-term gains in achievement
have been reported for the dyslexics so treated,
In the auditory domain, Tomatis (1978) advo- many, if not most, of the studies are neither construc-
cated audio-psycho-phonology training as a form of tively critical of the theoretical framework nor overly
habilitation for dyslexic children. The general princi- sophisticated in their research designs.
ple is that the voice could produce only what it hears The one exception is the careful, 2-year study of
and that many dyslexics have difficulties listening, the efficacy of the Tomatis LTP by Kershner, Cum-
particularly to high-frequency sounds. Within this mings, and Clarke (1986). These researchers evalu-
psychoacoustic framework, Tomatis suggested that ated the pretest, posttest, and follow-up performance
dyslexia can occur in children whose hearing acuity of three groups of a total of 42 children aged 8 to 12
is intact but whose ability to listen and to communi- with .. developmeiJtal learning disabilities" from a
cate is impaired. He conceived of the inner ear as a school recognized for its remedial work. The 16
kind of ''charging organ" that energizes sensory learning-disabled children in the experimental group
stimulation into neural energy to keep the brain alert. were given 100 hours of school-based Tomatis LTP,
This is analogous to a dynamo charging and recharg- over the school year. The 16 children in the placebo
ing a central battery. Furthermore, the inner ear in group were given a non-Tomatis audiovisual feed-
concert with the vestibular system coordinates and back tutorial program to control for placebo and
integrates various sensory and motor functions to Hawthorne effects; and 10 learning-disabled children
achieve equilibrium. As well, the inner ear is a major formed the "no treatment" group. The pre- and post-
.. vector" or force in establishing laterality (a leading test design was used with blind testing on a number of
right ear and .. dominance" of the left hemisphere). achievement tests, cognitive, neuropsychological,
If the ''charge'' of the brain is inefficient, the central psycholinguistic measures, social-emotional scores,
equilibrium is disturbed, and laterality is not estab- and dichotic listening. Multivariate analyses of vari-
lished. Consequently, speech and language problems ance (MANOVA) with age-adjusted scores were
may result. To keep this "charge" in a dynamic computed. The experimental and placebo groups
state, to maintain the sensory functions in balance, were further subtyped according to both a neuro-
338 CHAPTER 18
psychological dual processing model and an achieve- ing audio-psycho-phonology program is Bakker's
ment pattern model in order to minimize the effects of (1973, 1979, 1984; Bakker, Smink, & Reitsma,
heterogeneity and to study the possible interactions 1973; Rourke, Bakker, Fisk, & Strang, 1983) "bal-
of selective treatment effects for subtypes of dys- ance model" to explain reading disabilities in chil-
lexics. dren. Bakker hypothesized that the hemisphere-
In general, the results suggest that the Tomatis reading relationship is dependent on the phase of the
LTP did not have an effect on children's audiophono learning-to-read process. Proficient early reading,
development as tested on the key Tomatis Listening which demands more of the perceptual processes,
Test. In particular, the claim of treatment effect on may rely more on right cerebral laterality. Later-
hemispheric information processing was not substan- stage fluent reading, which requires more of lin-
tiated in dichotic listening; nor were there treatment guistic processes, may depend more on left hemi-
effects on specific subtypes of learning disorders. sphere laterality.
Furthermore, any apparent gains made by the experi- Following the above hypothesis, Bakker postu-
mental students were found to be the "combined lated two main types of dyslexias. His basic tenet is
result of individual care, motivation and effective that some children learn to read using mainly left
remedial instruction, and not the LTP" and that hemisphere strategies (as shown in right ear advan-
''time taken from school hours for such activities tage (REA) of verbal dichotic listening tasks) at the
[LTP] is without empirical justification'' (Kershner wrong time or that they tend to overlook the spatial-
et al., 1986, p. 43). This very careful empirical study perceptual features (mainly right hemisphere ac-
serves to alert us as to the validity of the theoretical tivities) of the text. These children, who rely unduly
conception of the LTP and the questionable value of on linguistic-semantic aspects of reading probably
the resource-withdrawal Electronic Ear training for because of a functional overdevelopment of the left
these children. hemisphere, are termed L-type (for linguistic) dys-
Just as Tomatis attributed much of normal lis- lexics. Other children may rely overly on right hemi-
tening and language development to the inner ear in sphere strategies as reflected in left ear advantage in
connection with the vestibular system, a hypothe- verbal dichotic stimulation. These children, who
sized relation between dyslexia or what is termed may have a functionally overdeveloped right hemi-
"dysmetric dyslexia" (DD) and cerebellar-ves- sphere, are termed P-type (for perceptual) dyslexics.
tibular (c-v) functions has been proposed (Levinson, The L-type dyslexics tend to make more substantive
1980). Levinson's thesis is that dyslexia results from reading errors such as omissions and additions; the P-
a c-v-related nystagmus or oculomotor dyscoordina- type dyslexics tend to make more time-consuming
tion. This dysfunction disturbs the temporal-spatial errors such as repetitions and fragmentations. The
sequence of visual symbols, leads to abnormal elec- reading error patterns by ear dominance in relation to
tronystagmograms (ENOs), and contributes to the the L-type and P-type dyslexias are shown in Figure
slower single-target blurring speed as found in one 1, which partially summarizes a collaborative study
sample of 300 dysmetric dyslexics and 25 control between the present author and Bakker with 38 Dutch
subjects. As a "solution to the riddle dyslexia," severely disabled readers (Bakker, 1979). The right-
Levinson prescribes "c-v harmonizing agents" in- ear-dominant dyslexics (L-type) make more omis-
cluding such anti-motion sickness drugs as meth- sion and substitution errors (class 2 and class 8); the
ylphenidate (Ritalin). He also suggests oculomotor left-ear-dominant dyslexics (P-type) tend to make
training including the use of a three-dimensional more time-consuming errors (class 12).
reader to present written materials in temporal se- In addition to their different patterns of reading
quence at a fixed locus so as to improve reading errors, the L-type and P-type dyslexics also show
functioning. Although the author and others with hemisphere-specific electrophysiological parameters
"solutions" to dyslexia have no doubt treated a (Bakker, Licht, Kok, & Bouma, 1980; Bakker &
number of dyslexics, their basic tenets need to be Licht, 1986). Analyses of event-related potentials
substantiated and their claims must be empirically (ERPs) to words and figures reveal that a significant
verified with rigorous experiments involving double- proportion of the variance can be accounted for by the
blind controls and refined experimental designs (see right temporal components in reading acquisition by
Masland & Usprich, 1981, for review). young children. There are also interactions with age
of slow positive wave activities at the temporal sites
Bakker's "Balance Model" and there are decreases at the parietal sites. These
interactions suggest that left hemisphere strategies
Subsumed under the category of direct ''train- for some reading components are established after I
ing of the brain'' but quite different from the forego- year and before 2 years of reading instruction. Those
REMEDIATION 339
24 fects were carefully evaluated (Bakker, Moerland, &

o----o LED
i.
9I Goekoop-Hoefkens, 1981; Bakker & Vinke, 1985).
23 I
---RED In general, the L-type dyslexics were given
22
'o
/r-: training with words flashed to the left visual hemi-
21 ,a_ field; the P-type dyslexics received words flashed to
20
,' t the right visual hemifield; and the controls for both
I
19 types received central field training or no training at

all. Significant interactions were found as to the am-
"Qz 18 plitude and latencies of some peaks in the parietal and
..."" 16 17 temporal areas and the asymmetric effects were most
...
1111:
noticeable for the parietal area (Bakker & Licht,
...... 1986; Bakker & Vinke, 1985). These results indicate
)(
15
the "rightening" of activities following right hemi-
~ 14
sphere stimulation with L-dyslexics and ''leftening''
"'01111: 13 of activities following left hemisphere stimulation in
......
1101
1111: 12 P-dyslexics. There were some between hemispheric
changes of activities, which tended to correlate with
... 11
......0"" 10
improvements in pre- and posttest reading perfor-
mance. Nontreated L-dyslexics seemed to persist in
...z0 9 left hemisphere strategies as suggested by the leften-
... 8
F. ing of early parietal positivity over time; nontreated
...v
1111:
A.
7 I I
I
'' I
P-dyslexics apparently continued to rely on right
hemisphere strategies as inferred from the rightening
6 I I
I I of parietal positivity over time.
I I
5 I I These neurophysiological results seem to pro-
I I
4 I
I I
1
vide some evidence for the differentiation of L- and
3 I
I I
1 I P-dyslexics. The findings also suggest that direct
I I
II right hemisphere stimulation of L-dyslexics would
2 \I
! lead to greater reading accuracy and reading efficien-
cy. However, direct left hemisphere stimulation in P-
dyslexics yielded some equivocal results in that read-
2 3 4 5 6 7 8 9 10 11 12
ing accuracy and efficiency measures were relatively
CLASSES OF ERRORS
unaffected (Bakker & Licht, 1986; Bakker & Vinke,
1985). Bakker and his colleagues further point out
FIGURE I. Type of reading error by ear dominance (LED, left that whereas their more recent studies confrrm their
ear dominance; RED, right ear dominance). (After Bakker, 1979, results of an earlier pilot study (Bakker et al., 1981),
Figure 4.) there are some variations owing to different training
procedures and stimulus materials. The pilot study
showed the temporal sites to be affected by hemi-
sphere-specific stimulation, whereas the more cur-
children who are inefficient in using, or changing to, rent studies revealed a predominantly parietal effect.
the appropriate reading strategies in concert with the The Bakker concept linking cerebral processing
demand of the reading tasks are likely to experience and early reading strategies is intriguing. It empha-
reading difficulties. sizes the different and conjoint contributions of the
The electrophysiological measures suggest that two hemispheres, especially at the learning-to-read
L- and P-type dyslexics can be distinguished as stage. His neuropsychological and psychophysiolog-
showing different cerebral activities during reading. ical findings may be explained according to the nov-
The ERP results also point to the possibility of selec- elty model of Goldberg and Costa ( 1981). These re-
tive visual and auditory stimulation of the right hemi- searchers suggest that the left hemisphere is more
sphere in L-type dyslexics, and of the left hemisphere capable of unimod&l processing, storage of compact
in P-type dyslexics to improve their reading perfor- codes of information; whereas the right hemisphere is
mance. Such hemisphere-specific stimulation studies more suited for intermodal integration and for novel
were carried out with the two types of dyslexics de- stimuli. Thus, right hemisphere functions are more
lineated according to the ear advantage of verbal di- critical at the acquisition of new descriptive systems
chotic listening tasks and reading errors and the ef- whereas left hemisphere functions are better at util-
340 CHAPTER 18
izing routine codes. The Bakker postulates could be read better words shown upside down in a mirror
accommodated within this framework in that chil- fashion. He interpreted the disorderly EMs or EMs
dren learning to read likely view the reading tasks as not in the preferred direction in relation to the lack of
both novel and perceptually complex and it is only cerebral dominance. A more plausible hypothesis
later that they shift to a linguistically coded system. was advanced by Geschwind and Galaburda (1985)
The Goldberg-Costa theoretical position goes be- to explain these observations. They suggested that in
yond relating functional cerebral asymmetry and in- presenting words in a mirror fashion, the next words
formation processing. It explains what information to be read would lie to the left of the fixation point and
the subjects process and how they process it. hence would be projected to the right hemisphere. If
The Bakker balance model, which is supported the left hemisphere of dyslexic children functions
by his ERP studies, was tested by Donders and van less efficiently than the right, then the visual process-
der Vlugt ( 1984) in their analysis of eye movement ing of the language would be more adequate on the
(EM) patterns of two age groups ("younger" and right side of the brain. This line of interpretation
"older") of good and poor readers during slide-pre- seems to bolster Bakker's balance model of early
sented reading and arithmetic activities. The EM pat- reading.
terns (and by inference, the reading strategies) of There is another intriguing possibility. Gesch-
young poor readers were found to be different from wind and Galaburda ( 1985) further hypothesized that
the EM patterns of all other children. The authors when words are presented in the traditional left-to-
suggested that the balance model needs further val- right fashion for these dyslexic children, the words
idation as it was probably only the group of older either fail to reach, or are slow in doing so, the more
good readers that might be said to employ a left hemi- efficient right hemisphere because the necessary cal-
sphere strategy in reading. losal connections are often poorly formed in many
The use of EM patterns to infer laterality pat- dyslexics. The abnormal corpus callosum leading to
terns is of some interest. There is evidence that dys- inadequate or inefficient interhemispheric connec-
lexics show more frequent fixations and regressions tions is also alluded to by Hiscock and Kinsbourne
than their controls (Pavlidis, 1985, 1986). Pavlidis (1987) as a possible "speculation" in connection
found significant differences in almost all EM pat., with anomalous hemispheric specialization. A more
terns in dyslexics and their nondyslexic "retarded" affirmative position of the potential role of in-
controls matched for reading and chronological ages, terhemispheric collaboration in reading acquisition
but not between the "retarded" and normal readers. was suggested by Gladstone and Best (1985). These
Furthermore, there was little overlap between the authors analyzed the ''contemporary mainstream
dyslexics and all other readers in the number of reviews'' of incomplete cerebral dominance derivable
gressions. There is, however, variant evidence that from Orton (1925, 1937) and of left hemisphere dys-
when older disabled readers and younger normal sub- function discussed by a number of authors in Knights
jects were matched in word recognition and their and Bakker (1976) in relation to early reading and
EMs were measured in the same textual material, reading disabilities. Gladstone and Best found these
there was no significant difference between the mainstream views inadequate to account for different
groups in the EM patterns (Olson, Kliegl, & David- sets of data in reading disabilities. Drawing on re-
son, 1983). The erratic EM patterns found in dyslex- search on callosal contributions to attention, bi-
ics are more likely the result, rather than the cause, of manual coordination, handedness, and gender dif-
poor reading. Pavlidis has advanced the possibility ferences, they presented an alternative explanation
that both EMs and reading performance may be sub- that deficient callosal functions could be a cause for
served by some neurological substrates. This claim some types of dyslexia. Their corollary is that read-
will need to be further tested. What is clear is that EM ing acquisition depends on the interhemispheric com-
variables such as frequency of fixations, fixation du- munication with decreasing degrees of collaboration
ration, frequency of regressions, average saccade needed as the skill develops. These notions of the
length all reflect orthographic and phonological pro- more important role of the right hemisphere in
cesses during reading and that disabled readers vary younger children learning to read and in reading
in their use of small or large units of orthographic or failures seem to be consonant with Bakker's hypoth-
phonological codes. esis of a shift from right to left hemisphere strategies.
They also seem to relate to the Goldberg and Costa
Callosal Connection ( 1981) concept of the right hemisphere being more
suited for new descriptive systems and the left hemi-
Parenthetically, it may be pointed out that Orton sphere as more efficient for categorical, routine
( 1925) observed that some dyslexic children could codes.
REMEDIATION 341
As a summary of these sections on the efficacy conjoint activities of a whole group of cerebral zone
of "training the brain" in remediating dyslexic chil- and the importance of the principle of double dis-
dren, Bakker's (1984) view that psychological stim- sociation between cerebral loci and cognitive pro-
ulation may have some effects on the physiology of cesses. This principle is well documented in clinical
the human brain has some theoretical and empirical studies by Luria (l966a,b, 1970, 1973, 1977). For
bases. He marshalls evidence from a number of neu- example, dysfunction in the parieto-occipital region
roanatomical, neurophysiological, neurochemical, of the left hemisphere disturbs the spatial organiza-
and neuropsychological studies to show the modi- tion of perception and movement shown in such ac-
fiability of the animal brain through environmental tivities as map reading, directional sense, and gram-
manipulation, sensory stimulation, and systematic matical relationship of the kind: "father's brother"
training. Knowledge gained in animal studies con- as distinct from ''brother's father''; but such a patho-
tributes to our understanding of habilitation in logical locus produces no disturbance of processes
humans. involving sequential activities as required in speech
There are neuropsychological programs based fluency, or the playing of musical melodies. Al-
on the adaptational capacities of brain-impaired chil- though advocating "syndrome analysis" of mental
dren to .fit their therapeutic needs (see Rourke et al .. disorders, Luria also draws attention to the need for
1983). With these pathological cases, we need to rigorous techniques such as factor analysis and Baye-
know the location and age of onset of their brain sian analysis to ensu~ consistency of neuropsycho-
damage, the nature of the lesion, its severity and rate logical studies.
of development. All these parameters are important The more functional analytical perspective of
determinants of responses to treatment. With brain- Luria provides the theoretical framework for the
different children, the volume Education and the present author's study of cognitive processing in dys-
Brain (Chall & Mirsky, 1978) published by the Na- lexic and less skilled readers. The position taken is
tional Society for the Study of Education attests to the that specific reading disabilities are best understood
interest in linking the neurosciences, psychology, as the interaction of neuropsychology, cognition,
and education. Various chapters in that book by neu- language, and education (Leong, 1987). The recent
roscientists indicate the role of cerebral specializa- articles in Developmental Review by Crowder
tion in cognition and the importance of timely and (1984), Mann (1984), Morrison (1984), and Wolford
appropriate environmental situations in the growth and Fowler (1984) have rekindled the debate on the
and development of the brain. This is a reminder of nature of the disabilities in dyslexics. Are these defi-
Bakker's (1984) concept of the brain as a "dependent ciencies specific to reading or are they more general?
variable.'' The consensus from that "debate" is that language
plays a large role in reading and its difficulties and
The 11Working Brain" that poor readers also show deficiencies in some cog-
nitive functions other than reading (Crowder, 1984).
The indirect and direct "training the brain" ap- The interplay between neuropsychology, cognitive
proaches all seek to elucidate the left-right axis re- psychology, language, and education is also empha-
sponsible for higher cortical functions. These sized as important in unraveling reading disabilities
discussions of the neuropsychological basis of learn- by Doehring, Trites, Patel, and Fiedorowicz (1981).
ing disorders must go beyond the brain-behavior re- In this section on cognitive processing of dis-
lationship to tease out the more complex levels of abled readers based on Luria's (1966a,b, 1970, 1973,
analysis. Kinsbourne and Hiscock (1983) state that 1977) "working brain" model, the basic neuropsy-
each higher mental function "comprises a complex chological concept is sketched below. This is fol-
set of component skills and even the component skills lowed by a summary of the application of the simulta-
may engage various brain structures. Nevertheless, if neous-successive syntheses and planning model.
all critical components of a function are represented
within the same hemisphere, it may be said that the Luria's Three Basic "Blocks"
function is lateralized" (p. 166). Similar statements
are found in Luria and Artem'eva (1978): "Neuro- In Luria's writing the "higher cortical func-
psychology is concerned with the analysis of cerebral tions'' of language, reading, and spelling are the re-
mechanisms of mental processes, and its primary sults of different components of a complex system
subject matter is the case in which circumscribed working in concert. A function or more exactly a
local brain lesions cause specific changes in mental functional system is explained as:
processes" (p. 283). Luria emphasizes mental ac- The product of complex reflex activity comprising:
tivities as a complex functional system reflecting the uniting excited and inhibited areas of the nervous sys-
342 CHAPTER 18
tern into a working mosaic, analysing and integrating lobe is involved in the fonnation of intentions and
stimuli reaching the organism, forming a system of programs for behavior. This block controls and regu-
temporary connections, and thereby ensuring the equi- lates human behavior.
librium of the organism with its environment. (Luria,
1966a, p. 23)
In Luria's words, these blocks can be approxi-
mated to ''a unit for regulating tone or waking, a unit
Futhennore, a function is stated as "a complex and for obtaining, processing and storing information ar-
plastic system perfonning a particular adaptive task riving from the outside world and a unit for program-
and composed of a highly differentiated group of ming, regulating and verifying mental activity''
interchangeable elements" (Luria, 1966a, p. 26). (Luria, 1973, p. 43, author's italics). It should, how-
Thus, according to Luria, psychological functions ever, be emphasized that any consCious activity is
cannot be adequately explained by some "mor- always a complex functional system and takes place
phological schemes'' of cerebral localization, but are through the combined, concerted working of all three
themselves complex, organized activities of a whole brain units. It should also be borne in mind that the
system. The dynamic grouping of the connections working zones underpinning complex cognitive
may vary even though the task itself remains un- functions are modified by the individual's experience
changed. The apparatus for the whole system is the in his or her acquisition of language, reading, and
upper associative layers of the cerebral cortex, the writing. The progressive emergence of these higher
cortical connections arising in the secondary asso- cortical functions may also be accompanied by neural
ciative nuclei of the thalamus, and the overlapping organization and reorganization and carried out by
zones uniting different boundaries of cortical ana- different constellations of cortical zones. Although
lyzers. Clinical observations of patients with gunshot the ''material basis'' for the higher cortical functions
wounds and brain tumors show that a disturbance of a is the brain as a whole, ''the brain is a highly differ-
particular complex function does not arise in associa- entiated system whose parts are responsible for dif-
tion with a narrowly circumscribed lesion of one part ferent aspects of the unified whole'' (Luria, 1966a,
of the cortex. A lesion of the same area of the brain at p. 35, author's italics).
different stages of ontogenesis may lead to quite dif-
ferent consequences. Moreover, the cortical inter- Simultaneous-Successive Syntheses and
central relationship does not remain the same at dif- Planning
ferent stages of development of a function.
In discussing complex functional systems, Luria's view of the working brain provides the
Luria (l966a,b, 1970, 1973) distinguishes "three neuropsychological model of cognitive processing in
principal functional units" of the brain. The first both nonnal and atypical children. Of particular in-
basic block regulates the energy tone of the cortex. terest are his two basic fonns of integrative activity:
This block includes the upper and lower parts of the simultaneous (primarily spatial, group) and suc-
brain stem, the reticular fonnations, and the hippo- cessive (primarily temporally organized series) syn-
campus. Damage to the first block, namely, the loss theses at the perceptual, memory, and intellectual
of the selectivity of cortical actions and of nonnal levels (Luria, 1966a,b, 1973). For example, simul-
discrimination of stimuli, will bring about marked taneous synthesis at the perceptual level may be
changes in behavior such as disturbances in wakeful- shown in: copying of geometric figures, drawing of a
ness, instability of memory traces. The second basic map, performance on Koh's Block; and at the memo-
block plays an important part in the analysis, coding, ry level in: arithmetic difficulties and ''grammatical
and storage of information. Located in the posterior structure involving arrangement of elements into one
part of the brain, the second block consists of a hier- simultaneous scheme." In successive synthesis, ex-
archical organization of these cortical areas: a pri- amples are counting sequences of tapping, digit span,
mary zone that sorts and records secondary infonna- and serial learning such as drawing ''0 + + - ''
tion, a secondary zone that organizes the infonnation while keeping the correct order. In Luria's terms,
further and codes it, and a tertiary zone where data simultaneous-successive syntheses can be identified
from different sources overlap and are combined to with the functions of specific parts of the cerebral
lay the groundwork of behavior. A lesion in a pri- cortex, although conscious activity as a complex
mary zone results in a sensory defect; a lesion in the functional system is the result of concerted working
secondary zone interferes with the analysis of the of different brain units. The occipital-parietal areas
sensory stimuli; a lesion in the tertiary zone can cause have evolved to be mainly responsible for simul-
complex disturbances as visual disorientation in taneous synthesis. The anterior regions, particularly
space. The third basic block comprising the frontal the frontal-temporal area, are more important for
REMEDIATION 343
successive synthesis. Both of these regions are con- sentence repetition devised by Leong. A cross-modal
cerned with coding and storage of information. The task or Auditory-Visual Coding was found to straddle
Luria model also assumes that the two modes of in- both the simultaneous and successive dimensions.
formation processing are available to the individual, The results from the different factor analyses and
depending on his or her habitual mode of activities factor matching show that the simultaneous-suc-
and the demand of the task. cessive dimensions are differentiated. The same rela-
tive orthogonal factor structure is shown in the cog-
Coding Processes. The Luria model provides nitive patterns of dyslexics and nondyslexics (Leong,
the neuropsychological basis for the process-based 1976) and with skilled and less skilled readers
Kaufman Assessment Battery for Children (K-ABC) (Leong, 1980). From the basic differential patterns of
(Kaufman & Kaufman, 1983) with its simultaneous components or factors, it is logical to derive factor
processing, sequential processing, and achievement scores as more parsimonious constructs and to use
scales. As the rationale of the K-ABC, its diagnostic these scores in multiple regressions or other multi-
utility and remedial applications have been analyzed variate analyses for prediction and explanation of
and critiqued elsewhere (Miller & Reynolds, 1984) reading proficiency.
and are further elaborated on in this volume, the work The Luria-Das paradigm and the Leong refine-
is not discussed here. Instead, attention is turned to ments for studying the cognitive patterns of disabled
the Luria model as first operationalized by Das, Kir- readers have some attraction. For one thing, the
by, and Jarman (1975, 1979) in their research pro- paradigm attempts to steer clear of the traditional
gram with different groups of children: retarded and memory-reasoning distinction with its implied
nonretarded, high and low achievers, children from lower-to-higher hierarchy. For another, the neuro-
different SES and ethnic backgrounds. Das et al. psychological framework focuses attention on the
emphasized the relative independence of simul- workings of cognitive processes and the possibility of
taneous and successive modes of cognitive activities training some precursors to reading. There are, how-
and the importance of processes, rather than products ever, limitations to the two-dimensional approach to
of learning. Leong (Das, Leong, & Williams, 1978; cognitive processing. Tasks requiring higher mental
Leong, 1976, 1980, 1982, 1984; Leong & Sheh, activities are too complex to be amenable to some
1982) predicated his studies of patterns of impair- dichotomous analysis even though the paradigm is a
ment of dyslexics and nondyslexics, below-average viable one. Furthermore, the simultaneous-suc-
readers and their controls, and unselected samples of cessive model would need to be further tested with
readers on the Luria-Das paradigm. He modified, more varied simultaneous-successive tasks of differ-
refined the basic Das battery, added some tasks, and ent levels of complexities, with larger sample sizes
used more rigorous methods of analysis such as dif- and more sophisticated multivariate analyses.
ferent factor analysis models (typically principal Within the stricture of the existing conceptual
component analysis, alpha factor and promax and methodological frameworks, the simultaneous-
oblique factor analyses) and factor matching to successive syntheses approach seems to explain the
achieve "method-independent" and more reliable available data well. However, certain aspects in in-
results. The findings are remarkably consistent in terpreting both the postulate and the findings of the
that the basic and relatively independent (orthogonal) Luria-Das paradigm would need to be further ex-
constructs or factors of simultaneous and successive plored. First, even though the simultaneous and suc-
syntheses emerged with the same basic battery of cessive factors are relatively independent, this psy-
tasks and the resultant factor scores were found to be chometric finding must also be psychologically
discriminating between the different reading groups. meaningful. Rather than conceiving of two distinct
The general results are in line with the Das et al. constructs, we would do well to think of the "simul-
(1975, 1979) studies. taneous-successive matrix" or "simultaneous-suc-
In Leong's research program, the typical marker cessive syntheses" to emphasize the integrative
tasks that loaded on the simultaneous dimension nature of the processes. Careful reading or rereading
were: Raven's Coloured Progressive Matrices of Luria shows his very cautious approach to the
(1947), Figure Copying (Ilg & Ames, 1964), Memo- conventional concept of simultaneous and successive
ry-for-Designs (Graham & Kendall, 1946, 1960). syntheses which ''are not sufficiently accurate'' and
For the successive dimension, the marker tasks were: his implicit assumption of a complex matrix embody-
Auditory Serial Recall (recall of four-word series of ing these syntheses. By simultaneous synthesis is
phonetically similar words), ITPA Auditory Memory meant the "synthesis of successive (arriving one
or digit span (Kirk, McCarthy, & Kirk, 1968), and after the other) elements into simultaneous spatial
344 CHAPTER 18
schemes" and by successive synthesis is meant "the and locations. Both the Euclidean and projective sys-
synthesis of separate elements into successive se- tems provide the framework for ''multiplicative clas-
ries" (Luria, 1966b, p. 74). The former process is sification." It is also likely that the poorer perfor-
characterized by "surveyability," the latter by mance of the "retarded" and "backward" readers in
"order" and "kinetic melody." These charac- Leong's studies (1976, 1980) suggests their use of a
teristics are close to the "logical multiplications" in "Gestalt algorithm" rather than an "analytic al-
the Piagetian concept of logical development (Piaget gorithm" in solving matrices (see Hunt, 1974). This
& lnhelder, 1956). More important for our purpose, qualitative interpretation of individual performance
Luria wrote of "integrative activity" and "analyt- will enhance the inference of processes from factor
ico-synthetical'' activities of the cortex to underline loadings and factor patterns of groups. It will also
the interrelatedness of simultaneous-successive syn- highlight the different procedures a child can draw on
theses (Luria, 1966b, p. 83). The following quota- in solving a cognitive task and the importance of
tion explains the holistic and localized "complex analyzing learning strategies, whether simultaneous
functional systems'' of the brain working in an inte- or successive.
grative manner:
Syntheses of elements into simultaneous groups and
Planning Component. In their relatively recent
successive series may fonn a part of any analytico- formulation, Das and his associates (Das, 1980,
synthetic activity and are two fonns of working of the 1984; Das & Heemsbergen, 1983) have extended
same brain sbUcture, two necessary aspects of each their work in coding processes (simultaneous and
neuro-dynamic process. The nervous processes con- successive syntheses) to investigate Luria's third
stituting the worlc of any analyzer always take place in block functions. Planning or planful behavior gener-
time and are always dependent on certain spatially orally refers to judgment, decision-making, and eval-
ganized sbUctures .... The correlation of dynamics uation of activities. The characteristics of planning
with SbUcture . . . WOUld be impossible Without taking include the encoding and recoding of information,
into account both these aspects of nervous activity.
the selection of appropriate ''programs,'' the evalua-
OLuria, 1966b,p. 79)
tion and execution of action. These and other tasks
These complementary-different functions are in ac- are suggested by Das as efficient for assessing plan-
cord with current views of cerebral mechanisms. ning: visual search, trail making, planned composi-
Over and above the quantitative aspect of per- tion, syllogistic reasoning, and the game of strategies
formance, the Luria postulate carries with it the im- Mastermind. Of particular interest among these tasks
plicit emphasis of the qualitative aspect. Attention is are visual search, which requires the subject to search
directed to how a function suffers rather than what visually different geometric shapes, letters, and
functions are deficient or inefficient. An example of number sets on an overhead transparency and to
the qualitative performance from the Luria dictum is make rapid decisions matching the stimulus to the
the solution of analogy items in Raven's Coloured target; and trail making, which involves the ability to
Progressive Matrices, one of the marker tasks for see relationships and to shift from one stimulus to the
simultaneous synthesis. Within the context of the other.
early growth oflogic in the child, Inhelder and Piaget Leong, Cheng, and Das (1985) recently tested
(1964, pp. 151-154) speak of the Raven's series of the validity of planful behavior as a construct within
tests as a good example of ''multiplicative classifica- the Luria-Das paradigm with elementary school
tion,'' which is mastered at about 8 years of age. By children. Factor analyses according to different
multiplicative classification is meant ''classing each factor models showed that the simultaneous-suc-
element simultaneously in terms of [the] two additive cessive syntheses and planning dimensions are well
orders.'' Thus, from the kernel 2 X 2 matrix involv- differentiated (see Figure 2) and that the simul-
ing two sets of elements such as red and blue squares taneous-successive-planning dimensions contribute
and circles, the combination can be extended to in- to reading proficiency as shown in multiple regres-
clude shape, color, line, position, and the like. Suc- sion analyses using the factor scores derived from the
cessful performance on the Raven's requires both domains.
"reasoning" and "spatial ability" as suggested by There is further statistical evidence that the
Kirby and Das (1978). Luria-Das model fits the data well (Leong, Cheng,
A child's poor performance on the Raven's Lundberg, Olofsson, & Mulcahy, submitted). In two
might be attributed to his/her failure to establish Eu- studies, one involving 129 eleven-year-old and the
clidean relationships and to coordinate projective other involving 164 ten-year-old unselected readers,
viewpoints as perspectives, sections, projections, Leong et al. tested the goodness of fit of the simul-
REMEDIATION 345
.9 j SIMULTANEOUS taneous-successive syntheses, planning, and speed .

.8 COMPONENT Some of the results are summarized in Table 1.
.7
.6 x2 is a goodness (or badness) of fit measure in
that large x2 values indicate a bad fit and small values
VI
ct<!l .5
....
vC .2-
o z .3.4
a good fit. The coefficient of determination is a gen-
<<
... o .I eralized measure of the reliability of the whole mea-
.... surement model. A high value indicates a good fit
-.1
-.2 between the conjoint measurable variables (x vari-
-.3 2 3 4 5
ables) and the conjoint unobserved or unobservable
variables (the simultaneous, successive, planning,
.9
.8
and speed domains). There is thus further psycho-
.7 metric evidence for the Luria-Das construct of si-
.6
VI
ct<!l .5 multaneous-successive syntheses and planning and
....oz
uO .3
- .4 the variant construct to include the speed domain .
<<
... o
.2
.1
....
-.1
-.2 Instructional Implications
-.3
2 34 5 6789
On the instructional aspect using the simul-
SUCC ESSIVE
taneous-successive paradigm there is evidence of its
COMPONENT relationship to reading and language disabilities
11'1
(Cummins & Das, 1977, 1978). There is further evi-
ct<!l
o z dence that these processes can be trained (Das et al.,
ti c 1979). Kirby and Das ( 1977) showed that both simul-
<<
... g taneous and successive processing are necessary, but
neither by itself is sufficient, for high performance in
reading and intelligence tests. For the simultaneous
2 3 4 5 6 7 dimension, Lawson and Kirby (1981) found some
VARIABLES success in training a "Gestalt strategy" and an "ana-
Cognitive Processing of Combined Group (N :: 129) lytic strategy" in processing Raven's tasks and the
different strategies in turn related to the performance
FIGURE 2. Simultaneous-successive syntheses and planning of their subjects. Leasak, Hunt, and Randhawa
components. Variables: I , Raven's Coloured Progressive Ma- (1982) carried out an intervention program specifi-
trices; 2, Figure copying; 3, Memory-for-Designs (negative signs cally designed to improve simultaneous processing
reversed); 4, Auditory serial recall; 5, ITPA auditory memory; 6, and found significant improvement in both reading
Sentence repetition; 7, Visual search time; 8, Trail-making time and arithmetic in their Grade 4 experimental chil-
(A); 9, Trail-making time (B).
dren. For the successive dimension, Krywaniuk and
Das ( 1976) found that remedial programs designed to
augment successive processing were successful and
taneous-successive and planning model and the had an effect on decoding subskills.
elaboration of that model to include the speed compo- More recently, Kirby and Robinson (1987) in-
nent. They used a maximum likelihood approach vestigated the effects of simultaneous-successive
with the LISREL (linear structural relationship) syntheses on a number of reading tasks in 105 eleven-
model (Joreskog & Sorbom, 1984) to test their hy- year-old children. Their results further uphold the
potheses. In essence, the maximum likelihood struc- viability of the simultaneous-successive syntheses
tural estimation using LISREL is both exploratory as a framework for remediation with simultaneous
and confirmatory with specification of parameters processing being implicated in lexical access and se-
and measurement errors. The approach emphasizes mantic explication and successive synthesis more re-
both theory and measurement and allows for hypoth- sponsible for decoding and syntactic analysis. In par-
esis testing of how well alternative models fit the ticular, the results suggest that reading-disabled
data. The Leong et al. study found that the three- children are likely to use an inappropriate strategy at
domain simultaneous-successive syntheses and a particular stage of their reading. They probably
planning fit the data well, but an even better fit is employ simultaneous processing in the early reading
provided by the four-domain model with simul- stage for both word recognition and syntactic analy-
346 CHAYfER 18
TABLE 1. LISREL VI Analysis of 10 Variables for Simultaneous Synthesis, Successive

Synthesis, Planning, and Speed (N = 164)
Maximum likelihood (ML) of components (standard errors in parentheses)

Manifest variables Simultaneous Successive Planning Speed
Raven's Coloured Matrices (x 1) 0.582 (0.092)

Figure copying (x 2) 0. 711 (0.092)
Memory-for-designs (x3) -0.555 (0.090)
Auditory serial recall (x4 ) 0.427 (0.089)
ITPA auditory memory (x 5 ) 0. 784 (0.096)
Sentence repetition (x6) 0.644 (0.091)
Trail making time A (x7 ) 0.644 (0.119)
Trail making time B (x 8 ) 0.850 (0.141)
Visual search time I (x9 ) 0.865 (0.229)
Visual search time 2 (x 10) 0.355 (0.118)
Error scores for memory-for-designs (x 3 ):
Chi square, X229 = 32.69, p = 0.290
Goodness of fit index (GFI) = 0.963
Adjusted goodness of fit index (AGFI) = 0.929
Total coefficient of determination p = 0. 991
sis tasks for which successive processing could be formation-processing approach with the neurological
more appropriate. It is this overuse or inappropriate underpinning, is the Tower of Hanoi task (Simon,
use of simultaneous processing and the inadequate or 1976), the processing of which requires the attain-
inefficient use of successive processing that may ex- ment of the goal by decomposition into subgoals with
plain some of their difficulties in reading. minimum individual moves. A modified form of the
Tower of Hanoi task has been shown to relate to
Luria's views on frontal lobe functions (Shallice,
Frontal Lobe Involvement in Planning 1982). These are just further suggestions to refine the
tasks with which to infer Luria's third block functions
Of the several components in the Luria-Das of executive intentions, maintaining and directing ac-
formulation, the planning domain merits particular tivities.
attention. This is an area that presents challenges in In addition to the need to refine behavioral
conceptualization and methodology. Several tasks tasks, there are neuropsychological implications for
hold promise in identifying planful behavior con- the role of the functional capacity of frontal systems
sonant with Luria's (l966a,b) neuropsychological in dyslexics. Denckla and her colleagues (Denckla,
concept of programming and regulating different 1983; Duffy, Denckla, Bartels, & Sandini, 1980;
activities. The Block Design of the WISC-R Duffy, Denckla, Bartels, Sandini & Kiessling, 1980)
(Wechsler, 1974) is a possibility, except that more investigated this issue in 13 ten-year-old ''pure dys-
spatial processing resources seem to be called for by lexic'' boys compared with ll controls and specu-
the task. The Wisconsin Card Sorting Test (WCST) lated on frontal lobe contributions to children's grow-
as a test of perseveration and concept shift from well- ing capacity to learn language. The dyslexic and
learned responses to new stimuli is another pos- control children all underwent sophisticated EEG re-
sibility. Milner (1963) found that patients with dor- cording including brain electrical activity mapping
solateral lesions were most impaired on the WCST (BEAM) (see also Duffy & McAnulty, 1985).
and suggested that it is not a defect of abstract think- BEAM is an elegant topographic imaging technique
ing that leads to the impairment but a generalized to record continuously changing spectral and spatial-
inability to shift behavior when needed to do so. temporal information with computerized analyses
Robinson, Heaton, Lehman, and Stilson (1980) and display of latency, amplitude, and frequency
showed that the WCST discriminates significantly band information accompanying each image. The lo-
between the neurologically normal and patients with cation and degree of abnormality for each individual
localized frontal lobe brain lesions. An even more are analyzed with a technique known as significance
promising task for planning, which combines the in- probability mapping (SPM). The goal of SPM is to
REMEDIATION 347
delineate regional topographic differences of brain with emotional behavior, even though he did not at-
activity using various statistical analyses of data. The tach great importance to the left-right distinction in
''pure dyslexic'' boys showed the alpha-type EEG the frontal lobe areas. The condition of developmen-
rhythmicity in the medial frontal regions but no alpha tal dyslexia may represent a disability involving a
blocking in the posterior regions, while they were complex and widely distributed cerebral system with
engaged in language-related cognitive activities in- breakdown in accessing the writing system.
cluding reading. Alpha rhythmicity is characteristic The research challenge should be the integration
of the resting or idling state of the brain, whereas of information processing and clinical neuropsychol-
alpha blocking suggests active engagement in cog- ogy to understand better language and reading disor-
nitive tasks. In contrast to the dyslexics, the normal der (Ellis, Miller, & Sin, 1983). Marin, Glenn, and
controls displayed alpha blocking or marked EEG Walker (1982) stressed "the relationship between
rhythmic changes while performing similar cognitive the molecular nature of the brain and the processes or
activities. operations which transform the neural activity into
What is particularly significant is that for the the integrated abilities that characterize human life''
dyslexics, much of the resting alpha rhythm organi- (p. 253). Rourke (1982) used the metaphor "dynam-
zation as shown in BEAM readings was found in the ic neuropsychology'' to emphasize the development
frontal convexity of the brain. The other cerebral of the brain and the development of the individual as
regions distinctive in the dyslexics were the left front- well as the interactions of both aspects to explain
al area (near Broca's area), the left midtemporal area learning and learning difficulties. Rourke's develop-
(the auditory associative area), all from EEG data and mental neuropsychological model proposed these
the left posterolateral quadrant (Wernicke's area) axes of importance in human neuropsychology: (I)
from the evoked potential data. These between-group progression from "lower" to "higher" cerebral cen-
electrophysiological differences including the in- ters, (2) progression from posterior to anterior re-
volvement of the bilateral medial frontal lobes found gions of the cerebrum, and (3) the left-right hemi-
by Denckla, Duffy, and their colleagues with the sphere reciprocal relationship. The significance of
BEAM technique are corroborated by the cortical his proposal is the interaction of these developmental
blood flow studies of Lassen, Ingvar, and Skinhfllj dimensions as a framework or a neurodevelopmental
( 1978) in normal subjects during speech and reading. model of central processing in children, especially
The BEAM and related findings led Denckla (1983) those with learning disorders.
to make the "bold suggestion" that "a pure dyslex-
ic, with no deficit in spoken language, appears to
have some subset of general verbal learning deficits
associated with left convexity frontal lobe" (p. 41, Interaction of Cognitive Processing,
author's italics). Language, and Reading
There is the further suggestion that ''pure dys-
lexia'' may represent the dysfunction of the entire Thus far, we have offered some evidence from
complex bihemispheric system normally involved in the neuropsychological, statistical, and instructional
language-related activities. This hypothesis does not perspectives for the viability of the simultaneous-
seem to be incompatible with the abnormalities found successive syntheses and planning model and its
primarily in the left posterior hemisphere with dys- variant paradigm including speed as correlates for
lexics in that these abnormalities may interfere with reading proficiency. Both the three-domain and the
functions over large cerebral areas. Duffy and his four-domain cognitive processing models are not in-
colleagues (Duffy, Denckla, Bartels, & Sandini, compatible with the Luria-Das paradigm. Which-
1980; Duffy, Denckla, Bartels, Sandini, & Kies- ever model that is used for research and habilitation
sling, 1980; Duffy & McAnulty, 1985) emphasize purposes must go beyond the statistical findings and
that the BEAM findings with the small number of must take into account the integrative nature of the
"pure dyslexics" may not be universally applicable mechanisms involved in information processing. In
to all dyslexics. Nevertheless, their studies further particular, theories should be developed to delineate
alert us to the need to formulate research hypotheses the nature of the interaction among components of
or further explore the role of Luria's third block and reading, language, and neuropsychological variables
to devise more refined paper-and-pencil tasks as and tasks should be designed to assess these interre-
clinical instruments. Parenthetically, Luria consid- lated subskills. The aim is to provide a profile of
ered the left frontal lobe to be more involved in verbal reading abilities or disabilities in such a multifaceted
processes and the right frontal lobe more concerned context (Doehring, 1984; Rourke, 1982).
348 CHAPTER 18
A good example of this interactive approach is and refutation of hypotheses that we gain a better
the detailed investigation carried out by Doehring et understanding of reading disabilities.
al. ( 1981) in 88 clinic-referred disabled readers rang-
ing from 8 to 14 years of age. From the Q-factor
analyses of the 39 reading-related and language-re- The Role of Language Access
lated tasks, Doehring et al. found different patterns
or subgroups of dyslexic readers. The largest group Although simultaneous-successive syntheses
(Type 0 for oral reading disability) tended to be and planning together with the speed variant have
much poorer in oral reading of words, syllables, and been shown to be antecedent factors of reading profi-
letters than in their visual and auditory-visual match- ciency in grade school children, the further research
ing performance. Type A (associative reading 9is- question is the role of language. Specifically, the
ability) tended to be very poor on auditory-visual monitoring, control, and repair of, and general re-
matching tasks. The third type, Type S (sequencing flection on language over and above language usage
reading disability), was much poorer in reading sylla- may provide the intermediate link between cognitive
bles and words than in reading single letters. Thus, processing and school achievement including read-
the careful study of Doehring et al. further elucidates ing. This metacognitive knowledge variously re-
Vellutino' s ( 1979) verbal deficit conceptualization of ferred to as "reflective abilities," "general devel-
dyslexia. Another powerful study, the Florida longi- opment of consciousness," or "metalinguistic
tudinal project by Satz and his colleagues (see abilities" is termed "language awareness" by
Fletcher, Satz, & Morris, 1984; Satz & Morris, Downing and Leong (1982, Chapter 6) and more
1981, for representative works), has again identified recently "language access" by Leong (1987). In es-
as dominant the different clusters of ''global lan- sence, this concept is implicit in Vygotsky
guage difficulties," "selective language difficul- (193411962, 1978) and Luria (1979, 1981). In their
ties,'' but with fairly ''normal'' performance on non- seminal writings, Vygotsky and Luria discussed the
language perceptual and neuropsychological tasks. notions of the internalization of higher psychological
Thus, from the clinical and cognitive neuropsy- functions; the regulatory functions of speech in
chological literature, there is the ongoing quest for a human cognition; the mediational role of language in
better understanding of both the nosology and patho- thinking; and consciousness as affective and cog-
genesis of specific reading disabilities. The nosology nitive phenomena. These key Vygotsky and Luria
or etiology delineates the ''disease'' entities, where- concepts of the roles of speech and language in higher
as pathogenesis considers the particular symptoms cognitive functions have been applied to pedagogy,
and symptom complexes that lead to the "disease" especially to the teaching and learning of reading
entities. From the habilitation point of view, patho- (Elkonin, 1963, 1973).
genetic rather than etiological considerations are Much of the current work (Downing & Valtin,
more likely to provide some direct principles and 1984; Sinclair, Jarvella, & Levelt, 1978; Tunmer,
useable approaches. Conceptually, we need to devel- Pratt, & Herriman, 1984) on bringing to the
op a theory-based, empirically verifiable framework awareness level of the learner the various linguistic
involving actual reading and not just reading-related activities, and relating these activities to reading as a
tasks and to assess the effects of systematic remedia- deliberately acquired, language-based skill, owes to
tion. These proposals are made forcefully by the integrative works of Vygotsky and Luria. Related
Doehring et al. (1981). Ever their own best critic, to the internalization of language for higher cortical
they acknowledge the need for such a theoretical functions is the need for the reader to access his or her
framework and emphasize the importance of "a tacit knowledge of grammar (see Leong, 1987). This
working theory that makes possible a unified assess- grammatical knowledge is intuitive knowledge and
ment and explanation of the entire pattern of deficit'' hen.ce accessible whereas strategies such as speech
(p. 241). Methodologically, these issues should be perception and parsing mechanisms are inaccessible
addressed: wider sampling of reading subskills and empirically, if not linguistically. Language access is
neuropsychological tasks, broader coverage of age thus a mental activity that interacts with other cog-
ranges and ethnic variables of the children studied, nitive activities, modifies them, and is in turn modi-
strengthening of criterion measures, judicious choice fied by them.
of statistical methods, and further validation of re- Studies of language access generally refer to
sults (Fletcher et al., 1984; Satz & Morris, 1981). It situations where children perform actions, the results
is only through the careful working and reworking of of which are apparent to them even though their
hypotheses and the twin processes of confirmation awareness may lag behind their success in their ac-
REMEDIATION 349
tions. Much of the Soviet literature is in this direc- mance of Grade 1, 2, and 3 children in segmenting
tion. Luria (1946, p. 61) in his glass window theory syllables into phonemes, words into syllables, pho-
pointed out that even though a child actively uses nological representation and understanding of sen-
grammar, "he is still not able to make the word and tence structure (Leong & Haines, 1978). The Leong
verbal relations an object of his consciousness." He and Haines results as shown in analyses of variance
goes on to say: "In this period [of the child's devel- and canonical correlations confirmed the Liberman et
opment] a word may be used but not noticed by the al. ( 1977) findings of the role of phonemic segmenta-
child, and it frequently seems like a glass window tion in early reading. These results are taken to mean
through which the child looks at the surrounding that, for young children, their awareness of words
world without making the word itself an object of this and sentences is at the subsidiary level. Their acquisi-
consciousness and without suspecting that it has its tion of verbal skills is facilitated if their understand-
own existence, its own structural features.'' It should ing is brought to the focal level. The reflection on,
be noted that the Vygotsky and Luria concept of con- and manipulation of, words and sentences can be
sciousness is paradigm-specific to the Marxist phi- taught in the form of word games and play activities,
losophy and is focused on how the individual reflects and will go some way toward helping the child in
on, or is influenced by, the socio-cultural environ- reading acquisition (Bradley & Bryant, 1985; Leong,
ment in which he or she functions (Luria, 1981). 1987).
Nevertheless, the basic .concepts as embodied in Although there is a considerable volume ofliter-
Elkonin's (1963, 1973) experimental work have a ature on the importance of phonological awareness in
direct bearing on fostering children's awareness of early reading, questions are often raised as to the
language. Elkonin has developed practical ap- precise nature of this contribution (Wagner &
proaches to help early readers and disabled readers in Torgesen, 1987). Are the different facets of pho-
understanding the concepts of language and in rea- nological awareness prerequisites to, or facilitators,
soning about the writing system. One of Elkonin's consequences, or correlates of reading? In a critical
key notions is his emphasis on the need to distinguish review of the development of individual differences
between "perceived phonemes" and their embodi- in reading ability, Stanovich (1986) hypothesized
ment of the natural flow of speech and the further that "if there is a specific cause of reading dis-
need for phonematic analysis, which enables chil- ability at all, it resides in the area of phonological
dren to gain an understanding of the language sys- awareness. Slow development in this area delays ear-
tem. To attain this phonematic analysis, Elkonin sug- ly code-breaking progress and initiates the cascade of
gests a series of stages. They range from establishing interacting achievement failures and motivational
the concept of the task, to mastering the concept with problems" (p. 393).
objects, with overt oral speech, then transferring the In a series of elegant studies, Lundberg and his
operation to the mental level and finally internalizing reading research group in Umea (see Lundberg,
of these series of activities. 1985, for representative work) have provided strong
Even allowing for the difference in the trans- evidence for the causal effect (in the descriptive
parency-opaqueness continuum between the Cyrillic sense) of phonological awareness and early reading.
and other alphabetic writing systems, the Soviet ap- The Umea researchers show that phonemic
proach to language access as represented by Luria awareness (rhyme recognition, segmental analysis,
and the role of phonematic analysis in early reading phoneme elision and addition, phoneme synthesis)
as emphasized by Elkonin are directly applicable to can be developed in prereaders outside the context of
English. These basic concepts are explicated in the formal reading instruction (Olofsson & Lundberg,
language-oriented approach to reading and reading 1983). Furthermore, phonemic training contributes
disabilities by Liberman and her colleagues at the to the long-term development of accurate concepts of
Haskins Laboratories (Liberman, 1983; Liberman, reading in preschool children and young readers
Shankweiler, Liberman, Fowler, & Fischer, 1977; (Olofsson & Lundberg, 1985). The Umea group fur-
Shankweiler, Liberman, Mark, Fowler, & Fischer, ther investigated the interactions of language (both
1979). Working within the language access frame- comprehension and production), cognitive develop-
work and drawing on the research programs of the ment as independent latent variables and "meta-
Haskins group, the present writer has attempted to phonological'' abilities and reading/ spelling as de-
tease out the contributions of cognitive processing, pendent latent variables in a follow-up of 46
language access, and reading. An early study in rela- dyslexics compared with 44 controls all drawn from a
tion to Luria's phonematic analysis and the Haskins longitudinal study involving over 700 children (Tor-
group's phonological awareness involved the perfor- neus, 1984). Subserving the latent phonological
350 CHAPTER 18
awareness domain were the measurable tasks of seg- The direct effect of successive processing on reading
mental analysis, sound blending, position analysis, as given by the path coefficient is 0.115, whereas the
and segment deletion. Using the maximum like- total of the indirect effect is 0.216. In contrast, the
lihood approach with different LISREL analyses per- language awareness tasks have a much greater direct
formed separately for reading and spelling, Torneus effect on reading as shown by the path coefficient
found strong support that reading/spelling is directly of 0.680. Thus, within the framework of the postu-
dependent on metaphonological abilities and only in- lated "causal" model, there is some evidence from
directly on other cognitive and language skills. the path analysis to support the assertion that the
The present writer's two recent studies (Leong, effect of simultaneous-successive syntheses on read-
1984; Leong et al., submitted) are in the direction of ing is mediated by language awareness and the latter
teasing out the reciprocal and interactive effects of in turn has a greater direct effect on the deliberately
cognitive processing, language awareness, and taught and school-based task of reading.
reading proficiency in older children (Grades 4 to 6). In addition to the findings of the greater direct
It is postulated that for older children, language effects of language awareness than cognitive pro-
awareness at the syntactic-semantic level involving cessing on reading, Leong and Carrier (1986) have
such tasks as the disambiguation of ambiguities and further shown in two experiments that less skilled
the solution of incongruities and anomalies should readers and dyslexics experienced difficulties with
contribute more of the variance to reading than cog- the processing of sentential ambiguities as compared
nitive processing (Leong, 1986; Leong & Carrier, with the dyslexics' chronological-age and reading-
1986). The multiple regression analyses of the 1984 age controls. Encouraged by these findings, Leong et
Leong study provide some answers to the relative a/. (submitted) further tested the extension of the
contributions to the variance in reading by the lan- model linking cognitive processing, language ac-
guage awareness aggregate, and simultaneous-success, and academic achievement with a maximum
cessive syntheses residualized for language likelihood approach. The generalized path model in-
awareness. These analyses show clearly the predomi- volving simultaneous-successive syntheses and
nant contribution to reading by language awareness, planning, language awareness, and achievement in-
whether considered as separate entities or as an ag- cluding reading is shown in Figure 3.
gregate. In a path analysis, the direct effect of simul- As the four-domain model involving speed as an
taneous processing on reading as given by the path additional domain provides a better fit to the data,
coefficient is 0.050, whereas the total of indirect ef- these results rather than the three-domain ones are
fect as mediated by language awareness is 0.254. summarized below. The exogenous simultaneous-
Simultaneous
Processing
Awareness School
Planning 1 - - - . - J (Hierarchy of
monitoring, control,
repair, reflection
processes)
Successive
Processing
FIGURE 3. Postulated path diagram showing direct and indirect effects of cognitive processing and language awareness on achievement
including reading.
REMEDIATION 351
successive syntheses, planning, and speed and the plicitly and systematically, to manage a set of options
endogenous language access domain have both direct when unknowns are encountered, to develop reflec-
and indirect effects on reading, but with different tive language skills, promotes literacy development
forces. The direct effect of simultaneous processing and is effective in habilitation with dyslexics.
on academic performance as given by the path coeffi-
cient is 0.532, the indirect effect via language access
is 0.196, and the total effect is 0.728. The direct
effect of successive synthesis on academic perfor-
Summary
mance is 0.199 as compared with the indirect effect
This chapter focuses on some neuropsycholog-
via language access of 0. 707 for a total effect
ical models that may contribute to the remediation of
of 0.906. These higher direct and indirect effects
children with developmental dyslexia. Indirect and
contrast with those provided by the planning and
direct approaches to ''training the brain'' are dis-
speed domains. Planning related to academic perfor-
cussed. Luria's "working brain" model of simul-
mance has a direct effect of 0.192, an indirect effect
taneous-successive syntheses and planning seems to
via language access of -0.066 and a total effect
offer promise for analyzing cognitive processes.
of 0.127. Speed (latency scores) related to academic
Such a model together with the inclusion of the speed
performance has a direct effect of -0.071, an indi-
domain fits well the data from unselected and poor
rect effect of -0.051, and a total effect of -0.123.
readers as tested with different models offactor anal-
Furthermore, the interaction between the endoge-
ysis and the maximum likelihood approach using
nous domain is more from language access to aca-
LISREL. Mediating cognitive processing and read-
demic performance as shown by the beta coefficient
ing proficiency is the latent domain of language ac-
of 0.478 and not the other way around (beta coeffi-
cient of 0.369). cess involving the disambiguation of ambiguities, the
resolution of anomalies and related reflective tasks
These results both support and elucidate
on the syntactic-semantic aspects of language. It is
Leong's (1984) path analysis showing the greater
suggested that the training of coding processes and
direct effect of language awareness than simul-
planning strategies and the development of reflective
taneous or successive synthesis on reading. The max-
language skills should help children with reading
imum likelihood results suggest the primacy of the
disabilities.
coding processes over planning and speed, probably
because of the need to refine the planning tasks. In
structural terms, simultaneous processing has a AcKNOWLEDGMENT
greater direct effect on reading and related academic
skills than successive processing, the effect of which I thank Dirk J. Bakker of the Free University of
is mostly mediated via language access. The Leong et Amsterdam for his insightful comments. Any short-
al. (submitted) findings also suggest the need to en- comings are necessarily my own.
courage readers to reflect on language at the syntac-
tic-semantic level. Teachers for their part should
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REMEDIATION 355
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19
Neuropsychological Approaches to the

Remediation of Educational Deficits
PHYLLIS ANNE TEETER
The primary purpose of this chapter is to introduce and psychological development has grown consider-
neuropsychological principles and approaches relat- ably with the advent of increased systematic re-
ed to the remediation of brain-related educational search. The neuropsychological basis of specific
deficits. General theories of how the brain functions childhood disorders has been widely studied, includ-
following damage or dysfunction will be discussed in ing learning disabilities (Gaddes, 1980; Rourke,
terms of prediction and outcome expectations, in- 1985), dyslexia (Hynd & Cohen, 1983), math defi-
cluding: neurodevelopmental factors that affect re- cits (Strang & Rourke, 1985), spelling disorders
covery of functions; how the severity of deficits af- (Sweeney & Rourke, 1985), hyperactivity (Rutter,
fects remediation; and the impact of associated 1983), and attentional deficits (Douglas, 1983). De-
medical and psychological deficits on remediation. A spite these advances in our understanding of the
review of several neuropsychological remediation brain-behavior relationship in specific learning dis-
programs will be presented, including Reitan's RE- orders, the area of remediation is an evolving study
HABIT Program and Kaufman's Sequential or Si- and specific neurocognitive treatment approaches are
multaneous Program. Finally, specific remedial still in their infancy. Rourke, Bakker, Fisk, and
techniques for treating brain-related deficits in read- Strang (1983, p. 153) indicated that there are "more
ing, math, spelling, and reasoning will be discussed. questions than answers with respect to the remedia-
Although this chapter will provide a theoretical basis tion of brain-related deficiencies."
for neuropsychological remediation, readers are cau- The application of neuropsychological theory to
tioned that there are still many questions to be an- treatment is predicted on the valid and comprehen-
swered because so few remedial approaches for spe- sive assessment of a child's individual strengths and
cific brain-related deficits have been empirically weaknesses across a variety of language, reasoning,
tested. motor, perceptual, and memory tasks. Valid neuro-
psychological assessment is particularly complex be-
cause the clinician must determine whether the child
Applying Neuropsychological Theory has a brain-related deficit, a developmental delay, or
to the Remediation of Educational a neuropsychiatric disturbance (Hooper & Boyd,
1986). There are a number of factors that further
Deficits affect treatment outcomes, including: the age of the
child when the damage occurred; the nature and se-
The field of child neuropsychology has made verity of the neuropsychological deficits; the pres-
enormous strides in recent years with regard to how ence or absence of specific strengths; the premorbid
the brain functions in children and young adoles- status of the child; and other environmental and moti-
cents. General knowledge concerning how brain vational factors (Rourke et al., 1983). For these rea-
damage or dysfunction affects a child's educational sons, remedial programs should be individually de-
vised and monitored (Hartlage & Reynolds, 1981).
PHYLLIS ANNE TEETER Department of Educational The emphasis on an individual approach makes sys-
Psychology, University of Wisconsin, Milwaukee, Wisconsin tematic research on the effectiveness of treatment
53201 problematic. Furthermore, it is difficult to make gen-
357
358 CHAPTER 19
eralizations from one child to another because the imating the learning capacity of their nonimpaired
neurocognitive deficits, the ability structures and en- counterparts. The effects of early damage reduced
vironmental factors vary across individuals. This the overall developmental potential of the young chil-
may also explain why so many studies investigating dren, and they never achieved the performance levels
treatment effectiveness have produced equivocal re- of their normal peers. These results led Reitan ( 1981)
sults. For example, many studies involve the pre- and to conclude that the longer the brain was intact, the
posttesting of groups of brain-damaged children who greater was its potential to develop higher-level lan-
have very heterogeneous abilities (Rourke et al., guage and cognitive abilities.
1983). Plasticity theories challenge Reitan's conclu-
In order to determine a child's remedial needs sions, and are based on the observation that young
and to design a remedial program, it is important to children show a greater capacity for recovery of func-
identify the etiology of the problem; that is, are the tion than do adults following left hemisphere lesions.
deficits a result of acquired (e.g., traumatic injury) For example, Alajouanine and Lhermitte (1965)
or neurodevelopmental (e.g., learning disability) found that children (aged 6 through 15 years) showed
anomalies? The deficits and the course of recovery remarkable recovery oflanguage abilities 1 year after
for each injury may differ significantly. See Berg insult to the left hemisphere. Basser (1962) and He-
(1986) for a discussion on recovery of function fol- caen (1976) also reported more severe language defi-
lowing closed-head injuries in children, and Hynd cits in adults following left hemisphere damage, with
( 1986) for a discussion of educational interventions milder disorders present in children. Although both
for children with developmental learning disorders. hemispheres appear to be anatomically different at
The purpose of this chapter is to provide the birth (Witelson & Pallie, 1973) and functionally
reader with principles that can be applied to the treat- asymmetrical, both appear to be able to assume ac-
ment of children with brain-related educational defi- tivities normally monitored by the opposite hemi-
cits. Several important issues that impact on remedia- sphere following injury (Kolb & Whishaw, 1980).
tion will be presented. Golden and Wilkening ( 1986) reported that transfer
of language to the right hemisphere is optimal prior to
the age of 2 years. The transfer is less complete for
Factors Affecting Outcome older children, and the deficits mimic those found in
adults.
In the following section a number of factors that Kolb and Whishaw (1980) provided a develop-
interact with and affect treatment outcomes will be mental matrix concerning cerebral asymmetry and
discussed. Three major areas will be included: neu- transfer of functions across the hemispheres follow-
rodeve1opmental issues; the nature and severity of ing injury. In this model, based on hemidecortication
deficits; and associated medical and psychological studies, both hemispheres have the capacity to as-
deficits. sume lower-level functions of the opposite hemi-
sphere. However, neither is able to fully assume the
functions of the other side. For example, if the left
Neurodevelopmental Issues hemisphere is removed, the right hemisphere can
Age of Onset of Injury. Neurodevelopmental perform simple language tasks without compromis-
factors increase the complexity of both the neuropsy- ing simple or complex visuoconstructional capaci-
chological assessment and the treatment of childhood ties; and simple visuospatial tasks can be performed
brain-related disorders. The age of onset of injury has by the left hemisphere without interfering with com-
been the focus of many studies investigating whether plex language abilities. The transfer of more complex
early or late damage is most debilitating. This issue is activities of either hemisphere seems to be in jeopar-
far from being fully resolved, but several studies pro- dy, however. Kolb and Whishaw (1980) suggested
vide a basis for predicting probable outcomes. Reitan that at birth there is considerable overlap in the func-
(1974) argued that early damage may be more signifi- tional capacity of the two hemispheres because cog-
cant than is later damage. In a longitudinal, cross- nitive functions at this age are primarily lower-level.
sectional study, Reitan ( 1981) compared the effects This overlap is significantly decreased by the age of 5
of injury on children 4, 8, 12, and 16 years of age. years because the developing "new functions" are
Distinctly different learning curves were plotted for more specialized. This, however, does not mean that
each age group. Although each brain-damaged group the hemispheres are "bc~oming" more spe~ialized
showed learning deficits when compared to ''nor- with age, but that higher-level abilities are more spe-
mal" peers, the older group came closer to approx- cialized. These results support the notion of plasticity
REMEDIATION OF EDUCATIONAL DEFICITS 359
but not equipotentiality because of the apparent loss .later developmental stages. Furthermore, it has been
of higher-level skills (Kolb & Whishaw, 1980). hypothesized that children may actually grow into a
Other studies also have shown that general intel- deficit when the functions subserved by the destroyed
ligence is lowered when one hemisphere is seriously tissue become increasingly more crucial for the be-
compromised (Milner, 1975). havioral repertoire during development'' (Rourke et
These theories have addressed transfer of func- al., 1983, p. 92).
tions only in children with severe brain pathology.
The course and nature of the transfer of functions Neurodevelopmental Stages. Golden and Wil-
across or within hemispheres for other milder dys- kening ( 1986) advanced a developmental paradigm
functions (i.e., developmental dyslexia) is not ade- based on Luria's concept of the functional units of the
quately understood. However, Luria's (1963) theory brain. They outlined five stages: ( 1) the development
of functional systems provides us with a plausible of the reticular activating system (from birth to 12
hypothesis for how transfer might occur. Generally, months); (2) the development of primary sensory and
the basic assumption is that any specific behavior can motor cortices (age range similar to Stage 1); (3) the
be performed by more than one functional system. development of secondary sensory and motor cor-
When injury occurs to one system, alternative func- tices (birth through age 5 years); (4) the development
tional systems may develop either spontaneously or of tertiary, association areas in the parietal lobe (5
through specific remedial approaches (by changing through 8 years); and (5) the development of associa-
the input or output demands of the task). This process tion regions of the frontal cortex (1 0-12 years
of developing alternative functional systems will be through adolescence). Golden and Wilkening (1986)
discussed in more detail later in this chapter. suggested that it is almost impossible to predict
Boll and Barth ( 1981) pointed out another whether a 4-year-old child has damage to the tertiary
important difference between children who have sus- parietal lobe because the effects of damage may not
tained lateralized damage that results in the removal be apparent until about the ages of 8 to 12 years.
of one hemisphere, and children who have sustained Obviously when designing remedial strategies,
generalized damage where surgery is not feasible. By clinicians must be able to formulate reasonable pre-
removing a damaged brain area, the abnormal influ- dictions about the developmental patterns that specif-
ence of this dysfunctional system on cognitive ac- ic disabilities may take. Predictions are most useful
tivities may be less significant than the effects of when they are based on an interaction between neuro-
continued influence from a pathological system. Boll psychological test results and their associated corre-
and Barth ( 1981) cited a number of studies reporting lates of brain dysfunction, and are interpreted in a
that intact systems (or hemispheres) may receive in- developmental framework (Rourke et al., 1983).
terference or competition from damaged areas when Boll and Barth (1981) indicated that the type, size,
healthy structures attempt to assume a specific func- extent, and location of damage must also be consid-
tion for the impaired cortical region. Consequently, ered ~~fore one can determine the nature of specific
milder brain impairment may be more detrimental to cogmttve losses. Other factors impact upon our abil-
the overall functioning of the brain than the absence ity to predict the outcome of brain damage, includ-
of localized or lateralized cortical regions (Boll & ing: the socioeconomic status of the family; the re-
Barth, 1981). sults of computerized axial tomography; loss of
. Det~rmining the effects of early versus late inju- consciousness following injury; and the treatment
ry IS obviOusly a complex issue, which is dependent following injury, such as surgery or cranial irradia-
upon the specific task being measured and the normal tion (Wilkening & Golden, 1982). Rourke et al.
developmental sequence of acquisition of that task (1983) suggested that predictions should be consid-
(Wilkening & Golden, 1982). Wilkening and Golden ered in terms of short-term and long-term conse-
( 1982) further theorized that different brain systems quences, and therapy approaches should include both
may be involved in the execution of specific behav- components.
iors at different ages. That is, whereas the behavior
may be essentially the same, the brain substrate and Nature and Severity of Neurocognitive Deficits
the psychological processes may be entirely differ-
ent. Teuber and Rudel (1962) showed that certain The first step in designing remedial programs is
behaviors may not differentiate brain-damaged from to determine the nature and severity of the child's
normal individuals at earlier ages, but with time the dysfun~tion. A comprehensive clinical neuropsy-
same tasks can be highly discriminatory. Thus, the chologtcal assessment, including intelligence and
effects of some impairment may not be apparent until achievement testing, is the starting point for deter-
360 CHAPTER 19
mining the child's remedial needs. Three child bat- nators, including signs for: dyscalculia, central dys-
teries are currently in use: the Halstead Neuropsycho- arthria, dysnomia, and dysgraphia, indicative of left
logical Test Battery for Children, ages 9 through hemisphere dysfunction; and constructional dysprax-
14; the Reitan-Indiana Neuropsychological Test ia, indicative of right hemisphere dysfunction. The
Battery, ages 5 through 8; and Lucia-Nebraska presence of these signs must be interpreted in terms
Neuropsychological Battery-Children's Revision. of the development of the child. That is, it is imper-
Individual tests for brain damage are also available, ative to determine whether the skill in question has
including: measures of visual-spatial abilities (e.g., been developed prior to injury before one can infer
Benton's Visual Retention Test), measures of memo- brain pathology. Lateralized sensory and motor defi-
ry abilities (e.g., Benton's Sentence Memory Test), cits are among the most valid signs of cerebral
and measures oflateral dominance (e.g., Dean's Test damage or dysfunction (Reitan, 1981), where uni-
of Lateral Dominance). Although individual tests lateral errors implicate the contralateral hemisphere.
may be employed, a comprehensive battery approach Rourke et al. (1983) indicated that the "general
is necessary to determine the full range of neuropsy- adaptational capacity" of the brain is a critical vari-
chological strengths and weaknesses. A broad range able in judging the child's ability to respond to treat-
of behaviors should be assessed to determine the ment. They suggested that the four levels of inference
functional integrity of neural structures and cortical can be helpful in determining the adaptational capaci-
systems that mediate cognitive and sensory-motor ty of the brain. Specific scores on the Category Test,
abilities. A thorough evaluation of the child's lan- the Seashore Rhythm Test, and the Tactual Perfor-
guage, intellectual, achievement, memory, sensory- mance Test (Halstead-Reitan) are good measures of
perceptual (auditory, visual, and tactile), motor, and the child's ability to profit from feedback and to at-
reasoning abilities is necessary. See Salvia and tend (Rourke etal., 1983). Scores on these tests are
Ysseldyke ( 1985) for a review of psychometrically assessed from a qualitative as well as a quantitative
sound achievement tests. approach. Rourke et al. ( 1983) concluded that chil-
Selz and Reitan ( 1979) supported a multidimen- dren with higher general adaptational skills are more
sional interpretative model, involving four levels of likely to profit from remediation, and may profit
inference: (1) analyzing the child's level of perfor- from more varied remedial approaches. This is con-
mance; (2) analyzing patterns of performance; (3) sistent with Luria's (1965) contention that the more
analyzing pathognomonic signs; and (4) analyzing systems that are functional, the greater is the poten-
right-left performance differences. The level of per- tial for identifying alternative functional systems.
formance is determined by using a normative ap-
proach. Because normal or abnormal levels of perfor-
mance cannot unequivocally indicate normal or
Associated Medical and Psychological Deficits
abnormal brain functioning, the presence of patho- There a number of medical and psychological
gnomonic signs and the pattern of performance are factors that should be considered before planning a
necessary to fully evaluate the integrity of brain func- remedial program for a child with brain-related edu-
tions. Also the level of performance may be similar cational deficits. Among the most important are sit-
for children with distinctively different types of dys- uations that may require drug intervention (e.g., sei-
function. Patterns of performance typically include zures and hyperactivity) or intensive psychotherapy
comparisons between: Verbal and Performance IQ (e.g., severe depression). These factors will be brief-
scores; Wechsler subtest patterns; scores on the Trail ly discussed in this section.
Making Test, Part A and B (Halstead-Reitan Bat-
tery); and scores on the Speech Sounds Perception Seizures and Behavioral Sequelae. Prevalence
Test (Halstead Battery). Patterns of performance can figures for epilepsy are difficult if not impossible to
be useful for lateralizing and localizing specific defi- gather; however, estimates range from I to 2% in the
cits. For example, significantly lower Verbal IQ general population.(Bolter, 1986). Bolter (1986) cit-
(compared to Performance IQ), lower Trails B score ed several studies indicating that the majority of re-
(compared to Trails A), and poor performance on the curring seizures first appear during early childhood
Speech Sounds Perception Test are often associated (25% before 5 years; 25% between the ages of 5 and
with left hemisphere dysfunction. 14 years) and adolescence (10% between 15 and 19
Pathognomonic signs are also useful because years). The etiology of seizures can also vary consid-
these specific deficits occur almost exclusively in erably according to Bolter (1986) and occur for nu-
brain-impaired children. The Aphasia Screening merous reasons including: head traumas, diseases,
Test (Halstead-Reitan) provides powerful discrimi- drugs, toxins, congenital abnormalities, and meta-
REMEDIATION OF EDUCATIONAL DEFIOTS 361
bolic disorders. Bolter (1986) further indicated that lems. The child with seizures also needs careful
many clinicians view epilepsy as the most common monitoring by a physician to ensure proper drug dos-
childhood neurological problem. ages when medication is necessary. The psychologist
There are conflicting data concerning the rela- will want to monitor closely the child's reaction to
tionship between seizures and behavioral disorders. medication, and should act as a conduit sharing this
Corbett and Trimble (1983) surveyed eight studies information with the pediatrician and the parents.
where the frequency of behavior disorders in children
with epilepsy ranged from 12% to 67%; whereas oth- Side Effects of Anticonvulsants. The side ef-
fects of common anticonvulsants should be consid-
ers suggest that the presence of EEG abnormalities
does not predict whether a child will exhibit psycho- ered when planning treatment programs. Corbett and
logical or adjustment problems (Boll & Barth, 1981 ). Trimble ( 1983) reviewed a number of studies investi-
gating the side effects of several anticonvulsants
Stores, Hart, and Piran (1978) found that the most
consistent deficit of individuals with epilepsy was an (i.e., phenytoin, valporate sodium, carbamazepine,
attention disorder. Stores et al. also found that some phenobarbitone), and provided useful information
concerning the behavioral and cognitive impairments
children with epilepsy actually performed better in a
associated with medication. Classical cerebellar dys-
high-stimulus environment that was otherwise dis-
function has been found in children who demonstrate
tracting to normals. Other studies have suggested that
EEG abnormalities do not necessarily indicate poor signs of toxicity following long-term treatment with
treatment prognosis (Hughes, 1968; Tymchuk, phenytoin; carbamazepine has been associated with
Knights, & Hinton, 1970). When seizures occur in deterioration of behavioral and cognitive abilities in
the first year of life (for reasons other than high tem- some childem (Corbett & Trimble, 1983). Several
peratures), Chevrie and Aicardi (1978) found the studies have reported beneficial side effects with val-
prognosis to be more guarded, with as many as 50% proate sodium, including increased visuomotor coor-
of 313 children showing signs of severe mental retar- dination, alertness, and general school adjustment.
dation. Boll and Barth (1981) indicated that prog- Many anticonvulsants have an adverse effect on
nosis is best when: (1) the etiology of the seizure is cerebral metabolism, resulting in low levels of serum
unknown; (2) the child is older; (3) there is a history folic acid. In one study of children with complex
of seizures in other family members; and (4) seizures epilepsy requiring multiple drugs, serum folic acid
are generalized and of short duration. levels were related to signs of neurosis, depression,
Although cognitive deficits do not accompany and intellectual deterioration (Corbett & Trimble,
all forms of seizures, some children do evidence pro- 1983). Although psychiatric disorders have been
gressive intellectual deterioration (Corbett & Trim- found in individuals with folic acid deficiencies, the
ble, 1983); and in one study, one in five children with administration of folic acid has not been shown to
complicated seizures displayed severe reading retar- reverse behavioral disorders (Corbett & Trimble,
dation. Seizure type appears to be associated with 1983). Although this review suggests that there is a
varying degrees of neuropsychological deficits. need for further research on side effects, it does point
Tonic-clonic (grand mal) seizures have the most out that psychologists and educators should work
negative impact on generalized functioning com- closely with the physician to get as much information
pared to other seizures; whereas petit mal seizures as possible prior to formulating an educational treat-
typically do not significantly impair performance on ment plan for children with seizures.
measures of neuropsychological and emotional func- Attention Deficit Disorder and Hyperactivity.
tioning (Berg, 1986). Interest in the diagnosis and treatment of children
The psychosocial adjustment of children with with attention deficit disorders (ADD) with hyperac-
seizures can be an important variable in treatment, tivity has increased considerably in the past ten years.
because they often experience social isolation and Barkley ( 1982) and others (Douglas, 1983) provided
rejection from peers (Corbet & Trimble, 1983). Pa- numerous classification criteria and outlined associ-
rental attitudes also appear to be a critical factor to the ated features of this complex disorder. Although cog-
child's adjustment to seizures. Some parents have nitive deficits can be present (Lambert & Sandoval,
lowered expectations for their child's academic po- 1980), many researchers stress the importance of dif-
tential (Long & Moore, 1979); and Kleck (1968) ferentiating children with an ADD from those with
found that children learn feelings of shame about primary learning disabilities (LD) (Barkley, 1982;
their condition from their parents. The clinician Douglas & Peters, 1979). For the purposes of this
working with a child with seizures will want to con- chapter, discussion of ADD (with hyperactivity) will
sider the need for family therapy to avoid these prob- be limited to "pure" cases without evidence of pri-
362 CHAPTER 19
mary language processing or visual-perceptual disor- observed after long-term drug usage so that adult
ders, which are often found in LD children. growth does not appear to be affected (Rapoport,
Generally, behavioral characteristics for ADD 1983). Despite these findings, most investigators in-
include: ''impaired attention and effort, poor inhib- dicate that more research is necessary to understand
itory control, arousal modulation problems, and in- fully how stimulants work on the central nervous
clination to seek immediate reinforcement" (Doug- system.
las, 1983, p. 323). These deficits negatively affect
cognitive development, because these mechanisms Psychological Factors. The incidence of emo-
interfere with the child's ability to formulate mental tional disturbance in children with brain damage is
representations or schemata (Douglas, 1983). Inade- significantly high, and should not be overlooked in
quate motivational and ineffective coping skills may any remedial plan. Rutter, Graham, and Yule (1970)
also interrupt problem-solving abilities. Douglas and Rutter, Tizard, and Whitmore (1970) found the
(1983) suggested that differences in cognitive abili- incidence of emotional disturbance for brain-im-
ties between ADD and normal children increase with paired children to be approximately 6 times higher
age due to the nature of more complex learning. That than for the normal population. Boll and Barth ( 1981)
is, "later learning often requires more deliberate, suggested that there are a number of factors that are
active, and conscious effort than early learning,'' and not usually associated with emotional adjustment that
''later learning is dependent upon early learning'' may influence this occurrence. These factors pri-
(Douglas, 1983, p. 283). Poor planning, organiza- marily involve: the child's self-image concerning
tional, and problem-solving strategies are seen on their impairment or loss of functions; the difficulties
complex tasks due to the child's inability to regulate they may have in learning; and the way they interact
responses, to inhibit impulsivity, and to exhibit suffi-with others (Boll & Barth, 1981).
cient effort. Douglas ( 1983) believes these factors are Attempts to identify specific types of psychi-
most critical, and challenges research suggesting that atric disorders in brain-injured children have not been
poor selective attention and distractibility result in asuccessful. Rutter, Chadwick, and Shaffer (1983) in-
child's failure to select the relevant dimensions or dicated that the pattern of psychiatric disturbance is
elements necessary to complete a task. relatively the same for normal and head-injured chil-
dren. When differences were found, the psychologi-
Side Effects of Stimulants. When children with cal disorder manifested as disinhibited social behav-
hyperactivity require drug treatment, stimulants such ior (Rutter et al., 1983). Specifically, only children
as methylphenidate are administered (Barkley, 1977; with very severe head injury displayed signs of a
Taylor, 1983). In a review of several studies, Taylor "frontal-lobe syndrome," where social behaviors
(1983) initially found that children show decreased were significantly impaired and were characterized
restlessness, impulsivity, and inattention following by: outspokenness that was socially inappropriate;
medication. Despite these behavioral improvements, delving into personal information of self and others;
learning and academic achievement do not neces- and undressing in socially inappropriate situations
sarily improve with drug treatment alone (Rapoport, (Rutter et a/., 1983).
1983). Studies combining drug treatment with be- The prevalence of frontal lobe damage in chil-
havior modification typically show greater cognitive dren sustaining closed-head injury appears to be high
improvements than drug treatment alone (Gittelman, because many accidents involve an impact to the
Abikoff, Klein, & Mattes, 1979). Side effects of back of the head (Berg, 1986). In accidents of this
stimulants have been reported in a number of studies nature the brain is thrust forward, resulting in tissue
investigating how social-emotional variables are in- damage opposite the original impact site or in the
fluenced. In two studies, stimulants (i.e., meth- frontal lobes. Berg (1986, p. 125) indicated that dam-
ylphenidate) reduced the social interaction of boys age to the frontal lobes can result in behaviors that
with peers and parents (Barkley & Cunning- impair social behaviors and judgments, and ''may
ham, 1979; Whalen, Henker, Collins, McAuliffe, & likely impede or completely arrest development of
Vaux, 1979). Although children on medication functions that are critical to adequate functioning as
showed more compliance, they initiated fewer in- an adult."
teractions and appeared to be more unhappy or de- Although early studies with brain-injured chil-
pressed than were their hyperactive counterparts on a dren suggested that they were likely to show signs of
placebo. Other side effects have been reported, in- hyperactivity and noncompliance, this has not been
cluding decreases in weight and height gains. How- confirmed (Rutter et al., 1983). Research evidence
ever, these effects seem to be short-term, and are not indicates that there are no unitary or stereotypic emo-
tional patterns that result from childhood brain dys- proaches is that remediation focuses on training-spe-
function. However, children with brain damage ap- cific processing deficits (e.g., form perception, per-
pear to be at risk for displaying emotional problems, ceptual-motor match, auditory discrimination).
and they must develop coping mechanisms to deal Whereas there may be some improvement in the pro-
with their particular deficits. Treatment plans must cess itself, there is no positive transfer of learning to
address the child's social and emotional needs to reading or other academic areas. Similar conclusions
avoid significant disturbances that may be more de- have been reached concerning techniques directed at
bilitating than the brain dysfunction itself. The clini- "training the brain," such as the Dolman-Delacato
cian should look for signs of depression, withdrawal, Neurological Approach (Hynd & Cohen, 1983;
and poor self-esteem prior to and during treatment. Hartlage & Reynolds, 1981; Zarske, 1982).
Psychotherapy may be warranted and a psychiatric Rourke et al. (1983) argued that there are in-
evaluation may be needed. stances when "attacking weaknesses" is not only
warranted but may be preferred. First, for young chil-
General Approaches to Educational dren the remediation of neuropsychological deficits
may help in the reorganization of damaged cortical
Treatment
areas. Second, older children may avoid using a defi-
After a comprehensive neuropsychological cit area completely, which can impede the remedial
evaluation, the child's functional status can be deter- process. For example, Rourke et al. (1983) sug-
mined and steps can be taken to plan an appropriate gested that older children with auditory-perceptual
remedial program. Remedial programs usually com- deficits may ignore verbal imput and rely almost ex-
bine a number of different techniques and strategies clusively on visual input. Third, direct remediation
that are individually designed according to the ~hild' s of deficits should begin as early as possible for chil-
neuropsychological, educational, and psychological dren with head injuries. Rourke et al. indicated that
needs. Once a child's needs are determined, there are this reduces the possibility of deficits becoming en-
a number of general principles that affect the way trenched or characteristic of the child's learning
particular remedial strategies are employed. Depend- style. Fourth, deficits that are prevasive in nature
ing upon the theoretical orientation of the profes- should be remediated directly, such as attentional and
sionals working with the child, a program may be motor deficiencies. Fifth, children with mild impair-
designed to: (1) attack the child's weaknesses; (2) ment may show marked improvement. Finally, direct
teach to the child's strengths; or (3) address both remediation may be the only approach possible for
strengths and weaknesses (Rourke et al., 1983). The children with pervasive brain dysfunction, such as
adoption of one of these theoretical approaches will mental retardation. Rourke et al. indicated that direct
affect both the techniques employed and the course of remediation of deficits should be abandoned in cases
the remediation program. In this section, a review of where the child is not responding well to treatment,
the three orientations will be briefly presented. or is developing emotional problems.
Reynolds ( 1981) was more critical of the '' defi-
cit" approach to remediation for several reasons.
Attacking Weaknesses First, he asserted that this method is likely to be
ineffective because the focus of remediation is on
When attacking weaknesses, direct remediation
brain areas that are damaged or dysfunctional. Sec-
of the child's neuropsychological deficits is under-
taken. Deficit training has a long-standing prece- ond, by teaching the child through methods that re-
quire activation of cortical areas that are not intact,
dence in educational circles (Ayres, 1974; Frostig &
Home, 1964; Kephart, 1971; Kirk & Kirk, 1971). we increase the child's potential for failure and this
Hammill and Larsen (1974) conducted an intensive may be harmful to the individual (Hartlage & Rey-
nolds, 1981). Finally, Reynolds (1981) pointed to
review of the literature of several of these ap-
research indicating that these remedial practices have
proaches, most notably the psycholinguistic training
program proposed by Kirk and Kirk (1971). Good- been found to be ineffective.
man and Hammill (1973) also reviewed the percep-
tual-motor training program introduced by Frostig Teaching to Neuropsychological Strengths
and Home ( 1964). Almost without exception, effec-
tiveness studies of these programs do not support Strength approaches support the practice of
their utility (Hynd & Cohen, 1983). One of the pri- identifying the child's most intact abilities, then plan-
mary reasons for the negative results of these ap- ning and implementing a remedial program that
364 CHAPTER 19
focuses on these strengths. This approach is depen- nication and organizational abilities, and strengths
dent upon an ipsative interpretative model, where a in visual-spatial abilities. The child would receive
child's pattern and level of performance are analyzed speech therapy to improve expressive abilities. Con-
in terms of relative strengths and weaknesses based currently, the child would also be taught to use visual
on the individual ability structures or profiles (Rey- imagery to help monitor verbal expression. Thus,
nolds, 1981). Although normative interpretation deficits would be directly attacked and the child
should be part of the analysis of test scores, sufficient would be taught strategies that capitalize on indi-
information concerning individual strengths and vidual strengths.
weaknesses cannot be gathered when this is the only Obviously the distinction between these ap-
method of analysis. proaches is critical when designing intervention pro-
Selz and Reitan ( 1979) developed a set of rules grams. Decisions about whether to attack a child's
for classification of children, using the Halstead weaknesses should be made in the context of the
Neuropsychological Battery, incorporating both nor- severity of the damage, and the emotional and adap-
mative and ipsative interpretations of test scores for tational capacity of the child. When a direct approach
classifying children as brain damaged, learning dis- is taken and the child is not progressing, a strength
abled, or normal. Raw scores are converted to a four- approach is recommended. Once a child starts to ex-
point scale (0 for normal performance and 3 for ab- perience success with learning again and his or her
normal performance), which allows for a more direct self-concept is strong, a mixed approach could then
comparison across different tests. Scaled scores can be implemented. However, the clinician should in-
be summed and cutoff scores can be used to deter- troduce remedial techniques for weaknesses in small
mine the severity of deficits. However, more impor- time units every day. Sessions should be designed so
tantly, "the scaled score conversion provides a that the child can end each lesson with an accom-
means of evaluating the relative quality of a child's plishment. Techniques for remediating weaknesses
performance in different areas: one can determine should be introduced early in the teaching session,
quickly whether a child's 3s are cropping up in the and the child should finish by practicing highly im-
areas of motor performance, reasoning, or language proved or consistently strong skills.
skills" (Selz, 1981). The following specific neuropsychological re-
There are a number of reasons for adopting a medial programs utilize various aspects of the
"strength" model of remediation. First, this method strength/weakness paradigm.
may be helpful for children who are resistant to direct
remediation of weaknesses (Rourke et al., 1983).
When self-confidence is low or when a failure syn- Specific Neuropsychological and
drome emerges as a result of frustration, a strength
approach should be adopted. Second, by teaching to
Neurocognitive Programs of
the child's strengths we may reduce the possibility of Remediation
the child falling farther and farther below peers in
academic areas. Finally, Luria suggested that recov- Presently, a number of neuropsychological re-
ery of function following cortical damage can be medial programs are available for children with
achieved ". . . by the replacement of the lost cere- brain-related cognitive deficits. Two of these pro-
bral link by another which is still intact" (Luria, grams will be briefly reviewed: (l) REHABIT, the
1963, p. 55). For example, a child with an impaired Reitan Evaluation of Hemispheric Abilities and
auditory system could be taught to differentiate sim- Brain Improvement Training (Reitan, 1980), and (2)
ple sounds using visual or nonverbal images. the Kaufman-Sequential or Simultaneous program
(Kaufman, Kaufman, & Goldsmith, 1984). Al-
though these intervention programs are based on
neuropsychological and cognitive theories, each is
A Combined Remediation Approach still in the developmental stage and in the process of
A combined approach would incorporate both being empirically validated.
strengths and weaknesses in the remedial plan. In this
model, the children could be taught new information Reitan's REHABIT
through their strengths while deficiency areas would
receive direct remediation. Rourke et al. (1983) sug- The beginning of a formal study of child clinical
gested that a ''mixed'' intervention strategy could be neuropsychological assessment can be traced to
used for a child with weaknesses in verbal commu- Ralph Reitan's early work with Ward Halstead in the
1950s. The Halstead Neuropsychological Test Bat- most favorably and have shown increased abilities
tery for Children, for ages 9 through 14 years, was when repeatedly trained on alternate forms of the
standardized in 1954 and was followed by the devel- Category test. Finally, Reitan identified a number of
opment of the Reitan-Indiana Neuropsychological other teaching materials that can be used to train
Test Battery for Children, for ages 5 through 9 years children with brain impairment.
(Reitan & Davison, 1974). In 1965, the first report of The materials used in the third phase of RE-
an extensive data base was published after 12 years of HABIT have been gathered from a variety of training
research (Boll, 1974). The development of these bat- procedures and vary from simple to complex tasks.
teries provided a standard battery for assessing child- Training procedures have been developed for three
hood brain dysfunction, and offered child clinical fundamental areas: (1) language and verbal abilities;
neuropsychologists a methodology for obtaining val- (2) abstract thinking, reasoning, and problem-solv-
id descriptive information about the behavioral con- ing skills; and (3) visual-spatial, motor, and sequen-
sequences of brain pathology. More recently, Reitan tial abilities (Reitan, 1980). Reitan (1980) empha-
( 1980) developed a rehabilitation program for chil- sized the importance of training general skills that
dren with brain-related disorders, and again pi- require integrated brain functioning, especially rea-
oneered a critical phase in child clinical neuro- soning, abstraction, and logical thinking. These gen-
psychology. eral skills may be more critical for overall brain func-
REHABIT is the most comprehensive neuro- tioning than are highly specialized skills.
psychological remediation program presently avail-
able for children with a variety of deficits. TheRE-
HABIT materials incorporate the basic principles of Five Tracts for Training Specific Abilities
the brain-behavior relationship as identified in the
Halstead-Reitan Neuropsychological Test Batteries These materials are presented in five tracts for
(Reitan, 1980). Diagnosis of the child's brain-related training general abstraction abilities. Reitan (1980)
deficits is the first step of this remedial program, and described the tracts as: (1) Tract A, materials for
results from the Halstead-Reitan are used to deter- expressive-receptive language and verbal skills; (2)
mine which training modules should be used. Reitan Tract B, materials for abstraction, reasoning, organi-
(1980) did not make a distinction between training zation, and logical analysis in the verbal domain; (3)
principles for adults and children. Reitan suggested Tract C, materials for general abstraction, reasoning,
that when children have injury to specific brain areas, and organizational skills; (4) Tract D, materials for
the deficits are similar to those observed in adults. abstraction emphasizing visual-spatial, manipula-
The major difference in remediation for specific defi- tion, and sequential processing; and (5) Tract E, ma-
cits is that children generally require less complex terials for basic visual-spatial and manipulation
levels than do adults. skills. The materials are arranged in order from sim-
ple to complex.
Based on the results of the neuropsychological
Three Phases of REHABIT evaluation, materials are selected from each tract de-
pending on the type and severity of the deficits identi-
REHAB IT is organized in three phases (Reitan, fied. Some individuals may require training in all five
1980): (1) the evaluation of brain-related deficiencies tracts, whereas others may require training in one
using the Halstead-Reitan batteries; (2) the training specified tract. Reitan (1980) suggested that training
of specific deficits using the test items from the should begin at a level where the individual can be
Halstead-Reitan batteries; and (3) the training of def- successful, and should proceed to more complex ma-
icit areas using special REHABIT materials. These terials. In doing this, the individual experiences suc-
phases were meant to proceed one to the other. As- cess and develops a positive attitude about the train-
sessment then is the starting point. According to Re- ing program.
itan (1980, p. 1), "inadequate evaluation of the Reitan ( 1980) provided a comprehensive list of
brain-behavior relationships for the individual sub- materials, described the ability functions necessary
ject has been the greatest impediment in brain-train- for completing each task, and indicated the primary
ing efforts.'' Reitan further found that items from the brain areas involved in each task. For example, a
neuropsychological test batteries can be used to train child with spatial-sequential and abstraction deficits
basic brain functions in individuals with impairment. could be trained with the "What Follows" item,
For example, Reitan found that individuals with rea- which progresses from simple to moderate levels of
soning and abstraction deficiencies have responded difficulty. The functions involved in the completion
366 CHAPTER 19
of this task are organization and picture arrangement affect classroom behavior, provides examples of re-
skills, which are primarily monitored by the right medial techniques, and shows how K-ABC scores
hemisphere but also require intact general brain func- can be translated into a remedial plan (Kaufman et
tioning. (A list of the publishers and distributors of al., 1984). In this remedial approach, children are
these materials is provided in Reitan, 1980.) taught through their mental processing strengths
based on scores from the K-ABC. Although K-SOS
Validation of REHABIT represents a ''strength'' method of remediation, it is
not analogous to the "visual" versus "auditory"
Presently, no published studies have em- methods of remediation. Das et al. (1979) stated that
pirically tested the REHAB IT procedures. However, it is not the content of the task (i.e., verbal versus
Reitan (1980) reported that this program was used nonverbal) that influences the mode of processing the
with success for a number of years at the Reitan child uses, but it is an interaction between the de-
Neuropsychological Laboratory at the University of mands of the task and the experience of the learner
Arizona. The procedures and materials available that influences the utilization of either processing
through REHABIT provide a preliminary step in the strategy. Thus, most cognitive tasks can be ap-
much needed link between assessment and remedia- proached and solved using either simultaneous or
tion of brain-related disorders. This program also has sequential strategies. However, Caplan and Kins-
a strong theoretical basis and has been clinically test- boume (1981) indicated that some tasks can be ade-
ed. However, controlled research studies are needed quately processed by either cognitive strategy,
to validate these procedures, and to identify which whereas others may require a specific approach for
kinds of deficits respond best to treatment. the most efficient or optimal performance.
Kaufman et al. (1984) began with the premise
that children who have similar simultaneous and se-
Kaufman-Sequential or Simultaneous quential skills will learn when lessons are presented
(K-SOS) Remedial Program through either processing mode. However, children
with poorly developed skills in one of the processing
Cognitive processing theories have been used to strategies may tend to solve a problem using their
investigate the neuropsychological basis and re- intact strategy. Kaufman et al. recommended that
mediation of severe achievement deficits. Das, Kir- clinicians identify the processing demands of a task,
by, and Jarman (1979) discussed a comprehensive and then modify or adapt these tasks based on the
theory, originally reported in Luria's (1966) theory child's learning characteristics. Kaufman et al. pro-
of functional units of the brain, relating simultaneous vided a thorough description of the characteristics of
and sequential processing abilities to brain function- the sequential and the simultaneous learner, and out-
ing and to academic performance. Simultaneous pro- lined possible techniques and methods for teaching
cessing involves a synthesis of stimuli into integrated specific subject areas.
units that typically have visual-spatial overtones. Se-
quential processing involves the sequential ordering
of information, with heavy language and time-se- Characteristics of the Sequential Leamer
quence overtones. These two processes have been
associated with right and left hemisphere functions, According to Kaufman et al. (1984, p. 6), "the
respectively (Cohen, 1973), or with posterior and sequential learner solves problems best by mentally
anterior cortical regions (Das et al., 1979). Kaufman arranging small amounts of information in con-
and Kaufman (1983) incorporated this neurocog- secutive, linear, step-by-step order.'' Sequential pro-
nitive processing theory into a comprehensive test cessing is evident in the following activities (Kauf-
battery, the Kaufman Assessment Battery for Chil- man et al., 1984); (1) understanding, remembering,
dren (K-ABC) and, more recently, used this theory to and using arithmetic facts; (2) learning to spell
develop a procedure for remediating cognitive defi- words; (3) matching sounds to letters; (4) understand-
cits in school-aged children (Kaufman et al., 1984). ing grammatical rules; (5) following the procedures
The K-SOS approach includes methods for in- of a science project; (6) remembering events in histo-
terpreting scores on the K-ABC from a practical perry; (7) problem-solving when a series of discrete
spective, and for developing remedial strategies for steps are involved; and (8) following directions or
children with learning deficits (Kaufman et al., rules. Children with strengths in sequential process-
1984). The K-SOS approach outlines two charac- ing may approach tasks by breaking them down into
teristic learning styles, suggests how these styles may smaller, meaningful units. For example, when learn-
ing a new vocabulary word, sequential learners might upon which to design classroom activities that cap-
associate the new word with one they already know; italize on the child's processing strengths.
e.g., "houseboat" is made up of the words "house" Specifically, Kaufman et al. described the fol-
and boat,'' and it must mean that a 'boat'' can be a lowing activities and principles. For the sequential
"house" or a "house" can be a "boat." learner, materials should be presented in segments,
If a child has strengths in sequential processing where the global skill or lesson objective is intro-
with marked weaknesses in the simultaneous mode, duced in a step-by-step fashion. Questions should be
Kaufman et al. (1984) suggested they might have interspersed throughout the segments to encourage
trouble when: identifying sight vocabulary; com- and reinforce comprehension and understanding of
prehending paragraphs and sentences, especially the construct being taught. Teach the child to ver-
when inferences are required; using arithmetic facts; balize directions and to employ verbal memory strat-
and benefitting from visual aids, like graphs and egies. New skills should be introduced and rehearsed
charts. in a series of steps. Once the new skill has been
mastered, the steps can be used as an outline or log-
ical structure for problem-solving.
Characteristics of the Simultaneous Learner Simultaneous learners will benefit from instruc-
The simultaneous learner evidences different tion when presented in the following ways (Kaufman
processing strengths, and "solves problems best by et al., 1984). Introduce the lesson objective immedi-
integrating and synthesizing many parallel pieces of ately. Give the children an overview of the concept or
information at the same time" (Kaufman et al., skill prior to having them begin the task. Encourage
1984, p. 6). Simultaneous strategies are evident the children to use visual imagery when they read and
when: (1) identifying and discriminating shapes of write. Visual aids, pictures, graphs, models, and
letters and geometric forms; (2) recognizing the concrete objects should be used whenever possible.
global meaning of a picture or chart; (3) comprehend- Although the simultaneous learner can grasp the
ing the essence of a paragraph or story; (4) under- ''whole'' picture, details of the task or lesson need to
standing math concepts; and (5) using visual images be pointed out and discussed.
or aids to solve a problem. Using the example of the For a list and description of numerous classroom
word "houseboat," the simultaneous learner might activities for the sequential and the simultaneous
develop a mental image of a 'house'' moving across learner, refer to the K-SOS manual (Kaufman et al.,
a lake or a house shaped like a boat. 1984).
The child who has strengths in simultaneous
processing, with marked weaknesses in sequential,
may have difficulty: learning a phonic approach to
Validation of the K-505 Approach
reading; analyzing the sequence of steps in a math Preliminary research with this cognitive re-
problem; recalling essential details of a picture or medial approach has been promising. Gunnison,
story; and following complex verbal directions Kaufman, and Kaufman (1982) reported that studies
(Kaufman et al., 1984). By analyzing the goals and utilizing the serial and simultaneous processing theo-
objectives of an instructional exercise, the clinician ry have found almost perfect performance when in-
can match methods of presentation with the learner's struction is matched to the learner's processing
processing strengths. The child can then be taught strengths. In two separate studies, Gunnison et al.
strategies for approaching tasks or solving problems (1982) matched remedial reading lessons to the
that capitalize on their abilities. children's simultaneous or sequential processing
strengths as measured by the K-ABC. In both in-
Guidelines and Activities for Classroom stances, results were positive as children showed
Instruction substantial gains over traditional teaching methods
and over methods that did not match the children's
Kaufman et al. (1984) provided a number of learning style.
useful guidelines for implementing remedial pro- Although the theory has been criticized for di-
grams for children. Ideas were discussed for present- chotomizing complex mental processes, and the K-
ing materials and modifying instructions that best ABC has been questioned on psychometric grounds
match the learning style of the sequential and the (Bracken, 1985; Goetz & Hall, 1984), the K-SOS
simultaneous learner. General instructional princi- remedial techniques should be more thoroughly in-
ples provide the clinician with a theoretical basis vestigated before they are dismissed. Rourke et al.
368 CHAPTER 19
(1983) highlighted some of the major impediments been identified (Horton, 1981). Reinforcement, con-
to conducting research with remedial programs, in- tracting, charting, and self-monitoring can be built
cluding: individual differences in the nature and se- into the child's treatment program to increase skills in
verity of neuropsychological deficits make it difficult specific areas. By integrating results from the neu-
to assign groups of children to the same treatment ropsychological assessment into a behavioral plan,
program; evaluating the effectiveness of programs is methods can be devised that capitalize on the child's
difficult because many assessment instruments may strengths while implementing operant procedures to
be related to the techniques used in the treatment; and increase motivation and learning (Reynolds, 1981).
the treatment needs of children vary over time, which It is obviously beyond the scope of this chapter
might mean modifying the original program. These to provide a detailed presentation of strategies for
same problems will influence research efforts to de- each, or even one, of the achievement areas men-
termine the effectiveness of intervention programs tioned above. Therefore, the following examples of
that follow any theory or principle of cognitive or activities or programs will serve to illustrate how
neuropsychological functioning. Thus, the most sig- neuropsychological principles can be integrated into
nificant contribution of the K-SOS may be that it curricular approaches for the remediation of cog-
provides the clinician with a theoretical basis upon nitive deficits.
which to design and test the effectiveness of remedial Many of the techniques that will be presented
programs for children with cognitive deficits. rely on the diagnosis of subtypes of learning disor-
ders. Subtype classifications evolved out of research
showing that learning-disabled children were not a
Remedial Techniques for Testing homogeneous group. Hooper and Boyd (1986) cited
Brain-Related Deficits in Reading, Spelling, 27 separate studies that investigated subtypes of read-
Mathematics, and Reasoning ing disabilities alone. Although the investigation of
group trends can be useful, the clinician should al-
In the following sections a number of techniques ways do a careful study of the individual child prior to
for treating general deficits in reading, spelling, adopting general remedial techniques or methods.
mathematics, and reasoning in children with brain- In the following sections, a number of general
related cognitive dysfunction will be presented. remedial programs will be discussed. The charac-
These techniques should be used only after a compre- teristics of subtypes will also be presented, with ideas
hensive assessment of the child's neuropsychological for implementing specific techniques based on an
strengths and weaknesses. There is a normal devel- analysis of the child's strengths and weaknesses in
opmental sequence of skills in each of these academic the different academic areas.
areas, so the clinician must do a careful task analysis
of achievement levels to determine specific deficits
for the individual child. The clinician should also Remedial Programs for Teaching Reading
work closely with the child's teacher when deciding Skills
which techniques and activities should be imple-
mented. It is necessary to have a thorough under- Lerner (1981) described a number of reading
standing of what has been tried in the classroom, and programs for children with learning disorders, and
how the child has responded to specific approaches four of these programs will be briefly discussed; (I)
and tasks. The clinical neuropsychologist and the the Language Experience Approach; (2) the Lin-
teacher must work together and combine their areas guistic Approach; (3) the Fernald Method; and (4) the
of expertise to plan specific classroom activities. The Orton-Gillingham Method. These techniques focus
neuropsychologist can provide a theoretical frame- primarily on teaching decoding skills, and other tech-
work for understanding the child's deficits, and the niques should be employed for teaching reading com-
teacher can provide suggestions for which curricular prehension. See Lerner ( 1981) and Vallett ( 1974) for
materials and methods would be best for instruction. a more in-depth treatment of the reading process.
This interchange should not be limited to commu-
nication through reports, but should be done in plan- Language Experience Approach
ning sessions so that ideas can be presented and ac-
tively challenged. The Language Experience method can be used
Behavioral principles can also be applied in the for developing reading and other language arts abili-
treatment program, to increase academic proficiency ties. Materials for this method are based on the
once the child's neuropsychological deficits have child's own language and experiences (Lerner, 198 I;
Hynd & Cohen, 1983). The child starts by dictating a "look-say-write" steps. In stage three, the kines-
story to the teacher. Reading and spelling lessons are thetic (writing) component is discontinued and the
developed directly from these stories. The basic as- child simply looks and says the word. In the last
sumptions for the child are: "What I can think about, stage, the child learns to recognize the similarity be-
I can talk about. What I can say, I can write (or tween word parts in new words and known words.
someone can write for me). What I can write, I can Hynd and Cohen ( 1983) indicated that in the VAKT
read. I can read what others write for me to read" method, the child is never read to, and the child never
(Lerner, 1981, p. 299). This method has a high in- sounds out new words phonetically.
terest factor because the instructional materials are
based on the child's own experience and creativity.
The Orton-Gillingham Method
Lerner (1981) indicated that this approach can be
used successfully with young children just learning to The Orton-Gillingham approach also employs
read, and older children with a history of reading tactile and kinesthetic exercises for teaching reading
problems. to children who fail to learn through other methods
that emphasize visual-perceptual techniques (Hynd
Linguistic Reading Approach & Cohen, 1983). This program differs from the Fer-
nald method in that is stresses the auditory compo-
The linguistic approach teaches children to read nents of the reading process. Hynd and Cohen ( 1983)
through a controlled introduction of words with con- outlined the following steps in this method. First, the
sistent letter-sound relationships, and regular spell- child is taught individual letters and sounds, and
ing rules (Lerner, 1981). This method relies heavily these are combined into letter groups using flash card
on the decoding process, where the phoneme-graph- presentations. Different vowel and consonant sounds
eme relationship is stressed. Reading materials are are represented in different colors, and once blending
carefully selected, so that consonant-vowel-conso- is fluid, words are introduced. The child uses tracing
nant pateros are presented in a uniform manner. For techniques in the early steps of letter-sound identifi-
example, the child is taught that the short "a" sound cation (Lerner, 1981). At the word analysis stage, the
by reading the words, "can, Nan, van, fan, Dan, teacher says the word and the child identifies the
pan, man, tan, ran" (Lerner, 1981, p. 302). The letter sounds. In the next phase, the teacher says
child is then taught to write sentences and paragraphs the word, the child repeats the word, identifies the
using these same words. This approach differs from individual letters, and writes the word while repeat-
other phonetic approaches in that the letter sounds are ing the word aloud. Phonetically consistent words are
blended immediately into words with regular spelling taught first, and once simple words (three letters) are
patterns and not in isolation (Lerner, 1981). Initially mastered, the child uses these in sentences and short
the child learns to differentiate only the beginning paragraphs. Hynd and Cohen (1983) indicated that
sounds, because the middle and ending sounds are children receive written material that has been care-
consistent. fully screened to ensure that words can be attacked
phonetically. Lerner (1981) also reported that inde-
Fernald's Visual-Auditory-Kinesthetic-Tactile pendent reading is curtailed until basic phonics are
learned.
(VAKT) Approach
Fernald's VAKT method employs four sensory Specific Reading Approaches for Dyslexic
systems simultaneously, to teach children to read Subgroups
(Hynd & Cohen, 1983). Hynd and Cohen (1983)
outlined the following steps to this reading program, After a careful review of traditional remedial
where the child begins by writing a story and asking reading programs, Hynd and Cohen (1983) con-
for unknown words. In the first stage, new words are cluded that no one approach is best for all dyslexic
printed in large letters on a piece of paper, and the children. Based on research findings with subtypes of
child traces over the letters while saying the word dyslexia, Hynd and Cohen provided recommenda-
aloud. This step is repeated until the child can write tions for which programs can be expected to be most
the word two times without looking at the paper. effective for different groups. They analyzed the
During this stage, clay or sand can also be used for learning characteristics of dylexics using Boder' sand
tracing. In the second stage, the tactile (tracing) com- Mattis's classification systems. Boder's diagnostic
ponent is dropped, and the child employs only the categories include three major groups of dyslexia: ( 1)
370 CHAPTER 19
the dysphonetic; (2) the dyseidetic; and (3) the alexic acter or name with that sound. The teacher then
(Boder, 1971). The dysphonetic dyslexic reader has writes the letter on the board and says the sound while
difficulty with the phonetic analysis of words due to the child points to the letter on the board. Then sever-
deficits in integrating sounds with their letter coun- al other letters are printed on the board and the child
terparts. These children rely on visual-perceptual identifies the target sound. Then the teacher writes
cues when reading, and analyze words primarily different letters, and while the teacher says each
based on the structure or configuration of the letters. sound, the child claps when he or she hears the target
Conversely, the dyseidetic dyslexic has intact pho- sound. This same procedure is repeated with the
netic analysis skills, with deficits primarily in the teacher's lips covered so that the child cannot rely on
visual perception of words. When reading, the dys- lip-reading to identify the target sound. This pro-
eidetic dyslexic can sound out words phonetically, cedure emphasizes recall and auditory discrimi-
and spelling errors are phonetically accurate. The nations.
alexic dyslexic child has deficits in both the auditory Kaufman et al. modified the phonic lesson for
and visual analysis of words. These children have the the simultaneous learner in the following ways. The
most severe reading deficits because they do not teacher writes a letter on a piece of paper and the child
appear to have an area of strength in the reading and traces the letter. The child is taught to visualize the
decoding process. Mattis (1978) also identified three shape of the letter, and cues about the letter shape are
distinct subgroups of dyslexic children: (I) a lan- provided. For example, the letter "m" looks like a
guage disorder group; (2) an articulatory and graph- ''roller coaster, mountains, waves, inchworm, bun-
omotor disorder group; and (3) a visual-perceptual ny ears" (Kaufman eta/., 1984, p. 5). Each time the
disorder group. child hears the sound, he or she traces the letter.
Individual letters are then combined, and the child is
taught to find them in words. For example, the "at"
Remediation for Dysphonetic and Dyseidetic sound-letter relationship is taught and the child finds
Readers "at" in the word "cat." Then other words like "fat,
cat, sat, and mat" are introduced, and the child tells
Hynd and Cohen (1983) recommended several how these words are the same and how they are dif-
reading programs that could be used for each sub- ferent (Kaufman et al., 1984, p. 5). The major em-
group. The Orton-Gillingham and other phonetic phasis for the simultaneous learner is on teaching the
reading programs (i.e., Distar and SRA) were recom- shapes of letters, and associating the sounds with the
mended for the dyseidetic, the language disorder physical characteristics of the letter.
group (once letter recognition skills have been devel-
oped), and the visual-perceptual disorder group. The
Fernald program was recommended for the alexic Remediation Techniques for Spelling
group, and for some dysphonetic readers. The Look- Deficits
Say and Language Experience methods were sug-
gested for the dysphonetic, the language disorder, Generally, spelling deficits are associated with
and the graphomotor disorder groups. Finally, the reading disabilities, but this relationship is not a per-
Linguistic Structural Analysis approach could be im- fect one. Occasionally, children with normal decod-
plemented in later stages for the dysphonetic and ing and comprehension skills have trouble spelling,
graphomotor disorder groups. Hynd and Cohen but children with decoding deficits almost always are
( 1983) indicated that three remedial programs were poor spellers (Lerner, 1981). Recently, Sweeney and
not appropriate for any of the diagnostic groups: (1) Rourke ( 1985) investigated the differences in psy-
the Doman-Delacato program; (2) the ITPA Psycho- cholinguistic abilities in children who are poor spell-
linguistic program; and (3) the Visual Perceptual pro- ers. They compared children with spelling deficits
grams of Kephart and Frostig. who are phonetically accurate to others who are pho-
netically inaccurate in spelling. Sweeney and Rourke
did not fmd significant differences in the Wechsler
Remediation Based on Kaufman's Theory Performance IQ, spelling levels on the Wide Range
Achievement Test (WRAT), scores on a test of au-
Kaufman et al. ( 1984) suggested that sequential ditory discrimination, scores on the Wechsler Digit
and simultaneous learners can be taught phonics Span subtest, or scores on a visual closure test.
through different exercises. For example, the follow- Difficulties appeared to be most significant for
ing activities would be appropriate for the sequential the phonetically inaccurate spellers on tasks involv-
learner. The teacher selects a sound and finds a char- ing memory for sentences, sound blending, and
memory for digits reversed (Sweeney & Rourke, involving the introduction of individual letters and
1985). This subgroup displayed significant deficien- sounds, then progressing to segmenting the sound
cies on complex receptive language tasks, similar to composition of words. A sight-word approach
patients with cerebral dysfunction in the secondary to reading is recommended (Sweeney & Rourke,
zones of the temporal lobe (Sweeney & Rourke, 1985), and it seems likely that this approach could be
1985). These deficiencies were found to be more extended to spelling as well. Lerner (I 981) described
pervasive than were deficits found in the phonetically a spelling approach that involves teaching children
accurate group. The phonetically accurate spelling from "frequency-of-use" word lists. AU of the stud-
group showed difficulty when analyzing visual-spa- ies analyzing frequency-of-use words suggest that
tial information, and showed patterns of deficits sim- 60% of our writing is composed of only 100 words
ilar to those in individuals with cerebral dysfunction (Lerner, 1981). See Lerner ( 1981) for this frequency-
to the tertiary zone where the parietal-occipital- of-use word list. This approach could be tried if the
temporal lobes converge (Sweeney & Rourke, phonetically inaccurate speller fails to learn through
1985). Both groups did not perform as well as normal other techniques.
spellers on the Information, Comprehension, and Another method for teaching spelling to older
Vocabulary subtests of the Wechsler scale. children is the test-teach-test approach. This meth-
The research of Sweeney and Rourke (1985) od differs from traditional approaches, which adopt a
provides evidence that spelling deficits are not a uni- teach-test-teach paradigm. Spelling words can be
tary disorder, and that subgroups exist with different generated from traditional spelling workbooks or
deficiencies. Although these subgroups may appear graded frequency lists. The child is initially tested on
similar in many academic areas, the treatment ap- a list of words, and then studies only those words he
proaches to remediating spelling deficits would differ or she is unable to spell. This reduces the potential of
(Sweeney & Rourke, 1985). The following activities having the children study words they already can
are recommended for remediating spelling deficits spell. Lerner (1981) also recommended the use of
for these two subgroups. crossword puzzles and games like Scrabble to in-
crease spelling. It should be noted that children with
significant visual-perceptual disorders may have
Activities for Phonetically Accurate Spellers trouble with crosswords.
Sweeney and Rourke ( 1985) suggested that pho-
netically accurate spellers would benefit from strat- Remediation of Mathematics Deficits
egies that emphasize ''right hemisphere strategies,''
such as: ( l) the use of sight-word reading approaches; Math computation is a complex academic skill
(2) the identification of visual-spatial features of that involves numerous operations to solve even a
words; and (3) the use of imagery techniques to men- single basic problem. Strang and Rourke (1985) sug-
tally picture the shapes of the words. Other tech- gested that there are as many as 33 steps involved in
niques might include tactile-kinesthetic components, calculating a two-digit multiplication problem (i.e.,
where the spelling words are repeatedly traced, pro- 62 x 96 = ). Also, a simple error can be costly in
nounced, spelled aloud, and written. For older chil- calculation problems, where similar errors in reading
dren, new spelling words could be introduced using (i.e., misreading a word in a sentence) will not neces-
the child's own stories, as explained in the language sarily interfere with the overall comprehension of a
experience approach for reading. sentence (Strang & Rourke, 1985). However, cog-
nitive deficits have been associated with math defi-
cits, including reading disabilities and visual-memo-
Activities for Phonetically Inaccurate Spellers ry disorders (Strang & Rourke, 1985). Other
noncognitive factors can also interfere with math per-
Sweeney and Rourke ( 1985) were more guarded formance, such as attentional, motivational, and
in their prognosis for improvement of phonetically emotional disturbances (Strang & Rourke, 1985).
inaccurate spellers because these individuals tend to Strang and Rourke (1985) identified subtypes
show more generalized linguistic deficits. For this of children with arithmetic disabilities, including:
reason, they suggested that this group will probably (I) children with a pattern of deficits suggestive of
only learn information that is "extremely elemen- left hemisphere dysfunction; and (2) children with a
tary, overlearned'' and involves ''redundant oral dis- pattern of deficits suggestive of right hemisphere
course" (Sweeney & Rourke, 1985, p. 163). They dysfunction. Of these two groups, the ''right hemi-
recommended that remediation be highly repetitive sphere'' group showed the most severe pattern of
372 CHAPTER 19
neuropsychological deficits, including: visual-per- problem should be recalculated (by hand) if the an-
ceptual, visual-organization, tactile-perceptual, psy- swer is not correct. (12) The teacher should keep a
chomotor, and conceptual disorders (Strang & Rou- record of the errors, task analyze these errors, and
rke, 1985). The "left hemisphere" group showed modify the remedial plan if necessary. (13) Relate
intact skills on the right hemisphere tasks, but dem- math concepts to something relevant or practical to
onstrated deficits on verbal and auditory-perceptual the child. That is, computation skills can be related to
tasks. Error patterns for the "right hemisphere" shopping. See Strang and Rourke (1985) for a more
group were pronounced in the following categories: thorough discussion of these steps.
organizing spatial information; attending to visual There are other strategies that may prove to be
detail; following procedures; shifting mental sets; helpful for the "right hemisphere" group. The child
writing numbers; remembering numerical facts; and can be taught to make verbal associations relating
reasoning (Strang & Rourke, 1985). Although the math concepts. For example, the child can be shown
two groups did not differ in terms of math achieve- the relationship between multiplication and division
ment scores, they demonstrated considerably differ- by the following elaboration:
ent underlying neuropsychological deficiencies,
which impact significantly on the type of intervention Multiplication is related to Addition:
strategies that should be utilized. 3X3=9 isthesameas 3+3+3=9
Multiplication is related to Division:

Strategies for the "Right Hemisphere" Group 3X3=9 is the same as 9/3 = 3
In a comparative sense, these children have Other mathematical computations can be ex-
more intact verbal abilities that can be utilized in the plained by using verbal analogies or verbal associa-
math area. Strang and Rourke (1985) suggested the tions. For example, in a multiplication problem
following strategies for this group. (1) Start math involving two double-digit numbers:
remediation by selecting a simple calculation prob-
lem where the child has difficulty. (2) Provide a de- 25 This problem can be solved
tailed verbal explanation of the steps involved in the in several ways.
calculation process .. Each step should be described, X 20 1. 25 X 20 = 500
then placed in context of the entire or ''whole'' oper- 2. 25 added 20 times
ation. The child should be taught to verbalize the 00
necessary procedures. (3) The teacher then presents
the steps verbally. For example, in the first step you +50 25 + 25 + 25 + 25 + 25
must name the mathematical sign in the problem; in 25+25+25+25+25
the second step you must look at and move your 25 + 25 + 25 + 25 + 25
pencil to the right side of the problem, and so on. (4) 500 25 + 25 + 25 + 25 + 25 = 500
Have the child describe the steps involved in the
operation. (5) Have the child write the "rules" or Shaded areas could be used to demarcate the columns
steps, and use these when solving other problems. (6) in the above example. Also this last example should
Once the child can progress through the first five be utilized only after the child has successfully pro-
steps, the visual component can be added. Have the gressed through the 13 steps outlined by Strang and
child verbally direct the teacher through the problem. Rourke ( 1985), and has achieved some initial success
(7) Concrete aids can be introduced at this stage. in basic computational skills in each of the number
Strang and Rourke ( 1985) indicated that this might be operations involved in the verbal analogy.
one of the most difficult stages of the remediation. (8)
Trial problems can be given at this stage. The child Strategies for "Left Hemisphere" Group
may use graph paper to reduce errors due to number
and column placement. (9) Graph paper may need to The "left hemisphere" group has relative
be color coded to highlight the right and left sides of strengths in visual-perception and visual-organiza-
the paper. ( 10) Have the child read the problem aloud tion, so these abilities can be emphasized in the fol-
before calculating the answer. Once this is mastered, lowing ways. Provide the child with visual or phys-
have the child read the question and the answer be- ical aids whenever possible. Lerner ( 1981) suggested
fore starting the next problem. ( 11) Teach the child to using concrete objects, such as: movable disks that
use a hand calculator to check for accuracy. The the child can manipulate; a "rectangle array" con-
taining rows and columns of ovals or squares; Michenbaum ( 1977) developed a cognitive-be-
number lines so the child can see the relationship havioral training program to teach children appropri-
between numbers when adding, subtracting, multi- ate verbal mediators to increase planning skills. The
plying, and dividing; flash cards; and addition and program has several steps wherein the child is taught
multiplication charts or wheels. Vallett (1974) pro- to: ( 1) define the problem, ''What is it I have to do?'';
vided an example of an activity using both the "ar- (2) focus attention to the task; (3) provide self-rein-
ray" and the number line for addition and forcement, "Good, I'm doing fine"; and (4) self-
subtraction. evaluate and self-correct, "That's okay .... Even if
I make an error I can go on slowly" (Michenbaum &
()() ()() ()()() Burland, 1979, p. 427).
Other problem-solving techniques can be used
0 1 2 3 4 5 6 to improve effectiveness and flexibility in planning
and decision-making strategies. D'Zurilla and Gold-
()() ()()() 3+2=
fried ( 1971) developed a method for systematically
~ teaching problem-solving skills. ''Means-end'' or
consequential thinking can be taught in structured
4 + = 6
activities by discussing a situation with the child that
has been problematic. Have the child generate as
0 1 2 3 4 5 6
many solutions to the problem as he or she can think
+ 2 6 of, regardless of the effectiveness of the solution.
Then have the child try the solution to determine if it
6-3=
is effective. Once a set of effective strategies have
6 2 been developed, then discuss what skills (or mate-
2 4 rials) are necessary for implementing a particular
solution. If the child needs skill training, such as self-
Lerner ( 1981) provided a general timetable for assertiveness, then this should be the next step. Final-
when basic math computational skills are introduced ly, the child should practice these skills in classroom
in the elementary grades. The clinician should be situations.
familiar with these sequences when planning re-
medial programs for math deficits. See Lerner ( 1981)
and Vallett (1974) for further details on other math
skills. Concluding Remarks
The primary purpose of this chapter was to dis-
Remedial Strategies for Reasoning and cuss neuropsychological principles and approaches
Planning Deficits to remediating brain-related cognitive deficits in chil-
dren. Factors that affect outcome and prognosis were
Children with neuropsychological and cognitive also presented, including neurodevelopmental is-
deficits often have associated deficiencies in reason- sues, medical problems, and psychological disor-
ing and problem-solving skills. These deficits are ders. These topics were related to the severity of
often overlooked in remedial programs because rea- deficits and the neuropsychological implications of
soning skills are seldom taught as a separate skill. dysfunction to determine the course and nature of the
When children cannot organize their work, cannot treatment program. Several neuropsychological and
decide which is the best solution to a problem, or neurocognitive remedial programs were also re-
cannot change mental sets to meet different situa- viewed. Finally, specific procedures and techniques
tions, they generally fall behind in assignments and were outlined for treating cognitive deficits in chil-
they can develop secondary behavioral problems. If dren with brain dysfunction. The successful treat-
these reasoning deficits persist, these children may ment of cognitive deficits is predicated on a valid and
have trouble learning basic concepts. Reitan (1980) comprehensive assessment of the child's neuropsy-
viewed the reasoning process as one of the most chological and academic functioning, and must be
important prerequisites for other cognitive learning. the first step of any remedial program.
The REHABlT program provides a number of ac- All of the specific programs and techniques in-
tivities designed to remediate weaknesses in this volved the identification of individual strengths and
area. weaknesses, and many were based on the diagnosis
374 CHAPTER 19
of subtypes of cogmt1ve deficits. Procedures for Boll, T. J., & Barth, J. T. (1981). Neuropsychology of brain
identifying and treating subclassifications of read- damage in children. InS. Filskov & T. J. Boll (Eds.), Hand-
ing, spelling, and math disabilities have increased book of clinical neuropsychology. New York: Wiley-
considerably in the past 5 years. However, issues of Interscience.
subtyping are far from being resolved in the liter- Bolter, J. F. (1986). Epilepsy in children: Neuropsychological
effects. In J. E. Obrzut & G. Hynd (Eds.), Child neuropsy-
ature, and problems of assessment and differentiation
chology (Vol. 2). New York: Academic Press.
are still unresolved. Although further investigation is Br11cken, B. (1985). A critical review of the Kaufman Assessment
needed to substantiate and validate these procedures Battery for Children (K-ABC). School Psychology Review,
and techniques, there is a substantial theoretical basis 14, 21-36.
upon which to guide research endeavors. There is a Caplan, B., & Kinsboume, M. (1981). Cerebral lateralization,
general need for empirical studies that test specific preferred cognitive mode, and reading ability in normal chil-
remedial techniques with homogeneous brain-in- dren. Brain and Language, 14, 349-370.
jured groups. Despite the difficulty in controlling for Chevrie, J. J., & Aicardi, J. (1978). Convulsive disorders in the
numerous variables that influence treatment out- frrst year of life: Neurological and mental outcome and mor-
tality. Epilepsia, 19, 67-74.
comes, the field of child neuropsychology is in dire
Cohen, G. (1973). Hemispheric differences in serial versus paral-
need of such a data base.
lel processing. Journal of Experimental Psychology, 97,
349-356.
Corbett, J. A., & Trimble, M. R. (1983). Epilepsy and anticonvul-
ACKNOWLEDGMENT sant medication. In M. Rutter (Ed.), Developmental neuro-
psychiatry. New York: Guilford Press.
The preparation of this chapter was supported by Das, J.P., Kirby, J. R., & Jarman, R. F. (1979). Simultaneous
U.S. Department of Education Grant G-00-8302986. and successive processes. New York: Academic Press.
Douglas, V. I. (1983). Attentional and cognitive deficits. In M.
Rutter (Ed.), Developmental neuropsychiatry. New York:
Guilford Press.
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20
The Biofeedback Treatment of

Neurologica l and Neuropsych ological
Disorders of Childhood and
Adolescence
ROBERT L. HODES
Biofeedback is one of several bemavioral treatments plaints, and neuromuscular disorders. In addition,
designed to increase an individual's self-regulation many contemporary clinical applications of biofeed-
of physiology. It employs instrumentation to provide back assume that the self-regulated modification of
patients with both immediate and precise information physiology leads not only to a reduction in physical
about otherwise occult physiological processes. In symptoms, but also to useful behavioral and cog-
clinical settings, biofeedback is typically used in con- nitive changes. For example, the use of EMG bio-
junction with other behavioral or medical interven- feedback for children with attention deficit disorders
tions to reduce the frequency of distressing symp- assumes that biofeedback prompts not only a reduc-
toms or to minimize physical impairments. The tion in muscle tension, but also reduces disruptive
mechanisms underlying biofeedback's clinical effi- classroom behavior, improves academic perfor-
cacy are unclear. Different theorists have advanced mance, and increases the child's sense of self-control
varying explanations including operant conditioning and self-esteem (Braud, 1978; Omizo, 1980a).
of discrete physiological responses (Miller, 1969),
the learning of a generalized relaxation response (Sil-
ver & Blanchard, 1978), and the production of cog- Biofeedback with Disorders of
nitive changes promoting an increased sense of self-
control and self-efficacy (Turk, Meichenbaum, &
Childhood and Adolescence
Berman, 1979; Holroyd et al.. 1984). Despite these
different viewpoints, agreement exists that motivated This chapter reviews the published work on bio-
individuals are able to use biofeedback signals to feedback training in neurological and neuropsycho-
learn voluntary control over a variety of physiologi- logical disorders of childhood and adolescence.
cal parameters. More general reviews of the application of biofeed-
The popular press has made "biofeedback" al- back in pediatric medicine are provided by Finley
most a household word and the technique has been (1983) and Andrasik and Attanasio (1985). In the
offered as a potential cure for a myriad of ills of the broadest sense, all biofeedback learning studies deal
mind and body. Although many of the early claims with the modification of neurally controlled phe-
were unfounded, biofeedback has earned a well-de- nomena. This chapter is limited to a review of the
served reputation as an effective treatment for several application of biofeedback technology to the symp-
chronic pain syndromes, psychophysiological com- toms of neurological disease or neuropsychological
dysfunction. In some of these studies, the evidence of
a neurological lesion is unequivocal; in others, such
ROBERT L. HODES Depanment of Neurology, Univer- evidence is presumptive (Cleeland, 1981). Specific
sity of Wisconsin, Madison, Wisconsin 53792. disorders considered include cerebral palsy. epilep-
377
378 CHAPTER 20
sy, neurogenic fecal incontinence, attention deficit ulus, most notably rapid stretch. Clinically, this is
disorder with hyperactivity, learning disabilities, and observed by asking the patient to relax and then to
migraine headaches. When available, controlled passively extend a limb. In normal muscles, no mus-
group treatment outcome studies are given emphasis cular resistance is observed. Spastic muscles, in con-
over both controlled and uncontrolled case studies. trast, reflexively contract to the attempted extension
For each disorder, the literature review emphasizes and resist the clinician's efforts (DeBacher, 1983).
four basic points relevant to the clinical use of bio- The degree of resistance is often determined by the
feedback. These issues are: velocity of the passive movement and the position of
the limb. In rigidity, muscles are almost continuously
1. Are patients able to learn the desired re- hypertonic. In contrast to spastic muscles, rigid mus-
sponse? cles resist movement throughout their entire range of
2. Does physiological self-regulation lead to motion and at slow movement velocities (Adams &
other clinically relevant changes in either Victor, 1977).
physiology, behavior, or cognition?
3. How effective is biofeedback relative to ei-
ther control or alternative treatment proce- Biofeedback Treatment of Movement
dures? Disorders in Cerebral Palsy
4. Are therapeutic gains maintained over time?
As defined above, spasticity and rigidity both
The vast majority of applications of biofeedback
involve hypertonicity of skeletal muscles. Increase in
have been with adults. Many of the techniques and
the severity of involuntary movements as a result of
insights generated by that literature are directly ap-
environmental stimulation and emotional distress is
plicable when working with children. For example,
also well known. Based on earlier work with pro-
the treatment of migraine headaches in children is
gressive muscle relaxation training in patients with
closely modeled after treatment protocols used with
cerebral palsy, Finley, Niman, Standley, and
adults (Labbe & Williamson, 1984). However, bio-
Wansley (1977) employed frontal region, EMG bio-
feedback training with children does require attention
feedback to produce a generalized state of muscle
to several issues, such as varying developmental lev-
relaxation and associated emotional calm. The effect
els, not typically addressed when working with adult
of this intervention on motor and speech behavior of
clients. The relevancy of these issues to the literature
four children with cerebral palsy was analyzed em-
reviewed in this chapter will also be discussed. Final-
ploying an ABAB design. All children were able to
ly, this chapter concludes with comments summariz-
successfully reduce frontal EMG after an initial 12
ing the current state of knowledge and offering sug-
training sessions. EMG activity increased during the
gestions for future inquiries.
first reversal phase but only one of the four children
was able to reinstitute control during the second treat-
ment period. Similar results were obtained for fore-
Cerebral Palsy arm flexor EMG, where a reduction was observed
during the initial training phase, but increases in flex-
Cerebral palsy refers to a group of nonprogres- or tension were found during the second training
sive motor disorders resulting from damage to the phase. The results were more encouraging for speech
central nervous system during prenatal or perinatal and motor skills. All children manifested statistically
periods. Several types of movement impairments significant improvement in speech and/ or motor
may be seen including spasticity, involuntary move- measures during initial training. These gains deterio-
ments, and incoordination. Although not invariably rated during the reversal phase and were reinstituted
present, associated symptoms may include sensory during the second training phase. Although statistical
abnormalities and mental deficiency. Cerebral palsy significance was demonstrated, judgments concern-
results from multiple etiologies and occurs with an ing the clinical significance of performance gains
estimated incidence of between 0.1 and 0.2% in chil- were not provided by the authors.
dren (Berkow, 1977). In a follow-up study, Finley, Etherton, Dick-
Of the various abnormalities of muscle tone and men, Karimian, and Simpson (1981) studied 15 cere-
movement found in cerebral palsy, spasticity and bral palsied children who primarily manifested spas-
rigidity have received the most attention from bio- ticity. In this study, the biofeedback was contingent
feedback clinicians. The essential feature of spas- upon the combined EMG activity from frontal region
ticity is an increased reactivity to an exciting stim- and forearm flexor sites. These children also received
BIOFEEDBACK 379
tangible rewards (e.g., candy, toys) for meeting per- lowing strokes). The training of neuromuscular con-
formance standards involving reductions in both trol in cerebral palsied children has typically taken
tonic and phasic EMG. For some children, rewards place while the affected extremity or joint is at rest.
were immediate, whereas for other children, rewards This is somewhat surprising given the definition of
were given at the end of the training session. The spasticity as hypertonicity produced by stretch. In
results indicated that children in both groups learned greater accordance with this physiological fact, clini-
to reduce their combined EMG, but larger magnitude cians attempting to reduce spasticity in adult patients
reductions were found for children receiving imme- (e.g., DeBacher, 1983) typically train muscle control
diate reinforcement for performance changes. Data not only while the muscle is at rest, but also during
on functional changes in motor behavior were not passive and active movement of the muscle and dur-
reported. ing activation of antagonistic muscle groups. The
Cataldo, Bird, and Cunningham (1978) em- application of these more sophisticated training pro-
ployed EMG biofeedback to increase neuromuscular cedures with cerebral palsied children is indicated.
control in two children with choreoathetoid cerebral
palsy. The first child was given feedback from the
right biceps with the effects of biofeedback evaluated
with an ABA design. The results suggested that the
Epilepsy
subject was able to produce muscle relaxation with
contingent feedback, and that control deteriorated Epilepsy refers to a group of related syndromes
during the no feedback phase, but was reinitiated characterized by repeated paroxysmal disturbances
during the final feedback sessions. Although func- in brain function. The resulting seizures may have
tional motor control was not formally assessed, the one or more clinical manifestations including impair-
authors noted that hospital staff indicated no notice- ments of consciousness, sensory or motor abnor-
able changes in adaptive functioning. For the second malities, or disturbances in cognition or emotional
child, feedback was given from multiple muscle functioning (Dodrill, 1981). Seizure disorders can
groups using a multiple baseline across-behaviors de- have a variety of etiologies that are too numerous to
sign. The data presented describe appropriate in- detail in this review. Although epilepsy may appear
creases or decreases in muscle control that follow the at any age, it most commonly emerges relatively ear-
intent of the study design. In addition, muscle control ly in life. It has been estimated that 64% of epileptics
generalized to no feedback conditions. Finally, the first develop seizures by the end of elementary school
authors reported that anecdotal observations indi- and 77% by the end of adolescence. The incidence of
cated functional improvements in some muscle epilepsy has been estimated as 1-2% of the popula-
groups. tion in the United States (Epilepsy Foundation of
In summary, only preliminary data exist on the America, 1975).
utility of EMG biofeedback in increasing neu- Treatment of epilepsy is primarily pharmaco-
romuscular control in children with cerebral palsy. logical with anticonwlsant medications providing
These initial data suggest that patients are able to varying degrees of seizure control for 70 to 80% of
learn to reduce undesirable levels of muscle tension. children (Johnston & Freeman, 1981). For a small
However, no study has demonstrated continued self- percentage of patients, surgical excision of abnor-
regulation of muscle activity during long-term fol- mally active brain tissue provides a second treatment
low-up. In this regard, Seeger and Caudrey (1983) alternative. Therefore, despite the many advances in
noted that therapeutic gains in gait training made with medical management, approximately 20% of indi-
sensory feedback from a load-sensitive insole were viduals with epilepsy have inadequate control of
not maintained after a follow-up period of 18-24 seizures.
months. The available data on the impact of en-
hanced muscular control on functional activity have EEG Biofeedback Treatment of Seizures
been mixed. Greater use of reliable observation
methods (e.g., Bird & Cataldo, 1978) or automated Feedback training for various parameters of
recording devices of functional activity (e.g., Seeg- EEG activity has been used as a method of reducing
er, Caudrey, & Scholes, 1981) is clearly indicated. seizures poorly controlled by medications. Several
Finally, it is revealing to compare this early lit- feedback protocols have been attempted with the pa-
erature on the biofeedback treatment of cerebral pal- tient often required to meet multiple contingencies,
sy with the more extensive literature on the treatment such as suppressing slow-wave activity while simul-
of adult patients with spasticity (e.g., spasticity fol- taneously generating increased activity in a faster
380 CHAPTER 20
frequency band. Uniformly, the training period re- feedback phase where patients were trained to in-
quired has been long, often several months. The ac- crease epileptiform activity. Training ended with a
cumulated evidence from such arduous training sug- final EEG normalization period. Dependent mea-
gests that certain epileptics can learn "something" sures included self-report of seizure activity and
that will allow for reduction of seizure frequency neuropsychological testing. In general, seizure ac-
(Cleeland, 1981). The reader is cautioned, though, tivity paralleled the feedback contingency; five of the
that the research discussed below has generally em- eight patients showed clinical improvement during
ployed patient populations that are a mixture of both the final treatment phase with an average seizure re-
pediatric and adult epileptics. Differences in the util- duction of 39. 7%, whereas four patients relapsed
ity of EEG biofeedback across age ranges have not when epileptiform EEG was reinforced. As EEG
been systematically evaluated. training was provided using double-blind pro-
The biofeedback treatment of seizures began in cedures, Lubar's data provide the strongest evidence
the early 1970s. It is rooted in the work by Sterman to date supporting the specific efficacy of biofeed-
and others on the sensorimotor rhythm (SMR). This back training in regulating seizure activity. Neuro-
rhythm refers to 12- to 14-Hz activity maximally psychological testing, including the Halstead-Reitan
recorded over the sensorimotor cortex. It was origi- Battery and either the WAIS or WISC, showed little
nally identified in the waking EEG of cats, where or no change following EEG training, replicating ear-
SMR' s most obvious behavioral correlate is immo- lier findings of Wyler et al. (1979).
bility and muscular inhibition (Donhoffer & Lissak, Sterman (1982) reported data relevant both to
1962; Roth, Sterman, & Clemente, 1967; Howe & the maintenance of therapeutic gains over time and to
Sterman, 1972). Clinical applications of SMR train- the generalization of EEG changes to nonfeedback
ing were initiated after it was observed that cats periods. Fifteen patients with poorly controlled sei-
trained to increase SMR power demonstrated in- zures received EEG training to reduce abnormally
creased threshold for seizures when challenged with low (1-5Hz) and high (20-25Hz) frequencies while
a convulsion-producing dose of monomethylhydra- simultaneously increasing intermediate (10-15 Hz)
zine (Sterman, LoPresti, and Fairchild, 1969). In this activity. Feedback was also contingent on the ab-
way, EEG biofeedback mimicked the therapeutic sence of high-voltage spiking. For five patients, EEG
mechanism of anticonvulsant medications. training was preceded by 6 weeks of symptom self-
Early studies of EEG training attempted to dem- monitoring; for a second group of five patients, 6
onstrate its utility for controlling a variety of seizure weeks of noncontingent (yoked) feedback was pro-
disorders. Two strategies for producing EEG nor- vided. The results strongly supported the role of con-
malization emerged. One involved the enhancement tingent feedback in controlling seizure rates. Seizure
of intermediate EEG frequencies, such as the SMR, reduction only occurred when the EEG normalization
which are thought to inhibit epileptogenic brain ac- feedback contingency was imposed, with 13 of 15
tivity(Sterman&Friar, 1972;Seifert&Lubar, 1975; patients reducing seizures by a mean frequency of
Kuhlman, 1978). A second set of strategies involved about 60%. Furthermore, seizure rates were still re-
training patients to suppress the excessive slow-wave duced by approximately 42% at follow-up.
activity and/or EEG spikes characteristic of seizure Finally, Sterman and Shouse (1980) performed
states. This latter training was provided either by spectral analyses of sleep recordings taken both be-
itself (Cott, Pavloski, & Black, 1979) or in combina- fore and after EEG conditioning. During periods of
tion with biofeedback training to increase either SMR maximal clinical improvement, EEG changes
(Sterman, Macdonald, & Stone, 1974; Lubar & showed increased power for intermediate EEG fre-
Bahler, 1976; Finley, 1976) or beta-range EEG ac- quencies but decreased power for both low (0-3 Hz)
tivity (Sterman & Macdonald, 1978; Wyler, Rob- and high (20-33 Hz) frequency bands. These data
bins, & Dodrill, 1979). When EEG activity was re- suggest that EEG training generalized from the
corded over the sensorimotor region, these various daytime laboratory, when feedback training oc-
training procedures produced significant seizure re- curred, to the sleep EEG.
duction in 60 to 80% of patients. In summary, several investigators have ob-
The most consistent criticism of these early tained data supporting the utility of biofeedback for
studies has been the lack of adequate experimental the control of a variety of seizure disorders. Even
controls. Recent work from the laboratories of Lubar mentally retarded children (e.g., Lubar, 1982) have
and Sterman has been responsive to this need. Lubar been able to profit from complicated feedback con-
(1982) provided patients with one of three types of tingencies to alter their EEG frequency distributions
EEG normalization training followed by an altered and reduce seizure rate. An evolution in training has
BIOFEEDBACK 381
occurred with earlier studies of the effects of specific absent contractions of the external anal sphincter
frequency band training (e.g., SMR training) giving when the rectum is distended (White et al., 1972).
way to efforts to produce EEG normalization across However, inadequate sensation in the rectum to cue
multiple frequency bands. Comparisons of different external anal sphincter contractions has also been
training procedures are just beginning and it is not implicated (Wald, 1983).
clear if one approach holds any superiority over the Medical management of fecal incontinence in
others in producing changes in either seizure rate or myelomeningocele typically involves placing the
neuropsychological functioning. Studies that have child on a regular schedule of enemas or supposito-
compared alternative frequency training procedures ries and timed defecations following meals. This reg-
have employed small sample sizes, limiting the imen keeps the rectum relatively empty. As a conse-
power of the design to offer reliable recommenda- quence, reflexive internal anal sphincter relaxations
tions (Lubar, 1982). Similarly, although some data are minimized, allowing internal sphincter tone to
suggest that treatment gains may be maintained over oppose successfully the movement of fecal matter out
time (Sterman, 1982), the reported sample sizes are of the rectum. For children who become constipated
too small to allow for a reliable conclusion. As noted on this regimen, a variety of stool softeners may also
by Lubar, ''It seems appropriate that wide-scale be employed. This regimen was effective in 58.6% of
clinical trials be initiated to determine whether EEG the children studied by White et al. (1972).
feedback conditioning can become a valuable adjunct
in the treatment of epilepsy" (Lubar, 1982).
Biofeedback Treatment of Fecal Incontinence
Engel, Nikoomanesh, and Schuster (1974) de-
Fecal Incontinence in scribed the first use of biofeedback to treat fecal in-
Myelomeningocele continence in myelomeningocele. As described by
these authors and others, biofeedback treatment of
Myelomeningocele or spinal bifida is a major fecal incontinence involves the use of three balloon
cause of neurogenic fecal incontinence in children pressure transducers inserted in the patient's anus and
and adolescents. This disorder involves a congenital rectum. One balloon is placed in the proximal rec-
neural tube defect with resulting lesions of some of tum, a second in the internal anal sphincter, and the
the nerve tracts in the lower spinal cord. These le- third in the external anal sphincter. Inflation of the
sions may interfere with the afferent and efferent balloon in the rectum simulates the presence of stool.
nerves that innervate the rectum and anal sphincters, Pressure measurements from the other two balloons
compromising the child's ability to voluntarily con- measure muscle tone in the internal and external anal
trol bowel habits. Although not medically serious, sphincters in response to this rectal distension. By
fecal incontinence often leads to significant social observing the manometric or pressure changes in
problems and embarrassments. these three balloons, patients are given feedback con-
An understanding of the treatment of fecal in- cerning these three physiological activities. Patients
continence requires some familiarity with the normal use this information to learn to produce voluntarily
physiology of bowel movements. The movement of external anal sphincter contractions that ( 1) occur in
stool out of the rectum is normally opposed by the response to rectal distension and (2) outlast the phase
tonic constriction of the internal anal sphincter. How- of internal sphincter relaxation.
ever, when sufficient amounts of stool or gas enter As outlined by Whitehead, Parker, Masek, Cat-
the rectum, the internal sphincter will reflexively re- aldo, and Freeman (1981), biofeedback training in
lax. This requires a voluntary contraction of the ex- myelomeningocele patients usually proceeds in four
ternal sphincter in order to avoid soiling (Marzuk, phases. An initial assessment phase tests the rec-
1985). From this brief description, it can be seen that tosphincteric reflex of the internal anal sphincter, the
normal toilet training in children requires three fac- strength of the voluntary contraction of the external
tors: voluntary control of external anal sphincter con- sphincter, and the patient's subjective sensory
tractions during the period of internal anal sphincter threshold for rectal distension. In the second phase,
relaxation, adequate sensations from the rectum to patients are trained to make skillful contractions of
allow for accurate timing of the external sphincter the external anal sphincter in the absence of rectal
contraction, and appropriate self-toileting behaviors distension. If possible, patients are trained to volun-
(Whitehead et al., 1986). Fecal incontinence in my- tarily contract the external anal sphincter. If this
elomeningocele is generally attributed to weak or proves too difficult, voluntary contractions of the
382 CHAPTER 20
nearby gluteal muscles may be adequate (Wald, ior modification training to teach self-initiation of
1981). During this phase, patients are typically given bowel movements. Briefly, this involved regular toi-
visual feedback in the form of observation of man- leting after meals with reinforcers for successful
ometric tracings from the external anal sphincter. bowel movements or for accident-free days. In addi-
Verbal and tangible reinforcers are also often em- tion, the program used enemas and/or stool softeners
ployed, especially with younger children. In phase under specified conditions to prevent fecal impac-
three, patients are trained to make voluntary external tion. For one group, biofeedback training was initi-
sphincter contractions in response to rectal disten- ated following I month of behavior modification
sion. Training often begins with distensions at the training. For a second group, biofeedback training
level of subjective appreciation and gradually pro- was provided after a 3-month delay.
gresses to increasingly larger amplitude distensions. The results were complex and were interpreted
During this phase, patients observe manometric trac- by the authors as suggesting that clinically signifi-
ings from all three balloons to aid them in producing cant reductions in incontinence occurred primarily
sphincter contractions of adequate amplitude, dura- during the behavior modification phase of training.
tion, and timing. In the final phase, patients are re- The authors also used Markov chain modeling to
quired to continue to demonstrate skillful control of analyze the separate contributions of behavior modi-
the external sphincter but without visual feedback fication and biofeedback. This analysis suggested
and without any cues concerning the onset or dura- that biofeedback and behavior modification "had
tion of rectal distension and internal anal sphincter differential effects on different types of incontinent
relaxation. states; namely, behavior modification was the only
Uncontrolled case studies (Cerulli, Nikooma- treatment effective in causing patients to move from
nesh, & Schuster, 1979; Whitehead et al., 1981; infrequent incontinence (staining or one acci-
Ward, 1981, 1983; Shepherd, Hickstein, & Shep- dent/day) to continence, whereas biofeedback was
herd, 1983) have all found manometric biofeedback more effective than behavior modification for high-
to produce clinically significant reductions in fecal frequency (more than once a day) incontinence."
soiling in the majority of children treated. Success Replicating Wald (1983), children with impaired
rates have varied from 46 to 96%. It should be noted rectal sensation showed a poor response to biofeed-
that these improvement rates are for children who back training. However, these same children were
have invariably failed to achieve continence via more able to improve bowel control, with four of these six
standard medical management. In addition to demon- patients achieving a 75% or greater reduction in epi-
strating biofeedback's utility, these preliminary data sodes of incontinence. This improvement was pre-
have suggested tentative guidelines for selecting pa- sumably the result of the addition of behavior modi-
tients who are most likely to benefit from manometric fication to these patients' training regimen.
biofeedback training. Wald (1983) observed that pa- Six-month or longer follow-up data were avail-
tients who benefitted from biofeedback had signifi- able on 66% of the patients in the Whitehead et al.
cantly lower thresholds of rectal sensation than did ( 1986) study. These data indicated that both the fre-
patients who failed to improve. He reported that of quency of incontinence and the number of enemas
the 43% of his sample of children with myelomen- per week were still significantly reduced relative to
ingocele who had impaired appreciation of rectal dis- baseline levels. Sphincter strength in patients who
tension, all failed to respond to biofeedback therapy. previously met a satisfactory training criterion was
Shepherd et al. ( 1983) also found a high incidence of also well maintained. However, the number of self-
impaired rectal sensation, with 18 of 22 children as- initiated bowel movements regressed to pretraining
sessed as having either subnormal or absent sensa- levels.
tion. However, they observed that following behav- The results of their experiments led both Shep-
ioral training for continence, previously absent rectal herd et al. (1983) and Whitehead et al. (1986) to
sensation developed in four patients. In those cases, similar conclusions. Both argued for a partitioning of
impaired rectal sensation was associated with fecal children with myelomeningocele into two groups
retention and megarectum. The authors suggested based on physiological criteria. In one group, rectal
that biofeedback training may be effective for these sensation is minimal or absent and augmented reflex
children following appropriate medical management activity of the external anal sphincter is present. In
of their megarectum. this group, chronic constipation and/or megarectum
Recently, Whitehead and colleagues reported a occurs. Whitehead et al. ( 1986) also characterized
study comparing biofeedback and behavior modifi- these patients as being more likely to have spinal cord
cation approaches (Whitehead et al., 1986). After a lesions at L-2 or above. These patients seem to bene-
2-week baseline period, all subjects received behav- fit the most from behavior modification combined
BIOFEEDBACK 383
with medical management to produce regular, com- doxical effect in hyperactive children, producing
plete evacuations of stool from the rectum. The sec- therapeutic sedation rather than stimulation. Howev-
ond group is characterized by normal or near-normal er, in the early 1970s, Satterfield and associates ob-
rectal sensation, inadequate reflex activity and mus- served that hyperactive children displayed both auto-
cle tone in the external sphincter, and multiple daily nomic and electrocortical hypoarousal (Satterfield &
bowel movements. These patients benefit the most Dawson, 1971). This suggested that stimulants work
from biofeedback training to augment the strength of not by producing a cortical sedation but by stimulat-
voluntary contractions in the external anal sphincter. ing cortical inhibitory mechanisms that are immature
Preliminary data suggest that therapeutic changes are or inadequate in hyperactive children.
maintained at follow-up. Studies evaluating the use of stimulants in chil-
dren with ADD have consistently found a reduction
in hyperactive behavior (Conners, 1972). However,
expected gains in academic achievement have not
Attention Deficit Disorder with been found (see Denkowski et al., 1983). Side ef-
Hyperactivity fects have also proven to be a problem, limiting the
use of these medications. Finally, behavioral gains
The essential features of attention deficit disor- are not always maintained into early adulthood when
der (ADD) are signs of developmentally inappropri- medications are discontinued (Ackerman, Dykman,
ate inattention and impulsivity (APA, 1980). DSM- & Peters, 1977; Weiss, Kruger, Danielson, &
III recognizes two subtypes of this disorder, ADD Elman, 1975).
with and without hyperactivity. They both share Behavior modification provides the most com-
signs and symptoms relating to inattention and im- mon alternative to medications. This approach in-
pulsivity, but problems with excessive motor activity volves the use of social learning theory to weaken
are only found in the former category. Associated maladaptive behavior and to strengthen systemat-
features vary but most often include negativism or ically behaviors incompatible with inattention, im-
noncompliant behavior, mood lability, low frustra- pulsivity, and hyperactivity (O'Leary. Pelham,
tion tolerance, and low self-esteem. Specific devel- Rosenbaum, & Price, 1976). Behavior modification
opmental disorders (i.e., learning disabilities) are techniques are often employed in conjunction with
also relatively common. In the past, this disorder has classroom management strategies (e.g., removing
received a variety of names, most typically minimal classroom distractors, providing a structured class-
brain dysfunction and hyperactivity. DSM-III opted room routine) that structure the learning environment
for the term attention deficit disorder because atten- to accommodate the behavioral and attentional style
tional difficulties are prominent and ubiquitous and of the hyperactive child. Behavior modification is
definite evidence for cerebral brain dysfunction is not clearly effective in changing specific behaviors, such
found in most children. In addition, the hyperactivity as in-seat behavior or time on task. Unfortunately,
often observed in these children frequently dimin- generalization to other syndrome behaviors such as
ishes during adolescence, while difficulties in atten- academic performance, or generalization across time
tion persist. The majority of the literature on biofeed- when contingencies are removed has been unsatis-
back and ADD selected children with excessive factory.
motor activity. As most of these studies labeled these In response to these deficiencies, clinicians pro-
children as hyperactive, this review will adopt that posed in the early 1970s that biofeedback may pro-
more common albeit outdated label. vide a useful primary or adjunctive intervention in
The onset of ADD with hyperactivity is typ- treating ADD with hyperactivity. Most investiga-
ically by the age of 3 although the diagnosis is usu- tions of the utility of biofeedback have employed
ally made during elementary school. This disorder is either EMG biofeedback to reduce generalized mus-
estimated to be I0 times more common in boys than cle tension or SMR biofeedback to promote a brain
in girls (APA, 1980). Lambert, Sandoval, and state associated with inhibited motor activity (Ster-
Sassone (1978) reported the prevalence of this disor- man, 1982).
der among elementary school children as ranging
from I to 6%. EMG Biofeedback
The traditional treatment of hyperactivity in-
volves one of two approaches (Walden & Thompson, Braud, Lupin, and Braud (1975) are generally
1981 ) . The most popular treatment approach has credited with first proposing the use of frontal re-
been medication management using CNS stimulants. gion EMG biofeedback with hyperactive children.
It was initially assumed that these drugs had a para- Braud's (1978) rationale for the utility of EMG bio-
384 CHAPTER 20
feedback was that ''hyperactive children are not only ulatory strategy. In support of this, Whitmer ( 1977)
overactive but also overly tense. The authors feel that trained one group of hyperactive children to decrease
these tension levels could aggravate the symp- frontal region EMG, but trained a second group to
tomatology." Since this initial hypothesis, eight increase EMG. Consistent with the underarousal the-
group outcome studies have been published evaluat- ory, reductions in hyperactive behavior were only
ing frontal region biofeedback in hyperactive chil- found for subjects trained to increase EMG.
dren and adolescents. All eight studies have employed multiple out-
Five studies (Braud, 1978; Bhatara, Arnold, come measures in evaluating the utility of biofeed-
Lorance, & Gupta, 1979; Denkowski. Denkowski, back therapy. Parent and/ or teacher ratings of hyper-
& Omizo, 1983; Dunn & Howell, 1982; Omizo, active and disruptive behaviors were made in four
1980b) reported EMG data for patients receiving studies. A striking disparity exists in the ratings made
from 3 to 12 biofeedback training sessions. All stud- by parents versus teachers. Parent rating scales con-
ies reported reductions in frontal region EMG follow- sistently indicated decreased behavior problems fol-
ing biofeedback. Further, three of these studies em- lowing biofeedback training (Bhatara et al., 1979;
ployed appropriate control procedures allowing the Braud, 1978; Dunn & Howell, 1982). In contrast to
conclusion that the observed reduction in EMG is not these positive findings, both studies assessing teach-
the result of habituation across repeated testing occa- er ratings (Bhatara et al., 1979; Denkowski & Den-
sions. Omizo (1980b) obtained similar results; how- kowski, 1984) failed to find an improvement in class-
ever, in his study biofeedback was confounded with room behavior. None of the researchers in this area
taped relaxation instruction. have commented on this apparent difference between
Three qualifying points need to be made. First, classroom and home behavior change. Possible ex-
the decision to train a reduction in frontal region planations include procedural differences between
EMG makes the implicit assumption that muscle ten- the studies (however, note that Bhatara et al. mea-
sion is elevated in hyperactive children. Borkovec sured both parent and teacher ratings), differences
and Sides (1979), among others, argued persuasively between classroom and home settings in provoking
that the choice of a relaxation strategy should be hyperactive behavior, differences in the amount of
matched with the response domains showing exces- contact between parents and researchers versus the
sive levels of arousal. Surprisingly, this assumption contact between teachers and researchers, dif-
has only been confirmed in one study (Braud, 1978) ferences in the level of objectivity between parents
where levels of frontal region EMG during rest were and teachers, and different levels of expectancy of
significantly higher in hyperactive than in control change between parents and teachers.
children. No other laboratories have replicated this Neuropsychological testing has involved either
important assumption. the Bender Gestalt, the Digit Span and Coding sub-
Second, it is often assumed that a reduction of tests from the WISC-R, or other tests sensitive to
frontal region EMG leads to a generalized state of attention and impulsivity. In general, the results sug-
relaxation at multiple body sites. This state of relaxa- gest improved performance on these measures.
tion ultimately translates into a decrease in overac- Braud (1978) found that biofeedback training led to
tivity. Unfortunately, none of the studies measured fewer errors on the Bender test and improved scores
EMG from additional muscle locations. Burish on the Illinois Test of Psycholinguistic Abilities. No
(1983) reviewed the research on frontal region EMG difference between biofeedback subjects and con-
biofeedback in adults and concluded that this type of trols was found on Digit Span and Coding. Dunn and
biofeedback does not reliably produce a generalized Howell ( 1982) found that hyperactive subjects im-
reduction in muscle tension or autonomic activity. proved on the Bender Gestalt and WISC-R subtest
Although the situation may be different with chil- following active biofeedback training but not follow-
dren, the existing research does not encourage the ing placebo treatment. Finally, Omizo and Michael
frequently made assumption that frontal region bio- ( 1982) measured both errors and response latency on
feedback in hyperactivity leads to a generalized re- the Matching Familiar Figures Test. They found de-
laxation response. creases in errors and an increase in latency following
Finally, Gargiulo and Kuna ( 1979) questioned biofeedback training and concluded that these
whether it makes theoretical sense to train reductions changes were consistent with decreased inattention
in physiological arousal in hyperactive children. and impulsivity in their subjects.
Based on the Satterfield and Dawson ( 1971) finding In other response domains, the data are more
of hypoarousal in hyperactivity, these authors sug- ambiguous. Academic skills were measured in only
gested that relaxation might be an inappropriate reg- two studies (Denkowski et al., 1983; Denkowski &
BIOFEEDBACK 385
Denkowski, 1984). Although the former study found either physiology or hyperactive behaviors). Unfor-
improvements in reading vocabulary and com- tunately, Dunn and Howell made no attempt to as-
prehension following biofeedback, similar improve- sess the placebo's credibility, so that one does not
ments were not obtained by the same investigators in really know if the placebo treatment prompted the
their second study. The authors attributed this dis- same degree of expectancy for change as did the
crepancy to differences in the tests used to measure biofeedback treatment (Borkovec & Nau, 1972).
academic abilities; however, numerous other pro- These methodological weaknesses make it impossi-
cedural differences between the studies (such as the ble to determine the role that the contingent presenta-
number of training sessions and the age of hyperac- tion of the biofeedback signal plays in producing the
tive children) may also be important. clinical improvement obtained in these research
Finally, in five studies, Omizo, the Denkow- studies.
skis, and associates assessed a variety of biofeed- Three studies compared EMG biofeedback to
back-induced changes in either locus of control or taped relaxation training. Braud (1978) and Dunn
self-esteem. These data are important to the hypoth- and Howell ( 1982) obtained comparable improve-
esis that biofeedback ''may demonstrate to hyperac- ments in muscle tension, hyperactive behavior, and
tive children that they have control over their phys- psychological test data between biofeedback and re-
ical behavior and this perception of self-control then laxation. In the Denkowski and Denkowski (1984)
generalizes to enable more selective socioeduca- study, the results were largely negative for both
tional behavior" (Denkowski et al., 1983). Four groups, with one analysis supporting a shift in locus
studies assessed locus of control. In two out of four of control toward internality only for subjects receiv-
studies, subjects demonstrated increased internality ing relaxation training. Hence, the data do not sup-
following biofeedback but not following placebo port the employment of the more expensive biofeed-
treatment (Denkowski et al., 1983; Omizo, 1980a). back training over the more cost-effective taped
Similarly, of the three studies measuring either self- relaxation training.
concept or self-esteem, two (Omizo, 1980a,b) found Because these studies were initial attempts to
favorable changes, whereas one (Denkowski et al., demonstrate the efficacy of biofeedback, it is not
1983) obtained no advantage for subjects receiving surprising that scant attention was paid to demon-
biofeedback. Hence, the literature is almost evenly strating the maintenance of change over time. In-
split between studies supporting the conclusion that deed, this crucial issue was assessed in only one
biofeedback produces favorable changes in self-con- study (Bhatara et al., 1979) and in that case, reduc-
cept and locus of control and negative findings in tions in hyperactive behaviors, as rated by parents,
these areas. Clearly, more research is needed before a regressed to pretreatment levels after 12 weeks post-
confident conclusion can be drawn. treatment. Clearly, the inclusion of an adequate fol-
Control procedures varied across the eight stud- low-up period is a prerequisite for all future treatment
ies reviewed. Braud (1978) employed a no-treatment outcome research in this area.
control group. Bhatara et al. (1979) connected con-
trol subjects to an inoperative biofeedback unit but
provided no other placebo treatment. Omizo EEG Biofeedback
(l980a,b) and Denkowski and Denkowski (1984) at-
tached subjects to inoperative equipment and also Nail (1973) provided the only controlled group
played for control subjects either neutral tapes or outcome study of EEG biofeedback as a treatment for
tapes of children's stories. This contrasted to the bio- hyperactivity. In her study, 48 children with hyper-
feedback subjects, who listened to relaxation tapes. kinesis associated with learning disabilities were as-
Denkowski et a/. (1983) employed a similar pro- signed to either a no-treatment group, contingent al-
cedure but substituted neutral conversations with the pha biofeedback, and false or noncontingent
children for the neutral tapes. It seems unlikely that feedback. Subjects in the latter two groups also re-
any of these control procedures were as credible as ceived brief relaxation exercises. Her results sug-
biofeedback for either parents or children. The only gested little or no difference between the veridical
study that used a potentially credible control pro- and placebo biofeedback groups. Alpha amplitude
cedure was Dunn and Howell (1982). In this study, increased in 9 of the 16 veridical training patients and
all children received 10 sessions of placebo treatment in 7 of the 16 placebo patients. Measures of hyper-
followed by 10 sessions of biofeedback treatment. kinetic and maladaptive behavior and overall aca-
Relationship and play therapy served as placebo demic achievement did not significantly differ be-
treatments (these indeed had no significant effect on tween the biofeedback and control groups.
386 CHAPTER 20
More recently, Lubar and his colleagues re- specific developmental disorders when referring to
ported a series of case studies employing an EEG learning disabilities.
biofeedback contingency designed to train an in- Learning disabilities are generally thought to be
crease in SMR in the absence of excessive theta wave about twice as common among males as among
activity (Lubar & Shouse, 1976; Shouse & Lubar, females (APA, 1980). Hyperactivity and other be-
1979; Lubar & Lubar, 1984). Lobar's case studies havioral disorders are often associated with learning
provide strong preliminary support for the efficacy of disabilities, and delinquency may be a complication
this form of biofeedback. Five patients were evalu- of learning disabilities among adolescents (Sattler,
ated with reversal designs and 6 were evaluated as 1982).
uncontrolled case studies. Of the 11 subjects re- The treatment of learning disabilities tradi-
ported, 10 learned to increase SMR and/or beta wave tionally involves some form of remedial education
activity while facial EMG and gross motor activity training, with the specific training methods tailored
decreased. Observational measures of classroom be- to the cognitive and academic strengths and weak-
havior improved in 8/ 13 categories for 4 of 5 children nesses of the child. Behavior modification principles
for whom these data were available. Electrocortical may also be employed to alter behavior patterns, such
and to a lesser extent behavioral improvement re- as overactivity, that impair the child's ability to profit
versed when the biofeedback contingencies were from educational experiences. Although remediation
withdrawn. For 6 of these children, information was is often effective, it is not uncommon for LD children
presented on academic test scores and/or school to demonstrate a pattern of academic difficulties
grades. In each case, unspecified "considerable im- throughout childhood and adolescence with many in-
provements'' were reported. These data suggest that dividuals showing cognitive problems in adult life
SMR biofeedback warrants an evaluation with a con- (APA, 1980).
trolled group outcome study or with a larger series of As noted above, it is not uncommon for children
controlled case studies. As Lubar and his colleagues with hyperactivity to display difficulties in learning,
treated patients with multiple therapies (EEG bio- either as a primary neuropsychological problem or
feedback was combined in various studies with medi- secondary to the behavior disruption inherent in hy-
cations, academic remediation, and feedback on peractivity. It is not surprising, then, that the biofeed-
muscle activity) it will also be necessary to determine back treatment of learning disabilities closely paral-
the relative contribution of EEG biofeedback. Final- lels the treatment of hyperactivity. Both EMG-based
ly, SMR biofeedback requires a relatively large in- relaxation techniques and EEG biofeedback have
vestment of both human and technological resources been employed.
and its cost effectiveness relative to other interven-
tions needs to be addressed.
EMG Biofeedback in Learning Disabilities
Carter and Russell ( 1980) reasoned that stress
Children with Learning Disabilities and muscle tension have a debilitating effect upon
academic attainment in LD children. They specu-
Learning disabilities refer to deficiencies in aca- lated that relaxation training would ''bring about a
demic performance that are not attributable to cognitive reorganization or integration which allows
lowered intelligence, emotional disturbance, sen- the recipient to use his abilities more efficiently.'' To
sorimotor problems, or significant socioeconomic test this, they gave four LD males, aged 8-13, ten
disadvantage (Rourke, 1981). The etiology of a sessions ofEMG biofeedback from the forearm flex-
learning disability is usually unclear. The definition ors combined with handwriting training. They were
of learning disabilities implies that they arise from able to demonstrate both a 62% decrease in forearm
neuropsychological inefficiencies in the perception, muscle tension and a mean increase of 0.65, 0.68,
organization, and/ or integration of information. The and 0.53 grade level equivalences in reading, spell-
specific type of brain-related disability has been ing, and arithmetic abilities, respectively.
found to vary among learning-disabled (LD) chil- The authors followed these uncontrolled case
dren. An excellent discussion of this issue is found in studies with two controlled group outcome studies
Rourke (1981, 1985). Learning disabilities can affect (Carter & Russell, 1985). In the first study, 32 male
any academic skill, but most typically involve lan- elementary students with learning disabilities were
guage-related problems. DSM-III employs the term randomized either to a combined biofeedback/taped
BIOFEEDBACK 387
relaxation/handwriting training condition or to a no- children. The authors reasoned that temperature
treatment control group. Each student also completed feedback would improve academic skills by teaching
a test battery measuring intellectual functioning, aca- LD children a "fully attentive, attuned, and stable
demic achievement, auditory memory, perceptual internal state in which background noise is reduced to
motor skills, and handwriting ability. The results a minimum.'' Hunter et al. randomized LD and nor-
demonstrated significantly greater improvement for mal children, ages 7-9 years, either to five sessions
the experimental group on all measures except the of "consistent" temperature feedback or to a false
arithmetic subtest of the Wide Range Achievement feedback "mixed reinforcement" procedure (the
Test. EMG was only measured for experimental sub- success feedback signal followed increases, de-
jects, with those subjects demonstrating a significant creases, and stable temperature patterns). The results
reduction in forearm muscle tension following bio- demonstrated modest (OSF) but statistically reliable
feedback/relaxation training. In a replication study, increases in skin temperature for both LD and normal
30 elementary school LD males were randomized children with veridical reinforcement. However, ver-
either to 18 sessions of a similar biofeedback/relaxa- idical feedback and false feedback LD groups did not
tion/handwriting training procedure or to a no-treat- vary in improvement on scores on a brief neuropsy-
ment control group. The results replicated the main chological battery.
findings from study I, with significantly larger gains In summary, EMG and temperature biofeed-
made by experimental subjects on all dependent mea- back training do seem to be associated with increased
sures except general intelligence and auditory memo- voluntary control over trained physiology. EMG bio-
ry. Finally, with an independent group of 20 LD feedback was also associated with desirable changes
males, the authors obtained significant improve- in behavior, academic achievement, and less con-
ments on the Tennessee Self-Concept Scale and on sistently self-report measures of self-concept and
the Child Behavior Rating Scale. Taken as a whole, locus of control. Unfortunately, the interpretation of
the authors suggest that (I) LD children are able to these findings is problematic. First, all of the studies
learn to reduce relevant muscle tension levels, and combined biofeedback with other training proce-
(2) these changes are associated with improvement in dures, making it impossible to identify the unique
cognitive abilities, academic achievement, behav- properties of biofeedback training. Second, although
ioral adjustment, and self-concept. all of the authors assumed that biofeedback leads to a
Omizo and Williams (1982) argued that "relax- sense of relaxation, no attempt has been made to
ation training is effective because the learning-dis- demonstrate a relaxation response involving multiple
abled child gains control over his muscle levels, thus response systems. Third, all of the studies employed
improving his ability to perform on visual/perceptual control procedures that may have been inadequate to
tasks that involve focusing on relevant cues and igno- control for nonspecific treatment effects, such as ex-
ring irrelevant stimuli." In a controlled outcome pectancy for change. As before, treatment credibility
study, the authors randomized 32 children, ages 8- was not assessed. Fourth, none of these studies in-
11 , either to three sessions of combined frontal re- cluded a follow-up period to determine the stability
gion EMG biofeedback, taped relaxation training or of behavior change over time. Finally, the rationale
to a placebo treatment involving listening to neutral behind the choice of relaxation as a specific interven-
tapes. The study found significant decreases in front- tion for learning disabilities has varied across studies
al region EMG only for subjects in the experimental and is poorly articulated at best. Greater conceptual
group. In addition, compared to the control subjects, clarity would aid clinicians in deciding which chil-
subjects receiving biofeedback/relaxation training dren might benefit the most from a relaxation-based
made significantly fewer errors on the Matching Fa- intervention.
miliar Figures Test and significantly increased their
responding latency. These findings were interpreted
as reflecting increased attention to task and decreased EEG Biofeedback in Learning Disabilities
impulsivity in the relaxation-trained LD pupils. Fi-
nally, control and experimental subjects failed to dif- As noted above, many theories of learning dis-
fer on a measure of locus of control, with both groups ability assume some underlying neurological dys-
showing little change from pre- to posttesting. function. Comparison of the EEG of normal and LD
Unlike the studies previously described, Hunt- children became one method of searching for this.
er, Russell, Russell, and Zimmerman (1976) trained Roberts ( 1966) demonstrated excessive amounts of
digital skin temperature increases to LD and normal slow-wave EEG activity, particularly in the 3- to 4-
388 CHAPTER 20
Hz frequency band, in LD children. More recently, right hemisphere frequencies and improvement on
Lubar et al. (1985) performed power spectral fast WRAT Arithmetic.
Fourier analyses of EEG in 69 children with learning Carter and Russell (1981) reported a single
disabilities and 34 controls. Among other findings, group outcome study on four LD children chosen on
LD children differed from controls by having signifi- the basis of having a WISC-R Verbal IQ score at least
cantly more power in theta and low alpha frequency 15 points below their Performance IQ (the mean Per-
bands, i.e., more slow-wave EEG activity. formance-Verbal discrepancy was 25.34 IQ
Based on these and other observations, it has points). These elementary school aged boys received
been suggested that biofeedback techniques might 16 sessions of EEG biofeedback training to volun-
prove useful in training LD children to alter dysfunc- tarily produce either alpha or beta activity coupled
tional patterns of EEG activity, and that this modifi- with taped relaxation training. Due to equipment
cation would produce salutary changes in learning problems, the EEG data were not reported. However,
and behavior. Gracenin and Cook (1977) gave eight posttest data suggested a marked decrease of 14.67
LD children 10 sessions of alpha biofeedback. Dur- points in the discrepancy between Verbal and Perfor-
ing the last 6 sessions, subjects were asked to in- mance IQ with the mean Verbal IQ increasing from
crease alpha while reading. Although statistical anal- 76.3 to 88.7.
yses were not reported, the authors suggested that Tansey (1984) also reported single group out-
four of eight subjects learned to increase alpha ampli- come data on six elementary school aged boys with a
tude and duration. However, alpha-trained subjects history of learning disabilities. Unlike the subjects in
did not differ from no-treatment controls on improve- the previous study, these children varied in the rela-
ments in oral reading and reading comprehension. tive strength of their Verbal and Performance IQs.
Cunningham and Murphy (1981) hypothesized Tansey's subjects received a variable number of bio-
from earlier research (Murphy, Darwin, & Murphy, feedback training sessions to increase bilateral SMR
1977) that different types of cognitive tasks (e.g., amplitude. Tansey reasoned that many forms of re-
visual spatial versus verbal) are associated with dif- medial therapy for LD children work by providing
ferent patterns of electrocortical arousal. They sug- external, task-relevant stimulation to the child's sen-
gested that LD children may lack the ability to pro- sorimotor cortex. He argued that SMR biofeedback
duce these patterns of cortical arousal in a fashion provides for internal cerebral stimulation. Further,
necessary to perform different types of cognitive by providing bilateral EEG biofeedback, remediation
tasks. Based on this assumption, 24 LD adolescents, should also occur for learning deficits caused by defi-
ranging in age from 13.1 to 17.9, were assigned to ciencies in normal interhemispheric interactions. The
one of three groups: ( 1) EEG biofeedback to produce results strongly supported the efficacy of SMR bio-
a pattern of increased right hemisphere and decreased feedback. First, as a group, SMR amplitude showed
left hemisphere frequencies, (2) training to decrease a mean increase of 138% above baseline levels. Sec-
EEG frequencies in both hemispheres, and (3) a no- ond, large increases, ranging from 7 to 25 points,
treatment control group. The results were complex were found for all six children in WISC-R Verbal,
and will only be briefly summarized here. First, EEG Performance, and Full-Scale IQ scores. These IQ
power data found lower left than right hemisphere increments were felt to be much larger than the
cortical arousal across both verbal and nonverbal change that would be expected by maturation alone.
tasks. These data support theories of left hemisphere Finally, SMR training attenuated the discrepancy be-
hypoarousal in LD children (e.g., Satz, Rardin, & tween Verbal and Performance IQ scores for the four
Ross, 1971). In addition, both biofeedback groups children with significant pretraining asymmetries in
displayed decreasing left hemisphere baseline fre- ability levels.
quencies across sessions. In terms of achievement It is premature to offer a reliable opinion on the
test data, subjects trained to increase right hemi- utility of EEG biofeedback as a therapy for LD chil-
sphere and decrease left hemisphere arousal showed dren. In part, this is caused by the lack of procedural
a significant improvement on the Wide Range overlap between the four published articles in this
Achievement Test (WRAT) Arithmetic subtest. area. However, several observations can be made.
Other subjects showed no change in arithmetic First, LD children and adolescents demonstrated reli-
scores. None of the subjects displayed significant able changes in physiology from pre- to posttesting.
improvement on measures of spelling, reading, or Unfortunately, the lack of appropriate control mea-
spatial abilities. Finally, a strong correlation (r = sures makes it impossible to determine if these
0.9) was found between subjects' ability to increase changes are due to the contingent presentation of the
BIOFEEDBACK 389
feedback signal, or are caused by other factors, such relief for migraine sufferers who present at headache
as confounding treatments, nonspecific treatment ef- clinics. Unfortunately, little systematic research has
fects, or mere instructions to attempt to control EEG. been done on medication protocols for childhood mi-
Second, psychoeducational data were limited. The graines. For adult patients with infrequent migraines,
two studies reporting achievement testing found, at abortive agents such as ergotamine or Midrin are
best, only minimal changes in academic skills. Also employed. These medications are vasoconstrictors
the absence of appropriate controls makes it difficult and presumably work by minimizing the vasodilation
to separate the effects of biofeedback training from phase of the migraine. For patients with more fre-
the influence of both maturation effects and practice quent migraines, prophylactic agents are recom-
effects caused by repeated exposure to tests. Third, mended. A variety of medications have been recom-
none of the studies obtained follow-up data to deter- mended, the most consistent efficacy being claimed
mine if reported benefits of treatment were main- for beta adrenergic blocking agents, such as pro-
tained. Finally, with the exception of the study by panolol (Fenichel, 1985). In addition, physicians
Carter and Russell, no attempt was made to sample a often counsel patients to avoid things that trigger
group of LD children or adolescents with rela- migraine attacks. Common triggers are strong emo-
tively homogeneous neuropsychological charac- tions, fatigue, dietary factors including a variety of
teristics. Rather, an invariant intervention is assumed foods and alcohol, and oral contraceptives (Saper,
to be equally effective for all LD individuals [see 1983).
Doehring, Hoshko, & Bryans (1979) and Leslie, The decision to supplement simple analgesics
Davidson, & Batey (1985) for criticisms of this strat- with more powerful medications is one that many
egy in LD research in general]. physicians are hesitant to make. Medications such as
ergotamine and propanolol have a number of undesir-
able side effects. In addition, many physicians are
reluctant to prescribe maintenance medications
Childhood Migraines chiefly due to concerns about eventual drug depen-
dency or to concerns about the unknown effects of
Despite the large literature on the biofeedback long-term use of these medications on children
treatment of adult headaches, little is known about its (Hoelscher & Lichstein, 1984). This reluctance has
utility in pediatric headaches. Of the studies that have motivated a search for effective, nonpharmacolog-
been completed, all have investigated biofeedback ical treatments of migraines in both children and
treatment of migraine headache. adults.
Migraines in Children and Adolescents

Biofeedback Treatment of Migraines
Migra4le headaches are characterized by parox-
ysmal alterations of cerebral blood flow. The pain of The research on the biofeedback treatment of
migraine is felt to be caused by excessive vasodila- migraines in adults provides a model for the interven-
tion of the cranial arteries (Fenichel, 1985), with tions used with children and adolescents. In a series
some arguing that substances such as bradykinin and of controlled group outcome studies, both digital skin
histamine play a role by sensitizing primary pain af- temperature biofeedback and cephalic vaso-
ferents during migraine attacks (Saper, 1983). The motor biofeedback have proven more effective than
source of this vascular instability is uncertain, but no treatment in reducing migrainous symptoms
neural and humoral factors may both be involved. (Blanchard & Andrasik, 1982). There is some dis-
The prevalence of migraine in children and ado- pute over the mechanism(s) underlying the effective-
lescents is estimated to be between 3 and 7% (Bille, ness of biofeedback training. Some (e.g., Elmore &
1962; Hoelscher & Lichstein, 1984). In early child- Tursky, 1981) emphasize the role of biofeedback in
hood, migraine has been reported to be at least as training patients to voluntarily produce cerebral ar-
frequent in boys as in girls, but this gender ratio tery vasoconstriction during the headache phase of
changes in late adolescence and early adulthood, the migraine. For others, the efficacy of digital skin
when females are more commonly affected (Rigg, temperature biofeedback rests on the observation that
1975). the vasodilation or headache phase of the migraine is
Although simple analgesics are often effective felt to be a reaction to a preceding phase of excessive
for childhood headaches, they typically provide little vasoconstriction. These proponents argue that train-
390 CHAPTER 20
ing subjects in peripheral vasodilation (increased dig- in medication usage. Improvement was maintained
ital skin temperature) produces a generalized over a follow-up period of 1-3 years.
decrease in sympathetic tone (smooth muscle relaxa- Labbe and Williamson ( 1984) compared auto-
tion) that minimizes the prodromal vasoconstrictive genic feedback and a no-treatment control group with
phase and aborts the headache before it starts regard to migraines in 28 children ages 7-16. Auto-
(Sargent, Green, & Walters, 1973). Despite this un- genic feedback led to significant improvement in
certainty, there is agreement that both procedures are headache intensity, frequency, and duration mea-
effective, with 50 to 70% of adults being signifi- sured posttreatment and at l month follow-up. In
cantly improved following biofeedback treatment addition, 93% (13/14) of the patients receiving auto-
(Labbe & Williamson, 1984). genic feedback reported at least a 50% improvement
The treatment of childhood migraine with be- in their average headache rating. Six-month follow-
havioral interventions has a relatively short history, up data were also available on 8 of the 14 treated
with only isolated reports appearing as early as the patients: 5 were found to be improved or symptom-
mid-1970s. During this period, the literature was free. In contrast, there were no mean group dif-
limited to controlled and uncontrolled case studies ferences in pre and post ratings of headaches for the
and single group outcome studies. These reports ex- control subjects, with only 7 and 14% rating at least a
plored the utility of a variety of behavioral self-reg- 50% improvement at posttreatment and l month fol-
ulation methods, the most common intervention low-up. Finally, across all training sessions, patients
being skin temperature biofeedback with autogenic were able to produce a statistically significant in-
training. Autogenic training is a relaxation method crease in digital skin temperature while the feedback
developed around the tum of the century in Germany display was available. However, no differences were
by Schultz and more recently reintroduced by Luthe found between the treatment and control group dur-
(Schultz & Luthe, 1969). The method involves pas- ing the pre- and posttreatment self-control assess-
sive concentration on a systematic set of phrases and ment; for example, patients were not able to increase
images suggesting control of physiological respond- skin temperature in the absence of feedback.
ing. The combination of biofeedback and autogenics Masek, Russo, and Varni (1984) reported on
was popularized by clinicians at the Menninger their research project evaluating a comprehensive
Foundation who labeled this integrated approach au- pain management program for childhood migraines.
togenic biofeedback training (Green, Green, Wal- Eighteen children ages 8-12 were randomized to one
ters, Sargent, & Meyer, 1975). In a review of this of three groups: (1) EMG biofeedback, meditative
literature, Hoelscher and Lichstein (1984) concluded exercises [similar to Benson's (1975) secular TM],
that, "it appears that skin temperature biofeedback and pain behavior management (operant control of
with autogenic training is associated with significant pain behaviors), (2) progressive muscle relaxation,
reductions in migraine headache activity.'' Howev- meditative relaxation, and pain behavior manage-
er, they cautioned that design limitations made it ment, or (3) a waiting list control group. The data
impossible to conclude that behavioral interventions supported clinically significant reductions in head-
were reliably superior to no treatment or placebo ache activity in both treatment groups averaging 60
treatment. The reader is referred to the Hoelscher and and 82% across all outcome measures for the bio-
Lichstein paper for a more detailed discussion of feedback and relaxation groups, respectively. In con-
these early studies. trast, patients in the control group reported a 19%
Since this review, one single group and two increase in symptoms. These changes were main-
controlled group outcome studies have been reported tained at 1 year follow-up. The authors concluded
(see Andrasik, Blake, & McCarran, 1985, for an that the behavioral management of migraines is very
excellent review of the current published and un- effective, but that EMG biofeedback does not appear
published literature on the treatment of pediatric to be an essential component.
headaches). Werder and Sargent (1984) treated 21 These preliminary studies encourage the use of
children, ages 7-17, with approximately 7 hours of behavioral techniques in the treatment of vascular
biofeedback (skin temperature and EMG) and relaxa- headaches in children. Impressive reductions in
tion (autogenics, progressive relaxation, guided im- headache activity have been found in all group out-
agery) training. Nineteen of the children had mi- come studies with benefits maintained over follow-
graine headaches; the other two were diagnosed as up. What seems less clear is the specific role that
mixed vascular-muscle contraction headaches. biofeedback plays in contributing to these positive
Treatment resulted in a 71% reduction in mean week- outcomes. In the three recent group outcome studies,
ly headache hours with a concomitant 87% reduction biofeedback was invariably combined with other
BIOFEEDBACK 391
physiological, cognitive, or behavioral pain manage- feedback signal and not primarily regulation of vas-
ment interventions. In addition, only one of these omotor activity (Holroyd eta/., 1984).
studies (Labbe & Williamson, 1984) measured phys-
iological responding and their trained patients were
unable to increase their skin temperature in the ab-
sence of a biofeedback display. Finally, the report by General Discussion
Masek eta/. (I 984) found no advantage in the use of
EMG biofeedback over progressive muscle relaxa- Several impressions emerge from this literature
tion. Unfortunately, this study included only six sub- review. The existing data indicate that children as
jects in each intervention, limiting the power of the young as 5 years old are able to learn to control
design when comparing treatment alternatives. It ap- targeted physiology following biofeedback training.
pears that much more research needs to be done in It also seems clear that many patients show clinically
these areas. Relevant unanswered questions are: significant improvements in symptom control fol-
I. Is biofeedback either alone or in combination lowing biofeedback interventions. These changes oc-
with other interventions more effective than suitable cur despite the fact that biofeedback is often at-
placebo interventions in reducing migraine headache tempted only when patients have not responded to
activity in children? Although it is of some academic previous medical interventions.
interest to determine if biofeedback works in isola- Although encouraging, the significance of
tion, it is very unusual for biofeedback to be clini- many of these findings is compromised by numerous
cally applied in pain management without combining methodological shortcomings (see Cleeland, I 98 I ;
it with other behavioral treatments (Roberts, 1985). Cobb & Evans, 1981; Kewman & Roberts, 1983).
2. If biofeedback is uniquely effective, which With the exception of the exemplary programmatic
modality is most appropriate for which patients? For research on the treatment of fecal incontinence and
example, skin temperature biofeedback may work epilepsy, the. following problems are common in the
best as a prophylactic treatment for migraine head- studies reviewed in this chapter.
aches, as it theoretically minimizes the sympathetic 1. Control procedures are typically inadequate
overactivity during the initial or prodromal phase of to rule out the contributions of nonspecific changes in
the migraine. In contrast, temporal artery pulse vol- attitude and motivation. Adequate designs, such as
ume biofeedback might have more benefit as an abor- the use of credible noncontingent feedback (Lubar,
tive treatment for modifying the vasodilation during 1982), the comparison of biofeedback with other ac-
the headache phase of the migraine. Finally, all tive treatments (Whitehead eta/., 1986), and the use
forms of biofeedback may be unsuitable for patients of appropriate single case experimental designs (Bird
with strong operant contributions to their pain com- & Cataldo, 1978) are rarely employed.
plaints (Haber, Kuczmierczyk, & Adams, 1985). 2. Interpretation is often clouded by the mixing
3. Much work still needs to be done explicating of biofeedback with other behavioral interventions
the physiological mechanisms underlying biofeed- including relaxation training, behavioral skills train-
back's effectiveness. Labbe and Williamson (1984) ing, and behavior modification. This is a thorny issue
did not find evidence for impressive posttraining self- in biofeedback studies as additional treatment ap-
regulation of skin temperature. Despite this, patients proaches, such as relaxation training, are often used
reported decreased headache activity both immedi- as home practice aids designed to help maintain
ately posttraining and at follow-up. This discrepancy symptom control in the home or school situation.
between skin temperature and headache changes re- Although there may be much clinical wisdom in ap-
quires further investigation. Possible explanations of plying a treatment package rather than an isolated
this discrepancy include: (1) it may be more relevant biofeedback intervention, these confounds obviously
to measure cephalic temperature than digital skin make it impossible to determine which treatment
temperature; (2) even though patients cannot increase should be credited for the obtained therapeutic gains.
skin temperature, biofeedback training may result in 3. Information concerning potentially important
a decrease in the vasomotor variability or instability patient characteristics is usually not reported. For
characteristic of migraines, (3) biofeedback and re- example, hyperactive children vary widely in their
lated techniques may be effective by modifying other levels of cortical and autonomic arousal (Finley,
physiologically relevant parameters implicated in the 1982). Despite this, not one study considered mea-
onset of migraines (e.g., blood pressure), or (4) bio- sures of physiological arousal when selecting pa-
feedback's efficacy may be a result of cognitive tients for biofeedback interventions, and only one
changes associated with successful control of the investigation (Denkowski, Denkowski, & Omizo,
392 CHAPTER 20
1984) correlated baseline measures of muscle tension (1984) observed that across several research studies
with therapeutic gains. The implications of indi- of EMG biofeedback with hyperactive children, a
vidual differences for the choice of a biofeedback tendency emerged for physiological learning to
intervention have been inadequately explored. plateau by the fourth session. They tentatively at-
4. Follow-up data are rarely collected. Erosions tributed any lack of further learning to boredom with
in therapeutic gains are the norm and this possibility the feedback task. One possible strategy for prevent-
must be assessed. When appropriate, treatments ing boredom is to reduce the length of biofeedback
should be altered to include elements promoting the sessions or to include a larger number of rest breaks
maintenance of symptom control (e.g., the gradual (Attanasio et al., 1985). Unfortunately, little is
fading of biofeedback contingencies, providing feed- known about the impact of these procedural changes.
back both during resting conditions and during situa- Others have attempted to maintain attention ei-
tional challenges). ther by employing tangible reinforcers or by altering
5. There is a tradition in behavioral medicine for the nature of the feedback display. Finley et al.
the use of relaxation as an intervention with broad- ( 1981) developed an automated reward system in-
spectrum healing powers. This has resulted in the volving a universal feeder that presented children
prescription of relaxation even when no compelling with reinforcers, such as candy or small toys, con-
rationale for its usage has been empirically docu- tingent upon appropriate changes in physiology. The
mented. For example, the use of frontal region, EMG use of this system led to greater and more rapid reduc-
biofeedback in the treatment of learning disabilities tions in EMG in a group of cerebral palsied children
has as much justification as the use of increased exer- than did the use of an audio feedback signal alone.
cise, adequate nutrition, or other formulas for im- Other recommended changes in reinforcement have
proving general well-being. In addition, Burish has included the use of music rather than a feedback tone
argued that frontal region, EMG biofeedback pro- (Walmsley, Crichton, & Droog, 1981) and the use of
vides only minimal benefit as a generalized relaxa- video game-like feedback displays. It will be impor-
tion procedure. Indeed, he and his colleagues have tant, though, to determine if the enhanced stimula-
employed this form of biofeedback as a control inter- tion provided by these changes leads to counterpro-
vention when evaluating the impact of other more ductive increases in physiological arousal.
potent relaxation procedures (Shirley, Burish, & Many of the studies reviewed in this chapter
Rowe, 1982). Taken as a whole, the data do not combined biofeedback with medical interventions,
support the relatively widespread use of this interven- mostly commonly medication. Despite this, interac-
tion for the pediatric problems reviewed in this tions between behavioral and pharmacological
chapter. therapies have received little attention. Linkenhoker
(1983) alerted clinicians to potential dangers caused
by failures to alter the dosage of medications whose
Patient-Treatment Interactions and the Art physiological effects parallel the physiological con-
of Biofeedback sequences of biofeedback. For example, Seeburg
and DeBoer ( 1980) reported a case study where EMG
The successful application of appropriate bio- biofeedback training in a diabetic reduced that pa-
feedback interventions with children and adolescents tient's need for Insulin, leading to harmful side ef-
often requires modifications in the training pro- fects until her medication regimen was adjusted. In a
cedures developed for adults. Experienced clinicians more positive vein, Surwit, Allen, Gilgor, and Duvic
have long recognized this point and helpful guide- (1982) investigated the concurrent effects of auto-
lines are provided by both Linkenhoker (1983) and genic training and sympathetic blocking agents on
Attanasio et al. (1985). For example, whereas adults skin temperature changes in patients with Raynaud's
typically tolerate the procedures involved in elec- disease. Statistically significant changes in skin tem-
trode applications, younger children may require perature were only obtained when both interventions
greater reassurance about the safety of instrumenta- were applied simultaneously. On a related issue,
tion. To date, most of the available advice is based on Cleeland ( 1981) suggested that the addition of behav-
unsystematic observations of patients. However, ioral training methods to medical regimens might
some useful data are beginning to emerge. allow for a reduction of medications, such as anticon-
Clinical researchers have commented upon the vulsants, which often suppress symptoms only at
challenges presented by the sometimes fragile moti- levels that are either toxic or produce unpleasant side
vation level and attention span of children referred effects.
for biofeedback training. Denkowski and Denkowski Finally, researchers are beginning to identify
BIOFEEDBACK 393
patient variables that predict success or failure with Bille, B. (1962). Migraine in school children. Acta Paediatrica
biofeedback interventions. Denkowski et al. (1984) (Suppl.), 136, 1-151.
employed multiple regression analyses to relate pa- Bird, B., & Cataldo, M. (1978). Experimental analysis of EMG
tient age, pretreatment EMG level, degree of hyper- feedback in treating dystonia. Annals of Neurology, 3, 310-
activity, and locus of control to decreases in EMG 315.
Blanchard, E. B., & Andrasik, F. (1982). Psychological assess-
levels following biofeedback training. The subjects ment and treatment of headache: Recent developments and
were 59 hyperactive males, aged 8 through 15. Only emerging issues. Journal ofConsulting and Clinical Psychol-
locus of control predicted posttreatment changes in ogy, 50, 859-879.
EMG, with internal locus of control associated with Borkovec, T. D., & Nau, S. D. (1972). Credibility of analogue
better outcomes. Whitehead et al. (1986) also found therapy rationales. Journal of Behavior Therapy and Experi-
that age did not predict response to biofeedback train- mental Psychiatry, 3, 257-260.
ing in their patients with neurogenic incontinence. Borkovec, T. D., & Sides, J. K. (1979). Critical procedural vari-
Children as young as 5 were able to successfully ables related to the physiological effects of progressive relax-
profit from biofeedback training as long as tangible ation: A review. Behavior Research and Therapy, 17, 119-
reinforcers were used to maintain the attention of 126.
Braud, L. W. (1978). The effects of frontal EMG biofeedback and
their younger patients. The authors did find, howev-
progressive relaxation upon hyperactivity and its behavioral
er, that physiological parameters were important in concomitants. Biofeedback and Self-Regulation, 3, 69-89.
determining which patients benefit from biofeedback Braud, L. W., Lupin, M. N., & Braud, W. G. (1975). The use of
versus behavior modification approaches. Quite ob- electromyographic biofeedback in the control of hyperac-
viously, we are only beginning to understand the tivity. Journal of Learning Disability, 7, 420-425.
impact of demographic, cognitive, behavioral, and Burish, T. G. (1983). EMG biofeedback in the treatment of stress-
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Carter, J. L., & Russell, H. L. (1980). Biofeedback and academic
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Carter, I. L., & Russell, H. L. (1981). Changes in verbal-perfor-
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396 CHAPTER 20
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21
Approaches to the Cognitive
Rehabilitation of Children with
Neuropsychological Impairment
JEFFREY W. GRAY AND RAYMOND S. DEAN
Historically, clinical neuropsychology in North 1981) this chapter examines the present status of cog-
America has focused on the prediction and localiza- nitive rehabilitation treatment with neuropsychologi-
tion of cortical dysfunction (e.g., Boll, 1974; Reitan, cally impaired children. Basic theoretical approaches
1974; Dean, 1985a). Although this emphasis on di- to rehabilitation are examined, with emphasis on im-
agnosis continues, the growing sophistication of ra- plications for cognitive rehabilitation. In addition, a
diological techniques may deemphasize this diag- number of specific cognitive rehabilitation programs
nostic role. A number of authors have argued that are reviewed with a focus on their potential clinical
clinical neuropsychology will focus on the under- utility with children.
standing of the patient's neurological deficits and the
planning of rehabilitation approaches (Dean, 1982,
1985a; Diller & Gordon, 1981; Piasetsky, 1981).
Cognitive rehabilitation involves the retraining of Theoretical Models
mental skills or abilities impaired as the result of
neurological disorders. Along these lines, Diller and An array of theoretical approaches to the re-
Gordon (1981) have stressed the utility of neuropsy- habilitation of the neurologically impaired have been
chology, with its foundation in brain-behavior rela- offered (e.g., Barth & Boll, 1981; Bolger, 1981;
tionships, in cognitive rehabilitation. Indeed, are- Diller & Gordon, 1981). Although related, each
cent survey of practicing neuropsychologists indi- views neuropsychological impairment and treatment
cated that nearly 50% of the respondents reported of such deficits rather uniquely. One basic approach
cognitive rehabilitation to be part of their clinical to rehabilitation centers around the patient's perfor-
practice (Seretny, Dean, Gray, & Hartlage, 1986). mance on specific measures of cognitive and neuro-
Thus, it appears that although the major focus in psychological functioning. Within this model, dys-
neuropsychology may continue to be on diagnosis, function is conceptualized in terms of impaired
an increasing number of clinicians seem to be ex- performance on psychometric tests. As such, re-
panding their practice to include some form of cog- medial strategies focus upon ameliorating individual
nitive therapy. test-specific deficits. Although therapy emphasizes
In light of recent data suggesting the utility of specific deficits, generalized cognitive/neuropsy-
neuropsychological information in the treatment of c_hological improvement is hypothesized to occur
cognitive deficits in adults (see Diller & Gordon, (e.g., Gudeman, Golden, & Craine, 1978).
Using what could be viewed as a mastery learn-
ing approach, the ''psychometric'' model (Diller &
JEFFREY W. GRAY Neuropsychology Laboratory, Ball
Gordon, 1981) of cognitive rehabilitation relies on
State University, Muncie, Indiana 47306. RAYMOND S. the analysis of task requirements and the systematic
DEAN Neuropsychology Laboratory, Ball State University, shaping and cuing of patient responses (see Block,
Muncie, Indiana 47306; and Indiana University School of Medi- 1971 , for a review of mastery learning). Early in the
cine, Indianapolis, Indiana 46282. rehabilitation process, patients are provided with nu-
397
398 CHAPTER 21
merous cues and as rehabilitation progresses cues are month), patients receiving the scanning exercises
faded out until the patient is able to perform the spe- were compared to groups of brain-damaged patients
cific task unaided. With the use of discriminative on a standard occupational therapy regimen. With
stimuli and small increments in the difficulty level, minor exceptions, those patients receiving the ex-
the probability of failure is virtually eliminated for perimental treatment showed significant improve-
the patient at any given level of the program. Ben- ment in attention to the complete visual field, com-
Yishay and his colleagues (e.g., Ben-Yishay et al., pared to the control group (Diller & Weinberg,
1979; Diller et al., 1974) reported success in the 1977). Of interest, the patient's ability to scan selec-
rehabilitation of cognitive deficits using such a "sat- tively all pertinent visual information was reported to
urated cuing" approach with brain-damaged adults. generalize to other more complex tasks (e.g., read-
Specifically, this treatment strategy has been re- ing, arithmetic, copying).
ported useful in remediating deficits on rather com- A third model of rehabilitation can best be char-
plex cognitive tasks as represented by the Block De- acterized as behavioral engineering (Diller & Gor-
sign and Similarities subtests from the Wechsler don, 1981). From this view of rehabilitation, the pa-
Adult Intelligence Scale (Ben-Yishay et al., 1970a; tient's impairment is defined in terms of operational-
Diller, 1976) as well as psychomotor difficulties sec- ired behavioral deficits. Inherent here is the assump-
ondary to neurological impairment (Ben-Yishay & tion that behavioral deficits are maintained by en-
Schoon, 1975). vironmental conditions. Therefore, the major objec-
A second basic approach to cognitive rehabilitative in treatment is to identify and systematically
tion focuses upon groups or patterns of behaviors modify the environmental antecedents that are as-
(e.g., Barth & Boll, 1981). Unlike the "psycho- sumed to underlie the problem behavior. To this end,
metric" model of rehabilitation, deficits are treated rehabilitation therapists utilize a number of common
as parts of a whole rather than as individual dysfunc- behavioral analytic techniques (see Wilson &
tions. Whereas the "psychometric" approach tore- O'Leary, 1980, for a review).
habilitation focuses predominantly on the patient's In keeping with a behavioral orientation, the
response to a given stimulus, the more "biolog- initial stages of treatment are marked by the identifi-
ically" oriented model emphasizes elements of the cation of target behaviors amenable to therapy. Once
stimulus itself (Diller & Gordon, 1981). Indeed, one behavioral deficits have been operationalized and
of the major tasks of the therapist in this approach is their antecedents identified, the emphasis shifts to the
to identify the specific components of a stimulus that establishment of a reliable baseline of behaviors from
contribute to the patient's deficit. From this perspec- which to evaluate progress. Finally, the target behav-
tive, one facet of treatment is to alter the stimulus in ior(s) is made contingent on a systematic program of
such a way as to offset the patient's behavioral defi- reinforcement. As was true with the ''psychometric''
cits. Moreover, proponents of this modal of cognitive or task analytic model, the target behavior is system-
rehabilitation argue that these stimulus alterations atically shaped in such small increments that failure
may bring to the attention of the patient both the is minimized. The difference between the psycho-
nature and extent of his or her disabilities as well as metric and behavioral engineering modes related to
potential compensatory strategies. Thus, a major the reliance upon a standardized neuropsychological
goal of this approach is to facilitate the patient's un- assessment in the former.
derstanding of the impairment. It has been argued Horton (1979a,b, 1981) argued in favor of such
that such insight is important if rehabilitation is to a behavioral approach with neuropsychologically im-
generalize to other problem behaviors (Diller & Gor- paired adults and children, citing a relatively large
don, 1981). However, it is not clear in this mode of literature. Indeed, in support of this stance, a number
therapy how to plan for or facilitate generalization. of investigators have reported behavioral techniques
Perhaps the best example of this path to re- to be effective in treating hyperactivity, impulsivity,
habilitation can be found in reported attempts to re- and perseveration in brain-damaged children (e.g.,
mediate spatial neglect in brain-damaged patients Hall & Broden, 1967; Krop, 1971) and short-term
(e.g., Diller, 1976; Diller et al., 1974; Diller & . memory disorders in adult head-injured patients
Weinberg, 1977; Weinberg & Diller, 1968; Wein- (e.g., Cooke, 1973). However, it is not clear how
berg et al., 1977). In accord with the "biological" such an atomistic therapy generalizes to system defi-
model of rehabilitation, patients are initially trained cits experienced by the neurologically impaired
to perform visual scanning tasks designed to promote patient.
awareness of the visual field deficit. Following a Although relatively little theoretical attention
predetermined amount of time (usually about l has been directed upon the cognitive rehabilitation of
COGNmVE REHABILITATION 399
neuropsychological impairment in children (e.g., Cognitive rehabilitation has been broadly de-
learning-disabled and head-injured children), anum- fined as a systematic effort to teach patients to over-
ber of authors have argued that the most appropriate come intellectual deficits arising from brain dysfunc-
approach with these children may be one that focuses tion (Task Force on Head Injury, 1984). This effort is
upon their neurological strengths (e.g., Hartlage & seen to involve the reinforcement and strengthening
Lucas, 1973a,b; Hartlage & Reynolds, 1981; of previously learned patterns of cognitive behavior,
Hartlage & Telzrow, 1983, 1984; Reynolds, 1981; as well as the establishment of new patterns of cog-
Telzrow, 1985). Specifically, remedial strategies are nitive activity that compensate for neurological sys-
planned in a task analytic fashion that are thought to tems too impaired for functional return to occur (Task
complement the child's observed mode of processing Force on Head Injury, 1984). Consistent with this
information. working definition, Ben-Yishay (1981) argued that
In an attempt to empirically test this strength the objective of cognitive rehabilitation must be to
model, Hartlage and Lucas (1973a) compared the .. overcome, i.e., to correct (and if that is not feasi-
word recognition performance of a group of normally ble, then at the very least, to significantly ameloio-
functioning first grade students receiving reading in- rate), the effects of generic cognitive deficits in such
struction based on their processing strengths with a a way as to enable the individual patient to find alter-
group of children in traditional reading instruction. native and adequate means of achieving specific
The two groups were comparable in reading read- functional goals" (p. 20).
iness at the beginning of the school year. At end of As part of a comprehensive rehabilitation pro-
one school year, the group receiving the neuropsy- gram, Ben-Yishay and his colleagues (e.g., Ben-
chologically based instruction significantly outper- Yishay & Diller, 1981) have developed a systematic
formed the traditionally instructed control group. In- or hierarchical program of cognitive rehabilitation.
terestingly, teachers' ratings of the child's reading Divided into five separate, yet interrelated modules,
skills paralleled the findings with the Reading subtest treatment emphasizes. the remediation of both lower
of the Wide Range Achievement Test. Thus, it ap- level (e.g., attention) and more complex (e.g., ver-
pears that at least with this sample the matching of re- bal-abstract reasoning) cognitive deficits. Modules
medial strategies to information-processing strengths are organized such that patients initially receive tasks
was successful. requiring more rudimentary cognitive skills (e.g.,
psychomotor manipulations), followed by more
complicated exercises involving abstract reasoning
Cognitive Rehabilitation Programs and mental manipulation. The patient is presented
with each module in such a fashion that failure is
One of the most common sequelae of brain minimized. To this end, the remedial tasks are ini-
damage in children is a generalized impairment in tially broken down into their smallest logical compo-
cognitive functions. This most often involves deficits nent parts. The patient is then guided through the
in memory, attention, and perception (Levin, Ben- tasks with the aid of prompts. The cues are made less
ton, & Grossman, 1982; Levin & Eisenberg, explicit with each trial until the patient is able to
l979a,b). With such neuropsychological impair- perform tasks within the module without error or
ment, it is not surprising that a significant number of prompting. In this way the patient procedes in a se-
these children subsequently experience difficulties in quential fashion until the final module is reached.
school that require special education services (e.g., Depending on the nature and degree of the neuropsy-
Klonoff, Low, & Clark, 1977). chological impairment, this program is often highly
Although cognitive deficits have been clearly ly redundant, which is seen to promote generalization
documented with brain-damaged children, few re- (Silver et al., 1983).
habilitation/remedial programs have been developed Ben-Yishay (1981) prioritized domains in cog-
specifically to ameliorate such deficits in children. In nitive rehabilitation as they related to (1) self-help
contrast, a number of programs have been offered for and daily living; (2) psychomotor, perceptual, and
brain-damaged adults. With this in mind, several of cognitive skills that underlie successful vocational or
the more well-known attempts at cognitive re- school functioning; and (3) socioemotional/interper-
habilitation with adults will be reviewed and implica- sonal skills. Telzrow (1985) stressed independent
tions d~wn for children. It is important to note that eating, dressing, and toileting; adequate perceptual-
although intuitively these programs appear to hold motor skills; proficiency in reading, writing, and
clinical utility for brain-damaged children, there are arithmetic; and interpersonal relationships at home
little data to support this argument. and at school as rehabilitation priorities with chil-
400 CHAPTER 21
dren. Clearly, the goal of any rehabilitation program abled children manifesting attentional deficits (e.g.,
must be the reintegration of the patients in their pre- Brown & Alford, 1984).
morbid environment. For the pediatric patient, Ben-Yishay and his colleagues (e.g., Ben-
school performance must be the focus. Yishay, Diller, Gerstman, & Gordon, 1970; Ben-
As a prelude to implementing cognitive re- Yishay, Gerstman, Diller, & Haas, 1970; Ben-
habilitation, a complete assessment of the patient's Yishay, 1983) have examined the clinical utility of a
overall neuropsychological functioning is necessary. "modular" approach to the remediation of cognitive
Specifically, the patient's ability to formulate, plan, deficits resulting from cerebral insult. Small sample
and implement goal-directed behaviors, selectively sizes, restricted patient selection criteria, and assess-
attend to a stimulus, process and retain various forms ment procedures that overlap with training tasks not-
of information, grasp the essential nature of problem withstanding, results from these studies suggest that
situations, and verbal interaction must be evaluated. the program may be effective in ameliorating a number
Only with such information can the neuropsycholo- of cognitive, perceptual, and psychomotor deficits.
gist plan a program of rehabilitation that fits the pa- Indeed, brain-damaged patients undergoing the treat-
tient's unique needs while taking advantage of spe- ment regimen have been shown to improve signifi-
cific strengths. This information is necessary in cantly more than those patients receiving a "stan-
estimating the patient's readiness to benefit from dif- dard'' rehabilitation program. However, in light of the
ferent remedial strategies (Ben-Yishay, 1983). This fact that the results of these preliminary investigations
patient-specific regimen of rehabilitation is appropri- may have been confounded by variables other than
ate with both adults and pediatric patients. treatment, the findings remain equivocal. Indeed,
Of particular interest to the present discussion, with the selection bias in these investigations, the
Ben-Yishay (1981) offered essentially two condi- generalizability of this treatment program to brain-
tions to the successful implementation of cognitive damaged patients in general would seem premature.
remediation. Perhaps most important, the patient Moreover, one is given to question as to the extent to
must be aware of the potential benefits of the specific which the improvement reported in many studies is a
exercise and must be motivated to participate in the function of the remedial program or simply the result
process. If one makes the assumption that repeated of spontaneous recovery (e.g., Diller & Gordon,
failure on a task may result in motivational deficits 1981). Although future research in this area is needed
(e.g., see Dean & Rattan, 1986; Fowler & Peterson, prior to the use of such an approach on a large-scale
1981; Seligman, 1975), it follows that a cognitive clinical basis, it seems clear that highly behaviorally
rehabilitation program must be constructed to em- oriented programs incorporating principles of task
phasize success and reduce error. As mentioned pre- analysis, reinforcement, "saturated" cuing, and
viously, Ben-Yishay ( 1981) espoused a remedial ap- shaping may be effective with both neuropsycholo-
proach in which tasks are "orchestrated" in such a gically impaired adults and children. A number of
fashion that success is "guaranteed." Of course, er- investigations using stringent controls have found
rorless learning is not unique to Ben-Yishay' s ( 1981) these behavioral techniques to be useful in treating
program. In fact, small increments of new learning cognitive deficits found in pediatric and adult patients
that reduces errors are the root of programmed in- with neurological deficits (e.g., Brown & Alford,
struction (see Anderson & Faust, 1967). However, it 1984; Cooke, 1973; Hall & Broden, 1967; Krop,
is clear that programming for success serves to ele- 1971). A heuristic value of a behavioral focus may
vate patient motivation and continued participation. well be related to our primitive understanding of
Linked to motivation in a complex fashion, a brain-behavior relationships.
successful cognitive remedial program also depends
on the patient's ability to focus attention on the task at
hand while ignoring irrelevant stimuli (Ben-Yishay,
1981 ). Underlying the importance of this condition, a A Developmental Approach to
number of investigators have showed that attentional Cognitive Rehabilitation
deficits may be a concomitant of childhood learning
disorders (e.g., Hallahan, 1975; Hallahan, Gajar, Based on a sequential approach to remediation,
Cohen, & Tarver, 1978; Hallahan, Tarver, Ka- Bolger ( 1981) developed a comprehensive program
ufman, & Grabeal, 1978; Ross, 1976). Consistent of cognitive retraining. Underlying the specific
with Ben-Yishay's (1981) methods with brain- methods is the hypothesis that efficient processing of
damaged adults, a number of behavioral techniques information is dependent upon the ability to execute
have been successfully employed with learning-dis- cognitive operations in an automatic fashion. Con-
COGNITIVE REHABILITATION 401
ceptualized within a limited capacity framework sug- and exerting adequate cognitive controls over their
gesting that only a given amount of attentional capac- behaviors. The actual tasks involve cognitive-be-
ity exists at any point in time (e.g., Case, 1972; Case, havioral techniques. For instance, Bolger and col-
Kurland, & Goldberg, 1982; Hasher & Zacks, 1979), leagues have used cognitive-behavior modification
it is hypothesized that many cognitive tasks place an to improve the patient's ability to maintain emotional
excessive cognitive demand upon brain-damaged pa- self-control. At this point in the training the patient is
tients. Moreover, it has been suggested that these involved in canned 'video games'' aimed at im-
patients may experience a significant reduction in proving basic math and reading skills. One such
available mental capacity evidenced by deficits in game that Bolger (1981) suggested is "Hangman"
both storage and retrieval of information (e.g., (marketed by Atari), which is seen to remediate spell-
Bolger, 1981). With this theory as a basis, remedial ing and dysnomic difficulties.
efforts are designed to improve the patient's execu- Underlying Bolger's (1981) approach to cog-
tion of cognitive operations and provide processing nitive rehabilitation is the notion that rudimentary
strategies to reduce the cognitive demands. Bolger skills (e.g., attention, word recognition) behaviors
(1981) argued that the goal of cognitive remediation must be made automatic'' before more higher level
. . . is to increase the mental capacity of the cognitive skills can be addressed. Based on this rea-
individual to process larger amounts of stimuli with soning, each task is practiced repeatedly even after
more accuracy and with greater attention to sub- the initial mastery has been reached. This "over-
tleties" (p. 67). Such an increase in the patient's learning'' is seen as facilitating the patient's ability to
ability to process information is seen as a necessary perform a number of important cognitive functions
component to the performance of complex cognitive spontaneously. Indeed, such "automatic" process-
tasks. For Bolger (1981), remedial tasks focusing on ing is a prerequisite for successful educational or
rudimentary (e.g., perceptual and attentional) pro- vocational generalization. Also inherent within this
cesses as well as higher cortical functions are present- program is an emphasis on remedial tasks that are
ed to the patient continuously throughout the re- both entertaining and reinforcing to aid the patient's
habilitation program. Of particular importance in this motivation and concentration (Bolger, 1981).
program is the emphasis on the patient's ability to Although the cognitive therapy described by
integrate these high-level cognitive functions. Bolger (1981) has clinical appeal, there are a lack of
Similar to the modular approach of Ben-Yishay data showing its benefits over spontaneous recovery.
(e.g., 1981), a three-step paradigm was offered by Future research with groups that differ in specific
Bolger (1981). The primary emphasis of the first neurological deficits would allow the examination of
stage is prolonging on-task behavior and stresses the the utility of the approach.
patient's ability to focus and sustain attention. Con-
sistent with the assumption that the patient must en-
joy tasks for the remediation to be successful
(Bolger, 1981), this program has utilized a number of Computer Programs in Cognitive
commercial microcomputer games. For example, the Rehabilitation
popular electronic game "Simon" has been used in
an attempt to improve the patient's attentional and With the availability of microcomputers has
on-task behaviors. come a growing reliance on cognitive rehabilitation
Upon completion of the first phase, the patient software. Indeed, the use of video games and cog-
advances to the next stage, which focuses on the nitive rehabilitation routines is not uncommon in
discrimination of visual and auditory information. therapy (Bracy, Lynch, Sbordone, & Berrol, 1985).
Early in training the emphasis is on the remediation A number of features make microcomputers attrac-
of eye-hand coordination, reaction time, and visual tive in rehabilitation. One of the clearest involves the
scanning deficits. As the patient progresses, a fact that computer programs present remedial tasks in
number of video games designed to improve visual a novel fashion (Lynch, 1981). Other than the fact
discrimination are introduced. Finally, a set of rather that these programs offer the portability and adapt-
innovative tasks have been designed to aid the patient ability necessary for most clinical settings, they also
in developing spatial skills. allow "individualization" of treatment in a cost-
After meeting the minimum requirements for effective manner. In addition, the cost of the base
stage 2, the patient progresses to a third and final equipment continues to fall within the means of pa-
module. This training is designed to improve skills in tients, thus enabling the practice of skills in the
making data-based decisions, thinking abstractly, home.
402 CHAPTER 21
A number of computer-based cogmuve re- from record keeping, allowing a focus on structuring
mediation programs have been developed for use cognitive therapy that meets the patient's assessed
with brain-damaged adults and children (e.g., Bracy, needs. Moreover, unlike most labor-intensive ap-
1983). Clinically based, these programs focus on im- proaches to cognitive rehabilitation, the psychologist
proving the patient's functioning in selective and sus- could monitor several patients' performances simul-
tained attention, verbal and nonverbal auditory and taneously. Of particular interest to the present dis-
visual discrimination, and stimulus differentiation cussion, it seems that computer-based cognitive re-
and generalization. Although a number of computer- habilitation may lend itself to use with children as
based rehabilitation programs have been argued to be well as adults. Although little evidence supports this
effective in remediating cognitive deficits (e.g., notion, Lynch (1979) suggested that such a comput-
Bracy, 1983; Bracy et al., 1985), little empirical er-based program has been successful in improving
$Upport exists for such claims. In the main, these the phonetic reading ability of children with learning
claims are supported by case studies showing cog- disorders.
nitive improvement in both children and adults who Parenthetically, the microcomputer has been ar-
have been involved with the programs (Bracy, 1983). gued to be a valuable tool in diagnosis as well as
Although of interest, the crucial test of any program remediation of cognitive deficits (Lynch, 1981). In-
comes with a comparison with untreated groups. As deed, the microcomputer holds a very clear potential
opposed to the programs described above, which rein neuropsychological assessment. However, with
quire psychological supervision, computer programs the proliferation of computer-based assessment pro-
with unsubstantiated validity can be misinterpreted cedures, one should examine reliability and validity
as a panacea. data with the same rigor applied to any standardized
Generally speaking, computer programs are or- assessment procedure.
ganized such that patients can work at home and Although a number of authors have extolled the
typically involve approximately 2 to 5 hours per day. virtues of a computer-based rehabilitation program,
Similar to the therapy programs previously dis- few controlled studies accounting for spontaneous
cussed, this approach initially focuses on more rudi- recovery exist. To be sure, the majority of supporting
mentary cognitive functions such as attention and evidence has been based on case studies. Conse-
stimulus discrimination and generalization. Upon quently, the generalizability of these results is highly
mastery of these basic cognitive skills, the patient is questionable. Investigations using larger numbers of
administered computer-based programming that pro- patients, adequate control groups, and appropriate
vides training in higher level areas such as memory criterion measures would allow a test of the potential
and problem-solving. However, unlike the clinically for many unsubstantiated claims.
based programs described above, little professional
supervision or evaluation is involved.
Generally speaking, the utilization of video Neurobehavioral Approach to
games in rehabilitation settings has centered around Cognitive Rehabilitation
reading and math skills, memory, visual-perceptual
functioning, and attention and concentration (see For many, the assessment of neuropsychologi-
Lynch, 1979, 1981, for a review). For example, a cal functions is tantamount to understanding the
number of Atari games require patients to label and problem. It is noteworthy that few cognitive re-
spell words of varying degrees of difficulty, as well habilitation strategies consider the potential interac-
as to add, subtract, multiply, and divide simple and tion between neuropsychological impairment and
complex number strings. Video games are available emotional characteristics. Indeed, attempts that have
that are said to emphasize short-term and long-term focused on various underlying cognitive processes
memory of both visual and verbal stimuli (Lynch, are often made to the exclusion of the patient's be-
1979, 1981). Other games focus more on motor coor- havior history and learned methods of coping with
dination, attention, planning, and visual scanning failure (e.g., Dean, 1978). This is a rather curious
(Lynch, 1979, 1981). state of affairs when one considers the frequency with
Aside from the systematic repetition of re- which patients having neurological disorders also
habilitation routines, microcomputers hold a clear present with maladaptive emotional patterns (see
potential for automating and individualizing cog- Boll, 1981; Dean, 1985b). These emotional factors
nitive rehabilitation in an economical fashion. In- would seem especially prominent in children with
deed, the use of computers, programmed to automat- cognitive deficits because reintegration into their pre-
ically record data, would free the neuropsychologist morbid environment involves return to school.
This emotional-cognitive dysfunction is por- low individualization, seems promising in planning

trayed quite clearly in children with long-standing treatment that capitalizes on individual strengths
learning disorders. Indeed, negative reactions to spe- (Golden, 1978; Hartlage, 1975; Hynd & Obrzut,
cific cognitive tasks and school in general exist in a 1981; Luria, 1963; Reynolds, 1981; Rourke, 1976).
large number of school-age children but may be Support for this diagnostic position comes from a
masked by seemingly unrelated behaviors (e.g., number of studies using a neuropsychological orien-
withdrawal, lack of compliance). So too, recent re- tation (Hartlage, 1975; Hartlage & Lucas, 1973a;
search indicates that neurologically impaired chil- Hynd & Obrzut, 1981). These findings have led
dren may develop maladaptive methods of coping some to argue in favor of therapy based on the assess-
with the stress of cognitive failure (Bender, 1985; ment of neuropsychological processing styles (Gun-
Dean & Rattan, 1986). Because of the length of time nison, Kaufman, & Kaufman, 1982; Kaufman &
thy have attempted to cope with the disorder, this Kaufman, 1979; Reynolds, 1981). However, few in-
cognitive impairment-emotional reaction may be vestigators have integrated this approach with more
more clearly portrayed with congenital learning dis- emotional-learning-based interventions. It has been
orders. However, such problems are evident in a hypothesized that children with neurological deficits
study by Klonoff and Low (1974) of children with cannot be treated simplistically from either a cog-
closed head injuries. nitive or a mental health point of view (Dean, 1982).
In fact, children may develop what would be It would seem that children with cognitive impair-
likened to a phobic reaction in an attempt to cope with ment would benefit from an approach that offers aca-
perceived cognitive dysfunction. Aversive reactions demic remediation while attempting to modify nega-
are seen to go beyond the immediate therapy session tive emotional responses.
to the creation of an emotional reaction to those cog- In a recent study in our laboratory, both the
nitive skills impaired. Unlike the adult who may at- goals of cognitive therapy and desensitization of
tempt to avoid situations in which cognitive deficits negative emotional reactions were considered simul-
are highlighted, the child who is expected to return to taneously. Each of these objectives was applied in a
school has few choices in participating. Thus, what systematic fashion during therapy sessions. Ses-
begins as a neuropsychological dysfunction may lead sions, while concentrating on cognitive skills, were
to a response set of failure-aversion-failure, as the structured so as to desensitize the child's emotional
child attempts to cope with the stress of cognitive reactions and reinforce appropriate coping behav-
demands. iors. Following a complete neuropsychological as-
Systematic desensitization is a behavioral thera- sessment, a hierarchy of remedial tasks were con-
py aimed at modifying phobic responses. This pro- structed for each child along an approach-avoidance
cedure includes the identification of an individual's continuum. Much like Ben-Yishay's (1981) pro-
hierarchy of aversive reactions to stimuli and then gram, sessions were structured using a task analytic
proceeds to pair positive (reinforcing) events with approach. In effect, this procedure is akin to the
those that have produced negative reactions (see philosophy of systems analysis, where aspects of a
Lang, 1964; Wolpe, 1969). This approach has been task are systematically explored. Moreover, task
shown to be successful in desensitizing children's analysis structures cognitive tasks in a step-by-step
aversions and irrational emotional responses (see fashion, with the patients experiencing success, re-
Wolpe, 1969). With such a perspective in mind, it gardless of their presumed level of cognitive
would seem that this treatment would be of utility in functioning.
treating children's acquired aversive reactions to In this mode of cognitive rehabilitation, many of
cognitive tasks. Specifically, this procedure may be the desirable qualities of neuropsychological tests
applicable during the actual process of cognitive ther- were used. A neuropsychological evaluation pro-
apy. Suggested some years ago by Severson (1970) vided an understanding of how children best process
with learning-disabled children, this format would information. This evaluation also allowed establish-
allow the cognitive therapist to offer both systematic ment of a benchmark to follow the success of thera-
desensitization of emotional aspects and cognitive py. In addition, however, the observation of children
rehabilitation simultaneously. as they learn was retained and considered valuable in
In general, ''canned programs'' that attempt to structuring individual programs.
focus on children's processing deficits have not been Rather than seeking to make differential diag-
shown to remediate cognitive impairment (e.g., nosis between various underlying neurological disor-
Ayres, 1972; Kirk & Becker, 1963). However, the ders, this program approached the cognitive deficit
utility of neuropsychological procedures, which al- through the use of a system that reinforced attempts,
404 CHAPTER 21
as well as successes, on the approach-avoidance hi- as the academic productivity of an 11-year-old male
erarchy. Patients choose rewards that correspond to with attentional deficits. Importantly, the behavioral
the task level they select from their individually pre- effects of this remedial strategy were maintained over
scribed cognitive skills hierarchy. Near the top of this a follow-up examination at 2 Y2 months. Although the
task-based hierarchy have been placed important single subject design of this investigation obscures
cognitive skills that are basic to remediation but may the generalizability of the findings, it appears that a
also have generated avoidance behavior due to a neu- self-monitoring procedure may be effective in the
rological disorder. Levels of the child's hierarchy remediation of some attentional deficits. The validity
ranged from the most obviously cognitively related of the approach was supported in a related study by
tasks to simply talking with the therapist. Of interest Brown and Alford (1984), who used a self-instruc-
also, the patient is able to choose tasks anywhere on tional technique to remediate both attentional deficits
the approach-avoidance continuum and receives dif- and academic difficulties in 20 learning-disordered
ferential levels of reinforcement depending on the children. Indeed, children receiving the cognitive
perceived difficulty of the task. training showed significant improvement on tests of
In an attempt to study the utility of this ap- learning aptitude, reading recognition, and the
proach, a group of children with long-standing cog- Matching Familiar Figures Test compared to the con-
nitive deficits were seen once a week for 8 months. trol group.
The results showed significant gains in rehabilitating In a somewhat different approach to selective
reading deficits and aiding patients in coping with the attention deficits, Ben-Yishay and his colleagues
stress offailure. Specifically, when compared with a (e.g., Ben-Yishay, Diller, & Rattok, 1978; Ben-
control group, children in the treatment group made Yishay et al., 1980) developed a set of tasks that
significant gains in academic skills, rated classroom focus on systematic remediation. Organized in a hier-
behaviors, and the ability to respond concomitant archy, these tasks require the patient to actively re-
with their measured skill level even after obvious spond to stimulus lights, estimate time, consciously
failure. Interestingly, although rehabilitation was scan and identify various stimulus signals, and freely
gained in specific cognitive areas, these impaired discriminate auditory and visual stimuli. The lack of
children showed little improvement in specific neu- a control group notwithstanding, Rattok et al. ( 1982)
ropsychological functions. Thus, the therapy would reported that these techniques significantly improved
appear to offer the child methods of compensation for the selective attention of head-injured patients.
neuropsychological impairment. A number of rather innovative techniques have
been proposed for use with brain-damaged patients
who experience perceptual deficits. For example,
Diller and his associates (e.g., Diller et al., 1974;
Strategies of Cognitive Rehabilitation Diller & Weinberg, 1977) reported the effective use
of visual cancellation exercises in the remediation of
Although relatively few empirically based pro- visual scanning deficits. Initially the patient is taught
grams of cognitive rehabilitation presently exist, a to utilize a left/righ~ field anchor to compensate for
number of specific techniques have been studied in his or her visual neglect. After this anchoring pro-
efforts to treat attentional, perceptual, and memory cedure is learned, visual stimuli are presented in the
deficits often associated with neurological impair- neglected field until the patient is able to follow the
ment. The frequency of attentional deficits in chil- stimuli to the outermost edges of that visual field.
dren with brain damage and neurologically based Weinberg et al. (1977) reported data consistent with
learning disabilities is well documented (Brown & anchoring skill generalization to paper and pencil
Alford, 1984). Rehabilitation programs for the most exercises as well as reading tasks.
part have included some form of cognitive self-con- It has been well established that brain-damaged
trol or, if you will, self-monitoring techniques. In the individuals often present with deficits in encoding,
main, research in this area has reported success in storage, and/or retrieval of information (e.g., Levin
increasing attention (Brown & Alford, 1984; Hal- et al., 1982). Remediating memory difficulties has
lahan & Sapona, 1983). The procedure involves long occupied neuropsychological research and
teaching the patient to cognitively monitor on-task clinical efforts. These disorders may relate to both
behavior via an array oflearned self-messages (e.g., attention problems as well as actual functional disor-
"Was I paying attention?"). Using such a self- ders of regulation, storage, or retrieval of informa-
monitoring technique, Hallahan and Sapona (1983) tion. Consistent with the notion that children with
reported improvement of the on-task behavior as well neuropsychologically based learning disorders may
COGNmVE REHABILITATION 405
fail to spontaneously utilize mnemonic strategies best (Adamovich, Henderson, & Auerbach, 1985).
such as rehearsal (e.g., Bauer, 1977; Hallahan & Whereas Ben-Yishay's (e.g., 1983) and our program
Sapona, 1983; Tarver, Hallahan, Kaufman, & Ball, have received some support, it is clear that with some
1976), remedial efforts often focus on the systematic 50% of neuropsychologists reporting involvement in
instruction of the child in the effective use of cognitive rehabilitation, the research base of this
mnemonic strategies (Hallahan & Sapona, 1983). practice is wanting. Although many of these pro-
Along these same lines, various mnemonic tech- grams have intuitive appeal for use with neuropsy-
niques have been used with brain-damaged patients chologically impaired children, little data support the
(e.g., Gianutsos & Gianutsos, 1979; Jones, 1974; use of these programs.
Leftoff, 1981; Lewinshon, Danaher, &Kikel, 1977). It seems clear that neuropsychology has the po-
For instance, Leftoff (1981) reported that similar to tential to continue contributing to rehabilitation in
normals when verbal information (i.e., high-fre- general and cognitive retraining specifically. Indeed,
quency nouns) was presented in a consistent order, the inertia of the field is moving toward a treatment
patients with left hemispheric dysfunction recalled emphasis (Dean, 1982, 1985a). Neuropsychology
significantly more words than when the words were with its emphasis on brain-behavior relationships
presented in a random fashion. Based on these data, may be the most relevant approach to remediating
Leftoff concluded that ordered information may neurologically related cognitive deficits. Although
serve as a salient cuing device. In other words, pa- such a trend in neuropsychology is clear (see Serebly
tients were better able to retrieve verbal information eta/., 1986), we may be entering the field without
if it was presented in an organized fashion. In a benefit of a firm empirical foundation.
related investigation, Jones (1974) showed that visu-
al imagery was effective in improving the paired-
associate learning of patients with documented left References
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22
Neuropsychological Aspects of
Epilepsy
Introduction and Overview
LAWRENCE C. HARTLAGE AND PATRICIA L. HARTLAGE
Although estimates of the prevalance of childhood Neuropsychological Substrates of

epilepsy in the United States vary, review of a Childhood Epilepsy
number of epidemiological studies suggests that this
condition may affect up to one million children Seizures can be classified in a number of ways.
(Hartlage & Telzrow, 1984). As for normal children, Perhaps the most widely used current classification
children with epilepsy differ from one another on a involves three major types: generalized tonic-clonic,
variety of dimensions. Unlike normal children, how- partial complex, and absence seizures. Although dif-
ever, children with epilepsy are subject to three con- ferent on a number of dimensions, this classification
ditions that contribute to increased variability. Two is similar to the earlier classification of grand mal,
of these conditions are primarily neuropsychological psychomotor, and petit mal types of seizures. In chil-
in nature. One involves the fact that epilepsy is symp- dren, there may be less correspondence between a
tomatic of some type of brain dysfunction, and such specific neurological abnormality and discrete be-
factors as locus, type, extent, age of onset, and sei- havioral symptoms. Further, the incidence of types
zure manifestations may each or in combination have of seizures differs between children and adults, to the
implications for how the child's adaptive behavior extent that in a number of respects childhood epilepsy
may be affected. The other neuropsychological con- represents a somewhat different phenomenon than
dition involves the effects of anticonvulsant drug adult epilepsy.
therapy on the child's development or manifestation Although not all children with epilepsy have
of adaptive behavior. The third condition represents intellectual deficits, for many years it was reported
an interaction between such social factors as the reac- than an unselected population of children with epi-
tions of the child's parents, peers, and teachers; the lepsy were likely to have mean IQ ranging up to a
neuropsychological substrates of appropriate adapta- standard deviation lower than average (Henderson,
tion to the requirements of given ages; and the effects 1953; Somerfild-Ziskind & Ziskind, 1940; Sullivan
of anticonvulsant medication on both peer response & Gahagan, 1935; Whitehouse, 1971). More recent
and the child's potential for utilization of underlying research has identified factors that contribute to our
neuropsychological assets. Although for a given understanding of correlations of depressed IQ in chil-
child with epilepsy these three conditions are likely to dren with epilepsy. Frequency of seizures is associ-
be interactive, it may be helpful to overview each ated with mental deficit, greater frequency being cor-
condition as a separate entity before attempting to related with more severe intellectual deficit (Farwell,
address the more complex issues involved in the in- Dodrill, & Batzel, 1985; Keith, Evert, Green, &
teractions of these conditions. Gage, 1955).
Type of seizure appears to be an important cor-
LAWRENCE C. HARTLAGE o Department of Psychol- relate of intellectual ability in that intellectual levels
ogy, University of Arkansas, Fayetteville, Arkansas 72701. within a given seizure classification are much more
PATRICIA L. HARTLAGE o Department of Pediatrics and homogeneous than those found among the spectrum
Neurology, Medical College of Georgia, Augusta, Georgia 30902. of childhood epilepsy. In general, absence types of
409
410 CHAPTER 22
seizures represent the class least likely to show intel- found that 11% had classic absence seizures, whereas
lective deficit (Collins & Lennox, 1946; O'Leary, a recent report from a major tertiary care epilepsy
Seidenberg, Berent, & Boll, 1981; Zimmennan, program found only 6% of children with this problem
Burgemeister, & Putnam, 1948), generalized tonic- (Farwell et al., 1985). Similarly, Gregoriades found
clonic seizures most likely to show greatest intellec- that 50% of children in his sample had only gener-
tual deficit, and partial complex seizures resulting in alized tonic-clonic seizures, whereas Farwell and
intennediate levels of intellectual impainnent. colleagues' sample had only 25% of this simple sei-
Although these findings are likely fairly com- zure type. In light of findings concerning intellectual
patible with impressions of clinicians who work with correlates of seizure types, it is obvious that conclu-
unselected populations of children with epilepsy, a sions concerning intellectual levels among children
carefully screened sample of tertiary center child- with epilepsy may be expected to vary as a function
hood epilepsy patients shows Full Scale IQ levels of of the types of children seen in a given setting. Al-
70 for minor motor; 74 for atypical absence; 96 for though there are no specific data relating to this phe-
partial plus generalized; 98 for partial; 99 for gener- nomenon, it seems likely that the extent of intellec-
alized tonic-clonic; 97 for classic absence plus gen- tual deficit in childhood epilepsy may be somewhat
eralized tonic-clonic; and 106 for classic absence exaggerated by the fact that careful psychometric
(Farwell et al., 1985). In this sample, the lowest Full studies of children with epilepsy are somewhat more
Scale IQ scores were found to differ (p < 0.05) be- likely to be reported from large epilepsy programs, to
tween the minor motor and atypical absence children which the more complicated and difficult-to-manage
and all other types. The finding of highest IQ scores seizure cases may be referred.
in the children with only classic absence type of sei- Fonnal neuropsychological studies involving
zures is similar to the average IQ levels of 106 and assessment of children with epilepsy typically have
113 reported, respectively, by Zimmennan et al. not found a specific profile or pattern of impainnent.
( 1948) and Collins and Lennox ( 1946) for samples of In tenns of seizure types, one recent study of children
children with classic absence seizures. tested with the age-appropriate Reitan Neuropsy-
Another important correlate of cognitive or in- chological Battery (Reitan & Davison, 1974) found
tellectual deficit in childhood epilepsy relates to age no significant impainnent among children with only
of onset. There is fairly consistent agreement that classic absence seizures; and only very mild or mild
earlier onset is associated with greatest intellectual impairments in children with minor motor, atypical
impainnent (O'Leary et al., 1981). Many years ago, absence, and classical absence plus generalized
research indicated that IQ scores were lower among tonic-clonic seizures (Farwell et al., 1985). These
children with epilepsy whose seizures began before researchers also found differences among seizure
age 5 (Sullivan & Gahagan, 1935), and more recent types on a screen for aphasia, with the aphasia
research has shown that seizure onset during the first screening scale differentiating between children with
year of life is related to greatest impainnent (Scarpa minor motor and atypical absence seizures compared
& Carassini, 1982). An important component of age with other seizure types, significance being more
of onset of seizures is that of duration of seizures, in pronounced (p < 0.01) for younger children. Some-
that earlier onset typically is related to duration. Re- what similar findings were reported by Matthews and
cent computation shows that overlap (r) between Klove ( 1967) who found that children with various
intelligence and age of onset accounts for 9% of vari- types of epilepsy perfonned poorer than controls on
ance, with duration accounting for 16% and number neuropsychological measures. Somewhat more spe-
of years with seizures accounting for most (38%) cific findings were reported by Epir, Renda, and
variance (Farwell et al., 1985). Baser (1984) in a study of Turkish children, wherein
It is likely that studies of intellectual findings receptive language and drawing ability were more
among children with epilepsy will not show a great impaired in children with epilepsy. The children in
deal of unifonnity across settings because the types the Epir et al. study were somewhat atypical from
of children with epilepsy who are evaluated at differ- those usually studied in that 80% were not receiving
ent types of referral centers may differ on variables seizure medication. With respect to reliability, one of
related to intellectual abilities. In tertiary centers, the few such studies was reported by Dodrill and
such as major medical center epilepsy programs, Troupin (1975), who found that the majority of
there is a likelihood that the more difficult cases will neuropsychological measures used for evaluation of
be studied because the relatively uncomplicated patients with epilepsy did not demonstrate significant
cases are less likely to be referred there. In a large practice effects. However, they concluded that per-
series of epileptic children, Gregoriades (1972) fonnance on Wechsler scales may be more affected
NEUROPSYCHOLOGICAL ASPECTS OF EPILEPSY 411
by anticonvulsant medication than many other neuro- With the advent of gas-liquid chromatography
psychological measures, thus raising the possibility (Woodbury, Penry, & Schmidt, 1972), it became
that specific tests used for assessment in epilepsy possible to assess the amount of anticonvulsant medi-
may have reliability differentially affected by anti- cation in the child's serum at the time of mental test-
convulsant drug therapy. ing. Approximately corresponding to the increased
availability of gas-liquid chromatography to investi-
gators in epilepsy, was the recognition of rela-
Medication-Performance Interactions tionships between the medications used for seizure
control and mental test performance in both children
The possible influence of anticonvulsant medi- and adults (ldestrom, Schalling, Carlquist, & Sjo-
cation on the mental performance of children with quist, 1972; Reynolds & Travers, 1974; Trimble &
epilepsy is of obvious relevance to neuropsycholo- Reynolds, 1976). Specific relationships between
gical study, in that the vast majority of children with given anticonvulsant medications and performance
epilepsy who receive neuropsychological evaluation on given psychological tests were studied in a series
will likely be taking one or more anticonvulsant med- of investigations wherein serum anticonvulsant lev-
ications at the time of testing. This factor has, how- els were determined on serial visits with psychologi-
ever, tended to be ignored in much neuropsycholo- cal testing done at the time serum levels were col-
gical research in childhood epilepsy. lected (Hartlage, 1984; Hartlage & Linz, 1984;
Perhaps the first long-range approach to study- Hartlage, Noonan, & Prim, 1983; Hartlage, Nance,
ing anticonvulsant medication effects on mental test Noonan, & Shaw, 1983; Hartlage, McCuiston, &
performance was reported by Lennox (1942), who Noonan, 1982; Hartlage, Hynd, & Telzrow, 1981).
studied more than 1000 patients of varying ages who For the major types of anticonvulsant medications
had received anticonvulsant medications for seizure studied (phenobarbital, primidone, carbamazepine,
control. He concluded that there was no relationship diphenylhydantoin, and valproic acid), most striking
between anticonvulsant medications and psychologi- relationships were found between phenobarbital and
cal function. Similar conclusions were reached by primidone and neuropsychological measures. The
other early investigators, who studied such anticon- neuropsychological measures most sensitive to
vulsant medications as phenobarbital (Somerfeld- serum anticonvulsant levels were coding, digit sym-
Ziskind & Ziskind, 1940), diphenylhydantoin (Love- bol, and symbol digit tests, all of which correlated
land, Smith, & Forster, 1957), and primidone (p < 0.01) with phenobarbital. Two of these mea-
(Loveland et al., 1957; Roye & Martin, 1959; Chau- sures (symbol digit and digit symbol) correlated (p
dhry & Pond, 1961). Thus, for approximately three < 0.05) with primidone serum levels. Neuropsy-
decades there was both belief, and research evidence chological measures that correlated with phenobar-
in support of this belief, that any behavioral impair- bital serum levels (p < 0.05) were finger oscillation
ment in children with epilepsy was not related to their (bilateral), digit span forward and total, and a sub-
anticonvulsant medication. scale involving a rapid symbol marking from the
A problem in the investigation of possible rela- General Aptitude Test Battery. Primidone correlated
tionships between anticonvulsant medication and (p < 0.05) with nondominant hand finger oscillation
mental function in children involved the individual and Minnesota Rate of Manipulation Test, bilateral
variability in drug metabolism and the considerable Minnesota Rate of Manipulation Test, digit spao for-
variability in size found in children at different ages. ward, and the General Aptitude Test Battery sub-
At a given dosage level of anticonvulsant medica- scale. With respect to actual levels of performance,
tion, for example, a child weighing 20 pounds might high serum barbiturate levels were associated with
show a different response than a child weighing 80 raw scores of 15.2, 15.5, and 11.6, compared with
pounds. Such fourfold variability in body weight is low serum barbiturate level scores of37.2, 27.9, and
relatively uncommon in adults, so that the technical 31.1, respectively, for performance on digit symbol,
considerations involved in studying drug-behavior coding, and symbol digit measures (Hartlage, 1981).
interactions in children posed a considerably greater Relationships between neuropsychological measures
challenge. Increased variability of metabolism in and other types of anticonvulsant medications (car-
children, as opposed to adults, may be related to the bamazepine, diphenylhydantoin, and valproic acid)
fact that adults typically have achieved a stable body did not exceed chance levels, and there were no sig-
habitus, whereas children at different growth stages nificant relationships between either phenobarbital or
may have considerably different growth and metabo- primidone and measures of word knowledge, con-
lism rates. cept formation, or dominant hand performance on the
412 CHAPTER 22
Minnesota Rate of Manipulation Test. Dodrill (1975) ( 1969) found that children who experienced only
reported that diphenylhydantoin depressed perfor- temporal lobe epilepsy were not likely to have so-
mance on a variety of motor tasks, but not with tasks cial-emotional pathology, whereas others have re-
emphasizing higher motor function, and MacLeod, ported contradictory findings (Bear, 1979; Blumer,
Dekaban, and Hunt (1978) found relationships be- 1975; Glass & Mattson, 1973; Waxman & Gesch-
tween phenobarbital concentration and short-term wind, 1975). Yet other investigators have found that
but not long-term memory. Skilbeck (1984) found combined seizure types are more likely to be associ-
memory impairment on reaction time for memory ated with emotional pathology (Hermann, Dikmen,
scanning affected by diphenylhydantoin, with slower & Wilensky, 1982), whereas no relationships be-
reaction times related to higher dosage levels. These tween seizure types and emotional pathology have
and other findings suggest that the relationship be- been found by other researchers (Lacher, Lewis, &
tween anticonvulsant medications and neuropsychol- Kupke, 1979; Hermann & Stevens, 1980; Matthews
ogical test performance may be fairly specific, both & Klove, 1967; Standage & Fenton, 1975).
with respect to anticonvulsant medication and the Although there is no common agreement con-
abilities affected (MacLeod et al., 1978). In any cerning relationships between seizure types and be-
case, however, there appear to be relationships behavioral pathology, there is agreement that emotional
tween some medications used for seizure control and adjustment among individuals with epilepsy may be
performance on special mental ability measures, to impaired. In a recent study of epilepsy in four coun-
an extent that merits consideration in the evaluation tries (Canada, Finland, German Democratic Re-
of the performance of a given child with epilepsy. public, and the United States), Dodrill et al. (1984)
found a number of common problems, with emo-
tional adjustment always representing the major area
of concern. Although these findings were limited to
Social and Emotional Correlates of adults, they are compatible with those of Bagley
Childhood Epilepsy (1971) with children. A feature of social-emotional
problems in childhood epilepsy, when compared
Although there has been fairly consistent agree- with healthy nonepileptic and chronically ill diabetic
ment that children with epilepsy differ from their children, has been found to involve the attribution of
nonepileptic peers on a number of social and emo- control over their lives to external sources (Mat-
tional variables (Bagley, 1971; Livingston, 1972), thews, Barabas, & Ferrari, 1982), with a secondary
there is no good agreement concerning either the feature involving lower self-concept. This feeling of
nature or the possible causes of these differences. external control over their lives may be related to a
Early work implicated psychopathology related to finding of increased dependency in epileptic children
temporal lobe dysfunction (Gibbs, Gibbs, & Forster, who were matched with (otherwise healthy) ton-
1948) as etiologic, although more recent work has sillectomy patients (Hartlage, Green, & Offutt,
indicated that as a group, individuals with epilepsy 1972). Other investigators have hypothesized that
do not manifest behavior disturbances at a level dif- dependency in epileptic children may be due to pa-
ferent from those found in groups with chronic illness rental attitudes (Bayley & Schaefer, 1960; Heathers,
or nonepileptic neurological disorder (Whitman, 1953), and this hypothesized relationship has re-
Hermann, & Gordon, 1980). However, these same ceived some support from Hartlage and Green
investigators found that when psychopathology was (1972), who also found parental attitudes to be relat-
present in individuals in each of the three groups, the ed to academic and social achievement in children
possibility of a more serious psychopathology was with epilepsy. When compared with matched con-
greatest in persons with epilepsy. This raises the pos- trols, children with epilepsy tended to perform less
sibility that, although epilepsy may not necessarily well academically than their ability levels would sug-
be etiologic in social-emotional problems, it may be gest, as well as tending to have poorer language
a condition that exacerbates such problems. Such a usage than what would be suggested by their mea-
possibility does not necessarily preclude the potential sured communication abilities (Green & Hartlage,
for specific types or causes of epilepsy to be associ- 1971). Although no causal relationships between epi-
ated with increased likelihood of social-emotional lepsy and academic underachievement have been
problems, and there is speculation that temporal lobe identified, there are a number of factors that may be
epilepsy muy huve different sociul-emotionul corre- involved. One involves the possibility of some de-
lates than other types. The nature of these correlates pressing effect of anticonvulsant medication on aca-
is not a matter of common agreement, in that Ounsted demic performance. Another factor may relate to de-
NEUROPSYCHOLOGICAL ASPECfS OF EPILEPSY 413
pendency, of whatever origin it may have. Yet zure itself. Although a seizure may have a focal dis-
another possible factor suggested by Dodrill ( 1980) charge, it may spread and become generalized. It is
involves some interrelationship between neuropsy- with these types of seizures that surgical disconnec-
chological substrates of learning. Although presum- tion of the cerebral hemisphere may be attempted to
ably impaired neuropsychological functioning might prevent the spread of discharge to the nonaffected
also be expected to depress intellectual level, Mat- hemisphere.
thews, Barabas, and Ferrari ( 1983) reported the inci- Although some types of seizures have certain
dence of learning disorders to range from 15 to 30% common EEG profiles, the absence of such a profile
among children with epilepsy, and Breger (1975) does not necessarily imply that this type of seizure is
also identified learning impairments in children with not present: approximately 25% of patients with gen-
epilepsy. eralized tonic-clonic seizures have completely nor-
Thus, there is agreement that problems in so~ mal EEG findings, in both waking and sleep tracings
cial-emotional spheres are not uncommon among (Boshes & Gibbs, 1972). For this reason, careful
children with epilepsy, although the causes of these history and sustained observation may be necessary
problems remain unclear. Although researchers have to determine the type of seizure involved. Although
identified a number of possible causes or at least this may suggest that the EEG is of relatively little use
correlates of such problems, the interpretation of in seizure diagnosis, there are a number of conditions
findings and implementation of intervention ap~ in which the EEG shows a strong relationship with
proaches for a given child still must depend heavily neuropsychological status. In infants and young chil-
on the skills and insights of the clinician working dren with a history of frequent brief spasms or quiver-
with the child. ing spells, an abnormal EEG pattern referred to as
hypsarrhythmia may predict significantly impaired
mental function or retardation.
Much less likely to predict mental impairment
Diagnostic and Classificatory Issues or even subsequent seizures are febrile convulsions,
which may appear in approximately 3% of children
Although mention of major classes of childhood below 5 years of age. In general, these types of sei-
seizures has been made, it is important to emphasize zures tend to resolve with age, and not be followed by
that there are many manifestations of seizures in chil- any other type of seizure disorder. Although there is a
dren. Noted epileptologists have said, "Epile~ fairly strong familial incidence of this type of epile~
sy . . . can masquerade in so many forms that any sy, what is inherited appears to be a low convulsive
busy doctor will be treating it knowingly or un- threshold for increased body temperature, which is a
knowingly" (Bashes & Gibbs, 1972, p. 3). These limited defect associated with spontaneous recovery
protean manifestations of epilepsy may be one reason (Garvin, 1970; Livingston, Bridge, & Kajdi, 1974).
for the lack of agreement among researchers studying Some seizure types are relatively age specific,
specific aspects of epilepsy such as the relationship with absence seizures rare in children below 2 years
between epilepsy and social-emotional adjustment of age and most common between 5 and 19 years of
in children. It may be helpful to keep in mind that age: these seizures tend to disappear with increasing
epilepsy represents a symptom rather than a specific age and are relatively rare in adults (Bashes & Gibbs,
disease entity, so that in addition to multiple man- 1972).
ifestations there may be multiple causes. In general, Another example of age-related seizures in-
epilepsy represents evidence of an irritative reaction volves what John Hughlings Jackson ( 1931) referred
to some type of brain injury. If the nature of the brain to as epileptic equivalents, and which have subse-
injury is known, such as might result in the case of an quently been called psychomotor seizures, temporal
identified neoplasm, the resultant epilepsy may be lobe epilepsy, and partial complex seizures. For
referred to as symptomatic. In the more common many years it has been recognized that this type of
cases where no specific cause is identified, epilepsy disorder typically has a spike focus in the anterior
may be referred to as idiopathic. Obviously, the ef- temporal areas (Gibbs et al., 1948), and is most com-
fects of a specific (e.g. , tumor) cause may differ from mon among adults, whereas children with this type of
those of unknown or nonspecific causes, on a number seizure are more likely to have a spike focus in the
of cognitive and behavioral dimensions. midtemporal area (Boshes & Gibbs, 1972). Further,
Another determinant of how epilepsy may affect a given child may demonstrate a series of seizure
a given child relates to how much of the brain is manifestations at different stages of life (Dreifuss,
involved, either as an underlying cause or in the sei- 1975).
414 CHAPTER 22
A unique feature of epilepsy, when compared 1950), and continues to attract interest (Green &
with most other chronic diseases, is that most of the Pootrakul, 1982; Flanigin, King, & Gallagher, 1985;
time the symptoms (seizures) are not present. Fur- King eta/., 1986; Whittle, Ellis, & Simpson, 1981),
ther, it is relatively uncommon for the child with the principal treatment involves medical (anticonvul-
convulsive seizures to demonstrate them on examina- sant drug) therapy.
tion, so that the diagnosis is not as straightforward as Since early in the 20th century, phenobarbital
it might be with many other childhood disorders. The and diphenylhydantoin have been widely used for
primary laboratory diagnostic tool, the EEG, may seizure control. The Epilepsy Branch of the National
well not be definitive because estimates of normal Institute for Neurological and Communicative Dis-
(i.e., nonepileptic) individuals with abnormal EEGs eases and Stroke (NINCDS) has documented 14
are approximately 25% (Kaufman, 1981), and nearly other drugs currently in use in the United States
that percentage of individuals with recurrent seizures (NINCDS, 1980). Although these anticonvulsant
do not have abnormal EEGs (Harris, 1976). medications differ from one another on a variety of
Although many texts in child development, edu- pharmacological properties and behavioral effects,
cational psychology, and general psychology have there is no universal agreement concerning which
used the classic terminology for seizure classification anticonvulsant medications may be specifically indi-
(e.g., grand mal, petit mal, psychomotor epilepsy), cated for treatment of seizures of a given type for an
since 1970 the International League Against Epilepsy individual child. The reported spectrum of psycho-
has used a classification system based on description tropic action of anticonvulsant medications in gener-
of seizure types. This classification system has been al is expected to produce psychomotor improvement
widely accepted by the medical neurology communi- (diminished retardation); cognitive improvement (es-
ty, and classifies seizures into four major groups. pecially concentration and attention); and affective
Group I (partial seizures) begin locally, and may improvement (diminished irritability, anxiety, and
have no impairment of consciousness, although there depression) (Parnas, Gram, & Flachs, 1980). It is
may be motor, sensory, or autonomic symptoms. A interesting to note that, as reported earlier in this
subtype within this class, generally accompanied by chapter, apparently the opposite effect of psycho-
impairment of consciousness, may have cognitive, motor improvement appears to represent the rule
affective, and psychomotor symptoms. Group II rather than the exception when barbiturates are used
(generalized) seizures include absence and gener- for seizure control. Valproic acid is a drug that, al-
alized tonic-clonic seizures. Group III seizures are though in common European use for some time, in
unilateral, and Group IV contains unclassified sei- the United States has been in use for approximately a
zures (Hartlage & Telzrow, 1984). Although issues decade. Its chemical structure differs completely
involving classification are important for epilep- from other antiepileptic drugs, and it appears to have
tologists, and for researchers who wish to define pa- very few and relatively harmless side effects (Parnas
tient populations, the complexity of criteria for clas- et al., 1980). Thus, the spectrum of psychotropic
sification of seizures tend to preclude understanding effects of anticonvulsant medications is a broad one,
by professionals from other specialties. As a result, and it is probably premature to generalize to behav-
the symptoms (epilepsy) of a variety of manifesta- ioral concomitants or effects of antiepileptic drugs as
tions of central nervous system disorders may be a generic group. Further compounding the problems
treated as if this represented a meaningful unitary in this respect, it is not uncommon for children with
classification in neuropsychological research or chronic seizure disorders to be treated concurrently
clinical practice. Given the heterogeneity of epilep- with more than one anticonvulsant medication, so
sy, it is often difficult to generalize across studies, that longitudinal, large-sample studies of children re-
even involving children who have seizures within a ceiving only one anticonvulsant drug are both diffi-
given class, in such a way as to generate hypotheses cult and rare.
with implications for neuropsychological assessment One novel approach to studying effects of (anti-
or intervention for a given child with epilepsy. convulsant drug) therapy on adaptive behavior, with
some control for environmental influences, involves
the study of operant responding rate, using a sample
of mentally retarded residents of an institution. In this
Treatment and Rehabilitation study, valproic acid therapy did not affect operant
responding rate, whereas patients receiving barbitu-
Although surgical treatment of epilepsy has rate therapy tended to show greatest performance de-
been in use for many years (Penfield & Flanigin, cline, although there were interactions between sei-
zure types and drug effects on performance (Gay, rejecting social attitudes (Hartlage & Roland, I 971 ;
1984). Hartlage, Roland, & Taraba, 1971; Hartlage & Tar-
Although such focused studies can contribute to aha, 1971; Hartlage, 1974). Further complicating the
understanding of the interaction between treatment problems of the adolescent with epilepsy is the pos-
and rehabilitation, the context of rehabilitation gen- sibility that the endocrine changes of adolescence
erally is much broader. Typically, such factors as may precipitate different or increased seizures, or
level of mental function, psychosocial and interper- may make stable levels of seizure control on given
sonal adjustment, and seizure type and frequency are medications less stable, thus precipitating more sei-
variables with important implications for rehabilita- zures or the need to establish a new regimen of effec-
tive prognosis. These variables, in turn, may interact tive anticonvulsant therapy.
with treatment variables; for example, seizure type
and frequency may influence the regimen of drug (or
surgical) therapy, which in turn may influence level
of mental function and psychosocial adjustment and Summary
how teachers, parents, and peers react to the child;
how well the child may perform academically with Consideration of the many dimensions on which
respect to his or her level of mental abilities; and so childhood epilepsy may vary, and the imposing com-
on. binations and permutations of interaction among
Prognosis for rehabilitative outcome of the child these dimensions that may affect children at differing
with epilepsy thus represents a multifaceted issue, ages who suffer from different degrees and types of
with so many potentially pertinent variables as to epilepsy, enhances appreciation of the complexity of
suggest that specific prognostic statements for a issues facing the child neuropsychologist who works
given child may need to be done on an indi- in this field. As with many specialty areas in child
vidualized, case-by-case basis. The adjustment re- clinical neuropsychology, more has become known
quirements for a child with epilepsy, as for any other about the field in recent years than was known for the
child, change with age. The child with epilepsy who preceding hundreds of years. It is hoped that, in the
has been overprotected by solicitous parents may brief span allocated to the topic relative to its com-
have special difficulty in separating from this protec- plexity, it has been possible to capture and expose
tive environment to enter school and make adjust- some of the challenges and accomplishments related
ments to teachers and peers who may be much less to the topic. An expanded hope is that the reader may
protective or supportive. find something of value and relevance to his or her
In middle school years the child with epilepsy professional work, with the result that increased re-
may encounter problems with self-esteem and peer search and clinical service in this field may be of help
acceptance due to being "different," especially if in solving the many remaining questions, and thereby
seizures occurring during school attendance are re- help to ameliorate the burden of epilepsy on afflicted
markable and violent. Further adjustment difficulties children and their families.
during this age span may relate to learning problems,
whether due to neuropsychological impairment or
medication effects. Participation in some playground References
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23
The Neuropsychology of Epilepsy

Psychological and Social Impact
THOMAS L. BENNETT AND LINDA K. KREIN
Epilepsy is a nervous system disturbance that abruptly Variables Producing Behavioral and
interferes with ongoing behavior, perception, move-
ment, consciousness, or other brain functions. Indi-
Cognitive Correlates of Epilepsy
vidual attacks are called seizures, and when the prob-
lem is persistent it is called either a seizure disorder or Neurological Variables
epilepsy. Seizures are relatively common among in-
fants, children, and adolescents. Probably 8 of every Cognitive and behavioral changes associated
1000 children experience some sort of seizure ac- with epilepsy are most commonly attributed to neu-
tivity, even if it is only a single occurrence of a febrile rophysiological dysfunction associated with ictal
seizure (Lechtenberg, 1984). Occasionally, a seizure (seizure) events or long-term alterations in the central
disorder will disappear as a child matures, but in a nervous system associated with repeated discharge.
majority of cases, childhood epilepsy persists into An example of the latter would be the kindling phe-
adulthood, and in about 80% of adults with epilepsy nomenon (e.g., see Post, 1983) or Bear's (1979) hy-
this condition developed when they were children. At pothesis that personality changes associated with
least 5 of every 1000 adults in the United States have complex partial seizures reflect a hyperconnectivity
epilepsy (Lechtenberg, 1984). The various types of or a hyperexcitability of the limbic system. A number
epilepsy were described in Chapter 21 of this vol- of variables, as reviewed by Hermann and Whitman
ume. The purpose of this chapter is to describe the (1986), have been posited as determining the magni-
neuropsychology of epilepsy, and the emphasis will tude of behavioral changes. In general, more signifi-
be to discuss the emotional/behavioral and cognitive cant effects are thought to result if the seizure disor-
concomitants of epilepsy. We use the term concomi- der starts at an early age, in patients with poor seizure
tants to underscore the fact that epilepsy is a complex control, in individuals who have had the disorder for
phenomenon, and the behavioral and cognitive a relatively long period of time, and if the person
events associated with it are the product of a complex exhibits multiple seizure types. Complex partial sei-
interaction among neurological, medication, and zures, particularly if of temporal lobe origin, are typ~
psychosocial variables (Hermann & Whitman, ically believed to produce more obvious cognitive
1986). and behavioral changes than most seizure types.
Antiepilepsy drugs or anticonvulsant medica-
tions have recently been implicated in producing
THOMAS L. BENNETT AND LINDA K. KREIN negative cognitive and emotional effects in patients
Department of Psychology, Colorado State University, Fort Col- with seizure disorders. As a general rule, toxic blood
lins, Colorado 80523. serum levels of antiepilepsy drugs adversely affect
419
420 CHAPTER 23
behavior and cognition (Reynolds, 1983), but ad- is begun, and before and after major medication
verse biobehavioral effects are sometimes associated changes, could be used to determine if such changes
with serum levels of antiepilepsy drugs that are with- produced positive effects for the patient; the evalua-
in the therapeutic range (Thompson, Huppert, & tions could help determine an antiepilepsy medica-
Trimble, 1981). Polypharmacy increases the risk of .tion regimen that would strike an optimal balance
epilepsy patients developing cognitive and emotional between seizure control and adverse cognitive effects
disorders (Thompson & Trimble, 1982). Generally, (Trimble & Thompson, 1986). Finally, knowledge
phenobarbital and primidone (20% of which is me- of the nature and extent of neuropsychological defi-
tabolized into phenobarbital) are thought to produce cits may be of help in devising remedial programs or
the most significant effects, but phenytoin has also compensatory strategies to alleviate these deficits.
been implicated. Sodium valproate and car- The neuropsychologist can provide a direct role
bamazepine have been found to produce less signifi- in treatment through traditional group and individual
cant effects. Generally, antiepilepsy drugs can mag- psychotherapy. The neuropsychologist can be an ed-
nify behavioral and cognitive changes produced by ucational source for the child and his or her family
the seizure disorder itself, but in contrast, car- about the nature of epilepsy, can help the child deal
bamazepine has been argued to produce positive psy- with psychosocial stressors associated with this dis-
chotropic effects (Dalby, 1975). order, and can help the family or teachers of the child
devise methods to manage objectionable behavior.
Psychosocial Variables As indicated, remedial or compensatory strategies
can be devised to alleviate cognitive deficits. The
Recently, many theorists have highlighted ways neuropsychologist may also be involved in stress-
in which unique social and interpersonal stresses as- management and/ or biofeedback training whose goal
sociated with having a seizure disorder may contrib- it is to reduce seizure frequency. Behavioral ap-
ute to behavioral and emotional phenomena at- proaches to the treatment of epilepsy will be de-
tributed to epilepsy (Whitman & Hermann, 1986). scribed in the last major section of this chapter.
Significant stressors include fear of seizures and re- Thus, the contributions of the neuropsycholo-
lated fears of injury and death, perceived stigma of gist to the assessment and treatment of epilepsy can
being "epileptic," perceived discrimination (partic- be significant, and indeed, it is not uncommon for a
ularly in employment) against the person with epilep- neurologist to request that a neuropsychologist do a
sy, loss of control over one's life due to the unpredict- behavioral/neuropsychological assessment during
ability of seizures, social support (or lack of it), and the initial diagnostic evaluation of a child thought to
treatment of the patient by family in the home have epilepsy. A common consultation question is,
environment. "What are the relative contributions of epilepsy and
emotional factors to a child's behavior?" To accom-
plish this, the neuropsychologist must have an under-
standing of the neurophysiology, cognitive deficits,
Contributions of Neuropsychology to and emotional consequences of epilepsy. The goal of
the Assessment and Treatment of this chapter is to provide an overview of cognitive
Epilepsy deficits and emotional consequences of this disorder
and describe behavior treatment approaches avail-
Regardless of the dynamic interactions involv- able to the neuropsychologist.
ing neuropsychological, psychosocial, and medica-
tion variables that contribute to the constellation of
symptoms that constitute epilepsy, behavioral and Epilepsy and Emotional and
cognitive correlates of this disorder are observed, and
the neuropsychologist can contribute in many ways
Behavioral Disorders
to its assessment and treatment. Because patients
with epilepsy frequently present with a variety of Introduction
cognitive and psychomotor deficits, as will be de-
scribed in this chapter, neuropsychological assess- Most children who have epilepsy without any
ment can be a valuable aid in establishing the severity other nervous system pathology have no obvious
of these impairments and monitoring the effects of emotional or behavioral disorders, but of course,
treatments on these deficits. Specifically, neuro- there are exceptions. Problems with behavior are
psychological evaluation before and after treatment more likely to occur if other neurological signs, such
THE NEUROPSYCHOLOGY OF EPILEPSY 421
as limb weakness or dyscoordination, accompany the that 21% exhibited prominent deviant behavior.
epilepsy. Overall, most authorities agree that emo- They concluded that the best predictors of behavior
tional and behavioral disorders are more common disorders were frequency of seizures during the past
among children with epilepsy compared to non- 12 months, educational retardation, and the absence
epileptic, healthy children or children with other of phenobarbital as an antiepilepsy medication.
chronic, nonneurological disorders, but estimates of Stores ( 1978, 1980) concluded that boys with epilep-
the scope of this problem vary widely (Corbett & sy had more psychiatric problems than girls, particu-
Trimble, 1983). For example, some studies have larly those with a left temporal lobe epileptiform
used a restricted sample by investigating the inci- focus. Ounsted (1969) reported that rage outbursts in
dence of behavior disorders in a school populated children with complex partial seizures of temporal
only by epileptic children or in a clinic for children lobe origin were associated with neurological and
with epilepsy. Such approaches inflate the incidence psychosocial factors including neurological insult by
of behavioral problems in children with epilepsy by head trauma, age of onset of seizures, and the pres-
only investigating children with complicated seizure ence of a disordered home. Pritchard, Lombroso, and
disorders. Thus, Bridge's (1949) study in the United Mcintyre ( 1980) also reported that early age at onset
States, which concluded that 46% of 742 children of epilepsy was associated with an increase in behav-
attending an epilepsy clinic had personality disor- ioral and emotional problems, and Rutter et al.
ders, is of interest only from a historical perspective. ( 1970) found that a lower socioeconomic level and
An epidemiological approach is required to obtain the psychiatric status of the child's mother increased
accurate population statistics. the risk of psychopathology in children with epilep-
Such investigations were conducted in the sy. Finally, Hermann ( 1982) found that children with
1970s by Rutter and his colleagues (Rutter, Graham, good neuropsychological functioning who had epi-
& Yule, 1970) on the Isle of Wright and by Mellor lepsy were more aggressive, showed more psycho-
(1977) in Scotland. These studies used standardized pathology, and were less socially competent than a
rating scales to assess behavior, and found an inci- matched group of children with epilepsy whose
dence of 27-29% psychiatric disorders in children neuropsychological functioning was poor.
with epilepsy compared with 12-15% in nmtched Taken together, these studies demonstrate that a
controls. These children did not experience addi- variety of factors contribute to the increased inci-
tional neurological disorders concurrently with epi- dence of behavioral dysfunction observed in children
lepsy. Estimates of epilepsy rose as high as 67% with epilepsy. They suggest that behavioral and emo-
when children with complicated epilepsy who at- tional disorders reflect a complex interaction among
tended a special school for children with epilepsy neurological, medication, and psychosocial vari-
were evaluated (Corbett & Trimble, 1967). (In cases ables. Examples of these variables will be discussed
of complicated epilepsy, the epilepsy is not idi- next.
opathic, but rather is associated with identified neu-
ropathology or structural lesion of the brain.)
A variety of behavioral and emotional disorders Neurological Mechanisms of Emotional and
have been noted in children with epilepsy including . Behavioral Problems
increased irritability, temper outbursts, violence, ag-
gression, hyperactivity, difficulty socializing with The view that neurological variables predispose
other children, low self-esteem, lowered self-expec- individuals with epilepsy to psychopathology is best
tations, impaired participation in family activities, supported in studies that investigated adult patients
and difficulties meeting the common demands that with complex partial seizures of temporal lobe ori-
any child must face (Keating, 1961; Lechtenberg, gin. These patients exhibited more psychopathology
1984). Although these problems are seen at a higher than patients with focal seizures originating from re-
frequency in children with epilepsy than in matched gions of the cortex other than the temporal lobes
controls, the basis for these behavioral disorders is (Gunn, 1977; Hermann, Black, & Chhabria, 1981;
not immediately apparent. Sherwin, Peron-Magnan, Bacaud, Bonis, & Tolai-
Several investigators have attempted to identify rach, 1982; Stevens, 1966). But there have been ex-
variables that might be associated with increased in- ceptions (e.g., Glass & Mattson, 1973). In addition,
cidence of emotional and behavioral problems in patients with complex partial seizures of temporal
children. For example, Holdsworth and Whitmore lobe origin have been reported to show a constella-
(1974), investigating a sample of 85 children with tion of personality changes that allegedly represent
epilepsy who attended ordinary schools, reported an organic personality syndrome (Bear, 1979; Bear
422 CHAPTER 23
& Fedio, 1977), but whether this syndrome is indeed Medication Variables in Emotional and
specific to complex partial seizures has been disputed Behavioral Problems
(e.g., Mungas, 1982; Stevens, 1982).
The central personality attributes seen in pa- Adverse personality reactions from some anti-
tients with complex partial seizures include deepened epilepsy drugs have been well documented, and as
emotions, increased aggressiveness, alterations in will be reviewed later in this chapter, some anti-
social interactions (interpersonal viscosity circum- epilepsy drugs produce cognitive deficits as well.
stantiality), hyperreligiosity, hyposexuality, and hy- Phenobarbital, used in treating generalized seizures,
pergraphia (Bennett, 1987). The neurological basis will at times produce hyperactivity in children, al-
for these personality changes is posited to be a hyper- though it is generally sedating in adults. Children
connectivity or hyperexcitability of the limbic system taking phenobarbital will, as a result, exhibit inatten-
(Bear, 1979), the system of the brain that processes tiveness, impulsiveness, and aggressiveness. Hyper-
and mediates emotional feelings and responses (Ben- emotionality and irritability may appear.
nett, 1982). Primidone, a drug popular in the management of
The neuropathological process by which hyper- complex partial seizures, can produce many of the
connectivity develops is thought to be analogous to same side effects as phenobarbital, but typically they
the experimental phenomenon of kindling, which has are not as pronounced. This results from the fact that
been studied extensively in recent years (e.g., Post, approximately 20% of primidone is metabolized by
1983). According to the kindling model, repeated the brain into phenobarbital. In both cases, the hyper-
discharge from an epileptic focus would result in a activity may be so extreme that family, social, and
lowering of threshold to excitation and seizure in school activities are severely disrupted. Car-
adjacent structures to which neurons from the focus bamazepine, the drug of choice for complex partial
project. The altered excitability of the latter struc- seizures, can, in contrast, produce positive psychi-
tures, in this case the limbic system, would produce atric effects (Dalby, 1975).
or underlie personality changes seen in many patients Generalized absence (petit mal) seizures are
with complex partial seizures. typically treated with ethosuximide. This medication
A compelling argument for the view that per- can also produce irritability, hyperactivity, ag-
sonality changes seen in the individual with complex gressiveness, and inattentiveness. Children being
partial seizures are neurologically based and reflect maintained on ethosuximide appear to have an in-
hyperexcitability or hyperconnectivity in limbic sys- creased susceptibility to disturbances of sleep, es-
tem neurons is its antithesis, the Kluver-Bucy syn- pecially night terrors.
drome (Kluver & Bucy, 1939). This syndrome refers Patients with myoclonic, absence, and other
to several behavioral changes, first observed in types of epilepsy who do not respond sufficiently to
monkeys, that result from bilateral temporal lobec- treatment with conventional antiepilepsy medica-
tomy. In contrast to the personality attributes charac- tions are often administered clonazepam. Behavioral
teristic of the complex partial seizure patient, the and emotional side effects include withdrawn behav-
temporallobectomized animal (and human; see Mar- ior, depression, mood swings, insomnia, and audito-
lowe, Mancall, & Thomas, 1975) shows a decrease ry hallucinations. Thus, a variety of antiepilepsy
rather than an increase in aggression. Sexual behav- medications may produce behavioral and emotional
ior and drive are increased rather than decreased. side effects. As a result, a compromise must often be
Social cohesion is diminished rather than heightened, struck between optimal seizure control and negative
and exploratory behavior rather than excessive atten- psychiatric effects of antiepilepsy drugs.
tion to detail is prominent.
These findings support the view that neu-
rological factors contribute to behavior and emo- Psychosocial Variables in Emotional and
tional problems seen in children with epilepsy. The Behavioral Problems
majority of the research that has evaluated the rela-
tionship between personality and epilepsy has been As indicated, psychosocial factors perform a
conducted using adults. Nevertheless, it is logical to major role in the establishment, maintenance, and
assume that similar factors, such as limbic system severity of emotional and behavioral problems seen
hyperconnectivity, contribute to the increased ten- in children with epilepsy. These variables include
dency toward emotional and behavioral problems in fear of seizures, social stigma, loss of control, and
children with epilepsy. treatment by family members and teachers.
Fear of Seizures teristic of the situation experienced by individuals

with epilepsy than is actual "enacted stigma" by
Mittan and his associates (e.g., Mittan, 1986) others. The perception of being different or stig-
have shown that fear of seizures may lead to signifi- matized is likely related to emotional and behavioral
cant psychosocial impairment in people with epilep- problems shown by children. This phenomenon has
sy, and their work suggests further that a high level of its roots in parental attitudes toward and treatment of
fear about seizures is associated with significant psy- the child and is expressed in such parental behavior as
chopathology. The most common fear (66%) in their concealment of the child's epilepsy, attempts to keep
patients was fear of death due to seizures. Patients the child "normal" and to deny the existence of
typically believed that they would die as a result of epilepsy, and a pattern of parenting characterized as
suffocation from swallowing their tongue. being overly restrictive and overprotective. Conceal-
Many other fatal consequences were feared as ment, and these other strategies, are eventually un-
well. The second most common fear was that they covered, and in the end, they perpetuate feelings of
would just suddenly die due to a seizure or that they shame and stigmatization by the child.
would have a fatal accident during a seizure. Many
thought that if they turned blue during a seizure
(cyanosis) they would die. Some thought that if they Loss of Control
had epilepsy they must also have a brain tumor.
Thus, a majority of patients are concerned about Because of the unpredictability of seizures, chil-
a variety of causes of death from epilepsy, and this is dren may feel a loss of control over their lives. Their
a significant source of psychological distress. Fear of belief is ''no matter what I do, I have a seizure.'' As a
brain damage was almost as common as was fear of result, the child may be prone to develop a general
death. Interestingly, fewer than I of 20 patients ever expectation that "my life is under the control of oth-
discuss these possibilities with their neurologist, and ers, and nothing I do matters.'' That is, they are
few neurologists ever bring up the topic. Indeed, likely to develop a belief in an external locus of con-
there appears to be a tacit understanding not to dis- trol (e.g., Matthews, Barabas, & Ferarri, 1982). In
cuss this topic. The fears about death and brain general, patients with epilepsy have a higher like-
damage can have a pervasive effect on the person's lihood of believing in an external locus of control
psychological adjustment in that they can lead to de- than either healthy people (DeYellis, DeYellis, Wal-
creased coping ability, social withdrawal, poorer ston, & Walston, 1980) or diabetic patients (Mat-
emotional adjustment, and disruption of family life. thews et al., 1982). Because individuals with a belief
Mittan's conclusions are based on data collected with in an external locus of control exhibit a higher inci-
adults, but it is reasonable to assume that similar fears dence of psychopathology than do individuals with a
exert a pervasive influence over children with epilep- belief in an internal locus of control (Lefcourt, 1976),
sy. Research is needed to verify this possibility. it is reasonable to assume that this factor has a role in
the development of psychopathology in children with
epilepsy.
Perceived Stigma Matthews and Barabas (1986) not only con-
cluded that this factor is involved in emotional and
It has long been believed that the stigma of hav- behavioral problems, but also discussed some of the
ing epilepsy could predispose the individual to vari- mechanisms by which an external locus of control
ous emotional and behavioral problems. A recent develops in children with epilepsy. One factor, de-
survey of adults by Arntson and his colleagues ap- scribed earlier, is that children with epilepsy are like-
pears to support this hypothesis (Arntson, Droge, ly to perceive that the occurrence of a seizure is un-
Norton, & Murray, 1986). Patients in their survey avoidable. Another is that many of these children are
complained of depression and anxiety, and they en- overprotected by their families, teachers, and others
dorsed statements about how epilepsy had stig- who, as a result, do not give the children the oppor-
matized their lives and left them with feelings of tunity to fully participate in decisions that directly
helplessness. affect them. Such an environment would confirm the
In reviewing the relationship between stig- child's belief that "I have no power in determining
ma and the development of psychopathology, West my future."
( 1986) concluded that ''felt stigma'' and a deep sense Matthews and Barabas ( 1986) asserted that de-
of shame about "being epileptic" are more charac- velopment of a belief in an external locus of control in
424 CHAPTER 23
children with epilepsy can impede their motivation to Identity may be negatively affected if peers know that
learn, to socially interact and form friendships with the individual has to take antiepilepsy medication or
others, to act appropriately with others, and to pursue suffers from epilepsy and, as a result, treat him or her
happiness. Chronic underachievement can result as being different.
from the child's inability to recognize his or her own Noncompliance with medication is a risk for the
responsibility in academic success and failure. As adolescent. First, the teenager may resent the fact
with the general population, this belief system can that epilepsy and the medication is controlling his or
produce feelings of helplessness and hopelessness, her life. Second, they may stop taking antiepilepsy
anxiety, and depression. drugs to counteract the perceived stigma of feeling
different. Finally, they may quit taking medication to
assert their independence from their parents who, for
Parental Treatment as long as can be remembered, have been reminding
them to take their antiepilepsy drugs. Reckless be-
Two aspects of parental treatment that might havior may likewise emerge to oppose their families'
contribute to behavioral and emotional problems excessive cautiousness.
were discussed earlier. It was indicated that (I) pa- Alcohol and other recreational drugs used by
rental treatment of children is one factor that can teenagers can alter the metabolism of antiepilepsy
result in children developing an external locus of drugs and, as a side effect, can increase the incidence
control and (2) by their attitudes, either overt or cov- of seizure activity. Excessive alcohol makes an indi-
ert, parents can also contribute to a child's belief that vidual more vulnerable to seizure activity. The sei-
he or she is stigmatized by epilepsy. zure occurs when the alcohol level of the blood falls.
Unfortunately, parents of children with epilepsy
may have unrealistically limited views of their chil-
dren's potential. Basically, if the parents believe that
the child will not achieve anything major in life, the Effects of Seizure Disorders on
child will develop this view as well. This expectation Intellectual and Cognitive Ability
may be directly or indirectly communicated to the
child, but as a result, the child may underachieve Introduction
because of a limited self-concept. The limited expec-
tations may lead to negative feelings of self-worth as Controversy has long surrounded the extent to
well, and this, in tum, can lead to emotional and which epileptic seizures themselves account for intel-
behavioral problems. lectual and cognitive deficits. However, there is
Parental fears of their child having a seizure in general agreement that observable impairments of
public may also be adopted by the child. This will memory, language, attention and concentration, psy-
accentuate any fears the child has about having sei- chomotor speed, and planning ability are present as
zures, and it will decrease the child's confidence that neuropsychological consequences of seizure disor-
he or she can manage outside the family. As a conse- ders in a large percentage of the epileptic population
quence, the child becomes overly dependent on and (Bennett, 1986; Dodrill, 1981; Folsom, 1953; Rei-
clings to the family. This phenomenon is another tan, 1974; Rodin, Katz, & Lennox, 1976). Whether
hindrance to establishing normal peer relationships these deficits would be alleviated through cognitive
and another reason why children with epilepsy often rehabilitation, as are deficits produced by other neu-
have difficulty developing and maintaining rela- rological factors such as head injury and stroke
tionships with other children. (Bracy, 1983), has yet to be formally investigated.
Historically, cognitive deficits and intellectual
impairment have been recognized as an element of
The Adolescent with Epilepsy the symptomatology of epilepsy for well over 100
years (Blumer, 1984). Attempts to measure these
Normal adolescent behavior can be a com- observed dysfunctions were, however, only as so-
plication for individuals with epilepsy (Lechtenberg, phisticated as the psychometric tools available. As a
1984). The crucial developmental issues during this result, the earliest studies reflect a degree of confu-
time of life are independence, identity, and confor- sion and misunderstanding surrounding what was ac-
mity. Part of independence is getting a driver's li- tually being measured. The concept of "epileptic
cense, and the adolescent may deny that she or he has dementia'' had gained widespread popularity by the
epilepsy if it will interfere with obtaining this goal. tum of the century, and in the absence of more rele-
vant psychometric instruments, cognitive function in Seizure Type and Frequency

patients with epilepsy was evaluated primarily with
IQ measures (Stores, 1971) and projective person- In addition to etiological factors, type and fre-
ality tests such as the Rorschach (Reitan, 1974). For- quency of seizures constitute important variables in
tunately, more recent work reflects a movement the determination of the nature and extent of intellec-
away from the evaluation of intellectual abilities tual and cognitive dysfunction. A number of studies
within a global intelligence perspective and subjec- have shown generalized major motor seizures to be
tive personality assessment toward the measurement associated with greater intellectual and cognitive im-
of specific cognitive abilities and impairments. pairment than are other types of seizures. An early
The literature concerning cognitive deficits as- study by Zimmerman, Burgemeister, and Putnam
sociated with epilepsy is varied with respect to meth- (1951) investigated intellectual ability in children
odology. Results are frequently contradictory, and and adults using the Stanford-Binet, Wechsler-
relatively few studies have been done with children. Bellevue, and Merrill-Palmer Performance Tests.
Although results of adult studies should not be uni- Mean IQ measured in children and adults with
formly generalized to children (Fletcher & Taylor, idiopathic petit mal seizures ranged from 10 to 14
1984; Rourke, Bakker, Fisk, & Strang, 1983) when points higher than in patients whose seizures were
interpreted within a framework of developmental and described as grand mal (generalized major motor).
maturational considerations, findings in adult studies Using theWAIS and items from the Halstead-Reitan
may be useful in understanding the neuropsychologi- battery, Matthews and Klove (1967) found that adult
cal consequences of seizure disorders in children, patients who experienced generalized tonic-clonic
and in guiding further research efforts in this area. or major motor seizures demonstrated greater overall
Results of well-designed adult studies appropriate to intellectual-cognitive impairment than patients with
the discussion of the following aspects of epilepsy other types of seizures regardless of whether etiology
will therefore be presented in addition to currently was known or unknown. Wilkus and Dodrill (1976)
published studies with children. also observed poorer performance by adults with
EEG evidence of generalized discharge, compared to
a focal seizure group. In addition, they noted that
Etiology more frequent seizures were associated with greater
deficits. This negative correlation between cognitive
Of the intellectual correlates associated with ability and frequency of seizures was also reported by
epilepsy and the variables that alter them, perhaps the Dikmen and Matthews (1977) in a study of 72 adults
most predictable is that of etiology and its rela- with major motor seizures of known and unknown
tionship to IQ. In his review of research concerned etiology.
with intellectual and adaptive functioning in epilep- A similar relationship between seizure frequen-
sy, Tarter (1972) summarized studies in which cy and intellectual-cognitive impairment has been
etiological factors were considered. IQ scores of in- reported in children. In an early study, Keith, Ewert,
dividuals whose seizures were idiopathic ranged Green, and Gage ( 1955) reviewed medical records of
from 4 to 11 points higher than scores attained by 296 children and found a regular decreasing progres-
patients whose seizures were secondary to known sion in percentage of retarded children as frequency
pathology. These differences were observed in both of seizures decreased. This relationship was con-
institutionalized and noninstitutionalized children sistent across all seizure types considered. Also,
and adults. cases in which etiology was known showed a greater
The same relationship between severity of IQ incidence of retardation (73%) than those in which
impairment in known versus unknown etiology has the cause of seizures could not be attributed to
been found to occur on measures of neuropsychologi- organic abnormality (22.2%).
cal functions as well. In one of a series of investiga- More recently, Farwell, Dodrill, and Batzel
tions, Klove and Matthews (1966) found that al- (1985) evaluated a large group of children whose
though adult patients with seizures of unknown ages ranged from 6 to 15 years. Within each seizure
etiology (idiopathic seizures) demonstrated neuro- type studied, lower seizure frequency was associated
psychological impairment as measured by the with greater intelligence test scores (WISC-R). In
Halstead battery, when compared to nonepileptic addition, seizure type was found to be a discriminat-
controls, the greatest degree of impairment was noted ing factor when both IQ and neuropsychological
in patients whose seizures were a result of known functions were evaluated. The minor motor and
brain pathology. atypical absence groups showed statistically signifi-
426 CHAPTER 23
cant lower IQ scores than all other groups. However, secondarily generalized seizures although significant
children with partial or generalized tonic-clonic sei- differences between groups on Full-Scale IQ scores
zures demonstrated proportions of Full-Scale IQ were not present.
scores comparable to those observed in the control In contrast, some studies have not shown a clear
group. When considered together, children with epi- relationship between seizure type and cognitive im-
lepsy showed significantly greater neuropsychologi- pairment (Arieff & Yacorzynski, 1942; Scott, Mof-
cal impairment than controls as measured by the age- fett, Matthews, & Ettlinger; 1967) or frequency of
appropriate Halstead-Reitan battery. Overall neuro- seizures and greater intellectual impairment (De-
psychological impairment was found to differentiate laney, Rosen, Mattson, & Novelly, 1980; Loiseau et
between seizure types with greater sensitivity than al., 1980; Scott et al., 1967). O'Leary et al. (1983)
Full-Scale IQ (WISC-R). Children with minor motor found only one variable that showed a significant
or atypical absence seizures showed mild impair- difference in performance between various groups of
ment. The majority of children who experienced only children with seizure disorders. Children with partial
classical absence seizures demonstrated no detect- seizures performed significantly better on the Tactile
able neuropsychological impairment, but when sei- Performance Test (TPT-total time) than children with
zure types were mixed (classic absence plus gener- generalized seizures. The partial seizure group in this
alized tonic-clonic) impairment was again evident. study, however, was composed of simple partial,
Seizure type has been found to affect selected complex partial, and partial secondarily generalized
cognitive functions differentially: Quadfasel and seizure types, and this wide variation of seizure types
Pruyser ( 1955) compared cognitive abilities in adult within one group may have accounted for the limited
male patients with generalized seizures versus com- differences seen when groups were compared.
plex partial seizures and found that memory was im- Because seizure classifications and their inclu-
paired only in the partial seizure group. Fedio and sion criteria have not been consistent, particularly in
Mirsky (1969) assessed the performance of outpa- the earlier studies, and populations tested have not
tient groups of children (6 to 14 years old) who had been uniform across investigations (institutionalized
left temporal lobe epileptic focus, right temporal lobe versus noninstitutionalized), direct comparisons be-
focus, or centrencephalic epilepsy (generalized sei- tween studies are not always appropriate. The study
zures). Children were evaluated using measures of of seizure type and frequency and its effect on intel-
attention, verbal and nonverbal learning and memo- lectual and cognitive function is further complicated
ry, and IQ. The performance of children with epilep- by the severity of seizures and the antiepileptic medi-
sy regardless of seizure type was below that of the cations necessary to achieve adequate seizure con-
epileptic control group. Of greater interest, however, trol. It is also possible that in some cases, the associa-
was the pattern of deficits observed between seizure tion between observed cognitive deficits and
types and within the temporal lobe seizure groups. frequency of seizures is due to the extent of cerebral
Children with left temporal lobe seizure focus damage which is responsible for both. When consid-
showed learning and memory deficits on measures ered as a whole, however, current studies suggest
that required delayed recall of verbal material where- that the extent of intellectual and cognitive dysfunc-
as children with right temporal lobe focus had greater tion in epilepsy varies with type of seizure, and in-
difficulty with recall tasks involving visuospatial creases with greater seizure frequency.
abilities. Significant differences between perfor-
mance on measures of short-term memory were not
evident between groups. Further, children whose sei- Age at Onset and Duration of Disorder
zures were centrencephalic in nature performed at a
significantly lower level on tasks of sustained atten- More than a century ago, Gowers recognized
tion than did the temporal lobe groups, but did not the relationship between early onset of seizure disor-
demonstrate either short-term or long-term memory der and poor prognosis for mental functioning
impairment. (Brown & Reynolds, 1981). In general, current re-
Patterns of intellectual performance on the search supports this observation. Studies of intellec-
Wechsler Intelligence Scales (WAIS or WISC-R) tual and neuropsychological functions in children
that varied with seizure type were observed by Gior- with epilepsy, regardless of seizure type, indicate
dani et at. (1985). Adults and children with partial that onset of seizures early in life and a consequently
seizures performed better on Digit Span, Digit Sym- long duration of seizure disorder places children at
bol (or Coding), Block Design, and Object Assembly higher risk for cognitive dysfunction. It should be
than did patients with either generalized or partial noted that in studies of children, long duration of
seizure disorder is necessarily associated with early surprisingly, these studies showed the IQ of children
onset. Many studies of the effect of age at onset in the with epilepsy to be well below that of children with-
past have considered only major motor (generalized) out seizures. More recent research has shown that
seizures. Dikman, Matthews, and Harley (1977) there is not a simple one-to-one relationship between
found that adult patients with early onset of major epilepsy and intelligence and has further acknowl-
motor seizures (0-5 years of age) obtained signifi- edged that both intellectual and cognitive impairment
cantly lower Verbal, Performance, and Full-Scale IQ in epilepsy appear to vary as a function of several
scores (W AIS) than a group of patients with later interrelated factors: location of lesion or epilep-
onset of seizures ( 10-15 years of age). Both seizure togenic focus, etiology, seizure type and frequency,
groups showed impaired neuropsychological func- age at onset and duration of seizure disorder, and
tions (Halstead-Reitan) compared to a nonepileptic anticonvulsant drug management. In addition, it has
control group. However, differences in performance been known for some time that test-retest measures
between the early and late-onset epileptic groups of IQ in children and adults with epilepsy fluctuate
were not significant. On the other hand, Matthews more widely and unpredictably in either direction
and Klove ( 1967) found that early onset of major than in the nonepileptic population (Patterson & Fon-
motor seizures resulted in greater impairment of both ner, 1928; Sullivan & Gahagan, 1935). This is per-
intellectual and neuropsychological abilities. This haps due to the frequent but inconsistent altered elec-
difference was observed in both idiopathic seizures trical activity of the brain in epilepsy and the serum
and seizures secondary to known pathology. anticonvulsant levei at the time of testing.
More recently, O'Leary eta/. (1983) studied the General intelligence in epilepsy was investigat-
effects of early onset of epilepsy in children 9 to 15 ed in a retrospective study by Lennox ( 1942) in which
years of age with partial versus generalized seizures. the mental status of 1905 patients with various sei-
Results indicated that both groups of children with zure types and etiologies was reviewed. Two-thirds
early seizure onset performed more poorly on mea- of these patients were described by Lennox as ''men-
sures of neuropsychological abilities than children tally normal." However, only 2% were considered
whose seizures began at a later age. These findings above normal and 36% were in the low normal to
are consistent with observations of the effect of sei- below normal range, resulting in a distribution in
zure onset by Farwell et al. (1985), who studied a which lower IQ scores were overrepresented. Realiz-
variety of seizure types, and Scarpa and Carassini ing the fallibility of a subjective evaluation of this
(1982) in their study of children with partial seizures. kind, Lennox conducted a study in 1951 in associa-
As in studies of seizure frequency, investigation tion with Collins (Lennox & Lennox, 1960). Using
of the effects of age at onset is complicated by anti- the Wechsler-Bellevue Scale, they found that mean
convulsant medications. Anticonvulsants have been IQ was significantly higher in patients seen in private
found to affect cognitive performance in both chil- practice compared to general or veterans hospital
dren and adults (Brown & Reynolds, 1981; Trimble, practice. Further, patients with complex partial
1981). In cases of early seizure onset, the effects of (known as psychomotor seizures at that time) sei-
anticonvulsants on the developing brain become an zures as their only seizure type demonstrated rela-
important consideration as well as the subsequent tively better intellectual ability than patients with
long-term drug therapy that must follow. These is- other types of seizures or mixed seizure types. In this
sues, and current studies that address them will be study as in others, early onset of seizures was associ-
discussed in further detail later in this chapter. ated with a poorer prognosis for mental ability
(Brown & Reynolds, 1981; Dikman, Matthews, &
Harley, 1977; Klove & Matthews, 1969; Rodin,
Epilepsy and General Intelligence 1968).
Numerous studies have reported the mean IQ of
Disagreement over the extent of the relationship children with epilepsy to be below average (Carlberg
between epilepsy and intelligence in both children & Kavale, 1980; Dennerll, Broeder, & Sokolov,
and adults is evident throughout the history of mod- 1964; Halstead, 1957; Keith et al., 1955; O'Leary et
em research in epilepsy. Early studies of intelligence al., 1983). Recently, Ellenberg, Hirtz, and Nelson
in children with epilepsy (Collins, 1941; Dawson & ( 1986) conducted a large-scale longitudinal investi-
Conn, 1927; Fox, 1924; Patterson & Fonner, 1928; gation that confirmed previous observations that, as a
Reed, 1951) were limited to cases so severe as to group, children with seizure disorders tend to attain
require institutionalization and thus were not repre- lower scores on tests of intellectual function than
sentative of the epileptic population as a whole. Not children without seizures. Children in this study were
428 CHAPTER 23
tested with the Bayley Mental and Motor scales at 8 detecting the neuropsychological deficits that may
months of age, the Stanford-Binet at 4 years of age, contribute significantly to overall intellectual dete-
and the Wechsler Intelligence Scale for Children rioration.
(WISC-R) at 7 years. The question of whether seizures are responsi-
Not all researchers have found this relationship ble for a gradual decline in intellectual ability is not
between general intelligence and epilepsy. Rutter et easily answered, and is complicated by several fac-
al. (1970) reported a distribution of intelligence in tors. First, as indicated, a wider variation in test-
children with epilepsy that closely approximated that retest scores (upward or downward) is observed in
of the normal population as did Angers and Dennerll patients with epilepsy than in the nonepileptic popu-
(1962) who concluded that IQs of noninstitutional- lation (Brown & Reynolds, 1981) and this factor
ized adults with epilepsy were comparable to those of makes evaluation of the extent of decline in scores
the nonepileptic population. difficult. As an example, Fox (1924) in his study of
Current studies of both children and adults have students in a special school for children with epilepsy
given more consideration to methodological control found that scores of37% of the children retested after
and representativeness of the sample studied, seizure 1 year declined, 22% improved, and 41% remained
type and frequency, age at seizure onset, etiology, unchanged.
duration of seizure disorder, medical intervention, Second, as in studies of intellectual and cog-
and psychosocial factors that interact to affect intel- nitive impairment, investigations of intellectual dete-
lectual and cognitive performance (e.g., Farwell et rioration are compounded by the factors that compli-
al., 1985; Giordani et al., 1985; O'Leary et al., cate assessment of performance: seizure type and
1983). Results of the majority of studies suggest that frequency, age at onset and duration of seizure disor-
IQ scores vary as a function of all of these factors. der, and the presence of an underlying progressive
However, there still remain unanswered questions pathology that is responsible for the seizures. Nev-
concerning the relative contribution of each factor to ertheless, animal studies have indicated that neuronal
the impairment of general intelligence. degeneration occurs as a result of recurrent seizures
that inhibit brain protein synthesis and growth (Har-
ris, 1972).
Epilepsy and Intellectual Deterioration A third factor complicating the study of intellec-
tual decline over time is the effect of anticonvulsants
The stability of intellectual ability in children on intellectual and cognitive abilities. As indicated,
and adults with epilepsy has been the subject of sev- recent research has shown that certain anticonvul-
eral studies, some of which have reported deteriora- sants cause impairment of selected cognitive func-
tion and others have not (Tarter, 1972). Recently, tions (Corbett, Trimble, & Nichol, 1985). In addi-
Ellenberg et al. (1986) compared Full-Scale IQs of7- tion, more adverse neuropsychological deficits might
year-olds who had experienced one or more non- be expected in patients whose seizures are frequent
febrile seizures to IQs of their seizure-free siblings. and began early in life, due to the higher doses of
Mean IQs of the children with epilepsy did not differ antiepileptics or combinations of medication neces-
significantly from previous assessment at age 4. In a sary to achieve maximum seizure control and the
substudy, children who had developed seizures in the longer periods of time these drugs must be taken
interval between the first (at age 4) and second. test (at (Dikmen & Matthews, 1977; Dodrill, 1981). Bour-
age 7) were evaluated. Analysis of this subset of geois, Prensky, Palkes, Talent, and Busch (1983)
children did not show a significant difference in IQ. conducted a prospective study of IQ stability in chil-
These data suggest that the occurrence of seizures dren aged 18 months to 16 years who bad various
does not result in mental deterioration; however, the types of seizure disorders. Children were evaluated
maximum duration of seizure disorder possible in the within 2 weeks of initial diagnosis, and yearly there-
substudy was 3 years. It has been proposed that se- after for an average of 4 years. In 45 of the 72 chil-
lected intellectual and cognitive deficits caused by dren tested, a nonepileptic sibling was evaluated in
some seizure disorders may require up to 10 years to parallel. The mean IQ for all of the children with
become evident (Mirsky, Primae, Ajmone-Marsan, epilepsy considered together initially did not differ
Rosvold, & Stevens, 1960). It should also be noted significantly from the siblings, nor did the scores
that two different psychometric measures, the Stan- change appreciably over time. Eight of the children
ford-Binet (at age 4) and the WISC-R (at age 7), did, however, show a decrease in IQ of 10 points or
were used in testing. Although these tests are com- greater. The authors explained these findings in
parable and much information can be gained from terms of drug toxicity, seizure type and frequency,
them, neither test was developed with the intent of and early onset. Further analysis revealed that of
these factors, the two best predictors of intellectual overrepresented among students who have difficulty
deterioration were age at onset and number of drugs in school. These results suggest that the school prob-
to which the child developed toxicity. This study lems experienced by the child with epilepsy cannot
draws attention to one of the many problems that be explained as a function of curriculum or classroom
arise in the treatment of children with epilepsy, the environment across cultures. The most frequent term
trade-off between maximum seizure control and pos- teachers use to describe problem classroom behavior
sible adverse drug side effects. in epileptic children is "inattentiveness" (Stores,
Finally, psychosocial factors may play a role in 1978), which is descriptive of both cognitive
the assessment of intellectual deterioration. For ex- and behavioral neuropsychological correlates of
ample, Carlberg and Kavale ( 1980) suggested that epilepsy.
the placement of children with epilepsy in special Bennett-Levy and Stores (1984) described re-
schools may be partially responsible for depressed sults of a study in which they used an evaluation of
performance in measures of intelligence. Also, as in classroom performance rather than psychometric test
school performance, parents and teachers may have a scores to assess the cognitive and behavioral dys-
less optimistic view of an epileptic child's ability and function in children with epilepsy. After discussions
potential. Deterioration in performance may then with teachers and observation of classroom behavior,
be a result of lowered expectation as weJI as neu- a questionnaire relevant to learning difficulties expe-
rological and medication variables (Lechtenberg, rienced by epileptic children was constructed. Four
1984). factors that were indicative of learning difficulties
Some of the inconclusive and negative results in and therefore predictive of poor educational attain-
past studies of intellectual deterioration may be ex- ment were identified: concentration, mental process-
plained by the history of the development of anticon- ing of information, alertness, and self-confidence.
vulsant drugs. Sullivan and Gahagan (1935) found Teacher ratings of children with epilepsy in this study
that premorbidly brighter patients showed greater de- did not differ significantly from ratings of their non-
terioration in intellectual ability over time, but im- epileptic classmates on concentration, mental pro-
proved seizure control tended to slow the rate of dete- cessing, or self-confidence; however, significant
rioration. Barbiturate anticonvulsants and bromide deficits in alertness were noted in the children with
were, however, the only available chemical means of epilepsy, and this deficit was evident in both boys
seizure control until the introduction of phenytoin and girls. It was further suggested that the lowered
(Dilantin) in 1938, and were not effective in control- alertness in these children was not associated with
ling all types of seizures. The development of newer type of seizure or drug effects, because the children
anticonvulsant drugs and therapeutic interventions with epilepsy who were no longer taking anti epileptic
such as biofeedback have gradually resulted in better medication were also significantly less alert.
seizure control than in the past. Until recently, educational attainment has been
Because of the numerous factors that affect test examined within the context of general intellectual
performance, intellectual deterioration is perhaps ability (Stores, 1971), but the focus of current re-
more effectively considered individually and relative search has gradually turned to the specific underlying
to premorbid ability rather than in terms of preserva- reasons for poor academic performance in children
tion of "average intelligence." For example, a per- with epilepsy. The previously discussed cognitive
son of superior intellectual ability who acquires a impairments in memory, language, attention con-
seizure disorder may subsequently score within the centration, psychomotor speed, and planning ability
average range of intelligence; however, this indi- that have been observed in children and adults with
vidual will have experienced marked deterioration in epilepsy represent deficits in mental abilities that are
mental ability, which may interfere with his/her pre- essential to learning and consequently to successful
vious work and leisure activities, and this loss may be academic performance.
extremely difficult for the individual to accept. Children with epilepsy are in special education
programs three times as often as other children (Har-
rison & Taylor, 1976). Furthermore, academic
Educational Attainment in Children with achievement is below expectancy even when epilep-
Epilepsy tic children have been placed in age-appropriate
grade levels in normal schools, and is below that
Surveys of schools in England (Pond & Bid- which might be predicted based on intellectual dif-
wen, 1959), Italy (Pazzaglia & Frank-Pazzaglia, ferences alone (Green & Hartlage, 1971; Rutter et
1976), and the United States (Green & Hartlage, a/., 1970). Farwell eta/. ( 1985) investigated school
1971) have indicated that children with epilepsy are experience of children with epilepsy and found that
430 CHAPTER 23
seizure type was an important determinant in a Epilepsy and Memory

child's academic experience. Twenty-seven percent
of the children with epilepsy (all seizure types con- A relatively large number of past studies of indi-
sidered together) were in special education or had viduals with epilepsy have focused on verbal memo-
failed a grade, versus only 20% of nonepileptic con- ry impairment, which has been observed by others as
trols. The poorest academic experience occurred in well as reported by epileptic patients themselves. As
children with atypical absence or minor motor sei- early as 1876, Samt, a Berlin psychiatrist, suggested
zures. Seventeen of the 20 children (85%) with these that the presence of memory dysfunction may be
seizure types had been held back a grade or were in useful in the diagnosis of epilepsy (Blumer, 1984).
special education classes. Farwell et al. (1985) fur- In 1881, Gowers also described memory deficits in
ther compared academic achievement using the Wide terms of impaired recent acquisiton of information in
Range Achievement Test (WRAT), as a function of patients with epilepsy (Hill, 1981). Quadfasel and
seizure type and found that children with classic ab- Pruyser (1955) found that a group of adult males with
sence seizures averaged 5 months ahead of grade temporal lobe seizures showed significantly poorer
placement, whereas children with other seizure types verbal memory (Wechsler Memory Scale) than pa-
averaged from 4 months to 18 months behind grade tients with generalized seizures. Glowinski (1973)
level. compared short-term memory in relation to a second-
A longitudinal study of children in England, ary distraction task in 30 patients with chronic gener-
Scotland, and Wales (Ross, Peckham, West, & alized seizures and 30 with chronic unilateral tem-
Butler, 1980) found that by age 11, children with poral lobe focus. The temporal lobe group showed
epilepsy who attended normal schools accomplished significantly greater deficits on the Wechsler Memo-
nonacademic tasks such as copying designs without ry Scale (WMS) than the group with generalized
difficulty, but their scores in reading comprehension seizures.
and mathematics were below those of their non- In contrast, Mirsky et al. ( 1960) failed to find a
epileptic cohorts. In addition, prolonged absence differential memory deficit when they compared
from school was common among the children with WMS scores of adults with temporal lobe foci to
epilepsy. A number of other authors have noted that scores of a matched group with generalized seizures.
for children with epilepsy, school achievement, par- However, patients with seizures other than those
ticularly in reading and arithmetic, averages behind originating in the temporal lobes may have inadver-
grade level. Green and Hartlage (1971) observed that tently been included in the focal seizure group. Sev-
WRAT scores in a group of children with epilepsy eral subsequent studies also found no difference be-
averaged approximately 1 year behind their grade tween memory function when seizure types were
level placement in reading and 1 year 8 months be- compared (Mignone, Donnelly, & Sadowsky, 1970;
hind in arithmetic. Still greater deficits in arithmetic Scott et al., 1967). Past studies have often investigat-
skills were noted by Bagley ( 1971) who estimated ed memory in patients with varying methods of
that children with epilepsy averaged 23.1 months clinical substantiation of seizure type, and specific
behind their nonepileptic classmates. memory functions have not always been consistent or
The learning and behavioral educational prob- clearly described. As a result, findings have been
lems that are characteristic of many children with mixed. Inconsistencies noted across studies may also
epilepsy have been attributed by various researchers reflect differential sensitivity of the measures that
to neuropsychological impairment, medical treat- have frequently been used to evaluate cognitive abili-
ment (anticonvulsants), and psychosocial factors ties and misinterpretation of what abilities the tests
(e.g., lower parent and teacher expectations and so- actually measure.
cial stigma surrounding the child with epilepsy). Laterality effects have been evident in memory
It has been suggested (Serafetinides, 1970) that studies with both children and adults. As previously
certain behavioral disturbances, for example, ag- described in part, Fedio and Mirsky (1969) observed
gressive behavior associated with temporal lobe epi- greater verbal memory deficits in children with left
lepsy, result from learning deficits-in effect, the temporal lobe foci. Conversely, children whose sei-
child fails to "learn to behave." On the other hand, zures originated in the right temporal lobe showed
the belief that social factors generate cognitive defi- greater nonverbal or visuospatial memory deficits.
cits that in turn result in poor academic performance Ladavas, Umilta, and Provinciali ( 1979) investigated
is not without support (Lechtenberg, 1984; Matthews both short-term and long-term memory in adult pa-
& Barabas, 1986). tients with specific left or right temporal lobe focus.
In the absence of evidence of structural lesions or the sample tested was small, significant differences
other brain pathology, patients with left temporal due mainly to the generalized seizure group were
lobe foci were shown to have greater deficits in long- noted on all tests. When epileptic groups were con-
term verbal memory, whereas presence of right tem- sidered independently, the performance of patients
porallobe foci was consistent with nonverbal memo- with partial seizures was similar to that of the non-
ry dysfunction. No differences in short-term memory epileptic group on learning and memory tasks.
were observed. Delaney et al. ( 1980) studied imme- Loiseau et al. concluded that epileptic patients suffer
diate and delayed recall of verbal and nonverbal ma- from both learning and attention disabilities.
terial in adult patients with left or right temporal lobe Memory impairment in patients with epilepsy
foci and a group of patients with frontal lobe foci who has also been explained in terms of language deficits
were matched on age at seizure onset, duration of by Mayeux, Brandt, Rosen, and Benson (1980) who
disorder, and seizure frequency. Both left and right investigated both interictal memory and language
temporal lobe groups showed impairment of immedi- dysfunction in volunteers with idiopathic seizure dis-
ate verbal recall when compared to the frontal focus orders. Participants were matched for age, seizure
and control groups. When the two temporal lobe frequency, duration of seizure disorder, and level of
groups were compared, the group with left temporal education. Patients with EEG confirmation of right
lobe foci demonstrated poorer performance on verbal temporal lobe foci, left temporal lobe foci, or gener-
tasks than the group with right temporal lobe foci. alized seizures were evaluated on measures of intel-
Nonverbal tasks resulted in poorer performance by ligence, auditory_ and visual memory, and language.
the right temporal lobe group. Other researchers have No significant differences were observed between
recently reported similar evidence of Iateralized ver- groups on the WAIS (verbal or performance sub-
bal and nonverbal deficits in focal epilepsy (Masui et scales) or memory measures including WMS (overall
al., 1984; Mungas, Ehlers, Walton, & McCutchen, or subtests), Rey-Ostereith Complex Figure Test, or
1985). These observations of lateralized cognitive Benton Visual Retention Tasks. However, markedly
processes in nonsurgical patients are consistent with significant deficits in the left temporal lobe group
results of studies that have considered the effects of were noted on the Boston Naming Test and Con-
temporal lobectomy in severe seizure disorders that trolled Word Association Test. The authors sug-
are refractory to other forms of medical intervention gested that anomia demonstrated in temporal lobe
(e.g., Milner, 1958; Novelly et al., 1984). epilepsy patients may be incorrectly interpreted by
Lateralization of verbal and nonverbal memory patients and their relatives as poor memory. Mayeux
impairment in epilepsy has not been demonstrated in et al. further suggested that the verbosity and circum-
all studies. As indicated, Quadfasel and Pruyser stantiality observed in some patients with temporal
( 1955) found verbal memory deficits in patients with lobe epilepsy (Bear & Fedio, 1977) may be the ex-
temporal lobe seizures, but similar deficits in nonver- pression of a compensatory mechanism for anomia.
hal memory were not noted and lateralization was not Few formal studies have directly investigated
apparent. However, some of the patients tested in this memory disturbances in noninstitutionalized chil-
study exhibited bilateral temporal lobe involvement, dren with epilepsy whose intelligence is normal or
making detection of left/right differences improba- above. Research more often has been concerned with
ble. Although Glowinski ( 1973) noted differences in school success or failure and has considered memory
verbal and nonverbal memory with respect to left and deficits as part of learning disorders in general. A
right temporal lobe foci, the magnitude of these dif- recent study by Camfield et al. ( 1984) compared cog-
ferences was not statistically significant. nitive ability, personality profiles, and school suc-
Some researchers have found that attention defi- cess in children with epilepsy. Groups tested were
cits related to seizure type occur in epilepsy and may children with clinically well-documented unilateral
in fact contribute to poor performance on learning left versus right temporal lobe origin of seizures. The
and memory measures. Children and adults whose children were tested using the WISC-R, the Hal-
seizures are generalized have shown greater attention stead-Reitan battery, and the Wide Range Achieve-
and concentration deficits than patients with partial ment Test (WRAT). Parents completed the Person-
seizures (Fedio & Mirsky, 1969; Glowinski, 1973; ality Inventory for Children (PIC). In contrast to
Kimura, 1964; Lansdell & Mirsky, 1964; Mirsky & Fedio and Mirsky's (1969) study with children, sig-
Van Buren, 1965). Loiseau, Signoret, and Strube nificant left versus right differences were not found
(1984) tested patients ranging in age from 15 to 36 on measures of cognitive ability, although the com-
years on learning, memory, and attention. Although bined left and right temporal lobe groups as a whole
432 CHAPTER 23
scored significantly lower than the nonepileptic con- sibility of cognitive impairment resulting from serum
trol group on the WISC-R, Halstead-Reitan, and concentrations of antiepileptic drugs in the therapeu-
WRAT. Failure to find left-right differences in cog- tic range that is of most concern in the long-term
nitive abilities may have been due to the wide range treatment of epilepsy. As indicated, detrimental ef-
ofchildren tested (6-17 years), the wide range of fects on neuropsychological abilities have been re-
duration of seizure disorder (1-12 years), and the ported for most anticonvulsants. The nature and ex-
relatively low seizure frequency. Results of past tent of these deficits vary with the drug or
studies indicate that duration of seizure disorder and combination of drugs administered, as well as the
seizure frequency are positively correlated with cog- serum concentration of the drug. Polytherapy (ad-
nitive dysfunction in epileptic children (Fedio & ministration of more than one anticonvulsant) has
Mirsky, 1969; O'Leary eta/., 1983). In addition, the been found to result in greater deficits (MacLeod,
test battery used in this study may not have been Dekaban, & Hunt, 1978; Shorvon & Reynolds,
adequately sensitive to the selective cognitive im- 1979; Thompson & Trimble, 1982). The reduction of
pairment seen in temporal lobe epilepsy. polytherapy in chronic epileptic patients, when pos-
Although the studies reviewed represent varied sible, has contributed to a better understanding of the
results with respect to the association between degree subtle effects anticonvulsants have on cognitive
of impairment and seizure type, frequency, and dura- function (Fischbacher, 1982; Shorvon & Reynolds,
tion, considered together, they suggest that in chil- 1979; Thompson & Trimble, 1983). A study of 312
dren and adults, cognitive deficits in memory exist as children with epilepsy (Trimble, Corbett, & Don-
a neurological consequence of epilepsy, that these aldson, 1980) indicated that children whose IQs dete-
deficits are present to differing extents in generalized riorated 10 to 40 points in an interval of at least I year
seizure disorders and partial seizure disorders, and had significantly higher blood levels of phenytoin
that verbal and nonverbal memory functions appear and primidone. A similar trend was found for phe-
to be Iateralized. Discrepancies in results can, in part, nobarbitone even though all serum drug concentra-
be explained by differences in test measures used tions were within the optimum therapeutic range.
across experiments, and the extent to which interven- The depletion of folate levels by anticonvulsants, in
ing variables such as seizure type and frequency, age particular phenytoin and phenobarbitone, has been
of onset, duration of disorder, and anticonvulsant suggested as the underlying mechanism of cognitive
medication were controlled. deterioration in children and adults with epilepsy
(Reynolds, 1970). This study supported this hypoth-
esis. The group with low folate levels also contained
Intellectual and Cognitive Effects of significantly more children who were being treated
Antiepileptic Drugs with phenytoin.
The antiepileptic drugs commonly prescribed
Intellectual and cognitive impairments, es- for children, their indication(s) for use, usual mainte-
pecially memory deficits, in the epileptic population nance dosages, and reported cognitive and behav-
were observed and noted in the literature long before ioral side effects are summarized in Table I. It should
the earliest anticonvulsant drugs were known (Trim- be noted that this information is representative of the
ble & Thompson, 1981). A recent study (Epir, Ren- average, and individual cases may vary.
da, & Baser, 1984) in which untreated children with
epilepsy performed more poorly on the Peabody Pic- Phenobarbital. Results of early studies (Grink-
ture Vocabulary Test and a drawing task than their er, 1929; Lennox, 1942; Somerfeld-Ziskind and
nonepileptic siblings and a control group lends sup- Ziskind, 1940) led to the conclusion that despite its
port to the earlier observations. Thus, cognitive defi- sedative properties, phenobarbital had no effect on
cits can result from seizures themselves. The disen- cognitive ability. However, with the development of
tangling of medication effects from seizure effects more sensitive neuropsychological tests and the med-
represents a formidable challenge to researchers. ical technology necessary to monitor accurately
However, there is increasing evidence that many blood levels of anticonvulsants, further investiga-
anticonvulsants affect cognitive abilities and thereby tions began to implicate antiepileptic drugs in the
add to the impairment of function caused by seizures impairment of intellectual and cognitive dysfunction.
(American Academy of Pediatrics, 1985; Corbett et Hutt, Jackson, Belshum, and Higgins (1968) tested
al., 1985; Reynolds & Trimble, 1985). the effect of phenobarbitone on nonepileptic volun-
Toxic doses of virtually all anticonvulsants can teers and found that it impaired sustained attention
affect mental functioning. It is, however, the pos- and psychomotor performance.
TABLE 1. Commonly Prescribed Anticonvulsants for Children
Usual pediatric
Generic name Chemical Primary maintenance dose
(trade name) classification indications (mg/kg per day)a Reported cognitive side effects Reported behavioral side effects
Phenobarbital Long-acting bar- Major motor 3-5 Impaired short-term memory and Hyperactivity, fussiness, disturbed
(Luminal) biturate concentration sleep, irritability, disobedience,
depressive symptoms, lethargy,
hyperemotionality, inatten-
tiveness
Primidone Barbiturate ana- Major motor 10-25 in children younger than See phenobarbital
(Mysoline) Iogue Psychomotor 8 (side effects not as pronounced)
250 mg three or four times daily
in children 8 or older
Phenytoin Hydantoin Major motor 4-8 Impaired attention and con- Fatigue, emotionality, involun-
(Dilantin) centration, problem-solving tary movements
and visuomotor performance
Ethosuximide Succinimide Absence 20 Impaired attention Mood changes, drowsiness, irri-
(Zarontin)
tability, insomnia, hyperactiv-
ity, disturbed sleep (especially 6!
night terrors), inattentiveness tll
Valproic acid Carboxylic acid Absence 10-60 Drowsiness
(Depakene) derivative Minor motor
Clonazepam Benzodiazepine Absence Not to exceed 0.2 Insomnia, aggression, irritability,
(Kionopinb) Minor motor hyperactivity, antisocial acts,
Myoclonic disobedience, social withdrawal,
auditory hallucinations, depres-
sion, mood swings
Carbamazepine Iminostllbene de- Major motor Varies with age: younger than Impaired performance on motor Agitation, insomnia, irritability,
(Tegretol) rivative struc- Psychomotor 6 years= 10-20 mglkg per tasks ~
turally similar
to the tricyclic
day; 6-12 years = not to
exceed I g/day
hyperemotionality
I
~
antidepressants
"American Hospital Formulary Service.

bformerly Clonopin. ~
e
434 CHAPTER 23
Primidone. Primidone is a barbiturate analogue Carbamazepine. Schain, Ward, and Guthrie

that is metabolized to phenobarbital and phenylethyl- ( 1977) evaluated the cognitive consequences of re-
malonamide (PEMA) whose actions may be syn- placing phenobarbital and primidone with car-
ergistic. There are little data available with respect to bamazepine treatment in children with major motor
the effect of primidone on cognitive ability in chil- or psychomotor seizure disorders. A battery of mea-
dren, although its sedative, and consequently cog- sures intended to assess general intelligence, prob-
nitive, effects may be expected to parallel those of lem-solving ability, and inattentiveness was adminis-
phenobarbital. tered. Substantial improvement in problem-solving
measures were noted with carbamazepine use. In ad-
Phenytoin. When phenytoin (Dilantin) was ini- dition, the children appeared to be more alert and
tially introduced as an antiepileptic drug, it was attentive than when they were treated with phenobar-
thought to improve alertness (Trimble, 1981). More bital or primidone and seizures were still adequately
recent research has indicated that phenytoin has ad- controlled. Thompson and Trimble (1982) also found
verse effects on psychomotor performance (Ide- carbamazepine to have a less detrimental effect on
strom, Schalling, Carlqvist, & Sjoqvist, 1972; cognitive functioning in adults.
Thompson & Trimble, 1982), concentration (An- Considerable progress has been made in the
drewes, Tomlinson, Elwes, & Reynolds, 1984; anticonvulsant control of seizures since the acciden-
Dodrill & Troupin, 1977), memory (Andrewes eta/., tal discovery of bromide at the tum of the century;
1984; Thompson & Trimble, 1982), and problem however, many questions remain concerning the ef-
solving (Dodrill & Troupin, 1977). fects of these drugs on cognitive functioning.
Of additional concern is the possibility of a phe-
nytoin-induced encephalopathy, which has been ob-
served without other clear neurological evidence of
toxicity (Reynolds, 1970). In patients with preexist- Behavioral Treatment of Seizure
ing mental retardation or brain damage, further dete- Disorders
rioration in intellectual functioning in the absence of
classical signs of toxicity may be intetpreted as an
Although a variety of antiepilepsy drugs are
effect of the underlying pathology rather than due to available to treat seizure disorders, 20% of epileptic
medication-induced encephalopathy.
patients report unsatisfactory control of their seizure
Ethosuximide. Browne et a/. (1975) studied activity (Masland, 1974). Higher levels of anti-
the effects of ethosuximide on psychometric perfor- epilepsy medication or polydrug therapy increase the
mance and noted an improvement in 17 of 37 chil- likelihood of cognitive and emotional side effects of
dren. Blood levels of ethosuximide were monitored these drugs. As a result, a compromise must often be
and remained within therapeutic ranges over the 8- achieved between minimal level of medication side
week duration of the study. These findings were in- effects and optimal level of seizure reduction. The
consistent with earlier reports (Guey, Charles, child may have to tolerate a low level of continuing
Coquery, Roger, & Soulayrol, 1967). However, 15 intermittent seizure activity because of the negative
of 25 children in the study by Guey et at. were men- effects produced by the medication.
tally retarded and taking other drugs in addition to As an alternative, behavioral treatment of epi-
ethosuximide. Nevertheless, there have been addi- lepsy may provide additional relief from the seizure
tional reports of psychosis or encephalopathy result- disorder. Biofeedback has recently been shown to
ing from ethosuximide administration (Roger, Gran- produce a significant reduction in frequency of sei-
geon, Guey, & Lob, 1968). zures, even in patients with very intractable seizure
disorders. Additional benefit is probably realized if
Valproic Acid (Sodium Valproate). Minimal the biofeedback is combined with stress management
adverse cognitive effects on psychological test per- training. Both individual and group psychotherapy
formance were noted with the use of valproic acid also yield beneficial results.
(Trimble & Thompson, 1984). In addition, it had
previously been suggested that administration of so-
dium valproate improved alertness and school perfor- Biofeedback
mance (Barnes & Bower, 1975). On the negative
side, there have been some reports of sodium valpro- Biofeedback has been used successfully over
ate-induced encephalopathy similar to that seen with the past two decades to treat a variety of psycho-
phenytoin (Davidson, 1983). physiological disorders. Biofeedback, and specifi-
cally EEG biofeedback, as a modality for treating volved in transmission of somesthetic information to
poorly controlled seizures has been shown to be of the sensorimotor cortex.
significant therapeutic value in a number of reports SMR, like alpha, theta, and other sinusoidal
published since Sterman and Friar ( 1972) published EEG rhythms, reflects an "idling" phenomenon in
their initial case study. the brain, and this may be associated with an inhibito-
Sterman and Friar treated a 23-year-old female ry process (Andersen & Andersson, 1968). How-
with a long-term seizure disorder. The seizures were ever, these sinusoidal rhythms do not reflect the same
of a nocturnal generalized tonic-clonic type and oc- process, can occur independently of one another, and
curred at a frequency of one or two per month. She have different neural generators (e.g., Shabsin,
had a childhood history of febrile convulsions but Bahler, & Lubar, 1979; Sterman & Friar, 1972).
there was no family history of epilepsy. There was Thus, these rhythms reflect idling phenomena in in-
no evidence of a localized brain lesion producing the dependent, but at times related, neurobehavioral sys-
seizure activity. She was treated with a combination tems. In the case of SMR, the idling or inhibitory
of phenytoin and mephobarbital. She was trained to process appears to be for movement or motor reflex-
produce 12- to 15-Hz activity monitored with scalp es, a view supported by some of the early research by
electrodes placed over the sensorimotor strip. Dur- Sterman and his colleagues (Sterman & Wywricka,
ing training, she showed an increase in sensorimotor 1967; Sterman, Wywricka, & Roth, 1969).
activity with depression of the alpha rhythm. She SMR biofeedback training-induced EEG changes
exhibited a rapid decrease in seizures and became that accompany seizure reduction are assumed by
seizure-free during several months of training. No Sterman ( 1984) to result from a decrease in abnormal
long-term follow-up data are available, but positive thalamocortical excitability. Wyler (1984) offered a
personality changes were reported: she became more different interpretation. He believes that the bene-
outgoing, more confident, and more interested in ficial effects of SMR training reflect a resulting pre-
her appearance. She also reported that her sleep be- vention and disruption of a synchronization of single
came more restful. neurons into an epileptogenic neuronal aggregate.
Subsequent relevant case studies and research The fact that SMR training appears to be as effective
on this procedure have been reviewed by Lubar in reducing the frequency of seizures without motor
(1984) and Sterman (1984). To date, more than 50 components as it is in reducing seizures with motor
published studies have demonstrated that EEG bio- components is support for Wyler's view (Bennett,
feedback can play a significant role in the manage- 1977).
ment of poorly controlled seizures. Unfortunately, The procedure used for EEG biofeedback in pa-
due to the cost and technological requirements of tients with epilepsy at most treatment facilities can be
establishing an EEG biofeedback laboratory, this summarized as follows (Bennett, 1977). The un-
procedure is used only by a small number of clini- filtered EEG, recorded from the sensorimotor cortex,
cians and researchers in selected medical and univer- is passed into two filters. An SMR filter selectively
sity settings. Lubar ( 1984) estimated that Jess than transmits 12- to 15-Hz activity, and the SMR is fur-
250 patients nationwide have had EEG biofeedback ther processed by an amplitude discriminator. Only
training for seizure disorders. EEG waves that are above a predetermined amplitude
The most effective EEG biofeedback approach requirement result in positive feedback to the patient.
for epilepsy appears to be a combination of training in The threshold (minimum amplitude required for
at least two waveforms. The first is the 12- to 15-Hz positive feedback) is gradually increased as training
sensorimotor rhythm (SMR), which the individual progresses.
learns to increase. The second is the 4- to 7-Hz theta In our program, for example, a green light
rhythm, which the client is trained to decrease. Pa- comes on if the threshold is surpassed; a series of
tients are typically taught to reduce the incidence of small LEOs indicates the relative waxing and waning
epileptiform spiking or sharp waves as well. of amplitude within an above-threshold train of SMR
SMR is recorded via scalp electrodes placed activity. Patients are trained to keep the large green
over the sensorimotor cortex (Rolandic cortex). SMR light on as constantly as possible and to illuminate as
is typically difficult to observe in unfiltered EEG many of the LEDs as they can.
records, but it can, at times, be fairly prominent in the The unfiltered EEG is also passed into a theta
records of highly trained individuals. This EEG filter that selectively transmits 4- to 7-Hz activity to
rhythm is generated by pools of neurons located in an amplitude discriminator. If the amplitude from
the ventrobasal nuclear complex, most likely in the this filter surpasses a predetermined threshold, nega-
ventral posteriomedial nucleus. This nucleus is in- tive feedback occurs (orange light is illuminated).
436 CHAPTER 23
The patients attempt to keep this orange light off as disorders, as it does for a variety of psycho-
much as possible. Similar negative feedback results physiological disorders, the greatest benefits of this
following the occurrence of spike waves, sharp procedure accrue when it is used as part of a total
waves, or excessive movements. treatment program. For example, for children whose
As training progresses, the patient becomes seizures are exacerbated by stress, stress manage-
more adept at increasing the incidence of SMR and ment training can be very beneficial.
decreasing epileptiform activity. Correlated with Many patients report that the connection be-
these EEG changes is a reduction in seizure frequen- tween stress and their seizures is obvious. Many
cy. The observed changes in EEG patterns during sources of stress are noted by patients, and one ap-
training are not restricted to the formal biofeedback proach is to help the child identify significant
sessions; they are observed in the sleep records of stressors in his or her life and the reactions they pre-
trained patients as well (Sterman, 1984). On the aver- cipitate. Some of these are obvious, such as stresses
age, seizure frequency decreases by 60% (Lubar, related to the home, family, friends, and school; oth-
1984; Sterman, 1984), an impressive result given the ers may be more difficult to express, such as fears of
fact that the patients who are referred for biofeedback injury or death from seizures. Once the child learns to
are typically only those with poorly controlled sei- identify the stressors and reactions to them, behav-
zures. Furthermore, both single- and double-blind ioral intervention into the stress-seizure chain is pos-
investigations have demonstrated the effectiveness of sible, and the child can master more adaptive and
this procedure (Sterman & McDonald, 1978; Lubar consequently less catastrophic responses to the
et al., 1981). Therefore, the beneficial effects that stressors. Cognitive psychotherapeutic approaches
result are not simply the product of placebo or non- can be helpful in reconditioning or substituting adap-
specific treatment effects. tive responses ~nd thought patterns for maladaptive
Since late 1980, one of us (T.L.B.) has treated ones.
approximately 30 patients with SMR biofeedback Part of stress management training can include
training (see Bennett, 1987), including children as conditioned relaxation and other techniques used to
young as 8. Results comparable to those reported by help the child maintain an overall lower level of reac-
Lubar and Sterman have been obtained. It is impor- tivity. In the first author's epilepsy treatment pro-
tant to note that we do not view biofeedback training gram, a series of tape recordings are used for home
as a "cure" for epilepsy (see also Lubar & Deering, practice including progressive muscle relaxation, au-
1981). The procedure does produce positive effects, togenics, and visualization. A visualization of epi-
but the individual is still at risk for seizures even lepsy tape is also sometimes used in which the child
though seizures have been reasonably well-con- or adult is guided in visualizing his or her seizure
trolled or entirely suppressed for a long period of focus and controlling its abnormal pattern of elec-
time. The "epileptogenic focus or seizure generator trical activity. This latter exercise generally is
process" has not been removed. For this reason, positively reviewed by the patients, partly because of
those who use these procedures should not encourage its educational value.
their patients to discontinue all antiepilepsy medica- Education is a critical component for anyone
tions. On the other hand, it may be possible with with epilepsy. As Mittan (1986) pointed out, "peo-
better seizure control following biofeedback training ple are not born knowing how to cope with epilepsy,
to lower medication levels while remaining in the and understanding does not come with the first sei-
therapeutic range or to reduce the number of drugs zure" (p. 116). As a result, the child needs to learn
taken for those individuals on polydrug therapy. about epilepsy; common fears that he or she might
These procedures would decrease the potential of have must be brought out and frankly discussed. The
negative cognitive and emotional side effects of the child must realize that there is nothing wrong in fear-
drugs, and it is certainly true that biofeedback has ing seizures or their consequences. By learning about
none of the common side effects that antiepilepsy them, the strength of the fears can be diminished.
drugs have. Family members are typically no more knowl-
edgeable than is the child with seizures, and they
must be educated about and allowed to frankly dis-
Psychotherapy cuss epilepsy as well. The child's friends or class-
mates may also want to discuss epilepsy and how to
Although biofeedback appears to produce sig- deal with seizures. The first author once talked to 80
nificant improvement for individuals with seizure fifth graders about a classmate with complex partial
seizures. It alleviated their fears (especially about the Because of the complexity of this disorder, many
risks associated with seizures), and it helped them children do not achieve adequate seizure control, and
treat their classmate more as "one of the gang." these behavioral approaches offer a promising alter-
Both children and adults with complex partial native to traditional therapy with anticonvulsant
seizures have wondered whether the symptoms of medications.
their epilepsy are a sign of psychiatric disorder. For
this reason, the child needs to be given a simple
explanation about neural mechanisms of emotional
behavior and how a seizure involving the limbic sys-
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epilepsy (pp. 224-242). Springfield, IL: Thomas. Trimble, M. R., & Thompson, P. J. (1986). Neuropsychological
Sullivan, E. B., & Gahagan, L. ( 1935). On intelligence of epilep- aspects of epilepsy. In I. Grant & K. M. Adams (Eds.),
tic children. Genetic Psychology Monographs. /7(5), 309- Neuropsychological assessment of neuropsychiatric disor-
375. ders (pp. 321-346). New York: Oxford University Press.
Tarter, R. E. (1972). Intellectual and adaptive functioning in epi- West, P. (1986). The social meaning of epilepsy: Stigma as a
lepsy: A review of 50 years of research. Diseases of the potential explanation for psychopathology in children. InS.
Nervous System, 33(12), 763-770. Whitman & B. P. Hermann (Eds.), Psychopathology in epi-
Thompson, P. J., Huppert, F. A., & Trimble, M. R. (1981). lepsy: Social dimensions (pp. 245-265). New York: Oxford
Phenytoin and cognitive function: Effects on normal volun- University Press.
teers and implications for epilepsy. British Journal of Whitman, S., & Hermann, B. P. (Eds.). (1986). Psychopathology
Clinical Psychology. 20. 155-162. in epilepsy: Social dimensions. New York: Oxford University
Thompson, P. J., & Trimble, M. R. (1982). Anticonvulsant drugs Press.
and cognitive functions. Epi/epsia, 23, 531-544. Wilkus, R. J., & Dodrill, C. B. (1976). Neuropsychological corre-
Thompson, P. J., & Trimble, M. R. (1983). The effect of anticon- lates of the EEG in epileptics. I. Topographic distribution and
vulsant drugs on cognitive function: Relation to serum levels. average rate of epileptiform activity. Epilepsia, 17, 89-
Journal of Neurology. Neurosurgery, and Psychiatry, 46, 100.
227-233. Wyler, A. F. (1984). Operant conditioning of single neurons in
Trimble, M. (1981). Anticonvulsant drugs, behavior, and cog- monkeys and its theoretical application to EEG operant con-
nitive abilities. Current Developments in Psychophar- ditioning in human epilepsy. InT. Elbert, B. Rockstroh, W.
macology, 6, 65-91. Lutzenberger, & N. Birbaumer (Eds. ), Self-regulation of the
Trimble, M. R., Corbett, J., & Donaldson, J. (1980). Folic acid brain (pp. 85-94). Berlin: Springer-Verlag.
and mental symptoms in children with epilepsy. Journal of Zimmerman, F. T., Burgemeister, B. B., & Putnam, T. J. (1951).
Neurology, Neurosurgery, and Psychiatry, 43, 1030-1034. Intellectual and emotional makeup of the epileptic. Archives
Trimble, M. R., & Thompson, P. J. (1981). Memory, anticonvul- of Neurology and Psychiatry, 65, 545-556.
24
Neuropsychological Effects of
Stimulant Medication on Children's
Learning and Behavior
RONALD T. BROWN AND KATHI A. BORDEN
Historical Overview (NIMH) established the Psychopharmacology Branch

Service Center to serve as a primary source of federal
Bradley's (1937) seminal publication of the ame- support for psychopharmacological research, and
liorative effects of Benzedrine on behavior-disor- greater attention began to be paid to the disparity
dered children had significant impact on pediatric between empirical validation and the clinical use of
psychopharmacology and to a large extent altered stimulants. The first NIMH grant in pediatric psycho-
child psychiatric and neurological services in this pharmacology was awarded to Leon Eisenberg, MD,
country. According to Bradley and his colleagues, of Johns Hopkins University, who investigated the
the main clinical effects of stimulant drugs were re- effects of stimulants on children's behavioral and
duced hyperactivity, distractibility, and impulsivity cognitive functioning. In collaboration with Conners
in children who had not responded to traditional psy- (Conners & Eisenberg, 1963), he replicated the
chotherapy. Ironically, Bradley's earlier clinical ob- clinical findings presented by Bradley and his group
servations, which were based on insufficient investi- (Bradley, 1937), thus empirically establishing the
gation and inadequate methodology, are generally short-term efficacy of stimulant medication through
consistent with contemporary research findings, well-controlled clinical trials.
which generally support the efficacy of stimulants in Despite the widespread clinical use of stimulant
improving performance on a wide array of cognitive medication in the 1950s, it was not until the 1960s
tasks and decreasing disruptive behaviors (Git- that extensive efforts were made to study systemat-
telman, 1983). ically the effects of stimulants in children. From
Building upon Bradley's work and attempting to those efforts grew a reliable and standardized rating
diagnostically classify behavior-disordered children system by which to assess stimulant medications
into more homogeneous subgroups, Laufer and his (Conners, 1969). Also during this time, research on
associates (Laufer, Denhoff, & Solomons, 1957) de- the effects of stimulant drugs became more meth-
termined that amphetamines acted most positively in odologically rigorous, and much greater emphasis
the behaviorally disordered children who exhibited was placed on assessing the target response in care-
the ''hyperkinetic impulse'' disorder. Methylpheni- fully controlled clinical trials. More important, care-
date was introduced in the 1950s to avoid the un- ful attention was paid to the systematic documenta-
toward side effects and potential abuses of amphet- tion of side effects, which had been clinically de-
amines. scribed as early as the 1930s (Bradley, 1937) but had
In 1956 the National Institute of Mental Health never been carefully documented. Because most re-
search on stimulant use with children (including our
own work) has been focused on attention deficit dis-
RONALD T. BROWN Division of Child and Adolescent orders (ADD), this chapter is largely devoted to the
Psychiatry, Emory University School of Medicine, Atlanta, Geor- ADD population.
gia 30322. KATHI A. BORDEN Department of Psy- Some have considered the 1970s a "profes-
chology, Pepperdine University, Los Angeles, California 90034. sional and lay backlash" (Dulcan, 1986) to the en-
443
444 CHAPTER 24
thusiastic use of stimulants; teachers and physicians erable progress has been made in the past 30 years to
were accused of "drugging children, especially poor examine more carefully the effects of stimulant medi-
ones, into submission" (Dulcan, 1985, p. 383). As a cation on children's learning and behavior. This pro-
result, research efforts in pediatric psychophar- gress has been largely due to the interdisciplinary
macology increased further, and even more meth- efforts of the neuropsychologist, the pediatric neu-
odologically rigorous studies proliferated. Some of rologist, the child psychiatrist, the pediatrician, and
the more fruitful studies provided valuable research the pharmacologist. Distinct but complementary
data on the characteristics of children who would knowledge from various disciplines has resulted in a
particularly benefit from the use of stimulants (Sat- more complete understanding of the actions and
terfield, Cantwell, & Satterfield, 1974). In the vir- mechanisms of stimulant medication in the research
tually unexplored areas of pediatric psychophar- laboratory and in the clinical setting.
macology, studies were concentrated on the dosages
of stimulant medication (Brown & Sleator, 1979;
Sprague & Sleator, I 977) (pediatric dosages had sim- Frequently Used Stimulant
ply been extrapolated from adult dosage levels). Fur-
ther, the side effects of stimulants in children were
Medications
studied much more systematically, for example, the
possibility of growth suppression (Safer, Allen, & Psychostimulants may be defined as the class of
Barr, 1972), the potential for deleterious drug in- drugs that produces excitation of the central nervous
teractions (Fisher & Wilson. 1971), and the long- system. The most commonly prescribed are the dex-
term effects of stimulants (Weiss, 1983). Well-con- troamphetamines, methylphenidate, and pemoline,
trolled clinical trials were conducted with pemoline each of which is widely used in treating behavior and
(Cylert), which was introduced for pediatric use dur- learning problems, which are typically associated
with externalizing disorders in children.
ing this period (Conners, 1972).
The late 1970s and the early 1980s have been a It has been estimated that I to 2% of all elemen-
tary school children are prescribed some type of stim-
very exciting tertiary stage in the refinement of drug
trials and systematic study of stimulants for chil- ulant medication (Bosco & Robin, 1980). Although
dren's learning and behavioral problems. Recent rates of diagnosis and stimulant drug treatment have
publications (Gittelman, 1983; Rapoport, 1983) have been found to vary widely among school districts,
stimulant drug treatment has not been found to corre-
typically underscored the generally accepted notion
that stimulants are the drugs of choice for decreasing late to socioeconomic status (Bosco & Robin, 1980),
restlessness and impulsive behaviors and for improv- thus contradicting the unsupported claim in the 1970s
that these agents were being used to "drug" poor
ing attention span in hyperactive and behavior-disor-
dered children. Research is under way to more care- children into submission (Dulcan, 1985). According
fully systematize target response to cognitive, social, to recent research, the rate of prescribing stimulant
and academic variables (Pelham, Bender, Caddell, medication has increased significantly in the past
several years, particularly for older children and ado-
Booth, & Moorer, 1985), and well-designed research
lescents (Safer & Krager, 1985), so the need for em-
(Douglas, Barr, O'Neill, & Britton, 1986; Pelham et
pirical knowledge of the long- and short-term effects
al., 1985; Stephens, Pelham, & Skinner, 1984) has
of psychostimulants has become even more pressing.
begun to address the general ineffectiveness of stim-
Agreement has been fairly widespread that the
ulants on academic achievement. In addition, the ef-
main indications for stimulant drug therapy are
fects of stimulants on growth have been studied more
hyperactivity 2 and short attention span (Rapoport,
systematically. Recent research efforts in the phar-
macokinetics (absorption, metabolism, distribution,
and excretion) of stimulants are providing greater 1Deanol is a stimulant that has yielded some positive clinical find-
knowledge of the physiological mechanisms that ings (Donnelly & Rapoport, 1985); however, it will not be cov-
will, we hope, translate into clinical application ered here, as it is not in general use and its pharmacology is not
(Rapoport, 1983). Although a prodigious amount of well described. Caffeine is another stimulant that will not be
discussed here, as no significant improvement has been found as a
empirical research has generally attested to the supe- function of therapeutic caffeine use (Donnelly & Rapoport,
riority of stimulants over other nonsomatic therapies 1985).
(Gittelman, 1983; Rapoport, 1983), the combination 2Jn accordance with the Diagnostic and Statistical Manunl ofMen-
of stimulant medications and other psychotherapeu- tal Disorders (American Psychiatric Association, 1980), children
tic approaches is also being studied (Gadow, 1985b). clinically diagnosed as hyperactive are referred to as having atten-
Although new areas await investigation, consid- tion deficit disorder with hyperactivity (ADD/H). Because many
NEUROPSYCHOLOGICAL EFFECTS OF STIMULANT MEDICATION 445
1983). In fact, Barkley (1977), in reviewing 110 Despite considerable debate in the pediatric lit-
studies of more than 4200 ADD/H children, found erature about the appropriate clinical dosage of dex-
that 75% could be judged as improved after a brief troamphetamine, we have few empirical studies to
course of stimulant drugs. Although much research guide clinical efforts. Wender (1971) and Solomons
has been conducted on the behavioral and cognitive (1973) recommended a starting dose of 5 mg three
effects of the stimulants, we have little data on the times per day, yet they emphasized that many chil-
cause, nature, and effects of any biochemical abnor- dren can tolerate much higher doses (20 mg per day is
malities that may exist in the groups that have been considered a median dose). Others have advocated
treated effectively with stimulants (Dulcan, 1986). lower doses for children (Gross & Wilson, I974).
Moreover, we know little about the pharmacodynam- According to some experts (Ross & Ross, 1982), one
ics (mechanisms of action and interactions with bio- advantage of dextroamphetamine over methylpheni-
logical receptors) of psychostimulants. date is that the former, because it is more resistant to
The most commonly used stimulants-dex- gastric juices, need not be administered on a special
troamphetamine (Dexedrine) and methylphenidate schedule related to meals (methylphenidate, which is
(Ritalin), both of which are sympathomimetic destroyed by gastric activity, must be administered
amines, and pemoline (Cylert)-and their basic ef- 30 minutes before meals).
fects are presented in Table 1.
Dextroamphetamine Methylphenidate
The oldest of the psychostimulants, dextroam- Methylphenidate, which is structurally related

phetamine is believed to potentiate both dopamine to dextroamphetamine, is a piperidine derivative that
and norepinephrine by stimulating the release of acts by releasing stored dopamine from the reserpine-
newly synthesized dopamine into the synaptic cleft, sensitive presynaptic vasicular pool, decreasing
inhibiting presynaptic uptake and inhibiting mono- dopamine reuptake, and inhibiting monoamine ox-
amine oxidase (Dulcan, 1986). Following the oral idase (Dulcan, I986). Similar to the dextroamphet-
ingestion of dextroamphetamine, peak plasma levels amines, methylphenidate is poorly bound to plasma
are believed to occur 3 to 4 hours after administra- proteins, but it is rapidly metabolized to ritalinic
tion; the elimination half-life of the drug ranges from acid. Peak serum concentration typically occurs I to
6 to 7 hours in children and is even more rapid in 3 hours after oral administration, although peak plas-
adults (Dulcan, I986). The behavioral effects typ- ma concentrations vary from person to person (per-
ically occur I to 4 hours after oral administration and haps because of individual idiosyncratic rates of ab-
often correspond to the absorption phase. Little rela- sorption) (Chan et al., 1983). The elimination half-
tionship has been found between behavioral response life of methylphenidate is rather short (2 to 4 hours),
ratings across individuals and plasma amphetamine so accumulation is virtually nonexistent.
levels (Rapoport, I983). Methylphenidate is given to approximately two
Dextroamphetamine may be administered in thirds of all children who have ADD and who are
tablet form or as a sustained-release (S-R) capsule, given stimulants. It is typically administered in two
which acts for 6 to I8 hours. No significant dif- divided doses, although some experts consider a sin-
ferences have been found in elimination half-life or gle morning dose (20 mg) sufficient to improve
behavioral response resulting from the two dosage school performance (Huey, 1985). Single doses of S-
forms (Ross & Ross, I982). Although tablets offer R forms are also available. Whitehouse and his asso-
the advantage of systematic dosage monitoring, the ciates (Whitehouse, Shah, & Palmer, 1980) com-
S-R form requires only one daily administration, thus pared S-R methylphenidate and standard doses and
eliminating the need for school personnel to admin- found no differences in clinical and side effects. The
ister medication. Some very recent research has sug- dependent measures they used were quite global and
gested adverse effects if the child chews the capsule thus did not permit sensitive comparison of the two
rather than swallows it (Dulcan, 1985). dosage forms. Moreover, because the clinical effects
have been found to dissipate 4 hours after administra-
of the studies reviewed in this chapter were published prior to tion (Ross & Ross, 1982), many practitioners consid-
1980 and used previous diagnostic criteria, the tenn ADD/H here er twice daily doses necessary to sustain clinical ef-
will signify any subjects referred to in research reports as either fects. Research using a more sensitive measurement
hyperactive, attention deficit disordered, or attention deficit dis- system of the efficacy of the S-R form needs to be
ordered with hyperactivity. undertaken.
~
1:1:1
~
~
TABLE 1. Indications, Adverse Effects, and Medical Management of Stimulants in Children
Dextroamphetamine Methylphenidate Pemoline

(Dexedrine) (Ritalin) (Cylert)
Diagnosis
Indications
Definite ADD/H ADDIH ADDIH
Possible Residual ADD/H Residual ADD/H Residual ADD/H
Conjectural ADD without hyperactivity; conduct disorder; behavioral impulsivity; inattentiveness; specific developmental
(learning) disorders; emotional lability
Workup Physical and neurologic examination (height and weight, blood pressure, pulse, and dyskinetic movements),
routine laboratory tests (CBC with differential, blood chemistry profile, urinalysis)
Pharmacology
How supplied (mg) 5, 10 5, 10, 20, SR-20 18.75; 37.5, 75.0

Single-dose range 0.15-0.5 0.3-0.7 0.5-2.5
Daily dose range
mg/kg per day 0.3-1.25 0.6-1.7 0.5-3.0
mg/day 5-40 10-60 18.75-37.5
Initial dosage 2.5 mg 2 to 3 times/day 5 mg 2 to 3 times/day 18.75 mg each morning
Therapeutic dosage I mg/kg per day 0.3 mg to 2 mg/kg per day 75 mg/day in single daily dose
Peak plasma level 3 to 4 hours I to 3 hours I to 3 hours
Plasma half-life 6 to 7 hours 2 to 3 hours 4 to 15 hours
Peak clinical effect I to 4 hours I to 3 hours If prescribed as indicated, several weeks
after treatment begins, therapeutic ef-
fect is generally sustained over several
hours
Onset of behavioral effect I hour I hour Variable
Duration of behavioral effect I hour 3 to 4 hours 6 to 8 hours
Side effects
Common adverse reaction Difficulty in falling asleep, mild elevation of pulse and blood pressure
Less frequent adverse reactions Decreased appetite (temporary), crying and dysphoria, growth retardation (height and weight, mild), drow-
siness, anxiety, and irritability
Serious but unusual adverse Psychotic thoughts, lowered seizure threshold, worsen- Psychotic thoughts, lowered seizure threshold,
reactions and precautions ing of tic disorder or dyskinesia, potential for medica- worsening of tic disorder or dyskinesia, po-
tion abuse, hypertension tential for medication abuse, hypertension,
hepatocellular injury, elevated serum glu-
tamic pyruvic transaminase
Special considerations
Relative contraindications Marked anxiety, agitation or psychosis, glaucoma, verbal-motor tic (Tourette's syndrome)
Toxicity/overdose Irritability, restlessness, agitation, nausea, diarrhea, High fever, sweating, high pallor, flushing,
fever, sweating, pallor, flushing, arrhythmias, tachy- arrhythmias, tachycardia, significant by-
cardia, significant hypertension, delirium, tremor, pertension, delirium, tremor, convulsions,
convulsion, coma coma
Drug interactions Increase blood level of tricyclic antidepressants, increase metabolism of phenytoin, oppose effect of anti-
hypertensives, acetazolamide increases renal absorption of amphetamines
;
~
Follow-up Record height and weight every 3 to 6 weeks, follow Record height and weight every 3 to 6
blood pressure, pulse, and dyskinetic movements, per- weeks, follow blood pressure, pulse, and
form yearly physical examination and routine labora- dyskinetic movements, perform yearly
tory tests physical examination and routine labora-
tory tests (liver function tests are particu-
larly important)
I
~
e
I
I
~
448 CHAPTER 24
According to some clinical literature (Gilman, their data as supporting a linear relationship between
Goodman, & Gilman, 1980), methylphenidate is doses of methylphenidate on cognitive and behav-
vulnerable to destruction by gastric acidity, thus re- ioral indices (Stephens et al., 1984; Rapport, Stoner,
quiring that the drug be administered 30 minutes be- DuPaul, Birmingham, & Tucker, 1985; Rapport,
fore meals. Swanson and his colleagues (Chan eta/., DuPaul, Stoner, Birmingham, & Masse, 1985b).
1983; Swanson, Sandman, Deutsch, & Baren, 1983) The disparity in findings is particularly troublesome
questioned this standard administration practice to practitioners seeking optimal doses for their pa-
(Gilman et a/., 1980) and specifically investigated tients. The high degree of variability among the chil-
the effect of food on the absorption of an oral dose of dren for whom methylphenidate may be considered
methylphenidate. Taking the drugs 30 minutes be- appropriate may in fact decrease generalizability be-
fore or with breakfast produced no significant dif- tween studies unless the conditions and subject sam-
ferences in the children's cognitive, behavioral, or ples are precisely replicated. Further, the side effects
physiological performance. In fact, the plasma con- have been shown to increase with higher doses
centration peaked sooner when the drug was ingested (Sprague & Sleator, 1977). The careful monitoring
after a meal rather than before, with no significant (cognitively and behaviorally) of individual patients
differences in plasma concentration. and the systematic documentation of side effects is
As is true of dextroamphetamine, little rela- indeed necessary to achieve the desired clinical
tionship has been found between plasma level and response.
oral doses of methylphenidate. To complicate this The comparative efficacy of methylphenidate
matter even further, dose-response curves vary in and dextroamphetamine has been investigated in
accordance with the effects measured (Sprague & well-controlled clinical trials (Arnold, Christopher,
Sleator, 1977). Thus, the appropriate dosage of & Huestis, 1978; Weiss, Minde, Douglas, Werry, &
methylphenidate has been a source of debate Sykes, 1971). Conners (1971) reported that the drugs
throughout the pediatric literature (Gittelman, 1983). seemed equally efficacious on most outcome mea-
For example, to better understand the effects of stim- sures except that methylphenidate was superior on
ulants on learning, several investigators have studied several subtests of the WISC and produced fewer side
the relationship between dosage of methylpheni- effects. Weiss et al. (1971) found methylphenidate
date and target response (Brown & Sleator, 1979; slightly more efficacious and the side effects com-
Brown, Slimmer, & Wynne, 1984; Sprague & parable to those of dextroamphetamine. Although
Sleator, 1977). Some of that research has provided some investigators have found that behavioral ratings
information on the methylphenidate dosage levels improve more with dextroamphetamine than with
that seem to enhance the learning performance of methylphenidate (Arnold et at., 1978), others have
ADD/H children. The data from all three studies found methylphenidate more effective in improving
indicate that learning performance in children is most learning (Fish, 1971). Some researchers have sug-
improved when methylphenidate is restricted to a low gested that a poor response to one of these medica-
dosage and that peak cognitive results are obtained by tions warrants a trial of the other.
administering 0.3 mg/kg body weight. Most impor-
tant, high doses (1.0 mg/kg) were detrimental to
learning performance on a short-term memory task. Pemoline
Lower doses (Brown & Sleator, 1979) enhanced
careful performance on the Matching Familiar Fig- A third stimulant medication-magnesium
ures Test (Kagan, 1965), a clinical index of im- pemoline-is structurally dissimilar to dextroam-
pulsivity on which ADD/H children generally re- phetamine and does not have similar sym-
spond rapidly or make many errors. In contrast, when pathomimetic activity, but it has compared favorably
the classroom behavior of each child was examined, with dextroamphetamine and methylphenidate in
the teacher reported continued improvement in the short-term trials (Dulcan, 1986). The particular ad-
child's social behavior as the dose increased from 0. 3 vantage of pemoline over other stimulants is that only
mg/kg to 1.0 mg/kg. Although these studies have a once-daily administration is necessary because its
been supported by subsequent empirical studies half-life averages 12 hours (Dulcan, 1986). Although
(Brown et al., 1984; Douglas et at., 1986), not all the mechanisms of action and the pharmacokinetics
studies have found impairment in cognitive perfor- are far less understood than for the other stimulant
mance and learning at higher doses (Charles, Schain, medications, one of the clear drawbacks of pemoline
& Zelniker, 1981; Stephens et al., 1984; Whalen & is its slower onset of action. Compared with meth-
Henker, 1984). Many investigators have interpreted ylphenidate and dextroamphetamine, in which
changes may be discerned a few hours following in- Despite the widespread usage of stimulant med-
gestion, the beneficial clinical effects of pemoline ication for this population, some experts have con-
may not be noted for several weeks (Dulcan, 1986). cluded that these figures may represent the overuse
Kinsboume and Swanson (1980) reported, however, and abuse of stimulants by many practicing profes-
that an initial larger dosage of pemoline (recom- sionals (Weiss & Hechtman, 1979). From our
mended dose is 18.75 mg to 37.5 mg) followed by clinical and research experience, we are inclined to
two daily doses of the recommended amount pro- agree. Nonetheless, the debate about the potential
duced an immediate effect. The clinical effects of overuse and abuses of stimulants has spawned many
pemoline have been sustained for as long as 2 weeks empirical studies on the efficacy of stimulant medica-
following its discontinuation (Conners & Taylor, tion. Having gathered several hundred reprints and
1980), and the half-life has increased markedly with preprints as well as many literature reviews while
continued administration (Sallee, Stiller, Perel, & preparing this chapter, we can certainly affirm that
Bates, 1985). psychostimulant medication is the most meticulously
Although the short-term efficacy of pemoline studied and best researched topic in pediatric psycho-
has compared favorably with the other stimulants pharmacology. Some practitioners, in fact, have en-
(Conners & Taylor, 1980), there has been some ques- dorsed the use of stimulants for ADD/H children
tion as to whether pemoline is as effective long-term. because it is the best-documented therapy in child
Some researchers have suggested that it is not (Swan- psychiatry (Gittelman, 1983).
son, Kinsboume, Roberts, & Zucker, 1978). Severe
dysphoria has been observed following the cessation
of pemoline therapy (Brown, Borden, Spunt, & Cognitive Effects
Medenis, 1985), and abnormal liver function tests,
particularly during prolonged therapy (Gillman et Many careful studies have clearly demonstrated
al., 1980), have been noted. Moreover, its safety and that stimulant drugs consistently improve perfor-
efficacy for children under the age of 6 have not been mance on basic laboratory tasks of cognitive perfor-
established (Gilman et al., 1980). The advantages of mance (Barkley, 1977). The efficacy of stimulants
pemoline over the other stimulants are the single- has been thoroughly documented in the areas of sus-
dose schedule and less significant cardiovascular ef- tained attention and vigilance (Solanto, 1984). Spe-
fects (Page, Bernstein, Janicki, & Michaelli, 1974). cifically, methylphenidate treatment has signifi-
Nonetheless the few studies that have been published cantly increased the number of ADD/H children's
have suggested that more studies must be conducted correct responses on the Continuous Performance
before the long-term clinical efficacy of pemoline Task (Mirsky & Rosvold, 1963) and has improved
can be endorsed. their simple reaction time on this task (Solanto,
1984); it has also improved performance on the
Matching Familiar Figures Test (Kagan, 1965) and
Clinical Uses on the Porteus Mazes, two frequently used laboratory
measures of impulsivity, both of which require the
inhibition of an incorrect response (Brown & Sleator,
ADD 1979; Rapport et al., 1985b).
On other cognitive tasks, including rote learn-
Treatment Prevalence ing, memory, and concept formation, stimulants
have been found to enhance performance. For exam-
The clinical use of psychostimulant medication ple, on the paired-associate learning test, in which
remains the most common treatment for ADD/H the subject is presented with word pairs and subse-
(Gadow, 1981). Gadow estimated that 300,000 to quently asked to respond with the stimulus (initial)
600,000 children in the United States were receiving word or picture alone, there have been several reports
stimulant medication to control hyperactivity. State- of fewer errors after methylphenidate administration
ments have been made as to higher rates to stimulant (Solanto, 1984). Weingartner et al. (1980), who
drug usage; in fact, the press once reported that 20 to found that amphetamines improved the cued recall of
25% of the children in Omaha schools were receiving acoustically processed words in ADD/H subjects,
these drugs (Weiss & Hechtman, 1979). Although interpreted their findings to suggest that dex-
those percentages were later disclaimed, they under- troamphetamine treatment merely stimulates memo-
score the enthusiasm for treating ADD/H children ry function rather than correcting or altering a basic
with stimulant drugs. deficit in cognitive processing. (The clinical implica-
450 CHAPTER 24
tions of this interpretation are discussed later in this ling, guiding, or disciplinary actions with children
section.) Gan and Cantwell (1982) found that al- who were receiving methylphenidate as compared
though methylphenidate improved acquisition on a with children on placebo doses (Whalen, Henker, &
basic learning task, it had no effect on retention 24 Dotemoto, 1981). Dextroamphetamine and meth-
hours after learning took place. Dykman and his col- ylphenidate have been found equally effective in
leagues (Dykman, Ackerman, & Oglesby, 1979), ameliorating behavioral difficulties in ADD/H
examining the effect of methylphenidate on a visual children.
search task, found a decreased frequency of after- Concerning motoric effects, the psycho-
search lapses and extraneous responses in ADD/H stimulants have decreased activity levels in struc-
children. tured settings, but the effects have been more vari-
The neuropsychological measures that have able in less restricted situations (Donnelly &
demonstrated greater variability in stimulant drug ef- Rapoport, 1985). One study, which took place in a
fects are the Bender Visual Motor Gestalt Test, the naturalistic setting and used 24-hour monitors, dem-
Frostig Developmental Test of Visual Perception, onstrated that dextroamphetamine significantly de-
and particular scales on the Wechsler Intelligence creased activity in a structured classroom and signif-
Scale for Children, such as the picture completion icantly increased activity during physical recreation
subtest (Kavale, 1982). It has been suggested that (Porrino, Rapoport, Behar, Ismond, & Bun-
because ADD/H children typically use more imma- ney, 1983). Similarly, Whalen and her associates
ture strategies for approaching cognitive tasks than (Whalen et al., 1978) found that methylphenidate
do normally developing children, stimulant drug im- reduced ADD/H boys' gross motor movements, vo-
provement may tend to occur more frequently on rote cal noise, and disruption in a classroom to a level
or simple tasks than on measures that require higher- indistinguishable from the boys' normal peers.
order information processing (Douglas & Peters, Methylphenidate has also been found to improve
1979). This hypothesis has been corroborated by handwriting (Whalen, Henker, & Finch, 1981) in
Adams (1982), who found that methylphenidate had ADD/H children.
limited effects on a task requiring higher-order
schemata.
Paradoxical Effects
The effects of stimulants on ADD/H children
Behavioral and Motor Effects have been regarded as paradoxical, and a favorable
drug response bas often been viewed as confirmation
A prodigious number of well-controlled studies
of a diagnosis of ADD/H. Contrary to this popular
have consistently demonstrated that psychostimu-
clinical lore, "normal" children and adults have
lants dramatically improve the behaviors of ADD/H cognitive and behavioral effects that are similar to the
children, sometimes to the point that the children are
effects of psychostimulants on ADD/H children
indistinguishable from their normal peers (Abikoff & (Rapoport, 1983). Moreover, normal and ADD/H
Gittelman, 1985; Whalen et al., 1978). Ullmann and
children have similar physiological responses (e.g.,
Sleator (1985), using a multidimensional teacher rat-
heart rate slows more during the foreperiod of a reac-
ing scale, demonstrated that methylphenidate dra- tion time task). This finding suggests that stimulant
matically improves attention and helps somewhat in
actions are not specific to ADD/H children and that
decreasing activity level but that it often has minor exploring the efficacy of stimulants with other clini-
effects on deficient social skills and aggressive-op- cal populations (e.g., children who have learning
positional behavior. Improvement on parent and disabilities and conduct disorders) may indeed be
teacher rating scales of hyperactivity has been shown
warranted.
in many studies (Rapoport, 1983).
Positive changes have also been reported with
stimulant drug treatment in mother-child interac- Learning Disabilities
tions (Barkley, Karlsson, Pollard, & Murphy, 1985)
and in teacher-child interactions (Whalen et al., Most of the studies on the effects of stimulant
1978; Whalen, Henker, &Dotemoto, 1981). Barkley drugs and learning performance have been conducted
(1981) found that as children's compliance to mater- with ADD/H children, some of whom were also
nal commands increased (as a function of stim- learning disabled (Gadow, Torgesen, Greenstein, &
ulants), mothers provided more positive attention. Schell, 1986). Few researchers have examined the
Similarly, teachers used significantly fewer control- efficacy of stimulants on non-ADD/H children who
have learning disabilities. Although we found no fig- 12 weeks. The subjects, none of whom demonstrated
ures on the number of learning-disabled children who signs of hyperactivity or behavior disorders, were 2
receive medication for learning problems alone, years behind in reading achievement. The findings
clinical experience tells us that the number is proba- indicated significantly improved performance on lab-
bly quite small (Gadow et al., 1986). oratory measures of attention, cognitive perfor-
Learning disabilities is clearly a heterogeneous mance, and arithmetic achievement for the meth-
diagnostic category. Children who have learning dis- ylphenidate group. The methylphenidate and placebo
abilities are typically categorized by a deficit in a groups showed no differences in reading achieve-
specific academic area, such as reading, arithmetic, ment. These findings may suggest that stimulants
or spelling. The diagnostic category is further com- significantly affect attentional deployment but have
plicated because the terms learning disability, hyper- little effect on complex academic tasks such as
activity, minimal brain dysfunction, and attention reading.
deficit disorder are used interchangeably. In fact, In an attempt to isolate a subgroup of reading-
these terms are often lumped under the diagnostic disabled children who might be positive meth-
rubric learning disability. To complicate matters ylphenidate responders, Gittelman (1980) examined
even further, much research has shown that many stimulant drug responses in reading-disabled chil-
children with learning disabilities have attentional dren who showed evidence of neurological soft signs
deficits (as do their ADD counterparts) and are more (minimal brain dysfunction) and in their reading-dis-
susceptible to extraneous distractors (Douglas & Pe- abled peers who showed no such signs. The data
ters, 1979). Because learning-disabled and ADD failed to indicate that the reading-disabled children
children share similar symptomatology (Douglas & with minimal brain dysfunction are more likely to
Peters, 1979), it is logical and enticing to expect improve in reading because of methylphenidate ther-
learning-disabled groups to respond to stimulants apy. This study is of prime clinical importance be-
similarly as do ADD!H children. It is of course quite cause it does not support the notion that learning-
dubious that stimulants enhance knowledge of com- disabled children who have neurological deficits
plex academic tasks. Thus, if psychostimulants were coupled with a specific learning disability (reading
to be effective for children with specific learning disorder) are necessarily good candidates for stim-
disabilities, it would only be reasonable to expect ulant drug therapy.
these children to learn better because their improved As stimulants have been found particularly
attentional capacity would increase their capacity for efficacious in ameliorating the attentional deficits of
instruction (Gittelman, 1983). ADD/H children, a reasonable hypothesis is that
A review of the empirical literature has revealed stimulant medication may enhance attentional capac-
very few stimulant drug studies of non-ADD/H, ity in learning-disabled children, thus making them
learning-disabled children. Of those few, most have more receptive to reading instruction. To learn
been conducted with reading-disabled children. Be- whether stimulant medication may facilitate a special
cause reading disabilities make up the largest catego- education or remedial approach to learning dis-
ry of learning disabilities (Bryan & Bryan, 1978), we abilities, Gittelman and her associates (Gittelman,
mainly review tbe studies of children with reading Klein & Feingold, 1983) compared two groups of
disabilities (we do mention stimulants and arith- reading-disabled children in a double-blind study.
metical disabilities). Both groups received reading remediation; one group
Huddleston, Staiger, Frye, Musgrave, and was given a placebo, and the other was given meth-
Stritch ( 1961) conducted the first placebo-controlled ylphenidate. Although the latter group showed en-
study of stimulant drug effects on reading perfor- hanced attentional deployment on a series of cog-
mance. Deanol, which is a relatively weak and less nitive tasks, the clinical advantage induced by meth-
potent stimulant than methylphenidate, dextroam- ylphenidate was not dramatic (Gittelman, 1983).
phetamine, or pemoline, was compared with placebo Although support for the efficacy of stimulants
doses in 60 retarded readers for 8 weeks. Scores on in the academic domain (Gadow et al., 1986) has
the Gates Reading Test showed no drug effects on been limited, some of the disappointing findings
reading performance. have been attributed to high doses of stimulants,
In a methodologically rigorous study of 6 I chil- which in comparison with relatively lower doses,
dren who had been referred by teachers because of have decreased cognitive effects (Brown & Sleator,
poor academic performance, Gittelman-Klein and 1979; Brown et al., 1984; Sprague & Sleator, 1977).
Klein (1976) investigated the efficacy of meth- Aman and Werry ( 1982) examined the effects of low
ylphenidate versus placebo in matched controls for doses of methylphenidate (0.35 mg/kg body weight)
452 CHAPTER 24
in a crossover design utilizing three drug conditions: & Clingerman, 1986), subjects included children
methylphenidate, diazepam (Valium), and a with dual diagnoses-conduct disorder and ADD/H.
placebo. Subjects were 15 children who lagged 2 Whether stimulants will prove effective for con-
years behind their mental age in reading achieve- duct disorders remains to be addressed, but we are
ment. No differences were found, probably because encouraged by the comprehensive reviews of stim-
of the short time (6 days) that the children received ulant drug effects (Pelham & Murphy, 1986) that
stimulant medication. The length of drug treatment is have suggested that the target behaviors demonstrat-
crucial in studying children with learning disabilities ing clearest improvement are the disruptive and anti-
because the capacity for improved learning over social behaviors. If that suggestion proves accurate,
time, not improved performance per se, is the vari- the response to stimulant drugs in conduct-disordered
able of interest (Gittelman, 1983). groups may be similar to the effects observed in their
We found only one methodologically adequate ADD/H peers. Rapoport (1983) pointed out that
study that included an arithmetic achievement test as many subjects in the earlier studies were unselected
a dependent measure (Gittelman-Klein & Klein, delinquent populations (Risenberg et al., 1963), sug-
1976). Clearly, additional research is needed before gesting that a "pure" conduct-disordered group
any definitive statement can be made about learning would in fact benefit from stimulants.
disabilities and stimulants. In comparison to the ex- Further supporting the clinical use of stimulants
tensive research on the effects of stimulants in for conduct-disordered children are the clinical gains
ADD/H children, studies of the effects of stimulants in sociability and the reductions in aggression seen in
on learning disabilities have been decidedly disap- ADD/H children (Rapoport, 1983). A double-blind
pointing. Aman (l982a) reviewed six fairly rigorous crossover study of the response to stimulants in a
studies of stimulant drug effects in children who had group of conduct-disordered children with atten-
academic difficulties. His conclusion agrees with tional problems and in a group without attentional
Gittelman's (1983) advice that clinicians should use problems should be conducted. The systematic study
caution in prescribing stimulants for learning-dis- of a group with dual diagnoses of ADD/Hand con-
abled children without hyperactivity until research duct disorders versus a group with "pure" conduct
shows more promise in using stimulants with this disorders would also be fruitful.
population.
Mental Retardation
Conduct Disorders
In a lucid and thorough review, Gadow ( 1985b)
We found no studies on the efficacy of stimulant noted that stimulants are the psychotropic drugs most
drugs in conduct-disordered children. As mentioned, commonly prescribed for the mentally retarded, par-
the idea that stimulants have a paradoxical effect on ticularly the educable and the trainable mentally re-
ADD/H children and that the effects are reversed at tarded youngsters who are hyperactive. This seems
puberty has not been supported empirically (Rapo- counter to clinical intuition in that neuroleptics are
port, 1983). This calls into question the diagnostic widely used in institutions serving the mentally re-
specificity of stimulant drug response and, more im- tarded in this country (Gadow, 1985a) and the
portantly, suggests that stimulants may be effective efficacy of stimulants for behavior disorders in this
for clinical populations whose symptomatology is population has been questioned (Aman, 1982b). Sur-
similar to that of ADD/H groups. In fact, the subjects prisingly, according to a very careful and thorough,
in clinical trials of stimulants have been fairly hetero- albeit limited, review of studies in which stimulants
geneous in age, intellectual functioning, degree of were given to retarded youngsters, the drugs pro-
attentional deficits, and amount of aggression duced therapeutic benefits comparable to those ob-
(Rapoport, 1983), even when all the subjects were served in youngsters who were not mentally retarded.
designated ADD/H in accordance with DSM-III cri- It was suggested that the degree of improvement from
teria (American Psychiatric Association, 1980). For stimulants relates directly to the severity of retarda-
example, in some clinical trials with ADD/H pa- tion, the more severely mentally retarded children
tients, conduct disorders and symptoms of aggres- benefiting the least (Gadow, 1985a).
sion were exclusionary criteria (Varley, 1983); in In the very early clinical trials, mentally re-
other studies (Pelham et al., 1985), including retarded children were commonly included as subjects
search from our laboratory (Brown, Wynne, & (Cutler, Little, & Strauss, 1940; Molitch & Sullivan,
Medenis, 1985; Brown, Borden, Wynne, Schleser, 1937). In those investigations, mentally retarded
subjects improved in much the same way as their (Gilman et al., 1980) for use with preschoolers; dex-
nonretarded peers. In only a few recent studies, how-
troamphetamine is recommended only for children
ever, have the subjects been retarded (Poling & aged 3 and older. Nonetheless, there has been some
Breuning, 1983; Varley & Trupin, 1982); in most debate concerning how early in life stimulants may
studies, mentally retarded children have been ex- be used without compromising the safety and well-
cluded (Kavale, 1982). Nonetheless, findings clearly
being of the child. Gross and Wilson ( 1974) recom-
support the efficacy of stimulant drug effects on amended 2.5 mg of amphetamines daily for children
wide array of dependent measures, including care- up to the age of 4; others argued for this dosage twice
giver ratings and psychometric tests. daily (Wender, 1971). In a double-blind placebo trial
Poling and Breuning (1983), in their researchin preschool hyperactive children, Conners (1973)
with trainable mentally retarded children, found a examined the effects of methylphenidate on cog-
curvilinear dose-response relationship in the behav-
nitive, motoric, and psychological test performance
ioral ratings of caregivers; that is, when methylpheni-
according to teacher and pediatrician's behavioral
date doses were particularly high, the behavioral rat-
ratings. The results were decidedly disappointing:
ings of teachers deteriorated. This finding is in stark
The children's overt behavior was little affected by
contrast to studies with ADD/H children (Charles etstimulant treatment. In another study, improvement
al., 1981; Rapport et al., 1985a,b; Sprague & Sleat-
occurred in only 3 of28 preschoolers receiving meth-
or, 1977), in which a linear relationship between et
ylphenidate (Schleifer al., 1975). These are con-
dose of medication and teacher ratings has been sistent with Conners's (1973) results, which offer
found. Poling and Breuning's findings lend tentative
little support for improved behavior or improved psy-
support to Aman's (1982b) hypothesis that an atten-chometric test scores of preschoolers in response to
tional deficit underlies retardation and that it can be
stimulant drugs.
exacerbated by higher doses of a stimulant drug. In addition to the limited efficacy of stimulants
Despite the widespread clinical use of psycho-
for preschoolers, an even greater concern has been
stimulants for the mentally retarded, the area has the untoward side effects. Although Conners (1973)
been decidedly neglected in pediatric psychophar- found minimal side effects, Schleifer et al. (1975)
macology research. Gadow (l985a) offered several found that methylphenidate was associated with in-
explanations for that neglect, including the fact that
somnia, anorexia, increased solitary play, and poor
most research-oriented hyperactivity clinics exclude
peer relationships. The mean daily dose for both
mentally retarded subjects because often there are too
studies, however, was more than 10 mg, a dosage far
few for systematic study. Although this population is
exceeding the recommended daily dosage for pre-
readily available in the public schools, conductingschool children (Gross & Wilson, 1974; Wender,
pharmacological research in an educ~tional setting 1971). Another pessimistic note was sounded in the
presents many obstacles and difficulties. Also, thefindings presented by Zara (1973): The positive re-
clinical myth that pharmacological intervention sponders to stimulants were less verbally competent
would have little effect with retarded persons has in an experimental learning situation when they were
unfortunately been promulgated throughout the receiving stimulants.
scholarly and research literature (Klein, Gittelman, In general, the clinical efficacy of stimulant
Quitkin, & Rifkin, 1980). Collaboration among in- medication has been more variable in preschool chil-
vestigators and single-subject designs will, we hope,
dren than in older groups, and the incidence of side
solve some of these problems (Gadow, 1985a). effects, including dysphoria, anorexia, and insom-
nia, has been particularly high in preschoolers. Such
Developmental Issues findings lead us to concur with Dulcan (1985), who
cautioned that stimulants be used for preschoolers
Although most stimulant research on learning only ''in the most severe cases where parent training
and behavior problems has been conducted with pri- and placement in a highly structured, well-staffed
mary school populations, the potential efficacy of preschool program have been unsuccessful or are not
stimulants in other age groups has recently been possible" (p. 395).
recognized.
Preschoolers Adolescents
Methylphenidate has not been specifically ap- According to clinical lore, stimulant medication
proved by the Food and Drug Administration is to be used with preadolescent children experienc-
454 CHAPTER 24
ing attentional difficulties, and the symptomatology (Clampit & Pirkle, 1983) that psychostimulants are
is simply "outgrown" at adolescence (Gross & ineffective for ADD adolescents. Moreover, two re-
Wilson, 1974). This notion has been one reason for cent double-blind studies (Coons, Klorman, &
the refusal to administer psychostimulant medication Borgstedt, 1987; Varley, 1983) and one single-blind
to these youths beyond puberty, despite the per- trial (Garfinkel et al., in press), as well as current
sistence of cognitive, emotional, and social problems research in our laboratory (Brown & Sexson, 1986),
well into adolescence (Hoy, Weiss, Minde, & Co- have yielded very encouraging data that moderate
hen, 1978) and even adulthood (Wender, Reimherr, doses of methylphenidate may improve behavioral
& Wood, 1981). ratings and enhance cognitive functioning in adoles-
Clampit and Pirkle (1983) speculated on other cents. Many practitioners share the notion that psy-
reasons that psychostimulants are believed to work chostimulants have a paradoxical effect on children
only until adolescence. At puberty, the most visible of elementary school age and that the stimulant ef-
symptoms (e.g., overactivity), which are so respon- fects are reversed at puberty. In truth, there are many
sive to stimulant medication, often diminish, and similarities in the stimulant drug effects in children
cognitive and social dysfunctioning assume center and in adolescents, including improved behavioral
stage. Thus, many practitioners have falsely rea- ratings and enhanced cognitive functioning (Klor-
soned that stimulants are no longer needed because man, 1986).
the visible symptoms have dissipated. Additional support for the use of phar-
A second possible reason that stimulant medica- macotherapy at adolescence has come from compre-
tion is not used with adolescents is that the school hensive reviews (Solanto, 1984; Whalen & Henker,
structure changes and the adolescent experiences 1984) concluding that the target behaviors that dem-
more social freedom and less classroom structure. onstrate the clearest improvements with stimulants
Although the youngster may no longer seem to need are the disruptive and antisocial behaviors, which are
the medication, the difficulty does not result from the generally characteristic of adolescents. In addition,
structure imposed by the elementary school class- the observation that adolescents with ADD/H man-
room and the adolescent with attentional problems ifest cognitive impairments similar to those of their
may be a "silent sufferer" (Clampit & Pirkle, 1983, younger counterparts (Hoy et al., 1978) suggests that
p. 816). judiciously monitored stimulant medication would
A third possible reason is the high level of vari- yield cognitive as well as behavioral results (Brown
ability in the behavior of normal adolescents and in & Sexson, 1986; Coons etal., 1987). All three of the
particular adolescents who have externalizing disor- empirical studies that have addressed this issue
ders such as ADD/H. Differentiating the changes due (Coons et al., 1987; Garfinkel et al., in press; Var-
to stimulant medication and the changes due to other ley, 1983) have shown significant behavioral im-
factors is difficult. provements in adolescents treated with stimulants.
A fourth possible reason is a dated theoretical See Table 2 for a summary of the studies on the
tenet rooted in the minimal brain dysfunction theory efficacy of stimulants in adolescents.
of hyperactivity: children who have attentional defi- Despite Varley's (1985) statement that "not a
cits are experiencing difficulty with an ''immature'' single study has reported a negative stimulant drug
central nervous system (Clampit & Pirkle, 1983), a effect outcome in adolescence" (p. 216), important
lag in neurological development, and they will questions remain. Although some researchers have
"catch up" at puberty. Thus, it was erroneously rea- suggested that a chief difference in the stimulant drug
soned that psychostimulants would not be effective at regimens of children and of adolescents is the marked
puberty and might even have behaviorally stimulat- variability in the effective dosages for adolescents,
ing effects. The notion that stimulant medication we have no systematic data about the effective dos-
does not act therapeutically on adolescents undoubt- age range for adolescents. Although the range of
edly explains the dearth of stimulant drug trials with methylphenidate dosages in adolescent studies-! 0
this group. Contrary to this popular misconception, mg to 60 mg per day-appears comparable to the
researchers have recently reached consensus that absolute dosages used with pediatric populations, the
adults (Wender eta/., 1981) and adolescents (Cant- effective dosages for adolescents are typically lower
well, 1979) once diagnosed as having attentional (mg/kg) than the dosage for prepubescent children.
problems can benefit markedly from stimulant drug Specific dose responses and dose requirements for
therapy. Open trials of stimulant medication (Lerer & adolescents still need to be empirically established.
Lerer, 1977; MacKay, Beck, & Taylor, 1973; Safer Also, is the variability in effective dosages in fact
& Allen, 1975a,b) have clearly refuted the myth marked for adolescents? Although clinical trials have
TABLE 2. Studies Examining Efficacy of Stimulants in Adolescents a
Study Population N Stimulant Dose Type of trial Results Abuse
Coons et at. (1987) ADD/H 19 Methylphenidate Placebo; 25 mg/ Double-blind Weekly ratings by parents on the NO
day, Week I; Conners's questionnaire and
40 mg/day, . global ratings of outcome indi-
~
Weeks 2 and 3 cated superior behavior under
methylphenidate; significant in-
creases in accuracy noted on Con-
tinuous Performance Test
Eisenberg et al. (1963) Delinquent boys 21 Dextroamphet- 40 mg/day Double-blind Reduction in aggression and gains in NR 0
amine C)
Garfinkel et al.
(in press)
ADD/H 17 Dextroamphet-
amine
Individually ti-
trated; mean
Double-blind
sociability and manageability
Improved cognitive response NR
I
8
dose not re-
ported ~
Korey (1949) Psychopathic and 20 Benzedrine sulfate 5 mg/day, Week q
Double-blind Subjects more compliant; behavior NR {/)
neurotic juve- I; 20 mg/day, improved
nile delinquents Week2 ~
Lerer & Lerer ( 1977) MBD 27 Methylphenidate 40 mg, total daily Open Improvement noted on Conners's NO
dose teacher ratings, academic perfor-
mance, and behavior control
(continued) !
~
0
~
0
z
m
~
I
~
Study Population N Stimulant Dose Type of trial Results Abuse
MacKay et al. (1973) MBD 10 Methylphenidate 30 mg, total daily Open Improvement noted in academic NO
dose functioning, Raven matrices, and
EEG abnormalities
Maletzk:y ( 1974) Delinquent boys 28 Dextroamphet- S mg per dose/40 Improvement in aggression and NO
amine mg total daily sociability
dose
Safer & Allen (1975b) ADD/H (some 24 Methylphenidate Not specified Open Reductions in pretreatment ratings of NO
patients also and dextroam- restlessness, inattention, and ag-
had Axis U di- phetamine gression, by ratings on an adapted
agnosis of conversion of Conners's Teacher
duct disorder) Questionnaire
Varley (1983) ADD/H; all 22 Methylphenidate Placebo; 0.15 Double-blind Significantly lowered hyperactivity NR
patients pre- mg/kg plus 0.3 ratings, by teacher and parent
viously deter- mg/kg b.i.d. Conners's ratings; clinical effects
mined to be only slightly greater with the
responsive to higher dose
stimulants
aNo, none observed; NR, not reported; MBD, minimal brain dysfunction; b.i.d., twice daily.
NEUROPSYCHOLOGICAL EFFECfS OF STIMULANT MEDICATION 457
suggested the short-term efficacy of methylphenidate cause of individual variables. For example, response
for adolescents, the major side effects have not been to methylphenidate has been established with as lit-
systematically reported-an important issue, partic- tle as 1 to 2 mg, but some patients have required
ularly given the sensitivity of adolescents to medica- significantly larger doses (up to 120 mg).
tion (Cantwell, 1985). For example, some research- Despite the promise of stimulants for adult pop-
ers have mentioned dysphoria and irritability ulations, Ross and Ross (1982) cautioned that adults
following methylphenidate administration (Donnelly are often noncompliant and actively resist phar-
& Rapoport, 1985). Whether these effects are in- macotherapy despite the fact that they typically un-
creased in adolescents who are receiving stimulant dergo treatment voluntarily and experience marked
medication will be a fruitful area for study. The side symptomatic relief when given stimulant drug thera-
effects influencing the cardiovascular system, blood py. Although stimulant drug therapy increases atten-
pressure, and pulse rate may be even more important tional capacity in adults, adults often become de-
in adolescents than in younger children (Cantwell, pressed as awareness of their life situations develops
1985). The need for additional well-controlled (Woods, 1986). Ross and Ross suggested that such
clinical trials with ADD adolescents is underscored dysphoria may result when the adult discontinues
by the research efforts of Safer and Krager (1985), drug therapy prematurely. Unlike adults who have
who found a prominent increase in the rate at which been diagnosed as depressed and who seek treatment
stimulant medications were prescribed from 1975 to because of their pain, ADD/H adults may have
1983 for secondary school pupils. adapted to their pathology and consider themselves
normal, making compliance even more difficult
(Woods, 1986).
Adults
Research on stimulant drug treatment for adults
In a series of impressive follow-up studies, the (e.g., specific dosages for specific symptoms) is an
outcomes for adults previously diagnosed as hyper- area ripe for further investigation. However, because
active have been examined (Thorley, 1984; Weiss, of the unique problems experienced by adult popula-
1983). The problems of the adults seemed to mirror tions, such research will undoubtedly prove chal-
the difficulties of their younger counterparts, includ- lenging.
ing attentional difficulties, impulsivity, temper out-
bursts, poor organization, an inability to complete
tasks, low self-esteem, and problems in social in-
teraction (Woods, 1986). A logical extension of that
Assessing Therapeutic Responses
research would be an examination of the efficacy of
stimulants in adult populations previously diagnosed Psychophysiological Correlates of Stimulant
as ADD/H. According to the limited literature in this Drug Response
area, adults may benefit significantly from psycho-
stimulants; Woods (1986) estimated, in fact, that 60 Extensive research has been conducted on the
to 80% of these adults would respond therapeutically behavioral effects of stimulant medication. Most of
to psychostimulant medication. As do their younger this research has been chiefly concerned with ame-
counterparts, adults tend to experience the direct ef- liorating overt clinical symptoms and has thus used a
fects of stimulant medication, including similar side variety of behavioral measures to evaluate clinical
effects (Ross & Ross, 1982). In reviewing positive response (Ross & Ross, 1982). Recently, however,
clinical response in adults who had received stim- efforts have been increasingly devoted to investigat-
ulant medication for more than 5 years, Woods rec- ing physiological and biochemical processes in an
ommended that drug therapy be continued in adults effort to understand the outcome of stimulant drugs
as long as they show undesirable symptoms, which for various disorders (Solanto, 1984; Yellin, 1986)
typically abate during later adulthood. and ultimately to predict more efficiently the re-
Despite the promise of psychostimulants for sponse to stimulant drug treatment. As Yellin pointed
adult populations, much variability has been re- out, clinical improvement in target symptoms is sim-
ported in the types of stimulants and the effective ply not sufficient for the evaluation of drug efficacy
dosages for adults (Ross & Ross, 1982; Woods, because some psychotropic medications, although
1986). Woods noted that most of the patients he particularly effective in improving specific target be-
studied required daily doses of 20 to 40 mg, but he haviors, have deleterious effects on other psycho-
pointed out that specifying dosages is diffitult be- physiological processes.
458 CHAPTER 24
Autonomic Nervous System Variables and decision making (Donchin, Ritter, & McCallum,
1978), have been related to CNS functioning. It is
Particular interest has focused on autonomic hoped that the study of CNS variables will help us to
nervous system variables in ADD/H children in an better understand how stimulant drugs affect infor-
attempt to assess whether cognitive processes such as mation processing.
attention are mediated by impairments in arousal and A number of studies have suggested a greater
orienting responses. Satterfield and Dawson (1971) overall percentage of EEG alpha waves, a smaller
proposed that children with ADD/H are under- percentage of beta waves, reduced alpha waves, and
aroused in comparison with normally developing increased EEG variability in ADD/H children (Yel-
children and that psychostimulants act by normaliz- lin, 1986). These data have been interpreted as indi-
ing the arousal level. Although that hypothesis has cating lower cortical arousal in these children. Ac-
not received widespread empirical support (Yellin, cording to Surwillo's (1980) data, the EEGs of
1986), agreement is fairly consistent that stimulants children with ADD/Hare immature in relationship to
do affect arousal level (Rosenthal & Allen, 1978; their chronological age and the stimulants have a
Solanto, 1984; Yellin, 1986). In general, stimulants maturing effect on the EEGs. Stimulants have also
produce increases on measures of arousal, including been found to have a normalizing effect on beta
skin conductance levels, frequencies of spontaneous frequencies.
skin conductance responses, heart rate, cardiac de- Event-related potentials (ERPs), also known as
celeration to an orienting stimulus, and decreased evoked potentials, are electrical changes in the brain
heart rate variability (Yellin, 1986). These measures in response to specific stimuli. They may occur in
have also been linearly related to dosage (Rapoport, response to internal events (i.e., the K-complex dur-
1983) and positively correlated with decreased reac- ing Stage 2 sleep, which may be a response to car-
tion time and improved performance on measures of diovascular events) or to external events, such as
sustained attention. Moreover, the cardiovascular ef- visual or auditory stimuli (Yellin, 1986). In many
fects of stimulants have been remarkably similar for studies the amplitude of several of the late negative
all age groups, although dextroamphetamine gener- and positive components of ERPs has been smaller in
ally produces more severe cardiovascular changes ADD/H subjects than in controls, particularly on
than does methylphenidate or pemoline (Huessey, tasks requiring active attention (Rosenthal & Allen,
Cohen, Blair, & Wood, 1979). 1978; Yellin, 1986). Interestingly, the positive late
Zahn, Rapoport, and Thompson ( 1980) com- component (P300) has occurred 300 msec after the
pared the psychostimulant effects on autonomic ner- initial stimulus, which has been sensitive to task-
vous system responses in normal and ADD/H pre- relevant aspects of stimuli. Specifically, the P300
pubescent boys. Both groups demonstrated similar components in ADD/H children (Michael, Klorman,
behavioral (reduced motor activity), cognitive (de- & Salzman, 1981) and adolescents (Loiselle,
creased impulsivity), and autonomic responses (in- Stamm, Maitinsky, & Whipple, 1980) were of small-
creased heart rate, increased cardiac deceleration er amplitude than in normal controls. Most impor-
during orienting, and decreased skin temperature). tantly, the smaller P300 components of the ADDIH
The investigators concluded that stimulants have subjects were correlated with poorer performance on
similar behavioral and autonomic effects in ADD/H the attentional measures. Unfortunately, this finding
and normal children, although the magnitude of the is not specific to ADD/H groups but has also been
effects may differ. They also noted that the beneficial found in learning-disabled and schizophrenic popula-
effects on behavior were not necessarily due to the tions. Methylphenidate has been associated with im-
activating properties of stimulants, as the increased proved performance on the attention tasks (reduced
autonomic responses of the placebo group were not reaction time and fewer errors) and a concomitant
accompanied by reduced motor activity, reduced im- increase in the amplitude of P300 (Michael et al.,
pulsivity, and enhanced attentional deployment. 1981). However, methylphenidate has been shown to
increase P300 amplitude in normal children and
adults, though less dramatically and during experi-
Central Nervous System Variables mental tasks requiring more effort (Coons, Peloquin,
& Klorman, 1981).
The interest in measuring CNS effects in clinical In short, these studies suggest that improved
populations and the effects of psychostimulants on attention subsequent to the administration of psycho-
these variables has evolved because various stages of stimulants is correlated with a normalizing of several
information processing, such as selective attention nervous system variables. However, the specific ac-
tions of stimulants on central and autonomic nervous al., 1985) have led investigators to examine other
system variables are not well understood. According hypotheses.
to one somewhat encouraging study (Yellin, 1986), A second possibility is that the duration of
dextroamphetamine may act on the CNS by activat- pharmacotherapy has been too short to allow the de-
ing the inhibitory norepinephrine receptors. Al- tection of improvement on standardized academic
though promising, the data also suggested that a sin- tests (Sprague & Berger, 1980). Specifically, the
gle mechanism does not sufficiently explain the brief intervention used in the studies, in combination
pharmacological effect of ERPs because different with academic measures of limited reliability and
cortical regions are differentially affected by stim- validity (Gadow & Swanson, 1985), which have
ulants. been designed to detect only gross changes in
Although research on the psychophysiological achievement level, imply that to show significant
response to stimulants is in its infancy, exciting hy- improvement on standardized tests, a child would
potheses about the dynamics of psychophysiological have to gain academic skills at an extremely high
processes are being evaluated. With increasingly so- rate, one much higher than expected for the normal
phisticated measurement of these processes and child.
greater subject homogeneity, the widespread clinical One widely accepted explanation for this dis-
use of psychophysiological procedures in the assess- crepancy has been the failure to use assessment de-
ment of stimulant drug responses will likely be com- vices sensitive to the level of change expected during
monplace in the near future. the relatively brief treatment periods of most clinical
trials (Sprague & Berger, 1980). This hypothesis has
been tested in recent studies in which academic mea-
Learning sures have replaced the traditional standardized
achievement tests. The new measures, which contain
Academic Achievement several items to tap each specific skill, do appear
more sensitive. Pelham and his colleagues (Pelham et
Psychostimulants have been found to affect at- al., 1985; Stephens et al., 1984) have developed
tention span and concentration favorably and to im- several tests to assess stimulant drug effects, for ex-
prove classroom behavior (Gittelman, 1983). More- ample, a spelling task based upon the requirements
over, many parents and teachers have reported that for spelling tasks in school. In the first study (Ste-
children show marked improvement in their school- phens et al., 1984), children were presented with
work in response to stimulants (Rapoport, Quinn, word lists and led through practice trials before being
Bradbard, Riddle, & Brooks, 1974; Sleator, von tested. In the second study (Pelham et al., 1985),
Neumann, & Sprague, 1974). These reports have arithmetic work sheets and multiple-choice reading
been contradicted, however, by the repeated failure comprehension problems supplemented the spelling
of investigators to detect these improvements on task, and the children were given a week of structured
standardized academic tests (Brown, Wynne, & practice before the test. Numerous problems adapted
Medenis, 1985; Brown et al., 1986; Gadow, 1983, to grade levels were presented on each task. Another
1985b). Because the basic cognitive skills needed for important innovation was the use of average daily
academic tasks have been so positively affected by performance scores on reading and arithmetic tasks,
stimulants (Swanson & Kinsbourne, 1979), re- thus reducing as a source of variance the day-to-day
searchers have been puzzled by the lack of improve- variability commonly reported for ADDIH children.
ment on standardized tests and have proposed several In a similar study, arithmetic and spelling tasks
hypotheses to explain the discrepancy. were designed with increased sensitivity to the short-
Drug dosage levels that are high enough to cause term gains observed with stimulants (Douglas et al. ,
learning to deteriorate have been proposed as one 1986). These tasks were scored for the number of
explanation for the rather disappointing findings in items attempted as well as the number correct.
the academic domain (Sprague & Berger, 1980). As Again, average daily scores were used to reduce the
mentioned earlier, some evidence bas suggested that effects of day-to-day variability.
dose response differs across domains of functioning The positive findings with these newer academ-
(Sprague & Sleator, 1977). Dosages determined by ic measures are very encouraging. They support the
parent and teacher ratings of behavior are often set hypothesis that the measurement procedure used in
higher than the level at which learning and cognition earlier studies (Sprague & Berger, 1980), not the
are optimally influenced (Sprague & Berger, 1980). inefficacy of stimulants, resulted in a failure to detect
Questions about dose-response curves (Rapport et academic gains. Whether stimulants affect learning
460 CHAPTER 24
by increasing attention and concentration or in some ylphenidate and pemoline on spelling word retention.
other way is unknown, but the use of sensitive aca- Because of this finding, they cautioned against using
demic measures should help elucidate stimulant drug both medications concurrently or switching the two
effects in the academic domain. drugs frequently for a given child. Although more
Long-term stimulant drug outcome studies for recent studies lack real support for state-dependent
ADD/H children have typically used special class learning between placebo and active drug conditions,
placement, grade retentions (holding back), and practitioners and researchers need to be aware of the
grades to evaluate stimulant treatment (Weiss, possibility and should evaluate learning outcome
Hechtman, Hopkins, Perlman, & Wenar, 1979). both on and off medication (Brown et al. , 1986).
Such measures are useful because they have "real-
world" implications for evaluating drug efficacy
(Gadow & Swanson, 1985) and may be used to assess Behavior
outcome over longer periods.
Academic productivity may be measured on Direct Observations
specific academic tasks (Douglas et al. , 1986) or by
teacher ratings of structured activities (Edelbrock & Direct observations of behaviors have provided
Rancurello, 1985). The use of such ratings has been important data concerning the efficacy of stimulant
efficient and cost-effective (Gadow & Swanson, drugs. These observations are typically conducted in
1985). a classroom setting by multiple raters who have been
extensively trained in the observational system. All
behavioral categories are precisely defined and a se-
lected period for observation is broken into subunits
State-Dependent Learning ranging from 5 or more seconds to I minute (Ross &
State-dependent learning has been implicated in Ross, 1982). For a representative sample of the
psychostimulant effects on learning (Swanson & child's behavior, observations are typically made for
Kinsbourne, 1976, 1979). State-dependent learning several days at different times during the day. Obser-
is characterized by decrement in transfer between vational systems have a threefold advantage: (I) the
medicated and undrugged states (i.e., information behavior to be observed can be defined by clear oper-
learned while the child is medicated is not easily ational criteria, (2) interrater agreement is readily
retrieved if the child is not medicated when tested). established, and (3) the technique requires little
More important, a decrement in transfer to the non- equipment and is quite simple (Ross & Ross, 1982).
drug state occurs when learning takes place in the The disadvantages of direct observations are that
medicated state. Swanson and Kinsbourne (1976) evaluating multiple categories can be quite demand-
cautioned that the effects of stimulants on ADD/H ing of the rater and the procedures are typically quite
children are state dependent. They found that nearly costly.
30% more errors were made in response to items The classroom observational schedules that
learned while the children were receiving meth- have been used successfully in stimulant drug studies
ylphenidate than were made while the children were are the Revised Stony Brook Observation Code
receiving placebos. This finding has evoked concern (Abikoff, Gittelman-Klein, & Klein, 1977) and the
among the professional community because it has Classroom Observation System (Whalen et al. ,
serious implications for the use of stimulants as the 1978). Several other reliable observational systems
sole treatment for ADD/H children. If the effects of are sensitive to stimulant drug effects (Blunden,
stimulant medication are in fact state dependent, Spring, & Greenberg, 1974; O'Leary, Romanczyk,
ADD/H children will demonstrate poor retention of Kass, Dietz, & Santagrossi, 1971). See the publica-
previously learned material when treatment ends, or tions of Ross and Ross (1982) and Sandoval (1977)
once drug therapy has begun, the children will have for more information on observational systems.
to be treated with stimulants indefinitely (which most
physicians are unwilling to do) (Douglas, 1980). Checklists and Ratings
State-dependent learning effects with stimulants
in ADD/H children have not been found in other Behavioral checklists and rating scales have
studies (Aman & Sprague, 1974; Gan & Cantwell, played a central role in evaluating stimulant drug
1982; Gittelman, 1982; Stephens et al., 1984), al- trials. Their advantages are many, including sim-
though Stephens et al. did find a significant state- plicity, cost-effectiveness, and reduced subjectivity
dependent learning interaction between meth- in parents' and teachers' judgments of improvement
in response to stimulants. Rating scales are typically although stimulants seem to improve self-ratings
valuable when behavior must be synthesized and in- (Brown, Wynne, & Medenis, 1985), few studies have
tegrated to evaluate drug treatment response. Of the systematically examined sociometric ratings in re-
host of rating scales, most have proven effective and sponse to stimulant drug therapy. Although person-
sensitive to psychostimulant effects (Edelbrock & ality change has not necessarily been an ultimate
Rancurello, 1985) and are available to teachers and goal of stimulant use, the evaluation of personality
parents as well as mental health professionals. (See change, particularly over long periods, would be
Edelbrock and Rancurello, 1985, for a thorough and especially interesting to the pharmacological
lucid review of the rating scales that may be used in researcher.
drug trials.) Typically, rating scales, whether com-
pleted by parents or teachers, tap similar domains of
Ecological Measures
child behavior (Edelbrock & Rancurello, 1985), thus
suggesting that multiple sources of behavior may According to the pediatric psychopharmacology
prove useful for evaluating stimulant drug effect- literature, too few real-world measures have been
iveness. used in evaluating drug outcomes. Weiss et a/.
The major standardized rating scales have con- (1979), for example, used measures of truancy and
sistently demonstrated drug sensitivity (Kavale, law violations in the Montreal follow-up studies of
1982), and global ratings by teachers and parents ADD/H children. Such measures are particularly ap-
have not differed significantly. Interestingly, teach- propriate for long-term (several years) follow-up
ers and parents are less inclined than clinicians to rate studies.
drug-treated subjects as globally improved (Kavale,
1982);
Despite the sensitivity of behavioral ratings to Psychological Testing
stimulant drug effects, rating scales have been less
powerful predictors of stimulant drug response than Clinical Evaluation
have laboratory measures of attention and concentra-
tion (Kavale, 1982; Edelbrock & Rancurello, 1985). The best approach to a clinical assessment of
High behavioral ratings of activity are weakly associ- stimulant drug effects may be to examine the clinical
ated with positive drug response (Edelbrock & trials that proposed to assess the individual symptoms
Rancurello, 1985); ratings by teachers are somewhat or deficits for which the medication was initially
better predictors than those of parents. High ratings intended. Because the effects of stimulants tend to be
of anxiety by teachers or by parents predict a poor so widespread, crossing a number of behavioral and
response to stimulant medication (Edelbrock & Ran- cognitive domains, Loney (1986) recommended that
curello, 1985). a comprehensive assessment be cross-situational,
multidimensional, and multidisciplinary. The diag-
nostic approaches range from traditional paper-and-
Measures of Personality and Social Functioning pencil tests to computers (Kiee, 1986).
Intelligence tests have also been used to assess
Other relevant measures are personality and the efficacy of stimulant drug therapy (Ross & Ross,
temperament scales as well as sociometric ratings. 1982). A detailed examination of individual subtests
Because of concerns about dysphoria, learned help- from the Wechsler Intelligence Scale for Children-
lessness, and anxiety resulting from initiation and Revised (WISC-R) can help determine whether a
cessation of stimulant drug therapy (Brown, Borden, child has demonstrated clinical response to stim-
Spunt, & Medenis, 1985; Cantwell & Carlson, 1978; ulants. For example, the Freedom from Distrac-
Whalen & Henker, 1980, 1984), the systematic tibility Factor (Kaufman, 1979), which consists of
quantification of these effects through the use of rat- digit span, arithmetic, and coding subtests, has been
ing scales, structured interviews, and objective per- responsive to stimulant drug effects (Brown et a/.,
sonality tests is certainly necessary. Although such 1984; Brown, Wynne, & Medenis, 1985). WISC-R
tests and rating scales are readily available to clini- subtests that reflect academic history and social rea-
cians and researchers, few of them have been used in soning would not be expected to be as responsive to
drug trials. The greater use of such instruments is stimulant drug effects.
necessary for future research. Sociometric ratings Kagan's Matching Familiar Figures Test (Ka-
and self-rating scales have been used in some stim- gan, 196.5), which was originally designated a test of
ulant trials (Brown, Wynne, & Medenis, 1985), and reflection-impulsivity, has demonstrated drug sen-
462 CHAPTER 24
sitivity and sensitivity across doses (Brown & nonresponders on this test (Shekim, Dekirmenjlan,
Sleator, 1979; Brown eta/., 1984). Ease of admin- & Chapel, 1979). Whether this test will help in
istration and scoring makes it valuable in clinical and predicting the responses to methylphenidate and
in laboratory settings. Its limited normative data per- pemoline in diagnostic subgroups should be a fruitful
mit only pre-post comparisons rather than com- investigative topic.
parisons with a child's peer group. . .
Several simple paper-and-penctl tests, mclud-
ing the Bender Gestalt, Trail Making Test, and Predicting Responses
Stroop Color Word Test (see Klee, 1986, for are-
The ability to predict the response to stimulants
view), are available for assessing drug responses,
would be of great clinical use. Time and worry would
although their responsiveness to medication has var-
be reduced, as would unnecessary adverse side ef-
ied somewhat across studies (Kavale, 1982). Stim-
fects. Prediction of response may be dichotomized as
ulants are also commonly used for children who have
the prediction of positive outcome and of deleterious
continually underachieved academically. Although
side effects. Barkley (1976) found that measures of
standardized achievement tests in short-term and
attention and concentration were the best predictors
long-term studies have demonstrated a fairly poor
of response to stimulant drug treatment; the severity
response to stimulant drugs, criterion-related tests
of attentional impairment seems related to the
may demonstrate greater sensitivity. (Gado:-v &
efficacy of stimulant drug response. Barcai's (1971)
Swanson, 1985) to stimulants. Readily available
Finger Twitch Test has been calle~ the single be~t
measures such as school grades and records of pro-
predictor of drug response, although Its psychometric
motion may also help in quantifying stimulant drug
properties have not been established (Loney, 1986).
response. .
Halliday, Rosenthal, Naylor, and Callaway (1976)
During the past 5 years, many computenzed
found that recordings of neurochemical activity were
tasks have been developed, some of which have
associated with stimulant drug response. Loney
claimed sensitivity to stimulant drug effects (Gar-
found no single variable clinically useful in predict-
finkel, 1986). Whether computerized assessment, a
ing response to medication; even the combination_of
new means of assessing drug response in children,
age at referral, birth complications, and the seventy
will withstand the empirical test of time will have to
of overactivity and attentional difficulties accounted
be determined through future research.
for only 25% of the variance in ADDJH children's
responses to stimulants. Considering a multitude ?f
Neuropsychological Evaluation predictors is clearly important, and more systematic
research must develop precision in predicting drug
No standard batteries of neuropsychological as- response. Until better prediction is possible, a
sessment instruments are available for measuring
clinical trial remains the practitioner's best tool.
specific responses to stimulant drugs. In fact, data
The predictors of side effects have not been well
concerning psychostimulant drug effects on neuro- documented. Clearly, the effects are related to the
psychological measures are scant. If we a~sume that
specific stimulants prescribed, th_e ~osa~e level, the
the neuropsychologist's task is to determme the _as- use of drug holidays, and the adminiStration schedule
pect of the functional system that is affected by stim-
(Loney, 1986). Certain family fact~rs ~ay also p~e
ulants, neuropsychological assessments would cer- dict side effects; for example, a family history of t1cs
tainly be of theoretical and clinical importance has been associated with the occurrence ofTourette 's
because they would help determine greater diag- syndrome following stimulant administration (Huey,
nostic specificity of stimulants. [See Lezak's (1983)
1985).
excellent compendium on neuropsychological tech-
niques.]
Just as neuropsychological techniques and in-
struments await careful trials with psychostimulants, Limitations
standardized tests of neurological soft signs also de-
serve systematic investigation. The Physical and Stimulants have been demonstrated to improve
Neurological Examination for Soft Signs (PA~~~S) the attention, concentration, cognitive impulse c~n
(Close, 1973) measures performance on activities trol, memory, and adult-rated and observed behaviOr
such as eye tracking, synergy, balance, and ~raph of children with learning and behavioral problems.
esthesia. ADD/H children who were responsive to However, a variety of limitations and adverse effects
dextroamphetamine scored significantly higher than have caused concern.
Questions have been raised about the efficacy of cence and adulthood (Weiss, 1983), the duration of
stimulants in the social and academic spheres. Stim- medication effects has become a greater concern.
ulant therapy is usually initiated during elementary Unfortunately, because of ethical considerations,
school, and a child who is given stimulant medication random assignment to long-term stimulant treatment
usually has a history of problems in school and at is not possible. Limited studies have compared two
home. Parents, teachers, school administrators, and types of long-term outcome research studies: studies
peers have experienced these children's uncon- of adolescents and adults who had taken medication
trolled, often annoying behaviors for months or even briefly in childhood and studies of adolescents and
years. That people in these children's social milieu adults who had taken medication almost continu-
already perceive them as problematic is supported by ously since childhood. Because of the alarming im-
parent, teacher, and classmate evaluations showing plication that patients might need to be maintained on
that ADD/H children have more difficulty with their stimulants for many more years than originally
peers than do other children (Ross & Ross, 1982). thought necessary, the search for longer-acting alter-
Perhaps even more important, these children rate natives has intensified (Sprague, 1983). The com-
themselves as less accepted by peers (Campbell, bination of stimulants with various psychotherapies
Endman, & Bernfeld, 1977); Pelham (1980) found offers hope. Many clinicians and researchers have
that rejection occurred as quickly as 2 hours after an assumed that educational programs and psycho-
ADD/H child met another child! therapy have greater effects when children are receiv-
A history of behavior problems that is known to ing medication than when they are unmedicated (in
others leads to the labeling of these children and ex- an overactive, inattentive state). Further, changes at-
pectations about their future behavior. Although tained through psychotherapy have been expected to
medication may produce change (e.g., the observ- last longer, resulting in the maintenance of therapy
able behavior of ADD/H children), the negative ex- gains long after medication is discontinued. Unfortu-
pectations of others may delay or even prevent the nately, this expectation has not been supported by
formation of new, more accurate opinions of them. most empirical studies (Brown et al.. 1986), al-
Thus, overattentiveness from teachers and teasing by though some researchers have reported long-term re-
peers may continue. sults (Hinshaw, Henker, & Whalen, 1984). (For a
ADD/H children's self-expectations may be thorough overview, see the excellent comprehensive
quite low, and they may become bewildered at the reviews by Gadow, 1985b, and Pelham & Murphy,
continued lack of acceptance by their peers. Even 1986).
worse, peers may use the medication as additional In summary, stimulants are effective only while
evidence that ADD/H children are "different" or in a child's system (gains are not maintained beyond
"crazy" and may tease them about the pills. Some treatment), and psychotherapy and educational inter-
ADD/H children may be teased less as their disrup- ventions combined with medication do not appear to
tive behavior decreases. If positive attention does not improve the maintenance of treatment gains. One
increase dramatically, the children may increase their possible solution lies in the efforts to develop more
disruptive behavior to gain attention. This problem is effective nonpharmacological therapies. Because
most difficult in older ADD/H children who have not many people are opposed to drug therapy, these
acquired the social skills and practice necessary to efforts will certainly continue. Although a second
gain positive social attention. In conclusion, the option is to continue children on stimulant medica-
negative expectations of the child and others, and the tion indefinitely, the concern about serious long-term
child's lack of knowledge about how to gain positive side effects increases with the duration of treatment.
peer attention may strongly attenuate the potential
influence of medication in the social domain.
The short-term efficacy of psychostimulants in Iatrogenic Effects
decreasing the symptoms of attentional deficits and
behavioral difficulties has been well documented Physical
(Ross & Ross, 1982), but we know that stimulants
directly affect behavior only while in the patient's The most common physical side effects of stim-
system in sufficient quantity (Brown eta/., 1986). ulants-anorexia and insomnia (Gittelman-Klein,
Until recently, it was commonly believed that Klein, Katz, Saraf, & Pollack, 1976)-are usually
ADD/H children outgrew their difficulties at adoles- transient and may be less severe with certain medica-
cence (Weiss, 1983). Because of recent evidence that tions (e.g., methylphenidate). Stimulants are fre-
ADD/H patients experience difficulties into adoles- quently withheld late in the day to prevent insomnia,
464 CHAPTER 24
but Kinsbourne ( 1973) cautioned against this practice (Sleator, 1980). This finding is not sufficient to infer
because of the overactivity "rebound" that occurs cause and effect, but the onset of tics following stim~
when the stimulant medication wears off. He argued ulant administration should be carefully monitored.
that withholding evening medication results in max- One researcher reported grand mal seizures as a side
imum overactivity at bedtime. According to this line effect of methylphenidate administration (Cham-
of reasoning, the use of stimulants late in the day berlin, 1974). Although this may have been an idio-
should decrease rather than exacerbate insomnia. syncratic finding, practitioners and researchers
An alternative strategy has been to decrease the should remain alert to this possible effect.
dosage when insomnia or anorexia becomes a prob- Growth suppression and weight loss have been
lem (these side effects seem more severe with higher reported with dextroamphetamine and moderate to
doses; Cantwell & Carlson, 1978). Relatively low high doses of methylphenidate (Safer & Allen, 1973;
dosages may be effective for many children in vari- Safer et al., 1972). The investigators later reported
ous domains of functioning (Sprague & Sleator, growth spurts when the children were taken off medi-
1977) and should result in less insomnia or anorexia cation during school vacations (Safer, Allen, & Barr,
while promoting desired therapeutic effects. Lower 1975). Several researchers have used methodological
dosages often decrease other side effects such as and measurement issues to refute the finding of
headaches, abdominal pain, and gastrointestinal growth suppression (Sprague, 1977). In a study of
distress. prepubescent children, no height suppression oc-
Concern has also been expressed about the car- curred with moderate doses of methylphenidate (Ka-
diovascular effects of stimulant drugs. Stimulants are lachnik, Sprague, Sleator, Cohen, & Ullmann,
known to cause increased heart rate, respiration, and 1981). However, more recent studies have associated
blood pressure (Gilman et al., 1980). Fortunately, stimulant therapy in adolescence with shorter adult
these effects are transitory, decreasing as the medica- stature (Loney, Whaley-Klahn, Ponto, & Adney,
tion is metabolized and eliminated from the body and 1981).
as tolerance to the medication develops (Cantwell, Although the height-suppressing potential of
1979; Safer & Allen, 1975a). In addition, the stimulants continues to be debated, the evidence of
changes in cardiovascular functioning are minimal weight loss in children on stimulants has been more
(Brown et al., 1984), and no abnormalities have been consistent (Roche, Lipman, Overall, & Hung,
found on children's electrocardiograms, even fol- 1979). The effects of stimulants on height and weight
lowing long-term stimulant therapy (Rapoport et al .. may be due to the anorectic effect of the medication,
1974). Nonetheless, the clinical implications of mild but other theories have cited drug action on pituitary
but long-term changes in the cardiovascular system secretions or direct action on bone and cartilage de-
are not known (Brown eta/., 1984). Mild changes in velopment (Ross & Ross, 1982). Until the issues of
blood pressure and heart rate have been observed growth suppression and weight loss are settled,
after medication has been discontinued (Boileau, Eisenberg's (1972) advice still seems wise: Children
Ballard, Sprague, Sleator, & Massey, 1976). The on stimulant medication should be monitored care-
effects of these changes must be studied, and until fully for physical side effects.
they have been thoroughly elaborated, caution must
prevail in prescribing these drugs.
In addition to these common side effects, sever- Psychosocial
al rare, but serious, physical problems can be caused
by stimulants. For example, blood dyscrasias may The most often reported psychosocial side ef-
result from long-term stimulant administration. Pre- fects of stimulants are emotional changes. Many par-
liminary evidence from one study has linked ents and children have reported increased sensitivity
Hodgkin's disease to stimulant use: More patients and emotionality in children taking stimulants (Git-
with Hodgkin's disease reported a history of telman-Klein et al., 1976), for example, an increase
amphetamine use than did nonpatient controls (New- in observations of depression, fearfulness, anger out-
ell & Henderson, 1973). Differences in the charac- bursts, or dysphoria. These symptoms are highly
teristics and experiences of the two groups, not the distressing to families and have been reported by
history of amphetamine use, may have accounted for parents in our laboratory as reasons to discontinue the
the finding. medication.
The onset of tics, similar to those characteristic Other parents have reported that the children
of Tourette's syndrome, has been reported in chil- become unemotional, passive, too quiet, or socially
dren treated with methylphenidate and pemoline withdrawn (Gittelman-Klein et al., 1976), changes
NEUROPSYCHOLOGICAL EFFECfS OF STIMULANT MEDICATION 465
that are also alarming to families. The far less fre- children's documented dislike of the medication and
quently reported symptoms of psychosis, such as hal- their avoidance of taking it (Sleator, Ullmann, & von
lucinations (Lucas & Weiss, 1971 ), usually abate Neumann, 1982). Also, children have rarely reported
when the medication is discontinued but are ex- craving or euphoric effects (Huey, 1985). Finally,
tremely upsetting to family members and persons at the social stigma associated with psychoactive medi-
the child's school who observe this reaction. cation is quite aversive to these children.
The professional labeling of a child has power- Recent studies of drug abuse in children who
ful effects. Children who are referred for stimulant had previously taken stimulants have been plagued
treatment have been labeled as deviant by parents, with methodological problems. However, the evi-
teachers, and peers long before the children came to dence from studies of ADD/H adolescents and adults
the attention of professionals, but the confirmation of has disconfirmed the fear that medicated children are
a label by a mental health or medical professional more at risk of drug and alcohol abuse than unmedi-
who prescribes medication alters the label, changing cated children (Henker, Whalen, Bugenthal, & Bar-
it from "deviant" or "uncooperative" to "sick." ker, 1981) or their normal peers (Gadow & Sprague,
Medication may lead to additional labeling and 1980). In fact, according to some empirical data, a
teasing by peers, and medication administration pro- positive clinical response to stimulants may be asso-
cedures may be the first information a new teacher ciated with a lower probability of drug and alcohol
receives about the child, biasing the teacher's first abuse than found in the general population (Blouin,
impressions. Parents and teachers may view children Bomstein, & Trites, 1978; Loney, Kramer, & Mi-
who are given medication as more seriously dis- lich, 1981).
turbed (Henker & Whalen, 1980) and less capable of Despite the limited evidence that stimulant ther-
taking an active part in solving their behavior prob- apy increases the risk for later drug abuse, several
lems (Borden, 1986) than are children who are not issues qualify that risk. First, many aggressive chil-
given medication. According to research with adults, dren, including those diagnosed as conduct disor-
altering labels and expectations may be quite diffi- dered, are at risk for juvenile delinquency and drug
cult, despite observable behavior changes (Rosen- abuse. Drug abuse may in fact be a problem for ag-
han, 1973). gressive children for whom medication is prescribed.
Perhaps more disconcerting is the influence that However, prescribing stimulant medication is not
medication may have on the medicated child's be- likely to cause drug abuse. Second, as the use of
liefs. Researchers have hypothesized that placing a stimulants for adolescents and adults increases, more
child on psychoactive medication may negatively in- occurrences of drug abuse may be observed.
fluence self-efficacy (Henker & Whalen, 1980), and Tolerance to some of the physiological effects
the children's external attributions for problem solu- of stimulants has been observed in as few as 2 to 5
tions may increase (Bugenthal, Whalen, & Henker, months following the commencement of phar-
1977). Increased external attributions may be related macotherapy (Allen & Safer, 1979; Weiss, Kruger,
to the lack of maintenance of treatment gains. Inter- Danielson, & Elman, 1975), and withdrawal of the
nally attributed changes are believed to be better medication has caused side effects, including severe
maintained than those attributed to external factors depression (Brown, Borden, Spunt, & Medenis,
(Bandura, Jeffrey, & Gajdos, 1975), although the 1985). Thus, addiction to prescribed stimulants may
evidence for this claim has been disputed (Grimm, indeed be occurring, and psychological dependence
1980). on the drug may develop in some patients. For exam-
Concern has been voiced that children who re- ple, Rosen, O'Leary, and Conway (1985) reported
ceive stimulants to treat neuropsychological disor- the case of a 12-year-old boy whose behavior had
ders may be at increased risk for addiction to pre- improved drastically when he was given meth-
scribed drugs. Children who learn to rely on drugs to ylphenidate. His behavior deteriorated rapidly when
solve problems might continue to use drugs to cope medication was discontinued but again improved
with stress. Taking prescribed stimulant medication when a placebo was introduced. Although psycho-
is often reinforced by adults as well as by the child's logical dependence differs from the physical drug
own positive behavior change, perhaps strengthening dependence defined in DSM-III (American Psychi-
the use of medication to solve problems. Further, atric Association, 1980), this child's psychological
children who have learning and behavior problems dependence on stimulants was maladaptive, and he
and are rejected by peers may begin to abuse drugs or required a program of attribution retraining before
sell their medication to gain peer acceptance. the medication could be discontinued. Psychological
Arguments against these concerns include the as well as physical addiction to medication should be
466 CHAPTER 24
carefully monitored, and we need interventions to had increased to nearly 50%. Most important, fewer
curtail these complications. than I 0% of these families consulted a project staff
member before they stopped giving the medication.
Societal In a study in which compliance was monitored
through pill counts, the 34 subjects who completed a
A final concern about the use of stimulants re- 3-month treatment program did not take an average
lates to the use of medication as a form of social of at least 25% of the prescribed dosages (Brown et
control. Stimulants prescribed incorrectly by mis- al., 1987).
diagnosis may mask the symptoms of the true prob- Because of nonadherence, attempts to deter-
lems, thus preventing proper treatment (Volkmar, mine the efficacy of these medications in clinical
Hoder, & Cohen, 1985). settings and research trials may be yielding spurious
Even when prescribed appropriately, unusually results. Obviously, if a child is not taking medication
high doses, which subdue social behavior, often have appropriately, it is difficult to evaluate the efficacy of
been used. This suppression of behavior, referred to the chemical itself. The long-term outlook for chil-
as a "chemical straightjacket" (Ross & Ross, 1982), dren on stimulants might well be improved if ad-
has become a greater concern as the reports of widely herence were improved (Firestone, 1982; Sleator,
ranging doses increase (American Academy of Pedi- 1985).
atrics, 1975). Controlled, apathetic behavior in chil- Investigators have identified patients at risk for
dren is intolerable to some adults and to some re- high levels of nonadherence (Brown et al., 1987;
searchers (Bosco & Robin, 1980). Others argue that Firestone, 1982). Identification of high-risk patients
this "control" is really increased freedom for a child combined with an examination of the causes of non-
who has been incapable of prolonged impulse control adherence might help in the design of interventions to
and attention to stimuli (Gittelman-Klein & Klein, improve adherence rates. The many hypotheses
1975). Consistent with legal and ethical principles, about the causes of nonadherence include the chil-
the least restrictive alternative should be used in treat- dren's dislike of the medication (Sleator et al.,
ment. In the case of medication, this implies titrating 1982). When we have asked children in our laborato-
dosages to the lowest effective level for each child. In ry why they dislike the medication, some have men-
addition, it implies that a course of medication should tioned side effects, such as stomachaches, or said that
be used only when other treatments have failed and "it makes my head feel funny." Others have com-
for the shortest time possible. plained about difficulty swallowing the pill or re-
membering to take it. Still others have complained
about the social ramifications, particularly when they
Compliance have to take the medication at school. In addition to
direct teasing by peers, these children probably rec-
Although the encouraging findings on the short- ognize more subtle changes in how others view or
term efficacy of stimulants are not matched by data interact with them (Barkley et al., 1985).
on the long-term outcome of stimulants (Weiss, Low adherence rates are also related to parents'
1983), many of the poor long-term outcomes may be concerns about having their children take medication
due to a failure of patients and families to adhere to for long periods (Whalen, Henker, & Hinshaw,
the treatment procedures. One type of nonadher- 1985); they worry about negative side effects, includ-
ence-attrition-is the premature discontinuation of ing addiction and health problems. The parents' feel-
treatment. A second type is the alteration of drug- ings about the medication, however, are probably not
administration procedures (e.g., increasing or de- independent of their children's dislike of it.
creasing the dose level). Both types are common in A third reason for poor adherence may be relat-
pediatric medicine (Sleator, 1985) and have been ed to the behavior of the child's physician, neuropsy-
documented in ADD/H children treated with stim- chologist, or psychotherapist. The child and the fam-
ulants (Brown, Borden, & Clingerman, 1985; ily may not feel close enough to the professional staff
Brown, Borden, Wynne, Clingerman, & Spunt, to express their concerns about treatment. In addi-
1987; Firestone, 1982). tion, some professionals fail to monitor adherence
To maintain treatment gains, a long-term course (Solomons, 1973).
of pharmacotherapy is often indicated. However, in Another factor in nonadherence is the intrusive
Firestone's (1982) pioneering study of adherence, routine of administering stimulants. Sometimes,
20% of his patients had discontinued treatment by the when medication is prescribed, the length of the ther-
4th month. By the end of the lOth month, this figure apy is left open. Having no end in sight may further
discourage the children and their parents. Finally, have demonstrated their effectiveness on tasks of
medication may communicate to family members higher-order information processing. Clearly, more
that a child's symptoms are out of the child's or the research is needed with ADD/H children to isolate
family's control (Borden, 1986). The belief in an the specific cognitive processes that are affected by
inability to effect improvements may be considered a psychostimulants.
form of "learned helplessness," which can com- Although the studies with learning-disabled
pound a family's demoralization. The incomplete re- children have been few and have not proven to be
sults of treatment, the inability to envision meeting particularly promising, this area is particularly ripe
hoped-for goals within a reasonable time, and the for future investigation. We know little about the
lack of a sense of control over symptoms may act efficacy of stimulants for children with specific
synergistically, leaving families too discouraged to learning disabilities, such as arithmetic, writing, and
follow through on treatment plans. spelling disabilities, disorders for which stimulants
Adherence must be assessed before unam- have proven effective in ADD/H samples. A careful
biguous conclusions about medication efficacy may examination of studies in which ADD/H children
be drawn. Attending to parents as well as children in have participated indicates that subjects have been
developing therapeutic rapport and providing support quite heterogeneous in degree of aggression and level
to parents and children will help them maintain ad- of intellectual functioning (Gadow, 1985b; Rapo-
herence. In addition, families must be given adequate port, 1983). Because many children with aggressive
information about the treatment and provided with symptomatology and children of differing levels of
strategies for overcoming the social and pragmatic intelligence have proven to be positive responders to
obstacles to taking the medication as prescribed. Fi- stimulants, it is reasonable to hypothesize that stim-
nally, the practitioner must monitor adherence care- ulants may prove to be a viable therapeutic modality
fully before evaluating the efficacy of the therapy. In for mentally retarded and conduct-disordered chil-
general, however, the more valid the monitoring ap- dren. Nonetheless, research on the use of stimulants
proach, the more intrusive and costly it will be with these two populations is scant. This notion of
(Sleator, 1985). diagnostic specificity also has implications for exam-
ining stimulant responses in subtypes of ADDIH
children. For example, future research efforts might
focus on comparing the responses in aggressive and
Summary and the Direction of Future nonaggressive ADD/H children; other studies might
Research evaluate drug response in subjects of differing de-
grees of intellectual functioning.
The past decade has witnessed the marked ex- The clinical use of stimulants with adolescents,
pansion of well-controlled empirical research in the a new avenue of interest in the past several years, has
use of stimulants for children. The clinical communi- demonstrated promise. The use of stimulants for ado-
ty's enthusiasm for the increased use of stimulants lescents has definitely increased (Safer & Krager,
has unfortunately been accompanied by some in- 198~). despite the very few research studies with this
stances of overuse and misuse of stimulants for pedi- population. More systematic research in this area re-
atric populations. The stimulants of choice are dex- mains a high priority for pediatric psychophar-
troamphetamine, methylphenidate, and pemoline. macology.
The short-term efficacy of these drugs has been thor- Most of the well-controlled studies with stim-
oughly documented, although the long-term benefits ulants have incorporated behavioral and cognitive
of stimulants remain uncertain. Research is sorely variables as dependent measures. Little is known,
needed on the relationship of dosage, plasma level, however, about psychophysiological responses to
and behavioral response. The specificity of various stimulants. In fact, the specific actions of stimulants
symptom responses across different dosages also on central and autonomic nervous system variables
begs for investigation. remain unclear. With the development of new psy-
The treatment of ADDIH with psychostimu- chophysiological instruments, this area is destined
lants is probably the best documented and researched for marked expansion in the late 1980s.
treatment in all of child psychiatry. According to Although it was once believed that stimulants
most of the studies reviewed, stimulants most influ- exert little influence in the academic domain, recent
ence the laboratory measures of attention and im- studies have been more encouraging. Much more
pulsivity, as well as behavioral ratings and observa- systematic research is needed, particularly well-con-
tions in ADD/H children. Few studies, however, trolled, long-term studies of stimulant drug effects on
468 CHAPTER 24
academic tasks. Although we have finally learned to study of the long-term effects of stimulants is the
evaluate appropriately the response to stimulants, un- obvious ethical limitations in placing children in no-
due optimism will not be warranted until we have medication or placebo-control groups for long peri-
evaluated long-term efficacy in the academic as well ods. Collaboration among investigators in research
as the behavioral domain. laboratories throughout the country may be one an-
Important treatment decisions such as when to swer to this dilemma and one that will help us deter-
initiate or discontinue medication have been the topic mine any possible long-term adverse effects in the
of much clinical and research literature, but no stud- physiological or the psychosocial domain.
ies have yielded definitive data. Treatment decisions Pending further, more definitive studies, clini-
continue to be chiefly clinical decisions, and a cians and parents must continue to struggle with
clinical trial is still the practitioner's best tool. Unfor- many unanswered questions about stimulant medica-
tunately, the practitioner has little qualifiable infor- tion. Until we have more definitive answers about
mation about terminating stimulant treatment for a long-term effects, research remains a high priority,
child. In fact, only one rating scale allows the practi- particularly joint research by the psychologist and the
tioner to document side effects systematically, thus physician.
permitting the quantification of such effects (Bark-
ley, 1981). Although we have used this instrument ACKNOWLEDGMENTS
with considerable success in our laboratory, addi-
tional scales with adequate reliability and validity This chapter was supported in part by BRSG
will be necessary for the careful monitoring of possi- S07 RR05364 from the Biomedical Research Sup-
ble adverse drug effects in children. Clearly, we need ported Grant Program, Division of Research Re-
systematic study of individual variables in adverse sources, National Institutes of Health, awarded to
effects and in the prediction of responses. R.T.B.
The limited generalizability of stimulant drugs, The authors are indebted to Marie. Morgan for
along with the realization that children may need to her careful editing of the manuscript and to Martha
be maintained on stimulants indefinitely to sustain Hagan for her skill in typing the manuscript. The
desired clinical effects, has been particularly disap- authors are also grateful to Kenneth Gadow for mak-
pointing to researchers and practitioners alike. In ing available to them so many reprints of his work.
fact, these drawbacks have caused some practitioners Our appreciation also goes to the Emory University
to be unduly pessimistic about the use of stimulants. School of Medicine, Behavioral and Developmental
As Gittelman ( 1983) pointed out, though, no medical pediatric residents and child psychiatry fellows as
therapy ameliorates a disease or completely reverses well as Sandra Sexson for their thoughts and clinical
symptoms to the extent that the symptoms are no insights, which in part shaped some of our thinking
longer visible when pharmacotherapy is discon- and views in preparing the chapter. The opinions
tinued. Thus, before indicting simulants as ineffec- expressed herein, however, are those of the authors,
tive, the practitioner must consider the alleviation of and they are not necessarily shared by others working
symptoms the only reasonable expectation. Although in the field.
we expected combinations of stimulants and non-
somatic therapies to prove most efficacious and
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474 CHAPTER 24
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25
Nonstimulant Psychotropic
Medication
Side Effects on Children's Cognition and Behavior
MANUEL L. CEPEDA
Nonstimulant psychotropic medications are used to such as Wechsler-type scales (e.g., WISC-R,
attenuate a limited number of target symptoms asso- WPPSI, KABC), Bender Gestalt, and achievement
ciated with childhood psychopathology. For some tests.
disorders, as the underlying disease process im- It is unfair to the child who is helped by a medi-
proves, cognitive performance also improves. The cation to request arbitrarily of the physician or parent
cognitive improvement is probably not a direct effect that the child be free of medication when tested.
of the medication, however. In addition to the pri- While on medication, the child may actually be giv-
mary effect on behaviors targeted for improvement, ing a more useful picture of test performance. It is
all medications have side effects. These may affect also misleading or a disservice to state in every psy-
behavior and cognition. This chapter summarizes the chological testing report based on data taken while
primary or desired effects of the major classes of the child was on medication that the report may be
nonstimulant psychotropic medications, and reviews invalid, or not represent a true picture of the child's
the behavioral and cognitive side effects that might performance because of medications. Not every be-
influence psychological testing. havior that "interferes" during testing is due to a
medication. Most medications, in routine doses, do
not impair test performance.
Psychotropic Medication and Some medications do have specific behavioral
Psychological Testing side effects that are easily recognizable. If the behav-
ior of concern is not one of these specific side effects,
the medication probably is not causing the problem.
Those engaged in psychological testing occa-
Behavioral observations made during testing may re-
sionally obtain and interpret data from children using
flect that the child "did not seem to hear what was
psychotropic medications. Most frequently, these are
said," or "seemed in a fog," or "appeared sleepy
the stimulant medications covered in the preceding
and could not concentrate." Seldom are behaviors
chapter by Brown and Borden. However, the major
such as this a side effect of nonstimulant psycho-
tranquilizers, anxiolytics, and antidepressants will
tropic medications. Dissociative states, situational
also be encountered. There is always a concern that
stress, or oppositional behavior patterns far more
the behavioral and cognitive side effects of these
often account for these common responses than does
medications may adversely influence the test results.
medication. Sometimes, it takes hours of diagnostic
This concern will be addressed for the more global
play therapy to discover the child's entire repertoire
psychological instruments administered to children,
of mental mechanisms and behavioral responses. The
psychometrician seeing the child only for testing can-
not put the behaviors seen in a true context. Many
MANUEL L. CEPEDA Depanment of Psychiatry, Univer- educational and counseling personnel working with
sity of South Alabama College of Medicine, Mobile, Alabama children are unfamiliar with medications. Some are
36617. philosophically opposed to drug use. All too quickly,
475
476 CHAPTER 25
behaviors or test results may be erroneously at- were being used to treat symptoms. No diagnostic
tributed to the influence of medication. nomenclature of childhood psychopathology ade-
This chapter is written to help place these issues quately identified the children who might be respon-
into perspective and help clarify the specific concerns sive to medication. No treatment-responsive symp-
that should be placed in psychological test reports tom is unique to a specific diagnosis. In contrast to
from a child-psychiatric perspective. It will also the psychopharmacological treatment of adult-onset
serve as a guide for discussing concerns about possi- major mental disorders such as schizophrenia or the
ble medication side effects with the prescribing phy- major affective disorders, childhood psychophar-
sician. Hospitalized children have ptore severe macology was at this time in its infancy and quite
symptoms and may be prescribed higher doses more confusing to mental health clinicians who saw chil-
quickly than would be given to outpatients. Those dren being treated for symptoms that may have re-
testing children on a hospital inpatient unit frequently sponded to medication by physicians who still argued
talk with the referring physician when a clarification about the diagnosis.
needs to be made about medication effects such as In 1973, a special issue of the Psychophar-
sedation. In the school or outpatient clinic setting, macology Bulletin (National Institute of Mental
similar consultation should be available although the Health, 1973) summarized the current needs in the
need may not be as frequent. For such a consultation, field of childhood psychopharmacology and present-
a parent should first give permission. ed a standardized package of rating scales and data
sheets that had been found valuable in clinical re-
search. This brought much needed uniformity to the
Psychopharmacology with Children field of childhood psychopharmacology. This infor-
mation has recently been updated (National Institute
The use of psychotropic medications in the of Mental Health, 1985). Although improvements
treatment of childhood psychopathology began in the will continue, there is now a considerable literature
late 1930s with the stimulant medication Benzedrine. on the reliability and validity of the psychophar-
It was almost 15 years later, following the introduc- macology assessment rating scales. A vast improve-
tion of the antipsychotic& such as chlorpromazine ment in the diagnostic nomenclature for children
(Thorazine) and thioridazine (Mellaril), that other came with the publication of the Diagnostic and
drugs were administered for the control of childhood Statistical Manual of Mental Disorders, 3rd edi-
behavior disorders. Most of the early target behaviors tion (DSM-lli; American Psychiatric Association,
involved psychomotor excitement, restless behavior, 1980). The DSM-lli has brought research-grade di-
anxiety, and hyperactivity. Many of the initial drug agnostic criteria that can be applied uniformly by
trials involved children with a diagnosis of delin- researchers and clinicians. It is now in widespread
quent behaviors, brain damage, cerebral palsy, or use. Refinements in the diagnostic categories, based
mental retardation. Quickly, antianxiety medications on both clinical use and statistical studies, are now
such as hydroxyzine (Atarax) and later, the tricyclic being made (American Psychiatric Association,
antidepressants such as imipramine (Tofranil) were 1985). The latest areas of research are looking at the
added. Most recently, the antimania drug l~thium and relationships between drug dosage and plasma lev-
anticonvulsants are being tried in conjunction with els. Hopefully, these pharmacokinetic studies can be
childhood psychopathology. The field of childhood used to establish therapeutic blood ranges necessary
psychopharmacology has always been one of symp- for clinical response. Several texts summarize both
tom treatment. Although many behavioral concomi- the history of childhood psychopharmacology and its
tants of specific diagnoses are responsive to medica- current use (Weiner, 1977, 1985; Werry, 1978).
tion, the underlying disease process has yet to be
treated directly. This point distinguishes childhood
psychopharmacology from the psychopharmacology Nonstimulant Psychotropic Drugs
of many adult mental disorders.
During the 1960s, research methodology im- Five general groups of neuroleptic medications
proved considerably. Single case studies and clinical are given to children: the antipsychotic, antidepres-
observations were replaced with controlled studies sant, antianxiety, antimania, and stimulant medica-
using rating scales, double-blind research designs, tions. The first four are discussed in this chapter. For
placebo, and statistical analysis. Research has al- each, a general outline of the clinical characteristics
ways been hampered by the fact that medications of the diagnostic categories associated with the use of
NONSTIMULANT PSYCHOTROPIC MEDICATION 477
the medication will be given. Then, the specific tar- Antipsychotics

get symptoms that are responsive to medication will
be covered. The discussion of side effects follows. The antipsychotics are used to treat psychotic
Side effects are physiological, psychological, symptoms in adults or adolescents with major mental
and behavioral responses to medication that are not disorders. These include schizophrenia, major de-
pertinent to the main purpose of the medication. All pression with psychotic features, bipolar disorders
drugs have side effects. Side effects are not neces- with manic symptoms, and delirium or dementia with
sarily undesirable. Often, they are only a nuisance. associated psychotic symptoms. The symptoms most
Frequently the patient does not realize that a side responsive to drugs are those of acute or sudden onset
effect is occurring because no real problem is caused. and include the disorganized thinking of the schizo-
Effect and side effect can change as the purpose for phrenic disorder, delusional thinking or hallucina-
which the medication is prescribed changes. Some tions of any psychotic process, and the confusion
medications impair motor performance or may cause associated with delirium or dementia. Symptoms that
bizarre motor responses. This may impede testing. are slow, gradual, and insidious in onset are poorly
Sedative effects common to the initial administration responsive. Psychotic symptoms accompanied by
of some drugs may likewise cause a problem. anxiety, agitation, and motoric hyperactivity are usu-
One of the earlier reviews (Baker, 1968) of the ally amenable to medication treatment. Medication-
effects of psychotropic drugs on psychological test- responsive psychotic symptoms seen in adult disor-
ing concluded that there were few or no changes in ders are not common to childhood psychopathology.
psychological test performance as a result of drug No childhood disorders respond as well to anti-
treatment. Common clinical tests such as the Bender psychotic medication.
Gestalt, Draw-A-Person, Wechsler Adult Intel- That childhood disorders are distinct from adult-
ligence Scale, Rorschach, Thematic Apperception onset disorders was made clear by the change in diag-
Test, and Minnesota Multiphasic Personality In- nostic nomenclature for the DSM-lli. The psychotic
ventory were reviewed. The author hypothesized that reaction of childhood and childhood schizophrenia
the lack of drug effects demonstrable may be due to diagnoses have been updated. The current nomen-
the relative insensitivity of the clinical tests. A sim- clature is pervasive developmental disorder. This re-
ilar conclusion was drawn concerning the Halstead- flects the extent of the possible impairments due to
Reitan Neuropsychological Battery (Howard, Ho- disordered growth and development in multiple sys-
gan, & Wright, 1975). This study controlled for age tems. There may be arrests or distortions in the devel-
differences and considered drugs individually and in opment of language, perception, social skills, reality
combination. The subjects were patients using anti- testing, and motor movement. Although childhood
psychotic, antianxiety, antidepressant, and sedative autism (onset before 30 months of age) is dis-
drugs. The conclusion held true for a wide dosage tinguished from the childhood-onset pervasive devel-
and range. opmental disorders (onset after 30 months of age and
Specialized research instruments do demon- before 12 years), this may be an unnecessary distinc-
strate the pharmacological effects of psychotropic tion. Probably there are several common etiological
medication upon cognitive and behavioral function factors that could serve as insult to account for devel-
(Nicholson & Ward, 1984). Variables studied in- opment of the problem. The age of onset may deter-
clude body sway, driving performance, vigilance, mine the specific clinical presentation.
pupillary function, ambulatory motor activity, sac- A lack of responsiveness to other people is the
cadic eye movements, and various pencil-and-paper hallmark of infantile autism. The deficits in language
tests. Most studies involve the single dose admin- development include echolalia, pronominal reversal,
istration of a drug to a healthy volunteer. This is not bizarre intonations, and bizarre motor patterns.
analogous to the clinical setting where patients take There is a resistance to change in the environment.
medication over a period of time and adapt to the The child may respond to people as he or she does to
initial side effects. Although not of relevance to the inanimate objects without giving cognizance to the
clinical testing of children, the reports from the jour- human qualities of the relationship. If the onset
nal edited by Nicholson and Ward (1984) do comes after the child has developed speech and a
represent the type of research that is necessary to relationship with a caretaker has been established,
demonstrate psychotropic medication effects on the clinical presentation is different. Although there
physiological and cognitive functioning through psy- may be a regression to a more autistic level of relating
chological tests. to others, many of the behaviors may be near normal.
478 CHAPTER 25
There may be episodes of severe or excessive anx- have behavior problems of this nature are given anti-
iety. Affect may be inappropriate to the situation. psychotic medications. The brain-damaged child
Bizarre motoric patterns such as walking on tiptoes or with aggressive and uncontrollable behavior may be
choreoathetoid-like hand or finger movements may medicated. Antipsychotics are often tried in the treat-
develop. Speech abnormalities are seen. Self-mutila- ment of any child with a pervasive developmental
tion may occur. Excessive fantasy play may occur in disorder even though now it is considered to be a
settings where other children the same age are work- developmental disorder involving multiple systems
ing and talking with a reality-oriented or task-di- rather than a psychotic process. Sometimes children
rected manner. who have a conduct disorder with an aggressive com-
Most current research suggests that a biological ponent may be medicated.
insult during the first trimester of pregnancy accounts The common behavioral side effects of the anti-
for at least some of the earlier-onset and more autistic psychotic drugs involve CNS-mediated behaviors.
disorders. The data are less clear for the later-onset One possible side effect is the acute dystonic reac-
disorders. It is only with onset of illness toward the tion. This involves rather sudden onset spasms of
end of latency that the clinical picture may be the several common muscle groups. Although a dystonic
same as that seen with the adult-onset schizophrenic reaction may look frightening to an observer, most
disorders. If hallucinations or delusions are present, cause little if any physical discomfort. The jaw may
the problem is not one of pervasive developmental pull over to one side and look as if it is dislocated.
disorder. Nomenclature designed for adult psycho- The head and neck may twist to one side in a tor-
pathology would then apply even though a child is ticollis position. The child may complain of his
involved. tongue pulling into the back of his mouth, or that he
One other diagnostic category in childhood is feels like he is swallowing his tongue. Both eyes may
treated with antipsychotic medication. These are roll up (oculogyric crisis) leaving only the bottom
children with tic disorders. At present, few therapists part of each pupil and iris showing. Rarely, the trun-
feel a tic disorder represents a specific psycho- cal muscles may be involved. The child may twist
dynamic conflict. Historically, it was thought to be into a opisthotonos position with the head pulled
so. Some 20% of children develop a transient tic at backwards and back arched with arms drawn up and
some time. The tic disorder of concern is Tourette's legs extended back. With the exception of the tongue
disorder. This involves multiple tics, including vocal complaint, the acute dystonic reactions should be
tics. The onset may be as early as age 2 and symp- easily recognizable.
toms may last a lifetime. They also remit and exacer- Dyskinesias should also be easily recognizable.
bate with a variable time course. Those who use psy- These include facial tics, lip-smacking, tongue
choptherapy to treat the tics point out that symptoms movements, blinking, and muscle spasms. Most of
exacerbate during stress. Intervention is directed to- these symptoms can occur in children who are not
ward stress reduction. Fewer psychotherapists at pre- receiving antipsychotic medication. Thus, it is diffi-
sent try to analyze the tic as a symptom representing cult to assign an etiology to these observations. They
psychological conflict. Both behavioral and medical may not be due to medications.
management programs have the same problem: dif- Akathisia is easily recognized in adults. It con-
ferentiating therapeutic response from the natural sists of an apparent inability to sit still. The legs may
course of the disorder. When medications are used, look as if they want to pace as they continue to move
usually haloperidol (Haldol) is prescribed. There is in a "walking" pattern even while the individual is
no good reason why this should be chosen over the sitting. In children, the "fidgetiness" of the hyperac-
other antipsychotic medications except that it has tive child may be mistaken for akathisia.
been studied more in the treatment of Tourette's A parkinsonian picture may be seen. There may
syndrome. be muscular rigidity, a pill-rolling hand tremor,
The target symptoms for treatment of childhood drooling, and masklike faces. The reduced move-
disorders with antipsychotic medications (with the ment may be confused with catatonia or with the
exception of the treatment of multiple tics, which appearance of a retarded depression.
came later) remain the same as when the medications A troublesome side effect is tardive dyskinesia.
were first used in the 1950s. Drugs are used to treat This involves abnormal mouth movements that may
the psychomotor agitation/hyperactivity, excessive look like persistent chewing, lip-smacking, or re-
and incapacitating anxiety, and aggressive behaviors petitive tongue protruding. Another name for this is
toward self and others common to a number of diag- buccolingual-masticatory (BLM) movements. They
noses. As a consequence, the mentally retarded who may go away if medication is lowered or discon-
tinued and may be hidden or masked if medication is cation not only did not impair performance on the
increased. Sometimes BLM movements increase in visuomotor tasks of the WISC, but accounted for an
intensity and do become disfiguring. The picture is improved IQ. Results such as this most often in-
confusing because withdrawal dyskinesias are ini- volved studies of children with an autistic process.
tially indistinguishable from tardive dyskinesia. The When antipsychotic medications were given to
withdrawal dyskinesias may appear transiently when children with a variety of diagnoses that included
the relative dose of antipsychotic medication is de- nonpsychotic processes (such as adjustment reaction,
creased. The literature that cites incidences of tardive psychoneurotic reaction, and personality distur-
dyskinesia probably includes withdrawal dyskinesia bance), the results more often were inconclusive or
symptoms also. Those at greatest risk are elderly actually showed some deterioration in test perfor-
women. Although reported in children, the incidence mance. It could be argued that in these latter groups,
probably is not as great. the symptoms of psychopathology do not directly
The dystonic reactions, most dyskinesias, impede the process of testing in the same sense that
akathisias, and parkinsonian symptoms should clear the symptoms of autism impede testing. Thus, in the
following treatment with an antiparkinsonian drug autistic child, the use of medications may have allevi-
such as benztropine mesylate (Cogentin) or with diated target symptoms and allowed testing to take
phenhydramine (Benadryl). Some of the anti- place. For the other diagnostic categories, medica-
psychotic medications may cause sedation when first tion either had no effect because there were no symp-
given or anytime that very high doses are prescribed. toms that impeded the process of testing or a sedative
This effect should abate over several days or weeks as effect actually impaired the test performance. Re-
the child adapts to the medication or as the physician peatedly, the comment was made that any untoward
decreases the initial treatment dose to lower mainte- effects on testing or learning were probably related to
nance levels. If antipsychotic medication is with- either the sedation seen at high doses, or the sedation
drawn, the clinical effects persist for about 24 to 36 seen upon initial administration. This was more true
hours. Essentially all of the drug will be metabolized when the drugs were used for treatment of the ag-
and cleared from the body within 3 or 4 days follow- gressive and explosive components of the conduct
ing cessation. At this point, there is no longer any disorders, and the hyperactive component of the at-
clinical effect. With prolonged administration, me- tention deficit disorder.
tabolites may persist in the urine for several months. Similar conclusions have been drawn in studies
These latter findings are not of clinical importance with adults (Braff & Saccuzzo, 1982; Spiegel &
because there is no pharmacological effect. Keith-Spiegel, 1967; Weiss, Robinson, & Dasberg,
Most research that considers the effects of anti- 1973). In an analogous manner to the studies that
psychotic medications upon cognition has studied showed an improvement in cognitive performance on
children with mental retardation or with autism. selected clinical psychological tests with autistic
Some 70% of this latter group have an IQ in the range children, those symptomatic with schizophrenia also
of the mentally retarded. When research subjects improved on similar tests following the administra-
have medication-responsive target behaviors, it is tion of antipsychotics. Again, the improvement came
difficult to design any research using common psy- with a reduction in the severity of symptoms of ill-
chological tests that specifically assess the effects of ness. It was postulated that those with severe hyper-
antipsychotic medications upon cognition alone. activity had excess dopaminergic activity and that
Most studies look at the effects of medications both haloperidol, a dopamine antagonist, reduced the hy-
upon behavior and upon learning ability (Anderson et peractivity and fidgetiness. This allowed an improve-
al., 1984; Campbell, Anderson, Small, Perry, ment in test performance.
Green, & Caplan, 1982; Campbell et al., 1982; Help- The following represents clinical guidelines.
er, Wilcott, & Garfield, 1963; Sprague, Barnes, & Antipsychotic medication treatment of children with
Werry, 1970; Weise, O'Reilly, & Hesbacher, 1972; a pervasive developmental disorder, in reasonable
Werry, Weiss, Douglas, & Martin, 1966; Wong & clinical doses and without obvious sedation, should
Cock, 1971). Several make the point that as the not adversely affect the test results on clinical instru-
symptoms of aggression, restlessness, and poor con- ments such as the Wechsler Scales or Bender Gestalt.
centration improve, tasks including learning and If anything, the medication will improve perfor-
school achievement improve. Most of the improve- mance by reducing many of the target symptoms that
ment seems to come following the first I to 2 months impair test performance. These symptoms include
of medication treatment. The study by Wong and hyperactivity, fidgetiness, aggressivity, and con-
Cock (1971) suggested that the antipsychotic medi- centration problems. It is possible that the same med-
480 CHAPTER 25
ications, used to treat similar symptoms in children medication is usually prescribed only after symptoms
with attention deficit disorders or conduct disorders, have persisted for at least 30 days. Adolescents with
may impair performance on those items that are the same melancholic symptoms as adults seem to
timed or require motor performance. This is difficult respond more poorly to antidepressants than do
to demonstrate in the common psychological tests adults. To account for the paucity of melancholic
used clinically and may only be of concern if the dose symptoms in children, the psychodynamic concepts
of medication is actually causing sedation. Adverse of masked depression, somatic equivalent of depres-
effects of medication upon test results will be more sion, and acting out of defense against underlying
frequent just after the medication is started. At rea- depression were formulated. Currently, psychosocial
sonable clinical doses, they will be of less or negligi- deficits and impairments in relationships are being
ble concern after the child has been on medication for discussed as diagnostic of depression in the school-
at least 4 to 8 weeks. If testing is to be used for age child. At best, the children meeting psycho-
educational placement, it should come 4 to 8 weeks dynamic formulation criteria for depression may also
after the child is on a stable maintenance dose. If the meet the diagnostic criteria for a dysthymic disorder
child must be tested free of antipsychotic medication, without symptoms of melancholia.
a 3- or 4-day delay following cessation of drug should In the early 1970s, the tricyclic antidepressant
be sufficient. imipramine (Tofranil) was used to treat hyperactive
children. Most of the target clinical improvements
included improved conduct in general, improved at-
Antidepressants tention span, and reduced motor activity. Most stud-
ies concluded that the antidepressant was effective
The antidepressants were developed to treat and also that the degree of improvement was
symptoms of melancholia in adolescents and adults eventually the same as with stimulant medication
experiencing depression as part of a major depression (Quinn & Rapoport, 1975; Rapoport, Quinn, Brad-
or the depressive component of a bipolar disorder or bard, Riddle, & Brooks, 1974; Werry, Aman, &
schizoaffective disorder. Symptoms most clearly re- Diamond, 1979). These medications never gained
sponsive to these drugs include crying spells, de- popularity, however. Today the stimulant medica-
creased appetite and weight loss, diurnal mood variations are used almost exclusively. An increased inci-
tion (less energy upon arising than later in the day), dence of side effects with the antidepressants may
difficulty falling asleep, middle of the night awaken- have led physicians to choose the stimulant med-
ing, early morning awakening, decreased libido, and ications.
impairment of concentration. Less responsive to Enuresis is still being treated with imipramine.
medications are subjective feelings of depression and Although this drug is the prototype antidepressant for
anhedonia. Drugs are of benefit in the treatment of a use with this problem, any tricyclic antidepressant
dysthymic disorder (depressive neurosis) only when should do equally as well. The most optimistic re-
the previously listed biological concomitants of de- ports come in the treatment of secondary nocturnal
pression are present. Antidepressants do not alleviate enuresis. It is called secondary because the child does
subjective feelings of depression or life circumstance have periods free of enuresis. Primary enuresis (nev-
dysphoria unaccompanied by these biological er has been dry) is less responsive. About half of
changes. those with secondary enuresis become asymptomatic
Although clinicians do not question the concept with medication. Probably only half of this group
of depression with melancholia in adolescents, the sustain the improvement. Imipramine treatment is
concept of childhood depression has caused diffi- superior to placebo treatment, but has not been dem-
culty. Young age and limited cognitive development onstrated to be superior to the many other alternative
are probably protective of the development of the treatments (bell and pad, token economy, brief fami-
nihilistic depressive delusional beliefs that are seen in ly or individual psychotherapy). There is a literature
adults. It is uncommon for the target symptoms (bio- on this topic (Behrle, Elkin, & Laybourne, 1956;
logical concomitants of depression) that so clearly Kardash, Hillman, & Werry, 1968).
respond to antidepressants in adults to persist in chil- Some children with severe separation anxiety
dren. When they occur, it is usually for only a brief disorders are treated with high doses of imipramine.
period of time. For adults, approximately 3 weeks of The child with this disorder may experience unre-
antidepressant treatment is needed for clinical symp- alistic worry that harm will befall a caretaker if they
toms of depression to respond. For children, the de- are out of sight. Associated behaviors include refusal
lay in response may be even longer. For this reason, to attend school so that the child may stay home with
the caretaker and insistence on sleeping with the care- ministered. The effects upon concentration for these
taker. Physical complaints such as headaches or tasks may have again become apparent during with-
stomachaches on school days only are reported. Anx- drawal following prolonged administration.
iety may be seen. Social withdrawal, apathy, sad- The memory and attention changes during anti-
ness, or difficulty concentrating may be so severe as depressant treatment of adults with depression have
to be judged melancholic components of depression. received more attention (Glass, Uhlenhut, & Wein-
Most medication treatment for this disorder comes reb, 1978; Glass, Uhlenhuth, Hartel, Matuzas, &
only after psychotherapeutic and psychosocial/edu- Fischman, 1981; Henry, Weingartner, & Murphy,
cational therapies have failed. It is always used in 1973; Lamping, Spring, & Gelenberg, 1984; Legg &
conjunction with other therapies. This is not a com- Stiff, 1976; Sternberg & Jarvik, 1976; Keeler,
mon treatment and the current literature is still sparse Prange, & Reifler, 1966). The effects of antidepres-
(Gittelman-Klein & Klein, 1971, 1973). sants upon cognitive function are unclear. Probably
There are no dramatic behavioral side effects of gross clinical measures such as the Wechsler Adult
antidepressants as there were with the antipsychotics. Intelligence Scale are not sensitive enough to reflect
Children are more comfortable if the dose is in- medication effect. When patients are tested for IQ
creased by increments every 2 or 3 days so that the changes following treatment with antidepressants,
therapeutic dose is reached after a week or so. If the scores do improve. But medication effects on test
dose is increased too rapidly, the child may complain scores cannot be separated from practice effect and
of sleepiness, tiredness, or drowsiness. These effects from improvement due to alleviation of depression.
are transient and should abate over a week or two. Depressed patients usually show an impairment in
Mild fine hand tremors may be seen or there may be short-term memory tasks without long-term memory
complaints of a dry mouth or blurred vision for read- impairment. The greater the clinical improvement
ing. These latter symptoms may be anticholinergic- with medications, the more short-term memory im-
mediated side effects that are more of a problem with proved. Imipramine probably does facilitate psycho-
some tricyclics than with others. These should abate motor tasks such as tapping or reaction time. It is
also. This may take a few months if the child is possible that those tricyclic antidepressants with
unduly sensitive or the dose must remain high. higher anticholinergic effects may potentiate memo-
Rarely, a child will complain of difficulty paying ry disturbances in depressed patients while they are
attention even on a reasonable dose. A different tri- clinically depressed and when drug treatment is first
cyclic may need to be prescribed. Because this is started. Again, this was not demonstrated on com-
such a common symptom of preexisting psycho- mon clinical measures, but could be seen on spe-
pathology, a decision to attribute these complaints to cialized memory tasks. The short-term memory
medication should be made with care. (improved accuracy without decreased speed) im-
When tricyclic antidepressants are stopped fol- provement may come just prior to improvement in
lowing prolonged administration, all biological ac- the clinical level of depression.
tivity or clinical medication effect should dissipate Cognitive effects of antidepressants have been
over a 7- to 10-day period. This may be even shorter studied in children being treated for enuresis, hyper-
with young children than with adults. activity, childhood depression, and aggression
The cognitive effects of single dose administra- (Brumback & Staton, 1980; Campbell, Small, et al.,
tion of antidepressants have been studied (DiMascio, 1982; Kupietz & Balka, 1976; Rapoport, 1965;
Heninger, & Klerman, 1964; Ross, Smallberg, & Staton, Wilson, & Brumback, 1981; Werry, Dow-
Weingartner, 1984; Thompson & Trimble, 1982). It rick, Lampen, & Vamos, 1975). The children with
is clear that some antidepressants are more sedating depression who received medication did have melan-
than others. Subjective reports of sleepiness peak cholic symptoms. Psychological testing after suc-
between 2 and 3 hours and are gone by 7 hours after cessful drug treatment usually showed an improve-
the drug is ingested. The same complaints do not ment in the pretreatment scores on such measures as
apply during long-term administration. Care should the Wechsler Intelligence Scale for Children. It may
be taken not to extrapolate from effects following take 2 or 3 months of drug therapy before these gains
single dose administration to effects following pro- can be shown. It was hypothesized and suggested that
longed administration. The latter group has an oppor- the symptoms of depression precluded accurate test-
tunity to adapt to the medication effects common to ing and that the educational and intellectual perfor-
single dose administration. The more sedating tri- mance of a'depressed child should be assessed after
cyclics did impair performance on serial addition and the depression is in remission. Although not a clinical
digit sub~titution tasks when the drug was first ad- measure, the Continuous Performance Test was used
482 CHAPTER 25
in one study to show that amitriptyline (Elavil) facili- sufficient to convince physicians to incorporate
tated vigilance performance. Several of the more lithium carbonate into the psychopharmacological
clinical studies commented that children receiving an armamentarium for use in childhood behavior disor-
antidepressant concentrated better. In those studies ders, research on the use of lithium carbonate to con-
that compared pre- and posttreatment IQs for chil- trol aggression in childhood has afforded an oppor-
dren treated for conduct problems or enuresis, no tunity to look at the cognitive effects. Lithium has
significant differences were found. been used as an antiaggression drug for school-age
The following clinical guidelines apply for rou- children with undersocialized and aggressive con-
tine psychological and psychoeducational testing. If duct disorders (Platt, Campbell, Green, & Grega,
the child is receiving tricyclic antidepressants to treat 1984). This is a disorder in which the child displays a
a depression with a melancholic component, testing persistent and repetitive pattern of aggressive con-
should be delayed until clinical improvement is seen duct. There may be physical violence against persons
if it is to be used for long-term educational place- or property, including vandalism, fire setting, mug-
ment. The delay may need to be as long as 2 to 3 ging, and assault. Fighting is the predominant symp-
months after medication is started. Testing earlier tom for the younger child.
than this probably reflects current function only and In usual therapeutic doses, monitored via serum
may be a poor predictor of future performance. For blood levels, lithium does not produce CNS-medi-
the child receiving antidepressants for problems ated behavioral side effects. One study (Judd, Hub-
other than depression, the initial sedative and/or anti- bard, Janowsky, Huey, & Takahashi, 1977) reported
cholinergic effect that may be seen in the first week or that in normal volunteers, therapeutic levels of
two of administration may influence the test results. lithium did impair performance on the Digit Symbol
It would be best to delay testing until the child has subtest of the W AIS and the Trail Making A Test.
been on medication a couple of weeks. If the child Another study concluded that lithium caused a decre-
must be tested free of antidepressant medication, a 7- ment in W AIS IQ (Aminoff, Marshall, Smith, &
to 10-day delay will be necessary. There is no re- Wyke, 1974) in patients being treated for Hunting-
search evidence to show that long-term administra- ton's chorea. This is a progressive neurological dis-
tion of tricyclic antidepressants impairs performance order. Dementia is a part of the expected deteriora-
on any routine psychological or psychoeducational tion and the concern was whether the lithium
batteries. potentiated the process. Other studies have looked at
memory tasks (Bonnel, Etevenon, Benyacoub, &
Antimanic Drugs Slowen, 1981 ; Christodoulou, Kokkevi, Lykouras,
Stefanis, & Papadimitriou, 1981; Huey, Janowsky,
Lithium carbonate is used for the treatment of Judd, Abrams, Parker, & Clopton, 1981; Kusumo &
the manic phase of bipolar disorders in adults. It is of Vaughan, 1977; Marusarz, Wolpert, & Koh, 1981;
unclear benefit in the treatment of the depressive Squire, Judd, Janowski, & Huey, 1980). All of these
phase and for many patients does not offer pro- studies used either specialized scales or selected parts
phylaxis against recurring depression. Because of more common tests.
clinical improvement of manic symptoms takes 7 to No consistent conclusion can be drawn. It might
10 days with lithium alone, an antipsychotic medica- be that those with a concomitant dementing process
tion that can reduce symptomatology over 3 or 4 days or those older are at more risk for memory dysfunc-
is often used first. If the manic phase of a bipolar tion when lithium is used. It may be that those who
disorder does occur in children, it must be rare. It is are the most ill show more impairment. There is some
seen in the adolescent. evidence that lithium does not affect the more global
The behavioral symptoms of a manic episode measures such as theWAIS or the Wechsler Memory
include an increase in activity or physical rest- Scale in nondemented patients. In contrast to the
lessness, a pressure to keep talking, racing thoughts, other drugs covered, studies with lithium did not
grandiosity, decreased sleep, and distractibility. The show an improvement in cognitive function with
individual in a manic episode often becomes irritable clinical improvements. There are insufficient data
when confronted with structure and control or if gran- from which to generalize concerning children and
diose schemes are thwarted. Physical and verbal ag- testing.
gression may result. Property may be destroyed.
Hospital personnel attempting to controi the patient Antianxiety Drugs
may be hurt if not trained to handle the physical
outbursts. Antianxiety medications are in widespread use in
Although the research evidence has not been the symptomatic relief of anxiety in adults. Anxiety is
a universal phenomenon and is not limited to psycho- are a vast improvement over the earlier research. Yet,
pathological states. Rating scales show that the de- for the physician prescribing medication, treatment is
pressed patient frequently complains more vehe- still directed toward a limited number of target symp-
mently of anxiety than does the patient with a toms such as motoric hyperactivity, aggressivity,
generalized anxiety disorder. Anxiety can be very psychomotor excitement, and enuresis. Much pre-
painful to those experiencing a psychotic episode. scribing is on an empirical basis and not for treatment
Children experience anxiety also. This may be part of a
of specific psychopathological disturbances.
specific diagnosis such as an overanxious disorder, a Nonstimulant psychotropic medications never
separation anxiety disorder, or an obsessive-com- constitute the sole treatment of any childhood psy-
pulsive disorder. Although antianxiety medications chopathological disorder. They are an adjunct at
lead the list of medications prescribed for adults, it is
best. Programs involving special education place-
relatively uncommon for the same drugs to be pre- ments and psychological interventions (psycho-
scribed for children. Some physicians do prescribe therapeutic and behavioral management) are the
anxiolytics for children as a part of symptomatic mainstay of treatment.
treatment of anxiety. This is usually for only very All medications have side effects. A side effect
brief periods of time. There is no clinical literatureis any pharmacological action that occurs in addition
advocating the use of anxiolytics to treat the common to the amelioration of target symptoms. That a side
childhood diagnoses associated with anxiety. effect occurs is neither desirable nor undesirable un-
There is a corresponding paucity of literature on
less it causes discomfort or dysfunction. Some be-
the cognitive and behavioral side effects of anx- havioral and cognitive side effects may influence or
iolytics in children. One study that evaluated anx- interfere with psychological testing.
iolytic drug effects on the cognitive function of chil- Most behavioral and cognitive side effects of
dren concluded that at therapeutic doses, there is no medications on test performance are easily recog-
adverse effect on cognition (Ferguson & Simeon, nized. Sedation is associated with both the initial
1984). Most studies of adults conclude that at com- administration and high doses of some drugs. Chil-
mon therapeutic doses, little if any difference be- dren adapt to common doses quickly. The recom-
tween placebo and drug groups can be demonstrated mended delay in testing following the start of drug
(Healey, Pickens, Meisch, & McKenna, 1983; management may be only a week or two. For some,
Pishkin, Fishkin, Shurley, Lawrence, & Lovallo, the recommended delay is also dependent on the di-
1978; Zimmermann-Tansella, 1984). Single dose ad- agnosis. For the latter situation, if the examiner must
ministration may reduce the speed of performance on wait until clinical response occurs, the delay may be
some items. At high doses, the sedative effect will as long as 2 months. The CNS-mediated side effects
impair cognitive performance. As with the antimanic for the antipsychotics are very specific. Probably,
drugs, there are insufficient research data with the dissociative responses and oppositional behaviors,
use of anxiolytic drugs in children to comment on the neither a side effect of drugs, account most fre-
cognitive effects in relationship to routine psycholog-
quently for the concerns that medications are ad-
ical testing. The clinical effect for single dose admin-
versely affecting psychological testing results. There
istration of most anxiolytics is about 4 to 6 hours. The
is little research evidence to show that nonstimulant
half-life for most is much longer and drugs may be psychotropic medications in common doses, once the
detected through blood and urine assays for I to 2 child is on a regular administration regime, affect the
days following single dose administration. If the routine psychological tests used with children. The
child must be free of anxiolytic medication effect at tests are just not sensitive enough to be influenced by
the time of testing, a delay of I day following the last
most nonstimulant psychotropics. There is some evi-
dose should be sufficient. dence that with the use of medications to treat major
depression or symptoms associated with the per-
vasive developmental disorders, there actually is im-
provement in test performance.
Summary This chapter has presented clinical guidelines
for use when testing children who are receiving anti-
Childhood psychopharmacology started in the psychotic, antidepressant, and anxiolytic drugs at the
late 1930s. The search for behavior-modifying drugs time of testing. These guidelines must be used in
for use with children continues today. Current re- conjunction with a knowledge of the class of drug
search methods with rating scales sensitive to behav- prescribed, the child's diagnosis, whether the dose is
ioral changes and pharmacokinetic studies that may common or high, and the length of time the child has
be able to link blood levels with medication response been receiving the medication.
484 CHAPTER 25
ipramine in outpatient depressives. Archives ofGeneral Psy-

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IV
New Aspects of Neuropsych ology

26
Establishing Neuropsychology in a
School Setting
Organizatio n, Problems, and Benefits
RUTH ADLOF HAAK
At this time, it is not standard practice to operate a separate functions but more interested-at least in
neuropsychological testing component in public the beginning-than skilled in neuropsychology.
schools. This chapter traces the problems of intro- Neuropsychological assessment capabilities
ducing such a component into the public school; the were introduced into the above special education sit-
model of operation that is presently proposed for such uation at a time when grant monies were more avail-
a component; the emerging, though still unclear, able for innovative educational practices (10 years
benefits of pursuing this task; and the general concep- ago). This was only one of several innovations intro-
tual model of neuropsychological underpinning that duced into the system at that time, the purpose of all
seems necessary for an adequate public school, based of them being to increase expertise in the assessment
on our experiences of neuropsychologically assess- and subsequent programming of special education
ing public school students for a decade. students. That remains the purpose of the neuropsy-
The operation to be described is that of the Bal- chological testing component today, which has oper-
cones Special Services Cooperative, a special educa- ated without interruption since its introduction.
tion service unit shared across school district lines in
Travis County, Texas. The special education unit is
relatively small, serving a student population of
about 1200 special education students. Excluding the
Operational Model and Operational
teaching staff, the central staff of this unit numbers Issues
approximately 20 persons, primarily assessment per-
sonnel but also including some occupational thera- Balcones Special Services Cooperative (BSSC)
pists, physical therapists, counselors, and special serves three (formerly five) school districts that view
itinerant teachers. The unit is directed by a combina- this service unit as their primary available resource
tion licensed psychologist-special education director for dealing with children who are experiencing se-
whose formal training is in counseling psychology rious learning problems or emotional/behavioral
and whose subsequent training in neuropsychology problems in school. All schools served by BSSC do
was self-acquired postgraduation. The situation is have regular counseling components as well as spe-
thus fairly representative of many special units across cial state and federal programs to serve their students.
the United States that may wish to contemplate intro- Nevertheless, any student who is experiencing se-
ducing a neuropsychological testing component into rious difficulties in these schools will probably be
their public school assessment capabilities; i.e., staff referred for assessment and possible services to spe-
members are well trained in assessment and in their cial education. We believe this attitude is proper be-
cause so many children are discovered to have bases
for their difficulties when they are properly assessed.
"Proper" assessment certainly can include neuro-
RUTH ADLOF HAAK Balcones Special Services Cooper- psychological assessment in many cases.
ative, Austin, Texas 78746. Because special education was already the com-
489
490 CHAPTER 26
prehensive assessment unit in our schools, and for gical testing. The director reviews these questions,
utility, the neuropsychological testing component may suggest others or better ways of looking at the
was placed within the province of special education questions, initials the form, and returns it to the diag-
when it was introduced into our system. If children nostician, who then schedules the neuropsycholo-
were indeed to be identified as having neuropsychol- gical exam with the neuropsychological testing
ogical problems, it would be hard to imagine how technician.
they would not be qualified for special education. When the technician has completed the testing,
Placing neuropsychological testing within special ed- the neuropsychological test results are given to the
ucation was done to effect a more logical flow of managing diagnostician. At this point the diagnosti-
services. cian has a choice: (I) interpret these data, write a
Utilitywise, it also effects a much higher degree short neuropsychological report, incorporate the
of time saving and efficient testing, because the test- findings of this report into the student's comprehen-
ing required by special education already covers sive assessment, and present these data to the next
much of the territory of the standard neuropsycholo- committee meeting regarding the child: or (2) request
gical exam, specifically: the administration of the the director or staff neuropsychological consultant (a
Wechsler scales, the gathering of health history, the diagnostician who has completed special study in
gathering of developmental milestones information, neuropsychological assessment) to interpret the
the gathering of information from observers with neuropsychological data, after which the managing
whom the students interact (family and teachers), and diagnostician then continues the process as above.
consideration of emotional and sociological factors. If the neuropsychological (and other) assess-
ment data indicate that a referral to a pediatric neu-
rologist is in order, the managing diagnostician can
The Operational Model do so, including writing the referral letter with at-
tached information, or may, as before, request the
There are two possible routes of referral for director or neuropsychological consultant to com-
neuropsychological assessment in the special educa- plete this step. If a referral is made to a neurologist,
tion operational model to be discussed here (see Fig- the finalization ofneuropsychological information in
ure I). One course is that neuropsychological testing the comprehensive assessment report awaits, of
be completed as part of a new referral for special course, the outcome of the medical tests.
services. The second course, much more common in Parents are requested to follow through on med-
our experience, occurs when someone within the spe- ical referrals; however, if parents are unable to do
cial education delivery system refers an already- this, BSSC pays for these neurological exams. It is
placed special student for neuropsychological assess- very important to include the monies to pay for medi-
ment. The latter occurs for a number of reasons: it cal exams in one's budget; otherwise, it will often be
takes a while for teachers and staff to become ac- impossible to carry a child's assessment to proper
quainted with a student's total behavior and to notice completion, and the time spent giving the neuropsy-
certain signs of possible neurological/neuropsycho- chological exam will not have been productive. It is
logical dysfunction; a student receiving services may frustrating and professionally inadequate practice to
begin to experience new difficulties and a neuropsy- have to abort a line of inquiry that appears headed
chological exam is desired to rule out certain pos- toward helping solve a child's problems.
sibilities; a student may be referred for an emotional The Comprehensive Assessment Report, into
evaluation; or the need for neuropsychological as- which all neuropsychological and neurological find-
sessment may emerge in a review of a student's case. ings are incorporated, lays out suggested methods of
From whatever source, once someone within the sys- intervention with the student, both instructionally
tem decides that a neuropsychological exam is in and behaviorally. These methods are discussed in
order, such a request is made through the managing committee meetings that either determine whether
diagnostician of the child's case. Most often, it is the the child will receive services or review the services
managing diagnostician who makes this referral. The the child is receiving. Any drug or medical treat-
diagnostician completes a short "Neuropsycholo- ments are also outlined in these meetings, including
gical Referral" form and submits it to the director. specification in the child's Individual Educational
The form is primarily designed for the referring diag- Plan (IEP) of parents' and school nurses' respon-
nostician to pose direct questions that he or she wants sibilities regarding medication. If the neurologist has
(or hopes to have) answered by the neuropsycholo- requested feedback from the school, the person to
ESTABLISHING NEUROPSYCHOLOGY IN A SCHOOL SETTING 491
Referral sources:
Outside School The staff Special education

professionals personnel psychologist(s) Parents committee reviews
-~~~
Neuropsychological
Managing diagnostician
of the child's case
I ~----------------~
Director of the
1-----+1 neuropsychological unit
consultant (or assessment unit)
Interpretation
of test data
~~ Posing of test questions
Interpretation of test data
~------------~ ~----------------~
~~.----------,
Neuropsychological Pediatric
testing technician neurologist
Actual testing (?)
/
Short neuropsychological report
Incorporation of neuropsychological data
into Comprehensive Assessment
Recommendations for remediation
or programming
l
Special education committee
Final recommendations for
remediation or programming
FIGURE 1. Operational model of a neuropsychological testing component within a special education department.
supply the feedback and its form are also specified in sessment upon finding indications of possible neuro-
the IEP. psychological dysfunctions; the occupational or
All special students' IEPs must be routinely re- physical therapist may request a neuropsychological
viewed by committees. In these reviews, neuropsy- examination; outside professionals in private prac-
chological testing is often first requested. It is also in tice-particularly psychiatrists and psychologists-
these reviews that methods of intervening with the will make referrals to the school for neuropsycholo-
child's neuropsychological deficits are discussed and gical testing; and even parents occasionally make
changed, if necessary. It is also not unheard of for such requests, especially if they are neighbors of a
such a child to pass through a particularly difficult child who was so assessed and whose assessment led
developmental period and to regain adequate func- to improvement in behavior and school attainment.
tioning, whereupon he or she may be dismissed from
special services. In short, the special education com-
mittee deals with the implications of neuropsycholo- Funding and Personnel
gical testing, as it must deal with all assessment
information. One hears objections, voiced in professional
There are other sources for neuropsychological gatherings, to the utilization of neuropsychological
referral besides those given above, for example, the testing based on its high use of time and money. This
managing diagnostician, the special education com- is not a real issue within special education. The only
mittee, or a teacher within the system. Many referrals person we have found it necessary to employ in order
come from the person completing an emotional as- to operationalize the neuropsychological testing
492 CHAPTER 26
component is a half-time neuropsychological testing Problems in Instituting

technician. The BSSC model retains the use of such a Neuropsychological Testing in the
technician, as is customary in neuropsychological as-
sessment. The alternative would be to attempt to
Public School Setting
teach all existing assessment personnel the skills of
neuropsychological assessment. This would indeed The major problems of instituting a neuropsy-
be time intensive; in addition, it might involve trying chological testing component in the public school's
to teach these skills to persons who do not wish to assessment capabilities are much less obvious than
money, personnel, or settling upon a working model
learn them. It is more efficient in practice to have one
of operation. Furthermore, the major problems will
person conducting all neuropsychological exams
not be immediately apparent. Some arise only after a
than to take large blocks of time from existing per-
relative degree of familiarity and success with the
sonnel's schedules.
new system. Many will be realized in retrospect.
There are other reasons for utilizing the services
of only one person to conduct the neuropsychological Many are not going to be resolved in the near future.
To institute such a component into the public
tests. When instituting a new testing system, prob-
school's assessment system is somewhat to do the
lems of reliability of test results are greatly mini-
proverbial "rushing in where angels fear to tread."
mized by using a lone tester. A whole group of as-
sessment personnel working with a new set of tests
may obtain dubious results for quite some time. Also, Developing Staff Expertise
if there is a subsequent attempt to subject the findings
to research, then the use of one testing technician will Obviously, the first major problem to be faced
have been a great advantage. by a school instituting a neuropsychological testing
We have had only two technicians in our decade capacity into its system is the training of on-board
of practice. Both were locally trained and then re- personnel. Some schools will be able to hire a profes-
viewed by professional neuropsychologists outside sional neuropsychologist to oversee the institution of
our system. Many neuropsychologists report, and we such a system and to manage the training of existing
have also found, that the personal attributes of the personnel. This would certainly be the logical way to
neuropsychological testing technician are of more begin.
importance than credentials. One of our technicians At the time we instituted our system, in a medi-
has a college degree; one did not attend college. Both um-sized American city with one of the largest uni-
have children and are very adept at relating to chil- versities in the nation, there was no professional
dren and obtaining the best possible performances neuropsychologist in practice in the city; nor was
from children. Both are acutely observational and there a course in neuropsychology at the university.
often make notes on test protocols that prove of more Although this is no longer true, many other school
worth than the test results. Both have insisted on systems may still find themselves in that position. So
working only half-time, and perhaps this has contrib- the training of existing personnel is a large task.
uted to their low level of "burnout." Funding for the This problem was ameliorated for us by the provi-
technician is provided by our participating school sion of sufficient grant monies to attend many frrst-
districts, just as it is for any other member of the class, out-of-state and in-state professional training
special staff. seminars. We were also able to obtain early in our
The initial expense of instituting the neuropsy- development an on-site visit and review of our system
chological testing component involves, of course, by a nationally known neuropsychologist (Lawrence
purchasing the necessary equipment. Though this C. Hartlage). As professional neuropsychologists
equipment is more expensive than other types of test- have moved into the city, we have been able to build
ing equipment, the increase in expense is only rela- relationships with some of them. And we have, over
tive. We purchased our equipment at the end of one time, established quite productive working rela-
fiscal year and the beginning of the next, spreading tionships with some pediatric neurologists, which is
the expense over two years. very helpful. All these opportunities have been invalu-
Though certain items of neuropsychological able sources of support to our developing neuropsy-
testing equipment are reputed to be fragile, particu- chological assessment capabilities.
larly the Halstead-Reitan Category machine, we If it is not possible to hire a professional neuro-
have not had that experience. OUr equipment has psychologist to institute the public school's neuro-
frequently been moved about for 10 years, with only psychological testing component, and if there are no
minor repair problems. local universities teaching formal neuropsychology
courses, then there is just no substitute for sending Inevitably, people leave and enter systems. New
staff members to professional training workshops- members of the staff will need to be added. Also,
and a lot of them. Also, at least some outside review current staff members who at first considered them-
of the developing system may well be required. selves uninterested in neuropsychology will become
Neuropsychology is one of the more complex fields interested. The original group in the new neuropsy-
in psychology, as is well known. A sufficient knowl- chological team will hardly be in midstream in their
edge base of this area to support the introduction of pursuit of knowledge when others will want or need
testing capacities is the first problem that must be to join.
faced. If this cannot be managed, the system proba- There are at least two methods of handling this
bly should not be instituted. problem. One is to have the original staff, along with
their leader, conduct in-house workshops in the rudi-
mentary knowledge they are acquiring. This is help-
Selecting Staff to Participate ful to the general staff and provides an entry point for
new and more involved staff. A second method is to
Because the issue of training is so obvious and
maintain an ongoing study group in neuropsychology
even oppressive in nature, existing staff in a school
within the assessment staff. This method is mostly set
assessment setting must be given a real choice about
up for the original staff and for the acquisition of new
whether to participate in the introduction of a new
knowledge, including the study of current cases
neuropsychological testing component. The major
being assessed. The two methods serve somewhat
reason for this is that even with the best of institu-
different purposes, and we have employed both.
tional support with regard to attending professional
New members added to the core group involved
training opportunities, a person entering this area will
in neuropsychological assessment need to be able to
have to devote an exorbitant amount of personal time
attend professional training opportunities. It is there-
to individual reading and study in order to begin to be
competent in neuropsychological test interpretation. fore judicious not to expand this original group too
It is far better to have an honest refusal from a staff quickly' or funds will not be sufficient to provide the
necessary breadth and depth of workshop oppor-
member to make such a commitment than to have that
person either abandon the pursuit (after spending val- tunities.
uable staff funds for training) or to be satisfied with a What the above infers is that much of the con-
centrated study required for a staff to take on the new
cursory and superficial knowledge of the subject.
This is no ordinary "in-service" undertaking! area of neuropsychological interpretation must be
provided on "company time." It is unrealistic for
It is probably wise, therefore, for the director of
the assessment unit to select a limited cadre of on- any organization to expect its employees to expend
the amount of energy that will be required to learn a
staff persons to begin instituting the new testing com-
ponent. Other staff members can (and should) be kept system as complicated as neuropsychological test in-
abreast of the developments in this area through gen- terpretation without an equal amount of dedication in
eral in-service staff training sessions. It should be time and funds from the organization itself.
understood by this new group that a great deal of
personal commitment is being called for; and it
should also be understood by the larger group that a Sustaining the Team's Motivation
high percentage of the total stafrs resources for at-
tending professional training opportunities will go to Remarkably, those who choose to involve them-
these people for awhile. Because the beginning selves with the pursuit of neuropsychological knowl-
neuropsychological "stafr' should be kept small, it edge seem to have more intrinsic motivation to
continue this pursuit than is observed in many areas.
appears that the smaller school system is at no disad-
vantage in introducing neuropsychological testing Nevertheless, this is a difficult area to enter: The
into its assessment system. pursuit seems unattainable. The more one learns, the
less one knows. Cases one considered understood
tum out to be enormously more complicated than
Broadening the Range of Involved Staff thought at first glance. There is remarkably little sup-
port for the public school psychologist or diagnosti-
Though problems of quality control can be kept cian performing neuropsychological testing and test
at a minimum when instituting the new neuropsy- interpretation. Initial successes are very important
chological testing component by keeping the number (as, for example, our discovery of three subclinical
of involved staff low, this cannot continue forever. seizure cases in one family); but this initial self-confi-
494 CHAPTER 26
dence can erode with less spectacular results. Some tern. Though some of the following methods may
methods we have used to attack midstream malaise strike one as indirect, they seem to work best in our
are the following: experience:
I. Put on general workshops for the teaching 1. First and foremost, do the best possible job
staff. In preparing for the workshops, one is of conducting neuropsychological assess-
forced to review concepts that have slipped ments. Avoid fanfare about the new system.
the mind and one is forced to organize what Just do the job of conducting these assess-
one knows. The general school staff has ments in the most careful, professional man-
some degree of sophistication and interest ner possible. When neuropsychological test
these days in neuropsychological function- results are fed back to staff members or the
ing. If such workshops are solidly done, special education committee (which in-
they can be very helpful to all concerned. cludes administrators and parents), use care-
Especially helpful are general workshops on ful, nonneurological language and concen-
basic brain functioning, attention deficit trate on how the assessment leads to ideas for
disorder, and physical problems (including intervention. There is no other method for
seizures) that may present as behavioral getting support for the new testing system
problems. that will even come close to being as impor-
2. Send one or two core staff members to a tant as this method-do a careful, competent
professional workshop. People always re- job on each assessment.
turn from such a venture with new informa- 2. Always report neuropsychological test infor-
tion and new enthusiasm. mation to the staff members who can benefit
3. Visit other professional neuropsychologists, from this information. Testing that is not re-
those in private practice or in nearby univer- ported is useless.
sities. Invite them to visit your establish- 3. Always make practical suggestions based on
ment. These visits create networks that the neuropsychological information. This
eventually will prove helpful and beneficial. does not mean that remediation suggestions
4. Arrange a consultation with a neurologist always need to be made: one may find that
with whom you are working on a child's remediation is not necessary. One of the ma-
case. This will help both parties to under- jor benefits of neuropsychological testing in
stand and to manage the child better. It will the school is to rule out problems, as well as
also lead to much more open communication rule them in. But in all cases, neuropsychol-
and trust regarding future cases. ogical assessment should lead to some kind
of increasingly appropriate action-or else
There are long droughts in the pursuit of neuro-
why do it?
psychological expertise. These become hard for a
4. Concentrate on the reporting of cases with
staff to tolerate. Inevitably the best cure for this prob-
administrators rather than on flashy explana-
lem is to persevere: a real breakthrough case wil1 tions of neuropsychology. Administrators
come along, a quite difficult child will be better un-
always know who their problem children
derstood and managed, and morale will rise again for
are; they have multiple sources of input.
a long time.
Nearly all administrators' ultimate concern
is the children. Solving a few difficult cases
Obtaining the Support of Others will go further than any other measure to
keep support for the new assessment unit.
If the introduction of a neuropsychological test- 5. Be careful and patient with parents. No par-
ing component into the public school's assessment ent wants to think that something serious is
capability is to obtain credibility, the support of many wrong with his or her child. This realization,
nonstaff persons is needed: school administrators, even if it is true, must usually come slowly.
board members, school staff members, and parents. The staff will need to be prepared for several
These people are usually not going to attend work- sessions with the parents regarding a child's
shops, nor do they have the patience to listen to long neuropsychological problems.
explanations about neuropsychology. This leaves Again, avoid neurological and tech-
one in the position of wondering how to get across to nical jargon. Do not try to urge parents into
this larger public the benefits of the new testing sys- seeking a neurological exam with too defi-
nite ideas about what is wrong with the child to develop neuropsychologically based intervention
neurologically. If a basic attitude of concern strategies (Rourke, 1985). One is operating in a new
is the attitude conveyed ("This is something area-conducting neuropsychological assessment
we need to check out"); if the problems are and intervention in the public school. This causes, or
discussed as possible problems; if the par- at least relates to, a number of concerns.
ents are convinced to take their child to a First, there is the matter of norms. Norms exist
neurologist and no physical problems are in various sources for normal children, children seen
found, the parents will still appreciate the in a clinical setting, hospitalized children, and chil-
concern but be relieved that nothing terrible dren seen in learning-centered clinics. Satisfactory
had been discovered. If a physical neu- norms for a wide range of public school children
rological problem is discovered, they will be referred for a broad range of learning and behavioral
even more appreciative of the careful type of problems are not easily obtained.
assessment done in their school. But in either Second, and related to the first, is the matter of
case, the school assessment staff will have the strongly deficient neuropsychological perfor-
acted responsibly. mances of many public school children. These chil-
If, on the other hand, the school assess- dren often score as poorly as do diagnosed, sick chil-
ment staff has gotten heavy-handed (and be- dren; yet they are functioning in the public schools, in
yond its depth) with neurological jargon and some fashion or other. Often after extensive pbysical
there turns out to be no identifiable neu- examinations, they are still not found to have estab-
rological problem, the possibilities for polit- lished disorders. The opposite also occurs: children
ical ramifications are real. Such an event with obvious neuropsychological signs from intellec-
could conceivably end neuropsychological tual test results and behavior will have few if any
testing as part of the school's assessment findings on neuropsychological tests. In short, the
capabilities. inferences one has learned often do not hold up in this
setting.
Neuropsychological testing in the public
schools is a new venture. If it is to receive broad Signs one has been taught to consider as pathog-
support, it will need to proceed slowly and most cau- nomonic often are not indicative of diagnosable pa-
tiously. The participating assessment staff, in partic- thology. One catches oneself disregarding such
ular, needs to have this attitude strongly impressed signs, often to one's grief. Contradictory results,
upon them. rather than recognizable patterns, become com-
monplace. Obviously, ignorance and inexperience
with neuropsychological data could be the culprit in
The Lack of a Body of Public School many of these cases; however, even when these cases
Knowledge are referred out, often inconclusive findings result.
Children assessed before the age of 9 often do not
Not only does the beginning neuropsycholo- appear to have the same level or pattern of problems
gical assessment team in the school lack its own body as they will when reassessed later. Obviously, these
of knowledge and experience, it cannot tum to a children change developmentally; however, their
broad body in the literature. Obviously, this is not to patterns of brain dysfunction should not change radi-
say that expert knowledge in the field of child neuro- cally over a short period of time, if indeed brain
psychology is not available. As examples of the work dysfunction is being adequately measured.
being done in child neuropsychology, one can cite The above are only a few of the sources of con-
Boll (1974), Gaddes (1980), Golden and Anderson fusion encountered as one examines more and more
(1979), Hartlage (1980), Hynd and Obrzut (1981), public school children using neuropsychological test-
Kinsbourne and Caplan (1979), Knights and Bakker ing methods. Naturally, of course, sometimes stan-
(1976), Lezak (1976), Reitan and Davison (1974), dard teaching and standard inferences lead to produc-
Reynolds and Gutkin (1979), Rourke, Fisk, and tive diagnoses, better management, and better
Strang (1983), and many others. These and other education. This happens, in fact, a great deal. But the
sources within the field of neuropsychology form the times that it does not happen provide the sources of
knowledge base that the school neuropsychologist concern for the person seeing large numbers of public
does use. school children receiving neuropsychological assess-
But there is no cumulative, broad experience ment.
regarding neuropsychological assessment in the pub- Obviously, there is something about the public
lic schools themselves. Only now has an effort begun school setting itself, its sequenced and institu-
496 CHAPTER 26
tionalized contexts and expectations, that interacts constant feedback about any particular child. There is
both with normal developmental stages and with nor- a huge ''information edge. '' The assessor also knows
mal and abnormal neuropsychological functioning. the various contexts in which the child may be found,
Our present conclusion is that neuropsychological for example, facts such as who is a tolerant teacher
testing in the public school can only be conducted and and who is a rigid disciplinarian, problems that are
utilized as part of a total, comprehensive. and con- endemic to certain campuses, and so on. These con-
textually related assessment system. Gaddes (1981, texts do affect the way a child behaves and can be
p. 28) arrived at this conclusion earlier. When a child taken into account. If a child's behavior changes for
is found to have neuropsychological dysfunctions, better or worse, especially within certain contexts,
invariably there are related developmental issues, the school assessor can easily know this. The child
difficulties with achievement, misunderstandings be- can be constantly monitored and a behavioral history
tween parent and child over expectations, misunder- established.
standings between school and child over expecta- Finally, assessment on site becomes a constant
tions, perhaps even worse disabilities in other areas, rather than a one- or two-shot process. When break-
and failure on the school's part to adapt to the child. downs occur in behavior, further assessment can be
Most children assessed by neuropsychological test- done (and nearer the point of the breakdown). One
ing display a set of nebulous findings calling for mul- does not have to give an initially excess number of
tiple adjustments in school, home, and child. tests in order to cover every possibility. Tests can
When a child is assessed by neuropsychological always be added as needed, with relatively little diffi-
testing, is found to display clearly recognizable signs culty in scheduling and at no cost to parents. In a true
of possible problems, is referred to the neurologist, is sense, assessment of a child in the public school set-
found to have abnormal physical findings, is placed ting is never considered to be completed. Assessment
on medication, and improves markedly in behavior becomes an ongoing process, with relatively easy
and academic functioning, the nice linear process one access to the child.
hopes to see in good assessment has actually oc-
curred! Thankfully, this does happen rather often,
but still in only a minority of cases. The rest of the
time the public school neuropsychologist is operating
Student Benefits Are Extended
within the realm of general systems theory-with a
360-degree set of facts and interactions, the in- Probably the most important reason for conduct-
ing neuropsychological testing in the public schools
ferences for many of these facts and interactions as
yet unknown. That will probably continue to be the is that a large number of children can be assessed and
benefit from this assessment-including many who
state of the art in public school neuropsychological
assessment for some time to come. would not otherwise be tested. Knowing the symp-
toms of neurological or neuropsychological dysfunc-
tion in children is not within the average parent's
training. Taking the child on one's own to a pediatric
Benefits of Instituting neurologist is not within the average parent's range of
Neuropsychological Testing in the actions. The very children who are most likely to
Public School exhibit symptoms of neurological or neuropsycholo-
gical dysfunction are those whose families are least
With such an array of problems, one may won- able to afford first-rate medical care. Therefore, the
der why anyone would attempt to carry out such a children most likely to need neuropsychological as-
venture. Fortunately, even though some of the bene- sessment are those least likely to get it-unless the
fits are only beginning to come into focus, there are public school provides the service. Finding causes
even at this point certain observable benefits. for children's learning problems can be a most re-
warding social venture. It is the children who profit.
The School Is an Ideal Test Site

Children with Neurological Dysfunctions
Though the school lacks some of the advantages Are Discovered
found in clinical test settings, it more than makes up
for this with some of its own unique advantages. For When one can amplify the standard testing done
one, the children are present every school day for six in the public school setting with neuropsychological
or seven hours. The school assessor has many lines of testing, one does indeed begin to discover a large
number of children with neurological problems. Es- his or her maladaptive behavior cannot be identified.
pecially is this true, in our experience, with sub- In this sense, neuropsychological testing is an enor-
clinical seizures. Subclinical seizures, if our popula- mous aid to the proper identification of children who
tion is at all representative (in fact, the average are emotionally disturbed from those who may be
socioeconomic level is higher than average), are experiencing secondary emotional distress.
much more common than suspected. Usually the be- At BSSC, we do not call a child emotionally
havior and learning of these children change radically disturbed unless the causes of the maladaptive behav-
once they are properly identified and medically treat- ioral reactions lie clearly within sociological or
ed. No longer are they viewed as mere candidates for human interactional areas (or, of course, in those
behavior modification. known mental diseases for which there is presently
The dysfunctions, disabilities, or diseases that no known cause, such as schizophrenia). This means
the children are "allowed" to have are no longer that if a child is identified as having, for example, an
limited to what the teacher or assessor knows. We attention deficit disorder, the impulsive behavior,
have found cases in a broad range of neurological and lack of reflectivity, general refusal to accept respon-
neuropsychological disorders in our decade of per- sibility for his or her actions, and difficulties with
forming neuropsychological testing. Only a few of peers do not constitute emotional disturbance. These
these children would have eventually been assessed are known and customary correlates of attention defi-
outside the public school setting. cit disorder, even though they are somewhat
emotional in nature. Nor do we call the periodic ex-
plosiveness, the circumlocution, the tendency to be
School Personnel Become More Scientific overconcemed with others' behavior, or the com-
The effect of having neuropsychological testing pulsive writing of the temporal lobe epileptic emo-
capabilities in the school and discovering many chil- tional disturbance (or borderline personality
dren who will be better understood and programmed disorder). In short, when there is a diagnosed neu-
through this testing is to increase the scientific per- rological or neuropsychological condition, and the
spective of the staff. Especially in special education, common correlates of this condition are known, these
the staff returns to searching for causes instead of expected emotional correlates of the problem are
merely applying its range of known treatments. seen as part of the problem-not as emotional distur-
It is beyond the scope of this chapter to consider bance. The children may still get the same treatment
the trends in special education that have in the last as they would have gotten with alabel of "emo-
few years appeared to cast special education back tionally disturbed": they will receive counseling,
upon the "underachievement" concepts of the 1950s family counseling, behavior modification, special
and away from the examination of brain variables. programming in an outdoor education unit, or what-
Nevertheless, when one begins to measure special ever is called for-but the problems will be associ-
students with neuropsychological testing procedures, ated with the neurological status and not with the
one is cast back inevitably upon brain and cognitive emotional status.
concepts for explanations-because the data force it. We have found the above approach to greatly
This redirection is especially beneficial to the child, "clean up" both the diagnosis and subsequent treat-
for it takes school personnel out of moralistic and ment of emotional problems. It also greatly cleans up
motivational thinking patterns and moves them into the attitudes and actions of those who educate or
the more objective patterns of scientific thinking parent the child. Much of the "blame" for the child's
about causes for the child's behavior. It is axiomatic actions is removed from the child and replaced with a
that what one understands reasons for, one deals with more scientific and supportive approach. Again, rea-
much more effectively. sons for the behavior make all the difference to the
adults who interact with the child. And they make
that same difference to the child, who is on the re-
Assessment for Emotional Disturbance Is ceiving end of these interactions.
Oarified As this scientific attitude spreads, all levels of
the staff become involved. For example, after a sum-
Emotional disturbance is a large and undeline- mer workshop last year on the subject of attention
ated concept within the general area of children with deficit disorder, a teacher called late one night to say
problems in school. Even within the defmition of the that she had just received word from parents (whom
federal law, emotional disturbance is often seen as she had herself suggested take their child to a pedi-
that condition of a disturbed child when the causes of atric neurologist) that the child was diagnosed as se-
498 CHAPTER 26
verely hyperactive and put on medication. She was
!
(/)
c:
very proud of the fact that she had known the right .g
questions to ask the parents, for example, questions ~
c:
about sleep disturbance. She had a right to feel proud u
of herself. A neuropsychological testing component E:g'
Q)._
Culture Deviation
in the public school inevitably forces the entire staff
to become gradually more scientific, that is, more ~~
0
::J-!2
Central model
accurate and just in their education and treatment of
(I) ...
Q) 0 Pathology
children. This is rewarding for all concerned. One .s::.-
t-
more child had escaped being seen as merely a behav- Brain Deviation
ioral problem. Adult interaction with that child be- Ill
gins to support, not impede, development. I: Central model
0
"+'
'6 Pathology
I:
8
Conceptual Model of a c:-a Emotional
status
Deviation
Neuropsychological Foundation
Ill .:
(I) I:
Ill ...
Q) ttl Central model
for a Public School u Q)
G)-
I: ...
Q)~ Pathology
Our decade of experience in neuropsychological ~
testing has led us to a number of tentative conclusions
In all areas there are the goal for which is
regarding the public school. One repeated finding-
that it is difficult if not impossible in many cases to a centrality (central model, provision
differentiate deviation from disability (an issue to be central tendency) which is
discussed in the next section)-has led us to look at positive, within limits
the adequacy of the school itself. It is often the deviation which is positive, allowance, tolerance,
within limits provision
rigidity and lack of range in the educational program
pathology which is negative reduction, elimination
that apparently moves what begins as a deviation in to any degree
the child into the realm of a disability.
If, as Plato might have suggested. the major FIGURE 2. A neuropsychological substructure for a school
working material of the school is the human brain, system.
should not the school be the brain writ large?
The writer has proposed a model of an adequate
neuropsychological substructure for a public school clition, and the culture-there exists a central tenden-
(see Figure 2). It should be emphasized that this cy (or model), with deviations from the model that
model presents a substructure-an infrastructure. It provide for evolutionary possibilities and differences
serves as a check on the adequacy of the total pro- from the model that are pathological in nature, the
gram of the school. A wide range of program ele- result of insults or errors. Both the central tendency
ments can satisfy the various demands of the model. and the deviations are normal, within certain opera-
Also, schools may differ in what they need to develop tional limits. Both can become pathological outside
to satisfy the model. For example, one of our own these limits and can constitute, along with the results
school systems is presently making massive efforts to of insult, accident, genetic error, and so on, the pool
increase its range of deviant offerings. of pathology.
The model for a Sound Neuropsychological The goal of education is to provide, through the
Substructure for a Public School acknowledges that culture, the development of learning in the indi-
learning takes place within a three-variable interac- vidual. This is accomplished through proper utiliza-
tion: the human brain, the emotional status of that tion of the individual's brain in a climate of emotional
brain at any time, and the environmental stimulation stability. Education needs to be carried out in both the
that is supplied by the culture to the brain. In a scien- central tendency model and the productive deviations
tific sense, the brain and the emotional status are the model, while attempting at the same time to modify
necessary conditions for learning; the culture pro- any pathology and to enlighten about possible pa-
vides the sufficient condition for learning. thologies. For example: A child who is of average
Within each of these three major components of intelligence and of sound emotional health for his or
the learning process-the brain, the emotional con- her age is operating in the central model, both in the
brain and in the area of emotional status. If that child through discovery, the school has the respon-
is exposed to the central model of education in the sibility to enlighten all its clients about these causes so
school (the culture), and that model is an adequate that they may be avoided in the future. Special educa-
model, all should go relatively well. If that school is a tion deals with pathological children. (Too often now-
deviant school-for example, a special private adays it also deals with deviant children and deviant
school with a unique philosophy of education-all children made pathological by the culture's failures.)
will still probably go well, though the emerging child The whole school needs to deal with instruction about
may be expected to be somewhat different in orienta- pathology (as well as dealing with pathological chil-
tion from the typical public school student. If that dren to the degree that their lives can be modified more
"average" child is, however, for some reason ex- toward the central model).
posed to a pathological educational system, that child Certainly the culture becomes pathological part-
may take on certain pathological behaviors. In all the ly as a cumulative function of the pathologies of the
above examples, the child has had the necessary con- individuals within it. But more than that, the culture
ditions for learning; but in one of the examples, the (and the school) becomes pathological when it en-
sufficient condition for satisfactory learning was not forces a too-rigid adherence to its central model or
there. In all cases one can think of, these sufficient when it fails to provide what is necessary for the
conditions will vary: this variation is of no conse- central model in the society. The deviant person is
quence unless deviation is not provided for, the cen- actually better off when the central model is insuffi-
tral model is outside its limits (either too strong or not cient than when it is too rigid; but in that case, the
strong enough), or pathology is definitely present. nondeviant usually pay the price of insufficient
Let us consider another example: Suppose the education.
individual is a deviant child with a nonverbal IQ of As the model proposes, both central tendency
130 and a verbal IQ of 95. Despite neuropsycholo- and deviant brains need to be seen as ''normal''; both
gical testing and a careful medical exam, with com- require emotional stability in which to learn; both
plete history, no basis in pathology can be found for should be offered an appropriate cultural menu to
this difference. To make the case even stronger, vir- enhance their capabilities. In the present time frame,
tually all the father's relatives seem to fit the same pathology is actually being rather well addressed by
pattern: at least in behavior this seems to be so (all are the public school. The school reforms sweeping the
in active occupations; they hardly speak a word at country are beefing up the central tendency. What is
school meetings). The father is called "Gary not being tended to presently in our experience and
Cooper" by the mother. The child has a deviant the experience of many others is proper provision for
brain. If the family is overconcemed with standard the educational needs of the deviant child.
cultural expectations, this child may not be operating For the culture to be able to function through its
in the central tendency of mental health. However, schools in a neuropsychologically sound way, we do
let us suppose this family thinks the child is wonder- not anticipate that a major revolution is required.
ful. We then have a deviant child in the central model Walls need not be tom down. Whole programs do not
of emotional health. What the culture does to the require introduction or abandonment. Much of what
child in school may then become critical. If the is required is in place. The model of neuropsycholo-
school tries to force the child to learn exactly in the gical adequacy we have presented provides a basic
central model, the child will have difficulty and be- infrastructure for the school-a guiding mechanism.
come discontent. The discontent will amplify the dif- It provides a way that a school can check the ade-
ficulties. What is required is for the school to have a quacy of its range of proceedings and offerings.
sufficient supply of deviant possibilities in its curric- Where ''holes'' exist in the content of this substruc-
ula, its methods, its materials, and its routes to gradu- ture for a particular school, there that school requires
ation so that the education of this particular child can additional resources. Usually this will be found to be
proceed "normally." the area of supplying a proper range of individual
A final example: Suppose that we have a patho- opportunities for deviant types of children-without
logical child, for example, an autistic child. The making these children feel emotionally any different.
causes are unknown. The brain of this child is assumed In an overall sense, the following will be re-
to be pathological. Despite a "good" home, the emo- quired in any school in order to satisfy the demands of
tional status of the child is pathological. The school this neuropsychological model:
(culture) inust now address the pathology if the child is
to learn anything, central or deviant. Furthermore, 1. A comprehensive and expert (though not
when the causes of pathologies become known cumbersome) identification (assessment)
500 CHAPTER 26
system for measuring the child's abilities in a nomonic -signs, starkness of findings in children
fairly wide range of areas functioning beyond prediction levels, and so on).
2. A faculty educated and operating within Obviously we need to know a great deal more about
sound mental health principles (i.e., a men- public school students and their neuropsychological
tal health "curriculum" for the school), conditions before we will be able to draw accurate
with mental health supportive services for inferences about many findings in our test results.
students (and perhaps faculty) One example may suffice: Any physician can identi-
3. A faculty educated and operating within fy a child with measles. But if that physician steps
sound teaching methods, including teaching outside his or her office and finds a whole population
methods for the deviant covered with red spots, either everybody has measles
4. An articulated, systematic curriculum (cul- or something else is going on. This dilemma faces the
tural menu) that contains the following: (a) person conducting neuropsychological testing in the
the customary central offerings (3R's, tradi- public school. Most of the inferences he or she has
tional curriculum, in Texas-the "essential learned were gleaned from clinical cases. These in-
elements"); (b) a range of deviant (indi- ferences are often still highly accurate. But when
vidual) offerings; (c) special education (for neuropsychological inferences drawn from certain
pathologies of the brain or emotional facts do not lead to the expected conclusions-as
condition) often seems the case in the public school-then the
assessor faces a dilemma. This dilemma, of course,
has to do with the hardly known or unknown.
Conceptual Issues: Neuropsychology The public school neuropsychologist needs a lot
in the Public School of company: researchers, professional neuropsychol-
ogists from the private sector, university faculty, and
graduate students, to name a few. But this company
Operating a neuropsychological assessment ca-
necessarily needs to work continuously in this set-
pability within the public school is not a simple mat-
ting-to share the same experience. So far little of
ter. We have addressed the operational problems
this type of cooperation has been available, and when
associated with that endeavor, as well as the opera-
it is, it is short-lived. The public school needs to be
tional benefits. We have also pointed out, in propos-
viewed as an appropriate arena for professional
ing a conceptual model of neuropsychological under-
neuropsychologists. The research needs of this set-
pinning for a public school, that neuropsychological
ting are extreme, and the service personnel presently
functioning in the school is dependent on more than
working in the schools will simply never have time to
merely neuropsychological assessment.
pursue research activities.
At this stage in our experience the following
appear to be some of the larger issues: it is still very
difficult to draw neuropsychological inferences Differentiating Deviation from Pathology
about a population so little studied to date; it is diffi- Obviously in our model, deviation is not viewed
cult in many cases to differentiate brain pathology as pathology. Deviation is viewed as nature's way of
from simple brain deviation in a population experi- being sure that the species survives under unforeseea-
encing difficulties with the structure of the public ble circumstances. It is often difficult in neuropsy-
school system; it is difficult to provide appropriate chological assessment to tell the merely deviant from
educational methods for a deviant or pathological the pathological. Testing procedures of the future
brain; and the issue of the ''general practice'' of need to build in controls for this necessary differ-
neuropsychology in the schools from the expert entiation. It has been our experience that adjusting
"specialized practice" of neuropsychology in the the school curriculum for a child with deviant neuro-
schools is only emerging. psychological test findings is the most potent way to
help that child in many cases. Square pegs simply
Neuropsychological Inferences in Public cannot be forced into round holes without emotional
School Populations abrasion. At present, we have to rely on family histo-
ry, statements a parent makes about "how I was,"
The operational problems associated with mak- preferences, and behavioral data in order to try to
ing inferences about the neuropsychological func- differentiate normal deviation from pathology. This
tioning of public school students have been is not such a difficult problem when the child has an
mentioned (proper norms, overoccurrence of pathog- 80 IQ (i.e., the child is seen as merely deviant when
often he or she is brain damaged). But it is a difficult scenario could be the school "neuropsychologist"-
problem when the nonverbal and verbal IQs differ by but it need not be.
30 points and neither is below average. The professional person with a proper sense of
One needs to remember this exercise is not perspective is not going to take on a whole new field
merely academic. The child who is deviant is in trou- of knowledge without some proper degree of caution
ble with the system and is being referred. Better ways and respect. Unfortunately, not all persons in a pro-
to measure both the child and the system seem to be fession operate that way. But as neuropsychology
required. A full-scale attack by the profession upon moves into the public schools, if this movement with
the issue of deviation versus disability would seem to so much potential to better the lives of children is to
be a fruitful venture. succeed, it must move in with this proper degree of
caution and respect. The matter of how a psychol-
ogist should behave who takes on the new practice of
Providing Remediation neuropsychology in the schools is of major concern.
If anything outstrips Mark Twain's subject of The new neuropsychologist or neuropsycholo-
the weather for having a lot of talk done about it and gical assessment person in the schools can behave
little else, it is the subject of individualized reme- like a general practitioner, screening for the most
diation. Despite recent efforts in this regard (e.g., obvious of problems and referring suspected clients
Rourke, 1985) and the daily deluge of slick-paper to outside experts. This is an appropriate model for
advertisements from education publishers purporting most entry-level persons within neuropsychology in
to deliver remediation materials of this or that vari- the schools. Unfortunately, this model will only go
ety, getting differentiated remediation delivered to so far. When students are referred to experts in the
assessed children is still a major obstacle. Assess- private sector, often these experts do not understand
ment far outstrips remediation when it comes to neu- enough about the context of the school to either (1)
ropsychological progress. make proper judgments about the student or (2) have
At this point, the creative and innovative teacher any notion of what to realistically recommend once
is the best attack on this problem. Teachers must be the child is assessed. The school neuropsychologist
encouraged to experiment with individual children, cannot avoid moving toward becoming more of an
based on the best assessment guidance they can get. expert practitioner.
Time for sharing ideas between assessor and teacher The question of how the school psychologist is
needs to be made available. Also, when an inno- to take on the role of the professional person in the
vative teacher discovers a productive way of working school with neuropsychological knowledge is a cur-
with a child, that wisdom needs to be better preserved rent issue for debate within the profession (for one
and generalized to the other teachers. This calls for a discussion, see Hynd, 1981). It will not be an easy
full assessor-teacher partnership. The pressures that question to answer.
many teachers presently face do not allow for this The public school is not the place it used to be,
creative use of time. Perhaps it is time to think about however. A few years ago it was relatively rare to
creating a special kind of teacher-an experimental find many doctoral-level faculty members in a public
teacher on a teaching team, who is given a certain school. This is not at all rare anymore. So it will be
amount of time from her or his schedule to work with with neuropsychology. The children who need the
the assessment team. But this teacher should not be a assistance of neuropsychologists are in the public
supervisor; this teacher should be the one working schools more than any other place. The movement
directly with the children involved or, at the least, toward the creation of the public school expert neuro-
with the teacher teaching the child. psychologist is inevitable. Let us be sure as this
movement is generated that the potential of this so-
promising field of science is preserved by our cau-
The General versus Specialized Practice of tious and discrete actions, for some day neuropsy-
Neuropsychology in the Schools chology should make it possible, at last, for every
child in school to succeed.
When a relatively new practice moves into a
new area, the potential for abuse is high. Hardly
anything is needed less in the public schools today References
than a new breed of "expert" antagonizing the gen-
eral staff with half-baked and largely nonutilitarian Boll, T. J. (1974). Behavioral correlates of cerebral damage in
knowledge about an esoteric subject. This negative children aged 9 through 14. In R. M. Reitan & L.A. Davison
502 CHAPTER 26
(Eds.), Clinical neuropsychology: Current status and ap- Hynd, G. W., &Obrzut, J. E. (1981). Neuropsychological assess-
plications. Washington, DC: Winston. ment and the school-age child. New York: Grune & Stratton.
Gaddes, W. H. (1980). Learning disabilities and brain function: A Kinsboume, M., & Caplan, P. J. (1979). Children's learning and
neuropsychological approach. Berlin: Springer-Verlag. attention problems. Boston: Little, Brown.
Gaddes, W. H. (1981). An examination of the validity of neuro- Knights, R. M., & Bakker, D. J. (1976). The neuropsychology of
psychological knowledge in educational diagnosis and re- learning disorders: Theoretical approaches. Baltimore: Uni-
mediation. In G. W. Hynd & J. E. Obrzut (Eds.), Neuropsy- versity Park Press.
chological assessment and the school-age child. New York: Lezak. M. D. (1976). Neuropsychological assessment. New
Grune & Stratton. York: Oxford University Press.
Golden, C. J., & Anderson, S. (1979). Learning disabilities and Reitan, R. M., & Davison, L.A. (Eds.). (1974). Clinical neuro-
brain dysfunction. Springfield, IL: Thomas. psychology: Current status and applications. Washington,
Hartlage, L. C. (1980). Neuropsychological assessment tech- DC: Winston.
niques for the school psychologist. In C. R. Reynolds & T. B. Reynolds, C., & Gutkin, T. B. (1979). Predicting the premorbid
Gutkin (Eds. ), A handbook for the practice ofschool psychol- intellectual status of children using demographic data.
ogy. New York: Wiley. Clinical Neuropsychology, 1, 36-38.
Hynd, G. W. (1981). Training the school psychologist in neuro- Rourke, B. (Ed.). (1985). Neuropsychology oflearning disabilities:
psychology: Perspective, issues and models. In G. W. Hynd Essentials of subtype analysis. New York: Guilford Press.
& J. E. Obrzut (Eds.), Neuropsychological assessment and Rourke, B., Fisk, J. L., & Strang, J.D. (1983). Child neuropsy-
the school-age child. New York: Grune & Stratton. chology. New York: Guilford Press.
27
Current Neurops ycholog ical Diagnos is

of Learning Problems: A Leap of Faith
DANIEL J. RESCHLY AND FRANK M. GRESHAM
Based on our review of the literature, we have handicaps have been described by several authors in
reached what may be a startling conclusion to readers recent years (Algozzine & Korinek, 1985; Gelb &
of this handbook: Neuropsychological diagnoses of Mizokawa, 1986; Reschly, 1986, 1987a). The major
mild learning problems are largely irrelevant, mis- characteristics are: (1) no identifiable physical basis
leading, and potentially harmful because they confor the problem behaviors; (2) initial identification
tribute to beliefs that probably impede rather than nearly always occurs after, rather than before, school
facilitate effective remediation. Strong statements? entrance; (3) problems with literacy skills, particu-
Yes, but entirely consistent with the available evi- larly reading, usually lead to teacher referral; (4) so-
dence, which we believe shows that neuropsycholo- cial skills problems usually accompany the achieve-
gical assessment and treatment based on neuropsy- ment problems; (5) most students with mild handi-
chological concepts have little or no treatment caps are not officially diagnosed by educational,
validity; rely on unreliable and invalid measures; and medical, social service, or rehabilitation agencies
impede efforts of nonneurologically trained persons after they leave school, i.e., in the adult years. In
such as teachers and parents to cope with learning contrast, the more severely handicapped (e.g.,
problems. Down's syndrome or early infantile autism) nearly
always have physical anomalies that lead them to be
diagnosed as handicapped prior to school entrance,
Scope of Chapter: Mild Handicaps often soon after birth, and they are usually regarded
as handicapped throughout their lives.
Our discussion in this chapter is restricted to the
The vast majority of the students classified as
mildly handicapped, particularly LD students. This
handicapped and served in special education pro-
population has an approximate prevalence of 3 to 4%
grams in the United States are mildly handicapped,
according to a recent neuropsychological analysis
most often in the category of specific learning dis-
(Hynd, Obrzut, Hayes, & Becker, 1986) as well as
ability. Mild handicaps, LD, mild mental retarda-
recent federal statistics (Algozzine & Korinek, 1985;
tion, most behavior disorders, and speech/communi-
Gerber, 1984). LD students do have serious learning
cation disorders can be quite serious impediments to
problems, but they meet the criteria presented earlier
successful school experiences and to successful ad-
for the concept of mild handicap; specifically, they
justment in the adult years.
do not have hard signs of neurological disorder or any
The typical characteristics of students with mild
other physical/biological anomaly. LD students con-
stitute approximately 1. 8 million or 44% of the 4. 1
DANIEL J. RESCHLY Department of Psychology, Iowa million students served in special education pro-
State University, Ames, Iowa 50011-3180. FRANK M. grams in the United States.
GRESHAM Department of Psychology, Louisiana State It is the LD population to whom neuro-
University, Baton Rouge, Louisiana 70803. psychological explanations of learning problems are
503
504 CHAPTER 27
most often applied, a population that has, we repeat, eta/. noted that LOs can exist with other handicap-
no hard signs of neurological disorder. We are not ping conditions, but these other conditions such as
discussing school-age children or adults who do have sensory impairments, mild mental retardation, or be-
hard signs of neurological disease or disorder. Fur- havior disorder/emotionally disturbed cannot be the
thermore, we wish to emphasize that our skepticism primary cause of the learning problem. Thus, these
about neuropsychological diagnoses of LD and other investigators recognized that LD can occur with other
mild handicapping conditions does not extend to handicapping conditions and that there are a number
basic research on brain-behavior relationships, labo- of LD subtypes.
ratory studies of neuropsychological phenomena, or The LD diagnostic construct has been severely
investigations of neuropsychologically based ap- criticized in recent years on the most fundamental
titude by treatment interactions. Although we are es- bases concerning reliability and validity (Algozzine
pecially skeptical of the latter, we see no particular & Ysseldyke, 1983; Coles, 1978; Epps, Ysseldyke,
danger in pursuing research in that area. We do see & Algozzine, 1983; Ysseldyke, Algozzine, & Epps,
danger in ''leap of faith'' assumptions about the ap- 1983; Ysseldyke, Algozzine, Shinn, & McGue,
plication of abstract neuropsychological constructs to 1982). Critics have asserted that no differences exist
the classification and/ or treatment of students with between LD students diagnosed as handicapped and
learning problems. And this chapter is about the lim- low achieving students who remain in regular educa-
ited foundation for those applications. tion programs and are regarded as "normal" learn-
ers. Furthermore, vast differences exist in state crite-
ria used in classification of LD students and
Uses of Neuropsychological significant differences exist between districts within
states (Mercer, Hughes, & Mercer, 1985; Shepard,
Diagnoses 1983; Shepard & Smith, 1983). Thus, current classi-
fication of LD students is, at least, unreliable. Per-
The debate over neuropsychological analyses of haps even more fundamental is the criticism that cur-
learning problems needs a context. The appropriate rent classification of LD students is also invalid, at
context is the three major ways that neuro- least in the sense of treatment validity. No unique
psychological information might be used in decisions methods or strategies exist for LD students and there
about students exhibiting learning problems: (I) clas- is reason to believe that the same results could be
sification of students as handicapped, particularly obtained with remedial programs within regular edu-
LD; (2) selection of teaching strategies or instruc- cation (Heller, Holtzman, & Messick, 1982; Lein-
tional methodology; and (3) determination of re- hardt, Bickel, & Pallay, 1982; Reynolds, Wang, &
mediation objectives, such as what needs to be Walberg, 1987).
taught. There is some evidence that neuropsycholog- Despite the negative evidence, the LD field con-
ical diagnostic information is used for each of these tinues to flourish and the number of students classi-
purposes, but the most frequently discussed purposes fied as LD has grown each year since 1976. This
are classification of students and/ or determination of growth cannot be understood from analysis of theory
instructional strategies or methodology. Each of and research in psychology, education, special edu-
these uses will be discussed in more detail below. cation, medicine, or any other discipline. The LD
movement is best understood as a social and political
Oassification of Students reality, which continues to search for a solid base in
theory and research. Neuropsychology is an attrac-
One of the most important possible uses of tive possibility to those frustrated with the negative
neuropsychological information is in the classifica- research on LD from other fields.
tion of students as handicapped, particularly LD. Three definitions of LD have appeared over the
Hynd et al. (1986) strongly endorsed the use of last 20 years and are, to varying degrees, adopted in
neuropsychological concepts as the foundation for state legislation and state special education classifi-
definitions of LD and in classification criteria to be cation criteria. The first of these definitions, devel-
used in deciding whether or not a specific student is oped by the National Advisory Committee on Handi-
LD. H neuropsychology was the primary basis for the capped Children in 1967, suggests that LD is based
LD diagnostic construct, that construct would pre- on psychological process disorders. That approach
sumably involve (1) problems with school learning; was severely criticized and ultimately rejected by
(2) other causes are ruled out as the primary etiology many persons in the field in the mid- to late 1970s.
of the learning problem; and (3) positive evidence of Two new definitions of LDs appeared in the first half
neuropsychological dysfunction is established. Hynd of the 1980s; both included phrases implicating neu-
A LEAP OF FAITH 505
rological dysfunction as the basis for LD. The Na- with the origins of the LD movement. Cruickshank
tional Joint Committee for Learning Disabilities (1972, 1979), one of the pioneers, has argued vehe-
( 1981) used the phrase, ''these disorders are intrinsic mently that the original meaning of LD was unwisely
to the individual and presumed to be due to central and inappropriately broadened by educators and oth-
nervous system dysfunction.'' A similar definition ers in the 1960s and 1970s. Cruickshank argued that
adopted in 1984 by the Association for Children and when LD was first adopted as a term in 1963, every-
Adults with Learning Disabilities referred to LD as one knew what it meant. According to Cruickshank,
"a chronic condition of presumed neurological ori- it meant perceptual disorders due to neurological dys-
gin .. .. " The explanations accompanying both of function. Therefore, neuropsychology might be seen
the definitions were careful to note that the neu- as a way to return to the fundamental bases of LD, as
rological origin of LD was presumptive, not a criteri- it is closely tied to part of the traditions of the field.
on that had to be used in a diagnosis. Both also noted However, whether or not it is a useful basis for LD
that many students with LD would not exhibit identi- classification depends on the currently available reli-
fiable neurological dysfunctions. The newer defini- ability and validity evidence concerning neuro-
tions appear to be quite different in that a neu- psychological principles. If this evidence is insuffi-
rological rather than a processing basis is suggested cient, then no useful purpose is served by returning to
for LD. However, as discussed later, there is more the neurological roots of LD. Reliability and validity
similarity in these bases for LD than might first ap- of diagnostic constructs were discussed with great
pear (see Figure 1). insight by Cromwell, Blashfield, and Strauss ( 1975).
Use of neuropsychological constructs in LD They established simple, straightforward criteria to
definitions and classification criteria is consistent judge reliability and validity of diagnostic constructs.
1. NACHC Definition nificant difficulties in the acquisition and use of listen

National Advisory Committee on Handicapped Children, Con ing, speaking, reading, writing, reasoning or mathe-
terence sponsored by Bureau of Education for the Handi matical abilities. These disorders are intrinsic to the
capped, U.S. Office of Education, Washington, D.C. Septem individual and presumed to be due to central nervous
ber 28, 1967: system dysfunction.
"Even though a learning disability may occur
"'Specific learning disability' means a disorder in one concomitantly with other handicapping conditions
or more of the basic psychological processes involved (e.g., sensory impairment, mental retardation, social
in understanding or in using language, spoken or writ and emotional disturbance) or environmental influ-
ten, which may manifest itself in an imperfect ability ences (e.g., cultural differences, insufficient/inappro-
to listen, think, speak. read, write, spell, or to do math- priate instruction. psychogenic factors), it is not the
ematical calculations. The term includes such condi- direct result of those conditions or influences."
tions as perceptual handicaps, brain injury, minimal
brain disfunction, dyslexia, and developmental apha- 3. ACLD Definition
sia. The term does not include children who have (Adopted by the Board of Directors of the Aasociation for Chil
learning problems which are primarily the result of dren and Adults with Learning Disabilities, September, 19841.
visual, hearing, or motor handicaps, of mental retar- Reprinted from LD Fotum, Council for Learning Disabilities,
dation, of emotional disturbance, or of environmen- 10(3), Winter 1985. pp. 12-13.
tal, cultural, or economic disadvantage."
"Specific Learning Disabilities is a chronic condition
Note: This definition was adopted In "Proceduresfor Evaluat of presumed neurological origin which selectively in-
ing Specific Learning Disabilities," Federsl Register. De- terferes with the development, integration, and/or
cember 29, 1977, Vol. 42, No. 250, pp. 65082-65085. (The
demonstration of verbal and/or non-verbal abilities.
NACHC definition appears on p. 65083.)
"Specific Learning Disabilities exists as a distinct
2. NJCLD Definition
.
National Joint Committee For Learning Diubllitles Position
handicapping condition in the presence of average to
superior intelligence, adequate sensory and motor
systems, and adequate learning opportunities. The
Paper, January 30, 1981. Reprinted in Society for LtHtrning condition varies in its manifestations and in degree of
Dis11bl1ities and Remedial Education Newsletter, August,
severity.
1981, Vol. 1, No.4, pp. 1-2:
"Throughout life, the condition can affect self-es-
"Learning disabilities is a generic term that refers to a teem, education, vocation, socialization, and/or daily
heterogeneous group of disorders manifested by sig- living activities."
FIGURE 1. Learning disability definitions.

506 CHAPTER 27
The reliability criteria have to do with the degree to cal processing models, the most prominent theme in
which the diagnosis can be made consistently across LD from the early 1960s to the mid-1970s, because
different clinicians, different settings, and different these approaches emphasized remediation of psycho-
times for the same individual. Diagnoses that are logical processing deficits (Hartlage, 1986; Hartlage
consistent and stable, and therefore reliable, have the & Reynolds, 1981; Reynolds, 1981, 1986). Their
potential for being valid. Diagnoses that are not reli- point of view, which appears to be well accepted
able, in the sense of being stable and consistent, can- among persons discussing neuropsychological ap-
not be valid according to fundamental psychometric proaches to learning problems, was expressed elo-
laws. Our contention is that an LD diagnostic con- quently in Hartlage & Reynolds ( 1981): ". . . the
struct based on neuropsychological principles is not deficit approach is doomed to failure since it teaches
reliable, and not surprisingly, not valid either. to dead tissue" (p. 358). Reynolds (1981) advocated
The validity of diagnostic constructs according a neuropsychological approach because it "matches
to Cromwell et al. was based on the degree to which up cognitive neuropsychological strengths with
the construct was related to specification of treat- methods of presenting and acquiring information that
ments (instructional methodology, teaching strat- rely most heavily on those strengths" (pp. 344-345).
egies, or remediation techniques) and the effective- The ''matching up'' process described by Reynolds
ness of those treatments. Diagnostic constructs was justified primarily because of the inherent prob-
related to unique methodology effective in remediat- lems in the deficit approach: "Viewed from contem-
ing problems were valid; however, diagnostic con- porary neuropsychological models, the deficit ap-
structs not related to effective interventions were in-proach to remediation is doomed to failure since it
valid. We propose to apply the Cromwell et al. takes damaged or dysfunctional areas of the brain and
criteria to neuropsychological diagnoses of learning focuses training specifically on these areas" (p.
problems. 343).
The fundamental assertions in the instructional
methodology use of neuropsychological information
rest on aptitude by treatment interaction. Aptitude,
Intervention Methods/Instructional conceived broadly, may be practically any charac-
Strategies teristic of the individual that can be reliably assessed,
and then, most important, related to differential per-
The second, and most prominent, use of neuro- formance under different treatment conditions (Cron-
psychological information is to determine approach bach & Snow, 1977). The assumption is that persons
to teaching, i.e., to specify intervention methods and will learn best if the teaching methodology or strat-
instructional strategies. From a neuropsychological egy is matched specifically. to aptitude strengths. In
point of view, students with learning problems are much of the neuropsychological literature the discus-
viewed as having quite uneven aptitudes and abili- sion focuses on finding ways around dysfunctional
ties. This unevenness is assumed to arise from differ- brain areas or "dead tissue."
ential efficiency or intactness of various sections of In a later section we address the aptitude by
the brain. For example, students whose abilities sug- treatment interaction assumptions and the evidence
gest a dysfunction in one hemisphere of the brain or on those relationships using neuropsychological
in one portion of a hemisphere would, according to concepts.
contemporary neuropsychologists, learn more effi- Using the Cromwell et al. (1975) approach, the
ciently if methods were used that placed as little de- validity of an LD construct based on neuropsychol-
mands on that part of the brain as possible, and that, ogy will depend on the degree to which neuro-
at the same time, capitalized on intact neurological psychological information is related to effectiveness
structures or processes. of interventions. If interventions or instruction can be
The emphasis on neurological strengths is con- made more effective with application of neuro-
sistent throughout most of the neuropsychological psychological concepts, then the LD diagnostic con-
literature on learning problems. Reynolds and struct based on neuropsychological concepts is valid.
Hartlage have been particularly prominent in advanc- On the other hand, if differential strategy and meth-
ing the argument that more efficient learning will odology cannot be related to these neuropsychologi-
take place if methodology or strategies are matched cal concepts, then these concepts are immaterial and
to intact neurological structures or functions and if irrelevant to interventions, and potentially mislead-
neurological dysfunctions are avoided. They have ing and harmful if they undermine other intervention
also been especially critical of the older psychologi- efforts.
A LEAP OF FAITH 507
Determination of Intervention Goals more complex, training deficit processes is entirely

appropriate.
A third possible use of neuropsychological con- The past debate over process training (Hammill
cepts is in determination of intervention goals. These & Larsen, 1974, 1978; Lund, Foster, & McCall-
intervention goals would then be pursued through the Perez, 1978; Minskoff, 1975;-Newcomer, Larsen, &
most effective instructional procedures available for Hammill, 1975) will almost undoubtedly reappear
teaching particular kinds of cognitive operations, when Das and Naglieri's assessment battery is pub-
problem-solving strategies, or specific skills. Most lished. However, for now, the use of neuro-
of the contemporary advocates of neuropsychology, psychological information to determine intervention
but not all, disavow this particular use. As noted in goals is not a major issue. The rest of the chapter will
the previous section, Hartlage and Reynolds view emphasize review of the evidence on classification
this particular approach as doomed to failure because and on selection of intervention strategies.
it rests on teaching cognitive operations that use neu-
rologically dysfunctional areas of the brain. How-
ever, other scholars using neuropsychological con- Fallacies in Neuropsychological
structs reach different conclusions (Das & Naglieri,
in press; Naglieri & Das, in press). Das;s concepts of Explanations
simultaneous and successive (Das, Kirby, & Jarman,
1979) are used widely by neuropsychological advo- Neuropsychological explanations of common
cates (Reynolds & Kamphaus, 1986). However, in learning problems are based on studies of highly se-
what would appear to be a break with most of the lected and often, extraordinarily rare, individuals and
neuropsychologists in this volume, Das and Naglieri then generalized to students whose developmental
suggest specific methods for improving coding strat- and neurological status are clearly very different
egies such as simultaneous and successive as well as from persons included in the basic research. These
other neurologically based conceptions of cognitive generalizations often involve inferences from per-
processing such as arousal and planning. For Das and sons with definite brain damage to children who have
Naglieri, low scores on a particular neurological indi- no identifiable brain injury. A number of the fallacies
cator apparently do not imply "dead tissue" but and the overgeneralizations made in neuropsycho-
rather a cognitive process that can be improved logical explanations of mild learning problems are
through instructional procedures. There is another discussed in the following sections.
fundamental difference between Das and Naglieri's
formulations, and contemporary advocates of neuro- Fact versus Concept of Brain Injury
psychological explanations of LD. This has to do
with assertions about actual brain structure or func- The overwhelming majority of students classi-
tion based on observation of behaviors. Das and fied as mildly handicapped, about 8% of the total
Naglieri generally avoid suggesting specific loca- school age population, as well as those classified as
tions of neurological dysfunction, probably because LD, about 3 to 4% of the school age population, have
of their recognition that several parts of the brain, absolutely no identifiable anomaly in actual neu-
usually including both hemispheres, are responsible rological structure, process, or function. This is
even with relatively simple behavioral routines. In openly acknowledged by neuropsychologists (e.g.,
contrast, contemporary neuropsychologists are quite Gaddes, 1981). The vast majority of mildly handi-
comfortable with attributing failure on simple or capped and LD students do not display any of the
complex tasks, e.g., copying Bender drawings or hard neurological signs of brain dysfunction (hard
determining conceptual likenesses on the Wechsler signs refer to relatively direct measures of brain
Similarities Subtest, to one or the other hemisphere structure, function, or process). Some of the assess-
or even to specific locations such as right occipital ment tools yielding ''hard'' evidence of neurological
lobe or left temporal lobe. Because some neuropsy- dysfunction are the electroencephalogram, pneu-
chologists seem to have a quite literal notion of per- moencephalogram, X ray, examination of cranial
formance variations resting on specific neurological nerves, and cerebral blood flow studies. These as-
dysfunction, it makes sense for them to be very skep- sessment devices allow descriptions of actual dys-
tical about approaches attempting to train weak pro- function or anomaly in brain structure, function, or
cesses (tissue). On the other hand, for scholars influ- process.
enced by neuropsychology, particularly Luria, e.g., A second level of neurological diagnosis is pro-
Das, whose model of neurological functioning is far vided by the so-called "soft signs" of neurological
508 CHAPTER 27
dysfunction. Most often these soft signs are used to anterior and posterior portions of one hemisphere
make inferences about neurological function and pro- or the other, or particular locations such as occipital
cess, although it is very easy to generalize further to or temporal lobe, they are applying results from
structure, as will be seen in interpretations quoted studies of adults and laboratory studies using highly
from model reports by neuropsychologists in later controlled conditions. They are not applying knowl-
sections. These soft signs of neurological dysfunc- edge based on hard neurological evidence gained
tion are based on observations of behavior, most with children of approximately the same age as the
often behaviors having to do with motor coordina- child being studied. To put it bluntly, they deal with
tion, perceptual functioning, and complex informa- the concept of brain injury, a concept based on a
tion processing. In many instances, contrasts are very high level of inference, rather than the fact of
drawn between behaviors that are presumed to be actual brain dysfunction or injury. This alone should
based on neurological processes from different parts create doubts about neurological explanations of
of the brain. These assertions about different parts of learning problems.
the brain are based on looking at differences in be-
haviors, not on hard neurological evidence. More- Overgeneralization from Atypical Subjects
over, the generalizations are from neurological stud-
ies of adults who had various kinds of neurological One of the major difficulties with neuro-
injuries or who were exposed to very narrowly con- psychological explanations of learning problems is
strued experimental tasks administered under con- the basis for many of the generalizations, usually
trolled conditions in laboratory studies, not children studies of highly unusual subjects or studies con-
who were similar to the child being examined by the ducted in tightly controlled laboratory situations. The
neuropsychologist. work of Sperry and his associates (Gazzaniga, 1970;
The analogue from adults to children and the Gazzaniga, Bogen, & Sperry, 1965; Sperry, 1968)
assertion that a complex of symptoms exhibited by on adult epileptic patients who had undergone sur-
children was due to minimal brain injury rests on gical severance of the corpus callosum is one of many
analogical reasoning of the 1940s, which, in tum, examples that could be cited of overgeneralization
was based on studies of soldiers in World War I who from extremely unusual subjects. Sperry and associ-
sustained and survived serious brain injuries. Al- ates were studying epileptic patients whose seizure
though this historical relationship is beyond the scope disorders were so severe and unresponsive to stan-
of this chapter, we do wish to note that much of what dard pharmacological treatment that severance of the
is asserted about minimally brain injured children corpus callosum, thus ensuring functional indepen-
today as well as the examination of children for dence of left and right hemispheres, was carried out
"soft" neurological signs rests on drawing in- in order to control the seizure disorders. The Sperry
ferences from studies by Goldstein during and just eta/. research resulted in the conclusion that complex
after World War I and the educational interventions linguistic functions are localized in the left hemi-
developed by Strauss, Werner, Lehtinen, and others sphere and visual-spatial skills are localized in the
at the Wayne County Training School in the 1940s right hemisphere. However, this generalization
(Widerholt, 1974). needs to be restricted to commissurized adult epilep-
The critical distinction is between the fact and tic patients. It does not apply directly to children with
the concept of brain injury. The fact of brain injury learning problems and it does not provide a secure
must be based on hard neurological evidence. The foundation for the frequent assertioll'S about right-
concept of brain injury is based on a complex of and left-hemisphere localization of complex school
symptoms first observed with adults who undeniably learning.
had brain injury. However, the brain injury etiology Overgeneralizations from the classic work by
was generalized to children who exhibited some, but Sperry et a/. are frequently made by neuropsycholo-
not all, of the same symptoms even though they had gists describing children with learning disabilities. A
absolutely no hard evidence of actual brain injury. WISC-R or other test tapping both verbal and spatial
Moreover, much of the information concerning lo- skills is administered. If the verbal scores are higher
calization within hemispheres or hemispheric spe- than the spatial scores, the diagnosis is usually some
cialization is based on highly unusual conditions that sort of right cerebral hemispheric dysfunction or
will be discussed shortly. weakness. An example of such an interpretation is
The fact is that when Hartlage, Reynolds, or given by Hartlage (1981):
other neuropsychologists analyze learning problems The score configurations, in addition to supporting hy-
in terms of left- and right-hemisphere functioning or potheses of fairly chronic functional superiority of left-
A LEAP OF FAITH 509
over right-hemisphere functioning, suggest that, while bidirectional and inseparable. Furthermore, the fre-
both anterior and posterior portions of the right-hemi- quent suggestions of quite specific relationships be-
sphere are depressed when compared to the left, there tween complex behaviors and a particul~ portion of
may be slightly Jess impairment on posterior than on the brain fail to appreciate the complexity of neu-
anterior portions of the right-hemisphere. (p. 364)
rological functioning, and the interdependen.ce ~nd
This interpretation can be traced back to the the inseparability of the hemispheres and brat~ sttes
original work of Sperry et al. ~eg~ding co~ within hemispheres. To suggest that a parttc~lar
missurized adult patients and localizatiOn of bram complex task such as recognizing letters or assoctat-
function. Because the data drawn from Sperry's work ing sounds with particular letters or vo':"el and conso-
were based on adults whose neurological condition nant combinations is located in a spec1fic part of the
made severance of the corpus callosum necessary, an brain is a vast oversimplification and an inaccurate
extraordinarily rare surgical intervention, generaliza- portrayal of brain-behavior relationships.
tions to children who perform verbal tasks better than O'Boyle (1986) pointed out that the cerebral
they put puzzles together is highly inferential, and hemispheres make interactive contributions to com-
not based on data from children. The relevance of plex human performance on a wide variety of co~
clinical samples as models of the functioning of nitive tasks. The differences between the hemi-
school-age children with no hard signs ~f neu- spheres, typically based on studies. of atypical
rological dysfunction remains highly questionable. subjects as noted above, are usually qutte small and
The fact is that relevant studies with school-age chil- observable only under very well-controlled condi-
dren have not been done and it is an extreme over- tions. The generalizability of these small differences
generalization to apply results of adult patients with to understanding learning problems is far from clear,
severe brain injuries to school-age persons. but the simultaneous functioning of several parts of
A second kind of overgeneralization occurs the brain in any complex task is a virtual certainty.
when results from studies employing well-con- Therefore, neuropsychological interpretations of
trolled, very specific laboratory conditions are ap- specific tasks being related to one hemisphere or ~
plied to school-age children. Many of these laborato- other or specific locations within or between hemi-
ry studies do show hemispheric differences, but these spheres simply cannot be plausible.
differences are extremely small, a matter of a few O'Boyle (1986) was particularly critical. to the
milliseconds or slight differences in percentage cor- "leap of faith" generalizations abou~ ~emtsp~er
rect, and are probably limited to relatively simple icity. According to O'Boyle, "~!early, _It 1s on~ ~mg
stimuli such as a letter, digit, word, or shapes to conclude that the right hem1sphere 1s spec1al1zed
(O'Boyle, 1986). The generalizability of these ~x for visuo-spatial processing on the bases of superior
ability to match shapes. It is quite another to ~oncl~de
perimental findings to extremely complex tasks hke
from the same data that we 'draw from the nght s1de
reading or mathematics reasoning !s
also tenu~us.
of the brain'. Translation errors like this are undoubt-
The degree to which a barely perceptible flash ofhght
measured in milliseconds generalizes to reading edly responsible for many of the misguided ed-
ucational applications of left-brain/right-brain
where exposure is longer, the information is being
differences" (p. 43). The alleged superiority of right-
received by both hemispheres simultaneously, and a
variety of cues are present, is highly questionable. brain functioning with visuospatial processing is
Again, most of the studies have not been conducted based on well-controlled conditions and very simple
with children, and even when they are, the degree to tasks. Learners in classrooms, even if instructed on a
one-to-one basis, are involved with a far more com-
which they adequately represent complex cognitive
plex array of relevant stimuli and much more compli-
functions remains uncertain. Overgeneralization
cated tasks. Furthermore, these complicated tasks in
from atypical subjects and laboratory settings is one
natural classroom settings typically draw upon the
of the most important errors in the neuropsycho-
processing characteristics, whatever those may be, of
logical explanations of learning problems.
both hemispheres. As O'Boyle points out, the hemi-
spheres are best understood as "equally important
Unsophisticated, Primitive Neurology partners of a processing team" (p. 42).
We acknowledge that hemispheric asymmetry
A third major problem in neuropsychological does exist, but dispute the degree of differences in
explanations is primitive, unsophisticat~d ap~recia processing functions associated with relevant le~
tion of the complex, interdependent relattonsh1ps being tasks. Both hemispheres are undoubtedly m-
tween brain and behavior. These relationships are volved. Even under highly controlled conditions, the
510 CHAPTER 27
differences between the hemispheres are relatively of the learning situation that can, indeed, be utilized
small in degree and far from universal. All of this has to improve skills (more on that later). At a minimum,
clear implications for neuropsychological explana- though, one-way causal thinking, brain to behavior,
tions of learning problems. Those explanations near- and unsophisticated applications of laboratory find-
ly always apply a highly simplistic conception of ings are at best highly speculative and, at worst, per-
neurological functioning that presupposes areas of petuate myths about the primacy of neurological sta-
the brain functioning independently and uniquely re- tus over environmental experiences.
sponsible for particular kinds of learning. There is Goodman also pointed out the fallacy of brain-
absolutely no evidence of any kind to support this behavior parallelism where neuropsychologists seem
degree of independence and specialization in areas of to make the assumption that the effects of brain
the brain relative toLD and other learning problems. damage are highly specific. There is little evidence,
The problems described above are related to however, to suggest that brain damage or dysfunction
what has been referred to as "the fallacy of brain commonly takes a very specific form, such as reading
damage as the first and final cause" (Goodman, problems, difficulty in processing certain kinds of
1983). Goodman pointed out that neuropsychologists information such as spatial relationships, hyperac-
assume a "closed circuit" relationship between tivity, and so on. Benton (1974) noted that the best
brain damage and behavior because they implicitly single index of the presence of brain damage in chil-
assume one-way causal relationships. That is, dren and adults is a lower than expected total score
causality for the neuropsychologists starts with the derived from a comprehensive test battery. Thus,
brain and ends with behavior when, in fact, there is there are little data to support the notion of localiza-
also good evidence that specific environmental expe- tion of brain damage leading to specific impairments
riences also influence brain function. Goodman reflected in behaviors observed during standard
pointed out that neuropsychologists typically assume neuropsychological assessment procedures. Despite
that, in the presence of both the neurological symp- this lack of research support for brain dysfunction
tom and a behavioral symptom, the behavioral symp- paralleling specific behaviors, neuropsychologists
tom must be caused by the neurological symptom. In attempting to explain learning problems frequently
fact, a variety of causes could be posited in what is use simple behavioral observations, say on the
essentially a correlation. That correlation does not Bender, or test scatter, as indications of specific brain
establish causality, is a dictum well understood by all dysfunction. Discussion of problems with neuro-
psychologists, including neuropsychologists, but psychological assessment procedures is given in the
often ignored in asserting relationships between spe- following section.
cific behaviors and neurological structure or func- There are numerous fallacies in neuropsycho-
tion. logical explanations of learning problems. First,
We, along with Goodman (1983), acknowledge there is the confusion over the fact versus the concept
that all learning has a biological substrate. We even of brain damage. Neuropsychologists are using the
acknowledge that there are probably neurological concept of brain damage, not the fact, in explanations
differences between a student who can recite the A, of learning problems. These explanations are derived
B, C's and recognize letters and students who cannot from studies of highly atypical subjects some of
perform those routines. To acknowledge that vir- whom have extraordinary neurological charac-
tually everything is neurological does not, however, teristics, such as severed corpus callosum, as well as
provide any validity for neuropsychological in- application of findings from extremely tightly con-
terpretations of specific behavioral events. The fact is trolled laboratory studies. These generalizations are
that the underlying neurological differences among dubious. Furthermore, the assertions of specific
persons who have mastered or who have not mastered brain status associated with specific observed behav-
specific routines are simply, at this point, unknown, iors are based on "leaps of faith" with little or no
and accurate descriptions of the precise neurological evidence with students of the kind involved in the
changes associated with learning are probably dec- recommendations (overgeneralizations). These gen-
ades away. But to say that everything is neurological eralizations reflect primitive, unsophisticated ap-
does not move us any closer to understanding or gen- plications of neurological findings as well as other
uine explanation of learning and human individual fallacies such as the brain as the first and final cause
differences. Moreover, premature, unsophisticated of behavior and the assumption of very close rela-
neurological explanations probably do more harm tionships between neurological status and specific
than good because they deflect attention from aspects behaviors. These problems alone should give pause
ALEAPOFFAITH 511
to widespread application of neuropsychological ble characteristics that can be used, with confidence,
techniques. Additional problems with neuropsycho- in prescribing remedial interventions. Calling the
logical assessment and educational implications of Bender a measure of "constructional praxis" or in-
presumed neuropsychological states create even cluding the WRAT as part of a neuropsychological
more formidable barriers to neuropsychological ex- test battery does not confer greater technical
planations of learning problems. adequacy for these weak instruments (Salvia &
Ysseldyke, 1985; Witt, 1986). Instruments do not
acquire essential characteristics simply because they
Fallacies in Neuropsychological are used to make highly speculative inferences about
underlying neurological status. In fact, the same defi-
Assessment ciencies identified when these instruments are evalu-
ated on their own undoubtedly further complicate and
One of the weakest aspects of the case for neuro- substantially diminish the reliability and validity of
psychological explanations of LDs is the nature and inferences about neurological status.
quality of the assessment procedures. These assess- Even the Wechsler Scales, which have good
ment procedures are subject to three major problems: technical adequacy for certain inferences, are used in
(I) the instruments are questionable due to limita- such a way to render them technically inadequate for
tions in reliability, validity, and norms; (2) phe- inferences about neurological characteristics. For ex-
nomena that occur at high base rates in the normal ample, the Wechsler Verbal and Performance IQs are
population are interpreted as indicating neurological frequently interpreted as indicating left- and right-
disorders; and (3) simple behaviors are interpreted as hemisphere specialization. Thus, a person with a
indicating complex underlying disorders through higher Performance than Verbal score is regarded as
very high levels of inference. These difficulties are having stronger left- than right-hemisphere function-
discussed in the following three sections. ing. The evidence for this assertion is dubious at best.
Even more dubious is the comparison of single pairs
Questionable Instruments of subtests to determine neurological integrity of dif-
ferent parts of the brain. Fluctuations among single
The instruments commonly used in neuro- pairs of subtests are known to be common (Kaufman,
psychological assessment batteries are, except for the 1976). Furthermore, simple comparisons of subtests
Wechsler Scales, widely regarded as having ques- are complicated by the relative unreliability of dif-
tionable technical characteristics. The instruments ference scores. In spite of these problems, we hear
listed in model case studies (Hartlage, 1981, 1986; the following from a well-known neuropsychologist
Hartlage & Reynolds, 1981; Obrzut, 1981) typically "Even greater refinement can be obtained by com-
feature the Wechsler Intelligence Scale for Chil- paring individual subtests, such as comparing func-
dren-Revised (WISC-R), the Bender-Gestalt, the tional integrity of left- and right-temporal lobes by
Illinois Test ofPsycholinguistic Abilities (ITPA), the the Similarities versus Picture Arrangement subtests;
Wide Range Achievement Test (WRAT), the Pea- or, left- and right-parietal lobe integrity by the Arith-
body Picture Vocabulary Test (PPVT), as well as metic vs. Block Design subtests" (Hartlage, 1982, p.
various techniques for examining motor skills such as 300). Here there is the implicit assumption that spe-
finger tapping with right and left hand, relative cific Wechsler subtests can be used to determine the
strength of right and left sides, and so on. Except for integrity of specific parts of the brain. There are
the Wechsler Scales, these procedures are widely many things wrong with this reasoning, beginning
regarded as having questionable technical charac- with the relative unreliability of difference scores,
teristics, including inadequate reliability for making meaning that the difference between subtest pairs is
decisions about individuals, undemonstrated valid- likely to fluctuate upon retesting. This, in turn,
ity, and/or unsatisfactory norms (Salvia & Yssel- means either that much of what is interpreted about
dyke, 1985). Instruments with poor norms, un- pair differences is error or that neurological status
demonstrated validity, and inadequate reliability changes fairly rapidly when testing is repeated. Al-
simply cannot yield valid information to be used in though we believe in relative plasticity of neu-
diagnosing complex characteristics such as learning rological functioning, we have trouble believing that
problems, and certainly not the more complex, un- the 'integrity'' of different parts of the brain is that
derlying neurological status of the individual. Unre- haphazard, and, for that and other reasons, we have
liable instruments measure error. not consistent sta- even greater reservations about whether individual
512 CHAPTER 27
Wechsler subtests can be used to make inferences neuropsychological dysfunctions and thereby be eli-
about specific parts of the brain. gible to be classified as LD based on the results of
neuropsychological assessment. The high base rates
make it almost certain that a very high percentage of
Base Rates normal learners would meet the criteria for having a
Base rate refers to the frequency with which neuropsychologically based LD. This result would
some phenomenon occurs in the general population. be identical to that reported by Ysseldyke et al.
Base rates are important because many of the charac- ( 1982) indicating a very high percentage (perhaps as
teristics interpreted as clinicially significant by high as 90%) of normal students show one or more
neuropsychologists occur frequently in the general LD symptoms.
population. The high-base-rate phenomenon has two Although studies of the percentage of normal
implications. First, the patterns interpreted as students who would show one or more significant
clinically significant by neuropsychologists are far signs of neurological dysfunction, using the kind of
from unusual and certainly not unique characteristics criteria applied in the model case reports cited earlier,
of individuals. Second, a study of a representative have not, to our knowledge, been done, we contend
sample of persons in the general population would that such studies do not need to be done because the
yield, for virtually everyone, suggestions like hemi- results <u \,; certain based on what we already know
spheric asymmetry, differential integrity of anterior about the performance of standardization samples on
and posterior parts of the brain, and differences in the Wechsler and other widely used assessment in-
left- and right-brain subareas such as left and right struments. If scatter is normal in the sense of occur-
temporal lobes. High base rates mean that the charac- ring very frequently, if pairs of subtest differences
teristic cannot be used to improve diagnostic ac- occur very frequently, and if subtest differences are
curacy in an area like LD, which has an estimated interpreted as indicating neurological dysfunction,
prevalence of 3% to 5% (Hynd et at., 1986). Fre- then virtually all normal learners will have neu-
quently occurring phenomena like subtest differ- rological dysfunctions. Given the base rates and
ences cannot be definitive characteristics of rarely neuropsychological methodology, we do not doubt
occurring disorders. that LD students seem to have neurological dysfunc-
Perhaps the best evidence on base rates comes tions. But so will nearly-all normal learners using the
from Kaufman (1976, 1979) concerning the amount diagnostic methodology of neuropsychology. So, we
of scatter on Wechsler subtests and variations in the return to a place similar to the trite observation that all
Verbal and Performance IQ scales. The only conclu- learning has a neurological base. Only now, we ob-
sion that can be drawn from Kaufman's studies of the serve that all learners have neuropsychological dys-
WISC-R standardization sample is that scatter is nor- functions.
mal. Contrary to traditional clinical interpretations, a
flat profile would be "abnormal" because the aver- High Level of Inference
age amount of difference between the highest and
lowest WISC-R subtest scores is about 7 points on a Level of inference refers to the relationship be-
scale with a mean of 10 and a standard deviation of 3. t~een the behavior observed and the meaning at-
Moreover, IQ scale differences of 15 points or more tributed to that behavior. It deals with the interpreta-
occur with 25% of the general population. This tion of behaviors exhibited under testing conditions
means that simple subtest variations of the kind in- and the meaning created for test score patterns. Cur-
terpreted by neuropsychologists (see the example in rent neuropsychology perpetuates the long and unfor-
the previous paragraph) will occur with virtually tunate tradition in applied areas of psychology of
everyone. using highly inferential interpretations of rather sim-
The high base rates of variations in measures ple behavioral events. The Bender Motor Gestalt
used to infer neurological integrity mean that most Test (Bender, 1938) is one of the most frequently
persons will be found to have one or more positive used psychological tests in general psychological
indicators of neurological dysfunction. It is therefore practice with adults and children (Goh, Telzrow, &
not possible for neuropsychological approaches to Fuller, 1981; Reschly, Genshaft, & Binder, 1987;
provide more accurate LD diagnoses, unless we be- Wade & Baker, 1977). Common interpretations of
lieve that most students are LD. As noted previously, the Bender reveal widely varying levels of inference
Hynd et al. ( 1986) suggested a conservative estimate ranging from simple description to assertions about
of 3% LD prevalence. A critical question is what neurological integrity or personality dynamics (Kop-
percent of normal students will show positive signs of pitz, 1975) (see Figure 2).
A LEAP OF FAITH 513
Danny's
Danny's Friend's Bender
FIGURE 2. Different levels of inference in in-

terpretation of Bender reproductions. The following
interpretations vary from low to high inference: poor
copying skills, poor visual-motor skills, develop-
mental lag or immaturity, neurological dysfunction,
emotional symptoms, personality dynamics.
A very poor drawing might be interpreted at latter point, although subtle, is extremely important.
five different levels of inference. The lowest level of Problems described in terms of neurological dysfunc-
inference would be to interpret the poor Bepder tion or deep underlying conflicts are less likely to be
drawings as indicating poor copying skills. A seen as amenable to instruction or treatment. On the
slightly higher level of inference might be to infer an other hand, straightforward and precise descriptions
underlying skill such as visual motor skills. A still of the same behavior without the presumed underly-
hi~her level of inference might be to make some as- ing cause are much more likely to be regarded to
sertion about maturation rate or developmental amenable to instruction or treatment (Tombari &
level, a common interpretation of the Bender. A Bergan, 1978). One further observation about highly
much higher level of inference that goes far beyond inferential interpretations in neuropsychology: Court
the actual behavior observed, which was-it is testimony based on high levels of inference is often
important to remember-merely copying a geo- challenged effectively on cross-examination (Ziskin,
metric figure, would be to assert some complex pro- 1981), because of the lack of empirical support.
cess like constructional praxis and to suggest an as- The problems of high base rates and high levels
sociated neurological dysfunction. A still higher of inference are typically combined in neuropsycho-
level of inference would be to make assertions about logical assessment. Consider this example: Perhaps
personality dynamics using the Bender emotional in- the most striking feature of his Wechsler profile is his
dicators (Koppitz, 1975). uniquely depressed similarities subtest. The relative
There are several problems with these highly isolation of this intellectual deficit is more compati-
inferential interpretations, particularly interpretable with some sort of acquired insult to the left tem-
tions having to do with either underlying physical poral tuea than to any generalized left hemisphere
status, as in neuropsychological interpretations of deficit, and in fact the majority of other test measures
Bender drawings, or underlying personality dynam- are reasonably close to normal" (Hartlage, 1982, p.
ics. The high levels of inference are generally not in 310). The similarities subtest score in the model case
the student's best interests because: (I) the highly study just quoted was 6. The highest subtest score on
inferential interpretations are rarely supported by sol- the Verbal Scale was 10; on the entire Wechsler bat-
id, empirical evidence; (2) the variables identified in tery the highest subtest score was 11. A four-point
the highly inferential interpretations are usually diffi- difference between pairs of subtests on the Verbal
cult to impossible to influence, at least directly; (3) Scale or a five-point difference between highest and
the highly inferential interpretations are rarely related lowest subtests across both Verbal and Performance
to educational interventions or psychological treat- Scales is a very frequent occurrence. Typical, normal
ments; and (4) the highly inferential interpretations, children have subtest differences of that magnitude or
because they focus on deep underlying problems, greater. Furthermore, the suggestion that a lower
frequently reduce commitment toward, and a sense Similarities score indicates "acquired insult to the
of efficacy about, carrying out interventions. This left temporal area'' can only be regarded as reflecting
514 CHAPTER 27
an extremely high level of inference because the rela- ventions that capitalize on the student's neurological
tionship between what is actually observed and the strengths. The evidence for both of these require-
meaning attributed to that observation is, at best, ments is negative.
extremely remote. Moreover, the observation is not
based on empirical research with normal and brain-
injured students who also differ in learning efficien- Aptitude by Treatment Interaction (ATI)
cy. Rather, it is based on analogical reasoning from
studies of very unusual adults. The most critical assumption to current neuro-
One of the major problems with neuropsychol- psychological approaches is that learning academic
ogy is in the realm of assessment. The assessment content such as reading or mathematic skills will be
instruments provide little reason for confidence in enhanced if a careful neuropsychological examina-
neuropsychological interpretations. These instru- tion is conducted and the student's best neurological
ments clearly do not become better or somehow ac- functions utilized in the methodology or strategy
quire technical adequacy because their results are used to teach academic skills. The notion of ''match-
interpreted as indicating neurological status. Neuro- ing up'' intervention methodology or teaching strat-
psychological assessment, in addition to being based egy to intact neurological structures or processes has
on questionable instruments, also reflects overin- tremendous intuitive appeal and almost inherent
terpretation of normal test score fluctuations as indi- credibility. The problem is that this intuitive appeal
cating neurological dysfunction and extremely high or inherent credibility has virtually no support from
levels of inference that have little or no foundation empirical evidence.
from empirical research. Based on these assessment Reviews of ATI studies using aptitudes like
problems, it is not surprising that little or no evidence processing strength or intact neurological struc-
exists to support educational interventions based on tures/functions have been published (Arter &
neuropsychological principles. Jenkins, 1979; Ysseldyke & Mirken, 1982). In the
absence of positive evidence concerning ATl, in-
cluding the specific kinds of assertions made by
Hartlage, Reynolds, Obrzut, and others cited in this
Fallacies in Educational chapter, it is very difficult to find support for con-
Recommendations Based on tinuation of neuropsychological interpretations and
Neuropsychological Principles educational recommendations based on neuropsy-
chology. This is not simply a matter of "we need
The principal recommended use of neuro- more research, but should continue what we're doing
psychological assessment of students with learning now in the absence of that research," but rather,
problems is for improved classification and/or deter- without some positive research evidence, the whole
mination of teaching methodology or strategies. The enterprise needs to be scuttled. The likelihood of
impossibility of improved LD classification was dis- positive ATl findings for current neuropsychological
cussed in the preceding section. In this section we principles is, we believe, highly remote. We suspect
will review evidence on the possible use of neuro- the outcomes of future research concerning ATis
psychological principles to determine how to teach with neuropsychological principles will be similar to
students with learning problems. The neuropsycho- findings reviewed by Arter and Jenkins (1979).
logical principles in this regard are fairly straightfor- A variety of reasons could be suggested for the
ward. Basically, neuropsychologists argue that intact failure of ATl studies. These reasons range from
areas, i.e., areas in the brain that are functioning doubts about the relationship of neurological integ-
properly, should be used in deciding how to teach rity to learning efficiency, the accuracy of current
important academic skills such as reading and mathe- assessment procedures in determining neurological
matics (Hartlage, 1981, 1982, 1986; Reynolds, integrity, the relationship of neurological integrity
1981; Hartlage & Reynolds, 1981). These neuropsy- to specific instructional procedures, particularly
chologists sharply reject being associated with the whether these instructional procedures do indeed tap
earlier processing view in LD, which they claim, specific neurological structures/functions; whether
generally accurately, involved efforts to remediate the instructional procedures were implemented prop-
deficits rather than capitalize on strengths. For this erly, whether subjects in the study were chosen ap-
use of neuropsychological assessment to be valid propriately, and so on. We have no way to determine
there must be evidence for aptitude by treatment in- which combination of these reasons accounts for the
teraction and there must be a set of instructional inter- negative findings to date. We can only say, however,
ALEAPOFFAITH 515
that negative ATI findings suggest we are wasting there are a variety of significant behavioral signs in
our time and the valuable time of children in conduct- D.K. 's performance that suggest left-hemisphere
ing elaborate neuropsychological analyses in order to dysfunction, such a diagnosis could only be made
prescribe some kind of instructional intervention. when correlated with medical data (e.g., an EEG
There is no evidence to suggest this entire expensive dysrhythmia in the left-hemisphere with none in the
and time-consuming enterprise is of value to anyone, right). This information was not available nor was
except to clinicians who are more ~atisfied with a deemed necessary in planning appropriately for re-
neurological explanation for behavior. medial activities" (p. 358). Gaddes (1981) expressed
his reservations in the following way: "School psy-
chologists are ill-advised to make diagnostic state-
Limited Instructional Interventions ments about a learning disabled child's brain unless
they have had extended and competent training in
One of the major weaknesses of educational ap-
clinical-neuropsychology; they do better to keep to
plications of neuropsychological principles is the
the behavioral data on the child's sensory, cognitive,
very limited range of educational treatments sug-
and motor strengths" (p. 40). Whatever instructional
gested by neuropsychological advocates. These in-
interventions are available, and those described in the
structional interventions are most often limited to
neuropsychological literature seem very restricted
vague generalizations about methods of teaching and simple, it appears that use of neuropsychological
reading with whole word or sight word approaches
constructs is unnecessary to "match up" the stu-
recommended for students with (allegedly) better
dent's strengths with instructional methodology.
functioning right than left hemispheres, and a more
Again, we find no basis for neuropsychological diag-
analytic or phonic method for students with (al-
nosis of learning problems from the literature on in-
legedly) better left than right hemispheres. Specific
structional interventions.
recommendations for students whose temporal lobes
are functioning better on one than the other or whose
brain anteriors are better than their brain posteriors Psychological Processing Revisited
have generally not been provided in the model reports
developed by neuropsychologists (Hartlage, 1981, Although strongly disavowed by contemporary
1982, 1986; Hartlage & Reynolds, 1981; Obrzut, neuropsychologists, the fact is that there are numer-
1981). One of the weakest aspects of the neuro- ous similarities between current neuropsychological
psychological approach, not appreciated sufficiently explanations of learning problems and the older, now
to date, is the relative absence of finely graduated widely rejected, psychological process explanation
instructional procedures that can be selected in order of learning problems. These similarities are immedi-
to capitalize on alleged neurological strengths. ately apparent if guidelines for developing instruc-
We doubt that these more finely differentiated tion to capitalize on psychological processing
methods are likely to have much effect because of all strengths are compared to guidelines for capitalizing
the problems discussed in other sections of this chap- on neuropsychological strengths (compare Kaufman,
ter. However, if all that can be done is to make a vague Goldsmith, & Kaufman, 1984, with Minskoff, Wise-
generalization about reading method, when in fact all man, & Minskoff, 1972). In comparing those mate-
reading methods undoubtedly involve complex pro- rials, the only changes needed to establish a very high
cessing ofboth hemispheres (O'Boyle, 1986), then we degree of similarity are to substitute auditory vocal
have to wonder about even the potential usefulness of channel for left-hemisphere or sequential processing
the neuropsychological principles. Finally, it is im- and visual motor channel for right-hemisphere or si-
possible to develop teaching methods multaneous processing. Otherwise the content, par-
or strategies that capitalize exclusively or even pri- ticularly recommendations for teaching strategies,
marily on a small area of the brain or on only one or the are virtually the same. Although we acknowledge the
other hemisphere. For all learners, except for those differences in the primary use of the information, the
extraordinarily rare adults with a severed corpus cal- contemporary neuropsychologists claim to avoid
losum, both hemispheres are working together. teaching ''dead tissue," the other inadequacies of the
Finally, we agree with Obrzut ( 1981) and earlier processing approach, particularly technically
Gaddes ( 1981 ), both of whom expressed doubts as to inadequate assessment instruments, undemonstrated
whether interpretations about neurological integrity ATI, and obscure relationships to instruction are rele-
should even appear in reports used by educators in vant to current educational applications of neuro-
school settings. Obrzut (1981) noted, "Although psychology.
516 CHAPTER 27
Potential Harmful Effects basic facts for a case, but different reports developed,
thus allowing contrasts in teachers' reactions to
All that has been said thus far could be dis- neuropsychological and behavioral explanations of
missed as merely an argument among persons with learning problems. We believe that the neuro-
different theoretical orientations; a kind of paradigm psychological reports, despite their advocates' vehe-
war among psychologists interested in learning prob- ment claims to create a more positive expectation
lems. We think this argument, however, has impor- through identifying neurologically functional areas
tant consequences for children. of the brain, will, in fact, have the effect of producing
A major problem with the neuropsychological teacher and parent beliefs that the neurologically
approach to learning problems is that it is heavily damaged child will be very difficult, if not impossi-
steeped in the medical model tradition. In fact, we ble, to change. In contrast, we believe that a behav-
find it difficult to think of anything that has more of a ioral assessment model with the identification of spe-
''medical model'' orientation than to make sug- cific behaviors and description of precise objectives
gestions like ''damage to posterior portions of the will lead to beliefs in greater efficacy in teaching the
right cerebral hemisphere involving deficits of func- child (Shapiro & Lentz, 1985). Interested readers
tion of both temporal and parietal lobes" (pp. 308- wishing to see the contrast of approaches might com-
309, Hartlage, 1982). Although neuropsychologists pare the model report in Shapiro and Lentz ( 1985)
claim to emphasize neurological strengths, the con- with the reports in the neuropsychological literature
tent of their reports typically is devoted more to a (Hartlage, 1981, 1986; Hartlage & Reynolds, 1981 ).
description of deficits, usually in what appears to the It is important to note that in the contrasts sug-
uninitiated to be in very technical, scientific language gested here the actual behavior of the student is the
related to specific damaged areas of the brain. Al- same. The difference is in the interpretation of that
though we and most neuropsychologists understand behavior. The critical questions might be framed as
the degree of speculation involved, most teachers follows: Are children served better by an interpreta-
will have little or no background to understand the tion that uses a very high level of inference, internal,
speculative nature of the inferences or the differences nonobservable states of the individual, and illusions
seen by the neuropsychologist in intact areas of the to damaged tissue (without any actual evidence of
brain as opposed to dysfunctional areas of the brain. damage), or are students better served by careful de-
We believe this focus on deficits couched in what are scriptions of relevant skills with thorough description
pseudoscientific behavior-brain links will lead of antecedent, situational, and consequent events fol-
teachers and parents to have low expectations for lowed by direct instruction on skills not mastered
students for whom neuropsychological diagnoses are with appropriate behavior analysis principles applied
provided (Sandoval & Haapanen, 1981). Drawing in diagnosis, instruction, and evaluation of the out-
from the learned helplessness model, parents, teach- comes of instruction? Our answer on that matter is
ers, and the diagnosed child may come to believe that obvious and we challenge the reader to weigh the
no matter what is done instructionally, it will not alternatives and consider which is more likely to lead
make any difference in terms of academic perfor- to better educational opportunities for students with
mance because the student's brain is not functioning learning problems.
properly. Moreover, none of these persons are likely
to realize that the ''concept'' of brain injury, not the
fact of brain injury, is the foundation for these neu-
ropsychological explanations. Special Education Reform
One study that demonstrates this problem con-
trasted behavioral and medical model approaches to The current reform movement in special educa-
conceptualizing learning problems identified by tion may render moot much of the discussion in this
teachers. Tombari and Bergan ( 1978) exposed teach- chapter. The special education system of the future
ers to either a behavioral or a medical model form of may very well eliminate classification of children
consultation. Results from a path analysis showed with learning problems in order for them to receive
that teachers receiving the behavioral model were some kind of remedial services. Future classification
better able to define the problem behaviors and this may place far less emphasis on diagnosis of underly-
definition of problem behaviors, in tum, led to higher ing, nonobservable traits or internal states of the or-
expectations regarding their perceived ability to ganism and far more emphasis on straightforward
solve these problems. We suggest that further studies curriculum-based assessment (Grimes & Reschly,
of this nature might be conducted using the same 1986; Reschly, 1987b; Shapiro & Lentz, 1985;
A LEAP OF FAITH 517
Shapiro, 1987). The relevance of neuropsychology sociation, No. 3.

to a reformed, radically different special education Benton, A. L. (1974). Clinical neuropsychology of childhood: An
delivery system is, at best, remote. Pending changes overview. In R. Reitan & L. Davison (Eds.), Clinical neuro-
in the data base for neuropsychology, particularly the psychology: Current status and applications. New York:
clear demonstration of aptitude by treatment interac- Wiley.
Coles, G. S. (1978). The learning disabilities test battery: Em-
tions, something not attained or even approximated
pirical and social issues. Howard Educational Review, 48,
to date, the reformed system described elsewhere
313-340.
(Graden, Zins, & Curtis, 1988) may render moot the Cromwell, R., Blashfield, R., & Strauss, J. (1975). Criteria for
issues debated in this chapter. classification systems: InN. Hobbs (Ed.), Issues in the clas-
sification of children. San Francisco: Jossey-Bass.
Cronbach, L. J., & Snow, R. E. (1977). Aptitudes and instruc-
tional methods. New York: Wiley (Halsted Press).
Conclusions Cruickshank, W. M. (1972). Some issues facing the field oflearn-
ing disabilities. Journal of Learning Disabilities, 5, 380-
Neuropsychological approaches to leru:ning 383.
problems, such as those exhibited by students now Cruickshank, W. M. (1979). Learning disabilities: Perceptual or
classified as LD, are irrelevant to accurate classifica- other? ACW Newbriejs, No. 125, March/April, 7-10.
tion, immaterial to effective remediation, misleading Das, J.P., Kirby, J., & Jarman, R. F. (1979). Simultaneous and
successive cognitive processing. New York: Academic Press.
by suggesting brain conditions for which there is no
Das, J. P., & Naglieri, J. A. (in press). Cognitive assessment
solid evidence, and potentially harmful in suggesting system. New York: Psychological Corporation.
deep underlying, indeed dysfunctional physical Epps, S., Ysseldyke, J. E., & Algozzine, B. (1983). Impact of
structures or processes as the cause of learning prob- different definitions of learning disabilities on the number of
lems. Neuropsychology carries the danger of sug- students identified. Journal of Psychoeducational Assess-
gesting damaged physical structures to teachers, par- ment, 1, 341-352.
ents, and students, with the connotation of immuta- Federal Register. (1977). Procedures for Evaluating Specific
bility, without providing a foundation for more effec- Learning Disabilities. Author, December 29, 42 (250),
tive remedial or developmental educational services. 65082-65085.
Neuropsychological constructs are largely unneeded Gaddes, W. H. (1981). An examination of the validity of neuro-
psychological knowledge in educational diagnosis and re-
to make the kinds of recommendations that appear in mediation. In G. W. Hynd & I. E. Obrzut (Eds.), Neuro-
model reports by neuropsychologists, and, in any psychological assessment and the school age child: Issues
event, there is no evidence that the aptitude (intact and procedures. New York: Grune & Strattan.
neurological structures/functions) does interact with Gazzaniga, M. S. (1970). The bisected brain. New York: Ap-
instructional methodology. Until such interactions pleton-Century-Crofts.
can be demonstrated, we find no basis to perpetuate Gazzaniga, M.S., Bogen, J. E., & Sperry, R. W. (1965). Obser-
neuropsychological assessment. We agree with the vations on visual perception after disconnexion of the cere-
dictum, "In God we trust. All others must have bral hemispheres in man. Brain, 88, 221-236.
data'' used as the opening for a chapter on bias in Geib, S. A., & Mizokawa, D. T. (1986). Special education and
social structure: The commonality of "exceptionality."
assessment by a well-known and widely respected
American Educational Research Journal, 23, 543-557.
psychologist (Reynolds, 1982). We believe the dic-
Gerber, M. M. ( 1984). The Department of Education's Sixth An-
tum also applies to those who would explain learning nual Report to Congress on PL94- I 42: Is Congress getting the
problems with neuropsychological constructs. full story? Exceptional Children, 51, 209-224.
Gob, D. S., Telzrow, C. I., & Fuller, G. B. (1981). The practice
of psychological assessment among school psychologists.
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A LEAP OF FAITH 519
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28
Child Behavioral Neuropsychology

ARTHUR MAcNEILL HORTON, }R.
Recognition of the overlap between neuropsychol- children. The extent of the empirical data base sup-
ogy and learning is not new. One of the first pioneers porting behavioral methods is only paralleled by that
to differentiate brain and mind was the famous Brit- amassed by human neuropsychology.
ish neurologist John Hughlings Jackson as early as Given these twin developments, a natural ques-
1872. Indeed, Gaddes ( 1981) suggested that contem- tion would be the possibility of amalgamation. As
porary notions and conjectures regarding learning might be expected, there have been some consider-
disabilities have their roots in the research of 19th able efforts devoted to the integration of assessment
century neurologists who first began to elucidate the methods derived from human neuropsychology and
complex interrelationship of brain structure and lan- treatment approaches based, at least initially, on
guage. As noted by Horton and Wedding (1984), learning theory. A new specialty that blends behavior
there is a long history of this work. therapy with neuropsychology has been proposed
In the last 20 years, however, interest in brain- (Horton, 1979) and tentatively titled, "behavioral
behavior relationships has expanded greatly. Con- neuropsychology.'' Psychologists and other profes-
tributing to this trend were striking demonstrations of sionals involved in the behavioral treatment of chil-
the cross-cultural validity of neuropsychological dren with learning problems that are related to neuro-
knowledge (Horton & Wedding, 1984; Golden, psychological functioning are expected to find this
1981; Luria, 1966; Reitan & Davison, 1974) as well area of research and clinical practice valuable.
as very successful demonstrations of the application The intent of this chapter is to explore the re-
of neuropsychological data to school-aged children search and clinical knowledge base that underlies
(Reitan & Davison, 1974; Horton & Wedding, 1984; behavioral neuropsychology and with that objective
Hynd & Obrzut, 1981). It would appear straightfor- in mind, the first step might be to delineate what is
ward that human neuropsychology is of great rele- meant by behavioral neuropsychology. The first use
vance to the practice of clinical child psychology. of the term was in 1978, when a Special Interest
In addition to the tremendous growth of neuro- Group (under that title) was formed under the admin-
psychology, there has been one other dramatic devel- istrative aegis of the Association for Advancement of
opment in the practice of psychology with school- Behavior Therapy (AABT). The first meeting of the
aged children. This, of course, is the development of group was held in Chicago at the annual AABT meet-
behavior modification/therapy programs (Rimm & ing and the Special Interest Group has continued to be
Masters, 1978; Wolpe, 1973). Since the first intro- active in AABT over the years.
duction of large-scale token economics following the Shortly following the founding of the Special
work of Ayllon and Azrin (Kazdin, 1978), there has Interest Group, a tentative definition was advanced.
been a strong and substantial adoption of behavioral This tentative definition was as follows:
methods by school-based, institution-supported, and
Behavioral Neuropsychology may be defined as the
independent providers of psychological services to application of behavior therapy techniques to problems
of organically impaired individuals while using a
Neuropsychological assessment and intervention per-
ARTHUR MAcNEILL HORTON, }R. Veterans Admin- spective. This treatment methodology suggests that in-
istration Medical Center, Baltimore, Maryland 21218; Depart- clusion of data from Neuropsychological assessment
ment of Psychiatry, University of Maryland Medical School, Bal- strategies would be helpful in the formulation of hy-
timore, Maryland 21201; and Psych Associates, Towson, potheses regarding antecedent conditions (external or
Maryland 21214. internal) for observed phenomena of psychopathology.
521
522 CHAPTER 28
That is, a Neuropsychological perspective will signifi- iables that are not observable stimulus-response
cantly enhance the ability of the behavior therapist to actions are not necessary to account for human be-
make accurate discriminations as to the etiology of pa- haviors (Marr, 1984). Variables that may not be
tient behavior. Moreover, the formulation of a cogent observed (i.e., inferred variables) are therefore
plan of therapeutic intervention and its skillful imple-
regarded as essentially worthless by radical be-
mentation could, in certain cases, be facilitated by an
haviorists.
analysis of behavior deficits implicating impairment of
higher cortical functioning. (Horton, 1979, p. 20) In order to understand how neuropsychological
data might fit into a radical behaviorist paradigm, it is
Although this definition is, of course, somewhat important to consider the proposition that there may
dated, it nonetheless provides a focus to further dis- be legitimate inferred variables in the functional
cussion. It is acknowledged that alternate interpreta- analysis of human behavior (Mahoney, 1974). As
tions of behavioral neuropsychology, as a field, agreed elsewhere (Horton, 1979), inferred variables
might be quite valid, and that many individuals in might be considered to come in two distinct catego-
either clinical neuropsychology or behavior therapy ries. These are intervening variables and hypo-
(or applied behavioral analysis) may have substantial thetical constructs (Craighead, Kazdin, & Mahoney,
reservations. 1976). As noted by Horton (1979):
The major portion of this chapter will be orga-
nized into four sections related to the specific . . . an intervening variable is a theoretical creation.
For instance, no one has ever observed intervening
application of behavioral neuropsychology with
variables, such as thoughts or feelings, yet they are
school-aged children. The first section will focus on used by cognitive behavior therapists to explain behav-
theoretical issues and will attempt to elucidate how ior. It could be said that, at least as far as we now know
behavioral neuropsychology is compatible with both it, it is unlikely one would be able to directly observe an
radical and contemporary variations of behaviorism. intervening variable. (Horton, 1979, p. 21)
The second section is concerned with treatment plan-
ning issues and will discuss some models for con- Simply put, intervening variables exist only in
structive intervention. The third section will examine theory as they are conceptual abstractions. Hypo-
selectively some of the existing research on the ap- thetical constructs, on the other hand, are generally
plication of behavioral methods with learning-dis- seen as more physical or empirical than intervening
abled and structurally brain-damaged children. The variables. As observed by Horton (1981):
fourth section will function as a concluding summa- . . . a hypothetical construct is an actual physical ob-
ry, but also will include some tentative hypotheses ject or process which is unobservable at the present
about possible future developments of child behav- time. For instance, hypothetical constructs in Neuro-
ioral neuropsychology. psychology tend to have physiological referents and
can, if so desired, be verified. If a child evidences
certain characteristics, it might be postulated that there
is damage to the right parietal lobe. In this case. our
Theoretical Issues hypothetical construct is based in our knowledge of
brain-behavior relationships and can be verified
through neurosurgical procedures. (Horton, 1981, p.
Behavioral Concerns 368)
The first theoretical issue to be dealt with is the In an earlier publication, Horton ( 1979) further
relationship of radical behaviorism with neuropsy- elaborated upon the differences between intervening
chology. The second theroetical issue is how more variables and hypothetical constructs. As observed
contemporary notions of behaviorism can be recon- by Horton:
ciled with neuropsychology. These comments will be
brief as more lengthy discussions are available (Hor- ... an example of this distinction would be the behav-
ton, 1979, 1981; Horton & Puente, 1986). ior of failing to draw a Greek cross and the explanation
of this behavior by each inferred variable. An interven-
Simply put, the radical behaviorist model holds
ing variable could opt for an explaining mechanism
that the totality of human behavior can be satisfac- such as an emotional state as the cause. Using a hypo-
torily accounted for by observed stimulus-response thetical construct, one might postulate the impairment
relationships (Watson, 1913). Proponents of this of the right parietal lobe. While this example is grossly
view agree that the behavior of humans can be ex- over-simplified, the major point should be clear. Hypo-
plained without the need to postulate covert or unob- thetical constructs tend to have physiological referents.
served factors (Skinner, 1938). Put another way, var- The major advantage is that at some point, by some
CHILD BEHAVIORAL NEUROPSYCHOLOGY 523
means, its existence or nonexistence can be verified. In In this context, it is worth recalling that when the
the instance cited, neurosurgical procedures could de- journal Behavioral Assessment was launched in
termine the actual condition of the right parietal lobe in 1979, the founding editor, Rosemary Nelson, in her
our subject. While in clinical practice, this is rarely editorial statement describing the role of the journal,
done, the distinction is important. At present, methods
stated that behavioral assessment emphasizes:
for the direct objective verification of a thought or feel-
ing have yet to be adequately developed. (Horton, . . . both meaningful response units and . . . their
1979, p. 21) controlling variables. Behavior is defined functionally,
in relation to its present controlling variables (both en-
Relative to neuropsychology and behavior ther- vironmental and organismic) and to its responsiveness
apy, the cardinal element of the preceding statement to intervention strategies.
is that neuropsychological data are hypothetical con-
structs. Therefore, neuropsychological data, because Along these lines, it might be stated that con-
they are hypothetical constructs, are in a different temporary behavior therapy has been characterized
class of elements from intervening variables. Be- by an evolving clinical acumen. A portion of the
cause of these differences, it might be argued that the increased sophistication in behavior therapy might be
inclusion of hypothetical constructs in the behavioral attributed to improved behavioral assessment tech-
paradigm has markedly different implications from niques. Indeed, in the last decade, there has been a
the inclusion of intervening variables. It is, of tendency to increasingly focus on the assessment as-
course, understandable that rejection of intervening pects of behavior therapy. Nelson (1983), for exam-
variables by the S-R model of behaviorism at the ple, stated that behavior therapy, to an increasing
time of John B. Watson (1913), and when B. F. degree, is defined by the techniques used. For exam-
Skinner (1938) did his early work, was a rational ple, some authorities in the field of behavior therapy
decision based on the inability of neuroscience to would classify "self-monitoring" as a clearly behav-
contribute to a functional analysis of human behavioral technique, while at the same time holding that
ior. With respect to hypothetical constructs and neu- the Minnesota Multiphasic Personality Inventory
roscience, however, there has been an explosive rate (MMPI) is clearly nonbehavioral (Hayes & Zettle,
of development over the decades. As noted by Hor- 1980). A difficulty with this assertion, however, is
ton (1979): that it is quite arbitrary, not to mention its nonem-
pirical nature (Horton & Puente, 1986).
Now, however, it could be observed that the knowl- It would appear that some better method of clas-
edge base of brain-behavior relationships has changed
sifying particular techniques as behavioral or non-
drastically since the days of Watson. At the time,
behavioral might be found. Interestingly, Hayes and
Neuropsychology was unable to provide even rudimen-
tary guidance for research minded behaviorists. Clear-
Zettle ( 1980) discussed a particularly progressive
ly, the most appropriate strategy has a benign neglect of conceptual model. Their paradigm is based on the
the area. Today, however, is a drastically different sit- distinctions between conceptual (how to talk about
uation. In the last 20 years, the knowledge base of techniques) and technical (how to perform tech-
brain-behavior relationships has increased geo- niques) dimensions of behavioral assessment and
metrically (Davison, 1974). Cross-cultural research treatment. They postulated that the most reasonable
has provided such impressive validation of Neuro- guideline is to favor conceptual as opposed to tech-
psychological insights that it would appear difficult to nical dimensions when attempting to distinguish be-
minimize their importance (Luria, 1966; Hecaen &
tween whether or not a technique can be discussed in
Ajuriaguerra, 1964; Faglioni, Spinnler, & Vignola,
terms of behavioral principles. Strictly speaking,
1969) of Neuropsychological factors, it would seem
that the time for their inclusion in an enlarged behav-
who devised the technique or the topographical de-
ioral paradigm is at hand. (Horton, 1979, p. 22) tails of the procedure are not relevant to the decision
of whether or not the technique is behavioral. The
Although the ultimate test of the above remarks major point is that both the antecedents and conse-
is of necessity empirical, it should be clear that quences of an act must be viewed in order to deter-
neuropsychological factors are accessible to mea- mine what the purpose of the action was. The simple
surement and therefore cannot be dismissed on the physical details matter little except to the degree they
grounds that they are unscientific. enable one to deduce the intended purpose of the
A related but clearly independent conceptual is- action under study. In short, if it is possible to talk
sue might be mentioned at this point. That is, how do about a method in terms of behavioral principles, and
contemporary views of behavioral assessment and the methods yield outcomes that can be objectively
treatment blend with behavioral neuropsychology? assessed, then it is behavioral.
524 CHAPTER 28
The above conceptualization of behavior thera- At this point, some consideration should be
py has some implications for behavioral neuropsy- given to the goals of treatment planning. Many treat-
chology. For example, as noted by Horton (1981): ment programs focus on either restitution of desired
If behavior therapy is defmed in a conceptual sense,
behavior or amelioration of undesired behavior. An
then clinical Neuropsychological assessment instru- assumption of this approach is a rigid localization
ments such as the Halstead-Reitan Neuropsychologi- model of brain-behavior relationships (Horton &
cal Test Battery or the Luria-Nebraska Neuropsychol- Puente, 1986). The result is a treatment program
ogkal Test Battery can be classified as "behav- focused on patient deficits. The actual value of this
ioral." ... If the most appropriate goal of behavior orientation has been questioned. Reynolds (198lb)
therapy is a "clinical science based upon clinical real- and others have suggested that a more powerful ap-
ities" (Hayes & Zettle, 1980), then it would appear that proach would be to focus on the child's strengths
a conceptual view would be preferable. Thus, a Neuro- rather than weaknesses. Horton, Wedding, and Phay
psychological perspective could be integrated into such
( 1981), as well as Horton and Miller ( 1985), provide
an enlarged and clinically realistic behavioral para-
digm. Whether or not such a blend of Neuropsychology
extended discussions of this issue and due to space
and behaviorism proves a potent addition . . . remains limitation, those discussions will not be repeated
an empirical question, which in the best tradition of here. Simply put, it is suggested that focusing on
behaviorism should be objectively tested. (p. 369) strengths is the best way to maximize treatment
efficacy.
Therefore, if the necessary empirical basis can
be amassed, then a neuropsychological perspective
could be profitably subsumed into a sophisticated and
augmented contemporary behavioral model. Treatment Strategies
Neuropsychological Issues Lewinsohn's Model

Important considerations relative to planning Over a number of years, Peter M. Lewinsohn at
behavioral treatments for brain-impaired children in- the University of Oregon Neuropsychology Clinic
clude consideration of the context of neurological has made impressive research contributions to the
development and appreciation of the behavioral se- literature on the remediation of memory deficits in
quelae of neuropsychological impairment. Regard- brain-damaged persons (Lewinsohn, Danaker, &
ing developmental neuropsychology, Miller (1984), Kikel, 1977; Galsgow, Zeiss, Barrera, & Lewin-
after reviewing the infrahuman research, observed sohn, 1977). As part of this research effort, Lewin-
that in all cases, a specific recovery pattern should be sohn, with his associates and doctoral students, has
expected and that the more practical the skills, the developed a valuable model for clinical work with
less impaired they are, as a general rule, and that neuropsychologically impaired persons that is likely
children show plasticity of neural and behavioral to work well in conceptualizing interventions with
functions. Perhaps most important, Miller (1984) children. The model is divided into four steps: the
concluded that intervention, particularly early inter- first two steps are concerned with assessment and the
vention, appeared to facilitate recovery of function. second two steps deal with treatment:
Another issue is the behavioral effects of neural
I. General assessment of neuropsychological
dysfunction. At least one group of authors (K.lonoff,
functioning
Crockett, & Clark, 1984) has concluded that there is
2. Specific assessment of neuropsychological
a significant relationship between environmental fac-
functioning
tors and brain injury and that the sequelae of brain
3. Laboratory evaluation of intervention tech-
injury are related to age with younger children show-
niques
ing emotional and personality changes and older chil-
4. In vivo application of intervention tech-
dren displaying learning and memory difficulties.
niques
Horton and Puente ( 1986) concluded that:
The following paragraphs will discuss each
. . . treatment planning should take into consideration
environmental factors such as actual physical environ-
step. Regarding the first step, usually standard neuro-
ment as well as family structure in order to minimize psychological batteries are used. For example, one
future occurrences of Neural impairment as well as to might use an age-appropriate Wechsler Intelligence
maximize the general ability of the office or institution- Scale, the Kaufman Assessment Battery for Children
based treatment program. (K-ABC), the age-appropriate Halstead-Reitan
Neuropsychological Test Battery, the Reitan-Indi- ety of situations and the technique may need to be
ana Neuropsychological Battery, or the age-appro- practiced until it becomes an automatic response to
priate Luria-Nebraska Neuropsychological Battery. emotional stimuli.
The purpose of the first step is to obtain normative Therefore, it can be seen that Lewinsohn 's para-
psychometrics. This enables a comparison of the pa- digm provides a robust model for conceptualizing
tient with other patients on the basis of descriptive clinical behavior therapy with the brain injured. The
statistics. This promotes a global understanding of overall framework of general and specific assessment
the patient's problem. with specific intervention in a controlling setting fol-
By contrast, the second step focuses on person- lowed by generalization to the real world can be
alized understanding of the patient's problem. Spe- adapted to multiple techniques and assessment de-
cifically, the intent is to examine in detail the precise vices. Indeed, the range of quantitative and
details of the patient's problem. For example, in qualitative measuring devices is only limited by
using the WISC-R Picture Arrangement subtest, it is ingenuity.
possible to obtain a standard score. That is, the use of To illustrate some of these considerations,
normative comparison as the standard score can be Goldfried and Davison ( 1976) proposed a framework
compared to other children in the normative popula- that overlaps with steps two and three ofLewinsohn 's
tion with great accuracy. To develop a more intuitive model. To provide a measure of conceptual depth,
understanding of the child's deficits, the child might some attention will be devoted to explicating the
be requested to verbalize what story he or she can Goldfried and Davison paradigm.
make out of the pictures and then progressively more In order to account for maladaptive behavior,
help can be given the child or prompts can be used. Goldfried and Davison proposed four types of impor-
By using this dynamic approach, a better understand- tant variables:
ing of the actual dimension of the child's deficits can
1. Stimulus antecedents
be elucidated, which is often different than that
2. Organismic variables
reached by normative psychometrics. In the second
3. Response variables
step, the emphasis is on interindividual comparisons.
4. Consequent variables
The risk of the second step, of course,. is that the
examiner will overinterpret the findings. On the other Essentially the paradigm is a liberalization of
hand, the advantage is great flexibility to investigate the classical S-R model of radical behaviorism. To
the actual S-R dimension of the problem behavior the traditional framework, the variables of "orga-
and conduct a functional analysis of the behavior nismic" (perhaps it could be suggested that in addi-
deficit. tion to other physiological factors, neurological
In the third step, the focus is on a controlled (or factors are included in this category) and "conse-
laboratory) setting. There, specific intervention tech- quents" (the roles that reinforcing and punishing
niques are introduced to deal with the problem behav- events play in determining the frequency of human
ior identified and defined in the first two steps. To actions (Skinner, 1981) are so well documented as to
extend the example of talking out loud to pictures of need no further explanation here) are added. The
the Picture Arrangement subtest of the WISC-R, one resulting model enables one to more adequately con-
technique might be to train verbal self-instruction to a ceptualize the various domains that need to be con-
variety of predesigned problem situations (i.e., sidered in an enlightened behavioral assessment
puzzles, role-playing). After intervention effective- model.
ness can be demonstrated, efforts toward generaliza- In order to futher develop this line of reasoning,
tion of the techniques might be initiated. it would be appropriate to devote some consideration
In the fourth step, the effective intervention to treatment planning issues. Due to space limita-
strategy of the laboratory is introduced to the real tions, these remarks will of necessity be quite con-
world. Clearly, there are major differences between a cise. More elaborate discussions are available else-
strategy working under a controlled laboratory situa- where (Horton & Wedding, 1984; Golden, 1981;
tion and a strategy working in the real world. Addi- Luria, 1963; Miller, 1984; Horton & Sautter, 1986).
tional adjustments, alternatives, and possible aug- Some issues selected for discussion might include the
mentations of treatment strength may be necessary, following: (1) self-efficacy, (2) personality x treat-
as well as rearrangement of environmental stimuli ment interactions, and (3) available resources for
and contingencies. Extending the example used ear- support.
lier, the patient might need to be trained to initiate Regarding self-efficacy, this notion was first
his/her verbal self-instructional technique to a vari- proposed by Albert Bandura (1982). He suggested
526 CHAPTER 28
that how a person perceives his or her personal effec- University and his colleagues have pioneered a cog-
tiveness is a major factor in accounting for a degree of nitive-somatic typology of anxiety-reducing ac-
therapeutic behavior change. To a large measure, tivities. Some clients/patients/subjects do better with
Bandura would assert that behavior change tech- relaxation as their anxiety is somatic based; others do
niques that work do so by the mechanism of inducing better with meditation as their anxiety is cognitively
and increasing an individual's self-estimate of effec- based. Interestingly, those with mixed cognitive-
tiveness. This personal belief system influences ac- somatic symptoms do best with active sports that
tivities chosen as well as the amount of the per- appear to involve both cognitive and somatic
sistence of effort when aversive consequences are dimensions.
encountered. In Bandura's initial formulation of the The availability of resources is the next topic for
concept of self-efficacy, he postulated that four data discussion. This refers to both the environmental
sources influenced these beliefs. Stated in a some- characteristics of the treatment setting (institutional
what oversimplified fashion, they are as follows: and/ or community based) as well as personal and
family qualities. In some cases, the skills of the thera-
1. Successful personal behavioral performance
pist(s) and referral sources might qualify. It has been
2. Observing successful performances by
well documented (Diller & Gordon, 1981) that fami-
others
ly members can serve as mentors and therapists and
3. Personal status of physiological arousal
their availability in these roles can be crucial. Also,
4. Verbal persuasion
selection of therapeutic techniques is related to the
These data sources are stated in the order of their ability of institutional and/ or community treatment
presumed potential for successful modification of settings to provide follow-up. It is of little value to
self-efficacy beliefs (i.e., personal behavioral perfor- propose a treatment modality that is impractical to
mance is the most powerful, verbal persuasion is the implement.
weakest). In summary, analysis and intervention utilizing
Some implications of self-efficacy for treatment the aforementioned models (Lewinsohn, behavioral
planning might be mentioned at this point. It should assessment and treatment planning) would appear to
appear clear that if possible, in vivo behavioral per- provide a robust paradigm for a successful behavioral
formance would be the preferred therapy mode. In neuropsychology program for children.
dealing with brain-injured children, the use of perfor-
mance-based feedback may, of course, be difficult
and the necessity for special facilitative conditions Guidelines from Behavioral
and assistance devices should be encouraged. In in- Neuropsychology
stitutions where successful personal behavioral per-
formance is impossible to arrange, the observance of Although the generation of behavior therapy in-
successful performances by others and so on should terventions for brain-impaired children is no easy
be used. If one can propose that motivation for task, some rudimentary suggestions might be gar-
change is related to the reinforcement for performing nered from careful if cursory attention to basic neu-
an action times the individual's assessment of the roanatomical dimensions. The neuro-cortex has been
likelihood of accomplishing the action successfully, described by Meier (1974) as consisting of three pri-
then it would appear wise to do all things possible to mary parameters:
increase subjectively assessed probabilities of suc- l. Left to right
cess. Simply put, personal predictions of success- 2. Front to back
ful performance are crucial factors in treatment 3. Top to bottom
planning.
Similarly, personality x treatment interactions Put another way, Horton and Wedding (1984),
deserve careful scrutiny. Personality x treatment in- in consideration of Meier's (1974) conceptualiza-
teractions are client/patient/subject characteristics tion, termed the left to right parameter as "later-
that influence the success of particular therapeutic ality," the front to back parameter as "caudality,"
methods. One example might be a client/ patient/ sub- and the top to bottom parameter as "dorsality." It
ject's personal standards for self-reinforcement should be well understood that these terms are util-
(Goldfried & Davison, 1976). Those with very high ized in a special context in this discussion. Similarly,
standards might be given relatively easy therapeutic the parameters are intended to illustrate very general
goals as any failure experiences might destroy moti- and rudimentary concepts and there is an extreme
vation for change. Similarly, Gary Schwartz of Yale degree of oversimplification. Knowledgeable schol-
ars could find multiple and valid exceptions by the tional interventions, emotional correlates, and prog-
score to this framework, but for the sake of concep- nostic predictions for three neuropsychological
tual communicative ease, the above framework will subtypes. In Table I, the neuropsychological profiles
be used. In addition, the following suggestions pre- for children are presented.
suppose circumscribed and localized cerebral insult. As can be seen from Table 1, Hartlage sees type
Hopefully, these suggestions will serve as hypoth- I children as exhibiting 'left hemisphere dysfunctions,
eses for future research that will enable the genera- type II children as typifying right hemisphere dys-
tion of more valid and generalized understanding of function, and type III children as demonstrating dys-
the delicate interplay of neuropsychology and behav- function of both cerebral hemispheres. It should be
ior therapy. well understood that Table I is a gross over-
simplification of the extremely complicated and
complex clinical reality. At the same time, this over-
Laterality simplification still is an attempt at general rules for
rational behavioral intervention procedures selec-
Perhaps no other single concept has generated tion. Even with rather dramatic limitations, it dem-
more research in American neuropsychology than onstrates some incremental validity over a random
that of laterality. The notion of laterality in the human trial-and-error procedure. As more specific under-
brain has been so well accepted that it has become the standings develop from the current research efforts in
stuff of popular culture. In terms of treatment plan- child neuropsychology, rather drastic modification
ning, Horton and Wedding (1984) observed that: of Table 1 will certainly be expected.
The two cerebral hemispheres process information in
different ways. Assuming right handedness, the left
hemisphere is logical and language oriented, while the
Caudality
right hemisphere is intuitive and concerned with spatial
aspects of stimuli. (p. 216)
This dimension refers to localized cerebral im-
pairment on the front to back or, put another way,
Similarly, Reynolds (l98la) noted that: anterior-posterior axis. Horton and Wedding (1984)
noted that:
For the vast majority of individuals, the left cerebral
hemisphere appears to be specialized for linguistic,
There is some agreement that the frontal lobes involve
propositional, serial, and analytic tasks, and the right
the planning, execution, and verification of behavior
hemisphere for more nonverbal, spatial, appositional,
while the posterior sections are involved with the re-
synthetic, and holistic tasks .... It is most important
ception, integration, and analysis of sensory informa-
to remember that cerebal hemispheric asymmetries of
tion .... (p. 219)
function are process-specific and not stimulis-specific.
(p. 109)
The frontal lobes, of course, have been a topic
Horton, Owens, and Hartlage (1980) observed of great interest in cognitive neuropsychology. Given
that modes of communication, therapy tasks, and the wealth of material, no attempt to condense it will
therapeutic management may all be influenced by be ventured here. Rather, interested readers are en-
hemispheric mental asymmetry. To cite but a single couraged to examine a recent paper that reviews the
example, many clinicians and researchers (Broder, behavioral effects of frontal lobe lesions and the at-
1973; Hartlage, 1975; Mattis, French, & Rabin, tendant emotional and psychological consequences
1975; Pirozzolo, 1981) have argued eloquently and (Struss & Benson, 1984). It might be mentioned,
presented data suggesting the existence of subtypes however, that it has long been recognized that frontal
of children with reading disabilities. Also, they have lobe impairment is of particular clinical significance.
indicated a consensus that neuropsychological as- For example, Luria (1966), in discussing his efforts
sessment is important to identify reading disability at the rehabilitation of brain-injured veterans of
subtypes and in guiding appropriate educational in- World War II, mentioned that those with frontal lobe
tervention. Of particular interest is that the two most impairment were rarely able to leave even a sheltered
common reading disability subtypes have auditory- workshop setting. It would appear that impairment of
linguistic and visuospatial elements (Pirozzolo, the frontal cortex is particularly dolorous for self-
1981 ). Hartlage ( 1975) has been among the leaders in management skills. Indeed, Horton and Wedding
this area of research and clinical practice. In his ( 1984) postulated that whether or not a lesion is in the
work, he has devised a conceptualization of hemi- frontal area is more important for predicting overall
spheric mental asymmetry with respect to educa- behavioral adjustment than even the overall extent of
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TABLE 1. Basic Neuropsychological Profiles for Childrena
Type I child Type II child Type III child
Neuropsychological profile Comparatively lower WISC-R Verbal Comparatively lower WISC-R Perfor- No consistent pattern of WISC-R
than Perfonnance IQ score with con- mance than Verbal IQ and con- strengths and weaknesses or clear
sistently lowered language ability sistently lowered perceptual-motor superiority of either language or per-
(i.e., depressed ITPA and PPVT ability relative to language skills ceptual-motor abilities and skills
scores) relative to perceptual motor
skills (i.e., Bender-Gestalt or VMI)
Neurological syndrome Left hemisphere dysfunction Right hemisphere dysfunction Generalized cerebral dysfunction
Emotional correlates Reserved, tentative, and uncertain of Impulsive and uncritical of personal Restless, irritable, and hyperactive
self-efficacy performance
Educational intervention Whole word or look-say reading pro- Linguistic and aural instruction modes Extreme structure and special place-
grams and perceptually oriented in- ment
structional modes
Prognosis Persistent problem during academic ca- Difficulty in early school grades (K-2) Little ultimate academic success
reer (after 3rd grade) but relatively but tend to do better in later elemen-
good adjustment in nonacademic tary grades (3-6) with generally suc-
pursuits cessful academic career
Adapted from Hartlage (1975).

brain impairment on objective measures of neuropsy- explained by the triune brain model of Paul MacLean.
chological functioning. (p. 220)
With respect to therapeutic implications with
children, there appear to be a number. One example
might be the use of Meichenbaum's (1977) self-in-
structional therapy to increase self-management Empirical Considerations
skills for frontally impaired children. It might be of
great interest to utilize developmentally appropriate In this section, research on the use of behavior
methods like the turtle technique (Schneider & modification/therapy techniques with children will
Robin, 1976). In a study with an adult with frontal be selectively reviewed. It is worth noting that the
lobe impairment, Horton (1984) utilized the turtle behavior modification/therapy literature, in general
technique, a method for the self-control of impulsive (i.e., adults and children), has been reviewed before.
behavior, to decrease temper outbursts. Because that lnce ( 1976) surveyed the use of behavior modifica-
case report was an extension of a technique originally tion with brain-injured persons in a review that was
developed for children with an adult, it would be noted by Diller and Gordon (1981). Similarly, Hor-
interesting to attempt the method with a brain-injured ton (1979, 1982) has twice surveyed the research
member of the population the technique was de- literature regarding the application of behavior thera-
signed for. PY with brain-damaged individuals. More recently,
Horton and Miller (1985) again surveyed this re-
search literature and found an increasing trend to-
Dorsality ward using behavior modification/therapy with
brain-damaged individuals. Table 2 is adapted from
This dimension is the vertical axis. Put another the review of Horton and Miller ( 1985) that focuses
way, dorsality refers to the top to bottom parameter exclusively on behavior modification/therapy stud-
of the brain. There is some theoretical (MacLean, ies with brain-damaged children from 1967 to 1984.
1973) and experimental work (MacLean & Delgado, A few limitations of Table 2 might be mentioned
1953) to suggest evolutionary distinct layers of brain at this point. First, although the available literature
tissue. Although there has been relatively little atten- was reviewed, Table 2 is, for the most part, a selec-
tion devoted to this dimension by clinical neuropsy- tive review and no claim of comprehensiveness is
chologists insofar as their test batteries are con- made. Also, studies focusing on biofeedback were
cerned, (Meier, 1974; Horton & Wedding, 1984), not included. Although it is clear that biofeedback is
there is considerable theoretical interest by work- often considered part of behavior therapy, it was de-
ers concerned with the neurobiology of aggression cided to focus primarily on more specifically operant
(Bear, 1986). In this light, Paul MacLean's theory of interventions as the biofeedback literature has been
the triune brain appears most insightful. competently reviewed many times by others. It is felt
There is, however, a dearth of well-accepted this more focused review will serve to highlight the
treatment implications. Horton and Puente (1986) value of the more classical behavior therapy tech-
observed: niques with children. Also, for the most part, studies
focused on structural brain damage rather than learn-
The clinical implication is that the depth of brain-im- ing disabilities.
pairment could have great relevance. It should be freely Inspection of Table 2 reveals a number of in-
admitted that at present, the knowledge of brain-be- teresting points. Of the 19 studies, only Dean ( 1984)
havior relations, relative to dorsality, is not adequate
and Denton and Citron (1983) were group design
enough to generate many meaningful treatment sug-
gestions for impairment to developing brains.
studies. Two were group case studies-Carlin and
Armstrong (1968) and Salzinger, Feldman, and Port-
Perhaps one of the few valuable suggestions is noy (1970); and three were single-subject design
one advanced by Horton and Wedding (1984): studies (i.e., multiple baseline or ABAB design)-
Campbell and Stramel-Campbell (1982), Gajan,
When there are cortical lesions, there are often con- Schloss, Schloss, and Thompson (1984), and Muir
comitant personality changes. It is also commonly ob- and Milan (1982). The remainder appeared to be case
served the premorbidly controlled antisocial character studies. The types of brain-damaged patients treated
traits of brain-damaged individuals are released after included closed head injury, cerebral palsy, and Hun-
the onset of the brain injury. This syndrome might be tington's chorea, among others.
(11
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~
TABLE 2. Selected Behavior Modification/Therapy Studies with Childrena.b

Author Population Method Remarks
Blyth (1969) Brain-damaged children Social reinforcement and stimulus con- Improved behavior
trol and token economy
Brannigan & Young (1978) 13-year-old male with minimal brain Social skills training Better social function and emotional
damage control improved
Campbell & Stremel- 10-year-old male with cerebral palsy; Social praise, repetition of child's re- Language generalization facilitated
Campbell (1982) multiple baseline design sponses, answers to child's ques-
tions, and a token
Carlin & Armstrong (1968) Four boys-two with brain damage; Token rewards and fines Improved social responsibility
group case study
Cinciripini, Epstein, & 7-year-old male with cerebral palsy; Overcorrection for self-stimulation and Behavioral treatment reduced self-
Kotanchik (1980) single-case design differential reinforcement of atten- stimulation and increased attention
tional responses and behavior in-
compatible with self-stimulation
Dean (1984) Ninety learning-disabled (reading dis- Following neuropsychological assess- Group design with significant im-
order) males, average age 10.6, ment of strengths, a hierarchy of re- provement in area of academic defi-
range 9-13; group design study medial tasks was constructed along cit and classroom behavior
an approach-avoidance continuum
and differential levels of reinforce-
ment were established
Denton & Citron (1983) Twenty adolescent males-seven with Cognitive behavioral treatment for im- Improved self-control
closed head injury; group design pulsivity
study
Gajan, Schloss, Schloss, & Two head trauma youths; ABCACB Light signal feedback versus self- Social interaction gains generalized to
Thompson (1984) design monitoring less structured situations
Gerber, Major, Adams, & 16-year-old male with traumatic closed Operant reward contingencies with Increases on Raven's progressive ma-
Spevack (1981) head injury; case study motorcycle pictures as rewards for trices and subscales of Pictorial Test
performing cognitive stimulation of Intelligence
exercises
Hall & Broden (1967) Three children with central nervous Social reinforcement Children improved in target behaviors
system dysfunction
Krop (1971) 8-year-old brain-damaged, emotion- Reinforcement (praise and/or candy) Reduced hyperactive behavior
ally disturbed male; case study
Krumchy & Kores (1971) Neurologically impaired pediatric in- Reinforcement (praise standing and Decrease in inappropriate behavior and
patients using binoculars) improved appropriate behavior
Muir & Milan (1982) Three children-two with cerebral Parents reinforced for child's progress Children improved in language skills
palsy and one with developmental with lottery tickets
delay and seizure disorder; ABAB
design _
Murray (1978) Brain-damaged children; case study Time-out procedure Tantrum behavior controlled
Reidy (1979) 7-year-old male with brain damage Verbal commands, praise, and manual Appropriate acting behavior was learned
guidance and generalized to home and school
Ribes-Inesta & Guzman 14-year-old female with deep brain Time-out, electric shock, and slaps Reduced behavior of placing nonedi-
(1974) lesion; case study bles in mouth
Salzinger, Feldman, & Twenty-three families with brain- Parents instructed in behavior modifi- Parents who carried out the program
Ponnoy (1970) damaged children (56% females, cation techniques reported success in changing their
44% males); group case study child's behavior Q
Sellick & Peck (1981) 28-rnonth-old male with cerebral palsy; In vivo behavioral flooding/extinction Decreased fear of physical insecurity
case study and positive generalization
6
Waye (1980) 16-year-old female with Huntington's Time-out contingencies and positive Decreased temper outburst and public
chorea reinforcement disrobing
Adapted from Horton and Miller (1985).
hSee the original for all references.
I
I
B
~
532 CHAPTER 28
In summary, the research literature on the use of The author's contributions to this chapter were made
behavior modification/therapy techniques with chil- in his private capacity and without support or en-
dren is still in an early stage of development. Perhaps dorsement by the Veterans Administration.
it's best to recall words written at the conclusion of an
earlier review: References
A limitation of this literature is the generally neu-
rologically simplistic adaptation of behavioral treat- Bandura, A. (1982). Self-efficacy mechanism in human agency.
ment methodology. Only recently have more sophisti- American Psychologist, 37, 122-147.
cated applications been attempted. . . . Still, the Bear, D. M. (1986, May). Hierarchical neurology of human ag-
uniformly positive results suggest great promise in this gression lecture presented to the Baltimore-Washington
area for future application. (Horton, 1982, p. 101) Neuropsychology Group meeting, Bethesda, MD.
Broder, E. (1973). Developmental dyslexia: A diagnostic ap-
proach based on three atypical reading-spelling patterns. De-
velopmental Medicine and Child Neurology, 15, 663-667.
Conclusions Campbell, C., & Stremel-Campbell, K. (1982). Programming
"loose training" as a strategy to facilitate language gener-
Recent years have witnessed impressive growth alization. Journal of Applied Behavior Analysis, 15, 295-
in neuropsychology. All expectations are for even 301.
more dramatic growth in neuropsychology in the next Carlin, A. S., & Armstrong, H. E. (1968). Rewarding social
decade. This chapter has reviewed the status of a responsibility in disturbed children: A group play technique.
subfield of neuropsychology-behavioral neuropsy- Psychotherapy: Theory, Research and Practice, 5, 169-174.
Craighead, W. E., Kazdin, A. E., & Mahoney, M. J. (1976).
chology. More to the point, attention was devoted to
Behavior modification: Principles, issues and applications.
the ability of behavioral neuropsychology to deal
Boston: Houghton Mifflin.
with the mental, emotional, and behavioral problems Dean, R. S. (1984, August). Treatment of learning disorders with
of brain-damaged children. neuropsychological impairment: A behavioral approach. Pa-
First, there is evidence that behavioral methods per presented at the American Psychological Association
are effective with brain-damaged children. Second, meeting, Toronto, Canada.
the value of neuropsychological assessment to select Denton, A., & Citron, C. (1983, August). The development of
behavior modification/therapy techniques is an area group intervention strategies for impulsive adolescents with
that will require much additional research. In truth, cognitive and language deficits. Paper presented at the annual
the majority of the research is at a case study or meeting of the American Psychological Association, Ana-
single-case design level, and there is clear need for heim, CA.
Diller, L., & Gordon, W. A. (1981). Interventions for cognitive
well-controlled and methodologically sophisticated
deficits in brain-injured adults. Journal of Consulting and
treatment group design research. Clinical Psychology, 49, 822-834.
It is clear that the final assessment of behavioral Faglioni, P., Spinnler, H., & Vignola, L.A. (1969). Contrasting
neuropsychology with children will rest on its ability behavior of right and left hemisphere-damaged patients on a
to solve the mental, emotional, and behavioral prob- discriminative and a semantic test of auditory recognition.
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value in this effort. Although much additional re- cational help or hindrance? School Psychology Review,
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Gajan, A., Schloss, P. J., Schloss, C. N., & Thompson, C. K.
efforts were somewhat successful.
(1984). Effects offeedback and self-monitoring on head trau-
Finally, as Horton (1982) observed:
ma youths' conversational skills. Journal of Applied Behav-
. . . It is clear that much additional work must be ioral Analysis, 17(3), 353-358.
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should be noted that the field of therapy for the brain- damaged individuals. Journal of Clinical Psychology, 33.
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29
Coping and Adjustment of Children

with Neurological Disorder
TIMOTHY B. WHELAN AND MARIE L. WALKER
Introduction developmental crises, the presence of neurological

impairment may force children and their families to
The opportunity to test the limits of one's question their fundamental assumptions and expecta-
clinical acumen is clearly apparent in the field of tions about themselves and their world, and to react
clinical child neuropsychology. The explosion of re- to or "cope" with multilevel effects of the disorder.
lated theory and research, the complexity of case It is therefore apparent that the helping professional
material, and the growing demand for applied exper- concerned with the psychological well-being of chil-
tise continue to challenge us daily. Indeed, the study dren must remain cognizant of the nonbiological sys-
of developmental brain-behavior relationships can tems with which children interface.
be so intrinsically fascinating, so alluring, that many This chapter is concerned with multiple systems
of us cannot imagine being satisfied in another do- affecting the coping and adjustment of children with
main of study. Yet there may be a subtle trap in all of neurological disorder. Investigation of this topic
this, the trap of becoming so enthralled with explor- often leads to psychological literature that is concep-
ing brain-behavior relationships in isolation that we tually relevant but somewhat apart from traditional
lose sight of tpe total experience of the child. neurodiagnostically oriented neuropsychology. For
It is the premise of this chapter that not only do instance, social psychologists investigating coping
children and adolescents who have sustained an in- mechanisms have primarily been concerned with
sult to the brain face the likelihood of altered brain adults, and the pediatric psychology literature re-
function and its attendant problems, they must also garding coping with neurological disorders is not
contend with the effects of neurological disorder in a highly developed. However, despite variation in spe-
social context. In other words, like children with cific targets of study, ''good practice'' in the area of
chronic illnesses, they may face severe developmen- clinical child neuropsychology requires a continual
tal challenges during diagnosis, hospitalization, integration of theoretical and applied information
medical intervention, rehabilitation, schooling, fam- from the domains of clinical child, developmental,
ily development, and socialization. As a conse- educational, social, and family psychology. A relat-
quence, there is the risk throughout the course of the ed point was made by Boll (1985) who described a
disorder for the creation of secondary deforming ef- ''threshold'' movement within the field of neuropsy-
fects on psychosocial adjustment in addition to the chology toward a more psychological emphasis:
primary cognitive, sensory, and motor changes com-
In addition to the utilization of behaviors for exquisite
monly associated with these disorders. As with the neuroanatomical appreciation which represents a con-
victims of other diseases, accidents, or undesirable tinuing and legitimate investigational area, neuropsy-
life events who are faced with major personal and chologists provide, with increasing sophistication,
psychological descriptions designed primarily to help
in understanding the whole person, rather than being
confined only to the person's neuroanatomy. (p. 474)
TIMOTHY B. WHELAN Department of Psychiatry,
Bay State Medical Center, Springfield, Massachusetts As detailed below, mechanisms of coping and
01199. MARIE L. WALKER Department of Educa- adjustment in neurologically impaired children are
tional Psychology, University of Texas, Austin, Texas 78712. perhaps best viewed globally from developmental
535
536 CHAPTER 29
and systems-theoretic models of child psychology. of nonbiological systems in the lives of neu-
After a discussion of this conceptual framework, rologically impaired children, however, is virtually
general considerations regarding the constructs of mandatory. Children do not exist in isolation from
coping and adjustment are presented. Further topics others as adults can choose to do. Rather, they are
related to the coping and adjustment of neu- enmeshed in nonself systems to a far greater extent,
rologically impaired children are then selectively re- influencing and being influenced by family, peers,
viewed and provide a flavor of the complexity of health professionals, and schools. One cannot even
related theory and practice. approximate a clear clinical description, however el-
egant, of a child without reference to relationships
between that child and those with whom they are
General Systems and Developmental Models bound.
An additional dimension of complexity must be
A conceptual framework for studying the pro-
added to the clinical child neuropsychologist's sys-
cesses of coping and adjustment in neurologically
tems-theoretic model: the process of development
impaired children can be derived from general sys-
and change. Although the notion that the individual is
tems theory, a general science of "wholeness" ex-
an active, developing organism is a fundamental con-
amining sets of elements standing in interrelationship
cept among child development and life-span psychol-
(von Bertalanffy, 1968). The systems-theoretic
ogists, neuropsychological literature has historically
model posits that the human organism exists in a
neglected this aspect of our functioning (Parsons &
hierarchy of systems, ranging from the biological
Prigatano, 1978; Smith, 1979). Walter Riese (1977)
realm, through cognitive, intrapsychic, and behav-
captured the problem aptly:
ioral levels of analysis, to the family and social
spheres. This is an information flow-through model Overpowered by the ever-increasing intricacies of ana-
in which developments at one level theoretically have tomical arrangements, ... yielding in this self-in-
ramifications throughout the systems hierarchy. flicted intellectual emergency to the always threatening
Whereas von Bertalanffy has perhaps been most elo- danger of oversimplification, the modern student of
brain lesions forgot that every functional disturbance
quent in expressing the systems approach, these cen-
has its natural or evolutionary history. Whether af-
tral tenets are not unfamiliar to scientists in general fected by neurosis, psychosis or brain injury, man must
and they have appeared in the writings of seminal write the history of his new condition which implies the
thinkers in the history of neuropsychology. For in- history of his whole life. Nobody, healthy or not, can
stance, more than 45 years ago Kurt Goldstein ( 1939, escape the law of time and change. (p. 77)
1940) concluded that any particular symptom dis-
played by a patient could not be easily understood as The particular need for consideration of developmen-
being uniquely the product of a specific lesion or tal issues in child health psychology has been well
disease, but instead had to be considered as a man- described by Maddux, Roberts, Sledden, and Wright
ifestation of the total organism that behaved as a (1986).
unified whole. This, then, is the model: the child is concep-
General systems theory has also been cited in tualized on multiple levels standing in interre-
support of a fundamental reorientation in medical lationship, with the hierarchy of systems set in tem-
education and practice (Engle, 1977, 1980). Such a poral motion. It would of course be extravagant to
shift in thought leads to reconceptualization of ''dis- assert that neuropsychologists can excellently or ade-
ease'' as a biopsychosocial product, and to the study quately conceptualize all of our clients in this fash-
of disease and medical care as interrelated processes. ion, but the goal of so doing seems worthy.
The reliance on such an approach is now particularly
evident in the literature on families with illness
(Gochman, 1985; Kerns & Curley, 1985; Kerns & Coping and Adjustment
Turk, 1985; Leventhal, Leventhal, & Van Nguyen,
1985) and in the field of clinical health psychology In most theoretical models, "coping" is a pro-
(Millon, Green, & Meagher, 1982). cess that is initiated when an individual perceives or
The application of a general systems approach experiences stressful stimuli, such as a change in the
to understanding the functioning of neurologically pace of life or a subjective perception of an event as
impaired adults seems reasonable and logical: disor- negative or undesirable and beyond the competence
ders of biological functioning are likely to affect an of the coping person (Chan, 1977). For example,
individual's psychosocial status. The consideration hospitalization, sensorimotor disability, or loss of
COPING AND ADJUSTMENT 537
cognitive integrity associated with neurological dis- Second, coping is a uniquely individual process
order could obviously all be considered untimely, and its exposition depends on experiential insight
unexpected, and undesirable life changes. Coping and/or observer inferences; it is not a construct that
presumably leads to adaptation or adjustment to can be measured directly. Currently, psychosocial
stressful events and perceptions, and successful cop- science relies on personality and adjustment mea-
ing implies successful adjustment. Generally, people sures, such as levels of self-esteem, depression, anx-
cope with daily stressors by responding with habitual iety, and locus of control, among others, to infer both
and automatic patterns of cognition and behavior the presence and the effectiveness of the coping pro-
(Folkman & Lazarus, 1980). Such coping strategies cess. Cognitive and behavioral components may also
may involve the cognitive functions of perception, be evaluated (Curry & Russ, 1985). Nevertheless,
memory, speech, judgment, and reality testing; though the processes of coping and adjustment are
motor activity; emotional expression; and psycholog- well understood intuitively, they remain scien-
ical defenses (Mattsson, 1972). When these custom- tifically and empirically vague.
ary automatic responses become unavailable, indi- Third, it should be noted that coping and adjust-
vidual attempts at coping will require that old ment are processes that occur continually; they are
resources be used in new ways. This may be particu- not discrete and isolated events. People experience
larly true for children whose increasing cognitive and multiple levels of stress simultaneously, from the
behavioral abilities continually alter the effectiveness trials of getting to school or work on time, to fears of
of their previous automatic responses. Coping, then, being perceived as different or odd, and feelings of
can be conceptualized as purposeful behavioral unworthiness. Even positive changes in life events,
and/or intrapsychic activity at either conscious or such as promotions, may be experienced as stressful,
unconscious levels that serves to ameliorate the expe- and the perceived intensity of a stressor at a given
rience of stress while facilitating adjustment to time will influence an individual's attempt at coping.
stressful stimuli. Further, what may constitute successful coping be-
In relation to coping, the process of "adjust- havior at one time may change with age and other
ment" allows a return to effective (though not neces- intervening variables. Again, this is especially true
sarily prior) automatic patterns of behavior, and im- for children where constant development in their
plies that an individual is functioning effectively. abilities may render previously effective patterns of
More specifically, for the neurologically impaired coping obsolete. When neurologically based disor-
child, adjustment includes acceptance and age-ap- ganization of cognitive and affective functions are
propriate understanding of the disease or handicap; superimposed on normal developmental patterns ol
medical compliance; absence of severe psycho- organization, the complexity of these processes can
pathology; age-appropriate interpersonal functioning be magnified.
with family, peers, and in school; and "normal" Finally, coping and adjustment are processes
or age-appropriate personality functioning (Drotar, that reflect an interaction between individual and en-
1981). vironment. It has long been recognized that people
perceive stressful stimuli differently and that indi-
viduals will make unique attempts to cope with
Cautions stress, whether by flight, fight, or inaction, based in
part on personality determinants, history with coping
Although full treatment of the constructs of cop-
experiences, and environmental constraints, includ-
ing and adjustment is beyond the scope of this chap-
ing peer and societal expectations (Chan, 1977). The
ter, several considerations are in order. First, we
significance of this interaction, especially for chil-
have implied that coping is a process and adjustment
dren, is reflected in increasing research on the influ-
is an outcome of this process, and this may indeed be
ence of the family on children's abilities to cope with
the case. However, such a scheme may also be an
their handicaps.
unfair simplification of the relationship between cop-
ing and adjustment. It may also be true, for example,
that levels of adjustment influence attempts at cop- Societal Influence on Coping and
ing. For instance, high self-esteem may be an out- Adjustment
come of a child's successful attempts at coping; simi-
larly, it may be that children who already experience A paradoxical dilemma exists when one consid-
high self-esteem will be better able to cope with ers the relationship of coping and neurological disor-
stressful events. ders. Traditional definitions of coping, including
538 CHAPTER 29
those presented here, suggest that stressors such as gentleman with cerebrovascular disease who had
neurological deficits are external to the individual carefully listened to his physician's explanation of
and must be adjusted to as unwanted alien agents. regional cerebral blood flow measurement, and who
This idea originates from the societal doctrine of nor- had given his "informed consent" to the procedure.
malcy, where certain parameters of behavior are ac- During a later neuropsychological exam he wanted to
ceptable and occurrences outside of these bounds are confirm his understanding of the procedure, and said,
regarded as deviant. Deviancy is then considered un- "This is something nuclear, right? Like the bomb,
acceptable, obviating the need for a return (adjust- right?''
ment) to normalcy. Examples of well-meant yet misjudged attempts
This viewpoint can be both unfortunate and not to convey the nature of medical problems to children
entirely necessary. Children born with a neurological are also present in the literature. Whitt, Dykstra, and
deficit, for example, have always interpreted their Taylor ( 1979) mentioned the potential iatrogenic
worlds through a unique lens, and their "deficits" harm that may come from such casual statements as
are a part of their identity as surely as being phys- "the doctor will inject some 'dye' ... "(thus effec-
ically "whole" is a part of most of ours. Often, tively raising the possibility of imminent ''death'') or
however, individuals with visible physical dif- "epilepsy is excess 'electricity' in the brain" (sum-
ferences are considered "deviant" and treated ac- moning up parental admonitions regarding wall sock-
cordingly. The process of "accepting" one's hand- ets, shocks, and terminal consequences). Similarly,
icap is thus made more difficult when one is Perrin and Gerrity (1981) have written on the young
continually regarded by peers and society as pediatric patient's assumption that when the doctor
"different." says "there's edema in your belly," the "demon"
The problem we are suggesting, then, is that was sent there to punish him or her for wrongdoing;
"handicap" is defined normatively and from an the notion of a "demonic" brain could evoke even
"outsider's" perspective (Shontz, 1982). "Insid- more primitive fears.
ers," or people who have either always experienced a The pediatric literature advises that health pro-
particular state, such as neurological disorder, or fessionals consider the child's level of cognitive de-
who have come to accept their differences and/ or velopment (typically in a Piagetian sense) when con-
limitations, do not necessarily view their handicap as veying information regarding disease processes,
something to "overcome" (Massie, 1985). Once an medical procedures, and health maintenance
individual has learned to cope with a handicap, the (Brodie, 1974; Campbell, 1975; Mechanic, 1964;
deficit itself no longer remains the focus of attention. Neuhauser, Amsterdam, Hines, & Steward, 1978;
Handicapped individuals, like ourselves, must an- Palmer & Lewis, 1976). The goals of such considera-
swer the question, how does one achieve satisfaction tion include improved regimen compliance, reduced
and happiness in life, given the uniqueness of every anxiety, and enhanced understanding and acceptance
individual? Although this question is made no less of the condition by the affected child and, if also
easy by the presence of a handicapping condition, the afforded developmentally appropriate explanations,
burden might be eased if it were not necessary to feel by healthy peers.
that one had to meet the normative standards of to- According to stage theorists, children function-
day's society. ing at a preoperational level of cognitive develop-
ment (normally between ages 2 and 7) center on sin-
gle external events, which are viewed from the
child's own perspective without generalization to
Making Meaning of Neurological other situations and without the application of logical
Disorder operations. Illness prevention and recovery may thus
be associated with sets of rigid rules surrounding
"Words, words, words"-Hamlet, Act II, immediate perceptual experience and concrete action
Scene ii (avoiding the touch of sick friends; staying in bed)
(Whittet a/., 1979; Perrin & Gerrity, 1981). Bibace
Whether in the role of consultant or therapist, and Walsh (1979) proposed refinements to this gen-
child neuropsychologists are often called on to pro- eral category of cognitive development, as well as to
vide information to their clients regarding the nature categories described below. For instance, preopera-
of the neurological disorders. The process of clear tional explanations of disease are divided into the
and appropriate explanation may be problematic categories of "Phenomenism" (illness caused by
enough with adults. We are reminded of the elderly single inappropriate, external, and spatially remote
COPINC AND ADJUSTMENT 539
sources) and "Contagion" (reliance on single causes crease in the degree of perceived control the child has
of contagion transmitted through mere proximity and over illness, with a concomitant decline in the sense
manifest in a single symptom). of personal vulnerability. For example, older chil-
At the stage of concrete operations (normally dren in the Internalization phase may believe there
between ages 6 or 7 and 11 or 12), the child's thought are things they can do to maintain bodily health,
becomes less egocentric and perceptually bound, and whereas young children in the Phenomenistic phase
reasoning becomes more logical. Specification of re- may believe themselves to be vulnerable to disease
lationships among events or objects, categorical clas- causes that are spatially remote and uncontrollable.
sification, and transformation comprehension be- These points are elaborated upon by Maddux et al.
come possible. Illnesses at this time may be defined (1986) in an article on developmental issues in child
by the child as a set of multiple concrete symptoms, health behavior that focuses on prevention of illness
and are often believed to be caused primarily by and injury, and on health promotion. It would be
germs. From such a perspective, diseases may im- erroneous, however, to suggest that feelings of con-
pinge on the body unless sick people are avoided, and trol and reduced vulnerability are inevitable accom-
cures may consist of passively allowing medicines to paniments of older age or later stages of cognitive
act on the body. A clear appreciation of the self- development. Once again, children's conceptualiza-
healing aspects of bodily functioning is presumably tions of their neurological disorders are likely to
lacking in the concrete operational child. Unlike the evolve over time, with general stages of cognition
preoperational child, the concrete operational child interacting with particular informational content and
can more clearly distinguish between internal and numerous other cognitive and affective variables.
external events, though the focus remains on the lat- The suitable selection of "words" of explana-
ter. Subdivision of this stage by Bibace and Walsh tion and due consideration of the nature of the child's
includes "Contamination," in which there is recog- beliefs about disease may still be insufficient to en-
nition of multiple disease symptoms caused by con- able children to understand neurological disorders, if
crete sources such as germs, dirt, or bad behavior. only because neuropathological processes are so
The "Internalization" subdivision of concrete oper- often without visible referents. The use of metaphor,
ational thought is characterized by the ways in which perhaps aided by drawings, to provide appropriate
illnesses are internalized: swallowing or inhaling explanations of medical events may be particularly
germs or other contaminants. The body's own re- beneficial for children who have not yet attained for-
cuperative powers become recognized, and rever- mal operational thought and/ or who are not likely to
sibility (the sick person can become well, and vice have a sense of the pathophysiology of the unseen
versa) is characteristic. nervous system. For example, in the case of seizure
With the emergence of formal operations in late disorders the analogy of a telephone system has been
childhood and early adolescence, illness may be con- suggested (Whittet al., 1979). In condensed form, a
ceptualized as having complex, interrelated, and discussion with the child might refer to the notion that
multiple causes that affect multiple internal systems the brain is like a telephone that sends messages to all
and result in multiple external symptoms. Bibace and parts of the body, and just like a telephone, the brain
Walsh decompose the explanation of illness in the sometimes gets a "wrong number" by sending mes-
formal operational stage into two subdivisions: sages to the _ _ (substitute relevant perceptual
"Physiological" and "Psychophysiological." In cues, perhaps those related to the aura). In some
the former, illness is defined by the child in terms of cases it can also be pointed out that just like a tele-
internal organs and structures whose malfunctions phone after a wrong number, the brain works fine
are manifest in multiple external symptoms and there again.
is a clear departure from previous reliance on con- The same authors have also provided metaphors
cretely perceptible reality. In the psychophysiologi- for other neurological conditions. For instance, the
cal category, psychological events are included as body can be analogously described as a large city
disease symptoms as well as causes of internal dys- made up of many people (cells) with important jobs
function. The etiologies of a headache, for instance, (e.g., telephone cells, garbageman cells, doctor
may at this developmental point include too much cells, carpenter cells, police cells), and cancer cells
worry. may be described as "outlaws" in the system. Treat-
Based on this six-stage developmental se- ment may then be presented as a means of helping the
quence, Bibace and Walsh contend that not only do body's police and medical forces to establish "law
conceptions.of illness shift in characteristic ways, but and order.'' Built-up pressure in a garden hose with a
that there is also a corresponding developmental in- blocked outlet may serve as a metaphor for children
540 CHAPTER 29
with hydrocephalus, and the swelling and potential healthy siblings of diabetic children failed to perform
bursting of a balloon may foster a better understand- at the expected cognitive level in conceptualizing
ing of aneurysms (though we personally find this last illness causality and treatment when compared with
example too likely to result in fears of imminent ca- children without ill siblings matched on demographic
tastrophe to be used with most children). variables and measures of Piagetian cognitive devel-
In considering the process of aiding children and opment.
their families to better comprehend their neurological In conclusion, conflicting data in the literature
or other medical disorder, it should be remembered suggest that a child's cognitive understanding of a
that the sophistication of children's concepts of ill- neurological disorder is not likely to be entirely pre-
ness may differ from their concepts involving differ- dictable simply on the basis of their age or measures
ent content. Perrin and Gerrity ( 1981) reported that in of their level of intellectual/ cognitive development in
a sample of normal children, illness-causation con- nonillness content domains. Attempts should be
cepts (e.g., "How do children get sick?") were made to integrate such information with their histor-
slower to develop than concepts to explain physical ical experience with the disorder.
causality (e.g., "Why does night come?''). More-
over, older children may indeed be able to provide
more sophisticated explanations of illness than "Facts are the enemy of truth."-Man of La
younger children, but in a conditional sense: younger Mancha
children with a history of poorer health have the least
sophisticated concepts, whereas older healthy chil- Quite apart from the strictly cognitive aspects of
dren may have less sophisticated concepts than peers comprehension, a child's construction of the person-
of the same age who have been ill more often (Camp- al "meaning" of neurological disorder, and thus re-
bell, 1975). In addition, the value of providing illness actions to it, are likely to involve processes that blend
explanations to healthy peers in order to facilitate cognition and affect, and that incorporate both past
acceptance of children with chronic illness has been and current experience. Perhaps a clinical anecdote
questioned (Potter & Roberts, 1984). As expected, can illustrate this point. A large and powerful adoles-
when groups of healthy preoperational and concrete cent boy with a vague history of seizures entered a
operational children were provided with either symp- children's psychiatric hospital with a diagnosis of
tom descriptions or metaphorical explanations of di- paranoid schizophrenia. Precipitating the hospi-
abetes and epilepsy, those receiving the analogous talization were social isolation, paranoid ideation,
explanations demonstrated significantly more gener- verbal threatening, and dangerous behaviors such
al comprehension of the illnesses, and perceptions of as jumping out of trees and leaping before slow-
personal vulnerability were reduced. However, these moving cars.
illness explanations did not significantly facilitate During the course of therapy, two primary
ratings of acceptance of a hypothetical child with themes emerged sequentially. First, he believed his
these diseases. seizures to be a pervasive and primitive loss of bodily
The presence of disease conditions may also and ''self' control, and that during these episodes he
alter the normal pattern and pace of cognitive devel- might unknowingly and unwillingly kill the small
opment (Mearig, 1985). Obviously this could be the children for whom he frequently cared at home.
case in those with brain dysfunctions that change Later, a history of physical abuse by the father was
cognitive integrity, and it may also occur in those revealed. After one incident during which the boy
with chronic illnesses whose intellectual functioning secretly wished his father dead, the father promptly
is relatively intact. Myers-Vando, Steward, Folkins, did die of a cardiac arrest. The boy was simul-
and Hines (1979) reported that although children taneously overwhelmed by a sense of omnipotence-
with congenital heart disease manifest lower levels of he believed he had actually caused his father's
cognitive performance on conservation tasks com- death-and by his perception of an organically based
pared with healthy peers (presumably because of the lack of control necessary to prevent harming those he
disruptive ''intrusive stress'' of the illness), some of most loved in the future. He projected great menace
the ill children were capable of thinking formally in onto his environment, and then attempted to prove
the content domain of illness causality, possibly be- that he himself could not be killed by engaging in (but
cause of the greater affective salience of the topic or surviving) potentially injurious behaviors. His be-
greater opportunities for direct education and experi- havioral symptoms, therefore, seemed indicative of
ence with illness. On the other hand, Carandang, dynamic issues influenced by the objective and sub-
Folkins, Hines, and Steward (1979) reported that jective realities of seizures and past experience. At
issue, then, are the interactions between the ways in have been able to recognize and then set aside dis-
which children and adolescents react to and under- turbing thoughts and feelings in order to concentrate
stand neurological disorder, with the ultimate targets on tasks at hand. The point, then, is that some of the
of interest being their construction of "meaning," behaviors and thoughts of those facing extraordinary
and daily coping and adjustment. levels of disruption in their lives may not be as psy-
chopathological as they might superficially appear.
Defense or Coping? If it is assumed that the Our evaluation of their actions to contend with severe
onset or diagnosis of neurological disorder represents stress needs to consider the degree (focal or per-
a threat not only to cerebral integrity but also to the vasive, flexible or rigid, transient or chronic) of dis-
child's "self'' or "ego" in a fundamental manner, tortion as well as the temporal relationship between
then it can be assumed that attempts will be made to crisis moments and defense quality.
control, contain, or minimize that threat. Such ac- The role of denial in the coping process has
tions often lead to distortion, illusion, or self-decep- perhaps been most clearly explicated. As Lazarus
tion (inaccurate reality testing), and may thus be con- (1983) suggested, the paradox of self-deception
sidered classical defense mechanisms; they may thus being both adaptationally sound and psycho-
seem contrary to mental health. Yet there can be a pathological may be resolved by asking the more
psychologically positive side to these actions as well, sophisticated question: "What kinds of self-decep-
and a number of early papers anticipated current tions are damaging or constructive, and under what
trends in social psychological research in this area. conditions?" Lazarus initially distinguishes between
Goldstein (1952) distinguished between "protec- classical "denial,'' e.g., the negation of some inter-
tive" and "defense" mechanisms, suggesting that nal impulse, feeling, or thought, or of an external
although both may be employed to protect one from reality, and "avoidance" or plain "ignorance" of
fear and anxiety, the former may arise in a neu- threatening events. He then describes a family of
rologically impaired individual from an inability to denials. Partial denial, or the temporary and tentative
function in a shifting environment, whereas the latter suspension of belief, often takes place among the
may develop in response to psychodynamic conflict. seriously ill in the context of reassuring social rela-
Kroeber (1964) categorized and paired ego defense tionships with concerned friends, family, or health
mechanisms (e.g., isolation, projection, repression) care providers. Such a situation is quite common
with parallel coping mechanisms (e.g., objectivity, among healthy young children who easily suspend
empathy, suppression). the reality of the moment, particularly when that real-
Both coping and defense mechanisms may be ity is unpleasant. In addition, Lazarus recommends
rooted in common attempts to deal with painful real- that psychologists shift their emphasis from consider-
ity, though defenses would be cast in more negative ing denial and other coping mechanisms as static
terms reflecting relatively poor adaptability, whereas states of mind to recognizing them as ongoing pro-
coping mechanisms may represent active, flexible, cess that are often not fixed or consolidated defense
and effective attempts to deal with conflict. For in- mechanisms and that depend on both internal events
stance, if an early adolescent girl hospitalized fot and the social context.
diagnostic tests is playing with dolls, she may be Perhaps most relevant are some of the conclu-
employing mechanisms of time reversal by recaptur- sions Lazarus reaches on the costs and benefits of
ing experiences, feelings, and ideas of the past. The denial. If direct action to change the relationship be-
behavior is not necessarily indicative of the defense tween person and environment is adaptationally nec-
mechanism of ''regression'' (i.e., age-inappropriate essary, denial and subsequent inactivity will be de-
behavior to avoid responsibility, aggression, or un- structive. On the other hand, when direct action is
pleasant demands), but rather of the analogous and irrelevant to the outcome, denial may reduce distress
healthy coping mechanism of "playfulness" (util- and afford the individual the possibility for good
izing feelings and ideas from past experience that are morale and hope. Note that this position to some
not directly ordered by the immediate elements of the extent contrasts with many of the cognitive or ra-
situation). Similarly, the 9-year-old girl with little tional treatment approaches employed with neu-
manifest anxiety during a neuropsychological eval- rologically impaired clients. An additional time-re-
uation on the day prior to surgery for an enormous left lated principle is that denial may be beneficial early
frontal tumor was perhaps not refusing to face painful in disease or immediately after severe injury when
thoughts, percepts, or feelings in the pathological individuals are actually unable to participate in their
sense of "denial" (or exhibiting frontal lobe signs, own care. Later on, during extended treatment, re-
as the evaluation itself indicated). Instead she may habilitation, or education, it may be more important
542 CHAPTER 29
to contend directly with the insult and to struggle in a because they may determine whether coping behav-
problem-focused manner. ior will be initiated, how much effort will be expend-
As an aside, it should be clear that reference is ed, and how long it will be maintained in the face of
being made here to secondary reactions to neu- obstacles and aversive experiences (Bandura, 1977).
rological events. The existence of neurologically Certainly children with DMD experience a par-
based forms of inaccurate perception and reality test- ticularly acute and reality-based loss of motor con-
ing is not ''denied,'' nor is their significance in case trol. Their perceptions of motoric, academic, and
management diminished. social competence, and general self-worth have been
subjected to empirical investigation (Whelan, 1986).
Perception of Competence. Forms of denial The Perceived Competence Scale for Children
may be related to other cognitive and conative at- (Harter, 1979), which measures perceptions in the
tempts to cope with neurological insult. Duchenne four mentioned domains, was administered to 31
muscular dystrophy (DMD) is a neuromuscular dis- boys with DMD. With regard to the central tenden-
ease beginning in early childhood and resulting in cies of the data, mean scores on the scales of cog-
relentlessly progressive muscle wasting and weak- nitive and social competence and on the scale of gen-
ness, and eventually in death by late adolescence or eral self-esteem were approximately at the normative
early adulthood. In part, an understanding of the psy- mean. Scores on the scale of physical competence
chological functioning of children with DMD may be (referring primarily to athletic skills) were about one
derived from their performances on intellectual and standard deviation below the mean for normal chil-
neuropsychological measures (Dubowitz, 1977; Ka- dren (Whelan, 1986).
ragan, 1979; Knights, Hinton, & Drader, 1973); On the surface, these results might suggest that
however, the literature in this area remains conflict- children with DMD maintain relatively accurate per-
ing (Mearig, 1979; Sollee, Latham, Kindlon, & ceptions of their own areas of competence and dis-
Bresnan, 1985; Whelan, 1987). While we are con- ability, or that the existence of a neuromuscular dis-
tinuing to research the intricacies of brain-behavior order resulting in motor dysfunction and a reduced
relationships in this population, we are also exploring sense of efficacy in that domain have not substan-
other aspects of their psychosocial functioning. In tially generalized to other measured domains. How-
this context, one motivational variable, perceived ever, scores on the scale of perceived physical com-
control of events, appears to affect a wide variety of petence were not significantly correlated with any of
psychological conditions. Indeed, perceptions of the neuropsychological measures used in this study,
personal control, especially inaccurate perceptions, including measures of motor performance. This sug-
have been seen as central components of problems gests that perceptions of physical competence or,
ranging from depression to paranoia to underachieve- conversely, of physical disability may vary widely in
ment (Weisz & Stipek, 1982). this population, with little relation to the objective
Although the conceptualization and measure- reality of assessed motor performance. That is, some
ment of the control dimension have been approached of the mildly physically impaired children may per-
from the perspectives of social learning and attribu- ceive themselves as severely limited, and others with
tion theories, the theory and concepts of intrinsic greater actual motor disability may not perceive
motivation are also important. Competence moti- themselves as so seriously impaired.
vation theoty assumes that humans naturally strive Other data in this study may contribute to an
for effective interactions with their environments. understanding of the ways in which dystrophic chil-
Successful mastery of a problem produces pleasur- dren make sense of their condition. The magnitude of
able feelings of efficacy or competence, which, in the correlations between scores on the scale of per-
tum, reinforce and lead the individual to seek out and ceived physical competence and those on the scales
attempt to master additional tasks (Stipek & Weisz, of general self-worth (0.65) and social competence
1981). Harter (1978) claims that in order for children (0.39) was considerably higher than in the normative
to experience a feeling of efficacy, they must per- population. Together, these data may suggest rea-
ceive themselves as responsible for their successful sons for the lack of a significant relationship between
performance. Moreover, she reasons, failures per- perceived physical competence and actual motor
ceived to be caused by a lack of competence or self- ability: denial of physical disability in the service of
worth can lead to anxiety in mastery situations and preserving a sense of self-worth may be a prominent
thus decrease the child's mastery motivation. Chil- coping mechanism in children with neuromuscular
dren's expectancies and perceptions of efficacy may disease.
consequently be particularly important to consider An examination of perceptions of competence
in other groups of children with suspected neu- and/or psychological alteration, they may justifiably
rological disorder has also proved interesting. For be considered "victims" in this sense. Even the
instance, the factor pattern of the Harter scales for a terms commonly associated with neurological dis-
sample of learning-disabled children showed that the ease or injury reflect this theme: cerebral "trauma"
physical and social competence factors were retained with "loss" of consciousness, brain "insult," vas-
as in the normal population, although cognitive and cular "accident." Considerable research on the per-
self-worth factors did not emerge as discrete entities. sonal and social consequences of victimization has
Instead, two cognitive-self-worth factors were ob- been conducted by social psychologists, and al-
tained, the first composed of traitlike descriptions though there are few available reports concerning
(e.g., being smart, liking yourself as a person) and those with neurological disorder, the findings are ge-
the second composed of concrete and behavioral nerically relevant.
items (e.g., feeling it is easy to understand what one One relatively well-developed domain of re-
reads, thinking the way one does things is fine). search on coping with victimization concerns attribu-
Thus, the learning-disabled child's sense of self- tions of causality of undesirable events. In part, the
worth seems directly tied to scholastic competence impetus for these investigations came from refine-
(Harter, 1985). Harter recommends that we treat self- ments of learned helplessness theory that were heav-
concept as neither epiphenomenal nor as a static con- . ily based on attribution theory (Wortman, 1983). As
struct and concludes that "we cannot simply treat all part of the learned helplessness reformulation
children with intellectual deficits as a homogeneous (Abramson, Seligman, & Teasdale, 1978), critical
group since clearly there are quite different processes questions on the nature of coping with adverse cir-
influencing the structure and content of their self- cumstances shifted from the undesirable events
perceptions." With necessary modifications, the themselves to individuals' interpretations of the
measurement of domain-specific perceptions of com- events. For example, the type, intensity, and dura-
petence and global self-worth in the neurologically tion of a victim's coping responses to serious acci-
impaired population of children may yield important dents may depend less on the precise physiological
data in the future. For instance, we are interested in deficits and more on cognitions regarding the cause
determining if the factor structure described by of the accident. One of the most relevant studies of
Harter for "learning-disabled" children is truly rep- this kind examined the relation between the attribu-
resentative for all those bearing that gross label. Cer- tions of causality made by adult accident victims with
tainly many investigators have recognized that learn- paralysis due to severe spinal cord injury and their
ing-disabled children may frequently have difficulty subsequent coping patterns (Janoff-Bulman & Wort-
recognizing and interpreting social cues (Maheady & man, 1977). The findings suggested that those who
Maitland, 1982). Based on the subtyping literature tended to blame themselves for the accident were
(e.g., Rourke, 1985), it seems quite possible that rated by medical and rehabilitation staff as coping
some learning-dis~bled children maintain accurate better than those who blamed others and who felt the
perceptions of their competencies and areas of dis- accident could have been avoided. Indeed, many re-
ability, whereas others do not. Interventions with spondents (e.g., passengers in cars, people acciden-
children who are accurately perceiving their abilities tally shot) seemed to attribute more blame to them-
may consequently differ from those with children selves than might seem objectively reasonable. The
who are not. Moreover, the assessment of self-eval- authors interpreted the findings as reflecting attempts
uative processes may be critically important to con- on the part of victims to gain some control over their
sider in the population of neurologically impaired situations, for blaming oneself may be preferable to
children: if these processes are more amenable to the conclusion that random harmful events may occur
change than structurally based abilities per se, then in a meaningless, chaotic world.
school and other performances might be indirectly The results of the attribution literature concern-
enhanced through alternative interventions. ing victims may be important in the field of clinical
child neuropsychology because these and other forms
Attributions. If by definition the word "vic- of cognitive distortions may partially determine the
tim" applies to "anyone who suffers as the result of quality of coping attempts. Moreover, "real world"
ruthless design or incidentally or accidentally,'' then findings may be counterintuitive at first glance; many
the term may be broadly invoked in the context of psychologists might not consider, from an outsider's
various life crises, whether accidents, crimes, or disposition, self-blame to be particularly adaptive or
eases (Janoff-Bulman & Frieze, 1983). Because neu- predictive of good progress in a rehabilitation pro-
rologically impaired children surely suffer physical gram. The clinical utility of these forms of cognitions
544 CHAPTER 29
remains to be fully investigated, especially with chil- sible for the situation, why it happened to them, and
dren and especially over the long term. to what they attribute their present successes and
Attribution theory has also been applied to other failures.
areas of child psychology: childhood depression and
learning disabilities. According to the reformulated
learned helplessness model (Abramson et al., 1978), Issues in Psychotherapy
depressed individuals make more internal, stable,
and global attributions forfailure and more external, The neuropsychological literature on profes-
unstable, and specific attributions for success than sional training models (e.g., Meier, 1981) and inter-
nondepressed individuals. Recent research has indi- vention procedures (e.g., Edelstein & Couture,
cated that, like adults, depressed children have a 1984; Miller, 1984; Trexler, 1982) generally reflects
more "depressed" attributional style than non- the position that intervention with neurologically dis-
depressed children (Kaslow, Rehm, & Siegel, 1984; ordered individuals is most commonly cognitive-be-
Blumberg & Izard, 1985), and that attributional style havioral in nature. Given the forms of neurological
can be used to predict depressive symptoms 6 months signs and symptoms, such procedures are often war-
later (Seligman et al., 1984). ranted, efficient, and effective. In addition, how-
With regard to learning difficulties, the attribu- ever, some of the challenges to children's mental
tion and learned helplessness literatures are also ap- health described in this chapter might also be ad-
plicable (Thomas, 1979). It has been reported that dressed within the context of a psychotherapeutic
children who attribute outcome to ability do not work relationship. Moreover, there may be acute (hospi-
as long or as hard as those who attribute outcome to talization for diagnosis or surgery) and chronic (con-
effort (Dweck, 1975), and those who attribute failure trolled epilepsy, minor head injury, learning disor-
to ability tend to be less persistent on learning tasks der, neuromuscular disease) situations in which there
(Hiroto & Seligman, 1975). Diener and Dweck are no major behavioral difficulties but in which cli-
(1978) indicated that "helpless" children attribute ents may benefit from, and psychologists may desire,
failure to lack of ability, and nonhelpless children a somewhat different style of intervention.
focused instead on self-monitoring and self-instruc- A number of general considerations to be kept in
tions. Compared with average and good readers, mind by the therapist have been provided by Christ
poor readers have been found to take less personal (1978), Geist (1979), and Small (1973). Therapeutic
responsibility for success, and when they did make goals may include the provision of nonconfrontal un-
internal attributions for success, they were more like- derstanding, support, and feedback during periods of
ly to make effort rather than ability attributions confusion, anger, anxiety, and depression. Strength-
(Butkowsky & Willows, 1980). The potential impor- ening of reality testing, learning to select areas of
tance of research in this area is that interventions success and to avoid those of failure, and the im-
designed to alter attributional patterns (e.g., to shift provement of relationships with others may also be
attributions for failure from insufficient ability to inappropriate targets. Traditional psychotherapeutic
sufficient effort) may result in improved academic emphases and processes may require modification,
performance (e.g., increased academic task per- however. For example, the development of a
sistence and achievement) (Dweck, 1975; Fowler & therapeutic alliance may purposely be extended, al-
Peterson, 1981; Schunk, 1983). lowing greater opportunities for clients to recognize
Taken together, these lines of theory and results and display their strengths. Primitive and fragile de-
suggest a convergence of information. Attribution fenses may crumble with mild cognitive or affective
patterns affect coping in affective and cognitive do- stress, leading to catastrophic reactions that seem
mains, and they seem important in adjusting to both disproportionate to an outsider's appraisal of the
acute insults or accidents and long-standing develop- stressor. It may thus be important to concentrate on
mental difficulties. Equally importantly, it is possi- building a "defensive superstructure," using de-
ble to modify children's attribution styles through fenses that are more negotiable than frank denial or
relatively brief interventions. Future research regard- projection, such as displacement, rationalization, or
ing the development and alteration of attributions intellectualization. The psychologist's concepts of
among children with neurological disorder may con- client resistance must be modified in the face of slow-
sequently prove worthwhile. It may be important, for ly improving or impaired cognitive and integrative
instance, to investigate not only a child's cognitive capacities, and the inability to recall may obviously
understanding of the ''facts'' of the disorder, but also reflect faulty memory and not repression of conflict.
to explore their perceptions of who or what is respon- Finally, it should be remembered that those with neu-
rological disorder do not "work through" a perma- dimensional, and although the cognitive and devel-
nent disability as with a neurotic problem, nor do opmental prerequisites of hope remain to be specified
they get over it'' as with some normal development for children, the idea that hope is a desirable state
hurdles; instead they must continually adjust to the during medical recovery and rehabilitation has been
dynamic nature of the disability itself and to its con- investigated with adults (Boone et al., 1978; Brody,
sequences at various levels in the systems hierarchy. 1981; Dubree & Voge'pohl, 1980; Heinemann eta!.,
For example, realistic limitations in adaptive abilities 1983; Perley, Winget, & Placci, 1971), and could be
may prevent the adolescent from taking steps of au- explored with chronically ill children.
tonomous action at the same age as most others. In-
deed, true termination from therapy may not be desir-
able, and the option to return at developmentally Psychosocial Adjustment
stressful times may be a sensible alternative.
There is another therapeutic issue that deserves
Much ambiguity surrounds the issue of whether
comment in order to provoke additional thought or
chronically ill children, including those with neuro-
research. A variety of sources suggest that it is impor-
psychological deficits, are maladjusted when com-
tant to instill a sense of realistic "hope" in neu-
pared to their "normal" peers. Findings are contra-
rologically impaired clients. Travis (1976) recom-
dictory, and diverse methodologies make com-
mended that those caring for children and adolescents
parisons between studies difficult. It is generally
with progressive muscular dystrophy establish a
accepted that children with chronic illnesses are at
''contextforsecurity and an avenue for hope.'' Wad-
one and one half to three times greater risk for be-
dell (1983) discussed the hope that medical and fa-
havioral, social, and psychological maladjustment
milial people consign to children with life-threaten-
than healthy peers (Perrin, 1986; Pless, 1984). Rut-
ing illnesses, and others considered the role of hope
ter, Graham, and Yule (1970a) reported that the oc-
in the process of rehabilitation (Boone, Roessler, &
currence of psychiatric disorders among the general
Cooper, 1978; Heinemann, Geist, & Magiera, 1983)
population of children and adolescents was 6.6%;
and psychotherapy (Erickson, Post, & Paige, 1975;
for children with nonneurological chronic disease,
Frank, 1968; Green, 1977; Smith, 1983).
11.6%; those with epilepsy and no other pathology,
Although "hope" is a term used frequently in
37.5%; and children and adolescents with epilepsy
everyday conversation, and although casual intro-
associated with organic brain disease, 58.3%.
spection suggests it is a pervasive human construct,
Professionals and individuals involved with
there is very little related psychological research.
neurologically impaired children should not be mis-
Classical literature provides some insight into the
led, however, by the temptation of such figures. For
concept. Hope was one of the evils contained within
any particular child, the presence of neurological dis-
Pandora's box, and indeed, the Greeks viewed hope
order does not necessarily imply lowered psycho-
as an illusion and as mankind's curse because fate
social adjustment. Individual reactions to disability
was seen as unchangeable. Such sentiment is re-
are diverse, and specific disabilities have not been
flected in lines from Antigone: "We are of the tribe
that asks questions, and asks them to the bitter found to be related to specific personality types
(Bronheim & Jacobstein, 1984; O'Dougherty, 1983;
end . . . we are of the tribe that hates your filthy
Roessler & Bolton, 1978).
hope, your docile, female hope; hope your whore."
On the other hand, the Judea-Christian message is
essentially one of hope, and in various cultures the Psychiatric Symptomatology
symbol now written in most medical charts for
"female" has meant eros, fertility, and hope (Men- The range of psychiatric symptoms displayed by
ninger, 1963). children with neuropsychological disorders is similar
Perhaps because of the religious nature of his- to the behaviors of their nonhandicapped peers. Re-
toric tradition and because hope is a difficult con- sults from large-scale epidemiological studies of
struct to operationalize, psychologists may have left children with chronic illnesses suggest that these
the study of hope to theologians and philosophers, children experience lower academic achievement,
and concentrated instead on hopelessness. Still, hope greater absenteeism and truancy, and increased be-
may rightly be classified as a coping phenomenon havioral difficulties, nervousness, and aggression
incorporating a future orientation, optimistic affect, (Pless & Roghmann, 1971; Rutter, Tizard, & Whit-
expectant cognition, response to external stress, and more, 1970). In addition, emotional dependence,
resultant motivation (Petiet, 1983). Although multi- poor social adjustment, low self-esteem, depression,
546 CHAPTER 29
anxiety, difficulties in sexual adjustment, embarrass- concept and self-esteem are intrinsic to the experi-
ment, regression, poor body image, excessive ence of chronic illness (Geist, 1979). Christ (1978),
shyness, lifelong feelings of failure and inadequacy, for example, suggested that neurologically impaired
immaturity, exaggerated self-consciousness, shame, children in psychotherapy view themselves as differ-
and fearfulness have all been used to describe the ent, weird, or defective, at least from the time peer
various experiences of children with spina bifida, comparisons are first made in grade school or pre-
epilepsy, muscular dystrophy, cerebral palsy, can- school. In general, greater agreement exists that chil-
cer, and closed head injury. dren with neurological involvement or deficits are at
A word of caution is necessary. Although it is increased risk for poorer self-concept and lowered
true that discrete symptoms or symptom clusters may self-esteem than their healthy peers (Lindemann &
be manifest by individual children, it should not be Stranger, 1981; Rutter et al., 1970).
construed that this laundry list of psychiatric symp- Although it is not yet clear precisely why these
toms uniformly affects all children with neurological children may be at increased risk for poorer adjust-
handicaps. All children, including those at high risk ment, perhaps an understanding can be found in the
for developing psychiatric sequelae, will be indi- nature of the relationship of neurological deficit to
vidually influenced both by the neurophysiological the development of self-identity. The key question
constraints of the disease and by events external to here may be, how does altered brain integrity affect
the presence of disease, such as premorbid coping the development of self-concept and self-esteem? For
style, family support, and social reaction to disease example, administration of a standard measure of
presentation. For example, social adjustment may be perceived competence to a group of educable men-
affected when children with spina bifida who are tally retarded children suggested that these children
incontinent of bladder and bowel are avoided or did not make the same categorical distinctions of self-
teased by their peers because of their ''outhouse syn- competence and general self-worth as children in the
drome" of smells (Bronheim & Jacobstein, 1984; standardization samples evidenced (Harter, 1982).
Shurtleff, 1980). Similarly, the social stigma of epi- At one extreme such a question implies that,
lepsy can increase embarrassment, feelings of because of physiological limitations, some children
shame, and a vigilant need for secrecy for some epi- do not develop self-concepts in the same manner that
leptic children (O'Dougherty, 1983). Depression, their normal peers do, due perhaps to a physiologi-
which is experienced by some children in all disease cally based lack of or unique processing of informa-
categories, may be exacerbated in muscular dystro- tion. This notion is reflected by parents and teachers
phy around the time the child becomes wheelchair who are unsure of how much to expect from their
bound and the relentless nature of the disease be- handicapped child and wonder whether the child's
comes less deniable (Lindemann & Stranger, 1981; behaviors reflect biological limitatioos. Yet, al-
Pierpont, LeRoy, & Baldfinger, 1984). Expression though brain integrity may indeed affect formation of
of psychopathology, then, should be considered in self-concept, the lack of findings correlating one spe-
context. cific emotional or social pattern of behavior with a
specific disease or deficit suggests that the rela-
tionship between brain functioning and self-concept
Self-Concept and Self-Esteem is complex, mediated by environmental and biolog-
ical variables, and cannot be subjected to unqualified
As empirical studies on the effects of pa- reductionism.
thoneurological involvement on children's self-con-
cept and self-esteem are sparse, the literature on
chronically ill children suggests an equivocal re- Socialization
sponse to this issue. Many studies offer findings of
lowered self-esteem and poorer self-concepts (e.g., Although undoubtedly some people are arrantly
Lineberger, Hernandez, & Brantley, 1984; Tro- satisfied living in relative isolation from family,
pauer, Franz, & Dilgard, 1970). In contrast, other friends, and community, most of us recognize the
researchers (e.g., Kellerman, Zeltzer, Ellenberg, immeasurable importance of our relations with other
Dash, & Rigler, 1980; Simmons etal., 1985; Tavor- people. Indeed, it is notable that children who are
mina, Kastner, Slater, & Watt, 1976) report no sig- withdrawn or elect not to participate with their peers
nificant differences between various groups of chron- are considered by many to be maladjusted or
ically ill children and healthy peers. Anecdotal "pathological. "
reports often emphatically suggest that impaired self- The relative importance of peer interactions in-
creases with age and growing autonomy. For both and withdrawal are means of coping with their dis-
normal and neurologically impaired children, the ease. Children who are frightened and embarrassed
peer group has been described as instrumental in by a loss of control during a seizure, for example,
providing confirmation or disconfirmation of chil- may consciously or unconsciously remove them-
dren's growing sense of competence and self-esteem, selves from the influences of peers in attempts to
meeting dependency needs, a reference point for reduce feelings of being different, unattractive, or
growing beliefs about sexuality, and a means of role socially rejected (Ozuna, 1979). Others have noted
rehearsal where dimensions of cooperative, com- that wheelchair-bound children and children with
petitive, and aggressive behaviors can be expressed progressive muscular weakness can become isolated
(Battle, 1984). Additionally, peer groups are seen as and withdrawn, relying heavily on fantasy and imag-
a major source of communication and support, con- ination (O'Dougherty, 1983; Lindemann & Boyd,
versation and companionship, and fun and socializ- 1981).
ing for most adolescents (Resnick, 1984). Although children with obvious physical limita-
The importance of peer groups may even be tions can face rejection from peers because of their
greater for handicapped children. For example, ado- visible differences, visible handicaps may also at
lescent cancer patients have reported that spending times be addressed and accepted more openly than
time with their friends is of primary importance in deficits with few noticeable manifestations. Indeed,
their ability to cope (Zeltzer, LeBaron, & Zeltzer, children whose disabilities are less obvious or are
1984). Based on a study of survivors of childhood better controlled may suffer as much or more than
cancer, O'Malley, Koocher, Foster, and Slavin their severely disabled counterparts (Hertzig, 1983;
(1979) reported that a decrease in the number of so- Pless, 1984). The "marginal child" may be teased
cial relationships during diagnosis and treatment had for being slow, clumsy, or different, and often faces
a negative impact on subjects' future adjustment. the dilemma of trying to "pass" as a normal peer,
Minde, Hackett, Killou, and Silver (1972) reported meeting the expectations of behavior and ability that
that almost 50% of children with cerebral palsy who such normalcy involves, or choosing to separate from
did not have a nonhandicapped friend were labeled the peer group, enduring consequent ridicule and iso-
psychiatrically deviant whereas less than 10% of lation (O'Dougherty, 1983).
those with nonhandicapped friends were so labeled.
This finding is even more striking when one consid-
ers evidence suggesting that nonhandicapped chil- Independence and Autonomy
dren, especially boys, who initiate contact with a
Emotional separateness and independence is
handicapped child generally have less social experi-
recognized as a significant goal of childhood and
ence, are more isolated, and adhere less to peer val-
adolescence, and a hallmark of adult adjustment. Al-
ues (Battle, 1984).
though being "special" may be a plausible role for
Although diminished interactions with one's
some handicapped people, American society expects
peer group can deprive children of valuable pleasure
disabled individuals to strive maximally toward inde-
and experience in their preparation for adulthood, for
pendence and autonomy (Parsons, 1964). The influ-
some children with neurological disorders, gaining
ences of neurological disorder, however, can run
access to and acceptance by their peer group can be a
counter to goals of individuation, as is illustrated in
formidable task. Hospitalization and requisite medi-
this case description quoted by Resnick (1984):
cal treatments for some diseases take time away from
school attendance and peer activities (Zeltzer et al., While his age cohorts were arguing with parents over
1984). At other times, peers' superstititions and mis- the length of their hair, he needed help washing his;
understandings about the nature of the disease can while they were resisting doing assigned chores, he
result in cruel teasing and unwarranted ostricism, was unable to perform any; while they were battling
especially when unfounded fears of contagion are curfew, he needed not only permission, but physical
involved (Isaacs & McElroy, 1980). Children who assistance in order to be out. Instead of sharing his
peers' increased independence from parents and oth-
experience a loss of mobility may also face social
ers, symbolized by mild acting out behaviors, this pa-
isolation as their opportunities to participate in the tient could merely fantasize his acting out, with his
normal activities of childhood and adolescence are illness providing a constant reminder of his chronic
restricted. dependent status.
In contrast to the external influences that may
limit a handicapped child's full participation in peer Though not all children with neurological hand-
group activities, for some children, social isolation icaps exhibit the same degree of physical limitation,
548 CHAPTER 29
they all share in an increased dependence on parents, can also complicate the process of separation and
medical staff, and sometimes siblings for physical, autonomy. For example, Zeltzer et al. (1984) re-
financial, and emotional support (Zeltzer et ported that immediately following diagnosis and dur-
al., 1984). Although disorders that demand large ing times of disease relapse, adolescents with cancer
amounts of time and care from parents and family prefer a more passive, dependent role, being less
might appear to encourage emotional dependence involved with the management of their disease than
compared to other diseases, the critical issue remains parents and physicians wish them to be.
how to foster developmentally appropriate indepen-
dence and responsibility within the context of a
child's neurological deficit. For "normal" children,
autonomy invariably increases with age, and parental
Impact on the Family
control usually decreases proportionally. Although
Nowhere is systems theory perhaps more useful
the progression toward adulthood may not always be
than in investigating the family. As a unit the family
as smooth as many parents and children would pre-
is affected by the presence of chronic illness, whether
fer, in most cases autonomy and responsible adult
the illness is of neurological origin or not. One is
action are considered birthrights. For children with
reminded of John Steinbeck's The Pearl, the story of
neurological disorders, however, both the pathway to
a poor fisherman who found a pearl so inordinate in
autonomy and the children's "right" to eventually
its beauty and consequences that the lives of the en-
assume traditionally adult responsibilities may be
tire village were altered. The birth or diagnosis of a
questionable (J(opelman, 1985). Physical and mental
child with neurological disorder is not unlike Stein-
abilities that have been compromised by presence of
beck's description that time had changed and every-
disease may in some cases realistically limit a child's
thing hence would be either before the pearl or after
ability to assume such adult activities as driving a car
the pearl. Although it is perhaps ubiquitous that a
or making important decisions regarding medical
neurological disorder will alter the lives of the family
treatment. With adults, an assumption is made that
and individuals close to the handicapped child, it is
everyone over a recognized legal age is competent to
also the case that not all families are similarly af-
make decisions for themselves, unless proven other-
fected. Some families report being strengthened by
wise, and implicit in this supposition is the attain-
the continuing challenge; other families cannot with-
ment of a certain, unquantified level of maturity. For
stand the stress and become dysfunctional or disinte-
children with neurological disorders, the issue of
grate. Presently, no direct cause-and-effect occur-
emotional maturity becomes inextricably linked with
rences have been identified that would fully explicate
physical disability.
or predict the interaction of chronic illness and family
The physical and other limitations that some
dynamics; rather, the influences are mosaic.
neurological disorders impose incite some parents to
become overly protective of their handicapped child.
Such overprotection can be detrimental to the child's Stages of Family Growth
quest for autonomy and can too easily create an atmo-
sphere that encourages children to remain overly de- Various theorists have proposed different stages
pendent, both emotionally and physically, on others. of family growth and development, including mar-
At one extreme, children may become complacent, riage, childbirth, early child rearing, child schooling
passively accepting the ministries of others. In con- and increasing independence, departure of children
trast, overly demanding, noncompliant, acting-out, from the home, and integration of loss as parents
or intentionally guilt-provoking behaviors may rep- adjust to problems associated with being alone and
resent attempts to separate from parental domination growing older. This model is influenced both by fam-
and establish self-responsibility, while also satisfy- ily subsystems and by groups external to the nuclear
ing certain emotional needs (O'Dougherty, 1983). family, such as extended family, friends, and com-
This secondary gain that many children experience munity. Stage theories depicting special times of
from their dependent roles can be reinforced when stress may inadequately portray the family of a child
parents are reluctant to expect or demand indepen- with a neurological disorder who must deal with bur-
dence from their handicapped child (Resnick, 1984). dens unlike those of their "average" counterparts,
Noncompliance with medical procedures can and additional crisis points have been suggested for
become a difficult issue when children and adoles- families of chronically ill children: when parents ftrSt
cents are unable to assert their autonomy in appropri- become aware of the child's handicap; when the child
ate ways. Similarly, changing needs during illness first becomes eligible for special educational ser-
vices; when the child leaves school; and when parents understandable defense against emotional pain, its
are aging and can no longer assume responsibility for consequences can be exacerbated when parents view
the care oftheir child (Bailey & Simeonsson, 1984). it as a sign of their own inadequacy. Embarrassed,
Stage models of family development are useful they may tum to friends or books for information,
in that they provide a framework with which to un- rather than repeatedly question professionals. Some
derstand family dynamics; however, variability of sources of information, although well-intentioned,
family structures due to single parenthood, and eth- may be highly inaccurate, and misconceptions about
nic, social, and financial differences make gener- their child's disease can linger for years, at times
alizations about the consequences of chronic child- to the detriment of effective treatment (Whitten,
hood illness, including neurological disorders, on Waugh, & Moore, 1974). During this initial period
family life a dangerous task at best. For example, it parents may also refuse to believe the diagnosis and a
has been suggested that the birth of a handicapped period of "shopping around" for second medical
child is more devastating for lower socioeconomic opinions may ensue.
status families than for middle- and upper-class fami- Sadness, anxiety, and grief, from its raging an-
lies; yet, little data are currently available on class- ger and tears to its heavy numbness and pain, fre-
related coping characteristics of parents (Schilling, quently occur next as parents begin to fully experi-
Schinke, & Kirkham, 1985). Similarly, anecdotal ence the unjustness of the situation (Blacher, 1984).
reports suggest the importance a family's ethnic Parents grieve for the feared loss of their child
background can have on family coping and adjust- through death, for the loss of their "normal" child,
ment, and on medical compliance (Hobbs, Perrin, & and for hopes and aspirations for their child that have
lreys, 1985). Although systematic investigation of been relinquished (Mattsson, 1972). The intensity of
socioeconomic-ethnic variables is sparse, such in- emotions experienced and the isolating effects of
fluences cannot be extricated from the daily lives of grief can cause some parents to wonder if their reac-
neurologically impaired children and must not be for- tions are normal. Customary sources of comfort and
gotten in our quest for greater understanding. solace, such as one's spouse, may be unavailable
because they too are grieving. Anger can become a
prominent emotion and parents may vent their anger
Stages of Parental Adjustment at each other, at other healthy children, at hospitals,
physicians, and psychologists, at their church or their
The diagnosis of a chronic illness or neu- God, and at times, at their ill child (McCollum,
rological disorder marks the beginning of a stressful 1981). Worry and anxiety may also increase as both
and confusing time for parents. Even when there has the demands of care and the family's limitations be-
been some suspicion of illness, diagnosis represents come more evident. The stress and anxiety of this
an immediate confirmation of parents' fears and a time may be associated with physical illness or symp-
removal of hope. Although each parent may not feel toms in the parents and can cause parents to fear that
each of these emotions, fear, shock, horror, they too are sick. Inevitably, their child's illness con-
numbness or detachment, relief, helplessness, de- fronts parents with their own mortality and eventual
nial, sadness, anger or rage, anxiety, depression, and death (Isaacs & McElroy, 1980).
guilt are all likely to be experienced at various times Progression to final stages in this coping model
(Drotar, Baskiewicz, Irvin, Kennell, & Kfaus, 1975; suggests parental acceptance of the child's handicap,
Hobbs et al., 1985; McCollum, 1981). an ability to emphasize positive aspects of the situa-
During the initial period of diagnosis, many par- tion, and attenuation of the intensity of earlier feel-
ents experience shock and bewilderment and some- ings (Hobbs et al., 1985). The ability to master guilt,
times feel that the situation is unreal, that it must fear, and self-accusatory feelings of responsibility
either be a dream or happening to someone else. They has been suggested as critical in determining parents'
may discuss their child as if he or she were a textbook acceptance of their child's illness or handicap (Matt-
case rather than their own child (McCollum, 1981). sson, 1972). Additionally, Mattsson suggested that
Parents will often have many questions, such as: the awareness of and ability to verbalize feelings in-
"How will my child's life be affected?" "Is there a dicates that parents are ready to accept the reality of
cure?'' "Will my child's life be shortened?" "What the illness. Parental coping and acceptance are fur-
does the disease do?" "Could I have done something ther facilitated through their use of various defense
to avoid this?'' Paradoxically, in their emotional tur- mechanisms, including rationalization; displacement
moil many parents are unable to remember what pro- and projection of feelings onto others such as medical
fessionals say and, although forgetting may be an professionals; intellectualization, including educat-
550 CHAPTER 29
ing themselves about medical, physiological, and overprotection. Family members become more lov-
psychological aspects of the disease; identification ing toward the ill child, and normal rules and disci-
with other parents of seriously ill children; and denial pline are suspended. Although allowances need to be
and isolation of helplessness and anxious feelings, made according to the realistic limitations imposed
especially during medical crises. The use of any of by the disease or illness, changes in family attitude
these defense mechanisms may at times be exasperat- can be confusing and sick children are likely to gain a
ing to people who are in contact with the ill child's sense of their own vulnerability through the fears and
parents, as is most obviously the case with angry and reactions of their parents and siblings (Mattsson,
obstreperous parents. It is important to realize, how- 1972). Mattsson described four situations that may
ever, that such "defense" mechanisms may be quite predispose parents to overprotection or rejection: the
appropriate at different times in the course of the child is afflicted with a hereditary disorder found
illness. among relatives; the child was unwanted; the child
Although useful as a structure for understanding was not expected to live at birth or as an infant; and
family adjustment, the utility of stage theories is lim- emotional conflicts around the death of a close rela-
ited in specific applications. The attendant feelings of tive are aroused by the child's illness.
a parent toward a chronically ill child may ebb and
flow chaotically, and even without apparent crisis or
problem they may experience many feelings simul- Parental Differences in Coping Style
taneously. Parents' grief and the need for coping may
reoccur as their ill child reaches chronological and The coping styles of parents may differ accord-
developmental milestones (Schilling et al., 1985). ing to sex. Findings suggest that women tend to em-
Some parents report that, although they may have ploy interpersonal and cognitive coping strategies
learned to live with their child's illness, they do not and men more frequently use cognitive coping pat-
feel they will ever accept it (Hobbs et al., 1985). This terns. Using their own health inventory, McCubbin,
sentiment is reflected in the words of one father: McCubbin et al. (1983) factor analyzed the scaled
The guilt, like all guilt, has both rational and irrational
responses of 100 families of children with cystic fi-
components. . . . The guilt that parents feel for a hand-
brosis. Mothers' coping efforts were directed at the
icapped child is much greater than anything you could interpersonal dimensions of family cohesiveness,
rationally calculate. It has to do somehow with having support, and expressiveness; fathers placed more em-
the feeling that one has imposed upon a child a kind of phasis on maintaining the family through cooperation
permanent burden that the kid dido 't deserve, so there's and minimizing conflicts in family interactions
no way that you can be forgiven for this. I have felt all through the use of rigid rules and procedures. Similar
along that the guilt factor, or by any other name the coping profiles were reported by McCubbin, Nevin
sense of having imposed on David a lifelong burden et al. (1983) in a study of parents of children with
that he had no reason to expect and had no choice about
cerebral palsy. Such findings are consistent with
and dido 't deserve, that that has affected both (my
available research on developmentally disabled chil-
wife) and me a lot.
dren that suggests that parents of handicapped chil-
When asked if he had come to terms with his guilt, dren tend to be more traditional in terms of sex roles
this father reported that it wasn't until he was about than other families.
50 years old that he could finally ''accept that life had Within traditional families the father's role is
to be the way it was so that you no longer grieve for most frequently as provider first and parent second,
the way it wasn't or feel a failure because of how your and for mothers the reverse is true (O'Donnell,
life turned out. " 1982). In a Colorado statewide survey by Linder and
The consequences of unresolved guilt and an- Chitwood (1984), fathers of handicapped infants and
guish, or the inability of parents to adequately accept preschoolers reported that their time with their handi-
and cope with their child's chronic illness can nega- capped child was limited by job and other family
tively affect their relationship with their ill child and demands, even though they desired to become more
other relations within the family. At one extreme, involved with their child. Mothers were found to be
parents may reject or severely neglect their disabled the primary source of information about their child
child by denying the presence of illness or the need for fathers, though fathers indicated that newsletters
for treatment, or by blaming abandoned careers, fi- or training in working with their child would be help-
nancial ruin, and much inconvenience on their ill ful. Additionally, survey replies indicated that fa-
child (Hobbs et al., 1985). More frequently, pro- thers were least interested in "someone to talk to
longed parental overconcern leads to indulgence and about my child'' as a means of information or source
of comfort and solace. Such responses are consistent Some reports indicate that siblings of chronically ill
with findings in other studies, and may be partially children are more likely to have adjustment, behav-
comprehensible when one considers that husbands ioral, and academic difficulties (Allan, Townley, &
tend to rely on their wives for intimate support, Phelen, 1974; Lavigne & Ryan, 1979). Others sug-
whereas wives report turning to other women and gest that although general mental health may remain
friends for support. Women in general report more stable, social adaptation may be compromised. Still
dissatisfaction with family life, less freedom and op- other studies report no significant differences be-
portunity to develop self interests, worse health, and tween comparison groups on measures of adjustment
less positive moods. This is perhaps not surprising, or sociability (Drotar, Crawford, & Bush, 1984).
as wives and mothers are called on to balance the Again, although generalizations are to be made with
needs of their handicapped or ill child, unaffected caution as methodologies, patient groups, develop-
children, and spouse, with their own needs. mental levels, and comparison groups vary across
studies, it may be reasonable to suggest that, like
their siblings, brothers and sisters of neurologically
Dyadic Relationships impaired children are at increased risk for psycho-
social maladjustment.
It has already been suggested that the diagnosis
In some families the needs of healthy children
of chronic illness or handicap in a young child may
can take second place to those of the ill sibling, es-
contribute to maternal overprotection (Mattsson,
pecially during times of stress and crisis, and
1972). Such overprotection may result in the forma-
throughout the course of the illness parental adjust-
tion of an intense dyadic relationship, usually be-
ment and coping styles will directly influence healthy
tween mother and handicapped child, that isolates the
siblings. For example, depleted emotional reserves
dyad from other family interactions (Shapiro, 1983).
and lowered ability to communicate may make par-
This relationship then becomes an axis around which
ents seem unavailable or rejecting. Younger children
other family relations develop, especially other chil-
who are not yet cognitively able to interpret their
dren's resentment of the special closeness between
parents' feelings or understand what is happening
mother and handicapped child. Paradoxically the
with their ill sibling will tend to effect individual
handicapped child may also develop feelings of being
interpretations of the family situation. They may feel
outside the family, participating primarily as an ob-
guilty, or blame themselves for their sibling's illness.
server who is never fully accepted by other siblings or
Children may also fear they are susceptible to the
is fully a part of family life. Although such an intense
same fate, and older children may wonder if they are
relationship may represent a mother's conscious or
potential genetic carriers (McCollum, 1981). Dis-
unconscious efforts to atone for the guilt she may
tribution of labor may change in the family and re-
feel, its effects on the family can be severe. Psycho-
searchers have suggested that older female siblings
dynamic theory clearly posits the insult to emergent
self-identity and resultant psychopathology in re- perform a disproportionate share of extra chores. In
sponse to prolonged and stage-inappropriate affec- other comparisons, younger male siblings have been
reported to be more sensitive to peer's comments
tive symbiosis. Spousal and sibling jealousies can
also arise within the family system, and consequent about the illness (Hobbs et al., 1985).
emotional alliances that demarcate the family may
actually only represent attempts at emotional connec-
tion and survival between members excluded from Discussion
the dyad. For example, the birth of a chronically ill
second child may leave the mother little time for her
It has been assumed in this chapter that the
first child, who soon may exhibit a clear preference
human organism is a complex web of interaction,
for the father. Such alliances can readily exacerbate
with normal and pathological developments taking
an already stressful family or marital situation.
place at multiple levels, from the biological to the
social. Under this assumption, the understanding and
Siblings significance of neurologically based changes in sen-
sorimotor functioning, in cognitive and executive ca-
Although it is reasonable to assume that brothers pacities, or in emotion and behavior are enhanced by
and sisters of children with neurological disorders placing these alterations in a social and historical
will be affected by their sibling's illness, little con- context. When neuropsychologists listen to their cli-
sensus exists regarding what those effects will be. ents, they may hear expected questions about the
552 CHAPTER 29
brain and the consequences of its disorder. Yet in our Boone, S. E., Roessler, R. T., & Cooper, P. G. (1978). Hope and
experience, these questions do not often end with manifest anxiety: Motivational dynamics of acceptance of
anatomy and physiology, or with strict brain-behav- disability. Journal of Counseling Psychology, 25, 551-556.
ior relationships per se. Instead, the concerns of cli- Brodie, B. (1974). View of healthy children toward illness. Ameri-
ents, both children and adults, extend to attempts to can Journal of Public Health, 64, ll56-ll59.
Brody, H. (1981). Hope. Journal of the American Medical Asso-
''make sense'' of their condition and to the ramifica-
ciation, 246, 1411-1412.
tions of their neurological disorder in the context of Bronheim, S. M., & Jacobstein, D. M. (1984). Psychosocial as-
family, school, and social settings, and in terms of sessment in chronic and fatal illness. In P. R. Magrab (Ed.),
past experience and future expectations. Considera- Psychological and behavioral assessment: Impact on pedi-
tion of these temporal and ecological dimensions atric care. New York: Plenum Press.
may thus lead to a richer understanding of the im- Butkowsky, I. S., & Willows, D. M. (1980). Cognitive-moti-
plications of neurological disorder in the lives of chil- vational characteristics of children varying in reading ability:
dren, and may suggest additional directions for as- Evidence for learned helplessness in poor readers. JourRDI of
sessment and intervention in clinical child Educational Psychology, 72, 408-422.
psychology. Some of the topics included here have Campbell, J. D. (1975). Illness is a point of view: The develop-
ment of children's concepts of illness. Child Development,
been selected because of their wide mention in the
46, 92-100.
related literature; others were chosen because they Carandang, M. L.A., Folkins, C. H., Hines, P. A., & Steward,
reflect questions generated in our own research and M. S. (1979). The role of cognitive leveland sibling illness in
practice, and for their utility in provoking additional children's conceptualizations of illness. American Journal of
research. In most instances, the topics purposefully Orthopsychiatry, 49, 474-481.
suspend the trend toward reductionism in the social Chan, K. B. (1977). Individual differences in reactions to stress
sciences and advocate the application of theory and and their personality and situational determinants: Some im-
methods from other domains of psychology to the plications for community mental health. Social Science and
field of neuropsychology. Medicine, II, 89-103.
Christ, A. E. (1978). Therapy of the child with true brain damage.
American Journal of Orthopsychiatry, 48, 505-515.
Curry, S. L., & Russ, S. W. (1985). Identifying coping strategies
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554 CHAPTER 29
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30
Child Neuropsychology in the Private

Medical Practice
ERIN D. BIGLER AND NANCY L. NUSSBAUM
Child Neuropsychology in the Private will focus on the role of the child neuropsychologist
Medical Practice in the context of a general pediatric practice.
Utilizing a broad definition of child neuropsycholo- Identification of the Patient

gical practice, the scope of such a practice would
encompass all children with developmental and ac- In the private medical setting, the pediatrician is
quired disorders that affect cognition, behavior, the individual who plays the pivotal role in identify-
and/or sensory and motor skills. National statistics ing children with a potential neuropsychological
(Department of Education) indicate that for 1982 and problem. In that considerable expertise is involved in
1983, approximately 11% of all children received the full evaluation of such children, the role of the
some form of special education (Weiner, 1983). pediatrician should be one involved in screening with
More specific to pediatric practice, Dworkin (1985) appropriate referral when a potential problem is
presented statistics indicating that approximately identified. Dworkin (1985) outlined a model of an
10% of a pediatrician's practice involves children office-based approach to the child with school and
with learning disabilities (LD), attention deficit hy- developmental problems. An adaption of this model
peractivity disorder (ADHD), speech-language dis- is depicted in Figure l. In this approach the pediatri-
order, mental retardation, cerebral palsy, and related cian constitutes the first line of contact with the child,
disorders (see Table 1). and the neuropsychologist functions as the sub-
Equally pertinent are the findings of Burnett and specialist providing specific evaluation, assessment,
Bell (1978) who reported that the greatest increase in and possible treatment for the referral problem. With
pediatric practice in terms of new referrals came in this model, potential medical problems (e.g., thyroid
the area of school and related problems. According- dysfunction, hypoglycemia) that can influence be-
ly, with such an incidence there is a clear indication havior and mimic neurobehavioral disorders can be
for the need and important role that the child neuro- addressed directly by the pediatrician. Likewise, cer-
psychologist can play in the pediatric and general tain conditions, such as ADHD, which may require
medical setting. The most common setting for child ongoing medical management (i.e., stimulant medi-
neuropsychology to interface with the private medication), can also be dealt with directly by the physi-
cal practice will be the general practice of pediatrics cian. In addition to a diagnostic role, the neuropsy-
or in pediatric neurology. Although there are other chologist is in the position (has the expertise) to assist
settings (i.e., family practice) or outlets for the prac- with behavioral management, family and school in-
tice of clinical child neuropsychology, this chapter tervention, as well as individual supportive
psychotherapy.
ERIN D. BIGLER Department of Psychology, University

of Texas at Austin, Austin, Texas 78712; and Austin Neurological Identification of the Problem
Clinic, Austin, Texas 78705. NANCY L.
NUSSBAUM Learning Diagnostic Center/ Austin Neu- As portrayed in Figure 2, there is a considerable
rological Clinic, Austin, Texas 78705. overlap between the medical and the neuropsycholo-
557
SS8 CHAPTER 30
TABLE 1. Pediatricians' Estimates of the Number of Children in Their

Practices with Handicapping Conditionsa
Reponed no. of
children
Disability Mean Range
Specific learning disability (as defined by physician or school) 50.6 0-300

Hyperactive/minimal brain dysfunction (as defmed by physician) 33.3 0-400
Language/speech impainnent (excluding developmental articulation problems) 29.3 0-100
Mental retardation (mild to profound) 27.0 0-250
Cerebral palsy (mild to severe) 14.1 0-150
Hearing impairment (nontransient conductive or sensorineural-mild to profound) 10.6 0-250
Serious emotional disturbance (as defined by physician) 8.2 0-100
Legally blind 2.1 0-50
8 Modified from Shonkoff et al. (1979).
gical sphere regarding the child with developmental related to the accurate diagnosis and definition of the
problems. Accordingly, this requires that there be a presenting problem.
systematic and integrated approach toward the detec- The overlapping area in Figure 2 illustrates the
tion, evaluation, and treatment of developmental dis- type of information that the child neuropsychologist
orders. A crucial dimension of such an approach is is uniquely suited to provide the medical practitioner
Yisn 1
History Direct Treatment Route
Physical Examination
Vision-Heertng Screen Possible Treatment Route
Disperse! of Questionnaires
1
VIsit 2
Neurodevelopmental
Assessment ---------------------------
Parent Conference
Review Test Results
Objectives --------------------------
Recommendations
I Medicel Intervention I Behavioral Management

Family Intervention
1
I Follow-up ~- ---
---
------- School Consultation
Indi vi due I Psychother11py FIGURE I. An office-based appro~K:h to
children with developmental problems.
(Modified from Dworkin et al., 1981.)
CHILD NEUROPSYCHOLOGY IN THE PRIVATE MEDICAL PRACTICE 559
Gross & Fine Motor

Viouel/Spetiel Processing Physico! Development
Sequential Proceni 114
Auditory/Verbal Processing
Body/Sensory A'Wareness Hearing/Vision
Cognitive Depelopment
Personality/Behavioral
FIGURE 2. Components of the assessment of children. (Modified from Dworkin & Levine, 1980.)
(this topic area has been more completely addressed organization of the measures into these areas can be
by Fletcher & Taylor, 1984). Information pertaining useful when the referral question calls for a more
to these particular areas of functioning can be consid- restricted rather than a comprehensive evaluation.
ered critical for the accurate diagnosis and definition For example, if the child's pediatrician has a specific
of childhood developmental problems. question regarding only the child's personality/be-
Using a carefully chosen battery of assessment havioral functioning, then the battery may be modi-
techniques, the neuropsychologist is able to thor- fied to focus on this referral question.
oughly define the child's ability structure. The The overlapping among the areas presented
neuropsychologist can provide information regard- above is indicative of the point that very few mea-
ing the child's strengths and weaknesses through the sures of ability are pure, but are more often interde-
selection of a broad range of developmentally struc- pendent. This is especially true for more complex or
tured tests. It is important to emphasize that these higher level areas of functioning such as cognition
measures should be chosen and interpreted within a and memory. Thus, it is the job of the trained child
developmental context; therefore, the use of nor- neuropsychologist to interpret the results from a bat-
mative data is essential in evaluating the individual tery of tests in a meaningful way. For example, if a
child (Fletcher & Taylor, 1984). child does poorly on the Digit Span subtest of the
Next, some specific methods for obtaining this WISC-R, is it due to an attentional problem, a memo-
developmental information will be discussed. The ry deficit, an auditory processing problem, or some
battery of assessment techniques given in Table 2 has combination of these three areas? One must attempt
been developed at the Austin Neurological Clinic in to integrate information gathered from a wide variety
order to provide a comprehensive evaluation of of sources to provide a complete understanding of the
neuropsychological functioning in children (Nuss- individual child. The meaningful interpretation of in-
baum, Bigler, & Koch, 1986). It was felt that the formation gathered through neuropsychological as-
measures included in this battery provided the neces- sessment is the truly unique capacity that the neuro-
sary information to the medical practitioner and other psychologist brings to a private medical setting.
professionals for the accurate diagnosis and remedia-
tion of the child with developmental dysfunction. Communication of Assessment Results
The measures included in the Comprehensive
Austin Neuropsychological Assessment Battery for The final stage in the process of consultation by
Children (CAN-ABC) have been found to be useful the neuropsychologist is the communication of the
in providing the pediatrician with the data needed to assessment results. The importance of this stage can-
accurately diagnose and plan remediation for the not be overemphasized for it is at this point where it is
child with developmental problems. The measures in determined whether or not the information gathered
this battery were selected to provide comprehensive during the evaluation can be used efficaciously by the
information in the areas shown in the overlapping pediatrician. The clear and effective communication
zone in Figure 2. As shown in Table 3, information of assessment results is crucial for the accurate diag-
obtained from the CAN-ABC can be organized in nosis and appropriate intervention for the child with
terms of these overlapping areas. In addition, the developmental problems.
TABLE 2. The Comprehensive Austin Neuropsychological Assessment
Battery for Children (CAN-ABC)a
General physical features
Physical measures Lateral dominance Physical anomalies
-Height -Hand -Facial features
-Weight -Foot -Epidennal features (e.g., cafe
-Visual acuity -Eye au lait spots)
-Head circumference -Hands
-Other anomalies (e.g.,
steepled palate)
The Halstead Neuropsychological Test Battery for Children and the Reitan-lndiana Neuropsychological
Test Battery for Children (selected subtests)b
Motor
1. Strength of grip
2. Finger oscillation
-Electric-5- to 8-year-olds
-Manual-9 and older
Tactual Performance Test
1. 6 fonn/horizontal-5- to 8-year-olds
2. 6 fonn/vertical-9- to 14-year-olds
3. 10 fonn/vertical-14 to adult
4. Sequin/Goddard (Anastasi, 1969)-poor cooperation, or under age 5
Sensory-Perceptual Exam
l. Tactile
-Single, double simultaneous, ipsilateral, and contralateral
2. Auditory
-Single, double simultaneous
3. Visual
-Upper, middle, lower visual fields
-Single, double simultaneous
-Visual fields
4. Finger recognition
5. Finger graphesthesia
-5- to 8-year-old, symbols X's and O's
-9 to adult, numbers
6. Fonn recognition
-Included if the child scores one standard deviation below the mean on tactile, finger
recognition, and/or finger graphesthesia
Reitan-Aphasia Screening Battery (Halstead & Wepman, 1959; Selz & Reitan, 1979)
1. 5- to 8-year-old fonn
2. 9 and older fonn
Wide Range Achievement Test (Jastak & Jastak, 1965)
1. Reading (primarily a test of reading recognition)
2. Spelling (provides quantitative spelling level)
3. Arithmetic
4. Preacademic tasks as indicated
Bader Test of Reading and Spelling Patterns (Boder & Jarrico, 1982)
1. Provides qualitative information on spelling/reading
Durrell Analysis of Reading Difficulty (selected subtests) (Durrell & Catterson, 1980)
1. Silent reading (measure of reading comprehension)
2. Oral reading (measure of visual/auditory processing and reading comprehension)
3. Listening comprehension (measure of auditory/verbal comprehension)
Beery Test of Visual/Motor Integration (Beery, 1982)
1. Measure of perceptual motor ability
Raven's Coloured Progressive Matrices (Raven, 1965)
1. Measure of nonverbal abstract reasoning
Wechsler Intelligence Scale for Children-Revised (Wechsler, 1974)

I. Verbal IQ subscales (infonnation, vocabulary, similarities, arithmetic, comprehension)
2. Perfonnance IQ subscales (picture completion, block design, object assembly, picture arrangement,
coding)
3. Digit span
Family history questionnaire
I. Background infonnation
2. Pregnancy history
3. Birth history
4. Developmental history
5. Medical history
6. School history
Child Behavior Checklist-Revised (Achenbach & Edelbrock, 1983)
I. Provides an easily reviewed list of possible behavior problems
2. Provides quantitative scores on such personality scales as Depression, Aggression, etc.
Personality Inventory for Children-Revised (Wirt, Lachar, Klinedinst, & Seat, 1982)
1. Provides quantitative scores on such personality scales as Depression, Aggression, etc.
Projective Drawings
I. House/tree/person (Buck, 1948), kinetic family drawings (Burns & Kaufman, 1972)
-provide qualitative infonnation on self-concept, family dynamics, etc.
Behavioral observation inventory
I. Provides a short informal assessment of behaviors observed during !he evaluation
Additional measures included as needed

Benton Visual Retention Test (Benton, 1974)
-included if:
1. questionable ADHD problems
2. deficient visuomotor performance (Beery) leads to questions about deficits in visual memory versus
visuomotor coordination
Kaufman Assessment Banery for Chikken (Kaufman & Kaufman, 1983)
-included if:
1. marginal or questionable LD
2. more in-depth information is needed concerning child's nonverbal intellectual abilities
3. particularly useful subscales
Hand Movements (useful attentional measure)
Gestalt Closure (useful visual processing measure)
Matrix Analogies (useful nonverbal reasoning measure)
Spatial Memory (useful visual memory measure without a motor confound)
Other
Halstead Neuropsychological Test Battery for Children subtests
Administered to 9- to 14-year-olds as indicated
1. Trails A (measure of sequential visual processing, attention)
2. Trails B (measure of sequential visual processing, attention, cognitive flexibility)
3. Seashore Rbylhm Test (measure of sequential auditory processing, attention, auditory memory)
4. Speech Sounds Perception Test (measure of auditory processing, attention, sight/sound matching)
aMeasures are scored according to individual norm tables provided with each specific test or according to nonnative
infonnation provided by Spreen and Gaddes (1969) or Knights and Norwood (1980).
~>Reitan & Davison, 1974.
findings so that the presenting questions may be an-

The Neuropsychological Report swered. Sufficient background history should be re-
ported to answer any questions concerning pregnan-
The exemplary report should always start with a cy, birth and delivery, developmental milestones,
specific presenting or identified problem. This per- and medical history that may be salient variables re-
mits focusing the results of the consultation and test lated to the presenting problem(s).
562 CHAPTER 30
TABLE 3. The Organization of Neuropsychological Test Results

Motor (fine and gross) Tactual Performance Test (memory for objects and location)
Strength of grip Seashore Rhythm Test
Finger oscillation Cognitive development (knowledge, reasoning)
Tactual Performance Test Raven's Coloured Progressive Matrices
Beery Test of Visual/Motor Integration WISC-R (Information, Vocabulary, Similarities, Arithmetic,
WISC-R (Block Design, Object Assembly, Coding) Comprehension, Picture Arrangement)
Visllllll spatial processing K-ABC (Matrix Analogies)
Visual acuity Auention
Sensory-perceptual exam (visual exam) Sensory-Perceptual Exam (tactile, auditory, visual,
Beery Test of Visual/Motor Integration finger recognition, finger graphesthesia)
Benton Visual Retention Test Benton Visual Retention Test
Trails A & B Trails A & B
Tactual Performance Test Seashore Rhythm Test
Reitan-Aphasia Screening Battery Speech Sounds Perception Test
(Visual Constructional tasks) Durrell (listening comprehension)
K-ABC (Hand Movements, Gestalt closure) WISC-R (Arithmetic, Picture Completion, Coding, Digit
WISC-R (performance IQ subscales) Span)
Body awareness K-ABC (Hand Movements)
Sensory-Perceptual Exam errors (tactile, finger recognition, Child behavior checklist
finger graphesthesia, fonn recognition) Academic skills
Tactual Performance Test Reitan-Aphasia Screening Battery (reading, spelling,
Auditory verbal processing arithmetic tasks)
Sensory-Perceptual Exam errors (Auditory) Wide Range Achievement Test (reading, spelling,
Seashore Rhythm Test arithmetic, preacademic tasks)
Speech Sounds Perception Test Boder Test of Reading and Spelling Patterns
Durrell (listening comprehension) Durrell (silent reading, oral reading,
WISC-R (verbal IQ subscales) listening comprehension)
Peabody Picture Vocabulary Test-Revised (1981) WISC-R (Arithmetic)
Sequential processing Personality/behavioral
WISC-R (Digit span, picture arrangement) Child Behavior Checklist
K-ABC (Hand Movements) Personality Inventory for Children-Revised
Trails A & B Projective drawings
Seashore Rhythm Test Behavioral observation inventory
Memory Psychosocilll factors
WISC-R (Digit span) Parent interview
Benton Visual Retention Test Family history questionnaire
K-ABC (Spatial memory, Hand Movements) Child behavior checklist
Durrell (silent reading-unstructured story recall;
listening comprehension-structured story recall)
In the next section of the neuropsychological tioning, and to provide the reader with ready access
report, a listing of the tests administered during the to pertinent information.
evaluation should be provided. This informs the The next section containing the evaluation sum-
reader of the specific measures that were used to mary and clinical impression is of critical impor-
obtain information regarding the child's ability struc- tance. It is in this section that the results of the assess-
ture or behavioral characteristics. ment are summarized and integrated in order to
As shown in Table 4, the section containing the provide a holistic understanding of the child's func-
assessment results has been divided into subsections tioning. In addition, this section contains the child's
dealing with the child's intellectual/cognitive func- DSM-III-R classification when such a categorization
tioning, academic abilities, neuropsychological is appropriate.
functioning, and personality /behavioral characteris- Finally, appropriate recommendations should
tics. We have found that it is useful to have the eval- be made based on the results of the assessment. These
uation results divided into these subsections in order recommendations should contain general as well as
to provide an organized picture of the child's func- specific information that may be helpful in treatment
TABLE 4. Format of the Neuropsychological Report
Presenting problem Language

Referral question (e.g. , presenting seizures) Articulation
Background history Receptive
Genetic history (e.g., Down's Syndrome, epilepsy) Expressive
Pregnancy (e.g., complications-alcohol use, etc.) Naming
Birth and delivery (e.g., complications-forceps, etc.) Spelling
Neonatal history (e.g. , birth weight) Reading
Medical history (e.g. , significant head injuries) Calculations
Family history (e.g., parents' education, LD in the family) Memory
Verbal
Tests administered
Visual/spatial
Assessment results General cognitive
Intellectual/ cognitive functioning
PersonalityI emotional functioning
IQ scores
Behavioral observations-subjective findings
Subtest scores
Projective test results
Clinical description/ interpretation
Projective drawings
Academic functioning
Thematic testing
Achievement scores
Rorschach (1942)
Clinical description/ interpretation
Objective personality scores/patterns
Neuropsychological test findings
Clinical summary
, Physical stigmata/physical measurements
Hand, eye, and foot dominance Clinical impression
Motor functioning Summary and integration of assessment results
Fine motor DSMlliR fonnat followed when appropriate
Gross motor
Recommendations:
Praxic ability
1. To referring doctor, including therapists
Visuomotor copying
who the child may be seeing
Sensory perceptual functioning
2. To school
Vision (acuity/fields)
3. To parents
Hearing
4. When to follow up
Tactile (double simultaneous)
5. Miscellaneous
Graphesthesia
Stereognosis
Finger gnosis
planning for the child. The important point that must Case Study Material
be emphasized here is that the recommendations
should clearly follow from the results of the eval- Next, a case study will be presented to illustrate
uation. the type and format of information typically obtained
in a neuropsychological assessment. First, the raw
Follow-up Conference data will be presented in terms of how they can be
conceptually organized as outlined in Table 3. Sec-
The parents play a focal role in assuring that ond, the results of the evaluation will be presented in
appropriate recommendations are followed; accord- the report format shown in Table 4 in order to
ingly, considerable effort should be directed at illustrate the communication of neuropsychological
providing a clear understanding on the parents' part. findings.
Typically, this will require at least an hour con- The case of JB presented in Table 5 and 6 illus-
ference to review test results and outline potential trates the way in which results from the neuropsy-
treatment options where appropriate. Also it is most chological evaluation can be communicated to the
helpful to have various reading lists available to the physician in report format. The goal of the neuropsy-
parents so that they can pursue on their own further chologist in writing the neuropsychological report is
enlightenment pertaining to the nature of their child's to: (1) address the specific referral question(s); (2)
problems. thoroughly present relevant test results; (3) pro-
564 CHAPTER 30
TABLE 5. Case Presentation for JB: Results of the Comprehensive

Austin Neuropsychological Assessment Battery for Children
Name: JB Education: 2nd grade Date: 1124/84
Age: 8 years, 1 month Race: Caucasian Examiner: MH
Sex: Male Location: Austin Neurological
Motor (fine and gross)

Strength of grip
Dominant hand= 15; Nondominant = 12.2
Finger oscillation
Dominant hand = 39.8; Nondominant = 35.2
SS* = 106 SS = 106
Tactual performance test
Dominant = 5.9; Nondominant = 4.1; Both= 1.5; Total= 11.5
ss = 99 ss = 99 ss = 100 ss = 100
Beery Test of Visual/Motor Integration
SS = 10; Percentile = 60; Age Equivalent = 7,9
WISC-R (Block Design, Object Assembly, Coding)
BD = II, OA = 13; Cod = 12
Visual/ spatial processing

Visual acuity
Uncorrected: Right = 20/50; Left = 20/30
Corrected: Right = 20/20; Left = 20/20
Sensory-perceptual exam (Visual exam)
Visual fields = Normal to simple confrontation
DSS errors: Right = 1; Left = 0
ss = 76 ss = 106
Beery Test of Visual/Motor Integration
SS = 10; Percentile= 50; Age equivalent= 7,9
Benton Visual Retention Test (normed IQ = 91, age = 8)
Expected correct = 2; Obtained correct = 5
Expected errors = 12-13; Obtained errors = 8
Errors: Right visual field = 4; Left visual field = 3
Trails A and B
Trails A = 43 sec, 0 errors Trails B = 52 sec, 0 errors
(9 y.o. X = 21 sec) (9 y.o. X = 49)

Memory = 3; Location = 0
ss = 84 ss = 74
Reitan-Aphasia Screening Battery (visual constructional tasks)
Within normal limits
K-ABC (Hand Movements, Gestalt Closure)

HM=8 GC=7
WISC-R {performance IQ = 102)
(Picture Completion, Picture Arrangement, Block Design, Object Assembly, Coding)
PC = 8 PA = 8 BD = 11 OA = 13 Cod = 12
Body awareness
Sensory-perceptual exam errors (tactile, finger recognition, finger graphesthesia, form recognition)
Tactile: DSS, Right = 0; Left = I
ss = 114 ss = 95
Finger Graphesthesia: Right = 0; Left = 0
ss
= 121 ss = 119
Finger Recognition: Right = 3; Left = 3
ss 70 = ss = 80
Dominant= 5.9; Nondominant = 4.1; Both = 1.5; Total 11.5 =
ss = 99 ss = 99 ss = 100 ss = 100
Auditory verbal processing
Sensory-perceptual exam errors (auditory)
Right = 0; Left = 0
ss = 105 ss = 108
Seashore Rhythm Test
Not applicable for this age
Speech Sounds Perception Test
Durrell (listening comprehension)
LC = second grade level
WISC-R (information, similarities, arithmetic, vocabulary, comprehension)
Info = 5; Sim = 6; Arith = ll; Voc = 7; Verbal IQ = 82
Peabody Picture Vocabulary Test-Revised (1981)
Mental Age Score =
5 years, 11 months;
ss = 75
Sequential processing
WISC-R (Digit span, Picture Arrangement)
DS = 6 PA = 8
K-ABC (Hand Movements)
HM= 8
Trails A and B
Trails A = 43 sec, 0 errors; Trails B = 52 sec, 0 errors
(SS, see above)
Memory
WISC-R (Digit Span)
DS = 6
Benton Visual Retention Test (norrned IQ = 91, age = 8)

Expected correct = 2; obtained correct 5 =
Expected errors = 12-13; obtained errors = 8
K-ABC (Spatial Memory, Hand Movements)
SM=7 HM=8
(continued)
566 CHAPTER 30
Dunell (silent reading-unstructured story recall; listening comprehension-structured story recall)

SR = Poor LC = Fair
Tactual performance test (memory for objects and location)
Memory = 3; Location = 0
ss = 84 ss = 74
Cognitive development (knowledge, reasoning)

Raven's Coloured Progressive Matrices
Percentile =
50
WISC-R (information, vocabulary, similarities, arithmetic, comprehension, picture arrangement)
Info = 5 Voc = 7 Sim = 6 Arith = II Comp = 7 PA = 8
K-ABC (matrix analogies)

MA = 11
Anention
Sensory-perceptual exam (tactile, auditory, visual, finger recognition, finger graphesthesia)
Tactile: DSS, Right = 0; Left = I
Auditory: Right = 0; Left = 0
Visual, DSS: Right = I; Left = 0
Finger Recognition: Right = 3; Left = 3
Finger Graphesthesia: Right = 0; Left = 0
(For SS, see above)
Benton Visual Retention Test
Expected correct = 2; Obtained correct = 5
Expected errors = 12-13; Obtained errors = 8
Trails A & B
Trails A = 43 sec, 0 errors; Trails B = 52 sec, 0 errors
(SS, see above)
Dunell (Listening Comprehension)
LC = 2nd grade level, fair structured recall
WISC-R (Arithmetic, Picture Completion, Coding, Digit Span)
Arith = 11 PC = 8 Cod = 12 DS = 6
K-ABC (Hand Movements)
HM = 8
Child Behavior Checklist
Mild attentional problems noted
No attentional problems noted on informal observation
Academic skills
Reitan-Aphasia Screening Battery (reading, spelling, arithmetic tasks)

Reading errors noted
Standard Score Grade Equivalent Percentile
Reading 89 2.4 23
Spelling 99 2.8 47
Arithmetic 105 3.1 63
Boder Test of Reading and Spelling Patterns

Reading/Spelling Pattern = Dysphonetic Type
Durrell (silent reading, oral reading, listening comprehension)
SR = Middle I st OR = Lower 1st LC = 2nd grade
WISC-R (arithmetic)
Arith = II
Personality! behavioral
Child Behavior Checklist (scale elevations above 70)
Aggressive, Internalizing, Anxious, Depressed
Personality inventory for children-revised (scale elevations above 70)
Adjustment, depression, withdrawal, anxiety
Projective drawings
House/Tree/Person: sparse, vacant, small, human stick figures
Poor eye contact, withdrawn, no spontaneous speech, brief verbal response
Psychasociol factors
Parent interview (significant points)
Slow progress in school, father reported similar learning problems, school phobia, temper
outbursts
Family history questionnaire (significant points)
Normal pregnancy, induced labor, forceps delivery, developmental milestones within normal
limits, allergies
Child behavior checklist
Noted to have poor peer and family interactions
SS = Standard score.
TABLE 6. Neuropsychologica l Assessment Report (Based on Data in Table 5)

Child's name: JB
Clinic number: 99999
Assessment date: 1/24/84
Presenting problem
This child was referred by Dr. K., pediatric neurologist, for a comprehensive neuropsychological evaluation due to questions concerning
a possible learning disorder.
Background history
JB was an 8-year-Qid boy who was in the second grade at the time of assessment. He had been referred for neuropsychological evaluation
due to inadequate academic progress and behavioral problems.
This child's medical history showed that he was the product of a full-term, normal pregnancy. InJB's birth history, it was reported that
labor was induced and he was delivered using forceps. His developmental milestones were reported to be within normal limits. He
crawled at approximately 7 months, walked at 12 months, and started saying his first words at about I year of age.
JB's parents were reported to have high school educations. His father was self-employed as a plumber and his mother was not employed
outside the home. Also, JB's father reported that he may have experienced similar learning problems as a child.
In addition, as part of his evaluation, JB received an electroencephalogram that showed sharp wave activity over the left temporal region
which suggested left temporal lobe dysfunction. No electroencephalographic seizure activity was noted. There were no other significant
findings in JB's medical history except that he was noted to have an allergy to milk and pollens.
(continued)
568 CHAPTER 30
Table 6. (Continued)
Tests administered
Comprehensive Austin Neuropsychological Assessment Battery for Children (CAN-ABC)
Wechsler Intelligence Scale for Children-Revised
Kaufman Assessment Battery for Children
Boder Reading-Spelling Test
Durrell Analysis of Reading Difficulty
Peabody Picture Vocabulary Test-Revised
Reitan-Indiana Neuropsychological Test Battery for Children
Raven's Coloured Progressive Matrices
Benton Visual Retention Test
Beery Visuo-Motor Integration Test
Behavioral Observations Inventory
Personality Inventory for Children
Child Behavior Checldist
Test results
Cognitive /intellectual functioning
WISC-R results
Full scale IQ = 91
Verbal IQ score= 82 Performance IQ score = 102
Information 5 Picture completion 8

Similarities 6 Picture arrangement 8
Arithmetic II Block design II
Vocabulary 7 Object assembly 13
Comprehension 7 Coding 12
(Digit Span) 6
K-ABC results
Mental processing composite = 83
Sequential processing = 74 Simultaneous processing 93
Hand movements 8 Gestalt closure 7
Number recall 5 Triangles 13
Word order 4 Spatial memory 7
Photo series 7
Raven's CPM Results: 50th percentile
Results of intellectual assessment indicated m 's level of intellectual functioning to be in the average to low average range. On the WISC-
R, m was found to have severely discrepant performance between the PIQ and VIQ scales, with his VIQ score over one standard
deviation below his PIQ score. He exhibited a great deal of scatter in his subtest scores, with particularly deficient performance on the
Information, Similarities, and Digit Span subtests of the VIQ scale. Similarly, on the K-ABC, ms score on the Sequential scale was over
one standard deviation below his Simultaneous scale score. He scored especially low on the Number Recall and Word Order subtests of
the Sequential scale. In addition, m scored at the 50th percentile on Raven's CPM, a test of perceptual discrimination and abstract
reasoning. Also, m showed adequate performance on the Beery Test of Visual/Motor Integration. His score on this test showed his
visual/motor skills to be at age level. Likewise, ms performance on the Benton Visual Retention Test was also within normal limits.
In general, it appeared that ms overall intellectual functioning was in the normal range, but he exhibited an abnormal pattern of
performance. His intellectual profile showed significantly more impaired verbal and sequential abilities than visual/constructional
abilities.
CHILD NEUROPSYCHOLOGY IN THE PRIVATE MEDICAL PRACI'ICE S69
Academic functioning
WRAT results
Grade level equivalent Standard score Percentile
Reading 2.4 89 23
Spelling 2.8 99 47
Arithmetic 3.1 105 63
Boder Test of Reading and Spelling Patterns

Reading/Spelling Pattern: Dysphonetic
Durrell Analysis of Reading Difficulty
Silent Reading =Middle 1st; Oral Reading = Lower 1st
Listening Comprehension = 2nd
Peabody Picture Vocabulary Test
Age equivalent = 5 years, II months; Standard Score = 75
On the WRAT, JB was found to have grade level academic skills, with slightly better arithmetic than reading and spelling abilities.
However, on the Durrell, JB's reading and language scores were below grade level. He was noted to have particular difficulties with
sound/symbol associations, and his reading comprehension was found to be quite poor. Similarly, JB scored over one and a half standard
deviations below the mean on the Peabody Picture Vocabulary Test-Revised (1981). Also, JB was reported to sometimes make
semantic substitutions in his reading. For example, when the stimulus word was "house" he responded with "home" and "her" was
read as "she," also "horse" was read as "pony." These types of reading and spelling errors have been associated with a dysphonetic
type of dyslexia (Boder & Jarrico, 1982).
In general, findings from achievement testing indicated that JB had some basic academic skills, such as word identification skills and
basic calculation skills. However, he also exhibited marked deficiencies in other academic areas, such as reading comprehension and
vocabulary development.
Neuropsychological functioning
At the time of the examination, this child stood 50 inches in height and weighed 54 pounds. His head circumference was measured at 53
centimeters. IB was right hand, foot, and eye dominant. No abnormal morphological physical characteristics were noted on a brief
physical examination.
Reitan-lndiana Neuropsychological Test Battery for Children

Test results for the Reitan-Indiana Battery were essentially within normal limits. His motor findings on the finger oscillation and strength
of grip test were in the normal range. However, on the Sensory Perceptual Exam, JB did exhibit mild, bilateral finger dysgraphesthesia,
but these results in isolation were not found to be clinically significant.
Language screening
On the Reitan-Aphasia Screening Test, JB was found to make numerous reading errors. He also exhibited marked dysnomia on the
Peabody Picture Vocabulary Test with an age equivalent score of only 5 years II months. (See the Intellectual and Academic sections for
a review of other pertinent information.)
Visual/perceptual tests
Graphomotor ability on the Beery VMI was approximately at age level. JB scored at the 7 year 9 month level with a standard score of 10,
which placed him at the 50th percentile.
Memory assessment
Test results from a wide variety of sources indicated that JB was having some difficulties with both verbal and visual/spatial memory. He
exhibited deficient performance on the recall of verbal information from the WISC-R, K-ABC, and the Durrell. Similarly, he showed
deficits in visual/spatial memory on the K-ABC and the Tactual Performance Test.
(continued)
570 CHAPTER 30
Summary of neuropsychological test results

Results from the neuropsychological assessment were in general agreement with other test results reviewed to this point. JB seemed to be
showing greater problems in the area of verbal language functioning than visual/spatial functioning. He also exhibited some memory
difficulties which may have been related attentional deficits.
Personality/ behavioral functioning
Objective data
JB was found to have significant elevations on the following scales from the Personality Inventory for Children (PIC) and the Child
Behavior Checklist (CBC): Depression, Anxiety, and Aggression. Also, his scale score on PIC-Withdrawal was over one and a half
standard deviations above the mean, which indicated significant problems with withdrawal.
It was reported that JB had apparently had some difficulty separating from his parents. He developed some form of school phobia during
kindergarten, and would become physically ill prior to school. This behavior apparently abated after several weeks of school attendance.
His teacher at the time of assessment noted that JB was a tense, shy child. He was also reported to have occasional temper tantrums with
his parents and siblings.
During assessment, the examiner noted that JB was very quiet and reserved throughout the examination. He was observed to be
cooperative, but in a passive way in that rapport was never established and he did not appear to become engaged during the evaluation. He
was reported to initiate no spontaneous conversation, and he had poor eye contact. Similarly, his affect was noted to be somewhat flat and
depressed.
Subjective data
JB's projective drawings were found to be somewhat vacant and sparse. He drew a very small, simple tree. Likewise, his human figure
drawings were sticldike. They were also quite small and placed at the bottom edge of the page. These findings may have indicated
significant self-esteem and adjustment problems.
Summary of personality/behavioral findings

In summary, JB appeared to have been experiencing general problems in the area of social interaction. Specifically, he seemed to be
showing internalizing-type problems with features of depression, anxiety, and withdrawal.
Clinical impression
In summary, this child performed poorly on a number of verbal/language/sequential tasks typically thought to be dependent on left-
hemisphere functioning; whereas he exhibited relatively intact visual-spatial functioning. Such findings suggested a probable left-
hemisphere-based learning disorder. This interpretation was supported further by abnormal EEG findings in the left temporal region.
In addition, at the time of the evaluation, JB appeared to be experiencing a number of significant emotional and adjustment problems
related to depression and impaired socialization.
DSM-III-R classification
Axis I: (309.28) possible childhood adjustment disorder with mixed emotional feature
Axis ll: (315.9) developmental disorder (learning disability)
Axis III: abnormal EEG (left temporal, sharp wave activity)
Recommendations
Given the results of JB's neuropsychological assessment, it is recommended that he receive special education services. With respect to the
special education curriculum, this child would probably benefit from a remediation program that focused on verbal/language training.
Some of JB 's verbal expression problems may be related to anxiety and a lack of spontaneity in social discourse. Thus, there may be some
improvement in his level of functioning as he becomes more relaxed and comfortable in communicating with others. In addition, because
of his verbal/language difficulties, JB may not have acquired the necessary interpersonal skills for good social interaction, which may
have led to depression and withdrawal. Compounding these problems were also left-hemisphere-based academic difficulties, which may
have aggravated self-esteem and adjustment problems. It is therefore recommended that he participate in a language enrichment program
with a qualified speech/language therapist in order to increase his confidence and social appropriateness in communication.
CHILD NEUROPSYCHOLOGY IN THE PRIVATE MEDICAL PRACI'ICE 5'71
In addition, JB appeared to show some significant problems with emotional adjustment. These findings indicated that he may benefit from
some supportive counseling that would focus on social skills training to improve the quality of his peer and family relationships. This
intervention should also take advantage of the strengths JB has in some nonverbal areas. Furthennore, his parents should encourage his
participation in other nonacademic activities that would help promote positive self-esteem.
Finally, JB 's progress should be closely monitored, and he should return for follow-up testing on an annual basis for the next two to three
years.
vide a clinicai interpretation of the data; (4) present Benton, A. (1974). The Revised Visual Retention Test (4th ed.).
pertinent recommendations; (5) communicate these New York: Psychological Corporation.
points clearly and effectively. Boder, E., & Jarrico, S. (1982). The Boder Test of Reading-
SpeUing Patterns: A diagnostic screening test/or subtypes of
reading disability. New York: Grone & Stratton.
Buck, J. (1948). House-tree-person test. Journol ofClinical Psy-
Summary chology, 4, 151-159.
Burnett, R., & Bell, L. (1978). Projecting practice patterns. Pedi-
The role of the child neuropsychologist in the alrics, 62(Suppl.), 625-680.
private medical practice is that of an expert consul- Bums, R., & Kaufman, S. (1972). Actions, styles and symbols in
tant. Due to the increasing identification and referral kineticftunily drawings. New York: Brunner/Mazel.
of children with developmental disorders (Dworkin, Dunn, L. M., & Dunn, L. M. (1981). Peabody
Picture Vocabll-
lary Test-Revised (PPVT-R). Circle Pines, Minnesota:
1985) to pediatricians, there is a growing recognition
American Guidance Service.
of the need for better diagnostic and remediation Durrell, D., & Catterson, J. (1980). D11rrellAnalysis of Reading
techniques. The child neuropsychologist is uniquely Difficllity. New York: Psychological Corporation.
suited to provide relevant information to the child's Dworkin, P. (1985). Learning and behllvior problems of school-
physician to aid in the delineation of problem areas children. Philadelphia: Saunders.
and to assist in formulating an appropriate interven- Dworkin, P., & Levine, M. (1980). The preschool child: Predic-
tion strategy. tion and prescription. In A. Scheiner & I. Abroms (Eds.), The
Specific information was presented earlier in practical mJZnagement ofthe developmentally disabled child.
this chapter outlining one test battery that has been St. Louis: Mosby.
developed to provide a comprehensive evaluation of Dworkin, P., Woodrum, D., & Brooks, K. (1981). Pediatric-
based assessment: Children with school problems. J0117111ll of
the child's neuropsychological functioning (see
School Health, 51, 325-329.
Table 2). The CAN-ABC is just one battery of tests Fletcher, J., & Taylor, H. ( 1984). Neuropsychological assessment
that can be used to obtain this type of information. of children: A developmental approach. Texas Psychologist,
The important feature is that a comprehensive and 36(3), 14-20.
integrative approach be used in the assessment of the Halstead, W., & Wepman, J. (1959). The Halstead-Wepman
individual child. Aphasia Screening Test. Journol ofSpeech and Hearing Dis-
In addition, a report format was presented to orders, 14, 9-15.
illustrate the organization and communication of the Jastak, J., &Jastak, S. (1965). The Wide Range Achievement Test
evaluation results (see Table 4). Finally, a case study mJZnual. Wilmington, DE: Guidance Associated.
Kaufman, A., & Kaufman, N. (1983). KtlllfmonAssessrMntBat-
was provided to exemplify the type of information
tery for Children: Administralion and Interpretive Manual.
gathered and the way in which it can be communi-
Circle Pines, MN: American Guidance Service.
cated to the child's physician. Knights, R., & Norwood, J. (1980). Revised smoothed normative
datil on the ne11ropsychological test battery for children. Ot-
tawa, Canada: Robert M. Knights Psychological
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Nussbaum, N., Bigler, E., & Koch, W. (1986). Neuropsycholo-
Achenbach, T., & Edelbrock, C. S. (1983). The Child Belulvior gical1y derived subgroups of learning disabled children: Per-
Checklist-Revised. University of Vennont: Burlington, sonality/behavioral dimensions. Journal of Research and
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Anastasi, A. (1969). Psychological testing (3rd ed.). London: Ravens, J. C. (1965). Guide to using the colored progressive
Macmillan & Co. mJZtrices. London: H. K. Lewis.
Beery, K. (1982). Revised administralion, scoring and teaching Reitan, R., & Davison, L. (1974). Clinical neuropsychology:
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tion. Cleveland: Modem Curriculum Press. Rorschach, H. (1942). Psychodi4gnostics: A dillgnostic test based
572 CHAPTER 30
on perception (P. Lemkau & B. Kranenburg, trans.). Bern: teen neuropsychological tests for ages 6 to 15. Cortex, 5,
Huber (U.S. distributor: Grone & Stratton). 171-191.
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Shonkoff, J., Dworkin, P., & Leviton. A. (1979). Primary care ED official says. Educational Handicaps, 9, 1-3.
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506-514. sonality Inventory for Children, Revised. Los Angeles: West-
Spreen, 0., & Gaddes, W. (1969). Developmental norms for fif- em Psychological Services.
31
Public Policy and Legal Issues for

Clinical Child Neuropsychology
ROBERT HENLEY WOODY
Clinical child neuropsychology has a myriad of Public Health Policy

forces that create countervalences for its definition,
identity, and placement in human services. While Of relevance to clinical child neuropsychology,
clinical neuropsychology, broadly defined, is still every person's health is influenced by society, and
striving to establish itself as capable of fulfilling a anything that connotes "welfare" seems to meet
function on behalf of human welfare, as would be with ambivalent attitudes from the public (AuClaire,
distinct from neurology, it must also justify being a 1984). That is, although the public wants to have a
specialization within clinical, counseling, and school healthy society, there is commonly a reticence to
psychology. In tum, clinical child neuropsychology grant social-health-welfare services total "sup-
must deal with the same issues, but must also carve port." As might be obvious, "support" goes beyond
out its uniqueness from clinical adult neuro- endorsement by policy-it requires funding, and this
psychology. provokes conflicting priorities:
The psychology of illness, and the importance that con-
sumers give to their own medical care, make policy
Public Policy. fonnulation particularly difficult. . . . There is agree-
ment that frivolous utilization and expenditures should
be discouraged, but few patients ever think their own
Clinical neuropsychology, be it for children or
problems frivolous or unworthy of the best care avail-
adults, is subject to the vicissitudes of public policy. able. (Mechanic, 1981, p. 82)
Public policy represents society's views, prefer-
ences, expectations, and demands. Authority to As detailed elsewhere (Woody, I985b), this is an era
achieve the objectives of public policy is vested in the wherein: (1) funding for human services has dimin-
governmental system: ished; (2) cost containment is the password to enter-
ing the domain of public policy; and (3) health policy
Public policies are developed by governmental institu-
tions and officials through the political process (or pol-
planning is plagued by competing and conflicting
itics). They are distinct from other kinds of policies objectives.
because they result from the actions of the legitimate
authorities in a political system. (Bullock, Anderson, Governmental Regulation
& Brady, 1983, p. 3)
Therefore, the political framework, which is con- One outcome is increased governmental reg-
stantly being altered (literally on a day-to-day basis) ulatory responsibility and authority over all profes-
has a major influence on public policy, which in turn sionals: "The atmosphere within which perennial
has a major influence on professional practices. issues of access, quality, and costs are considered
now involves formal public policies expressed in reg-
ulatory programs that are mandated and operated by
governments" (Bice, 1981, p. 12). Consequently,
ROBERT HENLEY WOODY Department of Psychology, all psychological practices, including (of course) by
University of Nebraska at Omaha, Omaha, Nebraska 68182. clinical child neuropsychologists, must receive rec-
573
574 CHAPTER 31
ognition, endorsement, and approval by the regulato- and the Divisions of (among others) Clinical Psy-
ry arm of the body of public policy relevant to health chology, Counseling Psychology, School Psychol-
care. ogy, and Clinical Neuropsychology will surely expe-
As clinical child neuropsychology develops, a dite the professionalization process for clinical child
first order of business must be to attain consonance neuropsychology. Specialty associations, such as the
with public policy. Fundamentally, it must be accept- National Academy of Neuropsychologists, will also
ed that the preexisting recognition, endorsement, and be facilitative. Nonetheless, public policy has not yet
approval assigned to clinical, counseling, or school embraced clinical neuropsychology to a satisfactory
psychology may not be automatically applied to degree.
clinical neuropsychology. This will be exemplified
later in the chapter in the discussion of the negativism
toward expert clinical neuropsychological testimony Professional Specialty Credentials
that has occurred in certain legal instances (Schwartz,
1987). Another means for promoting recognition, en-
dorsement, and acceptance of a specialty by public
policy is through a professional association's grant-
Determinations by the Profession
ing some sort of specialized credential. In psychol-
At this point, the emphasis should be on the ogy, there is the time-honored American Board of
profession's inability to self-ordain a psychological Professional Psychology (1984), which has here-
function, role, or specialty. There is no inalienable tofore administered an examination process for
right to operate as, say, a clinical child neuropsychol- awarding the status of Diplomate in the areas of
ogist-it must be accorded by society. To date, there clinical psychology, counseling psychology, school
is some doubt as to just how solidified are the recog- psychology, and industrial/ organizational psychol-
nitions, endorsements, and approvals via public pol- ogy. More recently, the Board (ABPP) has added
icy for neuropsychology generally and clinical child forensic psychology and clinical neuropsychology.
neuropsychology specifically. The ABPP' s program to award the status of Dip-
To earn this positive reception, a profession, lomate in Clinical Neuropsychology is conducted in
discipline, or specialty must have a proven track re- conjunction with the American Board of Clinical
cord of critiquing the would-be function, definition, Neuropsychology (ABCN). It is still in a fledgling
or role: state, and has not received uniform acceptance, even
among clinical neuropsychologists. For example, a
As society recognizes a profession, it imposes upon rival group, the American Board of Professional
that discipline a concomitant responsibility or duty-a Neuropsychology (ABPN), also grants Diplomate
set of expectations as to what should and should not
status (it is not, however, affiliated with the ABPP).
occur in professional practice. In other words, the quid
pro quo for societal recogniti!)n of professionalism is
Regrettably, the two neuropsychology boards have
professional accountability to society. (Woody, 1985a, repeatedly been at odds about standards. Some psy-
p. 509) chologists interpret these opposing views, allegedly
in service to establishing standards, as reflecting a
This mandate is typically fulfilled by a code of ethics battle for political power over clinical neuropsychol-
and a set of standards, as would be promulgated by a ogy and/or a skirmish between self-serving person-
professional association. alities.
The notion of having a specialty credential in
Professional Standards clinical neuropsychology to gain favor from public
policy is not necessarily hallowed. Aside from the
This introduces a problem for the clinical child possibility that competing politically motivated
neuropsychologist. Despite the many (too many?) forces within clinical neuropsychology could poten-
professional associations, there has yet to be a tially damage the specialty to the point of disarray
''homebase'' association for the clinical child neuro- and condemnation from the public and the profession
psychologist that provides the needed standards that of psychology (as well as the other health care profes-
are prescribed by public policy. sions) alike, it could well be that too much specializa-
The American Psychological Association has tion could prove to be detrimental to the profes-
meritoriously dealt with the issues of ethics (1981a) sionalization of clinical neuropsychology.
and specialty guidelines for the delivery of clinical First, it is feasible that overspecialization could
psychology (and other specialty) services (1981b), lead to faulty general underpinnings, both in academ-
PUBLIC POLICY AND LEGAL ISSUES 575
ics and in practices. Sarason (1987) raised the ques- . representative for clinical neuropsychology, one
tion ''what price do the student and the field pay for noted clinical neuropsychologist said, in effect,
specialization," regardless of level. He urged that "Let's face it, having a credential in clinical neuro-
this question be discussed, and cautioned that such psychology means money, that's why there is such
analysis and discussion may be preempted by a competition to become the source of the specialty
''marketplace mentality.'' Sarason sagely asserted: diplomate.''
The wrong motives could backfire on the spe-
The climate that provides no fonun for serious and
cialty of clinical neuropsychology (or any other spe-
sustained discussion is one that encourages early and
undue specialization. By undue I mean a degree of
cialty). Public policy usually reacts to battles within a
specialization that phenomenologically makes a part of profession as reason not to give endorsement. For
psychology the whole of it, that makes the student an example, discord between psychological special-
isolationist in the world of psychology. This happens ities, such as clinical psychologists' resisting the in-
unrcflectively and with the best of intentions. For me clusion of school psychologists in licensing laws, has
the question is not whether specialization should be a historically led to legislators' backing away from any
postdoctoral affair. The important question is: what governmental support, such as "sunsetting" a licen-
should be the core of the identity of a psychologist, sure statute. More certainly, motives that are more
regardless of special interest? (p. 37) self-serving for the professional than benefiting to the
In fairness to the previously mentioned programs for public could easily usher in a rejection within public
the status of Diplomate, there is a prerequisite of policy (such as, hypothetically, having language
being a psychologist first and a clinical neuropsy- within the statutory rules of evidence that would re-
chologist second (in other words, there are certain strict or negate courtroom testimony by a
core areas of psychological training that must predate neuropsychologist).
training in clinical neuropsychology), but Sarason's
question remains to be answered. The wrong answer
could be a harbinger of rejection by public policy. The Interface between Professional
Second, it seems feasible that the profession of
psychology could be damaged by too many specialty
Ethics and the Law
credentials. At the risk of sounding like an alarmist, a
proliferation of credentials for the wrong motive It is a myth to believe that professional ethical
could result in a public policy condemnation of the principles supersede the law. In fact, the ethical prin-
profession overall. As (past) president of the APA ciples of a particular professional association apply
Division of Clinical Psychology, Sechrest ( 1985) be- only to members of the association. An exception
lieves that the creation of specialties is occurring at a may occur if a state statute codifies a code of ethics,
"frightful rate." He reports 30 different groups' pro- such as a statute for the licensing of psychologists
posing themselves as specialties (apparently aligned mentioning that the ethics of the American Psycho-
with clinical psychology). Sechrest acknowledges logical Association (1981a) must be upheld by li-
the rationale that specialization credentials can assure censed psychologists in that state.
quality control to safeguard the public, but he notes Relatedly, it is a myth to believe that a long-time
the motives that special certificates accommodate ad- professional, such as the chair of a state psychologi-
vertising to increase income. He states: cal association's ethics committee, can give au-
thoritative conclusions about an omission or commis-
One suspects also that just sheer ego has something to sion . in professional practice. The experienced
do with the problem of specialization. Most diplomas, psychologist, such as the chair of an ethics commit-
at least in psychology, are probably of very little mate- tee, can offer guidance, but in no way does that opin-
rial value; they may serve no greater purpose than per- ion create a legal ruling. It is feasible that, should a
suading their possessors that they are in some way spe- legal action occur over a professional practice, such a
cial. Presumably some warm feeling flows through the
voice would be an important contribution to estab-
practitioner who can gaze upon the large array of neatly
framed documents decorating his or her office wall.
lishing the standard of care-but nothing more
One of my colleagues has suggested that we go into legally.
business manufacturing diploma wallpaper that would Professional ethics are important. For the psy-
simplify the whole thing. (p. 1) chologist, there must be strict adherence to the tenets
of the American Psychological Association's ( 1981a)
When talking about the furor about which group ethics code. Sanders ( 1983) provided a practical trea-
should be recognized by the ABPP as the legitimate tise on values and ethics in clinical psychology, which
576 CHAPTER 31
has direct relevance to clinical child neuropsychol- As a hypothetical (but quite likely) example,
ogy. In terms of sanctions, however, an ethics code is, suppose that all (or most) of the practitioners of
as stated, only applicable to the members of the clinical child neuropsychology did only a short form
association. of a particular neuropsychological test battery, even
though it was known to reduce substantially the reli-
ability and validity of the results. Assuming the ex-
Standard of Care penditure (e.g., professional time and costs to the
patient was not "excessive" (which has no prede-
As the practice of clinical child neuropsychol- termined definition) for and the benefits were sub-
ogy expands, there will be increasing legal liability. stantially greater from the long form of the test
That is, from justifying third-party payments (i.e., (e.g., reduced risk of diagnostic error), the practi-
getting a patient's clinical neuropsychological ser- tioners of clinical child neuropsychology could po-
vices reimbursed by his/her health insurance policy) tentially all be negligent by using the short form of
to allegations of malpractice, the clinical child neuro- the neuropsychological test battery. Common prac-
psychologist will be expected and required to main- tice within a profession does not establish the stan-
tain an acceptable standard of care. dard of care.
The term "acceptable" is defined by both the
profession and society. As will be discussed shortly,
the profession of psychology and, moreover, the spe- The Reasonable Practitioner Test
cialty of clinical neuropsychology and! or clinical
child neuropsychology will have to decide what are When determining the .standard of care, the
or are not to be the endorsed procedures. As men- court applies the "reasonable person" test. In this
tioned, there is still doubt about what professional instance, the test becomes the "reasonable clinical
source, if any, can speak definitively to the issue of child neuropsychologist.'' There is no exact pro-
standards for the practice of clinical child neuropsy- totype to which the clinical child neuropsychologist
chology. Society remains the final arbiter for the can compare his/her qualities.
choice of standards. Often the term "prudence" is integrated in
the conceptualization of "reasonableness." "Pru-
The Legal Test dence'' is but a short step away from ''conservative,''
which in tum could move to "traditional," which
Society expresses its decision through laws. Le- could lead to the notion that the standard of care is
gally, it is well established that a profession's encounter to innovation.
dorsed conduct will get the benefit of the doubt, but In legal reasoning, there is a certain truth to the
an entire profession could be negligent, for example, notion that tradition is favored over innovation. Inno-
have a standard of care that was unacceptable to pub- vation cannot be foolhardy or create an unreasonable
lic policy. The legal test is as follows: risk to the patient. In opposition, public policy holds
that a scientist-practitioner should, for the welfare of
It thus is fundamental that the standard of conduct
society, strive for advancement in competency, and
which is the basis of the law of negligence is usually
thus innovation should be encouraged and legally
determined upon a risk-benefit form of analysis: by
balancing the risk, in the light of the social value of the
protected-within reason. Generally speaking, if the
interest threatened, and the probability and extent of professional has performed an innovative technique
the harm, against the value of the interest which the or procedure that was predicated upon a reasonably
actor is seeking to protect, and the expedience of the sound theoretical basis, executed it with good inten-
course pursued. For this reason, it is usually very diffi- tions and logic, maintained precautions and safe-
cult, and often simply not possible, to reduce negli- guards, and subjected his/her work to professional
gence to any definite rules; it is ''relative to the need scrutiny (e.g., a research-review committee), there
and the occasion,'' and conduct which would be proper will be an effort to uphold the innovative dimension.
under some circumstances becomes negligence under
The "reasonable person" test does not require
others. (Keeton, Dobbs, Keeton, & Owen, 1984, p.
superiority per se: ''Professional persons in general,
173)
and those who undertake any work calling for special
Stated differently, just because the entire profession skill, are required not only to exercise reasonable
does or does not do a particular act (service), does not care in what they do, but also to possess a standard
justify it. minimum of special knowledge and ability'' (Keeton
et al., 1984, p. 185). If the issue is breach of the tion: "This does not mean, however, that any quack,
standard of care, such as in a malpractice action: charlatan or crackpot can set himself up as a 'school,'
and so apply his individual ideas without liability"
The formula under which this is usually put to the jury
is that the doctor must have and use the knowledge,
(Keeton et al., 1984, p. 187). By legal prescription, a
skill and care ordinarily possessed and employed by professional will only receive deference from public
members of the profession in good standing; and a policy on this matter if he/ she espouses a theory or
doctor will be liable if harm results because he does not "school" that has earned professional respect, has a
have them. Sometimes this is called the skill of the set of definite principles, and is based on a line of
''average'' member of the profession; but this is clearly thought that a reasonable number of qualified profes-
misleading, since only those in good professional sionals would share. The latter means that any
standing are to be considered; and of these it is not the clinical child neuropsychological view must be based
middle but the minimum common skill which is to be
on research, as would be compatible with the scien-
looked to. If the defendant represents himself as having
tist-practitioner model. Although apparently not yet
greater skill than this, as where the doctor holds himself
out as a specialist, the standard is modified according-
subjected to litigation in the area of clinical child
ly. (Keeton et at., 1984, p. 187) neuropsychology, a legal analysis of cases relevant to
alleged psychotherapy malpractice supports that non-
Perfection and/or superiority are not required, but traditional approaches would likely be tested against
this legal formula does require that the clinical child more traditional schools of therapy (Glenn, 1974).
neuropsychologist be in the mainstream of compe- Going from theory to procedures, public policy
tency for the specialty. requires that psychologists be qualified by, among
The foregoing introduces three issues unique to other factors, academic training according to stan-
clinical child neuropsychology: (1) the neuropsy- dards maintained for the profession. For example,
chological theory or procedure; (2) the group of child state licensing statutes consistently require a doctor-
neuropsychologists with whom there would be a ate from a regionally accredited institution of higher
comparison; and (3) the effects of having a specialist education. Some states require more; for example,
designation, such as considering oneself a "child Florida requires would-be psychologists to have:
neuropsychologist" as opposed to, say, a "clinical
child psychologist" or "school psychologist." Submitted proof satisfactory to the board that he has
received a doctoral degree with a major in psychology
from a university or professional school that has a pro-
Neuropsychological Theory or Procedure gram approved by the American Psychological Asso-
ciation or that he has received a doctoral degree in
Public policy is tolerant of disagreements be- psychology from a university or professional school
tween experts, as long as the differing views have a maintaining a standard of training comparable to the
reasonable semblance of being birthed by profes- standards of training of those universities having pro-
sional seeds. In clinical neuropsychology, there is grams approved by the American Psychological Asso-
ciation or the doctoral psychology programs of the state
rampant disagreement about: ( 1) the theoretical
universities. (Florida Statutes, 1985b, p. 1510)
explanation of neuropsychological structures and
processes; and (2) the assessment and treatment tech- To be deemed a clinical child neuropsychologist, the
niques most suitable for particular neuropsycholo- principle would seemingly be having fulfilled train-
gical conditions. ing and practice experiences compatible with special-
In his discussion of the development of theories ty. As mentioned, there is no definite source to date,
of brain function, Golden (1978) provided a histor- but the various specialty groups, such as (but not
ical trace up to localization theory and equipotential limited to) the ABPP, hold the potential for delineat-
theory, and noted: "Unable to accept either the lo- ing specific training and practice experiences that
calizationist or equipotentialist models of brain func- would be necessary if the clinical child neuropsy-
tion, psychologists and neurologists have searched chologist is to anticipate a protective legal frame-
for other models" (p. 8). When considering the di- work.
verse views expressed at the typical conference of Again there is professional debate about clinical
clinical neuropsychologists, it is tempting to assert neuropsychology procedures. For example, there is
that there is a model unique to each practitioner. contradictory research evidence and clinical views
Legally, although the clinical child neuropsy- about many (all?) neurological conditions (Walsh,
chologist will be supported in his/her professional 1978). Despite all the hullabaloo about the left brain
right to be aligned with a given theory of brain func- versus the right brain, the research is, by far, in-
578 CHAPTER 31
conclusive about numerous issues (Springer & criteria by which one psychologist would be com-
Deutsch, 1985). Perhaps the two most famous (or pared to another.
infamous?) debates center around: (1) whether the The prevailing approach is to: (1) consider the
clinical neuropsychologist should make use of an in- qualities of the targeted practitioner (e.g., holding a
dividualized set of tests or a standardized neuropsy- Ph.D. degree. licensed as a psychologist in the state,
chological battery; and (2) if preference is given to a X number of years of clinical experience, and so on);
standardized battery, whether it should be given to and (2) attempt to pinpoint a range of qualities that
the Nebraska-Luria or the Halstead-Reitan. Often it could be reasonably expected. Obviously such a
seems that there is a tendency to base one's prefer- comparison is based on a fiction: each practitioner is
ence on the shortcomings of the alternatives, which unique; but public policy holds that this exercise must
hardly seems the most professional way of garnering be fulfilled in legal proceedings.
support from public policy.
Specialization
Comparison to Other Clinical Child An exception to the foregoing occurs when the
Neuropsychologists practitioner asserts, or his/her patient has a reason-
able basis for believing, that he/she has special ex-
In the "good old days," any professional com- pertise. When this happens, the determination for
parison was made at the local level: ''Formerly it was whether or not an appropriate standard of care has
generally held that allowance must be made for the been maintained tends to based on a nationwide com-
type of community in which the physician carries on parison, with the comparison group being comprised
his practice, and for the fact, for example, that a of experts of the same ilk.
country doctor could not be expected to have the For declaring oneself a "clinical child neuro-
equipment, facilities, libraries, contacts, oppor- psychologist," as opposed to, say, a "clinical child
tunities for learning, or experience afforded by large psychologist" or "school psychologist," the title
cities" (Keeton et al., 1984, pp. 187-188). alone would likely elevate the standard of care (or
Today, with the advances in communication, competency) that could be reasonably expected by
travel, sources of research (e.g., the plethora of pro- recipients of the services. Although there may not be
fessional journals), and so on, the "locality rule" is an explicit assertion of "greater skill" by the practi-
far less important. Instead, a comparison is based on tioner, the legal perspective would probably be that
the qualifications and practices of the particular use of a special title makes an implicit promise of
professional. special or greater expertise, as compared to those
It is important to recognize, however, that states practitioners in the same discipline who lay no claim
(and even particular courts therein) differ in com- to a special title.
parative criteria. For example, some states still re- By legal principle, any certificate, such as being
quire that a psychologist testifying in a malpractice a Diplomate in Clinical Neuropsychology, is a defi-
case have a reasonable knowledge of the psychologi- nite statement of expertise. If a comparison with
cal standards and practices in the particular state or other clinical neuropsychologists is to be made, it
jurisdiction. would be with those who have the same (or compara-
Today the foremost source for deriving a com- ble) certificate.
parative framework would likely be the standards It is important to note that in some instances an
promulgated by the American Psychological Asso- implied credential, if reasonably derived by the pa-
ciation, especially as they receive more regional or tient, can cast the standard of care to a credential that
local endorsements through state licensing boards of the practitioner does not hold. Therefore, the prudent
psychological examiners. For example, the Florida approach is to studiously avoid fostering any notion
Psychological Association recommended that the in the.mind of a patient (or anyone else) that is not
Florida Board of Examiners (of psychologists) adopt truly compatible with one's qualifications.
the provisions of the American Psychological Asso-
ciation's (1981b) "Specialty Guidelines for the De-
livery of Services.'' In so doing, a national standard Malpractice
was used to create a standard of care for psychol-
ogists in the state of Florida; these standards essen- The standard of care is the critical component of
tially prescribe and proscribe the contents for the a malpractice legal action. This chapter is not
intended to be a treatise on malpractice. An elabora- chological test battery and/or the inept interpreta-
tion on and guidelines for avoiding malpractice in tion). Neither of these faults would necessarily have a
mental health services are available elsewhere causal connection to an injury. Suppose, however,
(Woody, 1983, 1988a,b). Whatisappropri ateherein that a more astute diagnostic evaluation would have
is to specify the criteria that are used for determining led to a treatment intervention that would have pre-
whether or not a malpractice action is appropriate, vented an exacerbation of the brain-related problem.
noting the current malpractice scene for psychol- In other words, the fact that the evaluation did not
ogists, and considering the relevance to clinical child detect the neuropsychological condition led to a de-
neuropsychology. lay in treatment intervention, and the passage of time
led to incre8sed severity. Thus, there would be a
The Negligence Formula causal connection to injury. Yet, there must be proof
of the fourth element: actual loss or damage.
''Malpractice'' is the popular term for profes- Damages are supposed to be compensatory. The
sional negligence. In order for a cause of action to be injured patient is to be restored his/her preinjury con-
founded on negligence, there must be four elements dition by the award of a monetary remedy. Unless
present: prohibited by a state statute, some courts will allow
punitive damages, such as to teach an entire profes-
1. A duty, or obligation, recognized by the law, re- sion a lesson. If there is proof of an injury, damages
quiring the person to confonn to a certain standard of
conduct, for the protection of others against unreason-
are assumed, such as pain and suffering (past, pre-
able risks. sent, and future). Damages cannot be unreasonably
2. A failure on the person's part to conform to the speculative, there must evidence, such as in the form
standard required: a breach of the duty. . .. of expert testimony, of the nature and extent of the
3. A reasonably close causal connection between the injury and how much damage there has been, is cur-
conduct and the resulting injury. This is what is com- rently being, and/or will be inflicted upon the pa-
monly known as "legal cause," or "proximate tient's life. As an example, it is possible that a
cause,'' and which includes the notion of cause in fact. clinical child neuropsychologist could have a duty to
4. Actual loss or damage resulting to the interests of his/her patient, breached the standard of care by
another.... (Keeton et al., 1984, pP. 164-165)
faulty services, and caused the patient to suffer long-
In applying this formula to clinical child neuropsy- er than was ideally necessarily-an d still the patient
chology: ( 1) it seems obvious that a clinical child would not experience nor be able to prove damages to
neuropsychologist has a "duty, or obligation" to the point of receiving more than, say, a nominal
each of his/her patients to conform to the standard of amount.
conduct or care relevant to professional practice; (2) a
breach of that duty is established by proof, such as by Malpractice Actions against Psychologists
testimony from another clinical child neuropsycholo-
gist, that there was an omission or commission of a Whereas psychologists once enjoyed a certain
procedure that did not meet the standard; (3) having a kind of relationship with their patients that served to
duty and a breach are not enough-the breach must minimize legal liability, their increased identity as
have a 'causal connection'' to the alleged injury; and health care providers leads to greater patient willing-
(4) even with the three previously mentioned ele- ness to file a legal action (Knapp & Vandecreek,
ments, the patient must have incurred damages. 1981). The medical context in which clinical neuro-
For example, suppose that the clinical child psychologists function would certainly lead to in-
neuropsychologist allegedly failed to diagnose a par- creased legal liability.
ticular brain-related problem with a patient. There Further, the principle of vicarious liability holds
was surely a duty to the patient. Assume that the that: ''One who is free from all moral blame or legal
clinical child neuropsychologist did, in fact, fail to fault is held liable for the tort of another, and this may
administer certain subtests of a neuropsychological be described as a form of liability without fault"
test battery that would have revealed the brain-related (Keeton et al., 1984, p. 593). For the clinical child
problem, or that he/she had the test data, but failed to neuropsychologist, this means that being a neu-
interpret the data properly. Other clinical child rological "team member" could result in being
neuropsychologists migltt well be willing to provide named a defendant, even though the direct cause of
expert testimony about the poor quality of the diag- the injury was allegedly due to the negligence of, say,
nostics (the faulty administration of the neuropsy- the neurologist or another health care provider.
580 CHAPTER 31
Psychologists are being subjected to an increas- will lead to liability for both the employing organiza-
ing number of lawsuits. The causes of action are tion and the professional-it is highly improbable
many, including (but not limited to) "involuntary that either defendant could find immunity because of
servitude, false arrest, trespass, malicious infliction the context in which the service was performed.
of emotional distress, abuse of process, loss of liber- The concept of immunity is important to psy-
ty, misrepresentation, libel, assault and battery, ma- chologists in the schools (as well as in other nonprofit
licious prosecution, and false imprisonment" (Ho- organizations). Often an employer, say a school ad-
gan, 1979, p. 7). Wilkinson (1982) categorized ministrator, will glibly assure the employees, say
malpractice cases involving psychiatrists as patient- school psychologists, that they will be covered by the
inflicted injuries and suicide, harm by the patient to organization's liability insurance, when the fact of
third persons, errors in judgment, faulty treatment the matter is that only the employer is covered by the
methods, drug-related liability, and sexual miscon- insurance for the commissions or omissions of the
duct. Fisher (1985) indicated that "the number of employee. Any relevant legal action can potentially
claims against psychologists have risen faster in the name the employee individually, and a judgment
past three years than for any other mental health pro- could be rendered against the employee that would
fession" (p. 6). There is no reason to believe that not be covered by the employer's insurance. There-
clinical child neuropsychologists would be able to fore, every clinical child neuropsychologist, wherev-
find any exemption from or exception to the increas- er employed, would be well advised to obtain a care-
ing liability; indeed, as stated, the medical context fully drafted statement of liability coverage and
probably increases the liability for clinical neuropsy- indemnification for any claims or legal actions that
chologists beyond the level of liability generally at- are associated with the employing source (this
tributed to psychologists. would, hopefully, cover the vicarious liability issue
as well).
Immunity
Because many practitioners of clinical child Expert Clinical Child
neuropsychology are employed as school psychol-
ogists, there might be the notion that any malpractice
Neuropsychological Testimony
legal action would be directed at the school sys-
tem/ employer, and that there would be no personal To provide expert testimony, a witness must
liability. Although an attorney would likely draft the have qualifications that will allow him/her to offer
pleadings to include the employer, under the com- special information to the trier of fact (the judge
mon-law principle of "Master/Servant" liability and/or jury). Although there may be slight dif-
(whereby the master/ employer may be held account- ferences between state statutes, consider the defini-
able for the actions or inactions of his/her sertion from Florida:
vant/employee), this does not, in any manner, ex- Testimony by experts. If scientific. technical, or other
empt the employee from personal liability. special knowledge will assist the trier of fact in under-
In the past, public policy supported that certain standing the evidence or in detennining a fact in issue,
persons or organizations should be immune from suit a witness qualified as an expert by knowledge, skill,
or liability. In other words, the public policy reason- experience, training, or education may testify about it
in the fonn of an opinion; however, the opinion is
ing held that there would be benefits from society's
admissible only if it can be applied to evidence at trial.
granting immunity to a designated class, for exam- (Florida Statutes, 1985a, p. 367)
ple, governmental officials or charitable organi-
zations. At first glance, it would seem like surely the testi-
Without going into a detailed exposition of the mony of a clinical child neuropsychologist would
legal theory and cases, suffice it to say that, at best, fulfill the requirements for being "expert" in nature.
the concept of immunity has been eroded. Indeed, Such may or may not be the case.
many legalists would probably assert that immunity For many years, only a medical physician could
no longer exists, certainly not for a health care practi- testify about the human condition. As the behavioral
tioner because of the employment source. For exam- sciences developed, public policy was altered to ac-
ple, the duty to warn others of the physical dan- commodate professional disciplines other than medi-
gerousness of a patient supersedes privileged cine. Now it is commonplace for, among others, psy-
communication, and failure to fulfill the duty to warn chologists to be qualified for rendering expert
testimony (Jenkins v. United States, 1962). Having For the foregoing and other reasons, certain
said this, however, the area of clinical neuropsychol- courts have excluded testimony by clinical neuropsy-
ogy has not yet received unequivocal acceptance. chologists on neurological conditions; or if the
Part of the reservation comes from the belief of clinical neuropsychologist has been qualified to testi-
many legalists that a patient's neuropsychological fy, the judicial opinion points toward very little
condition can only be adequately evaluated, diag- weight being accorded to the neuropsychological
nosed, described, and/or treated by a neurologist. data. Schwartz (1987) analyzed two court decisions
Another way of phrasing the problem is that neuro- in the Florida Court of Appeals that negated and/or
psychological tests have yet to receive adequate doc- restricted the testimony proferred by a clinical neuro-
umentation for reliability and validity. psychologist. As there are only limited cases that are
In point of fact, there is still a dearth of suppor- on point (and the rulings may be idiosyncratic to the
tive research for clinical neuropsychological judg- case, the judge, orthejurisdiction), areviewofthose
ments. For example, Shordone and Rudd ( 1986) had cases seems premature for purposes of deriving legal
psychologists examine clinical vignettes for purposes principles. Suffice it to say that there has not been
of recognizing neurological disorders, and found that unreserved judicial support for clinical neuropsy-
one-third of the psychologists failed to recognize the chological testimony.
underlying neurological disorder. It seems probable that childhood development,
Likewise, the use of individualized test batteries with its individual differences, and the malleability
allows for personal preferences by the clinical child of children will result in the reservations about expert
neuropsychologist. Consequently, the subjectivity in testimony on adult neuropsychology being as staunch
the choice of methods or instruments can lead to (or more so) for expert testimony on child neuropsy-
questionable validity for the decisions derived from chology. The principal message for the child clinical
the data, which may be compounded by the limita- neuropsychologist would certainly be: "Forensic
tions (e.g., inadequate standardization) of the tests cases have demanded an increasing sophistication on
(Golden, 1986). the part of the neuropsychologist beyond those issues
As another weak point, misdiagnosis can result encountered with other types of psychological testi-
from an overcommitment to clinical neuropsycholo- mony" (Golden, 1986, p. 1).
gical strategies. As Boll (1985) stated: To the contrary, there have been many instances
where the testimony of the clinical neuropsycholo-
All that produces cognitive dysfunction is not neces- gist, be it for an adult or child, has been readily
sarily, primarily, or even secondarily, neurological in accepted and accorded decisive weight by the court.
nature. Antecedent factors, such as disruptive environ-
Galaski (1985) described the present-day rela-
ments, poor opportunity, primary emotional pathology
not tied to neurological dysfunction, all can result in
tionship between the attorney and clinical neuropsy-
compromised mental performance. These deficits chologist, and indicated: ''Cases in which the neuro-
may, in some circumstances, appear strikingly similar psychologist can be of greatest practical help to the
to those which are likely to be produced by neu- attorney include cases of personal injury, especially
rological events themselves. (p. 480) when there has been head trauma caused by a fall or
sustained in a motor vehicle accident'' (p. 10). lncag-
A clinician must be attuned to both neurologically noli (1985) described how clinical neuropsycholo-
based and nonneuro1ogically based diagnoses. gists can fulfill a valuable role in litigation, and she
Related to the preceding point, there is often a recommended that: ''A clinical neuropsychologist
fine line between scientific assertions and proselytiz- should be called as an expert witness to evaluate any
ing for a cause that will benefit the professional. With client with suspected or known brain injury'' (p. 60).
any emerging strategy, and clinical neuropsychology Related to the previous comments about the res-
is no exception, self-serving motives may lead to ervation of courts to admit the testimony of clinical
''professional enthusiasm'' that is unjustified. Le- neuropsychologists, the ever-expanding recognition
galists are aware of this tendency in professionals. of the usefulness of clinical neuropsychological data
One trial lawyer commented about a deposition that for legal determinations creates a press for spe-
he had taken of a well-published clinical neuropsy- cialized research on applying neuropsychological
chologist, saying, "It should be easy to impeach his procedures to legal issues. Lanyon (1986) empha-
testimony during the trial because he comes across as sized that psychological assessment, in general, for
a 'True Believer' in the infallibility of the neuropsy- legal cases must go beyond the typical clinical pro-
chological tests.'' cedures. He provided a useful review of specialized
582 CHAPTER 31
procedures/instruments developed for such legal is- Florida Statutes. (l985b). Chapter 490, Psychological Services
sues as competency, insanity, dangerousness, child (see 490.005 (I) (b)), ISlO.
custody evaluations, homicide, and sex offenders. Galaski, T. (1985). The neuropsychologist: Key member of the
Regrettably, it appears that there has been precious doctor-lawyer team. Case & Comment, 90(4), 10, 12-14.
little research on the application of clinical neuropsy- Glenn, R. D. (1974). Standard of care in administering non-tradi-
tional psychotherapy. University of California, Davis Law
chology to legal issues per se, and few, if any, spe-
Review, 7, 56-83.
cialized procedures/instruments within the realm of
Golden, C. J. (1978). Diagnosis and Rehabilitation in Clinical
clinical neuropsychology that are tailored to legal Neuropsychology, Springfield, IL: Thomas.
issues. For example, an appropriate legal query could Golden, C. I. (1986). Forensic neuropsychology: Introduction and
be: What research findings have been obtained to review. In C. 1. Golden & M. A. Strider (Eds.), Forensic
connect certain data from children's neuropsycholo- Neuropsychology (pp. 1-47). New York: Plenum Press.
gical tests to a specific degree/amount of damages? Hogan, D. B. (1979). The Regulation of Psychotherapists (Vol.
The answer would likely be: None. ll)). Cambridge, MA: Ballinger.
Incagnoli, T. (1985). Clinical neuropsychologists: Their role in
litigation. Trial, 21(6), 60, 62-63.
Jenkins v. United States. (1962). 307 F.2d 637.
Summary Keeton, W. P., Dobbs, D. B., Keeton, R. E., & Owen, D. G.
(1984). Prosser and Keeton on the Law ofTorts (5th ed.). St.
Public policy has issued an invitation to clinical Paul, NM: West.
child neuropsychology to enter into human service. Knapp, S., & Vandecreek, L. (1981). Behavioral medicine: Its
In so doing, there will be exacting expectations, yet malpractice risks for psychologists. Professional Psychol-
ogy, 12, 677-683.
the practitioner has, to date, ill-defined guidelines.
Lanyon, R. I. (1986). Psychological assessment procedures in
The nebulous framework for practice combines with
court-related settings. Professional Psychology. 17, 260-
this litigious era to sound a caveat to clinical child 268.
neuropsychologists for reasonable ethical and legal Mechanic, D. ( 1981 ). Some dilemmas in health care policy. In J.
functioning. It would be foolhardy to plunge reck- B. McKinlay (Ed.), Issues in Health Care Policy (pp. 80-
lessly into a new specialty-instead, the clinical 94). Cambridge, MA: MIT Press.
child neuropsychologist must predicate all practices Sanders, 1. R. (1983). Values and ethics in clinical psychology. In
on a carefully studied rationale based on academics, C. E. Walker (Ed.), The Handbook of Clinical Psychology
research, and human need. (Vol. II, pp. 1328-1350). Homewood, IL: Dow Jones-
Irwin.
Sarason, S. B. (1987, January). Is our field an inkblot? APA
Monitor, 18(1), 37.
References Schwartz, M. L. (1987). Limitations on neuropsychological tes-
timony by the Florida appellate decisions: Action, reac-
American Board of Professional Psychology. ( 1984). Policies and tion, and counteraction. Clinical Neuropsychologist, 1, 51-
Procedures for the Creation of Diplomates in professional 60.
psychology. Columbia, MO: Author. Sechrest, L. B. (1985). Specialization. Who needs it. Clinical
American Psychological Association. (1981a). Ethical principles Psychologist, 38, I, 3.
of psychologists. American Psychologist, 36, 633-638. Shordone, R. 1., & Rudd, M. (1986). Can psychologists recognize
American Psychological Association. (1981 b). Special guidelines neurological disorders in their patients? Journal of Clinical
for the delivery of services. American Psychologist, 36, 639- and Experimental Neuropsychology, 8. 285-291.
685. Springer. S. P., & Deutsch, G. (1985). Left Brain, Right Brain
AuClaire, P. A. (1984). Public attitudes toward social welfare (rev. ed.). San Francisco: Freeman.
expenditures. Social Work, 29, 139-144. Walsh, K. W. (1978). Neuropsychology: A Clinical Approach.
Bice, T. W. (1981). Social science and health services: Contribu- Edinburgh: Churchill Livingstone.
tions to public policy. In J. B. McKinlay (Ed.), Issues in Wilkinson, A. P. (1982). Psychiatric malpractice. Identifying
Health Care Policy (pp. 1-28). Cambridge, MA: MIT Press. areas of liability. Trial, 18(10), 73-77, 89-90.
Boll, T.J. (1985). Developing issues in clinical neuropsychology. Woody, R. H. (1983). Avoiding malpractice in psychotherapy. In
Journal of Clinical and Experimental Neuropsychology, 7, P. A. Keller & L. B. Ritt (Eds.), Innovations in Clinical
473-485. Practice: A Sourcebook (Vol. II, pp. 205-216). Sarasota,
Bullock, C. S., Ill, Anderson, J. E., & Brady, D. W. (1983). fl.: Professional Resource Exchange.
Public Policy in the Eighties. Belmont, CA: Wadsworth. Woody, R. H. (and Associates). (1984). TheLawandthePractice
Fisher. K. (1985, May). Charges catch clinicians in cycle of of Human Services. San Francisco: Jossey-Bass.
shame, slip-ups. APA Monitor, 16(5), 6--7. Woody, R. H. (l985a). Public policy, malpractice law. and the
Florida Statutes. (1985a). Chapter 90, Evidence (see 90.704), mental health professional: Some legal and clinical guide-
367. lines. In C. P. Ewing (Ed.), Psychology, Psychiatry, and the
Law (pp. 509-525). Sarasota, FL: Professional Resource Woody, R. H. (1988a). FiftyWaystoAvoidMalpractice:A Guide-
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Jones-Irwin. Jossey-Bass.
32
Training and Credentialing in Child

Neuropsychology
LAWRENCE C. HARTLAGE AND CHARLES J. LONG
Background could be applied directly to children, then presum-

ably a downward extension of a battery appropriate
Although neuropsychology as a scientific field of for use with adults might be adequate for this pur-
inquiry has origins dating at least as far back as the pose. Conversely, if findings from adult neuropsy-
late 19th century, it is only during the past 20 years chology could not be applied to children, it would be
that neuropsychology has enjoyed widespread recog- necessary to develop a new data base for application
nition and acceptance as a formal applied profes- to child neuropsychology.
sional specialty area. Until recently, neuropsychol- Another scientific question dealt with whether
ogy was primarily identified with diagnostic testing findings from individuals with known brain damage
of adults with verified brain injury. With the increas- verified on neurological, neurosurgical, or neurora-
ing recognition of neuropsychological substrates of diological criterion measures, could be applied to
learning and adaptive behavior problems in adults children who were presumed to have neuropsycho-
with brain injury, there developed a progressive in- logical impairments on the basis of neuropsycholo-
terest in some possible central processing dysfunc- gical assessment, but for whom there was no defini-
tions as being etiologic in a wide variety of children's tive evidence of structural or physiological damage.
learning problems (e.g., Chalfant & Scheffelin. This scientific question translated into obvious pro-
1969). Given impetus and support by the focus of fessional issues. Because for many children whose
"The Great Society" programs on identification, de- neuropsychological examination findings suggested
scription, and treatment of childhood learning prob- a clear central nervous system dysfunction, there was
lems, neuropsychology increasingly was involved no external criterion that could validate such an im-
with the assessment of exceptional children. pression, the misclassification of such children as
The growing involvement of neuropsychology "brain injured" could adversely influence their edu-
with children's problems raised a number of scien- cational programming and management.
tific and professional questions and issues. As the Assessment Approaches. In response to the de-
body of research relating known brain damage to mand for neuropsychological services for children,
specific learning and behavior problems had for the and in attempts to address the scientific and profes-
most part involved adults, one obvious scientific
sional issues raised by this demand, two diverse ap-
question involves the extent to which this research proaches to provision of neuropsychological services
could be applied to children. Stemming from this
to children emerged. One approach involved modi-
scientific question arose a professional issue, name-
fied versions of traditional neuropsychological bat-
ly, which tests or diagnostic approaches are appropri-
teries such as the Halstead-Reitan (Reitan, 1955;
ate for use with children. If findings from adults
Reitan & Davison, 1974; Selz, 1981) and the Luna-
Nebraska Neuropsychological Battery (Golden,
LAWRENCE C. HARTLAGE Department of Psychol- 1981; Plaisted, Gustavson, Wilkening, & Golden,
ogy, University of Arkansas, Fayetteville, Arkansas 1983; Golden, Hammeke, & Purisch, 1980), which
72701. CHARLES J. LONG Psychology Depanment, standardized the adult battery items on a child sam-
Memphis State University, Memphis, Tennessee 38152. ple. For the most part, this standardization took the
585
586 CHAPTER 32
form of deleting from the adult battery those items Professional Context of Child
that were too difficult for children. There is reported- Neuropsychology
ly good congruence between the adult and child bat-
teries on classificatory accuracy, and also between
It has been argued that neuropsychodiagnosis
the Reitan-Indiana Children's Battery and the
has little or no relevance to education and/ or re-
Luna-Nebraska Neuropsychological Battery for
habilitation; however, with the advent of the CAT
Children (Geary, Schultz, Jennings, & Alper, 1984; scan, NMR, and other instruments, neuropsycholo-
Berget al., 1984; Golden et al., 1981). Even among gical assessment has shifted away from simple
proponents of a standardized battery approach, there yes/no "organic" diagnosis as a primary endeavor
is disagreement concerning which battery is best for
and has moved toward comprehensive assessment of
which population of patients (e.g., Adams, 1980a,b; cognitive skills relevant to planning for intervention.
Spiers, 1981). The second emphasis is on interpreta-
tion of standard psychometric tests from a neuropsy-
chological perspective, augmented by some mea- Levels of Inference
sures of sensory and motor function, using relevant
age-appropriate tests for children of given ages, rang- An important issue in training and credentialing
ing from preschool through adolescent ages in child neuropsychology involves the purposes for
(Hartlage, 1981, 1984; Hartlage & Telzrow, 1983; which neuropsychologically relevant data are to be
Telzrow & Hartlage, 1984). This approach uses stan- used. A comparatively low level of inference in-
dardized behavioral tests and interprets them accord- volves a conclusion that impaired brain function may
ing to the individual's strengths and weaknesses and be etiologic or at least contributory to a given prob-
in some cases makes inferences regarding neu- lem. An example of this level of inference might be a
rological integrity. Such an approach is popular with conclusion reached by a school psychologist that a
psychologists working in school settings, and in child's failure to acquire a given academic skill is
many cases may be adequate for child neuropsychol- likely related to brain damage or dysfunction. At a
ogical assessment. Although there is little evidence considerably higher level of inference are diagnostic
that one approach is clearly superior, "turf skir- statements indicating specific localizing and
mishes'' often center on the issue of qualifications. etiologic phenomena. An example of this level of
Psychologists who have developed expertise in the inference might be a statement, reached by a clinical
use of a given neuropsychological test battery tend to child neuropsychologist working in a neurological
support the view that the only legitimate neuropsy- setting, that a child appears to have an astrocytoma
chologists are those with a similar background and confined to anterior portions of the nondominant ce-
expertise. Psychologists who espoused diagnostic rebral hemisphere. Perhaps the highest level of in-
approaches involving traditional psychometric tests ference involves statements concerning some irre-
counter by questioning the relevance of a standard- versible intervention. An example of this type of
ized battery developed for adults with known brain inference might involve a clinical child neuropsy-
lesions for assessing children who often do not have chologist working in conjunction with a pediatric
evidence of brain lesions. They also question the neurosurgeon, who concludes that removal of a ma-
redundancy involved in adding a standard neuropsy- jor portion of a child's hippocampus will not impair
chological battery to the array of psychometric in- memory or other mental function. Between these low
struments required by most school districts for psy- and high levels of inference occur many intermediate
choeducational assessment. The second approach levels involving such matters as optimal instructional
appears to be preferred by most professionals. A sur- mode, referral to a neurological specialist, prog-
vey of internship training programs suggests that nostic statements based on inferred level of cortical
most professionals prefer the second approach (in- . integrity, or conclusions concerning whether (or the
terpretation of standard psychometric tests from a extent to which) a child's impaired cognitive perfor-
neuropsychological perspective) (Goldberg & mance may be due to an injury for which legal action
McNamara, 1984). In such settings, 78% employ is pending.
nonstandardized assessment strategies, 63% the It is possible that a well-trained clinical child
Halstead-Reitan, and 35% the Luna-Nebraska. psychologist or school psychologist, with only mod-
Even those individuals employing a neuropsycholo- erate training (or credentials) in child neuropsychol-
gical test battery frequently augment the battery with ogy, may make appropriate lower-level inferences
common psychological tests. concerning brain-behavior relationships. For exam-
TRAINING AND CREDENTIALING 587
pie, a school psychologist may, by training, experi- neuropsychology (Dean, 1982), it has already been
ence, and clinical skill, be quite adequately prepared argued that there is a need for some type of creden-
to develop perfectly appropriate academic interven- tialing and certainly for more specialized training if
tion programs for a child with a chronic or acquired one is to provide appropriate neuropsychological ser-
neurological impairment, and precluding such indi- vices to children.
viduals from such practice on the grounds that they Clinical psychologists have traditionally tended
are not sophisticated in brain-behavior relationships to function as generalists-setting few limits regard-
may serve to deprive a child of such a valuable pro- ing credentialing and developing no formal method
fessional resource. Conversely, it is not reasonable to for identifying a particular area of expertise. They
expect such a professional to detect manifestations of tend not to limit their practice to a specific problem
an early stage neurodevelopmental disorder or a neo- area or specific age group (VandenBos, Stapp, &
plasm of some slowly progressive type. On the one Kilburg. 1981). This state of affairs no longer ap-
hand, it can be argued that, until the proper diagnosis pears appropriate for the current practice of psychol-
is made, it is not possible to determine what level of ogy due to the dramatic change in the knowledge
inference may be required: this might suggest that all base. Certainly it is clear that neuropsychological
questions concerning possible brain involvement in assessment requires specific knowledge, not gener~
children require the involvement of a qualified child any obtained in traditional clinical psychology train-
neuropsychologist. On the other hand, in a typical ing programs. Furthermore, the techniques and is-
school population, the base rate of neurodegenerative sues in child psychology cannot simply be deduced
or slowly progressive neoplastic disorders is suffi- from knowledge of adults. Specialty training in
ciently low that such a requirement may be consid- school psychology and specialization in child psy-
ered to be unrealistic. chology also speak to the changes in training pro-
Interactive with the level of inference is the is- moted to meet the needs of the child.
sue of potential harm to the child. Some chronic neu- Although only four specialty areas initially were
rological conditions, such as might be represented by recognized by the American Psychological Associa-
chronic cerebral hemispheric functional asymmetry, tion, a recent review in credentialing activities by
can conceivably be overlooked without necessarily Sales ( 1985) identified 31 specialty credentialing
causing major problems. In cases where appropriate boards. Even though psychologists are identifying
educational and counseling services are provided, areas of specialization and devising procedures for
overlooking the neurological substrates of uneven membership inclusion, clinical psychologists seem
levels of academic performance may be only mini- reluctant to limit their practice by establishing formal
mally handicapping to the child. Conversely, label- specialties within clinical psychology.
ing the child ''brain damaged'' may deprive the child In the absence of credentialing, control is left to
of needed educational support. Similarly, the mis- licensing activities, done at the state levels, resulting
match between a child's neuropsychologically medi- in a wide variety of requirements for practice in a
ated abilities and deficits in an ongoing educational specified area such as neuropsychology, and a ten-
program that does not take these factors into account dency to rely on the individual practitioner with re-
may cause harm to the child, both in terms of frustra- spect to not making professional judgments at levels
tion and failure to achieve academically at ability of inference for which the practitioner is not
levels. Obviously, higher-order inferences regarding qualified. As has just been noted, however, in cases
brain-behavior relationships should only be made by involving some neuropsychological problems, an
individuals whose training, experience, and clinical otherwise well-trained clinican may not recognize
skills qualify them for such inferences. Although the neuropsychological nature of the problem, and at
guidelines concerning training and credentialing can the same time feel justified by avoiding any inferen-
and should address these issues, it is not reasonable to tial statements concerning CNS involvement. Al-
hope that such guidelines can resolve them all. though it could be argued that, in such a case, making
no inferential statement concerning CNS deficit may
in fact be inferring something about CNS integrity,
such activities are extremely difficult to control with-
Credentialing of Psychologists in limitations of generic state licensing laws.
A national credentialing board, not limited by
Although the study of developmental brain-be- whims and caprices of legislators who enact and
havior relationships is a relatively recent endeavor in amend licensing laws at the state level, is an accepted
588 CHAPTER 32
approach toward ensuring some level or degree of to be accepted in the near future by the vast majority
competence among practitioners who have met the of existing clinical psychologists. Therefore, training
requirements of that board. With credentialing re- must be designed and offered to best prepare these
quirements set by professionals, this obviously repre- individuals for their designated area of clinical ser-
sents an approach with considerable potential for vice. Such needs are being met by universities offer-
helping ensure such competence. As participation in ing specialty training in school psychology, child
the activities required for credentialing is entirely psychology, and/ or neuropsychology.
voluntary (and can entail a fair amount of energy,
frustration, and money), there is no assurance that the
only qualified neuropsychology practitioners are
those who are board certified. As with generic state
General Issues in Child Clinical
licensure, board certification in neuropsychology Training
does not necessarily guarantee expertise in all areas
of neuropsychology. Unlike the American Board of Clinical child neuropsychology may best be
Neurology and Psychiatry, which adds a ''with spe- viewed as a subarea of clinical child psychology, and
cial competence in child neurology" (or psychiatry) it is relevant to preface a review of issues in clinical
for practitioners who satisfy the required training and child neuropsychology training with an overview of
experience for this endorsement, neuropsychology training issues in clinical child psychology.
issues only generic endorsement. Presently, although there are seven formal pre-
Further complicating the issue of board cer- doctoral training programs in neuropsychology
tification, usually designated as "diplomate" status, (Lubin & Sokoloff, 1983), none are specifically de-
is the pervasive level of inference issue. Because signed for child neuropsychology. Thus, much of the
only the best neuropsychological clinicians-for in- specialty training in clinical child neuropsychology
stance, those qualified to make the highest levels of currently is provided by postdoctoral positions.
neuropsychological inference-are likely to receive The report of the task force from Division 40
"diplomate" status, who is to do the lower level of recommends that in the absence of formal accredited
inference work? As has been mentioned, whereas it educational programs:
might be considered optimal practice to have all chil- (l) The entry level credentials for the practice of
dren with any problem seen by a skilled child neuro- clinical neuropsychology shall be predicated on the li-
psychologist, to ensure that no problems of a neu- cense to practice at the independent professional level
rological nature are overlooked, this is obviously not in the state or providence in which the practitioner re-
realistic. One credentialing approach that attempts to sides; (2) In addition, 1600 hours of clinical neuropsy-
treat this issue in a realistic way is that endorsed by chological experience, supervised by a clinical neuro-
the American Board of Professional Neuropsychol- psychologist at the pre- or post-doctoral level, shall be
ogy (ABPN), which recognizes competence at two required; (3) Persons receiving a doctoral degree in
psychology before 1981 may substitute 4800 hours of
levels. With the diplomate representing the highest
post-doctoral experience in a neuropsychology setting
level of recognition (with requirements generally involving a minimum of 2400 hours of direct clinical
very similar to those of the American Board of Pro- service. (Newslener 40, 1984)
fessional Psychology), the ABPN also issues cer-
tification for competencies in neuropsychology at In the absence of formal training programs in
levels somewhat below those required for the diplo- child neuropsychology, specialization in child neuro-
mate status. psychology must either combine two existing areas
Presumably a number of levels of neuropsychol- or lead to even greater specialization.
ogical inference could be made by such certified Due to the changing nature of the nervous sys-
practitioners, while helping ensure that the child (or tem in the child and the impact of nonneurological
adult) was being evaluated by an individual suffi- factors on the child's behavior, the child neuropsy-
ciently trained to recognize most neurological condi- chologist needs to be trained in basic psychological,
tions that might require further evaluation. This developmental, and neuropsychological issues. In
model of a two-tier diplomate/ certification appears addition, the role of psychological assessment in
to have promise, but the relative newness of all cre- clinical child neuropsychology needs to be well
dentialing approaches in neuropsychology precludes understood.
the accumulation of such data concerning successes The reliance on standardized tests increases
or problems involved in such credentialing. with decreasing experience of professionals in any
It appears that specialty credentialing is unlikely discipline. Of primary importance is the issue to be
addressed or the question to be answered. If the pri- ogists to work with Children, Youth and Families
mary question relates to whether there is cerebral (Roberts, Erickson, & Tuma, 1985). In general, the
dysfunction, then regardless of the test employed, the other recommendations specific to clinical child psy-
evaluators' effectiveness depends on their training in chology training dealt with such issues as recogniz-
brain-behavior relationships and their understanding ing cultural diversity and the multiple contexts in
of the nervous system and its contributions to behav- which psychologists working with children, youth,
ior. Without such training, effective interpretation of and families must function.
behavior leading to decisions regarding brain dys- Internship training was recommended as involv-
function cannot be reached. Ifleaming disability is of ing at least two thirds of the training experience in
primary interest; then the evaluator needs to under- child clinical activity, with research incorporated
stand the relationship between test behavior and into the internship program. Postdoctoral and con-
learning disability. The same argument holds for de- tinuing education training in clinical child psychol-
velopmental delays, emotional disorders, retarda- ogy was recommended, although specific guidelines
tion, and so on. concerning required background prerequisities or
New graduates, individuals shifting their area of context areas were not proposed.
basic training, or researchers tend to depend on a With respect to recognition of proficiencies and
fixed battery or evaluation strategy and rigorously specialty areas in psychology, the APA Board of
defend it against all others. They thus exhibit a strong Professional Affairs (BPA) appointed a Committee
tendency to become method oriented, rather than on Specialty Practice from 1970 to 1980 to explore
problem oriented. With further education on the part such issues. Specialty guidelines for clinical, coun-
of the professional and understanding of the rela- seling, industrial/organizational, and school psy-
tionship between areas of primary importance, less chology were approved by the APA Council in 1980,
reliance is made on a specific test battery and a broad marking APA's first detailed public statement con-
range of assessment devices may be employed in cerning service provisions in specialty areas. The
order to effectively assay the behaviors in question BPA appointed a Subcommittee on Specialization in
and outline an effective treatment plan. 1980 to address the issues involved in criteria for
Clinical neuropsychology as a specialty within specialty areas not covered by these four major areas,
psychology is a very new area that is continuing to and in 1983 a second draft manual for the identifica-
undergo change and self-analysis in order to outline tion and continued recognition of proficiencies and
clinical courses most appropriate to the practice of new specialty areas in psychology was published
neuropsychology. The data base on neuropsychology (Sales, Bricklin, & Hall, 1983). Differentiation was
has also served to shift psychologists into a desig- made between proficiencies and specialties, on the
nated specialty area as the knowledge base required basis of several major criteria. A specialty was rec-
to pursue neuropsychological assessment is suffi- ommended as involving a body of knowledge with
ciently broad to make it difficult for traditionally (1) unique client populations, (2) specific techniques
trained psychologists to pursue effectively such and technologies, (3) problems addressed, and (4)
clinical activities without extensive training or settings wherein the knowledge is applied. A profi-
experience. ciency, on the other hand, would involve a body of
In 1977 it was recognized that a conference knowledge and skills that provide the basis for ser-
dealing with training in clinical child psychology was vices in one of these four parameters.
needed, and a preliminary working conference was The requirements for the identification of a spe-
held in 1983 with the principle conference held in cialty area involved (1) a formal organization, recog-
May 1985. In general, the recommendations in- nized in the field, that is responsible for managing the
cluded three features involving general clinical psy- development of a specialty; (2) a definition of the
chology training, involving requirements for training specialty, including knowledge and skills required;
in normal development; experience with normal chil- and (3) an educational sequence of training and expe-
dren; and minimal competencies in assessment, psy- rience. Requirements for the identification of a profi-
chopathology, and intervention with children (Tuma, ciency involved ( 1) a formal organization, (2) a defi-
1986; Johnson & Tuma, 1986). Specific to clinical nition, (3) evidence of need and parameters ()f
child psychology graduate training were seven rec- practice, (4) demonstrated efficiency, and (5)
ommendations, the first of which endorsed the Boul- uniqueness. In this context, neuropsychology could
der Model for clinical child psychology. Another rec- be viewed as representing either a specialty or an area
ommendation endorsed the APA Division 27 task of proficiency, with clinical child neuropsychology a
force documented Guidelines for Training Psychol- subarea of either a specialty or a proficiency.
590 CHAPTER 32
In a related and somewhat parallel area, the tional neuroanatomy, (2) clinical diseases, (3) child
APA Task Force on Education and Credentialing development, (4) changes in behavior as a function of
( 1985) published a recommendation concerned with aging, (5) behavioral psychopharmacology, (6) psy-
educational content required for designation as a psychophysiological principles underlying pathologies,
chology program. Although related in only a tangen- (7) sociocultural factors, (8) personality assessment
tial way to clinical child neuropsychology, the desig- and interviewing skills, (9) principles of test con-
nation system tends to discourage the graduate struction and validation, and (IO) test administration
education of clinical child neuropsychologists in aca- and interpretation. Properly trained neuropsycholo-
demic settings without a clear identification as part of gists should be able to outline treatment plans and
a psychology program (e.g., freestanding clinical consult with family members, educators, employers,
child neuropsychology programs in medical schools and so on, in order to aid in improving the behavioral
or professional schools would have difficulty meet- adjustment of the individual in specific situations.
ing the designation criteria). Remediation by a clinical neuropsychologist focuses
primarily on disability associated with cerebral dys-
function and secondarily on emotional or other mal-
adaptive behaviors that are a consequence of the indi-
Focus on Training in Clinical Child vidual's primary disability.
Neuropsychology That same report outlines the needs of the child
neuropsychology training to include much of the
Where does training in clinical child neuropsy- above with adjustment in training suggested to incor-
chology fit into this broader context? Training in porate bodies of knowledge as well as techniques and
clinical child neuropsychology is generally provided resources specific to clinical child neuropsychology.
in one of three ways: graduate coursework; in- Major issues such as child development, CNS plas-
ternship/practicum training; and postdoctoral train- ticity, and the nature of the referral questions are seen
ing fellowships. as primary additional areas of competence. One of
Graduate course offerings show considerable the primary distinctions between child and adult
variability. Approximately seven programs offer a neuropsychology is the emphasis on description of
terminal degree in neuropsychology; 40 clinical pro- processes in children, because the focus on process
grams offer some coursework in neuropsychology; helps delineate specific treatment plans. More so
and some half-dozen clinical programs offer lectures than with adults, children are often evaluated by a
on neuropsychology but no formal coursework multidisciplinary team; thus, child neuropsycho-
(Golden & Kuperman, 1980). Thus, among the 60 or logists must have knowledge of related professions
more APA-approved clinical programs that indicate so that they may effectively interface their findings in
they provide offerings in neuropsychology, these of- developing the final treatment plan.
ferings may range from formal coursework to prac- Among practicum offerings that indicate child
tica or even possible work placements. neuropsychology as an area of training, these offer-
Division 40 of the APA (Neuropsychology), ings in many cases exist as ancillary options, such as
aware of the need for establishing guidelines for being available on a limited basis within a child thera-
neuropsychology training, has formed a task force to py practicum. Even in practicum or internship set-
develop such guidelines. A preliminary report of tings wherein neuropsychology is mentioned as an
their efforts was published in Newsletter 40 (1984). area of training emphasis, there is considerable vari-
According to those guidelines the major function of ability. This variability appears to reflect both the
the clinical neuropsychologist is to assess current be- differing concepts of neuropsychology as a specialty
havioral disturbances associated with neurological area within clinical neuropsychology, and the unique
impairment. The report suggested that neuropsycho- backgrounds of the faculty who provide such train-
logical assessment should include measures of ( 1) ing. In one grouping of 28 graduate settings that of-
abstract reasoning and categorical thinking, (2) cog- fered neuropsychology training, for example, Gold-
nitive flexibility and planning, (3) language commu- en and Kuperman (1980) found that the tests used
nication, (4) learning and memory, (5) sensation and most frequently were the Wechsler and Bender
perception, (6) fine and gross motor functions, (7) Gestalt.
initiation and attention, (8) affect and mood, and (9) Postdoctoral training programs in clinical child
psychosocial adaptation. psychology are relatively rare. However, a number
In order to effectively pursue these assessment of postdoctoral programs in clinical neuropsycho-
goals, the diagnostician needs training in (1) func- logy offer some exposure to child neuropsychology,
and a few provide some segment of the program de- Unlike the adult brain, which is assumed to be
voted to work with children. Informal surveys of developmentally static with fixed effects associated
postdoctoral trainees who have had at least some with injury, the child's brain is characterized by
postdoctoral training in clinical child neuropsychol- growth and differentiation that extends from concep-
ogy reveal a rather wide range of backgrounds. Some tion until young adulthood (Renis & Goldman, 1980;
"retread" postdoctoral fellows, whose doctoral Rourke, Bakker, Fisk, & Strang, 1983). The effects
training is in nonclinical areas such as physiological of neurological damage are influenced by age, the
psychology, have very little background in either locus of the injury, the nature of the damage, the sex
child development or the special skills needed to and socioeconomic status of the individual, as well as
evaluate children. Others with backgrounds in areas the emotional adjustment, coping and adaptive skills
like school psychology may have excellent skills in of the individual (Bolter & Long, 1985). Thus, even
child assessment and good knowledge of develop- our limited understanding of chronogenetic localiza-
mental phenomena, but little expertise in functional tion can improve the assessment and remediation of
neuroanatomy or basic brain-behavior relationships. neurologically impaired children. Neurological dam-
Yet others enter postdoctoral child neuropsychology age during the developmental years may produce per-
training programs with good assessment skills in- manent deficits, temporary deficits, and/or delayed-
volving both children and adults, with coursework in onset deficits (Teuber & Rudel, 1962). Understand-
neuroanatomy and physiology, and prior exposure to ing the neurological contribution to the overall be-
neurologically impaired children from practicum or havioral complex is necessary in order to effectively
work experiences. Thus, the content of the "ideal" identify barriers and plan for remediation.
postdoctoral experience in clinical child neuropsy-
chology may relate to the unique backgrounds that
such postdoctoral fellows bring to the program.
Professional Relationships
All psychologists view behavior from a systems
Professional Context of Clinical Child perspective; however, problems are viewed some-
Neuropsychology what differently depending on the specialization.
School psychologists focus primarily on aca-
Neuropsychologists assume that understanding demic problems and secondarily on how non-
brain-behavior relationships is necessary for both academic factors influence this performance (e.g.,
diagnosis and treatment planning. Such knowledge is emotional, situational, neurological, genetic, devel-
not, however, sufficient; consequently, few neuro- opmental). Child psychologists focus primarily
psychologists focus on the brain as the only contrib- on emotional/behavioral problems with secondary
uting variable. Child neuropsychological assessment focus on other areas. The child neuropsychologist
must include measures of personalityI emotional focuses primarily on brain-behavior relationships
well-being and identification of environmental influ- with other factors being viewed as secondary.
ences. Given such a broad "systems" analysis, the The approach of child neuropsychologists has
child neuropsychologist can provide information of been challenged by professionals in other specialties.
benefit to a number of other disciplines. For exam- School psychologists have argued that understanding
ple, the interpretation of neurological dysfunctions in neurological systems is not important for effective
the context of situational, learning, emotional, and treatment (Senf, 1979). It is further argued that neu-
other important dimensions provides the neurological labeling connotes irreversibility and miti-
rosurgeon with a more comprehensive picture of the gates responsibility for remediation (Sandoval &
role that a lesion or area of damage might exert on the Haapanen, 1981). In fact, Hynd (1982) suggested
child's behavior. This can assist teachers in the class- that the neuropsychological evaluation may provide
room and parents at home by identifying strengths information that reduces the need for referral for ex-
and weaknesses and identifying those factors that pensive and nonproductive neurological evaluations.
appear to be most amenable to modification. The There remain many unresolved issues regarding
assumption is that one needs to identify factors that training and practice of clinical child neuropsychol-
contribute to aberrant behaviors and prioritize them ogy. As outlined in this chapter, the clinical child
regarding those that would appear to require primary neuropsychologist must possess a knowledge base
assistance as well as those that are most likely to that cuts across many existing areas of specialization.
change with remediation. Perhaps for this reason, individuals from a number of
592 CHAPTER 32
specialty areas may function in the assessment and to the Luria-Nebraska Neuropsychological Battery. Journal
treatment of children with neurological dysfunction of Consulting and Clinical Psychology, 49(3), 410-417.
in the future. Hopefully, with improved awareness Golden, C. J., & Kuperman, S. K. (1980). Graduate training in
and education, effectiveness of communication will clinical neuropsychology. Professional Psychology, 11(1),
55-63.
be enhanced across these specialties. This may lead
Hartlage, L. C. (1981). Clinical application of neuropsychological
us to recognize the requisite combination of broad
data. School Psychology Review, 10(3), 362-366.
skills in general child clinical areas and specific skills Hartlage, L. C. (1984). Neuropsychological assessment of chil-
in child neuropsychology, as constituting clinical dren. In P. Keller & L. Ritt (Eds.), Innovations in clinical
child neuropsychology; both a specialty and an area practice (Vol. III, pp. 153-165). Sarasota. FL: Professional
of proficiency. Resource Exchange.
Hartlage, L. C., & Telzrow, C. F. (1983). Assessment of neu-
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Index
Absence seizures, 409 Arithmetic disabilities, 137, 368 Behavioral neuropsychology, 521
Academic skills, 298 Assessment approaches, training in, 585 Behaviorist model, 522
tests of, 562 Assessment methods, 172 Bender Gestalt, 384, 462
Acetylcholine, 49 Association for Advancement of Behav- Benton's Sentence Memory Test, 360
Adjustment, 536 ior Therapy, 521 Benton Visual Retention Test, 431
psychosocial, 545 Astrocytes, 47 Benzedrine,443,476
Adjustment reaction, 479 Astrocytoma, 253, 586 Benzodiadzepine, 433
Adolescents, epilepsy and, 424 Asymmetry, 70, 294 Benztropine mesylate (Cogentin), 479
Aerosols, 315 neural, 70 Biofeedback, 377
Affective disorders, 97 morphological, 72 Bipolar disorders, 477, 482
Agenesis of corpus callosum, 25 somatic, 70 Blind, 558
Aggression, 529 Atrophy, cortical, 252 Boder Test of Reading and Spelling,
Agnosia, visual, 296 Attention Deficit Disorder, 95, 140, 149, 236
Agraphia, 299 361, 443-468 Body awareness, tests of, 562
Akathisia, 478 behavior and, 450 Boston Naming Test, 431
Alcohol, 322 conduct disorders and, 452 Bradykinin, 389
Alexia, 299 definitions of, 451 Brain and Language, 5
Alpha process, 267 ecological measures of, 461 Brain Electrical Activity Mapping, 302
American Board of Clinical Neuropsy- learning disabilities and, 450 Brain, 5, 37, 108
chology, 574 Attention span, 459 Brain injury, 35, 507
American Board of Professional Neuro- Attention, selective, 458 early, 35
psychology, 574 Attention, tests of, 562 frontal lobe, 36
American Board of Professional Psy- Attributions, 543 Bronchial Asthma, 117
chology, 574 Auditory verbal processing, tests of, Buccolingual-masticatory movements,
American Journal of Psychiatry, 5 562 478
American Psychological Association, 8, Aura, 539
574 Autism, 259 Caffeine, 444
Amitriptyline, (Elavil), 482 Autogenic training, biofeedback, 390 Carbamazepine, 420
Amphetamine, 280, 321 Autonomic nervous system, 42, 458 Carboxylic acid, 433
Anemia, 110 Autonomy, 547 Case study materials, 563
Anencephaly, 25 Axonal development, 21 Category Test, 182
Aneurysms, 252 Caudality, 527
Anorexia, 463 Background history of a child, 567 Cellular differentiation, 41
Anoxia, 259 Balance, 462 Central information processing, 58
Anterior metencephalon, 43 Bamazepine, 411 Central nervous system, 458
Antianxiety drugs, 476, 482 Barbituates, 322, 429 Centrencephalic epilepsy, 426
Anticonvulsants, 361,409 Basal ganglia, 43 Cephalic flexure, 42
Antidepressants, 432, 480, 481 Base rates, 512 Cerebellar agenesis, 25
Antiepileptic drugs, 419 . Bayley Scales of Infant Development, Cerebellum, 46
Antimania drugs, 419, 476 228 Cerebral aqueduct, 43
Antipsychotic drugs, 477 Behavior, 26 Cerebral asymmetry, 30
Anxiolytics, 475 aggressive, 430 Cerebral cortex, 43
Aphasia, 297 direct observations of, 460 Cerebral hemispheres, 47
Aphasia Screening Test, 186, 360 Behavior checklists, 460 Cerebral palsy, 378, 476, 558
Aptitude by Treatment Interaction, 514 Behavior modification, 383 Cerebrospinal fluid, 42
Archives of Clinical Neuropsychology, 5 Behavior rating scales, 460 Certification, 9
Aristotle, 3 Behavioral engineering, 398 Cervical flexure, 42
595
596 INDEX
Child Behavior Checklist-Revised, Dean's Test of Lateral Dominance, 360 Dysmetric dyslexia, 337
239, 561 Defense mechanisms, 541 Dysphonetic readers, 370
Child clinical neuropsychology, training Deficit training, 363 Dysthymic disorder, 480
in, 588 Degenerative syndromes, 249
Childhood autism, 274 Delirium, 477
Childhood schizophrenia, 93, 275; see Delusional thinking, 477 Ear dominance, 339
also Schizophrenia Echolalia, 477
Dementia, 477
Chlorpromazine (Thorazine}, 476 Dendrite development, 21 Ecological measures, 461
Circumstantiality, 431 Denial, 541 Educational deficits, 357
Classroom behavior, 429 Depakane (valproic acid), 433 Educational treatment, 363
Classroom instruction, 367 Depression, 424, 480 EEG, 54,425
Clinical judgment, 170 Descartes, 3 abnonnal activity in, 266
Clinical neuropsychology, 5, 14 Designer drugs, 325 maturation, 266
Clinical-inferential methods, 167 Development training in, 380, 425
Cocaine, 313 axonal, 21 Ego,541
Cogentin, 479 cognitive, 57 Elavil, 482
Cognitive development, 57, 59 dendrite, 21 Electric shock, 531
tests of, 562 glial, 23 Electronic ear, 337
Cognitive processing, 347 neurochemical, 23 EMG Biofeedback, 383
Cognitive rehabilitation, 397 perceptual, 57 Emotional disturbance, 361, 497
behavioral engineering and, 398 speech, 55 Encephalitis, 108, 260
computer programs and, 401 white matter, 52 Endocrine system, ll2
developmental approaches to, 400 Developmental dyslexia, 335; see also Enuresis, 480, 482
neurobehavioral approaches to, 402 Epilepsy, 482
Dyslexia
programs, 399 Developmental Test of Visual Motor adolescents and, 421
psychometic model of, 397 Integration, 238 age of onset, 426
strategies of, 404 Dexedrine, 445 assessment of, 420
theoretical models of, 397 Dextroamphetamine, 444, 445 biofeedback and, 434
Color Fonn Test, 186 Diabetes mellitus, 112 cognitive ability and, 424
Comprehensive Assessment Report, 490 Diagnostic and Statistical Manual of emotional disorders and, 420
Comprehensive Austin Neuropsycho- Mental Disorders, 3rd edition, 476 fears of, 423
logical Assessment Battery, 559 Diazepam (Valium), 452 general intelligence and, 427
Computer programs, 401 Dichhaptic recognition, 30 memory and, 430
Concentration, 431 Diphenhydramine (Benadryl), 411 myoclonic, 422
Concrete operations, 539 Dilantin (Phenytoin), 433 personality changes and, 422
Conduct disorders, 96, 452 psychosocial variables and, 420
Dissociative states, 475
Congenital anomalies, 259 Dopamine, 49, 445 stress and, 43
Connective tissue system, 121 Dorsality, 529 Ependymoma, 254
Consequent variables, 525 Down's syndrome, 503 Epilepsy, 261, 360, 379,409
Contamination, 539 Draw-a-Person, 477 Equipotentiality, 291
Context updating, 272 Ergotamine, 389
Drug abuse, 311
Contingent Negative Variation, 270 Drugs Ethics, 574
Continuing Education, 6 antianxiety, 482 Ethosuximide (Zarontin), 422
Continuous Perfonnance Test, 481 Evoked potentials, 458
anticonvulsants, 432
Controlled Word Association Test, 431 antidepressants, 475, 481 Executive functions, 301
Coping, 536 Expert testimony, neuropsychological,
antiepilepsy, 419
Corpus callosum, 299 antimania, 476 580
Corpus striatum, 43 External locus of control, 423
antipsychotic, 477
Cortex, 5 Eye movement patterns, 340
Duchenne muscular dystrophy, 542
regions of, 18 Durrell Analysis of Reading Difficulty, Eye tracking, 462
Cortical dysplasia, 259 560
Cranial Cerebral Trauma, 255 Discalculia, 300 Face perception, 32
Credentialing, 9, 574 Dysdiadochokinesis, 89 Face recognition, 30
CT scanning, 347 Dyseidetic readers, 370 Failure aversion, 403
Cylert, 445 Dyskinesias, 478 Family history questionnaire, 561
Cystic Fibrosis, 118 Dysphoria, 457 Family, impact of chronic illness on,
Cytoarchitectonic areas, 21 Dyslexia, 269, 279 561
developmental, 335 Finger Twitch Test, 462
Daily living skills, 399 dysmetric, 337 Fecal incontinence, 381
Deanol, 444 subgroups of, 369 Feedback circuit, 42
INDEX 597
Fernald method, 368 Holoprosencephaly, 25 Language Experience approach, 368

Filter, 271 Huntington's Chorea, 252, 529 Language, 297
Finger Oscillation, 184 Hydantoin, 433 development, 28
Fingertapping Test, 182 Hydrocephalus, 259 impairment, 558
Fingertip Number Writing Test, 186 Hydroxyzine (Atarax), 476 Lateral ventricles, 43
Fissures, 44 Hyperactivity, 89, 361,443,449, 479 Laterality, 73, 430, 527
Follow-up conference, 563 Hyperkinesis, 276 Lateralization
Food and Drug Administration, the, 453 Hyperkinetic impulse disorder, 443 central, 75
Fornix, 43 Hypotension, 120 cerebral, 59, 209
Freedom form distractibility factor, 461 Hypothalamus, 45 degree of, 77
Frontal lobe, 32, 301, 363 Hypothesis formation, 169 of function, 74
Frostig Developmental Test of Visual Learning disabilities, 132, 261, 335,
Perception, 450 503
Functional circuits, 42 Idiopathic seizures, 425 biofeedback and, 386
Illinois Test of Psycholinguistic Abili- classifications of, 504
Galen, 3 ties, 384 goals and, 507
Gasoline inhalation, 316 lminostilbene, 433 intervention strategies and, 506
Gastrointestinal system, 122 Imipramine (Tofranil), 476 Learning, 362, 459
Gastrointestinal distress, 464 Impulsivity, 443, 530 state dependent, 460
Gates Reading Test, 451 In-service training, 493 Leiter International Performance Scale,
General Aptitude Test Battery, 4ll Incontinence, neurogenic, 393 231
Gerstmann's syndrome, 295 Independence, 547 Leukemia, Ill
Governmental regulation, 573 Individual approach, 4 Leukodystrophy, 252
Glial cells, 21, 47 Individual Education Plan, 491 Levels of inference, 512, 586
Glial development, 23 Individualization of treatment, 401 Lewinsohn model, 524
Glioblastoma, 253 Infantile autism, 93, 477 Limbic system, 43, 419
Glucose utilization, 24 Infantile hemiplegia, 259 Linguistic reading approach, 369
Glue sniffing, 315 Infectious disorders, 258 Linguistic rules, 192
Graduate programs, 590 Inference, models of, 171 Lip-smacking, 478
Grand mal seizures, 409 qualitative, 173 Lissencephaly, 25
Graphesthesia, 462 quantitative, 173 Lithium carbonate, 280, 482
Gray matter, 249 Information processing, 58 Localization, techniques of, 291
Great Britain, neuropsychological infor- Inhalants, 315 Locus of control, 387
mation and, 4 Insomnia, 463 Low birth weight, 53
Great Society, the, 585 Interindividual comparisons, 525 Luminal (Phenobarbital), 433
Growth, family, 548 Internalization, 539 Lucia-Nebraska Neuropsychological
International Journal of Clinical Neuro- Battery: Children's Revision, 193,
Habilitation, 337 psychology, 5 217, 360, 525, 578
Haldol, 478 International League Against Epilepsy, clinical scales, 202
Hallucinations, 465 414 critical levels, 196
auditory, 422 Intervention techniques, 525 developmental issues and, 198
Haloperidol (Haldol), 478 IQ, 158 interpretation of, 195
Halstead-Reitan Neuropsychological Irritability, 457 qualitative analysis and, 202
Test Battery for Children, 181, scales, 194
220,365,431,432,477,578 scale interpretation, 197
Journal of Clinical and Experimental
Handicap, definition of, 538 Luria, Alexander, 4, 207, 343
Neuropsychology, 5
Hashish, 312 Lysergic Acid Diethylamide, (LSD),
Journal of Clinical Neuropsychology, 5
Head injury, closed, 529; see also Brain 320
Journal of Consulting and Clinical Psy-
injury
chology, 5
Headaches, 464 Macrogyria, 25
Hearing impairments, 558 Magnetic Resonance Imaging, 247
Hemispheres, cerebral, 47 Kagan's Matching Familiar Figures Malpractice, 578
Hemispheric specialization, 70 Test, 461 Marching Test, 187
Heroin, 321 K-SOS, 364, 365 Marijuana, 312
Herpes encephalitis, 296 Kaufman Assessment Battery for Chil- Matching Familiar Figures Test, 384,
Hetertopia, 25 dren, 149, 205, 296, 229, 230, 524 449
Hippocampus, 43 Kaufman Sequential or Simultaneous Matching Pictures Test, 188
Hippocrates, 3 Remedial Program, 364, 365 Maturational lag, 268
Histamine, 389 Klonopin (Cionazepan), 433 McCarthy Scales of Children's Abili-
Hodgkin's disease, 464 Kluver-Bucy syndrome, 422 ties, 232
598 INDEX
Medulla oblongata, 43 Neuroleptic medications, 476 Petit mal seizures, 409

Medullary plate, 42 Neurological reflexes, 52 Phencyclidine (PCP), 318
Mellaril, 476 Neuromuscular diseases, 109 Phenobarbital, 411, 420, 432
Memory, 256 Neuropsychologia, 5 Phenytoin (Dilantin), 4ll
epilepsy and, 430 Neuropsychology, 5, 14 Phonematic analysis, 349
nonverbal, 431 behavioral, 521 Phonemes, 30
tests of, 562 definition of, 573 Phonemic awareness, 349
Meningitis, 109 future of, 155 Physical and Neurological Examination
Mental Processing Composite, 210 Neuropsychological for Soft Signs, 462
Mental processing, 208 assessment, 490, 511 Piaget, Jean, 24
Mental retardation, 259, 269, 273, 452, constructs, 505 Piperidine, 445
558 diagnoses, 504 Placebo, 460
Merrill-Palmer Performance Tests, 425 models, 336 Placebo treatment in biofeedback train-
Methylphenidate, 280 reports, 561 ing, 387
Micropolygyria, 25 strengths, 506 Planning, 346
Midrin, 389 theory, 577 Plasticity, 18, 291, 358
Migraine headaches, 378 Neuropsychologist, role of, 570 Polycythemia vera, 110
biofeedback treatment of, 389 Nonstimulant psychotropic drugs, 476 Polydrug therapy, 436
Minimal brain dysfunction, 89, 451 Nonverbal memory, 431 Polysensory intergration, 42
Minnesota Multiphasic Personality In- Normative data, 148 Porencephaly, 25
ventory, 477, 523 Nutrition, 53 Porteus Mazes, 449
Minnesota Rate of Manipulation Test, Nystagmus, 338 Positron Emission Tomography (PET),
411 302
Monoamine oxidase, 445 Oculogyric crisis, 478 Postdoctoral training programs, 590
Mirror movements, 294 Oligodendrocytes, 18 Preacademic tasks, 560
Morphological asymmetry, 72 Optic vesicles, 42 Prematurity, 53
Motor development, 57 Organic personality syndrome, 421 Primidone, 411
Motor skills, assessment of, 293, 562 Organismic variables, 525 Problem solving, 31, 373
Movement disorders, 378 Orton-Gillingham method, 368 Professional
MRI. See Magnetic Resonance Imaging Overcorrection, 530 enthusiasm, 581
Multisolvent inhalation, 316 organizations, 6
Muscle spasms, 478 Papilledema, 295 relationships, 591
Muscular dystrophy, 109 Paradoxical effects of medication, 450 standards, 574
Music, 30 Paraphasia, 297 Progressive Figures Test, 188
Myelin development, 23, 48 Parasympathetic nervous system, 42 Projective drawings, 561
Myelomeningocele, 381 Parent interview, 567 Pronominal reversal, 477
Mysoline (Primidone), 433 Parental Prosopagnosia, 296
adjustment, 549 Psychological processing, 515
National Advisory Committee on Handi- coping styles, 550 Psychopathology, 87
capped Children (1967), 504 Parents, 491 Psychopharmacology, 476
National Institute of Mental Health, 443 Parkinson's features, 478 pediatric, 444
National Institute for Neurological and Partial complex seizures, 409 Psychopharmacology Bulletin, 476
Communicative Diseases and Pathognomonic signs approach, 189 Psychosocial adjustment, 545
Stroke (NINCDS), Epilepsy Pavlov, 4 Psychosocial factors, tests of, 562
Branch of, 414 Peabody Picture Vocabulary Test-Re- Psychostimulants, 444; see also
National Joint Committee for Learning vised, 237, 432 Stimulants
Disabilities, 505 Peer interactions, 546 Psychotherapy, issues in, 544
Nebraska Neuropsychological Chil- Pemoline, 444, 446, 448 Psychotic disorders, 93
dren's Battery, 193-204, 217, 360, Perceived Competence Scale for Chil- Psychotropic medication, 475
525,578 dren, 542 Public policy, 573
Negligence, 579 Perceptions, 542 Public Schools, 492, 573
Neoplasms, 249 Perception, visual, 295 Pyriform lobes, 43
Neural asymmetry, 70 Perceptual and motor skills, 5
Neural tube, 18 Perceptual development, 57 Qualitative inference, 173
Neurochemical development, 23 Peripheral nervous system, 42 Quantitative inference, 173
Neurocognitive approaches, 357 Personality Inventory for Children, 561
Neurodevelopmental issues, 358 Pervasive developmental disorder, 93 Raven's Progressive Matrices, 560
stages, 359 PET: see Positron Emission Reading disabilities, 133
Neurohormones, 49 Tomography Reading skills, 368
INDEX 599
Reasoning and planning deficits, 373 Simultaneous processing, 207 Syntactic deficits, 292
Reinforcement, 531 Social skills training, 450, 477, 530 Synthesis, 342
Reitan-Aphasia Screening Battery, 560 Socialization, 546 System of Multicultural Pluralistic As-
Rehabilitation, 397 Socioeconomic status, 359 sessment (SOMPA), 238
REHABIT, 364 Sodium valproate, 420
Reinforcement, 404 Soft signs, 507 Tactile difficulties, 295
Relaxation training, 385 Somatic asymmetry, 70
Tactile Finger Localization Test, 186
Remedial programs, 357 Sound Neuropsychological Substructure
Tactual Performance Test, 182, 426,
Remediation, 501 for a Public School, 498
560
deficit model, 223 Spatial/visual processing, tests of, 562
Target Test, 188
strength model, 223 Special Education, 491, 557
Task analysis, 399
Report format, 563 reform; 516
Teaching, 363
Response variables, 525 SPecial interest group, 521
Teacher-child interactions, 560
Renal system, 123 Specialization, 578 Tegretol (Carbamazepine), 433
Revised Behavior Problem Checklist, Specific learning disability, 505; see
Temperature biofeedback, 387
240 also Learning disabilities
Temporal lobe epilepsy, 263
Rey-Ostereith Complex Figure Test, Speech Temporal lobe, lesions of, 405
431 abnormalities, 478
Tennessee Self-Concept Scale, 387
Rhinencephalon, 43 development, 55
Test of Adolescent Language, 238
Ritalin, 445 zones, 18
Test of Language Development, 237
Ritalinic acid, 445 Speech Sounds Perception test, 182
Test of Written Language, 237
Rorschach, 477 Spelling disabilities, 135, 357, 370
Thematic Apperception Test, 477
Russia, neuropsychological infonnation Sperry, Roger, 4
Theta filter, 435
and, 4 Spina Bifida, 381, 546
Thioridazine (Mellaril), 280
Spinal cord fonnation, 44
Thorazine, 476
Schemata, higher order and, 450 Spinal medulla, 46
Threshold, 435
Schizoaffective disorder, 480 Spongioblasts, 47
Tics, 464
Schizophrenia, childhood, 93 Standard of Care, 576
Time out procedure, 531
Schizophrenia, 259, 477 Standard scores, 158, 210
Tofranil, 476
Schoolsettings,489 Stanford-Binet Intelligence Scale, 233
Token economies, 521
Seizures State-dependent learning, 460
Token Test for Children, 238
absence, 409 Statistics, 160
Tornatis Listening Test, 338
age of onset, 410 Stimulants, 314, 361, 443
Tourette's Syndrome, 98, 462, 464,
diagnosis of, 413 adolescents and, 453
478
emotional aspects of, 412 adults and, 453
Trails A, 183
generalized tonic-clonic, 409 administration of, 467
Trails B, 185
intellectual impairment and, 410 cardiovascular effects of, 458
Training, 577
medications and, 411 clinical evaluation of, 461
Tranquilizers, 475
partial complex, 409 iatrogenic effects of, 463
Transfer of functions, 359
psychomotor, 413 learning and, 459
Trycyclic antidepressants, 433
receptive language and, 410 learning disabilities and, 450 Tumors, brain, 109
social aspects of, 412 mental relaxation and, 453
Seashore Rhythm Test, 183 motor effects of, 443
Sedatives, 322 neuropsychological evaluation of, 462 Valium, 452
Selective attention, 458 preschoolers and, 453 Valproic acid (Sodium valproate), 411
Selective awareness, 45 psychological testing and, 461 Variables, inferred, 522
Self-concept, 546 side-effects of, 442, 462 Vascular disorders, 252
Self-control, loss of, 540 Stimulus antecedents, 525 Ventricle fonnation, 44
Self-esteem, 90, 546 Strength of Grip Test, 185, 564 Ventrobasa nuclear complex, 435
Self-help skills, 399 Stroop Color Word Test, 462 Verbal memory, 431
Self-monitoring, 531 Student benefits, 496 Verbosity, 431
Sensory Perceptual Exam, 185, 560 Substance abuse, 311 Veterans Administration, 5
Separation anxiety, 60, 480 Succinimide, 433 Video games, 402
Septeum pellucidum, 43 Sulci, 44 Visual acuity, 564
Sequential processing, 206, 562 Suprastriatal region, 43 Visual evoked responses, 282, 315
Serotonin, 49 Sympathetic nervous system, 42 Visual perception, 295
Siblings of children with neurological Symptomatology, psychiatric, 545 Visual/spatial processing, tests of, 562
disorders, 551 Synaptic development, 22 Vocational training, 399
Side-effects of stimulants, 447 Synergy, 462 Vygotsky, L. S., 205
600 INDEX
Wechsler Adult Intelligence Scale Wechsler Memory Scale, 430 Woodcock Johnson Psychoeducational
(WAIS), 425 White matter, development of, Battery, 234
Wechsler Intelligence Scale for Chil- 52 World War II, 527
dren-Revised (WISC-R), 150, Wide Range Achievement Test, 295,
205,230,296,426,430, 387,432,560 Zarontin (Ethosuximide), 433
461 Wisconsin Card Sorting Test, 301 Zone of proximal development, 221

Critical Issues in Neuropsychology

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Critical Issues in Neuropsychology

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Handbook of

Editorial Advisory Board:

ASSESSMENT ISSUES IN CHILD NEUROPSYCHOLOGY

HANDBOOK OF CLINICAL CHILD NEUROPSYCHOLOGY

MEDICAL NEUROPSYCHOLOGY: The Impact of Disease on Behavior

NEUROPSYCHOLOGICAL FUNCTION AND BRAIN IMAGING

NEUROPSYCHOLOGY, NEUROPSYCHIATRY, AND BEHAVIORAL

RELIABILITY AND VALIDITY IN NEUROPSYCHOLOGICAL

Springer Science+Business Media, LLC

1989 Springer Science+Business Media New York

AII rights reserved

Thomas L. Bennett Department of Psychol- Charles J. Golden Departments of Psychol-

Randy W. Kamphaus Department of Educa- Becky L. Rosenthal Department of Educa-

Marcel Kinsbourne Department of Behav- MarionJ. Selz Rehabilitation Psychology, St.

John C. Linton Department of Behavioral Marie L. Walker Department of Educational

I. Foundations and Current Issues

1. Historical Perspectives in the Development of Neuropsychology as a Professional

2. Development ofthe Child's Brain and Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

3. Higher Cortical Functions in Children: A Developmental Perspective . . . . . . . . . . . . . . 41

4. Mechanisms and Development of Hemisphere Specialization in Children . . . . . . . . . . 69

5. Neuropsychology of Child Psychopathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

6. Neuropsychological Sequelae of Chronic Medical Disorders. . .................... . 107

7. Neuropsychological Bases of Common Learning and Behavior Problems in

8. Measurement and Statistical Problems in NE:uropsychological Assessment of

9. Models of Inference in Evaluating Brain-Behavior Relationships in Children 167

II. Neuropsychological Diagnosis

10. Halstead-Reitan Neuropsychological Test Batteries for Children 181

11. The Nebraska Neuropsychological Children's Battery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

12. Applications of the Kaufman Assessment Battery for Children (K-ABC) in

13. Neuropsychological Applications of Common Educational and Psychological Tests 227

14. Radiological Techniques in Neuropsychological Assessment . . . . . . . . . . . . . . . . . . . . . . 247

15. Psychophysiological Evaluation of Children's Neuropsychological Disorders 265

16. Techniques of Localization in Child Neuropsychology 291

17. Neuropsychological Sequelae of Substance Abuse by Youths 311

III. Techniques of Intervention

18. Neuropsychological Models of Learning Disabilities: Contribution to Remediation 335

19. Neuropsychological Approaches to the Remediation of Educational Deficits . . . . . . . . 357

20. The Biofeedback Treatment of Neurological and Neuropsychological Disorders of

21. Approaches to the Cognitive Rehabilitation of Children with Neuropsychological

22. Neuropsychological Aspects of Epilepsy: Introduction and Overview . . . . . . . . . . . . . . 409

23. The Neuropsychology of Epilepsy: ~sychological and Social Impact 419

24. Neuropsychological Effects of Stimulant Medication on Children's Learning and

25. Nonstimulant Psychotropic Medication: Side Effects on Children's Cognition and

IV. New Aspects of Neuropsychology

26. Establishing Neuropsychology in a School Setting: Organization, Problems, and

27. Current Neuropsychological Diagnosis of Learning Problems: A Leap of Faith . . . . . . 503

28. Child Behavioral Neuropsychology 521

29. Coping and Adjustment of Children with Neurological Disorder . . . . . . . . . . . . . . . . . . 535

30. Child Neuropsychology in the Private Medical Practice 557

32. Training and Credentialing in Child Neuropsychology . . . . . . . . . . . . . . . . . . . . . . . . . . . 585

Foundations and Current Issues

Historical Perspectives in the

Although these freestanding workshops often counseling centers. Interestingly, approximately

specialty internship in 2. Licensure by a state board of psychology

b. Intelligence Assessment training program in one of the health service delivery

Development of the Child's Brain and

Introduction vivo so it is extraordinarily difficult to directly corre-

.-- _. -~--- - ;{---F -, '-- :;..-----.,,, _r ;--:co:-:."\,

25 DAYS 35 DAYS 40 DAYS 50 DAYS 100 DAYS .

TABLE 1. Sequential Lamination of the Human Motor Cortex in Ontogenesisa.b

TABLE 2. Neocortical Neurotransmitters"

Transmitter type Cell location

"After Coyle (1982).

amines) parallels functional development in the pre- Cortical Function at Birth