Dri.rIop. Mcd. Child

Nriiid.

1975. 17. 63-78

.4 Special Neurological Examination of Children with Learning Disabilities J. E. Peters J. S. Romine R . A . Dgkman

Introduction In 1960 the senior author assembled a group of neurologial tests which appeared to have promise for detecting subtle degrees of brain dysfunction in children who presented at the Child Psychiatry Clinic of the University of Arkansas Medical Center, the chief complaints being hyperkinesis, short attention-span and/or specific learning deficits. These procedures included items from the classical neurological examination and certain tests of integrated motor acts which were selected from several workers in this complex field (Teicher 1941, Strauss and Lehtinen 1947, Bender 1952, Silver 1952, Fink and Bender 1953, Strauss and Kephart 1955. Bender 1956, Kennard 1960). In 1962, Clements and Peters published a paper in which the then current battery was itemized, but descriptions of each test were not given. At that time there was little solid information about which items occurred most frequently and whether they were associated with particular symptom patterns within the ‘minimal cerebral dysfunction’ grouping (Clements and Peters 1962, 1972; Clements 1966). The various specialists working with these children sifted out the behavioral, perceptual and learning manifestations in terms appropriate to their respective Rrpriiit iwpesrs

specialties. However, as pediatricians, neurologists, ophthalmologists, language development experts, psychologists, psychiatrists and educators gradually became acquainted with each others’ work, they recognized that they were actually studying a large common ‘pool’ of signs and symptoms. I t emerged that while there appeared to be different signs and symptoms within the ‘pool’, there was much overlap; moreover, they varied from severe to mild. We have been particularly concerned with the plight of children with the less conspicuous mild to moderate deviations, in whom an incompatibility between the child’s cognitive or attention deficits and the expectations of normal performance held by the school and the family is likely to lead to stress and frustration (Clements and Peters 1962, 1972; Clements 1966; Clements et a/. 1970). Some of the earlier work on these children was on known post-encephalitic cases or on children whose motor symptoms placed them at the fringe of the cerebral palsy group-what could be called ‘minimal cerebral palsy’. Kennard’s ( 1960) research was based largely on institutionalized children, many of whom were classified as psychotic, or at least severely disturbed in behavior. There

to: J. E. Peters, M.D., Division of Child-Adolescent Psychiatry, University of Arkansas

Medical Center. Little Rock, Arkansas U.S.A.

63

DEVELOPMENTAL MEDICINE AND CHILD

NEUROLOGY. 1975, 17

hoped that various discrete sub-groups would emerge. We chose to qualify our area of research in certain respects: we included an excess of milder cases because of the paucity of research on such cases; we excluded children with lower IQS; and, because of our clinical experience at the time, we limited the group to Caucasian males aged between eight and 11 years. We did not single out a small and circumscribed symptom group within the ‘minimal brain dysfunction’ category; rather, we included children with varied patterns of symptoms, expecting that in time subtypes would emerge as the result of statistical procedures and clinical scrutiny. We did not propose that any single neurological test had a one-to-one relationship with a particular cognitive deficit; rather, we assumed that where one or several cognitive defects existed, the central nervous system of that child would be more likely to show signs of motor deviation. This would be especially the case in children with prenatal or perinatal complications, in whom some degree of damage to or derangement of the developing cell systems of the brain might be expected (Pasamanick et al. 1956). In deviations deriving from genetic causes, it is reasonable to expect that these could occur in a more singular, delimited form, with less coincidence of other dysfunctions. Such might be the case in pure reading disability (dyslexia) or some forms of hyperkinesis. The concept of developmental lag is not inconsistent with an etiology of severe social and emotional deprivation. When considering the moderate and milder cases of ‘minimal brain dysfunction’ it is imperative to recognise the importance of the environmental demands made upon these children by modern society and by particular educational systems and particular families. Such a child’s particular profile of talents and deficits interacts with

appears to have been considerable overlap both in the tests used by various people and in the kinds of children studied. We early took the position that the ‘minimal brain dysfunction’ category should be broadly defined (Clements and Peters 1962, Clements 1966), leaving to later research the task of working out distinct entities within the group. We defined the group as having dysfunctions in the brain, manifesting as circumscribed, cognitive deficits, as an inability to sustain attention (especially for static and symbolic material) and/or an inability to modulate activity level to fit ordinary learning and social situations. The children in this group are not mentally retarded; in fact they may have above-average intelligence* and yet usually fail to perform in basic academic subjects at the level expected from their IQS. Our very broad position developed partly as a reaction to the prevailing psychiatric attitudes at that time, that the learning and behavior symptoms which brought children to child-guidance clinics were caused almost entirely by interpersonal tensions, and that the treatment of choice was psychotherapy for child and parents. Another important factor was that although a few specialists at that time recognized a ‘hyperkinetic syndrome’ and ‘developmental dyslexia’, there was no term for the much larger group of children who had some of the symptoms of both the hyperkinetic syndrome and developmental dyslexia. The term ‘minimal brain dysfunction’ we felt covered this group. The term ‘specific learning disability’ has subsequently tended to be used to signify developmental dyslexia and such other specific cognitive deficits as dyscalculia and ‘dysmusica’ (Clements and Peters 1972). Having drawn a loose, ‘organic’ line around such a large and diverse group, we

* Determined by an individual as opposed to a group intelligence test. 64

J. t.. PETERS

J . S. ROMINE

a particular profile of environmental demands. For example, considerable overactivity, school failure and maladjustment might occur in a child of average intelligence who by nature has a fairly high activity level and a mild specific language disability. and whose family and school set high or rigid standards. When expectations are not so high, the same child may never develop noteworthy problems. Much depends on how a deviating child is handled at school and at home. A mild cognitive deficit is often made into a severe problem by the ‘average child’ approach in school. That a particular child seems average or above average in some respects immediately arouses the expect at ion that achievement will be average o r above average in all respects. In contrast, a talent ‘spike’ in a child’s profile is usually better accepted than is a narrow deficit or ‘downward spike’, which tends to be attributed to laziness, ‘badness’. emotional conflict or inept parents. Our cases were referred because of a learning or behavior problem, despite an average IQ. (In some of these children, conduct was not a problem.) Whether this mixed group would show a high percentage of neurological signs (classical or integrative) has not been well documented; however, certain isolated signs have been studied and reported (Harris 1957, Prechtl and Stemmer 1962, Birch and Belmont 1964. Wolff and Hurwitz 1966, Ozer 1967, 1968). In addition to studying the incidence of signs and the sub-types which might emerge, we also wanted t o study the decrease in signs to be expected with increasing age (Eustis 1947, Gubbay et a/. 1965). As stated above, the present study concentrated more on the moderate and mild cases, but it did include some extremely hyperactive children and a few w h o might qualify as pre-psychotic.

R . A . DYKMAN

Subjects

A total of 82 boys with learning and/or behavior problems (the index cases) and 45 academically adequate controls were studied. Their ages ranged from eight to 1 1 years. The control boys attended public schools in Little Rock: the index boys attended local public schools (63), parochial and private schools (11) or public schools in nearby towns (8). All boys came from adequate homes (as indicated by socio-economic data), mostly from middleclass families. All were in good physical health and none had gross neurological deficits. To obtain the control group, teachers at one local elementary school were asked to select boys aged between eight and 11 years with no serious problems in achievement or behaviour. Although the teachers were told not to select their best students. too many of the boys sent to the clinic were functioning in the bright-normal or superior range on the Wechsler Intelligence Scale for Children (WISC). To obtain a group with lower WISC scores, teachers in a second school were asked to select students whose scores on group intelligence tests were in the 90s and who were doing adequate work in school. Since there were still too few control boys in the eight- to nine-year-old range, a third local public school provided I 1 additional boys who were functioning adequately in school. The index boys were recruited from the University of Arkansas Medical Center Child Guidance Clinic and from those children in, or being screened for, learningdisability classes in public and private schools. The children included in this study had a verbal or performance IQ of at least 90 on the WISC. Children with neuroses were excluded, as were the frankly psychotic. The children recruited from the Clinic had been referred by physicians, parents or teachers. largely as a result of considerable 65

DEVELOPMENTAL MEDICINE A N D C H I L D NEUROLOGY.

parental concern about the child’s poor performance in school. The children already in or being considered for a learning-disability class had been evaluated by school psychologists at the request of the teacher and principal. The index boys were all working below capacity in one or more basic academic skills and many were considered to have behavior problems. 73 per cent had a significant reading disability* and the remainder had significant disabilities in mathematics, spelling and/or writing. The median age of the controls was nine years eight months and for the index boys it was nine years six months. The numbers of index and control boys by age-groups were: eight but less than nine years - 26 index, eight controls; nine but less than 10 years-23 index, 15 controls; 10 but less than 11 years-23 index, 1 1 controls; 1 1 but less than 12 years- 10 index, 1 I controls.

1975, 17

given in detail unless the exact method used is important. ITEMS 1 AND 2 have to do with motor stance persistence (Teicher 1941, Silver 1952, Bender 1956, Garfield 1964). Child was told “Stand up, put your feet together and close your eyes. Now put your arms straight out in front of you-spread your f i n g e r s d o not touch your thumbs together”. Some children held their arms rigidly at their sides, or in other ways showed that they did not comprehend “out in front”. If child did not understand instructions they were repeated; if he failed again, examiner placed his arms and hands in proper position. ITEM I-places arms elsewhere. ITEM2-arms drop or spread. ITEMS 3 TO 8 have to do with stance during passive head-rotation (Teicher 1941, Silver 1952, Bender 1956, Garfield 1964). Examiner said “This time I am going to put my hands on your headdon’t help me-let me turn it and keep your arms straight out in front, fingers spread and eyes closed”. Examiner slowly rotated child’s head 90’ in one direction. held it for a few seconds, then rotated head 180“ in opposite direction. This was repeated several times. Usually very light fingerpressure was sufficient. ITEM 3-during passive head-rotation, arms drop and spread. ITEM4 4 l b o w s bend. ITEM5 - 0 ~ arm drops. ITEM 6-irregular position of wrist, hand or fingers. ITEM 7-torso turn ( I to 3 i), or whole body turns (4+). ITEM 8-resistance of head to passive rotation. ITEM 9 was concerned with imitation of finger movements. Child was seated facing examiner and asked to copy finger-movements made by examiner. using one hand at a time. Examiner extended both arms with fingers slightly raised and palms towards child, saying ”Do exactly as I do”. Child then imitated finger-thumb touching a s done slowly by examiner, r . g . if examiner touched left thumb to left index finger, child executed the same maneuver using his right hand. Examiner switched about from hand to hand, slowly at first, then faster. If child copied movements of examiner’s left hand with own left hand (a more sophisticated response), he was asked to copy o n same side as the examiner. Examiner looked for quality of movement, speed of following, finger agnosia (especially of middle and ring fingers) and for associated movements in other hand.

Procedure All boys were given the special neurological examination by the senior author. In many cases the examiner knew in advance whether the child was an index or a control. All children were tested in the same manner. The neurological examination was done during the morning hours and the other procedures were carried out afterwards. The results of other laboratory tests are reported in earlier papers (Boydstun et a/. 1968; Dykman et a/. 1970, 1973; Ackerrnan ef al. 1 9 7 1 and ~ b). A response was scored by ranking it 0, 1 f, 24-, 3f or 4+, according to the degree of deviation from normal (0 being normal and 44- maximum deviation). Special Neurological Examination In the following list of all items used in this investigation, standard items are not * 18 or more months retarded in reading skills by achievement test. 66

J. I . I'ITIKS

J. S. ROMINI

ITEM IO+.horeiforni movements (Prechtl and Stemmer 1962, Wolff and Hurwitz 1966) o f tingers, arms, head or trunk during Items I to 9. ITEM 1 I-athetoid movements during Itenis 1 to 9. ITEM 12-tremor o f fingers during Itenis I to 9. ITEM I3--heel walk. ITEM 14-toe walk. I n M IS-hop on one foot (8 feet). then the other. ITFM 16--stand on one foot to count o f his age, then other foot. (According t o Sloan (1955), 90 per cent o f children between eight and I I years o f age can d o this on right leg and some 97 per cent on left leg.) ITCM 17-skip (average child can skip by age seven years. I T F M I X-aalk in tandem, a line or string. I T I M 19--speed o f tapping one foot. then the other. I i t M 20-note presence o f any associated movements during Items 13 t o 19. ITEM 21 -finger-nose test. ITFM 22-tinger pursuit. I T t M I.l---fingers-thumb test. Examiner bat close to and facing child, with hands on knees, palms up, and said "Watch me first. Look, I touch m y thumb to each finger (little finger first) one, two. three, four (slowly) one, two, three, four. N o w you d o it. Now a little faster. N o w the other hand." Examiner looked for inability to curl tingers. missed contacts, poor sequence, slowness, 'stickiness' o f release and reckless speed with inaccuracy. He also matched for symnietrical associated movements i n fingers o f the other hand and recorded them below in Item 27. (We have found slight symmetrical, associated movements to be normal up t o about age I I or I2 years.) I T t M 24~-alternating movements. Examiner placed his hands on his knees, palms down, and demonstrated very slowly h o w t o slap knees alternately with palms and backs o f hands. Child was asked to d o same. first with both hands then with each hand separately. A t first he was told to "go slow", then "faster". then "very fast". Child was scored for disorganization o f sequence and slow, 'sticky' turns, either o f one hand or both. I f child used edge o f hand as pivot he was asked to lift hands off leg between each turn. ITEM 25-finger tapping (Fisher 1960). Child was shown ho\v to tap curled index finger against distal joint o f thumb and was told "Do i t as fast as you can". Younger children are naturally slower. Euuniiner looks for slow. clumsy execution. A:.sociated movements o f thumb. wrist. arm. j a h or foot are recorded i n Item 28. I T ~ M 2h-c.omplex integrative task. C'hild was quick11 handed a paper-clip and three pieces of blank paper, arranged askem. Examiner said

R . A . DYKMAN

"Here, clip these neatly together as fast as you a n " . Score determined by clumsiness, associated movements o f mouth or face, not supporting paper near clip, and lack o f knowledge o f which end o f paper-clip t o use. ITEM 27-synim~trical associative movements during Items 21 to 26, i . ~mirror . movements. ITEM 28-asymmetrical associative movements during Items 21 to 26. i.e. jaw or other body parts. ITEM 29-deep tendon reflexes (Strauss and Lehtinen 1917, Kennard 1960). ITEM 30-plantar reflex. ITEM 31-plantar sensitivity to scratch with key: ticklish, painful or vigorous withdrawal response.

ITEM 32-clonus. ~ T E M33-~in~1siialbody

features (stigmata). o f right-left body orientation (Harris 1957. Money 1962). Examiner and child sat facing e x h other and examiner said "Put you1 right hand on your left ear: put your left hand on your right knee: put your left hand on your left ear", and so on. Degree o f hesitancy and inaccuracy determined the score ( I t for slight hesitation, 2 for initially wrong then corrects o r for long hesitation, 4 t for incorrect response). If results were unclear, examiner returned t o item later, being careful t o give child n o further clues as to correctness o f right-left. The average child can d o these movements by age seven. ITEM 35-right-left in facing person. Child was asked to point t o examiner's left hand, right foot. right hand, right ear, and so on. The normal child should pass this test by eight years. ITEM 36-turning right and left. Examiner asked child t o stand with feet together and said slowly. with appropriate pauses, "Turn t o the right. Turn to the left. T u r n to the left again. Turn t o the right. Turn to the right again", and so on. lteni was scored according t o confusion i n right-left awareness. The normal child passes this test by eight years. ITFM 37-relative right and left. Some children returned to starting position i n Item 36 before making second turn to right o r left, o r said "I am already turned right", indicating immaturity (common up to age eight years) i n lack o f awareness of new base for right o r left after each turn. i . ~a. relative right or left. l T t M 38-body part 1' whole part i n Item 36. Some children show immature o r aberrant concept o f body movement i n space. turning only head or torso. o r leaning to one side. ITFM 39-laterality. Preferred hand, foot and eye were determined by asking for simple demonstration\.

ITEM 34-kn3wledge

+

(2.6.

67

DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.

1975, 17

ITEM 66-strength of tongue. ITEM 67-tongue waggle. Examiner demonstrated how to waggle tongue rapidly from side to side, then asked child to do the same. Scoring depended on speed and whether there were associative movements of jaw or head. ITEM 68-speech. Child asked to repeat words and sentences. ITEM 69-stuttering noted. ITEM 7O-child asked to say rapidly “La, la, la” and “Da, da, da”. ITEM 7 I -dysarthric speech. ITEMS 72, 73-expressive and receptive dysphasia (not sufficiently significant as done by author to merit description). ITEMS 74 TO 76-writing to dictation. Child was given unlined paper and a pencil (without eraser) and asked to write on dictation the sentences: ( I ) a boy had a dog; (2) a dog saw a bird; (3) my name is . . . ; and (4) please come quickly. For follow-up studies on children aged 14 years, we use: (5) the question was about the constitution; and (6) it is a question of constitutionality. ITEM 74-examiner looked for letter reversals such as d for b. One reversal scored 2+ at age eight, 3 + at nine and 4 + at 10 years. (Up-down reversal of 9 for 6 in Item 77 was also scored here.) ITEM 75-spelling errors were scored according to age and grade, and to degree of departure from phonetic ‘logic’. ITEM 76-dysgraphia. The finished product is not sufficient basis for judgement ; examiner must observe the ucf of wiring. Look for labored formation or slow ‘drawing’ of letters, and for uncertainty in direction at start of letter or at any turnpoint. Eraser is not permitted; if child is dissatisfied he can write it again below original, thus visible record of efforts is obtained. ITEM 774ysgraphesthesia on palm of hand. With child’s eyes closed, several numbers from one to nine were ‘written’ on palms of hands. Each number was ‘written’ large and slowly. One error in identification scored I two errors 2+, three to four errors 3+, and five or more errors 4 + , counting both hands. Note whether initial success is followed by rapid falling off with fatigue of attention. [TFM 78-omitted. ITEM 79-dysgraphesthcsia on finger-tips. Procedure as for Item 77, except that numbers ‘written‘ on digital pad of index finger of dominant hand. ITFM X0-finger agnosia (Hermann 1959, Kinsbourne and Warrington 1962). The latter form IS ;idvocated.

ITEM 40-two-point simultaneous discriminations (face-hand test) (Bender 1952; Fink and Bender 1953; Ozer 1967, 1968). ITEM 4lLchild asked to wink each eye separately. ITEM 42-separation of movements. Ability to hold head fixed while executing extra-ocular muscle movements. Head-following is normal at age five but the six-year-old should be able to suppress head-following on request. ITEM 43Leye-tracking was scored according to whether eyes followed only approximately, or in jerks, or preceded the moving finger, or grossly overshot. ITEM 44-competing actions. Child asked to shut one eye and protrude tongue simultaneously. (This item is not significant for deviation of tongue.) ITEM 45-competing actions of blinking eyes and holding out tongue. ITEM 46-fixed strabismus scored 3 -t or 4 f,and inability to converge 1 or 2 - t . ITEM 47-transient strabismus noted during Items or 2+, depending on 42 to 45 and scored I degree. ITEM 48-nystagmus. ITEM 49-pupillary reaction to light. ITEM 5Gpupillary response to accommodation. ITEM 51-motor impersistence (Garfield 1964). Tongue held extended for 20 seconds. ITEM 52-eyes held closed for 20 seconds. ITEM 53-child asked to keep eyes directed at examiner’s finger while the latter counts to 20. 60 angle for child’s eye; repeated for other eye. ITEM 5Ldistractability. As in Item 53, child told to hold gaze on examiner’s finger, laterally placed, for count of 20. At about count 10, examiner used opposite hand to introduce waggling finger. Distraction on first trial rated 0, on second trial t 3 + , depending on amount of offrated 2 ~ or target glancing. ITEM 55-if child was distracted to examiner’s face during Item 54 or during preceding extraocular eye maneuvers, he received score of 3 t or 4+. ITEM 56-orbital muscles tested. ITEM 57-associative movements of mouth or nose during Item 56 scored 1 to 4+. ITEM 58-test of mouth grimace. ITEM 59-associative facial movements during Item 58. ITEM 60-whistle or purse lips. ITEM 61-frown. ITEM 62-raise eye-brows. ITLM 63-strength of jaw muscles tested. ITEM 6 k l e v a t i o n of uvula. ITEM 65-vocal abnormality.

+ +

+,

68

J . I . I'bTLRS

J. S . ROMINL

For those wishing to use an abbreviated form of this neurological examination, the following Items are suggested: 3 to 9, 15, 17, 23 to 25, 27, 34 to 36, 38, 43, 74 to 76.

R. A. DYKMAN

TABLE 1 Children with learning disabilities (82) versus controls (45): items significantly different on the Mann-Whitney U test

Results Reliahilitj. To obtain a measure of reliability, one of us (J.S.R.) re-examined 10 of the index boys who had been tested by the senior author within the previous six months. These children were selected to represent a wide range of neurological scores. The re-examiner was not aware of the scores on the original neurological examinations. The test items were dichotomized into negative (0 t o 1 -+) or positive ( 2 . to 4$-). and the results of the two examiners were compared. Agreement across all 10 children and all items was 84 per cent. Percentages of agreement for each child separately varied from 74 to 93 per cent. I n seven of the 10 children the agreement was more than 84 per cent.

2. Arms extended; drop or spread ? 3 . Head rotation: arms drop o r spread? 9. Copy finger movements 10. Choreiform movements 15. Hop on one foot 16. Stand on one foot 18. Walk a line 19. Foot tapping 20. Associated movements in lower extremities 21. Finger-nose test 22. Finger pursuit 23. Fingers-thumb 24. Diadochokinesia (hands) 25. Diadochokinesia (index finger against thumb) 26. Papers and clip 27. Associated movements (symmetrical) 28. Associated movements (non-symmetrical) 29. Deep tendon reflexes 30. Plantar reflex 3 I . Plantar sensitivity 34. Right-left confusion (on self) 35. Right-left confusion (on examiner or objects) 36. Right-left confusion (for body movements) 39. Mixed laterality 40. Two stimuli discrimination 42. Extra-ocular movements: head moves also? 46. Strabismus or can't converge 47. Transient strabismus 53. Lateral gaze (hold 20 seconds) 54. Lateral gaze; distraction 1 57. Eyes shut; associated movements? 58. Grimace 62. Raise brow 66. Tongue strength 67. Tongue waggle 68. Speech deviation 70. Speech (speed of la, la, da, da) 73. Receptive dysphasia 74. Writing; reversals'? 75. Spelling 76. Dysgraphia and slow writing 77. Dysgraphesthesia in palm 79. Dysgraphesthesia on index finger XO. Finger agnosia

linirariute Discrimination nf Indes and Control Childrerr For each test item on the 82 index and 45 control children, a frequency distribution was constructed giving the number of index and control boys within each rating (0 to 4:~). The resulting frequencies for both index and control groups were then compared, using the Mann-Whitney U Test (Fisher 1960) as a measure of their separateness. This statistical treatment implies that an examiner can detect gradations of normality-abnormality on a five-point scale. An alternative way of looking at the data is to employ a dichotomy ( e . g . 0 and 1-1for normal and 2+ to 4-t- for abnormal). Table 1 is based on the first approach and Table I1 is based on the second. Table I shows the test items which revealed a statistically significant difference between the index and control cases (i.~. items reaching at least the 0.05 probability '

level by the Mann-Whitney IJ Test). Frequency distributions for the items are given in Table 11. 69

IEVELOPMENTAI. MEDICINE A N D CHILD NEUROLOGY. 1975, 17

TABLE I1 Frequency distributions in percentages for all items in Table I

t GlY~llp

0 .2. Arms extended; drop or Control spread? Index _~ -______-___ 3. Head rotation; arms drop or Control spread? Index _______ 9. Copy finger movements Control Index

Percentage normal or trace

Pivcentugi) occurrericc

I 1 21 3 ' 4

(0 I 0 I

Percentage abnormal (2 1 to 4 1 )

t )

_ _ _ _ p _ _ _ _ _ -

1

100 94

i

15. Hop on one foot

--_____

0

0 i

98 67

2 7

2-1 0

86 71

27 44 29 0 16 27 23 29 _____ Control 84 4 9 2 58 13 16 I2 Index

0 5

64 22 44

'

i

Control Index

18. Walk a line

Control Index

.-

9 27 28

--___-____---

l

16. Stand on one foot

IOO

0 _ 0 12

Control Index

--

-

I

5 _ 71 27 2 38 29 21

-

10. Choreiforni movement

o o o o 1

I

~_______

~ 0

-

71 43

______ 2 33

-

_____-

14 29 -__29 57 ~

0 0

88 71

12 29

98 92

2 8

I00 81

0 19

96 82

10

2 6

0 2

0 1 0 '

89 68

II 0 13 16

0 2

0 0

2

5

-

__-1

0

95

_ ~ _ _ _ _ _ ~ - -

73 20 7 0 0 93 7 59 19 16 8 0 76 24 ~ _ _ __ Control 62 18 20 0 0 80 20 20. Associated movements in lower extremities Index 50 15 23 I I 0 65 35 __ ________-___ _-Control 98 2 0 0 0 100 0 21. Finger-nose Index 84 9 6 1 0 93 7 ____ ___~__ -___ ____ __2 22. Finger pursuit 98 Control 98 0 2 0 0 II 0 0 89 Index 77 12 I I 19. Foot tapping

Control Index

~

23. Fingers-thumb

I

I

Control Index

___24. Diadochokinesia (hands)

25. Diadochokinesia (index finger against thumb) 26. Papers and clip

____

__

27. Associated movements (symmetrical) _____~28. Associated movements (non-symmetrical)

-

29 Deep tendon reflexes

--______~ 30 Plantar reflex -___

31. Plantar sensitivity

'

Control Index

'

13 2 9 27

69 22 23 31

4 21

0 2

93 51

7 46

9 0 23 21

0 1 2 ,

91 54

9 46

4 18

0 10

0 I

96 71

4 29

________------

Control Index

' 89

7

55

16

Control Index

73 42

16

9

31

I6

2 10

0 2

89 73

II 27

Control Index

49 36 16 0 32 26 27 15

0 I

84 58

16 42

Control Index

76 59

0 2

_-_______ ______Control Index Control Index Control Index

_.____ 34. Right-left confusion on self Control Index 35. Right-left confusion on Control examiner o r objectc Index

I

80 42

18 10

4 2 13 16

4 6

2 15

0 6

87

13

66

21

0 13

0 0

71 13 I I 38 21 28

93 73

~

_

97 79

3 21

0 0

100

87

0 13

4 12

0 I

84 59

I6 41

7

0

7

7

2 9

91 77

II

7 II

2 II

80 60

____-____7 II

6 31

__ ~ _ _ _ - _ _ _

_-_______-__

___________ 73 49

1

0 0

_

___

84 7 54 23

94 69

1

I8

-

-___

9 22 - _ _ ~ 20 40

J . I-. PETLKS

J . S. KOMINE

K . A . IIYKMAN

TABLE I1 (ronr.)

I I

Grorrp

Tvsl item

1 -___

36. Right-left confusion for body movements __.

Ptwentagr abnornial

I * 2$ 3 : 4

(Owl!)

(21 1 0 4 : )

87 61

13 39

___-

I

Control Index

7 17

18

44 29 20 24 20 26

2 9

4 13

_-

-.____.

0 5

7 16

73 54

27 46

73 50

21 50

.~

40. Two \timuli discrimination

Control ' 64 Index 1 ~46 ~ Control ' 89 Index 82

~

42 Extra-ocular movement; head moves also?

I

43

~~

____.____

I

Percentagc normal or tracr

' 71 16

Control Index

39. Mixed laterality

0

Pr,rctwiuge occ~irri~ncc

~.

9 4

_

4 7

9 13 13 29 _

_

.-

2 I2

9 6

0 0

0

87 67

9 15

4 15

0 4

0 0

96 82

4 18

2

9 38

0

--

.____

9

91 94

6 -___

46. Strabismus or can't converge

Control Index

54. Lateral gaze; distraction'?

Control Index

73 55

18 7

4 12

II

2 I5

91 62

57. Eyes shut; associated

Control

I00

0

0

0

0

I00

0

66. Tongue strength

Control Index

91 68

4 12

4 I1

0 9

0 0

95 80

20

73 62

I6

7

11 0 16 I2

0 2

89 69

96 73

2 5

2 II

0 7

0

4

98 78

Control Index 1

89 72

II 13

0

0

100

-

0 7

-

7

0

Control Index

i

93 81

4 I2

3 7

o

o

1 1

76 20 54 6

4 18

o

o

1

~

~~

I

Control Index .~

68. Speech deviation

___ -

-

--

-

-

~

~

~

~

73. Receptive tlysphasin

-

'

75. Spelling .-

76. Dysgraphia or slow writing

l~77. Dysgraphesthesia in palm

~

~

_.

~~

Control Index

~

~

-

0

17

Control Index

_

0

85

_

__-_

2

_

22 - ___ 0 15 _

_

97 93

3 7

5

96 60

4 40

_____

_

13 I I 0 18 23 28

0 9

89 40

II 60

82 42

18 0 0 I I 23 20

0

I00 53

0 47

84 65

35

83 62

17 38

71 13 I I 43 22 22

4 10

73 20 4 44 18 21

2

-

~

~.~

76 22

-~

80. Finger agnosia

_

~.

~

1

Control Index

-- -

II 31

-

Control 1 Index ~-~ Control ' Index

79 Dysgraphesthe4a on index finger

___-_____

I

-

Control Index

_____~__

I

,

-~

74. Writing; reversals?

I

'

Control Index

70 Speech (speed of la. la. da. da)

I

5 -~

67 Tongue waggle

I

1

80 57

71

I1 I2

I6 __ 9 0

22

9

5

-

0

4 0 I

I6

_ .__.

0 0

91

9

69

31

~

DEVELOPMENTAL MEDICINE A N D CHILD NEUROLOGY.

TABLE 111 Product-moment correlation between age and item scores for children with learning disabilities Item

Two cautionary statements should be made. Firstly, in making 80 statistical tests and accepting an 0.05 probability level, at least four items could achieve significance by chance and not represent a true difference. Secondly, the practical usefulness of an item in discriminating a clinical group from the total population depends on ( a ) the incidence of the clinical group in the total population, and (b) the completeness of the separation between the clinical group and the normal sample: that is, an item should not provide too many false negatives or too many false positives. The clinician may more profitably use Table 11 for a selection of useful items. For example, on a five-point judgement scale Item 42 is significant (Table I); however, on a dichotomy of 0 and 1 v 2+ to 4+ (Table 11) it is not. This is still not the whole truth for the clinician, because in six- and seven-year-old children (who were not studied in this research), the tendency to head-following with eye movement is clinically important. Table I1 shows the items in terms of percentage occurrence for each degree of the 0 to 4 + scale; the last two columns also show the percentages dichotomized into clinically normal or merely 'trace' results v clearly significant results.

11

Correla- p valut tion

1975, 17

-'

*3. Head rotation; arms drop or spread ? .36 .01 6. Head rotation; irregular position of fingers, hands, etc.? .37 .01 7. Whirling .27 .I0 8. Whirling; resistance to passive .22 .05 rotation ? *9. Copy finger movements .37 1 .01 12. Tremor +.19 1 ,I0 13. Heel walk - .20 ,I0 '15. H o p o n o n e f o o t 1 -.44 .01 '16. Stand on one foot .24 .05 -,37 .01 17. Skip *18. Walk a line -.I9 '10 '19. Foot tapping -~~ .47 .01 &20.Associated movements in .40 i .oi lower extremities .36 ' .01 *21. Finger-nose test $22. Finger pursuit ,35 .01 $23. Fingers-thumb .58 .05 *24. Diadochokinesia (hands) 1 P.30 '01 *25. Diadochokinesia (index finger against thumb) --48 .01 *26. Papers and clip - . 4 1 1 .01 '27. Associated movement (symmetrical) *29. Deep tendon reflexes *31. Plantar sensitivity *34. Right-left confusion on self *35. Right-left confusion (on examiner or .35 .01 objects) 36. Right-left confusion (for body movemen t s) *39. Mixed laterality 41. Can't wink either eye *42. Extra-ocular movements; head movements also? 27 , .05 45. Rapidly blink eyes and hold o u t tongue *53. Lateral gaze (hold 20 seconds) *54. Lateral gaze; distraction ? 61. Frown 63. Jaw strength open , and shut *66. Tongue strength *67. Tongue waggle *68. Speech deviation ~

~

~

~

+

~

Age Variable Product moment correlations for both index and control children were obtained between age (in months) and item scores. While one might expect these to be 70. Speech (speed of la, la, da, da) 74. Writing; reversals? '75. Spelling 76. Dysgraphia and slow writing 78. Palmar reflex *79. Dysgraphesthesia on index finger

~

-.25 '24 -.21 -

.05 .05 .I0

.44 -.24

.01 .05

~

l

-

.35

.01 I

* 12

Items which also appear in Table 1.

J. E. PE'l'tKS

J . S . KOMINE

In order to further investigate the age variables. the index and control children were each divided into sub-groups aged less than 10 years and aged 10 years or older. A comparison was then made between older index children and older controls by contrasting the frequency distributions of item scores (using the Mann-Whitney U Test). Table V1 lists the statistically significant items.

attenuated by the limited range of scores permissible for each item, they yielded results consistent with those obtained when the children were classified into two age-groups-less than 10 years, and I0 years or older (as tested by Mann-Whitney U Test). The correlations, while underestimating somewhat the true relationship of age to neurological score, are useful both in indicating statistical relationship and in showing the magnitude of the relationship. Table 111 gives the product moment correlations for the index children only, Table IV for the controls only and Table V those common to both groups. The product moment correlations reboth in indicating statistical relationship between age and performance. This means that positive signs were less frequent in the older children.

Discussion Statistical Resitlts

The results of the univariate analysis leave little doubt that children with learning disabilities, as selected for this research, have a higher incidence of special neurological signs than do controls. Of the 80 items scored, 44 were significantly different-12 at the 0.05 level and 32 at 0.01 or less. An important finding of this study was that with increasing age there is a decrease in the incidence of special neurological signs in children with learning disabilities. By product moment correlation, 42 of 80 items showed a significant negative correlation of age to rank-score on each item in the index group alone (Table 111). Of that number, 31 are included in the significant items shown in Table 1. I n other words. the majority of items discriminating index from control children have a significant negative correlation with increasing age in the index group alone. Within the control group, only seven items have a significant negative correlation with age (Table IV) and only five of these were found to be significant in the index group (Table V). As shown in Table VI, when older index children (I0 years or older) were compared with older controls (using Mann-Whitney U Test), only 1 1 items significantly discriminated between the two groups, compared with 44 items which discriminated the entire index group from the entire control group. Choreiform movements,

TABLE 1V Product-momentcorrelations between age and item scores for control children C'orrrlu-

__-

tion

lreni

p value

-

I . Arms extended; drop or spread? 7. Whirling 10. Choreiform movements 20. Associated movements in lower extermities 23. Fingers-thumb 34. Right-left confusion on self 45. Rapidly blink eyes and hold out tongue

'

.28 .28

.05 .05

,2h

.05

.43

.01

R. A . D Y K M A N

TABLE V 1tems significant (p < .05) and common to both

index and control children in Tables I11 and IV Item -

7. Whirling

20. Associated movements in lower extremities 23. Fingers-thumb 34. Right-left confusion (on self) 35. Rapidly blink eyes and hold out tongue

73

DEVELOPMENTAL MEDICINE A N D CHILD NEUROLOGY.

1975. 17

TABLE VI Children 10 years or older, index (33) versus controls (23) items significantly different on the Mann-Whitney U test lrem

p ~~allrl,

-~

3. Head rotation; arms drop or spread? ____-__~-

24. Diadochokinesia in hands

- _ _ _ _ _ _ - ~

~ _- _ _ 62. Raise brow

Item

.05 .05

75. Spelling

.01

76. Dysgraphia and slow writing

~

.05

_ _ _ ~ -

.

____-

_

77. Dysgraphesthesia in palm

27. Associated movements (symmetrical)

39. Mixed laterality

_

__-

46. Strabismus or can’t converge

80. Finger agnosia

.05

___-__ .05

lower extremity co-ordination, motor functions of cranial nerves, and right-left confusion failed to discriminate the older index boys from the older controls, while items of fine motor co-ordination persisted (e.g.finger-thumb test, dysdiadochokinesia, symmetrical associated movements, dysgraphia, and inability to converge the eyes). Finger agnosia and dysgraphesthesia also persisted. The younger index children showed a much greater number of discriminatory signs compared with the younger controls. These findings indicate that children with learning difficulties tend to have a delay in motor development and that improvement occurs first in gross motor functioning and body orientation. This developmental delay is assumed to be due to delay in neurological maturation. Other investigators have implicated delayed neural maturation as a factor in learning disabilities, but most have used only a few test items. For example, Harris (1957) found that the ability to distinguish between right and left and a clear preference for one hand develops more slowly in poor readers. Gubbay et a/. (1965), in a case study of children with learning difficulties, noted in some a marked alleviation of clumsiness, mixed laterality and learning disabilities with increasing age. Eustis

(1947) maintained that delayed neuromuscular maturation was associated with a syndrome of language disability, confused laterality and clumsiness. He attributed the delayed maturation to an inherited predisposition. It is well to keep in mind that improvement with age in the still-developing organism does not rule out ‘minor’ or ‘subtle’ brain damage as a significant etiology. There is a tendency among some professionals to think that because the child matures and improves, his original deviations and deficits probably were not due to brain damage. It should be pointed out that some of the signs which were not statistically significant in our population probably would be in more severely impaired children. Our cases were heavily selected for mild to moderate problems. The ‘whirling’ sign is certainly important in severely atypical and in retarded children. It must be remembered also that our cases had to have either a WISC Verbal or Performance IQ of at least 90 to be included in the study. Some other researchers have not used such a high cut-off point. From other research we have done on learning problems in children with IQS between 75 and 90, it is our impression that (with certain exceptions) the lower the 74

J. 1:.

P1.7I.KS

J . S. KOMINE

the greater the number of positive signs, and the poorer the adjustment will be at home and at school. The neurological procedure described here cannot be expected to single out all children with minimal central nervous system deviations. A multitude of distinct deviations can exist in the higher integrative processes of the brain which this procedure does not tap at all. Therefore the fact that a child shows no significant neurological signs does not rule out the existence of a specific learning disability.

IQ

Clinical Sign$can re

Motor awkwardness has been one of the deviations most commonly described in studies of children with 'minimal brain dysfunctions'. At least 26 of the 44 statistically significant items used in this examination could be placed into that category. Some professionals maintain that a detailed and careful assay of a patient's complex motor performances, as described in this paper, has little practical value; what is more, they believe a clinician's over-all judgement of the presence or absence of clumsiness is essentially as good. This may be true of an experienced and perceptive pediatric neurologist, or of one of the few pediatricians w h o has made these children a special field of interest, but it is not true for most of the physicians who see children and who should be in a position to detect and refer such cases. For them. a s for any beginner in this complex field-and certainly for psychiatric and pediatric residents-this method provides a way of leariiiiig t o perceive these subtle but important variations in movement, stance and visuo-motor co-ordination. Frequently, a patient's poor co-ordination or directional confusion would not be apparent to such physicians unless specifically tested for. The pediatric neurologist, in the course of his examination, does test

K. A . DYKMAN

for a high percentage of these items and a great many more which do not directly concern us here. However, in contrast to the more localized and pathognomic signs to which he is attuned, our 'signs' (which do not indicate a threat to life or a threat of physical incapacitation) may appear to be too minor to arouse interest. Furthermore, many of these signs. having no established neuro-anatomical specificity, may appear to lie in a no-man's land of speculation. The importance of such items as directionality, eye-tracking, visuo-motor co-ordination and stance persistence-any one of which may appear unimpressivetake on meaning when transposed into the context of basic school skills. One must take the trouble to scrutinize and to analyze school tasks in order to appreciate their relevance. At the very least, if a child has school problems, either academic or behavioral, the physician should take pains to observe that child in the act of writing and in the act of reading. Merely for the child to write his name is not sufficient. Co-ordinative clumsiness in writing is not at all the same thing as conceptual confusion. Uncertainty as to the direction from which to approach an '0'. an 'a', a 'd', or a 'b' in writing, and a fumbling, approximate way of calling up visuo-motor responses to sounds can reveal to the physician i n a few minutes the frustrations a child is faced with in keeping up with his classmates. A further question is whether there is a practical value i n the physician carrying out the procedures of the special neurological investigation. Cognitive and attentional deviations are clearly relevant to how a child functions at school and can easily be delineated without the help of a physician. Hyperactivity may or may not be important, depending to some degree on whether the teacher perceives her endeavors and goals as being interrupted

DEVELOPMENTAL MEDICINE AND CHILL) NEUROLOGY.

1975, 17

special neurological examination and has correlated his findings with the child’s behavior and performance at school. With that degree of personal knowledge he is in a much better position to give or to withhold medication, to be more selective about the drug, and to be more discriminating as to dosage. It should be obvious that any physician who places a child on medication for such symptoms should see the child and the parents on a regular basis in order to better adjust the dosage, to counsel the parents, and to watch out for any undesired side-effects. It is of paramount importance that the physician, for the first few weeks of treatment, should be kept informed as to the effects of this treatment on the child’s behavior at school. Once every six months is not often enough to follow these medications. Moreover, the parents of these perplexing children usually need to talk to the physician every two to three months in order to regain their perspective and to be reassured. One of our hopes was to better define phenomenological sub-types within the diverse group of children who have learning disabilities or ‘minimal brain dysfunction’; however, in this report we have limited ourselves to incidence findings and to their significance in relation to controls and in relation to the age of the child. In two other publications we have suggested sub-types based on the total of our clinical experience, which includes this research (Clements et al. 1970, Clements and Peters 1972).

by the child. A specific academic disability will be self-evident, and the psychologist or educational diagnostician will be able to plot out the pattern of deficits and plan a remedial program specific for the child. The handicapped reader or the child with poor visuo-motor co-ordination is easily enough spotted by trained school personnel. So what would the physician’s special neurological investigation add? The above statements imply the existence of a superb school system, highly responsive to the subtle but crucial individual differences of its pupils. Such a school system is rare indeed. Where it does not exist, there is no question that for the psychiatrist, pediatrician or family physician the experience of certainty that comes from examining these children himself, and integrating his findings with the psychological, academic and home data, makes a major contribution to the diagnosis and management of children with learning difficulties. In effect, he says these deficits are significant, are due to irregular working of the central nervous system and that they require special consideration. Even in the rare school system which can deal properly with these children, there is usually a plea for medical sharing of responsibility. In addition, the physician may (in the more affected cases) administer medications which reduce activity and distractibility or which sharpen attention. Here his r81e is clear and traditional. It may well be today that we are going through a period of over-use of drugs for these purposes;* however, the physician is on solid ground when he himself has given the child the

* Many European pediatricians (compared with American) do not acknowledge the mild to moderate cases of ‘minimal brain dysfunction’ and find little need to use stimulant drugs for hyperactivity and short attention span. Different methods of home and school management, or perhaps even differences in habits of television watching and nutrition, could account for some of the discrepancy. The matter needs careful research and should not be dismissed lightly.

Acktiowk~~dgements: This work was supported by a National Institution of Mental Health Grant, Number PHS I R01 MH 12888. Dr. Dykman’s work was supported by Public Health Service Career Scientist Award (5-K05-MHO-2504-03). We are indebted to Dr. ArNell Boelsche, Department of Pediatrics, University of Texas Medical Branch, Galveston, for the initial impetus in collecting these items.

76

J. E. PKTtRS

J. S. ROMINE

R . A. D Y K M A N

AUTHORS’ APPOlNTMEN TS

John E. Peters, M.D., Professor and Head, Division of Child-Adolescent Psychiatry, University of Arkansas Medical Center, Little Rock, Arkansas.

J. S. Romine, M.D., Assistant Professor of Neurosciences, University of California at San Diego. R . A. Dykman, Ph.D., Professor, Department of Psychiatry, University of Arkansas Medical Center.

SUMMARY

Children with ‘minimal brain dysfunction’ and learning disabilities were found to have significantly more minor neurological signs than control children. Many of these signs become less obvious or disappear by the age of 1 1 years; therefore older cases are more similar to controls, whereas younger cases show lags or deficits at the highest levels of central nervous system functioning-language, fine motor co-ordination and cross-modality integrations. RESUME

Examen neurologique particulier chez les cnjants prPsentant des troubles des upprentissuges Les enfants avec des troubles cirebraux minimes et des difficultes d’apprentissage presentent plus de signes neurologiques mineurs que les contr6les. Beaucoup de ces signes deviennent moins Cvident ou disparaissent vers 1’5ge de onze ans; de ce fait, la similitude avec les contrbles chez les enfants plus i g t s est plus grande tandis que les plus jeunes cas montrent des retards ou des deficits au plus haut niveau de fonctionnement du systeme nerveux central: langage, coordination motrice fine et integrations complexes. ZUSAMMENFASSUNG

Eine spezielle neurologische Untersuchung der Kinder tilit Kernschwierigkeiten Kinder mit minimaler cerebraler Dysfunktion und Lernschwierigkeiten haben signifikant haufiger leichte neurologische Symptome als Kontrollkinder. Viele dieser Symptome gehen zuriick oder verschwinden bis zum elften Lebensjahr; daher sind die alteren Falle ahnlich den Kontrollen, wahrend die jiingeren Falle Verzogerungen und Ausfalle im Bereich der differenzierten Zentralnervensystemfunktionen-Sprache, feinmotorische Koordination und komplexe cerebrale Funktionsmechanismen-zeigen. RESUMEN

Un examen neuroldgico especial de nikos con dijicullucles en el apreridizage Se encontro que niiios con disfuncion cerebral minima y dificultades de aprendizage tenian significativemente mas signos neurol6gicos menores que 10s controles. Muchos de estos signos se hacen menos aparentes o desaparecen a 10s 11 aiios de edad; por ello 10s casos de mas edad son mris semejantes a 10s controles, mientras que 10s mas jovenes muestran lagunas o deficits en 10s niveles mas altos de las funciones del SNC: lenguage, coordinacion motora fina a integration cruzada. REFERENCES ) with specific learning disabilities, 1. WISC Ackerman, P. T., Peters, J . E., Dykman, R. A. ( 1 9 7 1 ~‘Children profiles.’ Journal of Learning Disabili/ic,.s, 4, 150. - - - (1971b) ‘Children with specific learning disabilities. 11. Bender Gestalt Test findings and other signs.’ Journal of Learning Disabilities. 4, 437. of Chilclren with Organic Bruin Di.sorder.s. Springfield, 111. : C. C. Thomas. Bender, L. ( 1956) Psvchopatholog~~ Bender, M . B. (1952) Disorders in frwc,pfion. Springfield, 111.: C. C. Thomas. Birch, H . , Belmont, L. (1964) ‘Auditory-visual integration in normal and retarded readers.’ American Journal of Orthopsychiatry, 34, 852.

77

DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.

1975, 17

Boydstun, J. A., Ackerman, P. T., Stevens, D. A., Clements, S. D., Peters, J. E., Dykman, R. A. (1968) ‘Physiologic and motor conditioning and generalization in children with minimal brain dysfunction.’ Conditional Reflex, 3, 81. Clements, S. D. (1966) Minimal Brain Dy3firnction in Children. Public Health Service Publication N o . 1415. Washington, D.C.: U.S. Govt. Printing Office. Peters, J. E. (1962) ‘Minimal brain dysfunctions in the school-age child.’ Archives of General Psychiatry, 6, 185. ( 1972) ‘Minimal brain dysfunctions, concepts and categories.’ World Medical Journal, 19, 54. - - Goolsby, C. M., Edginton, R., Davis, J. (1970) ‘Two cases of learning disabilities.’ In Tarnopol, L. (Ed.) Learning Disabilities. Springfield, Ill. : C. C. Thomas. Dykman, R. A., Walls, R. C., Suzuki, T., Ackerman, P. T., Peters, J. E. (1970) ‘Children with learning disabilities. V. Conditioning, differentiation and the effect of distraction.’ American Journal of Orthopsychiatry, 40,766. - Peters, J. E., Ackerman, P. T. (1973) ‘Experimental approaches to the study of minimal brain dysfunction: a follow-up study.’ Annals of the New York Academy of Scienc Eustis, R. S. (1947) ’The primary etiology of the specific language disab nal of Pediatrics, 31,448. Fink, M., Bender, M . 9. (1953) ‘Perception of simultaneous tactile stimuli in normal children.’ Neurology, 3, 27. Fisher, C. M. (1960) ‘A simple test of co-ordination of the fingers.’ Neurology, 10, 745. Garfield, G. C. (1964) ‘Motor impersistence in normal and brain-damaged children.’ Neurology, 14, 623. Gubbay, S. S., Ellis, E. E., Walton, J. M., Court, S. D. M. (1965) ‘Clumsy children: a study of apraxic and agnostic defeats in 21 children.’ Brain, 88, 295. Harris, A . J . (1957) ‘Lateral dominance, directional confusion and reading disability.’ Journal ofPsychology, 44,283. Hermann, K. (1959) Reading Disability. Springfield, 111.: C. C. Thomas. Kennard, M. A. (1960) ‘Value of equivocal signs in neurologic diagnosis.’ Neurolog.v, 10, 753. Kinsbourne, M., Warrington, E. K. (1962) ‘A study of finger agnosia.’ Brain, 85,47. Money, J. (1962) Reading Disability: Progress and Rescarch Needs in Dyslexia. Baltimore: Johns Hopkins Press. Ozer, M. N. (1967) ‘The face-hand test in children: directions and scoring.’ Clinical Proceedings of the Children’s Hospital, District of Columbia, 23, 305. - (1968) ‘The neurological evaluation of school-age children.’ Journal of Learning Disabilities, 1, 84. Pasamanick, B., Rogers, M. E., Lilienfeld, A. M. (1956) ‘Pregnancy experience and the development of behavior in children.’ American Journal of Psychiatry, 112, 613. Prechtl, H. F. R., Sternmer, J. (1962) ‘The choreiform syndrome in children.’ Developmental Medicine and Child Neurology, 4, 119. Silver, A. A. (1952) ‘Psychological aspects of pediatrics, postural and righting responses in children.’ Journal i f Pediatrics, 41, 493. Sloan, W. (1955) ‘The Lincoln-Oseretsky Motor Development Scale.’ Genetic Psychology Monographs, 51, 183. Strauss, A. A,, Lehtinen, L. (1947) Psychopathology and Education of the Brain-injured Child. New York: Grune & Stratton. - Kephart, N. C. (1955) Psychopatholugy and Education of the Brain-injured Child. Vol. 11. New York. Grune & Stratton. Teicher, J. D. (1941) ‘Preliminary survey of motility in children.’ Journal of Nervous and Mental Disease, 94, 277. Wolff, P. H., Hurwitz, I. (1966) ‘The choreiform syndrome.‘ Developmental Medicine and Child Neurology, 8, 160.

-

--

78