No Dearly Defined Neurological Abnormalities

I DOCUMENT RESUME ED 022 269 EC 001 078 By-Lambert, Nadine; Grossman, Herbert PROBLEMS IN DETERMINING THE ETIOLOGY OF LEARNING AM) BEHAVIOR HANDICAPS;REPORT OF A STUDY. California State Dept. of Education, Sacramento. Pub Date 64 Note-162p. EDRS Price l4-S0.75 HC-S6.56 1 Descriptors- ACHIEVEMENT GAMS, BEHAVIOR PROBLEMS, CLINICAL DIAGNOSIS,EDUCATIONAL DIAGNOSIS, *EDUCATIONAL NEEDS, *EMOTIONALLY DISTURBED, ETIOLOGY, *EXCEPTIONAL CHILDRESEARCH, GROUP ACTIVITIES, GROW COUNSELING, *IDENTIFICATION, *LEARNING DISABILITIES, MEDICALEVALUATION, NEUROLOGICALLY HANDICAPPED, PSYCHOLOGICAL EVALUATION, PSYCHOLOGICALTESTS, SPECIAL CLASSES, SPECIAL PROGRAMS Iduntifiers-Bender Visual Motor Gestalt Tests, Draw A Person Test Medical factors were assessed in 20 children (grades 1 to 10) withbehavior and learning problems, and an educational program was subsequentlyoffered. AN 20 had their case histories taken, were given pediatric and openelectroencephalograph examinations, and were evaluated by psychological tests.One team of physicians found no dearly defined neurologicalabnormalities; another team rated 10 of -the 20 records as evidencing neurological impairment. Two pairs ofpsychologists also differed in their diagnoses. The ratings of the medical and psychologicaldiagnoses were found to differsignificantly (p=.01). The educational program included the folowing: a special class, with individualized instruction for eight to 12 children,taught by a regular teacher assisted by a mental health specialist and theschool guidance and curriculum staff; a learning disabilities group, providing a specialist's instructionin remedial work for two to eight children; an activity group, structured as a clubwith craft and play sessions, conducted after school for six to eight children;and group counseling for the junior and senior high school students in groups of 10.Reading and achievement scores taken over a 2-year period indicated an average gainfor the group as a whole exceeding what would beexpected from pupils in regular classes. (JW) PROBLEMS IN DETERMINING THE ETIOLOGY OF LEARNING AND BEHAVIOR HANDICAPS

REPORT OF A STUDY

CALIFORNIA STATE DEPARTMENT OF EDUCATION MAX RAFFERTY, Superintendent of Public Instruction *SACRAMENTO, 1964

- '" Se"), U.S. DEPARTMENT OF HEALTH, EDUCATION & WELFARE

OFFICE Of EDUCATION

THIS DOCUMENT HAS BEEN REPRODUCED EXACTLY AS RECEIVED FROM THE

PERSON OR ORGANIZATION ORIGINATING IT.POINTS OF VIEW OR OPINIONS

STATED DO NOT NECESSARILY REPRESENT OFFICIAL OFFICE OF EDUCATION

POSITION OR POLICY.

PROBLEMS

DETERMINING THE ETIOLOGY OF

LEARNING AND BEHAVIOR HANDICAPS

REPORT OF A STUDY

PREPARED BY

NADINE LAMBERT Research Consultant Bureau of Special Education California State Department of Education

HERBERT GROSSMAN, M. D. Departments of Medicine (Neurology) and Pediatrics School of Medicine University of California, Los Angeles FOREWORD California schools are highly successful in providing equal educational opportunities for all.And although they are not totally successful in making it possible for all to profit fully from these opportunities, they spare no effort in their endeavor to do so.They maintain regular education programs that are strong and that meet the needs of most pupils; extended and enriched programs, for the gifted; and special programs, for the mentally retarded, the physically handicapped, the cerebral palsied, and the culturally deprived. But these provisions are not adequate to meet the needs of every pupil who enrolls in the schools as evidenced by dropouts and by failures. The study, "Problems in Determining the Etiology of Learning and Behavior Handicaps, " was undertaken to determine how pupils who are unable to profit fully from their educational experiences because of emotional problems might be helped. The results of this study should be of special interest to school ad- ministrators and others who are concerned with the problems of the emotionally disturbed pupil, especially those who are seeking ways to eliminate the problems or at least to hold the undesirable effects of these problems to a minimum.

Superintendent of Public Instruction PREFACE

California provides specialeducational help for a variety of handicapped pupils. At the present timethere are programs for severely andmoderately retarded pupils and for all typesof physically handicapped pupils.Children with learning and behaviorproblems who do not qualify for any ofthese types of programs but whose emotionaldifficulties handicap them from profitingfrom existing educational provisions face aschool life punctuated with difficultiesin learning, unsatisfactory peer andadult relationships, dropping out orexclusion from school, and eventual possiblecommitment. Increased public concern over thepublic and private costs of emotional and social breakdown places greateremphasis on the school as the institution responsible for early identification,help, and referral. In order for theschool to fulfill this role, theprocedure for early identification anddiagnosis of particular learning or behavioraldifficulties is a first step in establishingeduca- tional programs to assist suchpupils with their problems.Effective identification procedures require that allthe factors that influence a child'sschool problems must be surveyed todetermine (1) the nature of the difficulty;(2) the specific role of the school in assistingthe child; and (3) evaluation of the educational provisions which should bemade available.Medical, psychological, social, and educational areas comprisethe fields of investigation in a typical diagnosis of a child with school problems. This study is one of several conductedby the staff of the State Depart- ment of Education to evaluate thestatus of pupils identified asemotionally handicapped. The purpose of this report is toilluminate some of the problems inherent in making a medical diagnosisof related organic impairments in a sample of pupils identified as emotionallyhandicapped with severe learning and behavior problems in school. This project emphasizes the factthat there is no simple, clear-cut explanation of the causes of thecomplex problems which face pupils who areunable to profit from existingeducational provisions. In the etiologyof the learning and behavior problems of aparticular child, as great a varietyof pertinent information as possible must becollected, and the data must be related to a planned educational program forthat child. So far, we cannot point to anyetio- logical pattern upon which a specificeducational program can be based. Diag- nostic labels, which explain anindividual pupil's problems withoutspecifying an educationalplan to meet the pupil's particularlearning needs, offer false security. We must continue tofind ways to assist the pupil withproblems to be successful in school.

FRANCIS W. DOYLE CHARLES W. WATSON Deputy Superintendent of Public Chief, Bureau of Instruction; and Chief, Division Special Education of Special Schools and Services ACKNOWLEDGMENT not have beenprepared without the generousparti- This publication could and psycho- cipation of personnelfrom several schooldistricts, physicians, individuals were involvedin the project; logists.Specifically, the following research. They the positions listed arethose which they heldat the time of the willingness to contributetime to a projectwhich are to becommended for their of learning aimed to clarify someof the problems indetermining the etiology and behavior handicapsin children. William J. Brodsly,Director of SpecialServices, EnterpriseCity Elementary SchoolDistrict, Los AngelesCounty Los Angeles, Herbert Grossman,M.D.,University of California, School of Medicine of Los Angeles John W. Howe,Consultant, Researchand Guidance, Office County Superintendentof Schools Mrs. Berdine J. Jones,Consultant, Researchand Guidance,Office of Los Angeles CountySuperintendent of Schools Carol P. Lundberg,Psychologist, EnterpriseCity ElementarySchool District, Los AngelesCounty Robert H. Oyler,Psychologist, ClaremontUnified School District Bruce H. Peppin, Director,Guidance and SpecialEducation, AlhambraCity Elementary and CityHigh School District Jack Rouman, Director,Guidance, MontebelloUnified School District California Sch9ol of Medicine Robert Sedgewick,M.D.,University of Southern Richard Walter, M. D.,University of California,Los Angeles, School of Medicine Kenneth Zike, M.D.,Harbor GeneralHospital, Torrance,California California Ir la Lee Zumnerman,Psychologist, privatepractice, Whittier,

vi CONTENTS Page

For eword iii Preface v Acknowledgment vi

CHAPTER 1. Introduction 1

Background of the Project 3 Purpose of the Project 4

The Sample 5 Procedure 5 CHAPTER 2. Results of the Comparative Study of Two Diagnostic Teams Reviewing Records of Emotionally Handicapped Pupils 8 Results of the Medical Examinations and Comparison of the Medical Ratings 11 Summary of the Ratings of Personal History and History of the Problem 11

Summary of the Ratings of Family History 13

Results of the Pediatric Examination 16

Results of the Electroencephalographic Examination 16

Final Medical Diagnosis Based on Review of All Data 18

Results from the Review of Psychological Test Data 19

Summary of Ratings on the WISC 20

Summary of the Ratings on the Draw a Person (DAP) Test .. 23

Summary of Ratings on the Bender Visual Motor Gestalt Test 25

vii Summary of Comparative Judgments Madeby Physicians and Psychologists 26 Estimated Frequency of Neurologically Handicappedin a Sample of Emotionally Handicapped Pupils 27 CHAPTER 3. Comparison of Diagnoses of RandomSamples of Emotionally Handicapped and NeurologicallyHandicapped Pupils.. . 30

CHAPTER 4.Educational Programs for Pupils with SeriousLearning and Behavior Difficulties and the Effectsof these Programs 33 Types of Educational Programs Conducted forthe Sample of Emotionally Handicapped Pupils 33 The Special Class 33 Learning Disability Group 34 The Activity Group 34

Group Counseling 35 Effectiveness of Educational Programs forEmotionally Handi- capped Pupils 35 Recommended Educational Program forEmotionally Handicapped Pwoi ls with or Without Evidence ofNeurological Impairment ... 36 CHAPTER 5. Summary of the Findingsof the Project 40

Appendix 43 Selected References 45 Case Records 53

viii Chapter 1

INTRODUCTION In these days of high-speed data processing, computing machines are being developed which are capable of reproducing a variety of thinking processes with several thousand times the speed of the human brain. A short circuit in a computer will cause a faulty answer which can be corrected fairly easily by locating the poor connection and repairing it.Contrary to the processes of the human brain, there is a close one-to-one relationship between the data which are put into the machine and the results which come out, and there are few uncontrolled intervening variables which affect the results of computer thinking. Such computers offer a highly reliable procedure for handling, with considerable economy, some types of complicated human brain work. Confronted with the difficulty of understanding and assisting pupils with severe learning and behavior deviations, the educator might wish that human behavior would be as simple to understand as computer behavior and as easy to remedy as are computer short circuits. Psychologists have been trying for years to relate the mysteries of cortical activity to human behavior. Physiologists will perhaps unravel the skein of nerve tissue one day and be able to provide data which the psychologists can use in finding a behavioral correlate for a specific type of nervous activity.However, we are not yet at that point in understanding behavior and behavior deviations. Although we know that cortical and nervous system activity is related to behavior, we do not know the specific parts of the nervous system which can be identified with brain function or malfunction in relation to resultant behavior, and with the exception of a few distinct cases, we are at an inferential stage. Even with the further development of understanding the processes of the nervous system, it is doubtful that behavioral science will be able to arrive at a level relatively as simple as data processing. All behavior initiated within the network of the nervous system must be mediated through the human organism, and the complexity of this intervening variable is responsible for much of the lag in the behavioral sciences. Behav- ioral scientists agree that an individual's behavior is the result of genetic, constitutional, and environmental factors mediated by the sum of his experiences. When the educator is faced with a pupil who has difficulty profiting from a given educational program, it is common practice to examine the child's family history, his health, and his social environment for help in understanding the pupil's failure in the learning process. When the learning and behavior problems of pupils are found to have common ingredients, these pupils are studied as a homogeneous group in an attempt to correlate the homo- geneity of the children's etiological patterns with the similarity of their educational and behavioral difficulties. Examples of treatment ofetiological factors in educationalprograms are programs for thoseneurologically handicappedpupils who have beenidenti- fied for study because ofspecific types of behaviorand learning problemswith accompanying signs of prenatal orpostnatal injury to the nervoussystem or genetic factors resulting inmeasurable deviations. But ineducational programs of this type, evenwhen there are definitesigns of some neurological impairment, and we infer thatthe impairment hascaused the pupil's educational and behavioraldifficulty, we cannot infer thatother pupils with similar neurological difficulties wouldhave similar educationalproblems. This fact has been fairlx wellestablished by R. W.MacNeven,1 W. M. Cruikshank,2 R. D. Walter `) and otherresearchers who have found thatthere are diverse patterns of educationaland behavior difficulty evenwithin a group withclear- cut medical diagnoses.There is better understandingof cause-effect relationships in the developmentof problems for a fewchildren when the etiology and the problems arecorrelated; however, for mostof the children with learning and behaviordifficulties, the etiology andproblems are not correlated and few etiologicalclues can be found from themedical reports. In spite of the difficultiesinherent in establishingrelationships between etiology and behavior, physicians,psychologists, and educatorscontinue to search for connections betweenbrain and nervous systempathology in cases of severe learning and behaviordisabilities in efforts to makecomprehensive case studies. Although diagnosisof neurological impairmentoffers a clear-cut explanation for the pupil'sproblems and the opportunityto use an extensive body of specific educationaltechniques, the psychologistand the educator are still faced with theresponsibility for explainingthe learning and behavior problems of all pupils andfor recommending specificeducational assistance for those who do not have apositive medical diagnosis. Cruickshank's studies onhyperactive pupils with learningdisabilities showed that a neurologicaldiagnosis was not positive inall such cases. Since all the pupils identifiedwith behavior andlearning problems needed help,he concluded that the most usefulmethod of classifyingthem was to resort to the descriptive category"hyperactive children with learningdisabilities. " The use of adescriptive category does notindicate a denial of theetiological factors of a specific problem.It does mean, however,that the physician,

111. W. MacNeven and Others,"The Function of a Psychiatric Diagnostic Unit in the SchoolSystem." Presented at theAmerican Orthopsychiatric Asso- ciation Meeting, SanFrancisco, California,May 1, 1959. 2W. M. Cruikshank and Others,Teaching Methodology forBrain-Injured and Hyperactive Children.Syracuse, N. Y. : SyracuseUniversity Research Institute, 1960. 3R.. D. Walter and Others, "A ControlledStudy of the Fourteen- and Six- Per-Second EEGPattern," Archives of GeneralPsychiatry (American Medical Association), II (1960),559-66.

2 psychologist, and ,iducator must go back to the investigation of the genetic, constitutional, and environmental factors which contribute to a child's difficulty and plan an educational program that will have meaning for him. The educator does not have the security of a complete, well-planned educational program nor the false security of completeunderstanding of the child's problem, but he still has the child, the child's problem, and the job of bringing to that child all of the educational resources that might lead to solution or remediation of his difficulty. Children whose learning or behavior problems have been given similar descriptive classifications may have similar learning difficulties but dis- similar etiological patterns. From the standpoint of the school, the learning situation must meet the child at a level where he can besuccessful.If efficiency can be served by grouping children of similar educationaland behavioral problems together, such educational planning would be anappropriate procedure. Among the descriptive categories that are presently being used in thepublic schools in California to designate pupils who are notable to profit from existing educational programs are "emotionally disturbedchildren, " "emotionally handicapped children, " "neurologically handicappedchildren, " "culturally deprived children, " "delinquents,""dropouts," and "divergent youth." Although these categories are by no means inclusive of all the typesof problems confronted by the schools in designating pupils with learning andbehavior difficulties, they indicate the variety of such problems withwhich the schools are presently concerned. Since one element is common to all suchpupilsfailure to profit from existing educational provisions--a descriptivecategory which would incorporate all of their problems would be useful in programsdesigned to give them the special help they -need. BACKGROUND OF THE PROJECT The California State Legislature passed into law in1957 a bill authorizing the State Department of Education to conduct a studyof educational programs and identification procedures for emotionally disturbedpupils. A sample of pupils in this category was subsequently identified andhelped in a variety of educational programs in several school districts in California.Research on these programs has demonstrated that the learning andbehavior problems of emotionally disturbed pupils were diverse and oftenundifferentiated. These pupils had been identified previously as"neurologically handicapped, " "delinquent, "'"potential dropouts," "emotionally disturbed, " "severe learning problems, " or in other terms. In short, pupils who werethen identified as being "emotionally handicapped" were the same types as those who are currently being referred to as "emotionally disturbed," "neurologically handicapped, " "culturally deprived," and "divergent youth." After a search had been made

3 for a general term whichwould be useful in designatingthis complex segment of the school population,"emotionally handicapped" was chosen,because the primary explanation ofthe difficulty was thatsomething had gone wrongwith the complicatedmechanisms which mediate behaviorin all of these pupils. Consistent patterns related togenetic, hereditary, familial,cultural, intellectual, or social factorscould not be found in thispopulation. Although the origins of a pupil's problemcould be found in these areas,the origins varied with each pupil."Emotionally handicapped" may not bethe most adequate term to use to describepupils with marked learningand behavior problems, but it does give emphasisto the source of thedifficulty, focusing on the 'mechanism which mediates the behaviorof such pupils, regardlessof the etiology of specific problems.While a variety of datacollected during the research project supports thisview, this report concentrates onthe material which was collected onthe pediatric and neurologicalstatus of the pupils identified as emotionallyhandicapped. Other aspectsand findings of theproject, including thedivergency of the high schoolpopulation, and socioeconomic patterns of the emotionallyhandicapped group can befound in the final report of the project, TheEducation of EmotionallyHandicappedChildren.4 'PURPOSE OF THE PROJECT The research staff working onthe project conducted by theState Depart- ment of Education tostudy educational programsfor emotionally handicapped pupils included as part ofits investigations a surveyof the neurological and pediatric problems of pupilsidentified as emotionallyhandicapped. The purpose of thisadditional survey was todetermine whether or notmedical factors in the records of asample of emotionallyhandicapped pupils were of sufficient significance to warrantfurther identificationprocedures before providing a specific educational program.This survey ofneurophysiological pathology in a sample ofemotionally handicappedpupils was especially timely since the public schoolsin Los Angeles County,with the help of the State Department of Public Healthand the State Departmentof Education, were studying educational programsfor pupils who had beendiagnosed as neurologically handicapped aftertheir teachers had notedtheir severe learning and behavior difficulties.Additional goals of this survey wereto determine the extent of an overlapbetween the twoclassifications, "emotionallyhandicapped" (EH) and "neurologicallyhandicapped" (NH), if such an overlapexisted, and to clarify the problems facedby pupils identified asemotionally handicapped either with or withoutneurophysiological deviationsin the specific educational pro- grazns which werebeing evaluated.

4E. M. Bower, The Education ofEmotionally Handicapped Children. A Report to the CaliforniaLegislature. PreparedPursuant to Section 1, Chap- ter 2385, Statutes of1957. Sacramento:California State Department ofEdu- cation, 1961.

4 '40.0

THE SAMPLE From a representative sample of 53 pupilspicked at random from those identified as emotionally handicapped, 20 wereexamined at the University of California Medical Center in Los Angelesby Herbert Grossman, M. D. , and Richard Walter, M.D., both on thestaff of that institution.The 53 students were enrolled infour different school districtsthat provided experimental programs for emotionallyhandicapped pupils in special classes, learning disability groups, or group counseling classes. Theparents of the 53 pupils were given the opportunityto have their children examined at theMedical Center, and if they did not wish to follow through withthe examination, they were not urged to do so.Of the 53 parents thus contacted, 36stated that they would like to take advantage of the opportunityfor a pediatric and neurological workup, and of these, the parents of20 pupils were able to make and keep their appointments. There was no"selection" of these 20 pupils except through a process of elimination,the others and their parents havingwithdrawn because ot lack of interest orinability to make an appointment. These20 pupils can be consideredrepresentative of those identified in the schools asemotionally handicapped. PROCEDURE Medical and psychological examinations wereessential in establishing the pediatric, neurological, andintellectual status of these emotionally handicapped pupils. For purposes of this study,medical findings, including personal and family history, were needed aswell as pediatric, neurological,and electroencephalographic (EEG) examinations.Psychological data to support or clarify the medicalfindings were also needed. The case materialcollected during the identification procedure used in theproject was adequate. The costs of the medical and psychological examinations werepaid from project funds and were handled by the schools inthe same manner as routine physical orreferral examinations. Psychological examinationshad been administered prior to the conduct of this particular study. The procedurefor contacting parents and making appointments for the physicaland neurological examinations, which were given at the University of California at LosAngeles, included the following steps: 1. The plan was discussed with the schooldoctor and nurse and cleared through the school district superintendent. 2. The list of pupils identified in the springof 1958 as emotionally handicapped was used to contact all parentsof pupils on the list. Every parent was contacted. , If onedid not come to the school for the inter- view, the pupil was dropped fromthe list. 3. When the parent conference washeld, the parents were informed that the school district was makingavailable a school physical examination to determine whether medicalfactors were contributing to the pupil's 5 problems in adjusting to school.Each parent was told that the purpose of thephysical examination was not to providetreatment, but to investigate the health statusof his child. The procedurefor the examination was discussed, and everyparent was told that his child would have an EEG as part of theprocedure. 4. The parents could obtainthe results of the examinations bywriting to Dr. Grossman requesting that a reportbe sent to the family physician in charge of the pupil. 5. Once parents had given their consentfor the examinations, Dr. Gross- man's office contacted them directly to makethe appointments; can- cellations and management of the schedule werehandled by his office. The psychological examinationsadministered at school by a number of psychologists working on theproject included the Wechsler IntelligenceScale for Children, the BenderVisual Motor Gestalt Test, and theDraw a Person Test. The results of these tests,along with achievement testdata and a school history for each pupil, werecollected and used subsequently by Irla Lee Zimmerman, ClinicalPsychologist, in reviewing therecords of the pupils to determine whether or notthere were any organic patterns inthe psychological data. Of the 20 pupils on whom this report wasmade, two were in the first or second grade; three, in the fourth orfifth grade; 11, in grades six toeight; and four, in high school in thetenth grade. Only three ofthe 20 pupils were girls. Coincident with the medical examinationof this sample of pupils in the program for the studyof the emotionally handicapped,the public schools in Los Angeles County hadinitiated pilot programs for theeducation of pupils termed "neurologicallyhandicapped." The pupils in this pilot program were nominated by teachers, reviewedby a team composed of aphysician, a psychologist, and a educator, and givenpediatric and neurological examinations, including the EEG. Since behaviorproblems and learning problems were common to both theemotionally handicapped and theneurologically handicapped groups, the opportunity todetermine the overlap between these two groups presenteditself.Therefore, ati arrangement was madewith the staff of the office of theSuperintendent of Schools of LosAngeles County to have the medical and psychologicalrecords of the 20 pupils in thisstudy reviewed by the pilot program staff todetermine how many of theemotionally handicapped children would have qualifiedfor their program. The medicalstaff of the county project did not seethe pupils, but they used thecomplete family and medical histories as well asthe EEG reports, theneurological, and the physical examination data to make theirdeterminations. The psychologists

6 in the county project used thepsychological data prepared for eachpupil, and neither they nor Dr. Zimmerman sawthe pupils. Both groups, doctorsand psychologists, were asked to listtheir criteria for ratingsassigned to the collected data.These data are shown in thecharts, "Comparison of Pertinent Criteria for MedicalEvaluation" and "Comparison of Criteriafor Psychologi- cal Evaluations," which appear on pages14 and 24, respectively. Chapter 2

RESULTS OF THE COMPARATIVESTUDY OF TWO DIAGNOSTIC TEAMS REVIEWING RECORDS OF EMOTIONALLYHANDICAPPED PUPILS Current interest in the diagnosis ofneurological impairment to determine the etiology of emotional handicaps does notrepresent a new approach to understanding problems presented by childrenwith school difficulties.The early work of Kurt Goldstein on the aftereffectsof brain injuries is typical of the long standing interest of physiciansand psychologists in the physical and behavioral correlates of neurologicalimpairment.' Lauretta Bender's study of the psychopathology of brain disordersin children is another example of early work in this field.2 Such diagnostic procedure was primarily of medical interest until the work of A.A. Strauss and L. E.Lehtinen3 which provided for educational techniques to assistchildren identified as brain injured. The concomitant increase in pharmaceuticalresearch on medications which influence behavior resulted in increased interest onthe part of pediatricians and neurologists in the possibility of mediating someof the more severe behavior problems with medicine. Since the publication of the research of A. A.Strauss, CharlesBradley,4 M. W. Laufer,5 L. Oettinger, 6 and others, the diagnoses of hyperactivity with related neurological impairments have been increasinglypopular. These research workers described the symptoms of thehyperactive child with learning disabilitiesperceptual and motor handicaps, poor retention, poorconcept formation, anxiety, and other patterns of delayeddevelopment-- and postulated related neurological deficitt. These symptoms werealso typical of the group in the general medical category ofchildren with "mild neurologicalhandicaps," handicaps considered "mild" because there were no apparentphysical disabilities, convulsions, or other signs of braindamage. The problem became more

1Kurt Goldstein, After-Effects of Brain Injuries in War. New York: Grune & Stratton, 1942. 2Lauretta Bender, A Visual Motor Gestalt Test and Its Clinical Use. New York: American OrthopsychiatricAssociation, 1938. 3A. A. Strauss and L. E. Lehtinen, Psychopathology and Education of the Brain-Injured Child. Volume I,Fundamentals and Treatment of Brain- Injured Children. New York: Grune &Stratton, 1951. 4Charles Bradley, "The Behavior of Children ReceivingBenzedrine." American Journal of Psychiatry, XCIV(Novemoer, 1937), 577-85. 5M. W. Laufer and E. Denhoff, "Hyperkinetic BehaviorSyndrome in Children, " Journal of Pediatrics, L(1957), 463-75. 6L. Oettinger, "The Medical Treatment of BehaviorProblems," Mississi_Vapi h.cal Journal, LXXIV (1952), 74.

8 difficult when children had all the characteristics identified with mild neurological handicaps, but there was no basis in the medical findings for a diagnosis of brain injury, either mild or severe. Psychological tests were then relied upon to determine the nature of the child's concept formation, perceptual motor skills, and retention, and more emphasis was given to these types of data than to mildly offbeat electroencephalograms or to neurological data which were not conclusive. Much of the research in references included in the bibliography of this publication gives support to positive correlations of these specific behavioral signs with specific neurological or electroencephalographic data.The problem for the pupil personnel worker who wishes to increase his knowledge of the etiology of learning and behavior problems is that in most of this work one cannot be safe in making generalizationsbeyond the populations studied. Seymour Sarason criticized A. A. Strauss' procedures for the diagnosis of the neurologically impaired child because (1) no evidence was offered that behavior and learning problems were a result of brain injury; (2) the characteristics of brain-injured children cannot be found to exist in that population alone; and (3) diagnosing brain injury on the basis of psychological tests assumes a degree of validity for these tests whichdoes not seem warranted.7 Sarason also stated that when a neurological examination is found to be nega- tive, one is not justified in using specific personal history factors such as anoxia, prolonged labor, and feeding difficulties as conclusive evidence of organic impairment. Until base rates for all of these difficulties are established for the population, the degree to which any finding is particularly significant cannot be determined. L. Eisenberg delineates some of the professional considerations which need to be made in inferring brain injury from specific behavior difficulties.8 He notes that it is important to consider that the clinical features of known organic cases vary from case to case, and that the same symptoms can be found in cases without organic involvement. He also notes a reciprocal relationship between the child's neurological status and his environment, inadequate environment sometimes producing the same behavioral symptoms as known neurological impairment. Eisenberg stresses the fact that relationships between nervous structure and function, however useful they may be, cannot suffice for an understanding of the problems of the brain-injuredchild, and that evaluation of the child's behavior is impossible without psychiatric

7Seymour S. Sarason, Psychological Problems in Mental Deficiency (Third Edition). New York: Harper & Bros., 1959. 8L. Eisenberg, "Dynamic Considerations Underlying the Management of the Brain-Injured Child, " General Practitioner, XIV(1956), 4.

9 study both of the setting in which the behavior occurs and of the meaning of this setting to the child. William E. Block discusses mechanistic and dynamic theories of brain injury, citing W. M. Phelps, a mechanist, as an example.9 Phelps attributed fundamental behavioral differences to the two major types of cerebral palsy solely on the basis of specific neuromuscular disability.10 According to his stimulus-response theory, the spastic child would be introverted; the athetoid child would be extroverted. Block studied two groups of school children, half of whom were predominantly athetoid, the other half spastic, matched for age, IQ, socioeconomic status, ethnic group, and thie of brain injury.Phelps' theory on either overt or unconscious behavior.41 tendencies was not sustained by the studies of Block, who stated, "The resalts'agreethat the nature of the disability has no unique effect on personality." The differences with respect to area of brain injury as well as secondary physical defects in the groups that Block studied were a challenge to conditioning and organogenic explanations of personality in the brain-injured child. One can conclude, as Lee Meyerson did, that a disability is psychologicallyneutra1.11Its ultimate effects depend on the social-psychological situation, the person's self-evaluation, and the bar- rier presented by the disability to universal goals. There is no doubt that a disability makes the child more vulnerable to normal life stresses by remov- ing one or more of the specific resources with which the child can cope with his environment, but the specific effects of the disability are bound to vary from individual to individual and cannot be predicted on the basis of the disability alone. The neurologically handicapped and the brain-injured constitute an extremely heterogeneous group. As T. Ernest Newland indicates, this group shows patterns of poor conceptualization in abstract problems, limited attention span, distractibility, unpredictability, poor reading achievement, autism, aggression, apathy, resistance, withdrawal, hyperactivity, and anxiety.12 Not all of these characteristics can be found in any one child, and within a population of neurologically handicapped children there are an infinite number of variations of psychological and educational patterns.

9William E. Block, "Personality of the Brain-Injured Child, " Exceptional Children, XXI (December, 1954), 91-100, 108. 'OW. M. Phelps, "Characteristics of Psychological Variations in Cerebral Palsy," The Nervous Child, I (1948), 10-13. 11Lee Meyerson, "Physical Disability as a Social Psychologist Problem, " Journal of Social Issues, II (fall, 1948), 2-10. lgT. Ernest Newland, "Psycho-Social Aspects of the Adjustment of the Brain-injured, " Exceptional Children, XXIII (January,1957), 149-53.

10 asle ,

"Brain-injured" or "chronic brainsyndrome" (CBS), "mildneurological handicapped" (NE),"hyperkinetic, " handicaps, " "theneurological-endocrine referring to tlorganic, ""organic-driven, " and"impulse ridden" are terms children's learning andbehavior difficulties.The terms meandifferent things to different people. Intransferring the researchfindings from onepopulation to another, one musttake care that theselective criteriaemployed by different Although there is littledoubt that there arechildren researchers are the same. paucity whose brain injuries affecttheir learning andbehavior, there is still a such conditions canbe adequately diagnosedby a neur- of scientific proof that psychologist, internist, or any ologist, pediatrician,electroencephalographer, the combination of these. InMacNeven's study of thefirst 40 referrals from hyperactive, impulsivechildren who mostciosely behaved Kansas City schools of "there apparently like brain-injured children,the investigatorsconcluded that exists little or nocorrelation betweenhyperactivity and braindamage."13 RESULTS OF THEMEDICAL EXAMINATIONSAND COMPARISON OF THE MEDICALRATINGS

It should be emphasizedthat no specific medical orneurological finding has been correlated with aspecific behavioralmanifestation. The physiciantradi- tionally has used manytypes of data inevaluating a givenproblem. These were emphasis on theirapplication in solving thecomplex enumerated with particular and behavior diagnostic problemsinvolved in determiningthe etiology of learning problems of emotionallyhandicapped children referredfor medical diagnosis. of neurophysiologicalpathology was based onthe The medical diagnosis pediatric pupil's past history,history of the presentproblem, family history, examination, neurologicalexamination, and EEG.The four types of ratings and the symbolsdesignating the ratings were asfollows: posi- based on these data equivocal findings tive indication ofpathology (Ai; no indicationof pathology (-); Table 1,"Comparison of Diagnoses ofNeurophysio- (+); insufficient data(0). Identi- logical Pathology of 20Children with Learning andBehavior Difficulties Handicapped, " shows thefindings of the two groupsof physi- fied as Emotionally to each cians in terms of theseratings. The frequencyof the ratings assigned ,category by each ofthe groups of physiciansis shown at the endof Table 1. Summary of the Ratings ofPersonal History and History of theProblem developmental history isused typically byphysicians A child's birth and within normal to determinewhether his developmentalpattern can be considered

13R. W. MacNeven and Others,"The Function of a PsychiatricDiagnostic Asso- Unit in the SchoolSystem." Presented at theAmerican Orthopsychiatric ciation Meeting,San Francisco, May1, 1959. 11 ' 11111111111.1.1......

Table].

Camparison of Diagnoses of NeurophysiologicalPathology of 20 Children mith Learning and Behavior Diffioulties Identified asEnotionally,Handicapped

Personal history Medical and history of Family Pediatric Neurological examinationexamination EEG Case diagnosispresent problem histary number Sex Group Group Group Group Group Group , , I II I III I II 1 j 1-1 1 III I II

1 MID 1 MID MID

4WD 2 + MID MID 4. 4. 3 4 0 0 0 0 0 0 .11 0 0 5 ± 6 7 + + 0

9 + +

10 11

12 + + MID + +

14 + +

15 1.11 0 16 +

17 B f

18 0 -

19 0 0 0 0 AIM

20 GUM

Frequency of Ratings

MI& + Positive indication of pathology 4 0 8 4 2 0 0 0 0 0 3 4 i Equivocal indication of pathology 6 2 3 2 1 1 0 0 5 0 3 0 No evidence of pathology 9 17 6 12 11 17 19 20 1520 13 15 0 Insufficient data 1 1 3 2 6 2 1 0 0 0 1 1

Significance isve1 .01 NS2 NS NS NS NS

Robert Sedgewick, M.D., and Kenneth Zike, M.D., of the LosAngeles County Neurologically Handicapped Study were the physicians of Group I.Herbert Grosenan, M.D., and Richard Walter, M.D., of the Miversity of California, Ims Angeles, Medical Center werethe physicians of Group II. 2 Not significant.

12 limits. From the records of known brain-injured children,some of their characteristic types of developmental patterns have been noted in medical research. These findings, which have been generalized to includea larger child population, are applied in cases where the physician is interestedin establishing the normality or abnormality of the child's early life experience. Obviously, serious illness, prolonged febrile conditions withor without convulsions, head injuries, and the like are items of interest in establishing the possibility of some historical. condition which might be relatedto the present difficulty.The problem for the physician, once he has determined thepres- ence of any of these signs, is to relate the finding to the child's problem. While the particular pattern may be important in itself, it isnot a simple matter to be sure that the finding can be identified witha detrimental effect on the child. Many researchers in medicine and psychology have established the fact that extreme care must be used in correlatingan early historical finding with a present behavioral or learning difficulty.

The ratings assigned by the two groups of physicians workingon the project indicate the degree to which they believed thata given finding was related to a present difficulty.Contradictory ratings were assigned by the two groups of doctors to 12 of the pupils. Group I, the Los Angeles County physicians, rated as "plus" those pupils whose histories evidencedany of the following: neonatal cyanosis, dyslexia, hyperactivity, short attention span, learning difficulties, delayed development, enuresis, speech problems, poor coordination, and head injuries. Pupils rated as "plus" by the physicians from the University of California, Los Angeles, Medical Center were found to have injury with loss of consciousness, learning difficulties, speech disorders, and delayed development. While the criteria for a positive diagnosis in this category do notvary greatly between the two groups of doctors, there is evidentlya noted difference in the relative weight given to certain factors in the history of the pupils. The criteria used by both groups of physicians were developed primarily from post-dictive studies of children with known neurological impairments (see "Comparison of Pertinent Criteria for Medical Evaluation,"page 14 ). Summary of the Ratings of Family History The family history of convulsive seizures, neurologicalor psychiatric diseases, or mental retardation is of interest to the physician in establishing evidence for genetic conditions which might be related to the child's difficulty. As the pediatrician or neurologist obtains the history from theparent, he may find it useful in assessing the psychological and social environment in which the child lives. Often these areas of investigation offer help in interpreting historical data and may cause the physician to minimizea particular finding in the presence of convincing evidence of the inadequate socialor psychological relationships of the child.

13 COMPARISON OF PERTINENT CRITERIA FORMEDICALEVALUATION1 Criteria of group I physicians Criteria of group II physicians Personal History Prenatal: In mother, hypertension, Mother's pregnancy - evidence of com- bleeding, fevers, toxins, blood in- plications, illnesses, uterine bleeding compatibilities, and the like. EdemaLabor - duration prolonged, other in third trimester difficulties and complications Perinatal: Prematurity.Difficult orDifficulties in delivery prolonged labor; very rapid delivery.Birth weight - prematurity Cyanosis. Poor weight gain.Dehy- Neonatal period - resuscitative diffi- dration culties, feeding difficulties, excess- Postnatal: Unusual sleep-wake patternive irritability Maturational anomalies, e. g. ,cleft Early history - development impaired palate and lip, delays of coordination,in neuromuscular, social, emotional, speech.Pathological reflexes. Fe- and/or intellectual performance brile seizures.Continuing enuresis.Severe illnesses and injuries - espe- Head trauma with unconsciousness. cially those with disturbed sensorium, Attentional difficulties. History of e. g. , unconsciousnessand/or con- dyslexia, dysgraphia, dyscalcue vusions Convulsions Behavior disturbances Poor school performance 40, Family History

Presence of developmental anomalies;Presence of mental illness, organic learning failures, e. g. , reading, impairment, or convulsions in writing, and arithmetic in parents, family members grandparents, siblings Pediatric Examination Mixed dominance. Muscular signs ofImpaired physical condition spasticity, e. g.,tight heel cords, or weakness. Poor coordination, .e. g.,Congenital abnormalities, estimate of one-foot stands, awkwardness intellectual capacity, coordination, Nystagmus, "squint," imbalance of speech maturity, and affect extraocular muscles; tremor; speech defects 1These criteria are typical of those used. They are not to be considered an entire listing of all possible deviations.

14 Neurological Examination Spasticity Gross physical or neurological abnor- Tremors malities will be recognized. The Poor one-leg stand difficulty occurs when, as inhemi- Deficiency in recognition of simultan- paresis, we do not have any specific eous stimulation, face-hand correlation with behavioral phenomenon. Some of the less apparent "positive findings" follow: Visual disturbances- visual acuity, disturbance of extraocular movements Generally brisk deep tendon reflexes Presence of extensor toe signs (Babinski reflex) Gross motor awkwardness, e. g. , poor hopping, imbalance Minimal choreo-athetoid movements Crossed laterality Disturbance of two-point discrimination and double tactile stimulation Fingeragnosia Perceptual difficulties - copies geo- metric designs poorly, poor hand- eye coordination

15 There were eight pupilswith contradictoryratings on familyhistory data. "plus" rating by the doctorsfrom the LosAngeles County Those pupils given a disabilities, mem- study were found tohave siblings orrelatives with learning bers of the family withspeech problems, andother difficulties indevelopment family members.The family historyof the only pupil who in the history of physicians in Group IIshowed was given arating of"equivocal findings" by the a fatherwith a diagnosis ofschizophrenia andcommitment. Results of the PediatricExamination usually manifest someobvious physical impair- Brain-damaged children absence of a ment which can benoted during the pediatricexamination. In the notable physical defect,general physical conditions arestudied. Charles of the particularconditions which have been Bradley has commented on some diFtracti- found in cases ofbrain-damagedchildren.14 The physician can note bility, poor physicalcondition, impulsiveness,awkwardness, poor coordination, and otherdeviations from what isconsidered normal forthe child's age. object of study bypsychologists and neurologistsfor Handedness has been the literature on right-left some time.Recently, Arthur L.Benton reviewed the discrimination.15 His work indicates that westill do not know a greatdeal of the brain and about the relationshipof neurologicalfindings to certain areas research on some of theproblems presented bymixed laterality that continued in this is needed to confirmearlier research results.The diagnostic problem again one of determiningwhether a particular area ofmedical investigation is the finding is within normalvariation for age.If the finding is borderline, physician must predictwhether it is positivelyrelated to neurologicalimpairment. The fivepupils with"equivocal" ratings on the pediatricexamination assigned by the Group Idoctors were found tohave mixed laterality,defects movements, immaturespeech, and mentaldullness. The in rapid alternating examin- doctors in Group IIinterpreted none of theirfindings from the pediatric ation as indicativeof neurophysiologicalimpairment. Results of theElectroencephalographicExamination P. C. Bucy's workwill be helpful tothose who wish moreinformation about the diagnosticprocedures used inrelation toEEG.16

14Charles Bradley, "BehaviorDisturbances in EpilepticChildren, " Journal of AmericanMedical Association,CXLVI (1954), 436-41. 5Arthur L. Benton, Right-LeftDiscrimination and FingerLocalization: Development and Pathology.New York: PaulB. Hoeber, Inc., 1959. 16p. C. Bucy, "Electroencephalography'sProper Role, " Journalof the AmericanMedical Association,CLX (1956), 1, 232.

16 R. D. Walter and othersreviewed a particular EEG patternin their investigations of the relationshipof 14- and 6-per-second spikesto psychiatric judgments ofbehavior.17 His study was designed to correlatebehav- ioral patterns with specificEEG findings. The aim of hiswork was to see whether there were symptoms,somatic or social and/or behaviorpatterns, which distinguished childrenwith the 14- and 6-per-secondpatterns from patients with other EEGabnormalities or without EEGdisturbances. Of the four groups studied, 22patients had normal EEGs;23 patients had abnormal EEGs; 16 patients had both14-and 6-per-second, and otherabnormalities; and 13 patients had only14 and 6-per-second spiking.The patients were evaluated by a psychiatrist withoutprior knowledge of thepatients' classifications. Neurologicalstudies were also performed.The patients with only the 14- and 6-per-secondspiking demonstrated less inthe way of"emotional symptomatology" than either the normalEEG group or those with otherEEG abnormalities. Patients with14- and 6-per-second activityplus other types of abnormalities demonstrated more"aggressive behavior" than either the abnormal EEG group or thenormal EEG group. There was noevidence from this study of any markeddifference in emotional make-upbetween children with EEG findings of 14-and 6-per-second spikingand other children, regard- less of their EEG findings.R. D. Walter's work on thisparticular pattern will be of use to thosewho are interested in furtherstudy of the problem. The administration of theEEG for a diagnosis of cerebraldysrhythmia must be accomplishedunder such carefully controlledexamination procedures, since the results are sodisposed to artifact that withoutsuch controlled procedures the results of theexamination should be held inquestion. Specific discrepancies in an EEG recordfrom what is considerednormal for age and grade have been fairly wellestablished. The problem ininterpreting the EEG comes when aspecific deviation which does notfit into any previouslydefined category is noted. The physicianmust then determinewhether such a finding is within the normal rargeof variation, a functionof experimental conditions, or specificallyrelated to other findings withinthe case history. Even in classic cases ofepilepsy, where irritabilityand hyperacilvity are predictable, behavior characteristics arenot consistent from one caseto another. The criteria forevaluating electroencephalographicrecords are commonly agreed upon byelectroencephalographers and should bereported as specific deviations in the EEG summary.Some of the deviations that arefound in EEG records indicate tooslow a frequency for thechronological age, 14- and 6-per-second spiking, orfocal and/or paroxysmalfindings. The problem

and Six- ..to 17R. D. Walter and Others, "A Controlled Study of the Fourteen- Per-Second EEG Pattern, " Archivesof General Psychiatry(American Medical Association), II (1960), 559-66.

17 in using the EEG fordiagnosis lies in tle extentto which a particulardevia- tion is correlated with aspecific behavioral problem inthe eyes of the physician. Final Medical DiagnosisBased on Review ofAll Data The doctors in both groupsjudged the medical findingsin the light of their criteria for evidence ofneurological impairmentand used a similar rating procedure to classify allpupils. The significanceof the differencesbetween of physicians wasfound to be at the 1 percentlevel the ratings of two groups to the sepa- and can be explainedlargely by differencesin the weight attached rate items of datawhich make up the finaldiagnosis. To reiterate, thefive gathered on all cases were(1) past history and history types of information (4) neuro- of present problem;(2) family history;(3) pediatric examination; logical examination; and(5) electroencephalographicexamination. The following patterns werefound in those pupilspreviously identified diagnosis of neuro- as emotionallyhandicapped who wereassigned a positive logical impairment bythe Group I physicians: 1. Two "plue and two"equivocal" ratings 2. Two "plus" and one"equivocal" rating 3. One "plus" and one"equivocal" rating 4. One "plus" rating The'following patterns werefound in those pupilswho were assigned an equivocal diagnosis by theGroup I physicians: 1. Two "positive" ratings 2. One "positive" rating 3. Three"equivocal" ratings 4. Two"equivocal" ratings 5. Two pupils with one"equivocal" rating each -The physicians in Group IIdiagnosed only two of the20 pupils as"equivocal findings, " and theydiagnosed none having a"positive indication of pathology." Those with an"equivocal" diagnosis had thefollowing patterns: 1. Two positive ratings 2. One positive and oneequivocal rating The differences betweenthe ratings of the two groupsof physicians cannot be found in relation tothe criteria which wereused for the ratings.These criteria are listed forboth groups ofphysicians on page 14 .The difference between the two groupsis largely based ondifferences in thesignificance assigned to a particularfinding for the overalldiagnosis. In one casethe

18 doctors knew the pupils were identified as emotionally handicapped, so their focus was on social and emotional probleMs even though they were looking for neurological impairments. The Los Angeles County doctors were looking for neurological impairments even though they knew the pupils had been identified as emotionally handicapped, so their primary focus was on the possibility of neurological impairment. These results need careful interpretation. One inference, and perhaps the most important one, is that a diagnosis of neurological impairment on which physicians can easily agree is hard to get. The neurological impairment may, in fact, exist, but it is difficult to get agreement on what weights to assign to the findings. Once having agreed on the weights for the crite-.7 ia, it is still difficult to determine whether the criteria have been met in a particular case. Without the frame of reference of the referring problem, the physician will have considerable difficulty in arriving at a determination of the etiology of the problem which would be consistent with another doctor's findings. The second inference has to do with the relationship between the referring problem and the medical diagnosis, The referring problem is an essential part of the data used for interpreting medical findingS.If the pupil is referred by the school psychologist as a possible organi.c case, the physician naturally looks first for signs to support the referral.If the pupil is referred because of emotional difficulties, the physician looks for related medical findings but is comfortable in emphasizing social and emotional imbalance as the primary etiological base for the difficulty. We are not yet at the point where we can arrive at a consistent medical diagnosis in cases of complicated behavior and learning problems without reference to complete case information; and even when such information is used as a frame of reference, the attainment of a reliable diagnosis is relatively difficult.The psychological report of strengths and weaknesses in intellectual functioning, erratic test performance, and perceptual difficulties, which will be reviewed next, is an essential and commonly used addition to the battery of data used to make a positive diagnosis of neurological impairment.

RESULTS FROM THE REVIEW OF PSYCHOLOGICAL TEST DATA The psychological evaluations of organic impairment were based on investigations of intellectual functioning, perceptual motor skills, and general organizational and conceptualizing skills.Three of the most typical examinations administered to children by school psychologists were used in this study to evaluate specific aspects of cognitive and perceptual functioning.An estimate of the level of intellectual functioning was provided by patterns of theWech- sler Intelligence Scale for Children (WISC) and the IQ scores.Skills in conceptualization and reactions to the testing situation were also noted duringthe

19 administration of the WISC.Perceptual-motor functioning wasinferred from responses tocopying tasks such asthose presented in theBender Visual Motor Gestalt Test.The Draw a Person(DAP) test, which has receivedless note in the diagnosisof neurological impairmentsthan the WISC or the Bender tests, was found usefulin comparing socialand emotional developmentwith the norms establishedby F. L.Goodenough18 and Molly Harrower.19 The information rated byboth groups of psychologists asindicative of organic impairment wasof three types and wasbased on the WISC, Bender, and Draw a Person tests.Achievement test data andratings by teachers were also madeavailable. Both groups ofpsychologists establishedcriteria for their ratings andapplied these criteria tothe case material, usingthe same code asthe physicians: positiveindication of neurologicalimpairment (+); no evidence of neurologicalimpairment (-); equivocalindication of neuro- of ,1 logical impairment(+); insufficient data (0).The ratings by both groups psychologists for the 20 cases arepresented in Table 2. Summary of Ratings on theWISC In a review of psychologicaltests used for the diagnosisof brain damage, Aubrey J. Yates stated,"It is doubtful whether any aspectof psychological testing has been more inadequatelytreated than the diagnostic assessmentof brain damage."20 A review of available research on theWISC in an unpublished study by K.Hopkins indicates that the resultsof this test are conflicting andinconclusive.21 As another example of theconfusion, one report states that the comprehensionsubtest on the WISC is oneof the scales adversely affected bx brain injury,22 and another report states that it is one of theleast affected.2.5 Claims of the diagnostic significanceof many of the WISCsubtests

18F. L. Goodenough, Measurement of Intelligenceby Drawings. Yonkers, N.Y. : World Book Co. ,1926. 19molly Harrower, Personality Change andDevelopment as Measured by the ProjectiveTechniques. New York: Grune& Stratton, 1958. 20Aubrey J. Yates, "The Validity ofSome Psychological Tests ofBrain Damage, " PsychologicalBulletin, LI (July,1954), 374. 21K. Hopkins, "The Efficiency of the WechslerIntelligence Scale for Children in PredictingOrganicity in Children withNormal IQ's and a Note onMethodology." Unpublished study,1960. 22j Aita, S. G. Armitage, R. M. Reitan,and A. Rabinowitz,"The Use of CertainPsychological Tests in theEvaluation of BrainInjury," Journal of Genetic Psysly:212a,XXXVII (1947), 25-44. 23R. M. Allen, "The Test Performance ofBrain Injury," Journal of Clinical Psychology, III(July, 1947), 225-30.

20 Table 2

Comparison of Diagnoses ofNeurophysiologioal Pathology-Inferred from Psychological Test Findings for 20 Children,mith Learning and Behavior Difficulties Identified asIlnotionaly Handicapped

Psychological Draw a Person Case diagnosis MISC . Bender number Sex Groupl Group Group Group I IIx I 1 ii 1111 1111 . + + 1

MID 2 NO IWO f

3 + + 4 B

OW 5 G (uR.) + + 6 .10 a aa

7 4MI

Ole

10 IND Mo a + + 11 12 13 OW

24 MID 15

16 OM

17 OM NM

18 + + +

19 Oa 4. MN 1111

20 OM NIP ON 0

frequency of Ratings

+ Positive indication 0 of pathology 9 0 8 2 10 0 4 4 3 ± Equivocal finding 6 4 4 3 4 4 No indication of pathology 516 815 516 12 17 0 0 0 Insufficient data 0 0 0 0 1 0 2 Significance level .01 .05 .01 NS

1 Those of Group I who made the ratings wereBerdine Jones and John W. Howe of the Los Angeles County Neurologically Handicapped Study.Irla Lea Zimmerman, a psychologist in private practice, was the person whomade the ratings of Group rx.

2Not significant. 21 have been made in the workof J. Aita,24 R. M.Allen,25 Seymour G. Kleb- Levi,27 and J. W.Parker.28 Other research workerswho anoff, 26 Joseph S. could find no such positiveresults from WISC patternanalyses were Harry Beck,29 Jacob Cohen," G. H.Frank,31 JosephJastak,32 and C. H.Patterson.33 such conflicting reportshas been increasedby The confusion caused by generalized from the many suggestionsfor the use of theWISC which have been studies made with theWechsler Adult IntelligenceScale. Studies of theWISC children with ability abovethe range of mental re- performance of a group of judgment as to tardation are necessarybefore it will be possibleto make safe the importance of anyparticular subtest findings.Hopkins' careful analysis of a sample of 33pupils identified forthe Los Angeles of the WISC patterns consist- County neurologicallyhandicapped study indicatedthat there were no could be identified.The two subtests withthe lowest means ent patterns which of the differ- for the group wereArithmetic and Coding. Thelack of reliability ences between theWISC subtests was noted asbeing a significantlimiting factor organic impairment.The difference betweenverbal in making inferences of significant sign and performance IQhas been noted in theliterature as being a in interpretation.K. Hopkins foundthat only one-third ofhis population had higher verbal thanperformance IQs aspredicted, contrary to thework of

24Aita and Others, loc. cit. 25Ailen, loc. cit. 26Seymour G. Klebanoff, JeromeL. Singer, and HaroldWilensky, "Psychological Consequencesof Brain Lesions andAblations, " Psychological Bulletin, LI (January,1954), 1-41. ------21.Toseph Levi, Sadi Oppenheim,and DavidWechsler," The Clinical Use of the Mental DeteriorationIndex of theBellevue-Wechsler Scale," Journal of Abnormal andSocial Psychology, XL(October, 1945), 405-07. 28J, W. Parker, "The Validityof Some Current Testsfor Organicity," Journal of ConsultingPsycholomr, XXI(October, 1957), 425-28. ---2-9Harry S. Beck and Robert L.Lam, "The Use of theWISC in Predict- 1955), 155-58. ing Organicity," Journal of ClinicalPsychology, XI (April, 30Jacob Cohen, "Factors UnderlyingWechsler-Bellevue Performance of Three NeuropsychiatricGroups, " Journal ofAbnormal and Social Psy- cholo,XLVII (April, 1952),359-65. C. Carrie, and J.Fogel, "An Empi, 1.71..alCritique G. H. Frank, C. " of Research with theWechsler-Bellevue inDifferential Ps-dc',Jdiagnosis, Journal of ClinicalPsychology, XI(July, 1955), 291-93. 32Joseph Jastak, "RankingBellevue Subtest Scoresfor,Diagnostic Pur- poses," Journal of ConsultingPsychology, XVII(December, 1953), 403-10. 33C. H. Patterson, The Wechsler-BellevueScales -- A Guide for Counselors. Springfield, Ill. :Charles C. Thomas,Publisher, 1953.

22 R. M. Allen,34 C. H. Patterson,35 and David Wechsler.36 'More research is needed to establish base rates for particular psychological findings on the WISC before the school psychologist can place high hopes on the use of this instrument for the prediction of neurological impairment. William Littell reviewed all of the research on the WISC in the ten years since its publication and concluded that there was an appalling lack of predictive validity studies.37This is an area for important contributions to the understanding of intellectual functioning for those school psychologists who wish to explore research possibilities of the WISC. The differences between the distributions of rating on the WISC by the two groups of psychologists was largely aresult of the different criteria used for assigning the ratings. These criteria can be found in the"Comparison of Criteria for Psychological Evaluations, " page 24. Summary of the Ratings on the Draw a Person (DAP) Test Research on the use of the Draw a Person test in the prediction of organicity is scarce. Most of the research on the DAP by F. L. Goodenough,3' Molly Harrower,39 and KarenMachover40 has indicated that this test isuse- ful in making comparisons between the developmental age of the pupil, inferred from his drawing, and his intelligence, as measured by individual tests.Other research by these same workers has shown that the drawings can be used in evaluating progress in psychotherapy and as a possible means of measurement of personality change.Since the research support for such use is weak, much needs to be done in order to establish the validity of this instrument in abattery of tests used for the child with suspected organic impairment. Although limited research has been completed on comparing types of drawings with suspected neurological impairment, the DAP is commonly used as

34imen,loc. cit. 35Patterson, loc. cit. 36DavidWechsler, The Measurement and Appraisal of AdultIntelligence! Baltimore: Williams and Wilkins, 1958. 37William M. Littell, "TheWechsler Intelligence Scale for Children: Review of a Decade of Research, " Psychological Bulletin, LVII (March,1960), 132-56. 38Goodenough,loc. cit. 39Harrower, 40KarenMachover, "Drawing of the Human Figure: A Methodof Person- ality Investigation, " in H. H. Anderson and G. L. Anderson, An Introductionto Projective Techniques. New York: Prentice-Hall, Inc., 1951.

23 COMPARISON OF CRITERIA FORPSYCHOLOGICAL EVALUATIONS Criteria of group I psychologists Criteria of group II psychologists Wechsler Intelligence Scale for ChildrenTest Discrepancy between verbal and per- Low IQ formance score of 20 or more points VIQ higher than PIQ Scatter or unevenness ofsubtest scores manifest as arange of six orAmong the lowest subtests are object more pointsbetween highest and low-assembly, block design, and coding est scaled scores Lower digit span Relatively lower performance for the individual on certain subtests, infor-Higher subtest scores on arithmetic, mation, arithmetic, digitsbackward information picture completion, and vs forward, objectassembly, block picture arrangement design, and coding Draw A Person Test Grossly poor or immature propertiesPerc eptual-rnotor difficulties Insufficient detail or differentiation asImmature figure (deviating from men- expected from age, e. g. , lack of necktal age on WISC) and shoulders, tapering at thigh junc- ture, no hands or fingers, missing Confused body image head detail In addition to above signs, presenceof "flat" or decorticated heads (other than when represented as"flat-top" hair cuts) Bender Test

Marked size dftcrepancy between sub-Perceptual-motor difficulties not re- components of same figure lated to mental age Obvious distortions amounting to lossOrganization - placement inadequate or near loss of gestalt planning, confused sequence, variations in size, rotation Presence of recognized signs of imma-Reproduction - simplification, modi- turity or pathology of perception, i. e. ,fication, distortion, inaccuracy inability to draw oblique angles, loss (number of units, angulation, curva- of side or angle in hexagons ture) Reversals Rotations Primitivation or oversimplification if of a marked degree 24 part of a test battery.Unpublished work by Ir la Lee Zimmermanindicates that in the records of 25children diagnosed as neurologically impairedat the University of California MedicalCenter, perceptual-motor difficulties could be found in some drawings,immature figures were typical in others,and a diffuse body image typical ofstill others. Although care must be taken in making predictions from figuredrawings, the popularity of DAP as part of a test battery will probably continue. Summary of Ratings on the BenderVisual Motor Gestalt Test Following Lauretta Bender's pioneerwork in the development of the Bender Visual Motor Gestalt Test, anumber of research workers have usedthe instrument in studies of differentialdiagnosis of brain injury, severeemotional disturbance, and intellectualperformance.41 Anne Clawson found that arrangement, sequence, difficulties withclosure, change in angulation androtations, taken as independent signs, candiscriminate between clinic cases and asample of school children without apparentdifficulty. 42 Rotations, eitner in the reproduction of design, in rotations of the paper, orin turning the cards, have been studied by S. B.Chorost,43 Lewis R. Goldberg,44 RichardGriffith,45 L. J. Havnik,46 Elizabeth Koppitz,47 and AnneClawson.48 The results are

411auretta Bender, A Visual Motor Gestalt Test and Its ClinicalUse. New York: AmericanOrthopsychiatric Association, MonographNo. 3, 1938. 42Anne Clawson, "The Bender Visual Motor Gestalt Test as anIndex of Emotional Disturbance inChildren," Journal of Projective Techniques,XXIII (June, 1959), 198-206. 43S. B. Chorost, G. Spivak, and NI. Levine,"Bender-Gestalt Rotations and EEG Abnormalities inChildren, " Journal of ConsultingPsychology, XXIII (1959), 559. 44Lewis R. Goldberg, "The Effectiveness of Clinicians' Judgments:The Diagnosis of Organic Brain Damagefrom the Bender-Gestalt Test," Journal of Consulting Ps cholo XXIII (February, 1959), 25-33. Richard M. Griffith and Vivian H.Taylor, "Incidence ofBender-Gestalt Figure Rotations," Journal ofConsulting Psychology, XXIV(April, 1960), 189-90. 46L. J. Havnik, "A Note on the Limitations of the Useof the Bender-4 Gestalt Test as a DiagnosticAid in Patients with a FunctionalComplaint, " Journal of Clinical Psychology,VII (April, 1951), 194; and"A Note on Rota- tions in the Bender-GestaltTest as Predictors of EEGAbnormalities in Children, " Journal of ClinicalPsychology, IX (October,1953), 399. 47See the four references cited for ElizabethM. Koppitz in the selected referances. 48Clawson, loc. cit. equivocal in supporting the value of rotationsin predicting heain damage. Most of these researchers suggest thatthe Bender test has some value as a screening device but that it should beused only with other data in making personality predictions. In spite of thelack of firm findings on its use as atest for organicity, the Bender is found to beused more often by researchworkers in batteries of tests with organicsthan other tests that are commonlyused in psychological appraisal. Additional work is needed with the Bender,especially with random samples of school populations at various agescompared with the variables of intelligence, socioeconomic status,achievement, and age. Some workers have suggested that the Bender is overlysensitive, since it is typical for children to make a number of gestalt errors.Others, like Elnora Schmadel,49 in an effort to see how the Benderreproductions might differ in a groupof gifted, randomly selected, andneurologically handicapped pupils(from the Los Angeles Countyproject) found that few differences existedbetween these groups, but that certaingestalt devialions were found to a greaterdegree in the neurologically handicapped.All of the deviations were found in all three groups. The weakness of most of thisresearch results from the frequent useof the Bender or other perceptual motortasks as the basis for selecting the population to be studied. Predictions of moredeviations would be inevitable under such circumstances. Establishmentof base rates for a variety of child populations and follow-up work withpupils who show different gestaltdeviations and organizational patterns are needed beforethe predictive validity of this test can beestablished. The criteria for assigning ratingsindicative of neurological impairment to the Bender protocols were notmarkedly different for the two groups of psychologists. The differences betweenthe frequencies of the ratings notedin Table 2 are based on interpretationof the criteria and on differences inthe criteria that were used for predictingorganicity.

SUMMARY OF COMPARATIVEJUDGMENTS MADE BY PHYSICIANS ANDPSYCHOLOGISTS Only the distribution of ratingsassigned to the overall medical diagnosis of neurological impairment wasfound to discriminate significantlybetween the Group I and Group II physicians.Even though there were no serious

49Elnora Schmadel, "Comparisons ofVisual Motor Dysfunction of Hyper- active and Brain-Injured, MentallyGifted, and AverageChildren." Unpub- lished Study, 1962.

26 disagreements between the findings of the two groupsof doctors working with the same units of case data, a summarydiagnosis of the etiology of a child's difficulty was not consistent from one groupof physicians to another. The weight assigned to particular medicalfindings, while not showing up in significant differences in the distribution ofratings of specific case data, must have had a cumulative effect in arriving atthe total medical diagnosis. The general assumption from these data isthat a medical diagnosis of neurological impairment in these 20 cases ofpupils identified as emotionally handicapped is a highly presumptive, inferential.,and unreliable procedure. Three of the four distributions of ratingsassigned by the two groups of psychologists were found to be significantlydifferent. The one which did not meet the criterion of a 5 percentlevel of significance was the distribution of ratings on the DAP. The criteria forpresumptive ratings of organicity from Bender protocols were more refined than thecriteria for ratings on the WISC and the DAP. More research studies havebeen conducted illustrating the importance of gestalt distortionsand perceptual-motor difficulties. The results of these studies lend support to the useof particular Bender criteria for prediction of organic impairmentof some type.Since the criteria Zor the WISC and the DAP are much less welldefined, the psychologist must rely on previous experience and clinicaljudgments in using them. The ratings of the WISC and DAP would be considered,therefore, to be more subjective than those on the Bender. Such subjective ratingsmade by psychologists are analogous to the subjective ratings made byphysicians on the family history, personal history, and pediatric examination.The objective medical procedures of the neurological andelectroencephalographic examinations are not subject to as great a need for clinical interpretation.- An overall comparison of the medical and psychologicalratings assigned by the two groups of research workersindicates that significant differences in distributions of the ratings werefound only in relation to the Bender test and the WISC, not in any of the medical ratings.On the other hand, distributions of the ratings of themediCal and psychological diagnoses were both found to be significantly different at the1 percent level. The following inferences may be drawn fromthese comparisons: (1) a reliable diagnosisof neurological impairment is difficult to achieveeither by physicians judging medical data or by psychologists judgingpsychological case records; and (2) the more subjective the criteria for evidenceof organicity are, the greater the differences will be between two groupsjudging the same case material.

ESTIMATED FREQUENCY OF NEUROLOGICALLYHANDICAPPED IN A SAMPLE OF EMOTIONALLYHANDICAPPED PUPILS The percent of the 20 pupils identified asemotionally handicapped who were judged tobe neurologically handicapped by the LosAngeles County

27 medical and psychologicalproject staff determined the overlapbetween these two populations (EH andNH). The medical and psychological ratingsassigned demonstrated clearly that agreementbetween two groups of specialists working toward the same end wasdifficult if not impossible to find.At this point we have nodefinitive data to support the assumptionthat a given percent of emotionally handicapped pupils will have apositive diagnosis of neurological impairment. Nevertheless,educational programs for theneurologically handicapped in the schools often include,where there is long-standingdiag- nostic support for this classification,clear-cut cases of brair. injury and neurological impairment. There were nosuch cases within this sample of 20 pupils who were identified asemotionally handicapped. About 1 percent of the population is theestimated rate for such severeneurological impairments so that finding no cases ofthis type within a sample of20 might be due solely to sampling errors. Most of the recent concern over tneneurologically handicapped pupils has concerned those who hadperpetual impairments, severelyretarded school learning, and hyperactive, erraticbehavior with no evidence of braininjury or certaindiagnosis. Even though the diagnosisof neurological impairment was difficult to arriveat in such cases, one or twopositive signs in the medical record of a pupil was usuallyfound to be sufficient evidence to chancethe prediction of some organic involvement.This is supported by reference to the number of clinical signsused to arrive at a positive diagnosisby the Los Angeles County projectphysicians. The problem in etiologicalclassi- fication of neurological impairment wasthat many pupils with similarbehavior, similar perceptual distortions, andretarded learning and related difficulties could not be found to have even thissmall amount of medical support for a diagnosis of neurological deficits.In these cases, psychological casedata were resorted to,and the diagnosis was supported onthe basis of psychological findings.The results of the agreements reportedherein between two groups of experiencedpsychologists did not demonstrate agreementin the psychological findings over whatconstituted positive evidence of organic impairment. Because of theseproblems, the diagnosis of organic difficulty and neurological handicap wasusually made on the basis of collaboration between psychologist, physician,and educator. Consistency can be found in collaborative data, perhaps,but certainly there is little consistencybetween two groups of workers evaluatingindependently the individual pieces of information whicli go to make up the casestudy. The overlap between these cases canbe determined by noting the pupils in the emotionally handicappedclassification who would have qualified for the neurologically handicapped programbeing conducted at that time. In addition to judging individualitems of case data in diagnosesof neurological impairment, the Los AngelesCounty group was asked to determine,

28 from all the available data, thoseof the 20 identified as emotionally handicapped who would qualify for the programfor the neurologi,...ally handicapped which was then under way in the county.It was of interest to know which of these randomly picked emotionallyhandicapped pupils would have been found eligible for the neurologicallyhandicapped program if they had been inthe school population from which thosespecial class pupils had been selected. An overall summary rating of all ofthe data was then made of the eligibility of these pupils for the neurologicallyhandicapped program. The proportion of pupils of the 20 identified asemotionally handicapped found to beeligible for the neurologically handicapped program wasanother indication of the overlap between these populations. Since four of the 20 emotionallyhandicapped pupils were older than pupils in the neurologicallyhandicapped population, no comparativejudgment was made of them.Of the remaining 16 pupils, ten(or 62 percent) were judged to be eligible for the neurologicallyhandicapped program on the basis of educational, psychological, ormedical data or a combination of any of them. The diagnostic patternsassigned by the Los Angeles Countystaff to these ten pupils follow: Number of pupils with lasnaia r_32:)sti,c..2p_lt_lIi Diagnostic pattern Positive and/or equivocal educational, psychological, and medical ratings Positive and/or equivocal educational and psychological ratings Positive educational and medical ratings -

Chapter 3

DIAGNOSES OF RANDOMSAMPLES OFEMOTIONALLY COMPARISON OF HANDICAPPED PUPILS HANDICAPPED ANDNEUROLOGICALLY and negativediag- In order to comparethe frequency ofpositive, equivocal, in the EH sample(children identified asemotionally handi- nostic signs found Los AngelesCounty capped) with someother identified group,the staff of the Project was asked toselect a randomsample of 20 Neurologically Handicapped to review records. DoctorsZike and Sedgewickthen were asked pupils from its assign ratingsaccording to the county'smedical reports forthese pupils and the evidence ofneurological impairmentin the EH the categoriesused in judging Mr. Howe, sampi. Thepsychologists in thecounty project,Dr. Jones and and psychologicaldata for the samerandom made judgmentsof the educational handicapped). sample of the 20NH pupils(children identified asneurologically the Los AngelesCounty A summary offife distribution ofthe ratings by Nil sample appearsin Table 3; thesignifi- research staff forboth the EH and For each obtained by chi squarefor each set ofdistributions. cance level was reduced to a 2 X2 table in computation of chi square,the distributions were omitted from the small frequencies.The ratings of zero were order to avoid frequencies thusreduced by the table, andcomputations werebased on the total omission of zeroratings. County for the comparativeratings made bythe Los Angeles The distributions hi Table 3.Here the sample ofEH and NHpupils are presented staff between the two groups aremainly in those one findsagain that thedifferences between with one diagnosis subject toqualitative andnonobjective information, areas of assigned to theelectroencephalogram(EEG). exception: that ofthe ratings EEG may be due difference in thedistribution ofratings for the The significant interpretation of therecords or to realdifferences be- either todifferences in these two groups,it is not tween the twopopulations. Withoutfurther study of possible to assign properinterpretation tothis finding. however, that asignificantly greaterproportion of pupils One would expect, special educationalprograms designated as NHwould be found toqualify for the project and toreceive a positiveoverall diagnosis. in the LosAngeles County well as in thejudgment of eligi- Such was the casein the medicaldiagnoses as Of 13 comparisonsmade in theratings of these two bility for the program. significantly different;school behavior groups ofpupils, six werefound to be severely deviant,the pediatricexamination noted more wasjudged to be more judged to contain moreevidence questionable typesof behavior,the EEGs were times in the and the Draw aPerson was alsoquestioned more of abnormality, and the eligibilityfor the NH pro- NH sample.The overallmedical diagnosis gram werethe other twosignificant differences.

30 Table 3

Comparison of Ratings of Possible Neurological Impairment for a Sample of /Motion& llyHandicapped Pupils and a Sample of Pupils Judged to..be Neurologically Handicapped

Pupils NUMber receiving Significance rating level TYPe Total Type of data +11+2 2 le frequency of Medical Ratings 05 RP 4 6 9 1 20 NH6 14 6 0 0 20 Medical diagnosis 8 3 6 3 20 NS7 EH Personal history NH 11 8 1 20 History of family NE 2 6 10 2 20 .05 EH 0 0 19 I. 26 NH 4 8 8 0 20 Pediatric examination 't Neurological examination NH 3 5 1 20 al: 1 5 6 20 WIG frequency of Psychological Ratings NS EH 1 4 9 0 NH 7 11 2 0 20 WISC NS IgH 10 4 5 1 20 NH 12 2 1 4 20 Bender -I1-1 NH 7 4 4 5 20 DAP -EH -10 t 15 0 NS Psychological diagnosis NH 10 10 0 0 20 Frequency of Educational Ratings NS EH NH 117 2-7 81 13 20 ean nt .5 -EH 6 2 9 3 20 NH 14 1 4 1 20 School behavior Frequency of Overall Diagnoses and/or Eligibility for Special Los Angeles County Program

.001 EH 10 0 8- 2 20 NH 20 0 0 0 20

1 + support for positive diagnosis 2 I equivocal support for positive diagnosis 3 no support for positive diagnosis 40 insufficient data 5EH Emotionally handicapped.Cases included here are a random sampling of children identified as EH. 6NHNeurologically handicapped.Cases included here are a randan sampling of 20 taken from those in the Los Angeles County NHProJect. 7 NS No significance.

3 1 these findings, itis possible to saythat there is asignifi- To summarize selected from a schoolpopulation as cant comparabilitybetween those pupils and a sampleof those selectedbecause of noted neurologically handicapped made betweenthese emotional handicaps.In more thanhalf of the comparisons differences.At this point oneshould ask two groups ofpupils, there were no the school standing which educational programsseem mostuseful in improving of pupils with suchserious learningand behaviordisorders.

32 Chapter 4

EDUCATIONAL PROGRAMSFOR PUPILS WITHSERIOUS LEARNING AND BEHAVIOR DIFFICULTIESAND THE EFFECTSOF THESE PROGRAMS In all cases in the programsto be described here,parents of the pupils who were assigned wereapprised of the pupil's schooldifficulty, the general findings from the casework, and the prospectsof the specific programwhich was selected toassist the pupil in hisschool development. Thegeneral goals for the programs are toassist pupils in achievement,to help them develop more effective peer and adultrelationships, and for thepupil to experiencegenerally as successful aschool career as possible.The pupils are placedonly with parental permission, andfrequent parent-teacher-psychologistconferences are held. TYPES OF EDUCATIONALPROGRAMS CONDUCTEDFOR THE SAMPLE OF EMOTIONALLY HANDICAPPEDPUPILS

The Special Class The special class iscomposed of a group ofeight to twelve emotionally handicapped children who arewithin transportabledistance of the school where the class is established.The class is situated in anelementary school in a nonisolated but appropriatelocality on the school grounds.The teacher is a regular elementaryteacher, and he is servedby a mental healthspecialist (psychiatrist, psychologist, orsocial worker withwhom he consultsregularly) and members of theschooLguidance and curriculumstaff. The educational programis aimed atindividualizing instruction and providing appropriate limitsfor each child.Some may need and get arather tough regimen of work anddiscipline; with others, theteachers may move slowly within a more relaxedrelationship.In any case, the contentof the program is that of a basic educationalprogram appropriateto the grade levelof the child. Behavior standards aremaintained by theteacher, and referrals toprincipal utilized when necessary.The teacher, in manyinstances, or parents are relation- works with individualchildren or small groupsof children since this ship is found to be mostproductive for thechild's learning.The great range of interests, abilities,and emotional needs maymake the class arelatively heterogeneous group, butthe range of suchheterogeneity may varymarkedly from one group to another. Improvement and growth arecontinually assessed bythe teacher and psy- and behaviorally chologist.Children who show sufficientgrowth intellectually are returnedto an appropriateregular class.

33 Learning Disability Group In this program educational help is provided by a specialist in remedial work. Children leave their regular classes for one or two hours per day for the service.The maximum size of the group served by the specialist is eight, but instruction may be given individually, in groups of two or three, or as a group of eight.Children placed in the program are those who adalify on the basis of the general identification procedures for locating emotionally handicapped pupils, l have measured intelligence above or within normal range, and are retarded two or more years in school learning on the basis of normal expectancy. The instructional program for those who need remedial work begins with an analysis of each child's difficulty by the school psychologist and the teacher. Instructional methods used include phonics, structural clues, word meaning clues, kinesthetic techniques, visual techniques, and other appropriate avenues for increasing skill.Audio-visual materials such as filmstrips, tachistoscopes, and tape recorders are also used extensively.Flash cards, charts, and maps are employed to develop speed and confidence.Exercises in word building are used as much as possible. During the classwork, the teacher strives to restore the child's confidence by planning as many successful learning experiences as are realistically possible. The Activity Group This program is usually structured as a club and an after-school activity. In most cases, six to eight children meet about twice a week for a two-hour session.The children in the group are emotionally handicapped children who manifest a variety of problems -- some are extremely hyperactive, others are timid and withdrawn children. A variety of expendable craft, painting, clay, woodwork, and other expressive media are made available to the children. A teacher assumes the role of group leader.His role is to help the child to use the play materials and to provide a nonthreatening, nonpushing atmosphere for children :to express and explore emotional conflicts which frighten or embitter them. During the play sessions he is an active "neutral, " providing help when asked but avoiding any interference in or criticism about a child's work. The purpose of the activity group is to provide a safe place for children to "let off steam" and to develop relationships with other children of their age. It

1Nadine Lambert, Technical Report on the Process for In-School Screen- ing of Children with Emotional Handicaps.Princeton, N. J. :Educational Testing Service, 1961. A-

is successful primarily to thedegree that a child improveshis relationships with teachers and children inthe school.

Group Counseling In this program the groupleader is a competent groupworker with experience in workingwith adolescents. The groupof about ten selectedemotionally handicapped pupils in the junior orsenior high school meet withthe group leader for one period during the day,two or three times a week.Often the pupils in these groups are oneshort step from suspension orexpulsion from school. However, even in this programstudents placed there mustbe able to profit and to have a. capacityfor insight and an initialdesire to attend and participate. The purpose of the groupcounseling program is to assistadolescents to clarify and to reduce emotionalconflicts by permitting anencouraging discussion about problems in peerand authority relationshipsin school. The group leader can help the studentin his group put togetherseveral obvious facts about his behavior which mayenable him to understandwhy certain patterns of interpersonal difficulty alwaysarise in his relationships.In other instances, the supportive relationshipprovided by the group leader mayprovide a safe base for the student to test,for the first time in many cases, amature relationship with an adult. The success of all of these programsis based on the extent ofthe pupil's improvement in schoolachievement, the degree ofimproved relationships with peers andadults, and his ability tomaintain these changes aftertermination of special help. EFFECTIVENESS OF EDUCATIONALPROGRAMS FOR EMOTIONALLY HANDICAPPED PUPILS

The 20 pupils in this sample wereassigned to the four programsjust described. These programs were someof over ten differentapproaches evaluated in the researchproject of which this studyis a part.(For each pupil the program inwhich he was enrolled isindicated after his casenumber on Table 5.) Of interest at this point isthe degree to whichpupils selected as being typical of those enrolled inthe neurologicallyhandicapped study conductedby the office of the LosAngeles County Superintendentof Schools are able tomake progress inclasses in which there are avariety of emotionallyhandicapped pupils. The statementhas been made frequentlythat the disabilities of the neurologically handicapped pupil are sounique that he must beplaced in a class- others with similar medicaletiology.To the extent thatthe ten pupils room with be in the sample of 20emotionally handicappedstudents who were judged to eligible for the neurologicallyhandicapped program arelike pupils actually

35 enrolled in those classes, some comparisons can be made of their abilityto make achievement gains in a heterogeneous class of pupils with learning and behavior problems.

Tables 4 and 5 contain the educational information whichwas available on the sample of 20 emotionally handicapped pupils.In addition, these tables cite the type of program in which eachwas enrolled as well as a summary of the ratings assigned by the staff of the project in Los Angeles County.Achieve- ment test data were not available for some pupils because they moved fromthe district before a second test could be givenor because they were too young to be given achievement tests in the regular schoolprogram.For those pupils who did have test scores after one and two years iri theprogram, their gains in achievement grade placement for both reading and arithmeticare listed in Table 5.With such a small sample, the mean gain in achievement is not such a useful score, but it does provide, along with the range in achievement gain, some idea of the success of the special programs in meeting these pupils' learning needs.The average gains in achievement and range in gain afterone and two years are as follows: Change in Reading Achievement Grade Placement Average gain Range in gain After 1 year 1. 5 years 0 to 3. 5 years After 2 years 2. 2 years 0. 5 to 4. 5 years Change in Arithmetic Achievement Grade Placement Average gain Range in gain After 1 year 1. 4 years 0. 5 to 2. 0 years After 2 years 2. 1 years 0. 5 to 4. 5 years

RECOMMENDED EDUCATIONAL PROGRAM FOR EMOTIONALLY HANDICAPPED PUPILS WITH OR WITHOUT EVIDENCE OF NEUROLOGICAL IMPAIRMENT To suMmarize these data, one can conclude that the children in this group of 20 emotionally handicapped pupils are vulnerable to school difficulties fora variety of reasons, among which may be neurological impairments of some type.Though there are evidently no correlations of these impairments with specific medical findings and specific behavior deviations, one still needs as much information about the pupil's developmental history, his learning strengths

36 Table 4

Educational Information on a Sample of 20 Emotionally Handicapped Pupils with Ratings of Possible Neurological Handicap Made by the Staff of the Los Angeles County NE Project

Educational information Case number and ratings

Teacher ratin: ofu.till 1012 312567 8 9 111213loomil73111920 Gets into fights or quarrels vrithciTglIgji 21444 ig 5 44 5 512 4 5 2 Has TerITiccd--63-7-fid---t-o .4 work or play with others 41214g44 3 452 2 5 54 3

Has difficulty learninf 4552 2 c.., 5 544455 55 5 Is interested in activities 6 mtdch he can do himself 1 2 212 It 1 5 2 1 2 2 2 11 4 1 Mikes inappropriate responses o in the olassroam 2 2 55 3 rd 4 24 2254 55 2 4

Eehaves in mays wErih are Pci. _dangerousto self o r others 2 142 2 gio 41 2 4 2 2 2 3 5 2 4

Is often unhappy or depressed 4444 3 3 511 342442 5 5 4 2 3 Eecomes sick or upset when facea mith a difficult school prob lem or situation 2 1 112 41 3 1 1 342 2 4 5 1 2 Achieventent Reading 3 545 3 54 3 5 3 5554 5 54 3 4 Arithmetic 3 5 3 5 3 4 5 3 4 3 34 344 2 5

Ability (IQ)2 3 3 3 3 5 3 33 3 3 5 3 1 3 3 3 313 2

Summary of LoA Angeles County ratin s of NH.' Interpretation of educational data as indicative of neuro logical impairment by Los ++I0 ++I+0++ +++ 0 ._#n:elotniff . 'tex-fmpret---alopsychological data, and similar information I + a;MR +I+ i+±±+++++ . Medical diagnosis of suspeolea + ....rviirm ±0± +++± + + El g bi y for spëial program for NH as judged by Los . Angeles County medical and s bolo ioal staff + +0 I * ++ + ++ +++ 0 1 Legend: 1--never; 2--once in a while; 3--not observed;4--quite often; 5--all of the time. 2 Legend: 1--mell above average; 2--above average; 3 --average; 4--belomr average; 5--mell below'average. 3 Legend: + support for positive diagnosis; equivocal support for positive diagnosis; no support for positive diagnosis; 0 insufficient data; over 12--maximum age for pupils in the Los Angeles County NH Project; /extremely low IQ, possibly mentally retarded.

3 7 Table 5 Caanty Eligibility of Emotionally HandicappedPupils for the Los Angeles NH Program, the Type ofEducational ProgramProvided, andCanparison of Their Achievement Gains After Oneand Two Years

Achievement gain

Case Type of, rligibility Or Arithmetic Reading nmmber pvogramL NH program4 After one After two After one After two year years year years

1 A. 4,4 1e4 2.8 2 B + 1.9 2.2 0.7 2.0 3 B 4. 1.2 . . - 2.6 4 C 0 - a a a 5 D I a - a 6 A _ .6 1.3 .6 7 B + 3.5 3.8 8 B + 1.5 4.0 a - 9 D + . a - - - a 10 t. - .. .. - 11 B . . 2.4 12 C + 1.7 . 1.5 1.7 13 B + 1.0

...... 14 A e .. 1.0 1.1 15 C + 1.5 2.3 4.5 16 B + 1.0 3.8 2.5 a .9 0.0 5 17 B + a a - 18 B . .. a 19 B 0 - a a a . 20 A .1.111=

Average gain 1.4 2.3 1.5 2.2

1Type of programs Arm-group counseling; H--special class; C--learning disability group; D--activity club 2 - not eligiblefor NH program; Legend: + eligible for Los AngelesCounty NH program; possibly mentally retarded, would havequalified 4, too old for NH program; for other special help;0 insufficient data.

valy.

38 possible to obtain.When these and weaknesses,and socialrelationships as is for a particularpupil, they formthe basis for theeduca- findings are combined Schdol learning tasks. tional plan which isdrawn up to assistthe pupil in his learning disordersstem from someorganic Just as there arethose pupils whose adverse impairment, there are+hose whose learningdisabilities stem from circumstances. As one cansee byreviewing the casematerial environmental combinations of circum- (in the Appendix)for each of the20 pupils, different stances may causesomewhat rArnilarlearning difficulties. for different reasons. Two children maybe extremelyhyperactive in school medically andrecommended treatmenthas After each childhas been checked be quite similar the child'seducational programand needs may been instituted, this study indicatesthat two hyper- to those ofanother child.The material from have their learningneeds and behaviorproblems met quite active children may structure and theconsistency which adequately in a programthat provides the is this point one cannotgeneralize that aspecialized curriculum they need. At is the result ofbrain injury, whichis needed for the pupilwhose hyperactivity hyperactivity is theresult of different from thecurriculum for thepupil whose adjustments theschool needs tomake in home conditions.The educational based on pupils with severelearning and behaviorproblems should be cases of medical diagnosis. each pupil'seducational needsrather than on a this study wereassigned to the programswhich provided The children in If their problems them with the greatestopportunity for thehelp they needed. social relationship area,groupcounseling or activity wereprimarily in the For those whoselearn- clubs appeared topi-ovide the mostdirect assistance. so greatthat they couldnot continuewithout special ing disabilities were disability group orthe specialclass was remedial help,either the learning made on the basis The choice betweenthese two programs was applicable. well as the extentto which thepupil needed of the severityof the problem as could get alongwith assistance from aspecial teacher forthe whole day or special assistancefor only part of aschool day. helped to gain in Children withlearning and behaviorproblems can be relationships.If they are notprovided help achievement and inbetter school school with onlyabout when their schoolfailure is first noticed,they enter high In addition,those em(-tionallyhandicapped a 30 percentchance of graduating. those who have enrolled in highschool at thetenth grade are pupils who are are absent morefrequently, have significantly lowergrades than their peers, referrals to school more penaland vehicle codeviolations, and have more workers for specialhelp.Their problemsdo not disappear pupil personnel increase as thehelp they needis delayed without notice;their school problems from schcx.t1 yearto school year.

39 Chapter 5

SUMMARY OF THEFINDINGS OF THEPROJECT representative sampleof those identified as During 1959, 20 pupils, a schools, were emotionally handicappedin regular and specialclasses of public and neurologicalexamination at theMedical Center of selected for pediatric Herbert Grossman, the University ofCalifornia, Los Angeles.Two physicians, M.D., and RichardWalter, M.D. administeredthe examinations--one conducting the pediatricand neurologicalinvestigations and theother conducting the electroencephalographicinvestigation. The purpose of thismedical investigation wasto determine theincidence emotionally of neurologicalimpairments in a sampleof pupils identified as the reliability of themedical findings from handicapped. In order to compare Zike, M.D., and the UCLA. MyrlicalCenter, two otherphysicians, Kenneth Robert Sedgewick, M.D., wereasked to review Dr.Grossman's and Dr. Walter's work and tomake independentdiagnoses. The formerdoctors were locate neurologicalimpairments in a population conducting examinations to problems in a of pupils selectedbecause of seriouslearning and behavior conducted by schools inLos Angeles Countyand the office cooperative project of diag- of the Los AngelesCounty Superintendentof Schools. The two groups v-td one from the countyproject -- inferred noses -- onefrom the state project have a difficult from case material onthese 20 pupilsdemonstrate that doctors signs in the medicalrecords constituteevidence of neu- time agreeing on what made to correlate these rological impairment,particularly when attempts are phenomena. Thedisagreement increases asthe mate- findings with behavioral particular rial increases insubjectivity. In addition,the Weight given to a doctor to doctor, thusmaking the reliabilityof a diagnosis finding varies from learning and behavior of neurologicalimpairment in a sampleof pupils with It should be emphasizedthat many or problems in schoolhighly questionable. of "normal. " all of these"minimal" neurologic findingsborder on the spectrum A summary of themedical diagnosesof Dr. Grossman andDr. Walter these 20 pupils tobe children withgood overall physical indicated that they found medical health, no clearlydefined neurolegicalabnormality, and no other found to correlatewith the behaviorand learning prob- findings which could be these same 20 lems of the pupils.A summary of themedical diagnoses for and Dr. Sedgewickshowed that four pupils werediagnosed pupils by Dr. Zike found to asneurologically handicapped,and the recordsof six others were provide some evidence tosupport a diawsisof neurologicalimpairment. neurological impairmentby these latter doctors were When the diagnoses of for collated with the psychologicaland educationaldata and evaluated together impairment by thepsychologists working withthe Los evidence of neurological those Angeles County study, tenof the 20 pupils werejudged to be similar to

40 in the special classes for theneurologically handicapped conducted by the NH Project of the Los Angeles CountySuperintendent of Schools and would have qualified for that program had they beenin schools under the Los Angeles County Superintendent s jurisdiction. The 20 pupils described in this report wereenrolled in a variety of special educational programs conducted by theschools and the State Department of Education and designed to assist the pupils withtheir learning and related school problems. They were placed in the programs onthe basis of school difficulties, not on the basis of medicaldiagnosis. The statement has been made often that pupils with a positive diagnosis ofneurological impairment require a unique educational approach and that they cannot behelped successfully in programs with a heterogeneous group of pupils withdifficulties.In order to support this statement, a review was made of the educationalrecords of the ten pupils judged to be neurologically impaired by theLos Angeles County Superintendent of Schools group. When reading and arithmetic achievement scores wereavailable, the average gain was computedafter one and two years in various specialclass programs by these ten pupils.From the range of achievement gain listedfor both achievement areas, it was noted that somepupils were not able to improve very readily in achievement;however, for the group taken as a whole, the average gain in achievementin the special program exceeds what wouldbe expected from pupils in regular classes. Theinference is that as a result of the special program, the school learningof these pupils had changed f--n a nonfunctioning level to one where the possibility ofachievement consister h ability might be obtainable. This study provides information regardingseveral aspects of proposed educational programs for pupils with suspectedneurological handicaps. One is that a reliable diagnosis is difficultif not impossible to obtain in any but the most severe case. Another is thatassuming that one has reliable diagnoses, the education of these pupils can successfullyproceed in classes for children with a variety of learning and behaviorproblems. In addition, these data support the conclusion that a special educationalcategory for neurologically handicapped pupils separated from other pupilswith school difficulties is not necessary for the successful remediation of the learningand behavior problems of the pupils in school. The importance of this study for educational programsfor pupils with emotional handicaps is that these pupils ha iehad generally good physical health but serious learning and behaviorproblems, some of which can be remediated in special programs designed toassist them in the public school.In the major- ity of cases in which a pupil identified asemotionally handicapped might have a related organicimpairment, his educational needs can beadequately met in a

41 program in which he becomespart of a heterogeneous group of pupilswith a variety of problems. The important factorin school placement is that these children must have help. Successful school experiencesin some instances helped these children mediate a difficult homesituation. The ideal circum- stance is one in which the family and theschool reinforce one another. Even though this may not be the case, the schoolneeds to do its best for the child. In all cases it is essential to developspecial programs in terms of educational needs of children and not on the basis ofmedical, psychological, or socio- logical diagnoses.

42 APPENDIX

In addition to the, selectedreferences, which appearfirst, the case records of the 20 pupils onwhom this study isbased have been placedin the appendix. Included in each case is adescription of thechild's school history, testresults, medical records, schoolplacement, and a follow-upmade at least two years after the special help inschool was provided. These records have beenincluded in the publication sothat those who wish psychological, or may maketheir own ratings of theextent to which medical, social factors can beheld accountable inexplaining the etiology ofthe learning and behavior problemsof these pupils.

43 _

SELECTED REFERENCES

Bender, Lauretta, Psychopathology ofChildren with Organic Brain Dis- orders.Springfield, Ill. :Charles C. Thomas, Publisher, 1956. Bender, Lauretta. A Visual MotorGestalt Test and Its Clinical Use. New York: American OrthopsychiatricAssociation Monograph, 1938, No. 3. Penton, Arthur L.Right-Left Discrimination and FingerLocalization: Development and Pathology. New York:Paul B. Hoeber, Inc. ,1959. Bower, E. M. The Education ofEmotionally Handicapped Children. A Report to the California LegislaturePrepared Pursuant to Section 1 of Chapter 2385, Statutes of 1957.Sacramento: California State Depart- ment of Education, 1961. Cruikshank, W. M. , and Others.Teaching Methodology for Brain-Injured and Hyperactive Children.Syracuse, N. Y. :Syracuse University Research Institute, 1960. Doll, Edgar A."Behavior Syndromes of Central Nervous SystemImpair- ment, " in The Exceptional Child.Edited by James F. Magary and John R. Eichorn. New York: Holt,Rinehart & Winston, Inc. , 1960. Goldstein, Kurt.After-Effects of Brain Injuries inWar. New York: Grune & Stratton, 1942. Goodenough, F. L.Measurement of Intelligence byDrawings.Yonkers, N. Y. : World Book Co. , 1926. Halpern, F."The Bender Visual Motor GestaltTest," in Introduction to Projective Techniques, by H. A. andG. L. Anderson.- New York: Prentice-Hall, Inc.,1951, pp. 324-40, Harrower, Molly.Personality Change and Development asMeasured by the Projective Techniques. NewYork: Grune & Stratton, 1958. Hutt, M. L., and G. J. Briskin.The Clinical Use of theRevised Bender- Gestalt Test. New York: Grune& Stratton, 1960. Lambert, Nadine.Technical Report on the Process forIn-School Screen- ing of Children with EmotionalHandicaps.Princeton, N. J. : Educa- tional Testing Service, 1961.

45 v.

Lewis, Richard S.The Other Child: The Brain-InjuredChild. New York: Grune & Stratton, 1951. Machover, Karen."Drawing of the Human Figure: AMethod of Person- ality Investigation, " inIntrocluctiorni ues,iiy H. H. and G. L. Anderson.New York: Prentice-Hall,Inc.,1951. Paiterson, C. H. TheWechsler-Bellevue Scales - A Guidefor Counselors. Springfield, Ill. :Charles C. Thomas, Publisher,1953. Sarason, Seymour S.Psychological Problems in MentalDeficiency (Third edition). New York: Harper & Bros. ,1959. Strauss, A. A."The Education of the Brain-InjuredChild," in The Excep- tional Child.Edited by James F. Magaryand John R. Eichorn. New York: Holt, Rinehart &Winston, 1960. Strauss, A. A., and L. E.Lehtinen.Psychopathology and Education of the Brain-Injured Child, Vol.I of Fundamentals andTreatment of Brain-Injured Children. New York:Grune & Stratton, 1951. Strauss, A. A., and N. CKephart.Psychopathology and Education of the Brain-Injured Child,Vol. II of Progress inTheory and Clinic. New York: Grune & Stratton,1951. Taylor, Edith Meyer.Pvchological Appraisal ofChildren with Cerebral Defects.Cambridge: Harvard UniversityPress, 1959. Wechsler, David. TheMeasurement and Appraisalof Adult Intelligenct.. Baltimore: Williams & Wilkins,1958. Wechsler, David. WechslerIntelligence Scale forChildren Manual. New York: PsychOlogicalCorporation, 1949. Windle, W. F.Neurological and PsychologicalDeficits of Asphyxia Neonatorum.Springfield, Ill. :Charles C. Thomas,Publisher, 1958. Woltrnann, A. G. "TheBender-Gestalt Test," inProjective Psychology. Edited by Laurence E. Abtand Leopold Bellak. NewYork: Alfred A. Knopf, Inc.,1952, pp. 322-56.

46 B.PERIODICALS

Aita, J.,S. G. Armitage, R. M. Reitan, and A. Rabinowitz, "The Use of Certain Psychological Tests in the Evaluation of Brain Injury. " Journal of Genetic Psychology, XXXVII (1947), 25-44. Allen, R. M. "The Test Performance of Brain Injury." Journal of Clini- cal Psychology, XXXVII (July, 1947), 225-30. Apgar, Virginia."Neonatal Anoxia: A Study of the Relation of Oxygena- tion at Birth to Intellectual Development. " Pediatrics, XV (June, 1955), 653. Armitage, S. G."An Analysis of Certain Psychological Tests Used for the Evaluation of Brain Injury." Psychologi;m1 Monographs, LX (1946), 1-48.

Beck, Harry S.,Robert L. Lam, M. D."Use of the WISC in Predicting Organicity." Journal of Clinical Psychology, XI (April, 1955), 155-58. Bender, Lauretta."The Psychological Treatment of the Brain-Damaged Child," Quarterly Journal of Child Behavior,III (April, 1951), 123-32. Blackman, Leonard S."Research in Mental Retardation - A Point of View." Exceptional Children, XXVI (September, 1959), 12-14. Block, William E."Personality of the Brain-injured Child." Exceptional Children, XXI (December, 1954), 3, 91-100, 108-109.

Bowland, John A.,and Herdis S. Deabler. "A Bender-Gestalt Diagnostic Validity Study." Journal of Clinical Psychology, XII (January,1956), 82-84. Bradley, Charles."Behavior Disturbances Ln Epileptic Children." Journal of American Medical Association; CXLVI (1951),436-41. Bradley, Charles."The Behavior of Children Receiving Benzedrine." American Journal of Psychiatry, XCIV (November,1937), 577-85. Bradley, Charles."Benzedrine arid Dexedrine in the Treatment of Chil- dren's Behavior Disorders." Pediatrics, V (1950), 24-37. Bradley, Charles."Characteristics 6.nd Management of Children with Behavior Problems Associated with BrainDamage." Pediatric Clinics, North America, IV (1957), 1049-60.

47 -

Bucy, P. C."Electroencephalography's Proper Role." Journal of Ameri- can MedicalAssociation, CLX (1956), 1232. Burks, Harold F."The Effect on Learning of BrainPathology." Excep- tional Children, XXIV (December,1957), 169-72, 174. Byrd, Eugene."The Clinical Validity of the Bender-Gestalt Testwith Children: A Developmental Comparisonof Children in Need of Psycho- therapy and Children JudgedWell-Adjusted." Journal of Projective Techniques, XX (June, 1956), 127-36. Chorost, Sherwood B., GeorgeSpivak, and Murray Levine."Bender- Gestalt Rotations and EEG Abnormalitiesin Children." Journal of Consulting Psychology, XXIII (December,1959), 559.

Clawson, Aileen."The Bender Visual Motor Gestalt Test as an Indexof Emotional Disturbance in Children." Journalof Projective Techniques, XXIII (June, 1959), 198-206. Cohen, Jacob. "The Efficacy of DiagnosticPattern Analysis with the Wechsler-Bellevue." Journal of Consulting Psychology,XIX (August, 1955), 303-306. Cohen, Jacob."Factors Underlying Wechsler-Bellevue Performanceof Three NeuropsychiatricGroups," Journal of Abnormal and Social Psychology, XLVII (April, 1952), 359-65. Courville, Cyril B."Antenatal and Paranatal Circulatory Disorders as a Cause of Cerebral Damage in EarlyLife." Journal of Neuropathology and Experimental Neurology, XIX(1959), 115-40.

Denhoff, E.,M. W. Laufer, and R. H. Holder."The Syndromes of Cere- bral Dysfunction." Journal ofOklahoma State Medical Association, LII (1959), 360-66. Dinsmore, M. "Teaching Reading tothe Brain-Injured Child." American Journal of Mental Deficiency, IA III(February, 1954), 431. Doll, Edgar A."Mental Deficiency vs. Neurophrenia American Journal of Mental Deficiency, LVII (March,1953), 477-80. Eisenberg, L."Dynamic Considerations Underlying the Managementof the Brain-injured Child." GeneralPractitioner, XIV (1956), 4.

48 Farrett, E. S. , A. C.Price, and H. L. Deabler,"Diagnostic Testing for Certain BrainImpairment." Archives of Neurological Psychiatry (American Medical Association),LXXVII (1957), 223-25. Fouracre, Maurice H."Learning Characteristics of Brain-injuredChil- dren." Exceptional Children, XXIV(January, 1958) 210-12, 223.

Frank, G. H.,C. C Corrie, J. Fogel."An Empirical Critique of Re- search with the Wechsler-Bellevuein DifferentialPsychodiagnosis." Journal of Clinical Psychology,XI (July, 1955), 291-93. Goldberg, Lewis R."The Effectiveness of Clinicians'Judgments: the Diagnosis of Organic Brain Damagefrom the Bender-GestaltTest." Journal of Consulting Psychology,XXIII (February, 1959),25-33. Greenebaum, J. V. , and L. AJurie."Encephalitis as a Causative Factor in Behavior Disorders ofChildren." Journal of American Medical Association, QCXXVI (1948),923-30. Griffith, Richard M., and VivianH. Taylor."Incidence of Bender-Gestalt Figure Rotations," Journalof Consulting Psychology,XXIV (April, 1960), 189-90. Halpin, Virginia."Basic Issues Concerning the Eaucationof Children with Cerebral Defects." AmericanJournal of Mental Deficiency,LXIII (July, 1958), 31-37. Hanvik, L. J."A Note on the Limitations of the Useof the Bender-Gestalt Test as a Diagnostic Aid inPatients with a FunctionalComplaint." Journal of Clinical Psychology,VII (April, 1951), 194. Hanvik, Leo J."A Note on Rotations in theBender-Gestalt Test as a Predictor of EEG Abnormalities inChildren." Journal of Clinical Psychology, IX (October,1953), 399.

Hunt, Betty M."Performance of Mentally DeficientBrain-Injured Children and Mentally Deficient FamilialChildren on Constructionfrom Patterns." American Journal of MentalDeficiency, LXIII (January,1959), 679-87. Jastak, Joseph."Ranking Bellevue Subtest Scoresfor DiagnosticPurposes." Journal of ConsultingPsist9Joig, XVII (December,1953), 403-10. Klebanoff, Seymour G. , JeromeL. Singer, and HaroldWilensky."Psycho- logical Consequences of BrainLesions and Ablations."Psychological Bulletin, LI (January,1954), 1-41.

49 Koppitz, Elizabeth M."The Bender-Gestalt Test andLearning Disturbances 1958), in YoungChildren." Journal of ClinicalPsycholou, XIV (July, 292-95. Koppitz, Elizabeth M."The Bender-Gestalt Test forChildren: A Norma- tive Study." Journal ofClinical Psychology, XVI(October, 1960), 432-35. Koppitz, Elizabeth M."Teacher's Attitude and Children'sPerformance on the Bender-Gestalt Testand Human FigureDrawings." Journal of Clinical Psychology, XVI(April, 1960), 204-208. Koppitz, Elizabeth M. , JohnSullivan, David D. Blyth, andJoel Shelton. "Prediction of First Grade SchoolAchievement with the Bender-Gestalt Test and Human FigureDrawings." Journal of ClinicalPsychology, XV (April, 1959), 164-68. Laufer, M. W. , and E.Denhoff."Hyperkinetic Behavior Syndrome in Children." Journal of Pediatrics, L(1957), 463-75. Levi, Joseph, SadieOppenheim, and David Wechsler."The Clinical Use of the Mental DeteriorationIndex of the Bellevue-WechslerScale." Journal of Abnormal andSocial Psychology, XL(October, 1945), 405-07. Littell, William M."The Wechsler IntelligenceScale for Children: Re- view of a Decade ofResearch." PsychologicalBulletin, LVII (March, 1960), 132-56. Marrow, Robert S. , andJoseph C. Mark."The Correlation of Intelli- gence andNeurological Findings onTwenty-Two Patients Autopsied for Brain Damage."Journal of ConsultingPsychology, XIX (August, 1955), 283-89. Meyer, Victor."Critique of PsychologicalApproaches to BrainDamage." Journal of MentalScience, CIII (January,1957), 80-109. Meyerson, Lee."Physical Disability a 6 aSocial PsychologicalProblem." Journal of Social Issues,IV (Fall, 1948), 2-10. Newland, T. Ernest."Psycho-Social Aspects of theAdjustment of the Brain- Injured. " ExceptionalChildren, XXIII (January,1957), 149-53. Octtinger, L."The Medical Treatment ofBehavior Problems."Missis- sippi Valley MedicalJournal, LXXIV (1952),74.

50 Parker, J. W."The Validity of Some Current Tests for Organicity." Journal of Consulting Psychology, XXI(October, 1957), 425-28. Phelps, W. M."Characteristic Psychological Variations in Cerebral Palsy." The Nervous Child; I (1948), 10-13. Reznikoff, Marvin; and Tom D. Olin."Recall of the Bender-Gestalt De- signs by Organic ahd SchizophrenicPatients: A Comparative Study." Journal of Clinical Psychology, XIII(April, 1957), 183-85. Seashore, Harold G."Differences Between Verbal and Performance IQs on theWISC." Journal of Consulting Psychology, XV(February, 1951), 62-67. Silver, A."Behavior SYndrome Associated with Brain Damage inChildren." Pediatric Clinic, North America, V (1958),687-98.

Suczek, Robert F.,and Walter G. Klopfer."Interpretation of the Bender- Gestalt Test: The Associative Value of theFigures." American Journal of Orthopsychiatry, XXII(January, 1952), 62-75. Tamkin, Arthur S."The Effectiveness of the Bender-Gestalt inDifferen- tial Diagnosis." Journal of ConsultingPsychology, XXI (August, 1957), 355-57. Thelander, H. E."Brain Damaged Children." Journal of Pediatrics, XLVI (1955), 699-703.

Tobias, J.. S.,M. Lowenthal, and S. Marginer."Evaluation and Manage- ment of the Brain-damagedPatient." Journal of the American Medical Association, CLXV (1957), 2035-41. Tucker, John E., and Mimi J. Spielberg."Bender-Gestalt Test Corre- lates of Emotional Depression." Journalof Consulting Psychology, XXII (February, 1958), 56. Walter, R. D., E. D. Colbert, R. R.Koegler, J. 0. Palmer, and P. M. Bond. "A Controlled Study of the Fourteen-and Six-Per Second EEG Pattern." Archives of General Psychiatry(American Medical Association), II (1960), 559-66. Yates, Aubrey J. "The Validityof Some Psychological Tests of Brain Damage." PsychologicalBulletin, LI(July, 1954), 359- 79.

51 Young, Florence IVI. , andVirginia A. Pitts."The Performance of Con- genital Syphilitics on the WechslerIntelligence Scale forChildren." Journal of ConsultingPsychology, XV (June, 1951),239-42. Zolik, Edwin S."A Comparison of the Bender-GestaltReproductions of Delinquents andNon-Delinquents." Journal of Clinical Psychology, XIV (January, 1958), 24-26.

C.REPORTS Hopkins, K."The Efficiency of the Wechsler IntelligenceScale for Chil- dren in Predicting Organicityin Children with Normal IQ'sand a Note onMethodology." Unpublished Study, 1960. MacNeven, R. W. , M. Knobel, G.J. Lytton, and M. E.Kirkpatrick. "The Function of a Psychiatric Diagnostic;Unit in the SchoolSystem." Presented at the AmericanOrthopsychiatric Association Meeting,San Francisco, May 1,1959. "Report of the Los Angeles County PilotProject for Children with Mild Neurological Handicaps." LosAngeles: Los Angeles CountySuperin- tendent of Schools, Division ofResearch and Guidance, 1961. Schmadel, Elnora."Comparison of Visual Motor Dysfunction ofHyperative and Brain Injured, MentallyGifted, and AverageChildren." Unpub- lished Study, 1962.

52 CASE 1

Girl -- Thirteen Years, Eight Months

School Behavior

This girl's teachers describe her as having a lowself-concept. She doesn't amcept discipline well, either from her mother or fromthe teachers. She plays in the orchestra, but when the orchestra makes apublic Appearance, she doesn't come. She has been referred toA local child-guidanceclinic for tics and enuresis, but thel-ie pToblems have continued. She can be described best as a passive cbild who likes routine, monotonous tasksrequiring little effort and pwoviding little chance of failure. She is afraid of making mistakes, so any work that requires a small amount of additional effortis either not attempted OT Elven up after an initial effort.

°The Results

Both group-administered and. individualintelligence tests indicate that she has low average school learning ability.Accordingly, her achievement in reading and arithmetic has always been below grade.

Raw Scaled Rsw Scaled Verbal score score .,.arformance score score

Information 14 8 Picture Completion 10 7 Comprehension 11 7 Picture Arrangement 35 12 Arithmetic 8 7 Block:Design 12 Similarities 13 11 Object Assembly 23 9 Vocabulary 35 8 Coding (Digit Span) 9 8 (Mazes) Sum of Verbal Tests 49 Sum of Performance Tests 48

Verbal IQ 41 89 Performance IQ 48 97 Full Scale IQ 89 92

Medical Report (ten months after studybegan)

History of Present Problem. The patient is a very rervous child, according to the mother, and "blows her top" easily. She has many difficulties in relating to her mother; she used to be enuretic and had. tics of many kinds, particularly head shaking. At the age of tbree years, the mother took her to the Wbite Memorial Hospital tecause of her enuresis. Sbt was told that there was nothing wrong with the child. When the girl was in the fifth grade, her mother took her to the Los Angeles Child Guidance Clinic because ofhead- shaking tics. They attended the clinic an hour each per week for about six months. The mother ranained confused, feeling that she had not beenhelped to any extent, even though the child's tics decreased considerablyafter this experience at the clinic and. are very infrequent at the present time.

53 after her marriage. Past History. The mother became pregnant two years She states that she was sickall the way through the pregnancy,receiving three hours and intravenous fluids intermittently. She was in labor for about There was delivery was normal. The patient weighed 7lbs.,5i oz.,at birth. The mother states no resuscitativedifficulty, no jaundice, and noseizures. that she was run down for ten yearsafter her pregnancy withthis child. she never Because of the very poor stateof health during that pregnancy, for about one week andthen became pregnant again. The patient was breast-fed bottle-fed, because of inadaquate milk. She sucked poorly on thebreast but to be apparently did quite well when bottlefed. Her development was thought walked at about one within normal limits.She sat at about six months of age, year year, and talked at about15 monals. Toilet.training began at about one and was completed by two years of agewith no particular'difficulties.About one or two years afterbeing trained, the patient beganto have enuresis almost nightly until about a year ago. She had chicken pox at the ageof,three, mumps at seven, bothof which were uneventful. The patient had her menarche in Mhy, 1959, which was the onlyperiod thus far. She did fairly well in school until last year when sheflunked almost all of her cOurses. She is presently in a special group foremotionally disturbed childrenwhere she has been for the past year. The mother feels that she hasimproved greatly.

Family History. The family consists of the mother, wge 33; father, age43, a machinist; no siblings. There is no family history of any disorders of the central nervous system.

Ph sical Ekamination.The physical examinationreveals athirteen-year, eight-month-Old white female whosegeneral condition is good. Height, 151 cm.; 100/70; weight, 42.2 kgms.The patient is right-handed;blood pressure is pulse, 78; respiration,18. She is in a pUbescentstate--has pubescent breast developmentl axillary and plibichair.The rimainder of the generalphysical examination is not remarkable. pubescent Neurological Examination. Neurological examination revealed a White, right-handed female who wasalert and cooperative during theexamination. Her overall development appearedto be within normal limits for herchronological The optic age. Cranial nerves were examinedin detail and found to be intact. fundi mere normal.Examination of the motor systemrevealed no evidence of spasticity or weakness. The myotatic reflexes wereAysiologic and symmetrical. The abdominal reflexes werepresent. The plantar reflexes were flexor. Sensory-examination revealed noabnormalities in the modalities of pain,touch, position, and vibration. Stereognosis was normal. The patient's coordination The was good. There was no evidence to suggest anycerebellar dysfunction. patient's gait and speech Werenormal. The remainder of the examination was not remarkable. The Laboratory Data.An electroencephalogram wasdone on July 17, 1959. tracing was obtained using tenelectrodes with both ascalp-to-scalp and scalp- to-ear technique. There is a fairly rhythmicalbasis of frequency of nine to ten cycles per second of highamplitude appearing primarily overthe posterior scalp regions and to a lesserdegree in other channels. At times, 15 to 20 cps activity appeared anteriorly, prdbably resulting from sedation. During drowniness and sleep, some 14 cps sleep spindles are present along with biparietal bumps. Hyperventilation resulted in some.five to seven cps Iftves. A suspicious run of slow irregular five to seven cps waves appeared somelo seconds following the termination of ovextreathing. There are no focal abnormalities during the tracing.Photic stimulatidn did not significantly alter the record. Impression: essentially normal EEG. Comment: the single paroxysmal following hyperventilation, probably is not clinically significant.

School Placement

Case 1 was placed in a regular school program with the exception of one or two hours a week in an activity club with girls of her age mho were also experiencing some difficulty in school.About eight girls were in the group with a teacher who served as group leader. The activities of the club were determined by the girls with the primary goal of the group to provide for successful peer relationships.

Follow-up (two years, two months after study began)

Case 1 has been an unhappy child; however, her experienges in the small group project seemed to be helpful. She continued to be Apprehensive wten faced with an unfamiliar task. She disliked playing in the orchestra for pUblic appearances. She complained of illnesses, had a tendency to daydream, but teachers were encouraged by her willingness to cooperate. Last spring she received an unsatisfactory notice in English. She is presently enrolled in the beginning months of tenth grade. She failed the one test given in U.S. history, was "slow in getting ready to participate in P.E.," was "below average in her homework in English, and didn't contribute orally She had a tendency to be vague and preoccupied."

55 eN

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5. 4 Case No. 1 12 years, 6 rno. Girl Draw a Person

57 CASE 2

Boy -- Thirteen Years, Three Months

School Behavior

This boy lacks initiative and has always had trouble in school! His academic progress has been very slow. Be does not rossess the interest and dbility to do scbool work, but on the other hand, he cannot accert being surpassed by anyone. His principal difficulty in school learning has been with reading. He has needed special help since he first began school. He is small fOr his age, lacks self-confidence, plays with younger children, and behaves in a silly fashion in order to get their approval.

Test Results

Individnally administered intelligence tests have provided. a conflicting picture of his abilities. His scores have ranged from a mentally retarded to a slow learning level. His achievement test scores are above what would be predicted fromtiseintelligence test scores.They are below average but axe within the middle50 percent of achievement scores for that age and. grade. One could infer that he has, at best, average learning ability and. possiblyless ability than that. He is achieving below grade which if his ability is poor, would be exactly what he is capable of doing; but if his ability is average: his achievement is somewhat less than what could be predicted.. In any case, his school behavior and. problemsin classwork have necessitated additional attention by the school to enable him to achieveand. adjust adequately.

aw Sca.led Raw Scaled Verbal score score Performance score score

Information 6 Picture Completion 12 3.0 Comprehension 9 6 Picture Arrangement 16 5 Arithmetic 8 8 BlockDesign 14 8 Similarities 6 6 Object Assembly 19 8 Vocabulary 26 6 Coding (Mazes) 39 3.0 (Digit Span) 3.0 10 Sum of Performance Tests 41 Sun of ferbel Testa 142

Scaled score

Verbal Scale 35 81 Performance Scale 41 87 FUll Scale 76 83

Wdical Report (oneyear, three monthsafter study began)

History of Present Problem. Themotherstates that the patient's primary difficulty is that he just lacks initiative to do things, that he could do better

58 in school with some effort.For the past two yea-s, he has been in a special class doing seventh grade work; however, he should bedoing eighth grade work. He has had special remedial wnrk in readingsince beginning school; his mother attributes his lack of reading skill to "his not wantingto."

Past History. The mother's condition was good during pregnancy. She was in labor fOr 54 hours and finally had induction. The patient was a full-term, normal delivery, weighing 6 lbs., 2 oz., at birth.- Someslight cyanosis was reported in the neonatal period. No resuscitative difficulties were encountered. The patient's early development was thought to bewithin normal limits. He was toilet trained at one year by beingtied to the stool every hour. His tonsils and adenoids were removed at five years of age.He bad measles at six years and chicken pox at seven.He has bad immunizations fOr diphtheria, pertussis, tetanus, smallpox, and poliomyelitis.

Family H_l_st2a. The family includes the father, age 37, aconstruction worker; mother, age 35; brothers, aged six and eight. The older brother is right-handed (as are most of the family), wasslightly clumsy when younger, and has some reading difficulties.

Mysical_Examination. Physical examination, reveals a thirteen-year-old Caucasian male whose general condition appears to begood. His height is 153.5 cms.; weight,37.4. kgs.; blood p.essure, 94/60; pulse, 78; respiration, 20. General physical examination revealed sgJme dental caries. The patient is amphilateral, although he does most of his activities withhis right hand. There were minimal prepUbescent changes. The remainder of the examination was not remarkable.

Neurological Examination. EXamination revealed the patient to be alert and cooperative. He appeared to be of average intelligence forhis chronological age. Be presented same evidence of mixedlaterality. He was able to write with his left hand. He sights with his left eye and kicks withhis left leg. Bowever, he is able to use his righthand for eating and throwing, and he does some writing with his right hand. Examination of the cranial nerves revealed them to be intact. The optic funii were normal.Examination of the motor system revealed no evidence of spasticity, rigidity, orweakness. The my,tatic reflexes were physiologic and symmetrical. The abdominal and cremasteric reflexes were present. The plantar reflexes were flexor bilaterally. Sensory examinatlon revealed. no gross abnormality. The patient's coordination was good, and there was no evidence to suggest anycerebellar dysfunction.The patient's gait was normal. The patient did not appear to have anyperceptual difficulties in the visual motor area. The remainder of the examination was not remarkable.

Laboratory Data. An electroencephalogram was Obtained on December28, 1959, using ten electrodes with both a scalp-to-scalpand scalp-to-ear technique. A portion of the recording was Obtained duringlight sedated sleep. There is a very rhythmical basic frequencyof 9 to 10 cps appearing primarily over the occipital areas duringthe resting state. Some irregular intermittent 5 to 7 cps activity appears anteriorly. During sleep fairly symmetrical14 cps sleep spindles and.biparietal humps are present. Hyperventilation resulted

5 9 questionable high poten- of some anplitudeincrease with some in the appearance that apPeared waves withintermtttent spike discharges tial slow 1 to 3 cps normal The record wasinterpreted-as being to be artifactualin appearance. waking arl asleep. The above-mentioned for the patient'schronological age) both 1 to 3 cps wereinterpreted as beingartifacts.

School Placement with other boys ofbis grade Ito were Case 2 was placedin a special class difficulties in school. His teacher also experiencinglearning and. behavior He gpt alongwell with the other found him to becooperative and dependable. difficulties with girls onthe playground. He boys in the classand had few he gave up easily. toleratei the schoolwork initially, but

study began) 1.12112=2 (three years,three months after assignments alone. His able to read wellenough to do his He is still not signs of growth. states that he isbeginning to show some high school counselor with above averagecitizen- at an averagelevel in high school) He is performing be does pocal.nbut the counselor However, he is defiantin classes in which ship. standards and maybeable to complete feels that he acceptsgeneral discipline high school.

60 41 , 3 Case No. 2 e years, 3 mo. Boy 416 0

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43 .s,...... ' ettr--.--9 el,kr,

61 Case No. 2 11 years, 3 mo. Boy CASE 3

Boy -- Eleven Years, TwoMOnths

School Behavior has poor work hdhits, and This boy's teachersreport that he is aggressive, He is a poor annoys othersto the point of being aserious social problem. and is unable to do reader, cannot followdirections with the reading group, work on his awn. He is ineonsiderate of thefeelings of others and does not He is anxious, defensive, like school. He has a marked sense ofinadequacy. business, and he seriously doUbtshis and insecure. He sees life as a futile own dbilities tomaster his Teoblems. Even though he does have some success, He feels any positive he belittles such successand compyomises his achievement. comparison results only fromhisbeing compared. to others who are,surprisingly, even worse than heis.

Test Results of above average ability. Two individualintelligence tests indicate aboy his dailyclassroom His reading and. arithmeticachievement are below grade, and performance is even poorer thanthe achievement test scoreswould indicate.

Raw Staled Raw . Scaled score, score Veital score score Performance 12 lo Information 13 -12 Picture Completion 15 14 Picture Arrangement 26 ,lo Comprehension 13 _10 Arithmetic 8 10 Block Design. 5 6 Object Assembly 23 )12 Similarities 10 36 13 Coding (Mtzes) 32 Vocabulary 52 (Digit Span) 10 12. Sum of Performance Tests Sum of. Verbal Tests 67-56

Scaled score IQ

Verbal TQ 56 108 Performance- 52 103 FUll Scale. 108 106

Medical Report(one year,- two months after studybegan)

Rs:Igo of Present Problem.The patient is apparentlythe eldest of five,, examination by his Maternaluncle. The uncl* children. He was brought to the He is tho had some writteninformation given .to him by thepatient' s-.mother. behavior has to be a rather tenseand. apprehensive boy. No unusual acting- out been observed.He is described as beingwithdrawn.

41101111111111111.11Wwwwwwwwwwwwwwwwwwwwwwwwww. *111, *. apparently normal. Th6 patient Fast History. The mother's pregnancy was recorded. The weighed 7 lbs.,81 oz.tat birth. NO neonatal difficulties were of age and measles ateight years. He patient hadchickenpox at four years and dusts, primarilymani- has a history ofvarious allergies to weeds, grasses, rhinitis. He has had two seriesof allergy desensitization fested by allergic he At the age of five,the patient had anaccident during which procedures. lacerations over the rolled down a hill into aconcrete wall. He had some small At seven years of age,the patient eye but noloss of consciousness wasobserved. fracture of the left ran into amoving car while on a,bicycle.He sUstained a four sutures. arm and asmall laceration of thescrotum that required three or patient's appetite is good. HO eats well andsleeps well; his In general, the patient general health is thoughtby his mother to be good. Of interest, the since infancy in a to-and-fropattern has had a habit ofrocking himself to sleep special class in school with similar movements onarising. He has attended a in this class. since the sixth grade and ispresently in his second year

father, age 55; mother, age52; Family History.The family includes the brothers, eight years of age. sisters, nine and one-halfand five; and twin the parents were divorced oneyear ago.Mother has After a stormy marriage, been affected by the been nervous since Case3 was bcas. She feels that he has His father was committedto the marital discord more thanthe other children. months in 1955 and was signed Camarillo State Hospitalfor three and one-half paranoid schizophrenia,apparently out by his wife. Diagnosis at that time was cured or helped much. The mother of long standing andtoo deep-seated to be receives state ald fOr the careof her children. revealed an eleven-year-old Itysical Examination. Physical examination His height is 151 Caucasian male whose generalcondition appears to begood. 90/70; pulse, 78; respiration,18. cms.; weight,44.6 kgs.; blood pressure, There are no majorabnormalities. The patient's generalcondition is good.

Neurological eXaminationrevealed the patient to Neurological Examination. appeared to be that be right-handed, alert, andcooperative. His intelligence and apprehensive. EXamina- expected fOr hischronological age.He is quite tense The optic funii were tion of the cranial nervesrevealed them to beintact. EXamination of the motorsystem revealed noevidence of spasticity, normal. and symmetrical rigidity, or weakness. The myotatic reflexeswere physiologic good, and there was noevidence to throughout. The patient's coordination was normal. His sreech suggest any cerebellardysfunction. The patient's gait was abnormalities in theperimeters was normal. Sensory examinationrevealed no gross two-point discrimina- of paln, touch, position sense,vibration, stereognosis, or remarkable. tion. The remainder of theexamination was not 26, 1959, using ten Laboratory- Data. The tracing wasObtained on Octdber technique. There is a electrodes with both ascalp-to-scalp and scalp-to-ear appearing primarily overthe poorly organized basicfrequency of 8 to 10 cps random-appearing 5 to 7 cpsactivity posterior scalp regions. Agood deal of During drowtiness, theamount of appears anteriorlyduring the waking state. symmetrical 14 cps sleepspindles and 5 to 7 cps activityincreases with fairly recording, wominent biparietal humps. On a nuMber ofoccasions during the at 6 per second. appear repetitive positive spikes at14 per second and rarely

64 both in the temporaland occipital over theposterior aspectsof the hemisphere the right. Hyperventilation for three regions, usuallymost conspicuous on the record. The record wasinterpreted as minutes did netsignificantly alter repetitive positivespikes at14 per second being mildlyabnormal, demonstrating the right hemisphere,along with slightly primarily over theposterior aspects of would expect fOr thepatient's chronological more 5 to 7 cpsactivity than one age.

School Placement his age who had avariety in a special classwith other boys of He was placed in this class,Ids behavior difficulties.At the end of a year of learning and. more outgoingand no behavior and achievementhad improved. He had also become longer was such atorment to otherpupils.

Follow-up (three years,three months afterstudy began) stubborn, moody, andoccasionally The stibject'steacher describedhim as but does not*careabout neatness cooperative. He usuallycompletes his work difficult to contrdlat times. His and other workstandarls. He is still of a chance ifhis motheraccepts Idmas teacher says thathe would have more he is, not asshe wants himto be. Be dli his bestwork in Beading and language merestill trouble spots. tratiblei with allergy. arithmetic, art, andmusic. He is still

6 5 Case No. 3 9 years, 10 mo. Boy

CASEI.

Boy -- Eleven Years,Eleven Months

School Behavior grade in all learning areassince This child's teachershave found him below at others' mistakesand daydreams instead he started school..He giggles in class language handicap aswell as assignments. Teachers note that a of completing In short, he is acomplete have complicated hislearning problems. poor ability overly noticeable and a failure in school, amd hecomplicates this by-being He makes up fantastic constant source ofirritation and worry tohis teachers. getting attention. One day stories which have beenconsidered to be a way of elephant and had othermarked when he thought that hebad changed into an nature of his adjustment behavior deviations, theextremely serious and tenuous became obvious toteachers as well as toclassmates. recently as a Mongoloididiot. The brother of* Case4was institutionalized for help with In the past, Case4. has been referred. tothe school psychologist with his mother, she gavethe behavior problems. During a follow-up conference the family. The mother school psychologist someadditional information about She married a man fromMexico who has was raised in aconvent with "no love." When CaseI.was three or frightened and. dominated.hei since their marriage. child. took after himwith a knife. four, the father chokedthe mother, and this breakdown and_ tried tocoimnit suicide. She reported that shealmost had. a nervous constant fighting at homeand. hoped thatthis would be She commented on the feelings of returned to Mexico. She also had excessive reduced. when the father her ever self-reference and reported.that the neighbors"had been talking about since she went to themovies. "

Test Results his mentally retarded In spite of the factthat CaseII.feels that he is like on an individualintelligence brother in ability, hehad. a low average score the various individuallearning test with a fair amountof discrepancy between reading and. arithmeticachievement tasks required on thetest. He scored. well on well enough to achieve aminimum score on tests, but he was unableto read orally found to be fax belowgrade on reading examination. Since he has been an oral testscores and. all school tasks, onehas to minimize thereading and. arithmetic retarded. learning infer that Case 4 is aboy withlow average abilityand. accomplishments.

68 Scaled Raw Scaled Raw score score Verbal score score Performance 13 14 Information 10 8 Picture Completion Picture Arrangement 20 8 Comprehension 11 10 Block Design 18 11 Arithmetic 6 6 25 14 Similarities 4 5 Object Assembly Coding (B) (mazes) 29 9 Vocabulary 16 5 Tests 56 Sum of Verbal Tests 34 Sum of Performance

Verbal IQ 34 80 Performance IQ 56 108 Full Scale IQ 90 93

Medical Report

Historuf Present Problem.Details of the patient'shistory were impossible' could give little to obtain. The patient himself wasalert and cooperative but His uncle, who accompanied insight into the reason forappraisal by the examiner. and social history, butalso him, not only knew nothingof the patient's medical The patient bad spoke very little English sothat communication was aproblem. his been attending some specialclass in school. He related that the reason mother could not come tothis examination was becauseshe is on vacation. Unfortunately, no furtherpertinent items of historycould be obtained. nine PhsialMcamination. Physical examination,which was given one year, 12-year-ad male of Mexican months after the study began,revealed en alnost to be good. He was somewhat descent -whose generalphysical condition appeared 100/70; His height was140 cms.; weight, 36 kgs.; blood pressure, apprehensive. examination revealed no major respirationl 20; pulse,76. The general physical abnormalities. revealed the patient Neurological Examination. Neurological examination cooperattve, and hisintelligence appeared to be right-handed. He was alert and Examination of the cranial nerves to be that expected forhis chronological age. Examination of the revealed them to be intact. The optic fundi werenormal. rigidity, or weakness. The motor system revealed noevidence of spasticity, The abdominal andcremasteric myotatic reflexes merephysiologic and symmetrical. Examina- reflexes were present. The plantar reflexes wereflexor bilaterally, to pain, touch, position tion of the sensory systemrevealed no abnormalities The patient's sense, vibration,stereognosis, or two-pointdiscrimination. cerebellar coordination was good, and there was noevidence to suggest any The remainder of the dysfunction. The patient's gait andspeech were normal. examination was not remarkable.

the medical center severalhours late, Laboratory Data. The patient came to be obtained on June17, 1960. and unfortunately anelectroencephalogram could not back on June 20,1960, at 12:30 An appointment VAS madefor the patient to come that we do not have an p.m. The patient failed tokeep this appointment, so electroencephalogram on him.

69 School Placement

Special placement wasavailable, and Case 4 was ;laced with afew other boys and girls in a specialremedial reading group. The emphasis in this program was on the developmentaland remedial reading tasks in the'lope that improvement of school performance would aid thepupils in their school and behavioraladjustment.

F011ow-up at End of TWo Nears inReading Program

Classroom Teacher's Evaluation. The slibject's interest in readinghas *proved.He makes an effort to doadditional reading. Word analysis is easier for him. His comprehension is better. He has *proved remarkdbly.

psychologist's Evaluation and Recommendations. Case 4, due to a confUsed home situation, was often undble tocontain himself.Frequently he speaks out and argues, but this type ad' behavior, as awhole, seems to be lessening. Cheat- He ing has ceased. He has actually begun reading books uponencouragement. seems to appreciate theadditional support ofasmall group and accepts the teacher. known to be living Ey June,1961, this boy had left the district and. was last in Mexico.

70 Case No. 14 9 years, 10 1110. Boy Bender Gestalt

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+,e CASE 5

Girl -- Seven Years, One Month

School Behavior

Even though she is only in the first grade, Case5 has had serious prdblems as noted from the firstday of school. Her behavior can be described as aggressive, irritelle, and restless, and she often bits otherchildren. She is large with poor muscle coordination. She has speech difficulties fOr which her sister teases her regularly, and during kindergarten she often refUsesto speak. She is ill-tempered, and she baits other children in her class. She refUses to dbey the teacher, and when demands are made on her she sulks and becomes cross.

Test Results

Mich praise and encouragement were needed before she could complete the individual intelligence test; therefore, the results of the test mere notconsidered A valid. Her score, however, indicated borderline mental retardation with afairly wide range of performance. She has been in first grade too short a time to get a measure of her achievement, but her classroom performanceand behavior have inhibited what learning efforts she has made, if any.A prediction of her future success in school is problematical.

Ram Scaled Raw Scaled Verbal score score Performance score score

Information 5 7 Picture Completion 2 4 Comprehension 5 8 Picture Arrangement 2 5 Arithmetic 3 7 Block Design p 4 Similarities 2 6 Object Assembly 7 7 Vocabulary 12 6 Coding (mazes) 28 10 (Digit Span) 0 2 Sum of Performance Tests 30 Sum of Verbal sIsts 36-30

Medical Report (ten months after study began)

fistory of Present Prdblem. The patient has been ftssy in school and has had difficulty in relating to her peers. Academically, she has done quite well. She provokes her peers and also her older sister.Her mother did not feel that she was particularly nervous. She has just finished the first grade, having already failed one grade. She is among the tallest in her class and is also the oldest girl in the room.

Past History. The mother's pregnancy was uneventfUl. She was in labor for about two hours. The patient weighed 9 Ibs., 2 oz., at birth.NO resuscitative difficulties were encountered. The patient was bottle-fed and had no difficulties. Her development was thought to be within normal limits. She walked at 12 months of age and began to speak distinctly at three years of age. Her coordination was thought to be somewhat poorer than thatof other youngsters of her age. She has many fears. She cannot ride a two-wheel bicycle as yet and had. difficulty

73 learning to roller skate; however, she does the latter quitewell at the present time. She had German measles in June,1959;her tonsils and adenoids were removed in July, 1958. She has had no other illnesses of any kind.

Family History. The family consists of the father, age36, a factary4arker; mother, age 38, also a factory worker; sister, age 13. There is no family history of any mental disorder or disorder of the centralnervous-system.

ical Examination. Examination reveals a seven-year-oldWhite female whose general condition appears to be good. Her nutrition is eXcellent. Her height is 128 cm.; 'Weielt, 65 lbs.; blood pressure,104/72; pulse, 78; respiration, 20. The general physical examination revealed her overall state of health to beexcellent. There were no abnormalities.

Neurological EXamination. Examination reveals the patient to be a seven-year- old white female who was alert and cooperative duringthe examination. Her general development appeared to be within limits expected forher age.- The cranial. nerves were examined in detail aryl found to3-e intact. The optic fundi were normal. EXamination of the motor system revealed no evidence ofweakness or spasticity. The myotatic reflexes were physiological andsymmetrical.The abdominal reflexes were present;,the plantarreflexes-were flexor bilaterally. Examination of the sensory system revealed no abnormalities. The patient's coordination was generally quite good; however, she did have difficulty in performingrapidly alternating movements as well as most youngsters her age. This might have been due to tension during the examination. In general, her coordination did not reveal anyevidence to suggest any cerebellar dysfUnction. Her gait and speech were normal. The remainder of the examination was not remarkable.

Laboratoryrrlata. An electroencephalogram was done onJuly 10,1959.-The tracing vas Obtained., using14 electrodes, with bothascalp-to-scalp and scalp- to-ear technique.A, portion of the tracing was obtained. duringlight Sedated sleep. While the girl is awake, there is a poorly organizedbasic frequency of 6to 7 cycles per second(cps) of moderate to high amplitude appearing over the posterior scalp regions. In addition, fairly rhythmical8-cps activity appears over the central temporal andfrontal regions. On occasions during the recording, there is a shifting mAplitude asymmetry, aswell as some frequency changes over the occipital regions. A single focus cannot be identified. During sleep, 14 CrIS sleep spindles are present,along with fairly symmetrical biparietal bumps. BYperventilation resulted in an increase inamplitude, with the appearance of slow 5 to 7-cps waves. Photic stimulation did not significantly alterthe record. Impression:mildly abnormal EEG with slow5to 7-cps activity appearing posteriorly to a greater degree than would beexpected fOr the patient's chronological age. A focus cannot be identified.

School Placement

Case5'was placed among a small groupof other first-plade pupils for an hour a week and given opportunities for freeplay withfewdemands madeon her and under the direction of a trainedteacher. The emphasis of this program is on giving these young children anopportunity to work off_tensions and.. anxieties generated by the demands of the academic programof school. It is a place for them to find. success in contrast to thefailure they feel in the regular class program.

74 Follow-up (two years,two months afterstudy began) she acted like city on November180 1959.In first grade Moved to another She made fairlygood academic a spoiledchild and expectedto be waited on. progress thesecond year she wssin the firstgrade.

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Boy -- Fifteen Years, Seven Months

School Behavior

This boy is a high school student who hashad. difficulty in school since the first grade. The school believes that some of hisschool Problems are tied. in with a thyroid difficulty. Teachers usua31.y found him respectfuland polite, but he was not an asset to the class.He is occasionally truant fromschool, and. the attendance officer feels that the mcbbersupports him with excuses when le chooses to stay out for a day or two.

Test Results

An individual intelligence test placed. Case6in an above-average-ability classification. His ability far exceeds his achievement inschool. In the tenth grade his achievement test profileplaced him close to the national average, but such performance is not typical of his day-to-dayclassroom work.

Ralf Scaled. Raw Scaled Verbal score score Performance scorescore

Information 22 3.3 Picture Completion 17 14 Comprehension 17 10 PictureArrangement 31 9 Arithmetic 15 15 Block Design 33 10 srrities 12 9 Object Assembly 27 12 Vocabulary 58 Coding (mazes) 53. 12 (Digit Span) 10

Sum of Verbal Ists 58 Sum of Performance Tests 57

Verbal IQ 58 no Performance IQ 57 110 Full Scale IQ 115 111

Medical Rekort (nine months afterstudy began) History of Present Problem.The patient has badiome difficulties in school and was doing poorly to the pointwhere he was a serious problem to histeachers while be was in the sixth grade. His d.evelopnent in other spheres basbeen thought to be normal.He has had psychologicalstudies in school which, according to his mother, reveal that he has anormal IQ; however, she does not feelthat be He gets uses his potential. He apparently does notmake good. use of his time. along fairly well with his peers althoughbe fights a great deal with his sister. Of interest is that later during theinterview the mother felt that the patient was not liked by his peers buthad. no trouble with people at home. He acts out through other boys and. apparently getdthem into difficulties.

78 The patient has bad low grades inschool ever since beginning the primary grades. He bas a great deal of difficultygoing to sleep and wakes up rather late. Ordinarily he wakensabout 10 a.m.and feelsfine. He bad. been examined by the family physician and had a basalmetabolismtest anda blood test. A diagnosis ofhypothyroidism was made and the patient was advised totake two tablets of thyroid daily, which he has done for thepast year.No particular effect, either good or bad, has been apparent to themother since he took this medication. The patient refuses to accept authority from anysuch figure. He is a passive-aggressive personality,according to themother. The patient apparently hes missed a greatdeal of school, and he says hedoesn't know why. The mother feels it is because he slept too late and,that he had thyroid. gland trouble. The patient is to repeat the tenth gradebut should be going into the eleventh grade.

Past History. The mother's pregnancy was uneventful. The patient was born after an uneventful labor and wasapparently a normal delivery. Thepatient weighed 7 lbs., 14 oz., at birth. No resuscitative difficulties were encountered. The patient was born while hisfathei was in service.His earlydevelop:lent was thought to be within normallimits. He had the usual childhood, diseases, which apparently wereuneventful. The patient has had no seriousaccidents nor is there evidence to suggest any disturbance ofthe nervous system.

Family History. The family consists of the mother, age45years; stepfather, 38years, who is an electronic inspector;and a sister, 17 years, who attends high school.The patient's mother and father were divorcedin1954.His father, who is a buyer, has a history of excessivealcoholism. The patient's mother was married prior to her marriage in 1932. Her first husband died. of peritonitis after six years of marriage. She has two sons from this marriage,aged. 27 and 24. years; both are married.

Physical Exaznination. The physical examination revealed apubescent white male whose general condition is good.His height is175cms.; weight,65.8 kgs.; blood pressure, 110/70; pulse,78;and respiration, 20.The patient's general condition was excellent. He was in a good. nutritional state. Mere was a fairly largetense bydroceleonthe right side of the scrotal sac about8 cms. in diameter.This was nontender and, according to thepatient, caused him no particular difficulty. He bas been aware of it for some monthsbut apparently has not seen a physician about it. Hedenied any concern about this difficulty. The genitalia werepubescent. He had. axillary and, pubic hair. Theremainder of the general physical examinationdid not reveal any abnormalities. Neurolnicai Dramination. The patient was right-handed, alert, and. cooperative, and his general development seemed to be asexpectedfor his chronological age.The cranial nerveswere examined in detailand. found to be intact. The optic fundi werenormal.Examination ofthe motor systemrevealed noevidence of spasticity or weakness. The znyotatic reflexes were physiological.and symmetrical. Sensoryexaminationrevealed, no abnormalities. Theabdominal and. cremasteric reflexes were present. The plantar reflexes were flexor bilaterally. The patient'scoordination was good. and there was noevidence to suggest any cerebellardysfunction.Hisgait and speech were normal. The remainder of the examination was not remarkable.

'79 The An electroencephalogramwas done onJune26, 1959. Laboratory Data. scalp-to-scalp and. scalp- using 14 electrodes,with both a tracing was obtained, in all leads. The basic frequency wasabout 10 cps appearing to-ear technique. significantly alter therecord. Hyperventilation for threeminutes did. not The electroencephalogramwas interpreted Therewere no signsofabnormality. as beingnormal for thepatient's age. manifestations are primarilythose of Impression. The clinical Summary and appraisal and electro- emotional disturbance.Clinical neurological a basic evidence to suggestany organic encephalographic examinationdid not reveal any disturbance of thecentral nervous system.

School Placement for five for a group counselingclass one period a day Case6was scheduled for school year.The group leaderprovided opportunities days a week for one relationships with peer and discussion of school programs,vocational plane, authority figures, andother topics of interest.

Follow-up (three yearsafter study began) counseling class, the schoolrecord of At the end of the yearin the group standpoint of bothcredits earned and. absence Case6wasundistinguished from the of high school, hismarks were mostly"F." Drops rate. During his second year He prominent on his record. He bad a 30 percentabsence rate. and. cuts were of the next fallsemester, was barely inschool during that year. At the beginning weeks and was droppedfrom school records. he attended onlythree days in two denied by the juniorcollege. Rumored enrollment in anearby junior college was and then in a smallelectronic-parts He secured employmentin a bowling alley No further informationis manufacturing firm wherehis mother wasemployed. available on his work program.

80 Case No. 6 114 years, 6 mo. Boy Bender Gestalt

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82 CASE 7

Boy -- Eleven Years, 113m Months

School Behavior

This boy has been suspended from school at least five times, but never officially excluded. He is very active, pays no attention to his classroom group, and has no interest in school. His teachers have had trouble with him constantly. He does no classwork unless the teacher works with him individually. Occasionally, he wishestohelp with classroom chores but then often gets upset when he cannot have his own way. He uses obscene and. vulgar language, constantly fights, has tantrums, takes things belongingto others, and has assaultedthe teacher. Beyond these, he is explosive and destructive. Test Results

The results of an individually administeredintelligencetest indicate average intelligence with no particular strengths or wealmesses, except perhaps weakness in tasks which require concentratedattention.Hisachievement is below grade, but he is not severely retarded in learning tasks.Hisgreatest handicap is self-destructive emotionalbehavior which prevents him from applying himself to any school task whatsoever.

Raw Scaled Raw Verbal Scaled score score Performance score score Information 9 7 Picture Completion 11 D. Comprehension 9 Picture Arrangement 27 11 Arithmetic 8 Block Design 26 13 Similarities 10 12 Object Assad:ay 22 Vocabulary 33. 13. Coding (mazes) 23 7 Stun of VerbalTests 55-46 Sum of Performance Tests 53

Verbal IQ 95 Terformance IQ 104 Full Scale IQ 99

MedicalReport(one year, one month after study began)

History of Present Problem. Thepatient has always beena very active youngster, even as a small baby, with a very shortatt.,,tion span since early infancy.Hehad difficulties, being hYperactive, and Ttasplaced in a nursery school at two years of age, at which time be was described as not wanting to share arid wanting to be alone. Since three or four years of age, he hasbeen rather quia-tempered.He-has been having difficulty in school since hebegan, and hasbeen in a special, ungraded room for the past two years. She sustained a Past History. The mother's pregnancy wasuneventful. penicillin "penicillin poisoning," with"blisters in her mouth," from a, After five or injection for a coldjust two or three daysbefore delivery. 8 Ms., 15i oz. six hours of labor,the patient was bornfull term veighing difficulties were encountered. Tilepatient was bottle-fed No resuscitative she always had towake with no feedingdifficulties. The mother states that in toilet training, up the patientto take the bottle. He had no difficulties of age.His early although he hail bedwettingwoblems until fOur years He walked at one year neuromuscular development isdescribed as being normal. seeminglq uncontrolldble. of age. He has occasionalfits of temper which are the mother, age 31, adeputy sheriff; Family History. The family consisis of The patient's parentshave been a sister, age12; brothers, ages 5and 6. bearing is due in_ the nearfuture. separated for the restthree years. A custody who has two children,ages16 The mother has beenseeing a great deal of a man family of Case 7 fOr over a and 17. These children havebeen living with the retarded. The ratient's year. The 17-year-old son isdescribed as mentally lboth boys. mother thought thathaving thistoy in the home was good for revealed an eleven-year- Physical The physical examination Height;, 158 cms.; weight, old Caucasian male whosegeneral condition wasgood. General physical 44 kgs.; blood pressure,94/68; pulse, 74; respiration, 20. exandnation did not reveal agydbnormalities. patient to be right- Neuromuscular Examination.Examination revealed the He was alert andcooperative, but hisintellectual development bandel. Examination of appeared tote less thanexpected for hischronological age. revealed them to be intact. The ortic fundi werenormal. the cranial nerves rigidity, Emndnation of the motorsystem revealed no evidenceof spasticity, physiological and symmetrical.The or weakness. The myotatic reflexes were The plantar reflexes were abdominal and cremastericreflexes were present. revealed no gross abnormalitiesto flexar 'bilaterally. Sensory examination two-point discrimina- pain, touch, position sense,vibration, stereognosis, and there was no evidenceto suggest tion. The ratient'scoordination was good, and and speech werenormal. The amycerebellar dysfunction.The patient's gait laterality and, with his eyes patient bad somedifficulty differentiating left side vas beingstimulatel. closedl could not indicatewhether his right or Rather, this insensi- There is no evidenceto suggest anytactile inattention. of a cross-laterality. The remainder tivity reflected somesubtle manifestation of the examination vasnot remarxable. was obtainedonOctdber 19, 1959, Laboratory Data. An electroencephalogram scalp-to-ear techniq4e. using ten electrodeswitb both a scalp-to-scalp and rbythmical basic frequency of 10 cps appearingwimarily There.was a fairly wesent scalp leads. Some scattered 5-to 7-cps agtivity is over the posterior of 5- to 7-cps activity During the patient'sdrowsiness, the amount anteriorly. symmetrical.14-cps sleep spindles appear increases, and during hislight sleep, there any focal orparoxysmal anteriorly. At no time duringthe tracing are minutes and photicstimulation did abnormalities. Hyperventilation for three The record wasinterpreted as beingnormall not significantlyalter the record. chronological age. both awake and asleep,for the patient's

84 School Placement with other boys ofhis grade who had Case 7 was placedin a special class special class werestormy and learning and behaviorproblems.His days in the class was consideredoften on a day-to-dezr uncertain. Continuation in the for two years end.showed some basis.However, be didcontinue in the class improvement. began) Follow-up (three years,three months after study less trouble than everbefore General improvementnoted in the class and occasional outburstsof temper and wofane on the schoolgrounds. He still has wOblem on the busaround the firstOf the year and Isngmage. He was a decided She mother still doeslittle to follow through was requiredto'vaik to school. maxTied but he has beencleaner. The mother finall,y with school recommendations, Nbther and they all moved acrossthe street into hishouse. bbr gentleman friend Academically, this wasthe best paans to resign fromthe sheriff's department. the progress room cme moreyear and then year for Case7. He mill remain in improvement the wognosisIs poor. gp on to highschool. In spite of marked

8 5 1',

CASE 8

Boy -- Thirteen Years, Seven Months

School Behavior

This boy's teachers find. him happy, cheerful,and nice-amearing.While he likes to do things for the teacher, beis often not able to complete the job. His schoolwork has been marred by poorachievement from the very beginning. He claims to have finished his assignments,but when theyare checked, he has done little.He is a boy with a good front, one whichis acceptable and desired by adults, but one whichis unacceptable to his peers.He often fightswith them, avoids contact with them on other occasions,and. would generally prefer to work alone.He hastroubleconcentrating on his schoolwork and needs alot of individual attention and external pressure fromthe teacher in order to get finished.. Most of his classroom time has been spent inavoiding thebasic requirements set by the teacher.

His learning problems have to dobasically with readingand arithmetic. While he has had. difficulty in school fromthe very start, his oldest brother in college has been a model student and hasalways done well in school. The degree to which the obvious difference betweenthe boys has contributed to Case 8's difficulties can only be guessedat, but there is no doubt that it has been afactor in his problems.

Test Results Individual and groupintelligence test results indicate that Case8 has about average learning ability. On an individual intelligence test, his verbal learning was found. to be sUnificantly lowerthan hisnonverbalability, with a number of high and. low scores. Such a pattern predicts uneven applicationof ski/ls in schoolwork and. reflects a lack ofachievement in school.His achievement test results indicate approximately onegrade retardation in arithmetic and reading.

Raw Scaled Raw Scaled Verbal score score Performance score score

Information 12 7 Picture Comletion 16 15 Comprehension 8 Picture Arrangement 31 10 Arithmetic 6 5 Block Design 30 3-1 12 10 Object Assembly 25 11 Vocabulary 32 7 Coding (mazes) 41 9 (Digit Span) 10 10 Sum ofVerbalTests 47-39 Sum of Performance Tests 56

Scaled score IQ

Veital Scale 39 85 Performance Scale 56 108 Pull Scale 93 96 88 MedicaL.Remrt(one year, two months after study began) difficulty bas to do with History ofPit blemPro . Most of Case8's reading and. arithmetic. His behavior has been difficult at times, andhe has beenindifferent to school work. He has been attending a special class. He did not do well in his regular classes. At present he is apparently able to do seventh gradework. He has been less of a problem the last year or sobut has bad difficultiesin school from the start. Case8 is described by his parents as being the exact reverse of his brother, anhonor stadent who has been attending college forthe past year.The comparisonsbetween him and. his brother are unfortunate; one is Impressed that he certainlyis not the mare favored of the boys. Past History.The mother's pregnancies with both Case8 and. his brother were marked. by some byperemesis,but this condition was worse during her pregnancy with Case8.She was in labor for about ll hours.The patient *weighed 7 lbs. at birth, andthere were no neonatal difficulties.He was breast-fed until threemontbs ofage; no feedingdifficulties were encountered. He has bad. measles, mumps, chicken pox,and pertussis without event.He has bad no surgical procedures. His early neuromusculardevelopment was thought to be within normal limits. Toilet training was accomrAished in the fir stfew years of life. The patient bad enuresis almodt nightlyuntil two years ago. He bites his nails constantly. Family' History.The familyconsists of the father, age47; mother, age45; and a brother, age 18.

Physice.:3.Examination.Examination reveals alai-year-old Caucasian male Whose general.condition is good. Blood pressure is90/60;respiration, 18; pulse, 72; height, 155 cms.; weight,40.5 kgs. There were early prepubescent genital changes; he had no axillary hair.There were no other findings of interest.

Neurological Examination. Examination revealed, the patient to beright- banded. He was alert and cooperative, and, hisintellectual development appeared to be that expected for his chronological age. Examination of the cranial nerves revealed, them to be intact. The optic fundi were normal.. Examination of the motor system revealed noevidence of spasticity, rigidit3r, or weakness. The myotatic reflexes werephysiological and symmetrical throughout. The abdominal and. cremasteric reflexes werepresent. The plantar reflexes were flexor bilaterally. The patient's coordination was good,and. there was no evidence to suggest anycerebellar dysfunction. Sensory examination revealed no disturbance of functionof pain, touch, position sense, vibration, stereognosis, or two-pointdiscrimi.nation. The patient's gait and. speech were normal. The remainder of the examination wasnot remarkable.

89 was obtained onNovember 16, Laboratory Data.An electroencephalogram scalp-to-ear tech- 1959, -using tenelectrodes with both ascalp-to-scalp and portion of therecording, there is abasic frequency nique.During the early potential 15- to20-cps activity of 5 to 7 cps,with a good. dealof moderate slow 5- to 7- appearing anteriorly.During the patient'sdrowsiness, random present, with 10- to12-cps sleep spindlesand. biparietalhumps. cps waves are there any cleex-cutfocal or paroxysmal. At no time duringthe tracing axe stimulation did not activation.Hyperventilation for threeminutes and photic record.During the latterportion of therecording, significantly alter the electroencephalogram the basic frequencylias 9 to 10 cps.Upression: a norma1 for the patient'schronological age bothawake and asleep. School Placement In this class were15 boys of sixth-, Case 8 vas placed.in a specialclass. behavior and. eiglith-gradelevels who were havingdifficulty with school seventh- class regularly fortwo years. At theend of andlear;ing.He attended this in school was this period, hisachievement was at gradelevel, ani his behavior generalry Imroved.. Follow-up (two yearsafter studybegan) leaving the specialc3ass. He was assignedto a regu3sxschool program after school was uneventful.The other studentsdid not like Adjustment at the new His school work wasweak, and he needed him, and. he was verycritical of them. ineffective in herability continual urgizg.His mother wascooperative but to handle him.

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92 CASE9

Boy -- Seven Years,bne Month

School Behavior

This boy is described by histeacher as high-strung and nervous. He has a vivid imaginationand tells weird and fantastictales. On the other hand, restless. he is an intelligent child endquick to learn. In kindergarten he was A sister says that he is a badboy at home and. often getspunished. He has been observed as being apprehensiveand preoccupied. He is difficult to understand because he has a noticeablespeechproblem.He is occasionally cheerful. but more frequently has momentsof gloominess and.listlessness which appear inappropriatefor the environmental situation.

Test Results

Intellectually, Case9is functioning within the average rangeof ability. His verbal learning abilities axelower than his nonverbalabilities. His test perfornance is difficultto interpret in the light of hishandicapped speech and communicationdifficulties. No doubta notedpreoccupation with fantasies and hallucinationsinterferes with his performance ontesting and school tasks.

Raw Scaled Raw Scaled score Verbal score score Performance score 11 Information 5 § Picture Completion 7 Comprehension 4 8 Picture Arrangement It 9 6 12 Arithmetic 4 10 Block Design 8 lavities 3 9 Object Assembly 9 25 Il Vocabulary 11 6 Coding (mazes) 52 Sum of Verbal Tests 41 Sum of Performance Tests

Verbal IQ 41 88 Performance IQ 52 103 FUll Scale IQ 92 95

Ladica1 Report(ten months after study began)

History of Present Problem. The patient isdescribed by the parents as being basically a very nervouschild who is easily upset andhas been since ;-;:;.c.lractive. infancy. He is very distractable and, onoccasion, becomes very He has great difficulty inestablishing peer relationships. He l',11P, some articulatory speech defect and canbe uwlerstood onlywith intensc: concentra- born 1953. tion. He is extremely jealousof his sister, who was on August 1, parents feel She, too, is thought bythe parents tobe somewhatnervous. 1.32e that Case9 has donebetter in school in the pastyear than previously.

93 Her preg- Past History. The patient is the first child ofthe mother. There was no nancy yes marked byback: peln and a weight loss of tenpounds. hy*remesis. She was in the hospital for two orthree days during the second month of pregnancy because of backpain, but the diagnosis as tothe cause of this difficulty is uncertain. Subsequent to this, the pregnancy wasuneventfml. After 23 hours in labor, the fall-termpatient was born in normal,spontaneous delivery, weighing 5 lbs., 12 oz. There was some gas anesthesiabut no resuscitative difficulties were encountered. There was no neonatal jaundiceand no convulsion.The patient was bottle-fei and earlydevelopment was thought to begen be normal. He sat at about six or sevenmonths, walked at nine nmmths, to talk distinctly at three or fOur years. His speech pattern was somewhat immature, and the patient still has animpairment of speedh so that he cannot be understood eas4y. He was toilet-trained, between the agesof 12 months and 18 months. Be had chickenpox at three years of age,amd. nmmps at four -- both uneventful. He had enuresis almost nightly until May,1959. He is in need of an immunization(booster dose) for diphtheria, pertussis, and tetanus.

Family History. The family consiqs of father, age 32, machineoperator; mother, age 26, assembler in a factory; andsister, age 6, who is slight4 nervous.On the maternal side of the family,there are several individuals who 'lame a history of speedh difficulties.An uncle and great-aunt on the maternal grandfather's side of the family hadspeech difficulties. The aunt had difficulty pronouncing many sounds. The uncle is said to have stuttered, and his speech, as a Child, vas verymuch like that of Case 9.

Physical Examination. Physical examinationrevealed asevenyear-old, right-handedl white male whose general condition wasexcellent. His overall state was good. There were no 'gross abnormalities. The general physical examination was not remarkable.

Neurological EXamination. Emanation revealed aright-handed, white male who was alert and cooperative throughoutthe examination. His overall develop- met appeared to be as expected forhis chronaogical age. His height was 114 cm.; weight, 20 kgms.; blood. pressure,110/70; respiration, 18; pulse, 76. The cranial nerves were examinedin detail and forum:Ito be intact. The optic fundi were normal.EXamination of the motor systemyevealed noevidence of spesticity or weakness. The myotatic reflexes werephysiological and symmetrical. The abdominal and cremasteric reflexes werepresent. The plantar reflexeS were flexor bilaterally. Sensory examination revealed noabnormalities. The patient's coordination was good, and there was noevidence to suggest any cerebellar dysfunction. The patient's gait was normal. The patient had an articulatory speedh defect primexily reflecting animmature pattern of speech. Tbe remainder of the examination wasnot remarkable.

Laboratory Data. An electroencephalogram was done onJuly 17, 1959, using ten electrodes, with both a scalp-fp-scalpand scalp-to-ear technique. There was a fairly rhythmicalbasic frequency of 8 to 9 cps appearingprimargy over the posterior scalp regions.During the patient's drowsiness, randan, slow 5- to 7-eps waves axe present withsymmetrical 14-cps slaep spindles and biparietal humps. Wperventilation for three minutes resulted in aslight increase in amplitude without paroxysmalactivation. Photic stimulation at

94 flash rates between 5 and. 30 flashes per seconddid not significantly alter the record.Impression:normal EEG during both waking and sleepingstates for the patient's chronological age. School Placement Case 9, along with some other children of his firstgrade, were scheduled once a week for a two-hour free playperiod.A trained teacher provided a permissive, nonthreatening group atmosphere which was acomplete contrast to the daaands of the regular school program. Follow-up (two years and two months after studybegan) From the time of identification and schoolplacement, Case 9 made little academic progress in his classroom work.He read at the easy third-grade level when he was in the third grade two years later.He could not keep up with third-grade arithmetic.His frustration level was low.If work vas hard, he did. not attempt it.He constantly talked out loud and. sometimes read alout this apparently being the only way he could concentrate.His teacher felt he still had. serious problems besides those recognized in school.By the end of the school year, be had been fairly quiet inclass, but his work had not improved,.

95 Case No. 9 6 years Boy 0 Bender Gestan I aB 0 8 .. 0 0

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Case No. 9 6 years Boy Bender Gestalt

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CASEle

Boy Sixteen Years, Six Months School Behavior Case 10 has a long history of school difficultiesculminatingTn expulsion from school.He has not achieved well and. often gets into fights or quarrels with other pupils.Out late at night with friends, he has had. minor difficulties with the police for violation of curfew laws.He is unsure of himself sad manifests this in hostile or eccentric behavior.

Test Results

An individually administered intelligencetest indicates that he has above- average learning ability.His pattern of learning abilities is reasonably even, indicating, if one were touse solely the intelligence testpredictions, that le should be able to achieve yell in school.The contrary is tle case.His achievement in reading and arithmetic is below average for his grade,and be is seriously deficient inarithmetic, getting one of the lowest scores in tbe school.

Raw Scaled Raw Verbal score score Performance score

Information 20 10 Picture Completion 15 Comprehension 20 13 Picture Arrangement 40 Arithmetic 15 14 Block Design 41 17 12 Object Assembly 24- Vocabulary 51 11 Coding (Blazes) 52 (Digit Span) 13 13 Sum of Performance Tests Sum of Verbal Tests 61 Scaled score IQ

Verbal Scale 61 114 Performance 52 103 nalScale 113 109

Medical Report (elevenmonths after studybegan)

History of Present Problem. The patient has a long history of behavioral difficulties. He is described by his parents as being a nonconformist, very inconsistent, and not doing the work expected of him atschool. He has had. some minor difficulties with the police,primarily because of disobedience of the curfew laws.He has been a student in the groupcounseling class inhigh school. He is physica13,7 well. He recently sustained. a fracture of the right thumb, but this basmendedadequately. -

Iaboratory.1._ata.An electroencephalogram wasdone on August 10, 1959,using a scalp-to-scalpand. scalp-to-ear technique.The basic frequencies werenormal at various stages of theelectroencephalographic recording. There were no paroxysmal discharges, nor were there anyevidences to suggest focalabnormalities. Hyperventilation ivvealed no abnormality.The record was interpreted, asbeing a patient's age. normal electroencephalogram, bothawake and asleep, for the

The clinicalmanifestations reflect anemotional disturbance. There is no evidence to suggest anyorganic disorderof the centralnervous system on the basis of a clinicalneurological examination ore1ectroencepha10- graphic examination. School Placement Case 10 was enrolled for one yearin a group counseling classwith other boys of his grade who were alsohaving learning and behaviorproblems. Me activities in the special class werefocused. on administering andinterpreting aptitude tests, discussing schoolproblems and study habits, and.providing interest to information about vocational placementand other matters of common the boys.

Follow-up (two years and time monthsafter study began)

Case 10 left school March 11,1959,to go to work after failingrequired. upon the English and. elective art. He returned, to school inSeptember,1959, request of his parents. He carried only five subjects,earning a D in two his tardiness was the worstin electives. His lack of interest was obvious; school. He failed thetenth grade social sciencesrequirement. spring semester. In January,1960, he entered. a junior college for the the His grades were Fs. He dropped out(no official withdrawal) to enlist in U.S. Navy with the intentionof getting training inbaking. He was honorably discharged. but under questionablecircumstances. Hehaa.graduated previously He then from "boot camp," havingbeen recruit petty officerand squad leader. be completed was able toqualify for further schoolingbut vas discharged before the work.

He married. the daughter of awealthy rancher whom he metin the sumer of California and she also was an adoptedchild. He is living in northern 1961; He his mother reports thathe enjoys hunting, fishing,and horseback riding. part-time job with a market has no significantemployment history beyond one of1963.in Lassen as a boxboy for about four months. He worked in the summer Volcanic National Park; heis now employed asmechanic's helper with a bottling company and hasprospects for a routeman'sposition. o

of age. The adoptive The patient wasadopted at four weeks Past History. The patient had of the detailsof the mother's pregnancy. parents are unaware months, he was placed difficulty as aninfant.At the age of five some feeding while the mother washospitalized. home two and. a half months in a nursing for regularly, toilet-trained at twoand a half years,but has bad. enuresis He was three and, a half years,the averaging once ortwice a week. At the age of said to be deliriousfor one and. a patient had a feVerof 105 degrees and was of the fever is notknown.Histonsils and adenoids were half days; the cause struck his headbut sus- four and a half,he fell and. removed.At the age of fever of 105degrees At seven yearsof age he had. a tained no seriousinjuries. mononucleosis. He illness was diagnosedasinfectious for severaldays. nis At eleven years,because sustained a fracture ofhis clavicle and,right leg. electroencephalogram was done. The of various behavioraldifficulties, an &normality over theright side of parents were told thatthere vas a slight Dexedrine, and. thiscalmed the brain. He was givenmedication consisting of chicken pox, bothuneventful. At him down for sometime. He had measles and just about dry atnight, having only a rare thirteen years the patient was forehead and the however, he wasaccidentally hit on the occasion of enuresis; thrown from a immediately. In1958he was accidentally enuresis started again The patient is an truck and sustained sometransient loss ofconsciousness. only child. photographer, and. the The familyconsists ofthe father, a Family History. psychiatric history of emotionaldifficulties and has had mother. The mother has a and The parents recognizethat therehas been a distinct care for some years. since the considerable rejection ofthe patient by thepaternal grandparents with the grandparents'attitude toward time of his adoptionwhich is inconsistent their othergrandchildren. 16i-year-old, right-handed, Physical Examination.Examination revealed a condition isexcellent. His height is185.5 ems.; white male whose general General physical examina- blood pressure,100/70; pulse, 72. weight, 83.7 kgs.; pubertally enlarged; thereis tion reveals noabnormalities. The genitalia are axillary and pubic hair. the patient to beright- Neurolo(ical Examination.Examination reveals intellectual development appears He is alert andcooperatite, and his handed. The crania3. nerves wereexamined to be that expectedfor his chronological age. optic fund.i werenormal.Examination of in detail and. foundto be intact; the of spasticity orweakness. The myotatic the motor systemreveaed no evidence throughout. The abdominal and reflexes were physiologicaland symmetrical reflexes were flexorbilaterally. cremasteric reflexes werepresent; the plantar The patient'scoordina- Sensory examinationrevealed no grossabnormalities. indication to suggest anycerebellar tion was excellent,and there was no and. speech werenormal. disturbance. The patient's gait

404 Case No. 10 15 years, 3 Tao. Boy

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105 Case No. 10 15 years, 3rio. Boy CASE 11

Boy -- Thirteen Years,Pow Months

School Behavior does not make friends Case boy.He is withdrawn, 13. is a grossly disturbed Besides having easily, and is unable toparticipate in a group ofhis peers. school has been poor considerable behavioral, difficulty,his achievement in and he is repeating theseventhgrade.He is tense, biteshis fingernails, on and is difficult to communicatewith. He seems to beturned in himself.

Test Results

intelligence test data wereavailable. However, No group-administered results indicate a boy ofslow learning ability individual intelligence test level with a fairly even patternof abilities.However, he functionsat a higher question the relationshipbetween in school; he learns taskswhich causes one to to perform schoolwork. His his measured intelligenceand his real. ability retardationin both latest achievement test scoresindicate about one grade reading and exithmetic. Scaled Raw Scaled Raw score score Verbal score score Performance

Picture Completion 8 6 Information 10 7 Picture Arrangement 20 6 Comprehension 12 9 Block Design 6 5 Arithmetic 7 6 Object Assembly 22 9 Similarities 7 7 Coding (mazes) 34 8 Vocabulary 31 8 (Digit Span) 8 7 Tests 311. Sum of Verbal Tests 44.37 Sum of Performance

Scaled score /Q

Verbal Scale 37 84 Performance Scale 78 Full Scale 79 study began) Medical Report(one year, two months after by thefather as having Histary of PresentProblem. The patient is described He is a tense,hard-to most of his difficultiesin the area ofdeportment. make friends easily.He does not seem manage, withdrawnyoungster who does not to be able to play withothers of his age.He also hadconsiderable difficulty in school. He is also enrolled in aspecial class. second marriage. The patient was bornfollowing his father's Past History. of age. His mother left the boyand his father whenthe boy was three years

107 fam_Ly.1Historz. The family consists of the father; the father's wife of recent marriage; a brother, age 11; and. a foster brother, 18, born of the father's first marriage. The familypresently lives at therear of the paternal grandmother's home. The patient's behavior has improved somewhat since this time.

Physica3. Examination= The physical examination revealed the patient's general condition to be good. His height was 152 ems.; weight, 47.11. kgs.; blood pressure,90/60;pulse, 72; respiration, 18. The general physical examination revealed some early prepubescent changes. There were no other remarkable findings.

Neurological Examination. The neurological examination revealed the patient to be right-handed. He seemed to be alert and cooperative during the examination, and his intelligence appeared to be that expected for hischronological age. He was quite tense; his fingernails showedevidence of being bitten frequently. Examination of the cranial nerves revealed them to be intact. The optic fundi were norms/. Examinationof the motor system revealed. no evidence of spasticity,rigidity, orweakness. The myotatic reflexes were physiological and symmetrical throughout. The abdominal radcremasteric reflexes were present. The plantar reflexes were flexor bilaterally. The patient's coordination was good, and. there was no evidence to suggest any .cerebellardysfunction. Sensory examination revealed no abnormalities to pain, touch, position sense, vibration, stereognosis,or two-point discrimination. The patient's gait and speech were normal. The remainder of the examination was not remarkable.

Laboratory Data. An electroencephalogram was obtained on November160 1959,using ten electrodes, with both scalp-to-scalp and. scalp-to-ear technique. A portion of the record.ing was obtained during the patient's light sedated sleep. There is a fairly rhythmical basic frequency of 9 to 10 cps appearing in all leads although most prominent over the posterior scalp regions. Some occasional 5- to 7-cps activity appears anteriorly.During drowsiness, the amount of5- to 7-cpsactivity increases with biparieta3. humps and 3A-cps sleep spindles. Hyperventilation and. and. photic stimulation did not significantly alter the record. The record is interpreted as being normal, both awake and, asleep, for the patient's chronological age.

School Placement

Case 11 was placed in a special class composed. of boys with a variety of learning and behavior difficulties.

fonow-1. (twoyears, two months after study began)

Case 13. let% the progress room in February,1960,to attend a military academy. He had been extremely difficult, and his father had been pressured to place him. None of the earlier recommendations by the school had. been followed by his father. The new stepmother, who hoped to bring about a change in both Case 11 and the father, had an emotional collapse resulting from the family problems and. insisted that Case 31 board away from home (January,1960).

108 In September,1960,the father asked for him to be reenrolled in the special class since he could not afford private placement. This was not allowed.. He did. return to school in the eighth grade on trial. His behavior was very difficultincessant talking,vulgar behavior at the lunch table, calling girls on the phone, defiance in the classroom, and the like.

On October 12,1960,he staged an accident with his bicycle. He rode off an embankment into the wash.The police and ambulance came. He was not hurt although he said. he was. During aconference with thefather, apsychiatric evaluation was recommended for Case 11.The father agreed, but the boy later told. the teacher at school that his father had. no intention of doing anything. About a week afterthe "accident,"hebrought a satchelto school. The contents included six hypodermic needles and 118 samples of various drugs.The school doctor examined themand the police were notified..On October 27, 1960, Case 11 enrolledat a boys' home. He wrote a letter to his former teacher asking to be rememberedto everyone. -.1......

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1111.311outuil i CASE 12 Boy -- Ten Years, Four Months

School Behavior

Case 12 has a noticeable speech defect. He gives the impression of being retarded. His parents state that he is sensitive, quick-tempered, easily frustrated, and. hurt. He has nightmares, and his brother teases him for bed- wetting.His teacherreports that be gets along nicely with the boys in his class and admires and talks often of his brother. It is haxd for him to express himself. His mother is hard ofhearing and is unableto understand. him.He has poormotorcontrol, which has beeninterpreted as being a sign of anxiety and tension. A low frustration tolerance makes him vulnerable to awessive flare-ups, screaming, and yelling, especiallywhen things donot gollis way.

Test Results

An'individue/ intelligence test indicates low average mental ability. His achievement is extremely poor, and he bas been recommended for remedia/ reading help.

Raw Scaled Raw Scaled Verbal score score Performance score score

Information 9 7 Picture Completion 11 12 Comprehension 9 9 Picture Arrangeme 28 12 Arithmetic 7 9 Block Design 10 9 Similarities 3 5 Object Assembly 25 9 Vocabulary 21 7 Sum of Veztal. Tests 37 Sum of Performance Tests 42

Verbal 9cale 37 Performance Scale 53 104 Full Scale 90 93

Medical Report (eleven months after study began)

History of Present Problem. The history reveals that the patient's primary difficulties have been those of keeping up at school.He has been in the fourth grade this fall and repeated. the third grade last year. He is probably not ready for the fourth grade at this time, The parents state that the patient has always had a problem in learning. He seems to have poor retention and, in addition, is a poor reader and. a poor speller.When he began school in the first grade, a "poor teacher" advised that he be retained there for another year. When he was in the third grade at school,aNegro teacher commented that she could not understand him very well. He subsequently had. psychological studies, primarily because of his speech difficulties. He was told after that evaluation that psychiatric care was necessary. The patient has had no major problems of acting out behavior.

112 She was in labor Past . The mother's pregnancy was uneventful. for about two hours. The patient was a full-term, normaldelivery weighing 8 lbs., 8 oz. There was no resuscitativedifficul.ty. The patient was fed with bottle feedings, and. nodifficulties were encountered.. He bad. measles at five years of age and. mumpsat eight. His tonsils and. adenoids were removed. at six years of age. The patient's development was thought tobe somewhat slow. His parents revealed that the patientstayed.longer in ababy stage tban his three siblings. He was toilet-trained at two yearsof age; howver, he continues to have enuresis nightly. The parents feel that he is anextremely tense child. He has frequent nightmares and has a veryrestless sleep. He also talks in his sleep ratherfrequently. The patient is described as"flies off the handle" and screams and, yellswith theslightest provocation orwhen things do not go his way.

Family History. The family consists of the father,45years old; mother, 42 years old.; brother, 18 years old.; sister, 17 yearsold; and a brother, 13 years old., who is an honorstudent. Of interest is that a paternal unclehad a similar speech defect but wasreported as "outgrowing it." Ph sical Examination.Examinationreveals a ten-year-old. Caucasian male whose general condition amears tobe good.Hisheight was 143 cms.; weight, 31 kgs.; blood pressure,90/60; respiration, 18; pulse, 72.The general physical examination was not remarkable.

Netlrolo ical Examination. Examination revealed, the patient to be right- banded.. He was alert and cooperative, but hisintellectual development appeared. to be slightly retardedfor that expected for his chronological age. He bad. a mild articulatory speechdefect primarily reflecting an immature speech pattern. The cranial nerves were exemined in detailand. found to be intact.Theoptic randi were normal.Examination of the motor system revealed no evidence spascticity,rigidity, or weakness. The myotatic reflexes were physiological and. symmetrical. The abdominal and cremastericreflexes were present. The plantar reflexes were flexorbilaterally.The patient's coordination was good,and. there was no evidence to suggest anycerebellardysfunction. Sensory examination revealed no evidence ofimpairment to pain, touch, position sense, vibration,stereognosis,and two-pointdiscrimination. The patient's gait was normal. The remainder of the examination was notremarkable.

Laboratorata. An electroencephalogram wasdone on July 31, 1959, using tenelectrodes, with both scalp-to-scalp and.scalp-to-ear techniques.A portion of the recording vas obtainedduring lightsedated. sleep. During the waking phase there is a fairly rhythmical basicfrequency of9to 10 cps appearing primarily over the posterior scalp regions. Some occasional 15 to 20 cps is present anteriorly. During drowsinesc, random, slow5- to 7-cps wavesare present with fairly symme-Acal14-cps sleep spindles appearing anteriorly. During the phase of drowsiness and. 1-Y3htsleep, some repetitive6-to 14-cps positive spikes appear over the posteriorscalp regions. Hyperventilation and. photic stimulation did. not significantlyalter the record.. The record was interpreted, as being normal with repetitive14- and6-cpspositive spikes during drowsiness and light sleep.

113 School Placement

Case 12 was placed in a remedialreading class from September,1958, through June, 1960. He made better than two yearsgain inachievement during this time. He responded well to help, andincreased maturity was noted.

Follow-up (two years, four months afterstudy began)

Speech problems and. enuresis continue.He seems to be better liked in school, but his inability to communicate withothers makes life difficult for him. Shortly after the beginning of the school year,he moved front this district.

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116 CASE 13

Boy -- Eleven Years,One Month

School Behavior

This boy's teachers report hini to be aslow learner. He behaves in an infantile fashion, but he is not particularly abehavior problem.He puts forth little effort in a regular class.He likes to show off and.gets attention inwhatever way possible. Hecompetes with his twinbrother and is anxious not to fall behind him. Case 13 gives up easily and is proneto ask for extra assistance. He feels littleunderstanding from his parents end is upset bytheir relationship to him and to eachother. Test Results Inlividualintelligence exandnations gace Case13 in a lowaverage ability range. His achievement is not consistent withhis ability expectation, and he is working below his grade.

Raw Scaled Raw Scaled Verbal score score Performance score score

Information 7 6 Picture Completion 11 13 Comprehension 32 13 Picture Arrangement 20 9 Arithmetic 7 10 Block Design 6 8 TAYsities 4 7 Object Assembly 16 9 Vocabulary 28 11 Coding 24 9 (Digit Span) 7 7 (Mazes) 11 8 Sum of Verbal Tests 54. Sum of Performance Tests 5647

Scaled score IQ

Verbal Scale 45 94 Performance Scale 47 96 Full Scale 92 94

Medical Report (one year, two monthsafter study began)

1)re.s_s_itProblem. The patient apparently has beenattending a special class in school along with tenother boys. He has been in this class for approximately two years,primarily because he is a slow reader. He is doing sixth grade work and is apparentlymalting reasonably good progress. No behavioral difficulties, at least in the area of acting-out, hasbeen observed.

117 Past History. Thepatient is the second of fraternaltwins.The mother's pregnancy during thistim.e was thought to be all right, butlabor began about six weeks prematurely. Thepatient's older twin weighed51lbs. at birth, and. the patient weighed 5 lbs. atbirth. Labor was rather short. No neonatal difficulties were encountered, butthe twins werekept in "heatboxes" for about three weeks.There aretwo other children in the family, agirl 7 years old. arid. a boy 14 years old. The patient's early development wasthought to be normal. Hewalked at 1.4 months of age, ran at 17 monthsof age, and. talked distinctly at three years of age. He has had difficulty in schoolsince the beginning.He wastoilet-trained at two and a half years.No enuresis is observed.He is thought to have a rather shortattention span.The patient had measles at sevenyearsof age and chicken pox at five years of age,both without event. His twin brother is apparently doing fairlywell in school.

Physical Examination. Examination reveals an 11-year-old Caucasianmale whose general condition appears to be good.There are no slips of prepubescence. respiration, 18; Height,140.5cms.; weight, 30 kgs.;. blood pressure,92/62; pulse, 74-. The general physical examination wasnot rmarkable.

Neurological Examination. Examination revealed the patient to be right- handed. He was alert and. cooperative, and hisintelligence appeared to be that expected for his chronological age. Examination of the cranial nerves revealed. them to be intact. The optic fundi. were normal.Examination of the motor system revealed no evidence ofspasticity, rigidity, or wealmess.The myotatic reflexes were physiological andsymmetrical throughout. The abdominal and. cremasteric reflexes were present. The plantar reflexes were flexor bilaterally. Sensory examination revealed noabnormalitiesto pain, touch, position sense, vibration, stereognosis,or two-point discrimination.The patient's gait andspeechImre normal. The remainder of the examination was notremarkable.

Laboratory Data. An electroencephalogram was done onNovember 2,1959, using ten electrodes, with both ascalp-to-scalp and scalp-to-ear technique. A portion of the recording wasobtained duringthe patient's light sedated sleep. While he is awake, there is afairly rhythmical basic frequency of8 to 9cps, with some scattered,irregular, moderate, potential5- to 7-cps activity appearing in ell leads.At no timeduringthetracingare there any focal or paroxysme/ abnormalities. During drowsiness, the amount of 5-to 7- cps activity increases, ar i.therearesymmetricalbiparietal humps and.3.11.-cps sleep spindles. Hyperventilation and photic. stimulationdid. notsignificantly alter the record.. The record was interpreted asbeing an essentially normal electroencephalogram, both awake and asluep, forthe patient's chronological age. Comment: the amount of 5- to 7-cps activityduring the waking state approaches the lower limits of normal forthis age.

Sumnaryand. Impression. The clinics/ manifestationsreflect primarily an emotional disturbance. The etiology of thesedifficulties is not apparent. A careful clinical neurologicalexaminationdid. not reveal any abnormalities. The electroencephalographic examination wasessentially norms/ for the patient's chronological age, in spite of the amount of5-to 7-cps activity during the waking state which. approached the lower limitsof normal. In summary, we did

118 not feel that there isanyclinical or electroencephalographic evidence to indicateanyorganic disease of the centrel nervous system. School Placement

Special class placement was recommended and. provided for Case 13.The class was oriented to improvement in school learning and emphasis was placed on setting andassisting the pupils to maintainbehavior standards appropriate to their age and grade. He made some gains in the special class, but his improvement was below the average for the other pupilsplaced.there. Provi- sion for continued. help was needed.

Follow-up (two years, six months after study began)

Case 13 returned. to a regular class inSeptember, 1960.The work in the class was far above him, but his nzther insisted that heremain withhis twin. After one month the work became Imwssible. His mother called the school counselor for an appointatent. Case 13 was crying and. spending fouror five hours a day on homework. A plan was worked. out with the motherand teacher to give easier work.The rest of the year wasuneventful.Ile still hasserious academic problems, and. the obvious difference between him and other pupils has aggravated his emotional problems.

119 Case No. 13 8 years, 5 months Boy

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121 CASE 14

Boy -- Fifteen Years, Nine Months

School Behavior

This boy's teachers say that there is no doubt that he iscapable of at least average performance in high school, but they arealso convinced that he is completely resistant to doing anything but failingwork. He is a natural target for school "bull" either physical3,y or verbally.Anything which is taboo is the most sought-after activity. The fact that he is bright makes it even more difficult for him to get along with others.

Test Results

Case 14 has mental ability well above average. Hisachievementtest results are not too far below what is expectedfrom his intelligence; however, his performance in class is so inconsistent from day to day that hecannot earn average grades. This boy has great potential but has emotional problemswhich prevent him from using his capabilities.

Raw Scaled Raw Scaled Verbal slore score Performance score score

Information 23 14 Picture Completion 16 13 Comprehension 19 12 Picture Arrangement 52 20 Arithmetic 16 18 BlockDesign 45 13 Simi lPrities 19 14 Object Assembly 28 13 Vocabulary 46 10 Coding 55 10 (Digit Span) 12 12 Sum of Verbal Tests 67 Sum of Performance Tests 69

Verbal Scale 67 123. Performance Scale 69 127 Full Scale 136 126

Medical Report (ten months after studybegan)

History of Present Problem. The patient has not been doing too well in school academically during the past year or two. He has a great tendency to daydream and dawdl?.. There isno particular difficulty withacting-out behavior. He presentsno problems inmanagement at home or at school. At the present time he has completed. the third yearof high school and. in genera3. has bad poor gradesthroughout hisentire high school experience. He has bad. a rather profoundgrowth spurt during the past year and in the sameperiod began to smoke. The father feels that he is basically lazy, buthe has a great deal of empathy for his son's problemsand is most anxious to obtain some help for him.

122 11E1_111 ELIE& The patient is the first of two children. The mother's pregnancy was uneventful. He was delivered by forceps after a labor ofseveral hours. Apparently a version was necessary to make the delivery moresatis- factory. The patient weighed 8 lbs.,9oz. There was no neonatal distress. There was no jaundice and no convulsions. His growth and development were thought to be within normal limits. He did fairly well while he was in grammar school. His tonsils and adenoids were removed at the age of five years. He has had measles, mumps, chicken pox, and German measles, all without event. He has had no serious illness or any injuries .

The family consists of the father, age 40; mother, age 41; a sister, age 10. There is no family history of emotional disease or organic nervous system disease.

Plawsical Examination. Examination revealed a white male, 15 years ana nine months old, whose general condition is good. His height is 172 ems., weight, 61.5kgmr,.;blood pressure, 110/72; pulse, 80; respiration, 20. The patient's general condition was ekcellent, and his state of nutrition was good. He had. achieved development of secondary sex characteristics and. in general was well into pubescence. His genitalia were pubertally enlarged; he had axillary and pubic hair. The remainder of the general physical examination was not remarkable.

Neurological EXamination. The patient !as right handed and alert and cooperative during the examination. His development appeared to be within limits expected for his age. Examination of the cranial nerves revealed them to be intact. fte optic fundi were normal. Emanation of the motor system revealed no evidence of spesticity or weakness. Sensory examination revealed. np abnormalities. The myotatic reflexes were physiological and symmetrical. The abdominal and cremasteric reflexes were present. The plantar reflexes were flexor. The patient's coordination was excellent, and there was no evidence to suggest any cerebellar disturbance. The patient's gait and speech were normal. The remainder of the examinationws not remarkable.

An electroencephalogram was done on June5, 1959. Me tracing was obtained, using ten electrodes, with both scalp-to-scalp and scalp-to-ear techniques. A portion of the recording was obtained during the patient'slight sedated sleep. There is a fairly rhythmical basic frequency of 10 cycles per seconds (cps) appearing primarily over the posterior scalp regions. During drowsiness, random, slow5-to 7-cps waves are present with symmetrical14-cps sleep spindles and biparietalhumps duringlight sleep. Hyperventilation did. not significantly alter the record. During a portion of the period of drowsiness, briefly appearing 14.-cps positive spikes were present along withanotherperiod of question- able6.-cpspositivespiking. Photic stimulation did not significantly alter the record. Impression:very mildlyabnormal EEG with rare14-cps spiking appearing over the posterior scalp regions during drowsiness.

Summary and. Dvression. The clinical manifestations are primarily those of a basic emotional disturbance. Onclinice/-neurological appraisal and. electroencephalographic examination, there is no evidence to suggest anyorganic disease of the central nervous system.

123 School Placement

111-participatedin agroup counseling During the1958-59 school year, Case days a week. The emphasis inthils program class which met onehour a day, five help with peer and.authority was onvocational an4educational guidance, interest to the group. relationships, andother topics of

Follow-up (three yearsafter studybegan)

graauated from high schoolin June,1961. He is reportedly Case 14 is studying night schooi at ajunior college. He states that he enrolled.in nationwide "advanced field. of electronics. He won a place in a in the general In the eleventhand amateur" contest inphotography in his senior year. Hemade Cs and Ds, butthese twelfth grades, hisschool behavior wasmarginal. earned in the tenthgrade. Even though grades were animprovement over what he high school, by thetine he graduated, he was not anoutstanding student in chance of making out as anadult. school personnelfelt that he had some laboratory prior to the summerof1961. He worked. at oddjobs in a photo landscaper. He then found.full-tine work with a

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4. CASE 15

Girl -- Nine Years, Eleven Months

School Behavior . conditions at home This girl's teachers statethat she is so disturbed by that she cannot concentrate onschoolwork. She is below average in group participation, doesnotcomplete her workon time, cannot followdirections, personal worth or is unable to work independently,and. has little feeling of Her father is an accomplishment. She is an anxious, disturbed.little girl. alcoholic who beatsthe mother and runs thefamily out of the home when.drunk.

Test Results slow-learning category. An individual intelligencetest placed her in a Her achievement is extremely poor,and. she is eligible forspecial reading help to assist her in keeping upwith the classroomachievement.

Raw Scaled Raw Scaled score score Verbal score score Performance 8 8 Information 9 8 Picture Completion Comprehension 7 7 Picture Arrangement 12 7 6 8 Arithmetic 6 8 Block Design 14 8 Similarities 11 14 Object Assembly 31 . .11 Vocabulary 22 8 Coding (Digit Span) 6 6 42 Sum of Verbal Tests Sum of' Performance,Tests

Scaled. score IQ

Verbal Scale 43 91 PerformanceScale 42 89 Full Scale 85 89 Medical Report (ten monthsafterstudy began) the patient has been in a History of PresentProblem.For the past year, special class for thepurpose of assistingher withreading. She apparently in September on the conditionthat she go to summer will go into the fifth grade thought school this current session.Mostof herdifficulties apparently are has a slight to be due to her readingimpairment. In addition, the patient articulatory speech disturbance.According tothemother, she presents no particular problem in behavior. She is a reasonably happychild.

She was in labor for Past History.Mother's pregnancy was uneventful. delivery about one hour. The patient was a full-term,normal,spontaneous and weighed5 lbs., 14 oz., at birth. She was breast-fedforabout one year, distress. She and no difficulties wereencountered. Liere was no neonatal

127 thought to be Her earlydevelopment vas had no illnessesduring infancy. She was eight months of ageand talked at15months. normal. She walked at at She had measlesat three years, mumps toilet-trained at18 months of age. all of which wereuneventful. The patient six, and chdckenpox at eight years, had enuresisuntil the age of seven. house painter; The family consistsof the father, age34, Family History. Negroes and brother, age 11; sister, age7. The family are mother, age 30; The patient isright- have come toCalifornia from NewOrleans, Louisiana. handed.; her maternalgrandfather wasleft-handed. reveals an almosttentyear-old Emamination. The examination is excellent. Her weight is37 kgms.; Negro femalewhose generalcondition 92/70; pulse, &O; respiration,18. The height, 141 cm.;blood pressure, and no majorabnormalities were seen. patient's general stateof health is good revaled a right-handed.female Neurological Examination. This examination examination. Her overalldevelopment who was alert andcooperative during the chronological age. Examination of the appeared to be thatexpected from her The optic fund.i werenormal. cranial nerves revealedthem to be intact. evidence of spasticityor weakness. Examination of the motorsystem revealed no and symmetrical. The abd.ominal The myotaticreflexes were physiological the plantar reflexeswere flexor. Sensoryexamination reflexes were present; sense wasnormal. of pain, touch,vibration, and position in the modalities patient had,somedifficulty in Stereognosis was intact. With eyes closed the 'examination. She basically identifying her rightside from her left ontactile and right-footed.The patient's appeared to beright-handed., right-eyed, cerebellar disturb- and there was noevidence to suggest a coordination was good, characterized, by aslight The patient's gait wasnormal. Her speech was ance. be explained byher New Orleans articulatory defect, someof which might background. was doneon July 17,1959, using Laboratory Data. An electroencephalogram A portion scalp-to-scalp andscalp-to-ear techniques. ten electrodes,with both There is a fairly obtained duringlight, naturalsleep. of the tracing was posterior cps appearingprimarily over the rhythmical basic.frequency of8 activity appear- low-voltage, fast,15- to 20-cps scalp region. There is some are the rhythmicalruns of 5-cpswaves ing anteriorly. During drowsiness, sleep fashion along withsymmetrical 14-cps ?resent in amildly paroxysmal resulted in Hyperventilation forthree minutes spindles andbiparietal humps. paroxysmalactivation.Photic an increasein amplitudewithout clear-cut and 30 flashes persecond. did. notsignifi- stimulation at flashrates between 5 this was a normalEEG, both wakingand cantly alter therecord.. Impression: sleep, for thepatient's chronologicalage. appear to be The patient'sprimary difficulties SummarLsdression. there is anyrelationship to the those related. to reading. Whether or not differentiating rightfrom left is not that she has somedifficulty fact is often associatedwith reading Certainly mixed-handednessas such clear. often in boysthan in girls. The difficulties, and. in genera/is seen more ofmixed-handedness, although patient does not exhibit anyparticular problems

128 of interee, is the fact that hermaternal grandfather was left-banded. The relationship between her reading difficultiesand the possibility of mixed- bandedness should be a matter of conjecturefor the present time. Certainly there is no obvious evidence on clinicalneurological examination or electro- encelpbalographic study of any organic disease of thecentral nervous system.

School Placement

Case 15 was placed in a remedial reading programand received this special help from September, 1957, through June,1960. She made fairly good gains in achievement, but she needed help with home problems to support thegains made In school.

Follow-up (two years, four months after studybegan)

Home problems continue. Case 15 badly needs attention from someone. When she did not return to school in September,1960, a follow-gip indicated that she had moved to some other school district. No further contact has been made.

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2 r CASE 16

Boy -- TwelveYears, Three Months

School Behavior prOblem in theclassroom. teachers reportthat be is quite a This boy's talking and argueswith short attention span. He is constantly He has a very standards, teachershave a hard his teacher on anypoint. He cannot accept to say, he is aschool disciplineprablem. time controllinghim, and, needless

Test Results classi- tests place Case16 in an average-ability Individual intelligence in the borderlinerange. His scores on groupintelligence tests are fication. consistent with the groupability test Classroom achievementtests results are achievement. .Grauptests reflect find him farbelow his grade in scores and it would bedifficult to do individualtests; therefore, achievempnt more than meet withoutfurther standard. whidh hecoal successfully set an e,..lhievement tasks. knowledge of his successwithremedial learning Raw Scaled Raw Scaled Performance score score Verbal score score 6 8 Picture Completion 7 Information 11 13 Picture Arrangement 34 Comwehension 9 7 7 8 8 Bloc': Design 9 Arithmetic 20 9 10 Objec:t Assembly Similarities 9 12 Coding 4.3' Vocabulary 31 9 (Edgit Span) 9 9 Sum of PerformanceTests 47 sum of VerbalTests 51

Scaled score IQ

Verbal Scale 43 21 Performance Scale 47 96 Full Scale 90 93 after studybegan) Medical Re:port(one year, two months apparently beenattending a History of PresentPrOblem. The patient has He was referredthere originallybecause special class forthe past two years. failed any specificgrades. In this necial of poor learning. He bad not fifth-grade "seventh-grade work."He reads at the class he is apparentlydoing arithmetic at thesixth-grade level.The level and bas theability to perform "been bad" ever sincehe was a baby.He mother states thatthe patient has patient bac . The motherstates that the cannot take any kindof instruction. do so since at all forseveral years but can been nerraus andcould not write that tbe patientisalot like his father; Septedber, 1959. The mother feels end hard to getalong with; butshe feels that is, be israther belligerent

132 that in thelast six months be has"come out of it a bit."The patient had which was reported. asbeingnormal. anelectroencephalogram several years ago other children are asbelligerent as the The mother doesnot feel that the patient although attimes they have thisdifficulty. The mother's pregnancy wasthought tobe normal except for Past History. factor between the fact that she Vastold. that there was anRh incompatibility would be born dead. her husband and her. Themother wastold. that the patient the delivery by Caesareansection and that they originally had. planned toperform onset, but this did not occur. two weeks prior to theestimated time oflabor 8i lbs. at Labor was about twohours in duration, andthe patient weighted The patient wasbreast-fed No difficulties were encountered. birth. neonatal difficulties were observed. for about two anda half months,and no feeding have been withinnormal limits. The The patient'sdevelopment is thought to rather clumsy. She "can't mother has felt that thepatient has always been rather well in let him get awaywith anything."Thepatient apparently does and. diver. Four He is described. as"fearless" and as a good swimmer sports. against a rock. He years ago thepatient was injured onthe head.when he fell observed,atthat time. was dazed amoment or so, but nounusual occurrences were five and. seven years of age. He had. chicken pox,measles, and. mumps between There issome historyof His tonsils wereremoved. with his adenoidsin 1956. ear infectionsbetween six and seven yearsof age. mother, age35; Family History. The family consistsof the father, age35; 17 and: 15, who arechildren of the mother'sfirst two older children, ages had. marriage; Case 16, age 12;and. a sister, age 5 years. A brother apparently during which he wasratber restless at night while sleeping and. some difficulty problem in the past couple occasionally wakened., butthis hasnot been a major described. asbeing alot like of years.As mentioned before,this patient is her husband as believing belligerent. The mother describes his father, rather difficulty in feelingthat it isnormL.to be aggressive. The mother as great this is right. examination reveals a12-yew-oldCaucasian Physical Examination.Physical condition is good.. Height 151 ems.; weight,51 kgs.; blood. male whose g.-neral. appears pressure,90/60;pulse, 72,respiration, 18.General physical condition to be good. There were minimal signsof prepubescence. No abnormalities were observed. on general physicalexamination. the patient to beright- Neurologica/ Examination. Examination revealed development appeared. and cooperative, andhis intellectual handed.He was alert Examination of the cranial to be that expected forhis chronological age. normal. Examination them to be intact.The optic fundi were nerves revealed wealmess. The myotatic of the motor system revealed noevidence of spasticity or Theabdominal and. reflexes were physiologicaland symmetricalthroughout. flexor bilaterally. cremasteric reflexes werepresent.The plantar reflexes were evidence to suggest The patient's coordination wasexcellent, and there was no revealed no abnormalitiesto dysfunction. Sensory examination any cerebellar two-point discrimina- pain, touch, position sense,vibration, stereognosis, or The remainder of theexamination. The patient's gait andspeech were normal. tion was not remarkable.

133 November230, Laboratory Data. Anelectroencephalogram was obtained on and. scalp-to-eartechniques. 1959,using ten electrodes,with both scalp-to-scalp during light sedated.sleep. There is a A portion of therecording was obtained. frequency of 8 to9cps appearing overthe posterior fairly rhythmical basic present Duringdrowsiness, random slow5- to 7-cps waves are scalp regions. Hyperventilation with symmetrical14-cps sleep spindles and.biparietal humps. npt significantlyalter tle `record. for three minutes andphotic stimulation did both awake and asleep, forthe Impression: a normalelectroencephalogram, patient's chronological age. reflect essentiallya Summary and. Impression. The clinical manifestations in school. basic emotionaldisturbance along with somelearning difficulties neurological examination and.electroencephalogram did not Careful clinical central nervoussystem. reveal aRy evidence tosuggest any organicdisease ofthe

School Placement learning and Case 16 was placedin a special classwith other boys with educational. plan was onremedial help behavior problems.The emphasis in his behavior and disciplinecommit- and improvement in theability to make and keep During the two yearsin the special class,his improvement ments inschool. with the prediction was remarkable.His achievementtest scores were consistent made from the individualtesting.

litalow-up (two years, ninemonths aftor studybegan) class,Case 16 has doneexcePtionally At the end. of two yearsin the special the fell He was able to returnto a regular class. HiS adjustment during well. difficulties with histeacher. semester of1960was generallygood., but he had behavior standards are inconflict with what theschool His and. his family's There was a noted.improvement expects, ani thiscomplicates his schoolproblems. in his attitude laterin the school year.In Sepbember,19611there were no school problems, but Case16 stole a ear.At school Le was fullof "big talk" his 20-year-oldhalf about the theft andgetting drunk.He hangs around with Although the special classproiram helped. him a brother, who is a delinquent. 16. Me hone environment* istoo influen- lot, the prognosis isnot good for Case the special tial in keeping himfrom maintaining thesocial gains he made in program.

134 -

Case No. 16 10 years, 10 mo. Boy

135

CASE 17

Boy -- Eleven Years,Two Months 4

School Behavior

Case 17 has weeklyheadaches, is tense, nervous,and. subject to motion time he Hehas had serious learningproblems in school from the sickness. immature, and he began. His teachers explain hisaggressive behavior as being is childish, nervous, andunhappy.He likes school butdoesn't want to cooperate. inattentive, impulsive, and He constantly moves around.the room; is restless, He is described as infantile. He can neither attendwell nor concentrate. difficulties careless andprone to giveup easily, and hewould rather run from either than face them. He is a lonesome littleboy whohasn't much to grow on in himself or from external.support. Test Results Both individual and groupintelligence testresults placeCase 17 in an below expectancy for his average-Aility classification. Hisachievement is ability andbelow grade level.

Raw Scaled Raw Scaled score Verbal score score Performance score 7 6 Information 8 6 Picture Completion 31 32 Comprehension 12 ii. Picture Arrangement 15 10 Arithmetic 7 8 Block Design 20 10 Similarities 7 9 Object Assembly 28 8 Vocabulary 27 9 Coding 8 8 (Digit Span) Tests Sum of Verbal Tests 53. Sum of Performance 46

Scaled score IQ

Verbal Scale 43 91 PerformanceSca/e 46 94 Full Scale 89 92 /*dictaRezort (one year, onemonth after studybegan) difficulties in school. History of PresentProblem.Thepatient had. learning difficulty in read- He was retained in thesecond. grade after havingconsiderable special ungraded room. Most of ing. For the past two terms,he has been in a He has had. no overtmanifes- his difficulties have beenin the area of reading. months, he has beencomplain- tations of acting-out behavior.In the past several These do not necessarily ing of headaches which occurabout once a week. inter- fere with his physical activities.He is described asbeing arathertense and. nervous child.who is subject tomotion sicbiess. ,

137 Past History. The mother's rregnancy was uneventful. She was in labor fOr about seven hours.The patient weighed 7 lbs., 12 oz., at birth. No neonatal difficulties were encountered. He was fed 'by bottle and had minims0 feeding difficulties fOr about two months. His neuromuscular development was thought to be within normal limits. He was able to walk at one year of age. At nine months of age, the patient apparentlyfell, and nine sutures were required to repair the laceration sustained to theforehead. The mother also states that the patient has had two or three minor"concussions" without any difficulties. He had measles at one year of age andscarlet fever at three years of age.

Family History. The family consists of the mother, age 35; and thepatient. The father, age 39, is not living with the fftmily. The parents are divorced.

Physical EXamination.EXamination reveals an 11-qear-old Caucasian male whose general condition appears to be good.Since he is under the influence of sedation, an appropriate estimate of his intellectual abilitycannot be made. His height is 153 ems.; weight, 37 kgs.; blood. pressure,92/60; respiration, 18; pulse, 74. There is a small "cafe au lait" spot over the anterior aspect of the right thigh measuring 0.5 by4 ems. No other similar areas are observed. The remainder of the general physical examination is notremarkdble.

Neurological Eicamination. Examination revealed the retient to be right- handed. Although under the influence of sedation following an electroencephalogram, he was alert and cooperative. Because of the sedation, an accurate appraisal of the patient's intellectual abilities could not be made. There was some evidence to suggest that he mightbe somewhat retarded. The cranial nerves were examined and found to beintact. The optic fUndi were normal. EXamination of the motor system revealed no evidence of spasticity orweakness. The myotatic reflexes were physiological and symmetrical throughout. The abdominal and cremasteric reflexes were present.The plantar reflexes were flexor bilaterally. The patient's coordinationwas good, amd there was no evidence to suggest any cerebellar dysfUnction. Sensory examination revealed no abnormalities to pain, touch,position sense, vibration, stereognosis, and two-point discrimination.%be patient's gait and speech were normal. The remainder of the examination was not remarkable.

Laboratory Data. An electroencephalognowas dbtained on Octdber19, 1959, using ten electrodes, with scalp-to-scalp and scalp-to-eartechnique. There isafairlyrhythmical basicfrequency of 10 to 11 cps appearing primarily over the posterior scalp regions. During the patient's drowsiness, 5- to T- ops yames are present withsymmetricalandbiparietal humps and 14-cps sleep spindles during light sleep. Hyperventilationfor three minutes and photic stimulation did not sigmiftuult4 alter the record.The record was interpreted as being normal for thepatient's chronological age both awake and asleep.

The clinical manifestations reflectbasica* a learning difficulty, difficulty in school(manifestedessential/byinability to read), and difficulty with other areas oflearning. The etiology of these difficulties is not apparent. From clinical neurological examination and electroencephalographic observation, no organic disease of the nervous system was apparent.

138 School Placement

in a special classwith other boys withserious learnm Case 17 was placed he had. made little ing and behaviorproblems. Aftertwo years' placement, and the prognosis forimprovementin if any gain inmeasured achievement, schoolwork and attitudeis poor.

Follow-up (two years,nine months after studybegan) He grows taller Case 17 is the boyhelped least by theL.pecial class. individual help. Enotionally and. that is aboutall. He cannot work without behavior is more fixatedthan retro- and socially, he ismuch retarded.; his year's growth in achieve- gressed. Between1959 and 1961,he made about one one more yearand then go on ment. Hewill remain in thespecial class for to high school. The prognosis is very poor.

139

Alemodsg,

Case No.17 9 years, 8 mo. Boy

141

1=111111.11MINM...... CASE 18

Boy -- Twelve Years, Nine Mbnths

School Behavior

Case 18 has had a learning difficultysince he started school. His mother feels that this may be because he began schocl too early and the fact that he failed tbe first grade. He is tense, tends to cling to his mother, and is always afraid, especially of physical contact durimg physical education.Even though his teachers report that he is not a behavior prOblem4 he tattles, pretendi to be sick when it is time for a test, and is handicapped in school learning. He likes school but plays with only a few children, and he is immature socially.

Test Results

Individual intelligence tests indicate that he has average ability.His achievement was about at grade level in the first grade, following the year of retentiohl but subsequently on three annual tests, he showed no growth in school learning tasks. His ability wedicts average achievement in school, but he has never met this standard.

Raw Scaled Raw Scaled Verbal score score Performance score score

Information 14 lo Picture Completion 13 12 Comprehension 14 11 Picture Arrangement 34 12 Arithmetic 7 6 Block Design 6 5 Similarities 11 11 Object Assembly 20 8 Vocabulary 30 8 Coding 27 6 (Digit Span) 5 Sum of Verbal Tests 51-43 Sum of PerfOrmance Tests 43

Verbal Scale 43 91 Performance Scale 43 90 Full Scale 86 90

Medical Report (one year, two months after study began)

History of Present Problem. The mother states that the patient has had a "learning block since starting school. She feels that this, in some ways, is because the patient began school too early, at four and a half years of age. He failed the first grade and has been in a special class for the past two years. The mother characterizes the patient as rebelling against anything that is required of him.He is a rather tense youngster who tends to cling to his mother. The patient w4s adopted at the age of 11 days. He weighed 7 lbs. at birth. No neonatal difficulties were recorded. He ,had no feeding difficulties. He has a sister, age ten years, who was adopted at the age of two years. His mother states that they fight all the time. Both youngsters are aware of the adoption. His neuromuscular The patient has had noserious illnesses orinjuries. difficult time with development vas thought to benormal. He had a rather done rather forcibly toilet training, and themother states that this was until five or between two and three yearsof age. The patient had enuresis between five and six years of age. He had measles,chicken pox, and mumps always afraid, seven years of age. The mother describesthe patient as being dodges even of physicalcontact. He is afraid ofphysical activities and have been the ball when it is thrownat him. The mother feels that she may somewhat overprotective of her sonbut not of her daughter. The patient is He has described as running to hismother to tattle and beingrather selfish. great difficulty in relatingto his peers.

the father, age 50; themother, Family }jistory. The famrrly consists of age 51; and the twochildren. 45 kgs., blood pressure, Physical Dcamination. Height, 159 ems.; weight, condition is good. 90/60; respiration, 18; pulse, 74. The patient's general General physical examinationdoes not reveal any majorabnormalities. to be right- Neurological Examinatian. EXamination reveals the patient His intellectual handed. He was alert andcooperative during the examination. development appears to be thatexpected for his chronological age. He is examined. especially tense and. bites hisfingernails. The cranial nerves were in detail and found to be intact. The optic fundi were normal. EXamination The of the motor system revealed noevidence of spasticity orweakness. The abdominal myotatic reflexes were physiologicaland symmetrical throughout. flexor and cremasteric reflexes merepresent. The plantar reflexes mere good, and there was noevidence to bilaterlly. The patient's coordination was suggest any specific cerebellardysfunction. Sensory examination revealed no stereognosis, and two- abnormalities to pain, touch,position sense, vibration, The remainder point discrimination. The patient's gait andspeech were normal. of the examination was notremarkable.

Laboratory Data.An electroencephalogram wasdone on Novedber 23, 1959, A portion using 12 electrodes, withscalp-to-scalp and scalp-to-eartechniques. of the recording was obtainedduring the patient's lightsedated sleep. While he is awake, there is a fairlyrhythmical basic frequency of8 to 9 cps smear- law-voltage, fast ing over the posterior scalp areas. Later in the recording, to sedation. 15- to 20-cps activity appearsanteriorly, wdbably secondary raesent with During the boy's drowsiness andlight sleep, 5- to 7-cps waves are some briefly appearing14-cps sleep spindles.There are no clear-cut focal Hyperventilation for three minutes or paroxysmal findingsduring the recording. and photic stimulation did notsignificantly alter the record. The record is interpreted as being normal, both awakeand asleep, for the ratient'schronological age. reflect primarily a Summary and. Impression. The clinical manifestations evaluation and. basic emotional disturbance. Careful clinical, neurological to suggest any electroencephalographic examinationdid. not reveal any evidence organic disease of thecentral nervous system. School Placement other boys with similarlearn- Case 18 was placedin a special class with special teacher was onimprove- ing and behaviorprOblems. The emphasis of the behavior standards. EVen though he ment of academicskills and maintenance of research project, was absent forall the tests givenduring the period of the that he bad managed toachieve close to a testadministered later iraicated his partand the partof grade-level standardsafter considerable effort on the teacher.

Follow-up (two years,nine months after studybegan)

regular claswark in theseventh grade.Els teacher made He returned to Some of the help, and things seemed to gorelative4 smoothly. no request fOr provided boys picked on him, butthis was stopped. Withoutthe intensive help time maintaiaing hisachieve- in the special class,he is having a, difficult he has done well. His ment growth in a regularclass. On the whole, however, the past, so her pressureon mother has not come toschool as regularly as in he will continue tobe her son maybe lessening. The indicat'ons are that helpei in the specialclass. academically and sociallyretarded although he was

144 *0 *

l' ' t l't, \I 1 II` \ \ \ E., e , Case Vb. 18 1 % o t % 11 years,-2 mo. .il .6 1/6 to/ Bay

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Case No.18 11 years, aso. Boy

-146 CASE1.9 Boy -- Twelve Years, Six Months School Behavior This boy is in need.of constant attention fromthe teacher and avoids peers for contact with adults.At the time of identification inthe stateresearch project, little schooldatawere available. He was one of the pupils-identified. by the procedures developed by the researchstaff and. would not have come .tothe notice of the school ifit had not been for the identification process.

Test Results

Hisachievementtests indicate approximatelygrade-levelachievement, Which is consistent with an individualintelligence* test result placinghim in in average-ability classification

Raw Scaled Raw Scaled Verbal score score Performance scorescore 8 Information 14- 11 Picture Completion 9 Conrprehension 16 13 Picture Arrangement 34 13 12 Arithmetic 8 8 Block Design 28 Similarities 13 13 Object Asbembly 23 11 Vocebularly 32 9 Coding 30 7 Sum of Verbal Tests* 54 Sum of Performance Tests 51 Scaled scOre IQ

Verbal Scale 54. 195 Performance Scale 51 101 Full Scale 105 1011. Medical Report (one year, two monthssayerstudy began) History of PresentProbleM.The patient has had some difficultiesin school, and for the past two years:hehas been attending a special, roomin school doing approximately seventhgrade work.The patient apparently is in need. of a great deal ofattention and is constantlyseeking some type ofidenti- fication with adults. He doesnot successfullyestablish relationships with his peers.He was adopted at the age ofeight: He previously had been in many foster homes.The previous history is not too welldocumented.He apparently has bad.some childhooddiseases and hadafracture of the left filth finger; The patient all of theseapparent4improved, without any unusual'sequelae. has been receivingsome psychotherapy sinceJuly,1959,andhasbeen attending regularly for about six months. The parents feel that there has been some improvement since this time.

147 Family History. Father, age4-5;mother, age4.5. The patient is an only child.

Physical acamination. Examination reveals a 12-i-year-old. Caucasian male whose general condition is good. Height,3.55.5ems.; weight,43 kgms.;blood pressure,94/68; respiration, 18, pulse, 72. The patient's general physical condition was good. There were a few small scars over the scalp secondaryto previous trauma. There is a mild. first-degree hypospadias. The remainder of the general physical examination was not remarkable.

Neurological Examination. Examination revealed thepatient to beright- handed. He was alert and cooperative and hisintellectualdevelopmentappeared. to be that expected for his chronological age. The cranial nerves wereexamined in detail and. foimd to be intact. The optic fund.i were normal. Examination of the motor system revealed no evidenceof apasticity, rigidity, .or weakness. The myotatic reflexeswere physiological andsymmetrical throughout. The patient's coordination was good, and. there was no evidence tosuggest any specific cerebellar dysfunction. The abdominal and cremasteric reflexes were present. The plantar reflexes were flexor bilaterally. Sensory examination revealed no abnormalities to pain, touch, position sense, vibration,stereognosis, and two-point discrimination. Thepatient's gait and. speech were normal.The remainder of the neurological examination was not remarkable.

Laboratory Data.An electroencephalogram was obtained on November30, 1959, using tenelectrodes, with scalp-to-scalp and. scalp-to-ear techniques. There is a poorly organized basic frequency of8 to 9cps with some scattered 5-to 7-cps activity appearing anteriorly. Duringdrowsiness, the amount of 5-to 7-cps activity increases with fairly symmetricalbiparietal humps and. 14.- cps sleep spindles appearinganteriorly during light sleep.At no time during the tracing are there any focal or paroxysme/abnormalities.Byperventilation for three minutes resulted in the appearanceof aome slow 1- to3-cps waves, but this was not paroxysmal in type.Photicstimulationinduced some driving at the flash ratesbetween 15and. 20 flashesper second. The record was interpreted., however, as being normal, both awake andasleep, for the patient' s chronological age.

Summary andImpression.Theclinical manifestations reflect fundamentally a basic emotional disturbance. Careful clinical neurological evaluation and electroencepbalographic examination did notreveal any specific evidence to swggest an organic disease of thecentral nervous system.

School Placement

Case 19 was placed. in a specialclass withother boys with learning and. behavior problems. No follow-up achievement test data wereavailable since he

was absent on the days thatthe tests were given. -

148 Follow-up (two years, nine monthsafter study began)

He went back to a regularclass from the special placement, and his adjustment there was only fair. He was very unpopular with his peers andneeded continual supervision. He was suspended for foul language inthe classroan and for the may be talked to girls about sex. The fatber came to talk with the principal and counselor. The mother had left his supervisioncompletely to the father. Case 19 went to high sdhooll andat this time there mere no complaints. The prognosis is very poor since it is expectedthat be mill soon fall into the usual pattern of having difficultywitt his peersat school.

1 49 cCase No. 19 12 years,5 mo. .1 Boy

4.5

150 F7*- -11!rr Case No. 19 12 years, 5 mo Boy CASE 20

Boy -- Fifteen Years, ElevenMonths

School Behavior

The boy's teachers describe him asbeing disinterested and lacking in energy and vigor. He is always alert to every chance forthrowing spitballs and creating other classroom diversions,but, if he wished to, he could make a substantial contributionto classroom activities. He has poor work habits and smalathetic attitude.

Individual test results are typical of aboy with above-average intelligence. His marks in school range from"incomlete" to F.Wo teacher surveyed for ratings of Case 20 was able to saythat he was doing well in school with the exception of the study hallteacher who thought that he was fine.

Raw Scaled Raw Scaled Verbal score score Performance score score

11 Information 21 12 Picture' Completian 14 Comprehension 10 Picture Arrangement 37 11 Arithmetic 14 13 Block:Design 44 13 Similarities 15 11 Object Assembly 28 13 Vocabulary 54 13 Coding (mazes) 65 13 Sum of Verbal Tests 60 Swn of Performance Tests 61

Verbal IQ 60 113 Performance IQ 61 115 Full Scale IQ 121 45

Medical Report (nine months after studybegan)

History of Present Prdblem. The patient has had many difficulties in adapt- ing to school and at times has had.problems of a delinquent nature. The mother apparently does not have great insightinto his emotional difficulties.

His mother's Ftst Bastory. The patient has been well mostof his life. pregnancy was uneventful. She was in ldbor for severalhours, and the delivery was thought to be normal. The patient weighed(s lbs., 14. oz., at birth. He was bottle-fed and. nodifficulties were encount)red. His development wns thought to be within normal limits. His mother feels that he has beenaccident-prone since early childhood. At the age of eight years he wasknocked off a horse and 'tea a period of impaired memoryfor several hours. Re was not unconscious at at that time. Also at eight years, he wasinjured when a log was thrown him and was unconscious for a fewmoments. He has had the usualchildhood have diseases with no ;articularcomplications. The patient is thought to mornings on asthma about once every three years. He has a stuffy nose most

153 T-

amakening, whiCh subsides after an hour or so. The patient apparently bad taeath-bolding spells with loss of consciousness as aninfant, particularly when frustrated in any way.

Family History. Father, age 41, is an engineer. His sister, age 19, is withdrawn at times, depressed, and alsohas asthma and emotional difficulties; she is a freshman at college. A brother, age14, is; according to the mother, brilliant like his father. A maternal grandfathercommitted sUicide, using carbon monoxide, after World War I. The remainder of the history is notremarkable.

Physical examination reveals an AlmostI6-year-old - Physical Examination. white male Whose general condition is good. His height is 169 cm.; weight, 55.2 kgms.; blood pressure,110/70; pulse, 82, respiration, 18. The general physical examination reveals the patient'soverall condition to be good. There are noabnormalities.

Neurological Examination.INamination reveals a16-yearold, right-handed, white male who was alert and cooperative duringthe exmnination. He appeared to be of average intelligence. The cranial.nerves mere examined and foundto te intact. The optic fundi were normal. Examination of the Motor system revealed. nd evidence of spasticity or weakness. The myotatic reflexes were physiological and symmetrical. The abdominal and. cremasteric reflexes were present. The plantar reflexes,were flexor.Sensory examination reVealed no abnorMalities in the modalities of pain, tough, vibration, orposition.- Stereognosis was normal. The patient's coordination was quite good,and there was no evidence to sqggest anycerebellar dysfUnction. The patient's gait and speechwere normal.,Thexemainder of the examination was notremarkable.'

Ldboratory Data. An electroencephalogram was done onNay 29, 1959. The tracing was obtained, using 12 electrodes,with scalp-to-scalp and scalp-to- ear techniques. There is a very rbythmiCal basic frequency.of 10 to 11 cps' appearing in all leads, although most prominent overthe posterior scalp areas. ruring portions of this recording, there is amild amplitude asymmetry with the lower pOtentials appearing over the leftoccipital region. There are no frequency Changes,. however, in, association withthis asymmetry. Hyperventila- tion kor three'minutes didnoi significantly alter this record.IMpression: normal EBG.

Summary end Impression. The einical manifestationsreflect primarily a behavioral disorder with some acting-outdifficulties which tend to assume a' delifiquent pattern. A careful neurological andelectroencepbalographical' examination revealed there'is no evidence'tosuggest any organic disorder of the central nervous-system.

School Placement

During the 1958-59 school year,Case 20 participated in a groupcounseling class for one hour a day, five days aweek. The group leader plannedactivities designed to give opportunities forexploring educational and vocationalgoals and for discussing school-relatedproblems and relationships with peersand adults.

154 F011ow-up (three years after studybegan)

Case 20 graduated fromhigh school at the end ofthe 1961 summer school 2.1, a C average. Disciplinary session. His overall grade point average was during his senior year. referrals to the vice-principalhad dropped off markedly Previously, he was referred oftenfor calling a teacher byher first name, bad behavior during assembly, andpainting signs on the campusof a rival school.

His His mother remarried in August. Case 20 thinks his stepfatheris "OK." brother is an outstanding student. Case 20 drinks alcoholic beverageswith impunity and is very much involvedwith girls. He has worked part time as.a after graduation summed up hisimpres- truck driver. The viceprincipal's report I sion of Case 20 with thisstatement: "Case 20 pas made splendid progress, and feel he is on his wayto'good,citizendhip."

15 5 Case No. 20 15 years, 0 mo. Boy

. Draw a Person

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