Develop. Med. Child Neurol. 1977, 19,495-502

Recovery of Intellectual Ability after Closed Head-injury Paula Altman Fuld Phgllis Fisher

functioning in relation to the demands of the school in order to modify such demands (Symonds 1962). If children return to school with unrecognized gnostic, language or memory impairments (Dillon and Leopold 1961) or with difficulties in abstract thinking, figure-ground discrimination, speed, distribution of attention, or manual co-ordination (Dencker and Lofving 1958), their position is similar to that of adults who become more difficult to treat after returning to work prematurely (Gronwall and Wrightson 1974). Hjern and Nylander (1964) and Shaffer et al. (1975) point out that children and their parents may require and can benefit from more prolonged supportive follow-up than is usually provided. That such follow-up should be based on an understanding of the specific changes that have occurred in the child’s intellectual, sensorimotor and perceptual functioning is evident; a child who appears to the physician to be functioning at a level average for his age may once have been far superior to that level and may be suffering considerable emotional distress because of the discrepancy between his own expectations and his post-traumatic abilities (Naughton 1971). As neuropsychologists at an urban

Introduction The literature on recovery from closed head-injury in children gives the impression that, while slight intellectual impairments may sometimes occur, these tend to be self-limited and of brief duration (Ruesch 1944, Lewin 1966, Mealey 1968). Mealey (1968) and Ford (1973) stressed the importance of a rapid return to the normal routine and made no mention of possible school problems or the desirability of follow-up. Dillon and Leopold (1961) pointed out that eight of their 50 cases had posttraumatic school difficulties. Similarly, in a long-term follow-up of 3 I unselected closed head-injury cases with co-twin controls, Dencker and Lofving (1958) found long-term residual difficulties with some intellectual tests. Because they found no difficulty with a number of their tests, including tests of concentration and immediate memory, this study has been cited informally as evidence that people recover completely from closed headinjury. Even if it were true only occasionally that children suffer significant intellectual impairment as a result of closed headinjury, it would be important to obtain detailed evaluations of those children’s

Correspondence 10 Dr. P . A. Fuld, Room 154, Jacobi Hospital, Pelham Parkway and Eastchester Road, Bronx, New York 10461.

495

Soedly and intellcaually normal child; mild reading problems

Bright child; above average student in good parochial school

M

M

F

F

4

5

6

7

-

Normal child

M

3

retardation; teachra felt he was educable; mildly hyperactive

child with mild mental

Microccphalic

poor school prognss

dclinqueacy;

M

Hit by car

Four tincar,

29 days

fractures, left frontal. parietal and temporal areas

skull

non-depressed

Hit by car

Concussion

13 days

Dclayed return to school; home tutoring and IMgUaW therapy

Abnormal EEG (paroxysmal region); dysfluent language with occasional paraphasias; mild receptive language difficulty; concentration problems; mild h e motor inco-ordination

slow activity in left frontal

Out-of-school tutoring by special reading teacher

class to program for children with learning disabilities

regular school

Transfer from

Continue placement in class for educabk mentally rdarded- obtain c o d g and tutoring scrvias

Placanent in a special full-time remedial mading program' psychological cd.uoseling

Retention in grade completed the previous year

class for learningdisabled children

placementiin a

Educational recommendations

Concentration problems, irritability; no neurological signs

~

Tonic-donic scizurca controlled .__- bv medication: loss of lan&s. with . gradual return aRer one year; severe school learning probhn.9. especially with d m g ; marked hyperactivity; night terrors

Generalized Seizurca controlled by medication; has not learned to read or do arithmetic: behavior problanf; &ked hyperactivity

Fell from 5th floor

Concussion, sfalp lacerations

Beaten on head with lead pipe

Fine motor incoordination; attention and verbal memory problems: no neurological signs

Protruded head from window of moving train, head hit post

Bilateral frontal contusions. right worsc than lcft

Hit by car Mild language problems; mild fine motor incoordination; increased deep tendon reflexes on right ; some difficulty with rapid alternating movements

Migraine headaehes; mild behavior problems and difficulties with concentration; no neurological signs

Sequelae

Concussion

Hit by car

Nature of accident

Concussion

'

Concussion

TYW ?f head injury

TABLE I Details of seven children with closed head-injury

c ISmins 1of consciousness

5 days

15 days

1Smins

Long history of truancy.

&

Period of coma

17 days

Years since 'njury

Normal child

socially and intcuectuplly normal child; non-reader. probable leamine disability

Status before i&ry

2 K.B.)

M

-

1

E.B.)

Sex

Case

--

~~

this)

Child rrturned full time to rcgular class approximately 15 months after inj?; shc is said to be doing average work (parents refuse permission to contact school to confirm

Tutoring obtained from special education teacher; child now getting above avcrase grades in reading; concentration and personality back to normal

Child ~~101led in Learningdisability class. p w t reports (after 8 months in this class) that child is karning to read, M sleeping well. and IS less hypcractive

stling smias

Child ranained in claw for mentally rrtarded; fi.cqumtly truant; parent refused tutoring and coun-

and mothcr refused follow-up and further help

recommendations. After initially.agrcciq chddto

Chid was 'danotcd' and in slow class group where he is functioning adequately; he. asked not to return to his old class level CnrOUd

reports improved academic and sofial fUnctionin& fewer headaches

disability Child enrolled class;inparent learning-

Outcome

PAULA ALTMAN FULD

teaching hospital, we have been asked over the past four years to evaluate 18 children after head trauma. (Undoubtedly this represents only a fraction of the children who present to the pediatric clinic after head injury.) These patients appear to differ from those described in other studies in the types of accidents suffered. These included being thrown from a fifth-storey fire-escape, being beaten on the head with pipes and bottles, and being hit by a post when the head was protruded from a moving subway car. We have seen only three children who could be described as academically and socially normal before their accidents. All the others had had problems ranging from mild school learning difficulties to mental retardation and severe delinquency. The seven patients for whom we have follow-up information are described in Table I.

if possible, a few months after the injury. Those tests which may demonstrate improved functioning, and two or more which should remain stable, usually were re-administered when patients were reevaluated six months to a year later in order to assess the degree of recovery, to detect fluctuations in performance for other reasons, and to verify our estimate of pre-morbid ability. If the child’s premorbid school history was not available we used his best test performances on any occasion (after consideration of his previous opportunity to develop the relevant skills) as the basis for our estimate (Ruesch 1944).

In working with these children, we have found that neither the child’s mother nor the physician can be relied upon to be an accurate judge of the child’s mental status; some tend to deny and others to exaggerate changes in the child’s abilities. We present the following cases in detail (a) in order t o illustrate these points, and (b) because it seems important to illustrate that whether or not closed head-injury generally leads to any residual intellectual impairment, serious impairment does occur in some cases.

Method Table 11 shows the tests we administered, TABLE I1 Standardized and experimental tests used for neuropsychological and psycho-educational evaluations Wechsler Intelligence Scale for Children (WISC or WISC-R) Raven Colored Progressive Matrices Benton Test of Visual Retention (Copying and Memory) or Beery-Buktenica Test of Visual-Motor Integration Saul R. Korey Department of Neurology Memory and Learning Evaluation (Buschke-Fuld) Gates-MacGinitie Reading Test or Metropolitan Achievement Tests Wide Range Achievement Tests Reading Arithmetic Spelling Language Screening Battery (Spreen-Benton) Purdue Pegboard Kinsbourne and Warrington Test of Finger Differentiation Fuld Tests of Performance Consistency Graphomotor Serial Search Gray Oral Paragraphs Vineland Social Maturity Scale Tests adapted from the extended neurological examination E

PHYLLIS FISHER

Case Reports CASE

1 (E.B.)

This child’s pre-morbid development was said t o be normal, except for reading problems. There was a family history of reading difficulty. At the age of 9 years 9 months he was hit by a car and lost consciousness for 15 minutes or less. Skull X-rays were negative and he was not admitted to the hospital. He later complained of headaches, but returned t o school after a week. There were no seizures, no diplopia, no localized weakness, and no problems with speech. H e was never sent home from school. After a possible seizure five weeks later he received an extensive neurological evaluation during a two-day hospital stay; there were n o significant findings. His EEG was mildly and diffusely abnormal, but no medication was prescribed. There were no abnormal findings o n monthly neurological examinations thereafter, and

497

1977, 19

DEVELOPMENTAL MEDlClNE AND CHILD NEUROLOGY.

a repeated EEG three months after the injury was normal for his age. Because he continued to complain of frequent, severe headaches, he was referred for neuropsychological evaluation in July 1975, six months after the accident. He had been attending school regularly, but his teachers and his mother reported great post-traumatic changes in him, including inability to concentrate on school work, television or games. He had formerly been a shy, compliant boy but was now intermittently lethargic or aggressive. Intelligence testing (Wechsler Intelligence Scale for Children, Revised) revealed a pattern of unusually discrepant abilities. On the basis of average and low-average scores on the Arithmetic, (social) Comprehension, and Object Assembly (jigsaw puzzles) subtests, it was estimated that the child had been of average intelligence before the accident. The post-traumatic level of functioning (Verbal and Performance IQs), however, was only at the borderline level, with significantly impaired performances (mental defective range) on the Similarities, Picture Arrangement, and Digit Span subtests. Fig. 1 shows the results of those tests that were given both six months and 14 months after the accident. Performance was also defective on the Spreen-Benton Token Test (language comprehension), and Sentence Repetition Test (attention and immediate recall) and the BeeryBuktenica Test of geometric figure-copying. No deficits were evident on other tests of language, sensory or motor functioning. Scores on all academic achievement tests were below grade level, but there was no indication of higher pre-morbid ability. A report from his school revealed that he had

E.B.

- I I

I

I

I

DULL -AVERAGE

CASE

I

I

- BRIGHT



I

LWISC-R

e

H

(K.B.)

K.B.

BR

iiH T

’ INFORMA1lr)Pi

-- 1 -

COMPRE HENSlON

M

PICTURE ARRANGEMENT

VERBAL I.Q. PERFORMANCE I.Q. PURDUE PEGBOARD

d uL L -IAVER‘AGE c,

SIMILARITIES DIGIT SPAN

*

2

This boy’s birth, development and school progress had been normal. He was hit by a car at

STANDARD NORMAL DISTRIBUTION

n

m

been performing at a level far below his actual grade even before the accident. He had been a non-reader and also had been having some difficulty with arithmetic. On the basis of our findings, we referred him to his school’s special education unit which accepted him for evaluation but could not immediately place him. The pediatric neurologist offered a tentative diagnosis of postconcussion syndrome with migraine-likeheadaches, and ‘Cafergot’ was prescribed. The child remained in his regular school class. Over the next six months, his mother reported that his headaches were decreasing and that the lethargy was gradually abating. By February 1976 (14 months after the accident), when he returned for neuropsychological reevaluation, she described him as “like his old self”, able to watch television and play games. She said that he was still making no progress in school but had been accepted for special class placement late in the spring. Neurological evaluations throughout this period were normal, as before. Neuropsychological re-testing revealed that his intelligence test performance had improved to the dull normal range and no longer showed significant differences among the scores of the various subtests. He had made highly significant gains in tests of ability of abstract thinking and sequencing. Language comprehension had returned to normal. All test scores were either improved or stable, except those for academic achievement tests and the figure-copying test, which failed to show the age-appropriate increments.

ARITHMETIC

c--*

WlSC

c,

L

BLOCK DESIGN CODING VERBAL I Q PERFORMANCE I Q . PURDUE PEGBOARD TOKEN T E S T

Fig. 1. Patients E.B. and K.B.: tests showing significant changes between first and second evaluations.

498

PAULA ALTMAN FULD

PHYLLIS FISHER

only at second-grade level. Despite the substantial objective evidence of residual intellectual dysfunction, his mother always described him as “normal” although, if pressed, she would admit that he was “improved”. He returned to school five months after the accident and was placed temporarily in an intellectually slow second grade instead of being promoted to a bright third-grade class. Anticonvulsant medication was discontinued three months later. Monthly neurological evaluations were normal, except for increased deep tendon reflexes on the right and some difficulty with rapid alternating movements, greater on the right than on the left. He was retested the following March, almost one year after the accident. At this session he was, for the first time, alert and normally talkative, but he still tended to tire quickly. His Verbal and Performance WISC IQs showed significant increase to the dull-normal to normal range (Fig. 1). His scores on the Spreen-Benton language comprehension and Buschke-Fuld verbal learning tests were now within normal limits. He made no errors on informal sensori-cortical tests. Fine motor co-ordination of the left hand was within normal limits, while the right hand still showed some impairment (Costa el a/. 1964). His scores on the WRAT tests of reading single words and spelling were now at the fifth-grade level, but reading comprehension was not significantly improved. He had adjusted well to the second grade and asked to be allowed to remain in that class.

age 7 years 10 months, and was admitted to the hospital in a light coma. Skull X-rays on admission were negative. Results of cerebral angiography were normal except for a slight midline shift to the right. He had several seizures on the day he was admitted to hospital. Neurological examination revealed left gaze preference, left Babinski response, and the right pupil to be larger than left. He remained stuporous and aphasic for approximately three weeks. Two days after the accident a right hemiparesis of arm and leg were noted. There were no further seizures. He received physical and speech therapy, with gradual improvement in motor and language abilities. An EEG four weeks after admission was normal, and he was discharged on phenobarbital 30mg a.m./ 6Omg p.m. He was referred for neuropsychological evaluation two months after the accident. At this time his mother reported and the pediatrician concurred that he was “back to normal”, with no language or attention problems and nochange in personality. His mother did admit to changes in his toy preference and said that he was having difficulty in his relationships with other children. During our evaluation he was unusually silent and lethargic. He became visibly confused when confronted with verbal tests, so the verbal intelligence tests were discontinued. His best scores on the Performance subtests of the Wechsler Intelligence Scale for Children were consistent with an estimated pre-morbid IQ within the average range. There was evidence of motor, attention and comprehension deficits. When tested again four months after the accident he was still somewhat lethargic but was better able to deal with verbal material. He achieved a borderline WISC IQ, with scores within the mental defective range on those subtests which required him to understand lengthy verbal instructions (Arithmetic and Comprehension). His scores on tests that had brief questions and short responses (Information, Similarities and Digit Span) were within low-normal limits. Performance on a test of language comprehension (SpreenBenton Token Test) and a test of verbal learning (Buschke and Fuld 1974) were defective, as was fine motor co-ordination bilaterally (Purdue Pegboard test). He made errors on informal tests of sensorycortical functioning. On visuospatial reasoning (Raven’s) and on constructional tasks (Block Design and Object Assembly), his performance was well within the average range. His scores on tests of arithmetic, spelling and reading single words were at second, third and fourth-grade level, respectively, but reading comprehension was

Discussion Both cases presented here show continued, serious post-traumatic intellectual impairments long after their EEGS and neurological examinations had returned to normal (Ruesch 1944, Lewin 1966, Mealey 1968, Ford 1973); indeed, it is not certain that maximum recovery has yet occurred (Dencker and Lofving 1958), although significant gains in objective test scores were made in both cases within a year. It is possible to document impairment and improvement in these children’s intellectual functioning because several standardized tests of complex intellectual functions, with appropriate norms, were available. The reading comprehension test 499

DEVELOPMENTAL MEDICINE A N D CHILD NEUROLOGY.

1977, 19

suggests that it is an interaction between social or academic adequacy and the degree of brain damage that must be considered in evaluating such cases (Richardson 1963, Hjern and Nylander 1964, Naughton 1971). We have found that questioning the parents about changes in the child’s style of play, in friendships, and in ability to watch television programs formerly enjoyed often enables one to elicit indirect evidence of impairments that parents may otherwise be reluctant to acknowledge. Case 2 shows that even when a child is obviously lethargic and withdrawn and has such impaired language comprehension that verbal intelligence tests cannot bc administered, the mother may deny any impairment at all. In cases like these it is important to delay the child’s return to school and to adjust the school program to limit stress (Symonds 1962, Gronwall and Wrightson 1974). In Case 2, the five-month delay in returning to school was not planned by the physician, but occurred adventitiously. This child had a long summer vacation in which t o rest and recover, and then had a lengthy period in which academic demands were limited and he could rely on old learning. A satisfactory adjustment to school, without aggressive behavior, was thus possible in this case, despite initial obvious language and motor impairments and despite the mother’s denial of any change. Case 1, on the other hand, points up the importance of evaluating post-traumatic change against the pre-morbid level of functioning. This boy might have received benefit from special schooling before his head injury, but the interaction of his temporary impairments with his previously borderline functioning appeared to have created intolerable stress (Gronwall and Wrightson 1974), which may account for

was especially useful because (a) it measures the type of cognitive activity that is most highly correlated with both general intelligence and success in school (MacGinitie 1973), (b) such tests appear to be sensitive to disruption by either diffuse brain damage or focal damage anywhere in the brain, and ( c ) performance could be compared with information about the child’s pre-morbid functioning at school. If pre-morbid test scores are not available, the reading comprehension test score can be compared roughly with the score on a test of reading single words, which, in our experience, tends to reflect pre-morbid ability fairly well because it is not particularly vulnerable to deterioration resulting from mild to moderate organic brain dysfunction, unless there is a posterior focal brain 1esi on. Personality changes occurred to some extent in both cases (Dillon and Leopold 1961, Jacobson 1963, Black et al. 1971). Case 1 showed aggressive behavior in school, while Case 2 changed his preference from constructional toys to aggression toys, and had frequent fights in the playground. We interpreted these changes to be consequences of impairment in constructional abilities and in comprehension of other children’s language, as well as of frustration in the playground because of motor inco-ordination. These changes reportedly disappeared in both cases about a year after the accidents happened, when cognitive, language and motor functioning improved (Dillon and Leopold 1961). The pre-morbid school history of Case 1 showed him to have been functioning marginally well from a social point of view, but he had been weak academically, unlike Case 2. The head injury of Case 1, however, seems to have been much less serious than that of Case 2. That both had significant post-traumatic psychiatric symptoms which abated after about a year 500

PAULA ALTMAN FULD

PHYLLIS FISHER

Director of the Children’s Evaluation and Rehabilitation Clinic of the Albert Einstein College of Medicine, for his encouragement and for reading and commenting on the manuscript. This paper was supported by grant No. NS 03356 from the National Institutes of Health ( U S A . ) .

his inore serious behavioral difficulties at school (Hjern and Nylander 1964). Both cases demonstrate the importance of neuropsychological and psycho-educational evaluation and follow-up after closed head-injury, and suggest that a delay in returning to school and a modified school program may be as desirable for children as a delay in returning to work appears to be for adults (Symonds 1962, Lewin 1966, Gronwall and Wrightson 1974).

AUTHORS’ APPOINTMENTS

Paual Altman Fuld, Ph.D., Assistant Clinical Professor of Neurology (Psychology); Phyllis Fisher, M.A., M.Ed., Staff Neuropsychologist ; The Saul R. Korey Department of Neurology, Albert Einstein College of Medicine, and the Bronx Municipal Hospital Center, Bronx, New York 10461.

Acknowledgements: We thank Professor Gerald Golden, Director of Pediatric Neurology and

SUMMARY

Seven children with intellectual and personality changes after closed head-injury were followed-up with neuropsychological and psycho-educational evaluations. Two cases are presented i n detail. Persistent intellectual changes documented on standardized tests were not always apparent to parents or physicians, and recovery of intellectual abilities lagged behind the disappearance of neurological abnormalities. Some of the children required special class placement for several years after the injury. Personality changes were thought to be secondary to stress on impaired perceptual and cognitive abilities, and the desirability of limiting such stress is emphasized. RESUME

RPcupPration de I’aptitude intellectuelle a p r h traumatisme crdnien fermP Sept enfants ayant prtsentt des modifications de I’intelligence et de la personnalitk a p r b traumatisme criinien fermt ont CtC suivis par des Cvaluations neuro-psychologiques et psycho-Cducatives. Deux cas sont CtudiCs en ddtail. Les modifications intellectuelles persistantes, rCvClCes par des tests standardisds, n’itaient pas toujours apparentes aux familles et aux mddecins; la rCcupCration de l’efficience intellectuelle trainait derriere la disparition des anomalies neurologiques. Quelques uns des enfants ont demand6 un placement en classe spdciale, durant plusieurs annCes apres l’accident. Les auteurs pensent que les modifications de personnalitk Ctaient secondaires a une atteinte des aptitudes perceptives et cognitives et I’intCrCt de limiter une telle atteinte est souligni. ZUSAMMENFASSUNG

Normalisierung der intellektuellen Fahigkeiten nach geschlossenen Schadel-Hirn-Traumen Sieben Kinder mit Veranderungen der Intelligenz und der Personlichkeit nach geschlossenen Schadel-Hirn-Traumen wurden anhand neurophysiologischer und psychologischer und schulischer Tests nachuntersucht. Zwei Falle werden ausfiihrlich dargestellt. Bleibende Intelligenzdefekte, die durch standardisierte Tests nachgewiesen wurden, waren nicht immer fur Eltern oder h t e offenbar. Die Normalisierung der intellektuellen Fahigkeiten war gegenuber der Ruckbildung neurologischer Veranderungen verzogert. 50 I

DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.

1977, 19

Einige Kinder mufiten fur mehrere Jahre nach dem Unfall in eine Sonderschule. Die Personlichkeitsveranderungen hat man darauf zuriickgefiihrt, daB die Kinder mit ihren eingeschrankten kognitiven und perceptiven Fahigkeiten uberfordert wurden und es wird mit Nachdruck darauf hingewiesen, daB diese uberforderung vermieden werden muB. RESUMEN

Recuperacidn de la habilidad intelectual tras un traumatismo cerrado de crcineo Siete nifios con cambios en la inteligencia y en la personalidad despuds de un trauma cerrado de craneo fueron seguidos con evaluaciones neuro-psicolbgicas y psico-educativas. Se presentan dos casos con detalle. Los cambios persistentes en el intelecto documentados por test standarizados no siempre eran aparentes a 10s padres o a1 mtdico, la recuperacibn de la habilidad intelectual llevaba retraso con respecto a la desaparicibn de las anomalias neurol6gicas. Algunos nifios requerian una escolaridad especial durante varios aiios despuds del trauma. Los cambios en la personalidad se pens6 que eran secundarios al stress en caso de alteraciones perceptivas o cognitivas. Se insiste sobre la necesidad de limitar tal stress. REFERENCES Black, P., Blumer, D., Wellner, A. M., Walker, A. E. (1971) ‘The head-injured child: timecourse 01 recovery, with implications for rehabilitation.’ In Proceedings of an International Symposium on Head Injuries Held in Edinburgh and Madrid, 2nd to 10th April, 1970. Edinburgh: Churchill Livingstone. Buschke, H., Fuld, P. A. (1974) ‘Evaluating storage, retention and retrieval in disordered memory and learning.’ Neurology, 21, I0 19- 1025. Costa, L. D., Scarola, L. M., Rapin, I. (1964) ‘Purdue pegboard scores for normal grammar school children.’ Perceptual and Motor Skills, 18, 748. Dencker, S. J., Lofving, B. (1958) ‘A psychometric study of identical twins discordant for closed head injury.’ Acta Psychiatrica et Neurologica Scandinavica, 33, Suppl. 122. Dillon, H., Leopold, R. L. (1961) ‘Children and the post-concussion syndrome.’ Journal of the American Medical Association, 175, 86-92. Ford, F . R. (1973) Diseases of the Nervous System in Infancy, Childhood and Adolescence, 6th edn. Springfield, 111.: C. C. Thomas. Gronwall, D., Wrightson, P. (1974) ‘Delayed recovery of intellectual function after minor head injury.’ Lancet, 2, 605-609. Hjern, B., Nylander, I. (1964) ‘Acute head injuries in children : traumatology, therapy and prognosis.’ Acta Pediotrica, Suppl. I S Z . Jacobson, S. (1963) The Posttraumatic Syndrome Following Head Injury. Springfield, 111.: C. C. Thomas. Lewin. W. (1966) The Manapenlent o f Head Injuries. London: Bailliere. Tindall & Cassell. MacGinitie, W. (1973) ‘What are we iesting?’ fn Problems in the Assessment of Reading. Newark, Delaware: International Reading Association, pp. 3 5 4 3 . Mealey, J. (1968) Pediatric Head Injuries. Springfield, Ill. : C. C. Thomas. Naughton, J. A. L. (1971) ‘The effects of severe head injuries in children, psychological aspects.’ In Proceedings of an International Symposium on Head Injuries Held in Edinburgh and Madrid, 2nd to 10th April, 1970. Edinburgh: Churchill Livingstone. Richardson, F. (1963) ‘Some effects of severe head injury: a follow-up study of children and adolescents after protracted coma.’ Developmental Medicine and Child Neurology, 5,471482. Ruesch, J. (1944) ‘Intellectual impairment in head injuries.’ American Journal of Psychiatry, 100, 480496. Shaffer, D., Chadwick, 0.. Rutter, M. (1975) ‘Psychiatric outcome of localized head injury in children.’ In Outcome of Severe Damage to the Nervous System, Ciba Foundation Symposium 34 (new series). Amsterdam: Elsevier. Symonds, C. (1962) ‘Concussion and its sequelae.’ Lancet, 1, 1-5. ~~

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Recovery of intellectual ability after closed head-injury.

Develop. Med. Child Neurol. 1977, 19,495-502 Recovery of Intellectual Ability after Closed Head-injury Paula Altman Fuld Phgllis Fisher functioning...
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