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Neurological Soft Signs: Their Relationship to Psychiatric Disorder and IQ in Childhood and Adolescence

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Neurological Soft Signs: Their Relationship to Psychiatric Disorder and IQ in Childhood and Adolescence City University of New York (CUNY) CUNY Academic Works Publications and Research CUNY Graduate Center 1986 Neurological Soft Signs: Their Relationship to Psychiatric Disorder and IQ in Childhood and Adolescence David Shaffer Columbia University Irvin Sam Schonfeld CUNY City College, CUNY Graduate Center Patricia A. O'Connor Russell Sage College Cornelius Stokman Columbia University Paul Trautman Columbia University See next page for additional authors How does access to this work benefit ou?y Let us know! More information about this work at: https://academicworks.cuny.edu/gc_pubs/260 Discover additional works at: https://academicworks.cuny.edu This work is made publicly available by the City University of New York (CUNY). Contact: [email protected] Authors David Shaffer, Irvin Sam Schonfeld, Patricia A. O'Connor, Cornelius Stokman, Paul Trautman, Stephen Shafer, and Stephen Ng This article is available at CUNY Academic Works: https://academicworks.cuny.edu/gc_pubs/260 Neurological Soft Signs Their Relationship to Psychiatric Disorder and ; Intelligence in Childhood and Adolescence David Shaffer, MB, MRCP, FRCPsych, DPM; Irvin Schonfeld, PhD; Patricia A. O'Connor, PhD; Cornelis Stokman, PhD; Paul Trautman, MD; Stephen Shafer, MD; Stephen Ng, MB, BS, MPH • Sixty-three male and 27 female adolescents known to have rological disease; the examination of neurological and psy­ had neurological soft signs at the age of 7 years were com­ chological features should be carried out "blind" to each pared with controls with no soft signs at age 7. Adolescents other; the evaluations should be standardized and impor­ with early soft signs had significantly lower IQs and were more tant biases in the population should be known. Findings likely to have a psychiatric disorder characterized by anxiety, that have emerged - from the relatiyely few studies that . withdrawal, and depression. All the girls and 80% (12/15) of the fulfilled some, if not all, of these requirements are as boys with an anxiety-withdrawal diagnosis showed early soft follows�(1) soft signs are foundmore often in male pediatric 4 5 signs. There was no relationship between early soft signs and psychiatric patients than in normal controls • ; (2) within a attitntlon deficit or conduct disorders. Examination of the group of disturbed children, soft signs are more common in relative contributions of anxiety at age 7, IQ, and social and those who are impulsive, distractable, dependent, and 6 7 family disadvantage to later diagnosis showed that most of the sloppy than in those who are not • ; (3) within a group of variance was accounted for by soft signs Independently of IQ. adult psychiatric inpatients, soft signs occur more often in Soft signs and anxious dependent behavior at age 7 were schizophrenics who have a history of social difficulties in 8 · strongly predictive of persistent psychiatric disorder charac­ childhood and in patients with labile mood ; and (4) in terized by anxiety and withdrawal. nonclinical pediatric populations signs are more common in (Arch Gen Psychiatry 1985;42:342-351) boys and are associated with social immaturity, lack of motivation, lack of cooperativeness, and poor reading at­ neurological soft sign is a particular form of deviant tainments. 9-n performance on a motor or sensory test in the neu­ These findings suggest a relationship between soft signs rologicalA status examination. The designation soft is usually and a variety of cognitive and psychiatric problems. How­ taken to indicate that the person with the sign shows no ever, the investigations from which tpey originate leave a 8 12 other feature of a fixed or transient neurological lesion or number of questions unanswered. Studies on inpatients • -" disorder. 1 The clinical importance of soft signs lies not in any may not have revealed a relationship between soft signs and impairment of motor or sensory function associated with a type of psychiatric disorder that did not usually lead to their presence, for there does not seem to be any, but in hospital admission. Studies on specialized clinical or insti­ their value as an indicator of some CNS "factor" that might tutional populations, such as hyperactive children or delin­ 7 16--18 have causal or predictive value for associated psychological quents, 6- , may not have revealed a relationship with dysfunction and in particular learning an,d/or psychiatric other psychiatric conditions, and referral bias in such abnormalities. studies may lead to unrepresentative findings. The few The relationship between soft signs and cognitive and studies in nonreferredpopulations have .either been limited psychiatric disturbance in children and adults ha:s been to the examination of a single neurological sign, such as the 9 19 2 8 choreiform syndrome, , did not examine behavioral or reviewed previously. • Ideally, studies exploring this rela­ tionship should exclude patients with evidence of neu- emotional variables, n or examined only a limited set of behavioral variables so that a full psychiatric diagnosis could not be made. 10 Finally, because all previous studies Accepted forpublication April 19, 1984. are cross-sectional, they provide no information on the From the Division of Child Psychiatry, Columbia University College of value of signs as a predictor of later or continuing psychi­ Physicians and Surgeons and the New York State Psychiatric Institute, New York. atric or cognitive disturbance. Reprint requests to Columbia University College of Physicians and To address some of these issues, we have carried out a Surgeons, 722 W 168th St, New York, NY 10032 (Dr Shaffer). controlled psychiatric and· cognitive follow-up study on a 342 Arch Gen Psychiatry-Vol 42, April 1985 Neurological Soft Signs-Shaffer et al nonreferred sample of adolescents whose soft-sign status was known at the age of 7 years. In a previous report on this Table 1.-Losses From Sample 1 .!,,:>Toup, we noted a relationship between the presence of Boys Girls neurological soft signs and withdrawal-dependency be­ ~ havior during psychological examination at age 7. The Soft Signs Soft Signs ,--- ,-- -, ��.M,mt report focuses on psychiatric disability, diagnosis, PresentI Absent Present Absent and IQ at the age of 17 years. Eligible 63 63 27 27 SUBJECTS AND METHODS Not located . 3 . ... Subjects Refused 2 3 1 5 Examined 61 57 26 22 Subjects were drawn from the 1962-196� birth cohor� ofEngl�sh­ speaking boys and girls of the Columbia-Presbyterian Med1�al Excluded after examination 3 . ' 1 ... Center (CPMC) New York City, chapter of the Collaborative 20 Data base* 58 (97) 57 (90) 25 (96) 22 (81) PerJnatal Project (CPP). The sample frameoriginally comprised . fifth woman registering during pregnancy at the CPMC *Parenthetical numbers indicate percent of eligibles less late exclusions . clinic excluding only declared adoption donors and women who r�ceived only brief prenatal care. Subjects in our sample were of the same racial background because as a g:oup t�ey psychologist had no knowledge of the child's status on all other had a higher prevalence of soft signs than the others. This findmg examinations. We constructed three a priori scales from the was not generally true within the CPP population, and sex and 21 _ behavioral ratings assigned to all (N = 440) children in the 1962- ethnic rates overall did not differconsistently. Index subJects (63 1963 CPP birth cohort to denote (1) hyperactivity, (2) aggression, boys and 26 girls) had received a positive :ating on �ny one_ of eight and (3) dep�ndency-withdrawal.1 Internal reliability as indicated specific neurological signs on a neurologwal exammat10n at age 7 by Cronbach's a-value forthe dependency-withdrawal scale used in but had been foundfree of any frankneurological disease or mental this report was . 71. retardation (IQ <60). The same number of subjects of similar race Neurological Assessment at Age 7.'-The neurological ex­ and sex but who had no evidence of abnormality at the seven-year aminations at age 7 were conducted in 1969 and 1970 according to neurolo�ical examination and who were closest in birt� date to an the National Collaborative Perinatal Project protocol (PED-76). index child were selected from the same CPP register to be Board:certified pediatricians, under the supervision of a senior controls. Subjects with and without signs at age � did not differ certified pediatric neurologist, performed all examinations with­ with respect to age at examination, cohort of incept10n, anomalous out knowledge of the children's medical history. The examination familysituation, welfaredependency, poverty, or level of maternal included tests for18 neurological softsigns. Test-retest agreement ,)ducation . was determined in a subsample21 and was found to be 85% in the Six groups of signs were found represented in the gr?up: most frequently diagnosed group of signs (poor coordination). It is awkwardness or poor coordination during finger-nose testmg, probable that there were substantial threshold differe: �ces in finger pursuit, and complex fine-motor activitie�; dysdiadochoki­ different collaboratingcenters, and they were reflectedm different nesis ie the inability to perform rapid alternatmg movement of prevalence rates. The prevalence of sig�s at CPMC w�s the_ high�st hand� a�d feetin a smooth, fluent, and rhythmic fashion; mirror of all participating centers, suggestmg that the identificat10n movements; tremor; dysgraphesthesia, ie, the inability to de�ect threshold was probably the lowest. In view of the uncertainties predisplayed
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