If you have issues viewing or accessing this file contact us at NCJRS.gov. ",~. :.-!:~,~----'---~,:-,--~"""------=:;~--- ,I ,' .. r ' '. " , , . ":1" .. ':\ :' I: ;- , . ' NINDQ MONOGBAPH NO:, 3'
. " ".'
, . '
I, • I I
,1 ' Minimal, ,Brain Dysfunction .in" Children
Terminology and Identification Phase One' of a Three-Phase Project . .
... i j' ..------~------=>'>'~ ------NINDB MONOGRAPH NO.3
FEB 1419~9
ACQUnSHTllONS; Minimal Brain Dysfunction in Children
Terrninology and Identification Phase One of a Three-Phase Project
by SAM D. CLEMENTS, Ph. D. Project Director; Consultant, National Institute of Neurological Diseases and Blindness; Associate Professor, Departments of Psychiatry and Pediatrics, University of Arkansas Medical Center, Little Rock, Arkansas
Cosponsored by The Easter Seal Research Foundation of the National Society for Crippled Children and Adults, Inc. and National Institute of Neurological Diseases and Blindness Public Health Service
DHEW Publication No. (NIH) 76-349
U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health S.ervice National Institutes of Health 1966 Public Health Service Publication No. 1415 1966 Foreword
Deviations in nervous system function may lead to a wide variety of disabilities. These range in severity from the most subtle alteration of complex thought process to the grossest mental and motor disability. Their nature depends upon the indi. vidual's basic inheritance, the impact on his nervous system of any deletenou,; pren RICHARD L. MAS LAND, M.D., Director) National Institute of Neurological Diseases and Blindness, Public Health Service JANUARY 1966 iii Table of Contents SecUon Page I. Introduction to the problem ..' ...... • . 1 II. History and blueprint of the project...... • 3 III. A brief history of the concept of minimal brain dysfunction. 5 IV. Toward clarification of central issues . . . 6 V. Nomenclature ...... 8 VI. Symptomatology-identification of the child 11 VII: Diagnostic evaluation and criteria 14 VIII. Bibliographies ...... 16 Section bibliographies. . . . 16 References not cited in article 17 v I. Introduction to the Problem A large number of individuals within our population Educators cannot defer dealing", ith the educational show deviations of intellect and behavior of such a na disabilities of these children or the behavioral disturb ture as to require special resources for their manage ances they frequently display pending scientific clarifi~ ment and education. The concept of brain dysfunction cation of the issues. as a primary causative factor in these learning and be The rise in the number of so-called "children with havioral disorders of children has received increasing minimal brain dysfunction" may, in part, be explained atteption over the past 20 years. This concept has on the basis of one 01' more of the following factors: attained particular prominence in the fields of medi 1. The increased refinement in diagnostic techniques and skills over the last several years. cine, psychology, education, and the language 2. The growing necessity for more precise classifi~ specialties. cation of the learning and behavioral disorders of chil The current extensive concern for, awareness of, and dren. The usefulness of statistical data for such pur interest in children with minimal brain dysfunction is poses as reporting to central agenciesJ program plan. not restricted to the prQfessional groups who work with ning, and research depends on precise classification. and for children. Indeed, the stirrings of discontent This is particularly true of outpatient child guidance have been intensified by parents of such f.hildren. Par clinics. In these clinics, there is a general agreement ents alonc, or more recently through organized local, that the standard psychiatric nosology as outlined hl. State, and National groups, have demanded increased the Diagnostic and Statistical Manual of the Ameri public and professional acknowledgment of J-J.s host can Psychiatdc Association (1952) is tmsatisfactory of handicapped youngsters. Parents want services to and, for the most part, inaPPl'opriate for use with chit. aid each such child to develop to his potential; they dren. (It was developed mainly £01' the classification have appealed for specialized academic training for of adult disorders.) professional groups, to give such services effectively. 3. An apparent increase in the number of children Fcw subject areas have occasioned such wide multi compromised by neurologic dysfunctions, which, un.. disciplinary concurrence and collaboration while simul fortunately, is often the unintentional afterrrtath of ad· taneously provoking professional disjunction and dis vances in medical knowledge and care. cord. In fact, the role of brain injury within this broad 4. A growing dissatisfaction on the part of many constellation of physical, intellectual, and behavioral medical workers with children with purely psycho deviations has not been determined with precision. genic and interpersonal explanations for any disorga. The educators and, in particulat, the elementary nized or poorly understood behavior. classroom teachers must provide programs for such A commonly expressed concern of both professionals individuals, regardless of the exact cause of their dis and parents is the general lack of knowledge, underw ability. In some instances this situation has led to standing, and agreement in the broad area of minimal hastily conceived public school programing, involving brain dysfunction among the clinicians who arc ac a considerable e."penditure of money, with inadequate countable fot the diagnosis and treatment of deviating provisions and criteria for student selection, teacher children, training requirements, program supervision, and evalu The concept of minimal brain dysfunctions in chil ation. dren and the implications for child psychia.try, child 1 psychology, education, legislative action, neurology, Adults, Inc., provided the initiative for clarification of perliatrics, rehabilitation, and research, have top pri the iSlmes involved and the development of a blueprint ority with parents and professional persons. The Na for action. tional Institute of Neurological Diseases and Blindness, The following document preseTlts. one segment of and the National Society for Crippled Children and this collaborative effort. 2 II. History and Blueprint of the Project On August 22, 1963, a steering committee meeting Task Force lI-8ervices to develop a symposium On the "Child with Minimal Extent o( need: For medical diagnosis and tl'~atnlcnt. Brain Dysfunction" was held in Washington, D.C It For identification of cduca\ional capabilities and wa.,> sponsol'ed by the National Society for Crippled methods of educating a£llictcd children. Children and Adults, Inc., in cooperation with the Availability; In medical centers? In public Neurological and Sens01,}, Diseases Service Program schools? What services from 0. practical viewpoint should of the Dlvision of Chronic Diseases, U,S. Public be made available? Hearth Service. What should a =,ublic infonTIr.tion program include The group was in accord that considerable thought to acquaint the community with the problem? Task Force III-Research and planning must precede a high~level svmpositlm on Applied research. this complex subject. It was agreed that small groups Basic rcselU'ch. (task forces) should meet to work on specific aspects In July 1964, the National Society for Crippled of the general subject of the child with minimal brain Children and Adults, Inc., and the National InstivJte dysfunction. Suggestions included a subcommittee on of Neurological Diseases and Blindness, of the National terminology and identification, a classification of Institutes of Health, agreed to C05POllS01' Task Forces criteria for diagnosis, a survey of the magnitude of the I and III. The Society and the Neurological and problem, a.nd a listing of available faciliti(Js f01' diag Sensol,}, Disease Service Program arc cosponsoring nosis, therapy, education, and rehabilitation. Various Task Force II in cooperation with the Office of methods of financing such .~ project were discussed. Education. On October 10, 1963, a meeting of the Committee These members of the Task Force I Committee and on Task Forces was held in Chicago, 111., sponsored a Project Director were named in August 1964: by the National Society for Crippled Children and Richmond S. Paine, M,D,. Children's Hospital and Adults, Inc. The following individuals attended: George Washington University School 1;)£ Medicine, Washington, D.C.--Committee Chairman. Edward Lis, M.D.; Helmer Myklebust, Ed. D.; Ward Herbert G, Birch, M.D., Ph. D., professor of pediatrics, Halstead, Ph. D.; Meyer Perlstein, M.D.; Ralph H. Albert Einstein College of Medicine, New York, l·~.Y. Kunstadtel', M.D.; William Gellman, Ph. D.; Miss Raymond L. Clemrnens, M.D., Department of Pediat Jayne Shover. The purpose of the session was to de rics, University of Maryland School of Medicine, Baltimore, Md, lineate the objectives of the task forces as recom· Leon Eisenberg, M.D., professor of child psychiatry, mended at the Washington conference and to consider Johns Hopkins UniVl'rsity, Bnltimore, Md. their membership. Ralph H. KUllstadter, M.D., chnirmtm, Professionnl Ad visory Council, National Society for Crippled Children The task forces were profiled as follows: and Adults, Inc., Chicago, 111. ('x offido). Edward Lis, M.D., professor of pediatrics, University of Task Force I-TermitlOlog), and Identification Illinois, Chicago, Ill. Define problem. Rir,hard L. :Maslnnd, M.D., Director, National Institute Suggest nomenclature. of Neurologietll Discases and Blindness, National In Identify child. stitutes of Health, Bethesda, Md. Delineate relationship of this problem to other Helmer Myklebust, Ed. D., director, Institute for Lan handicaps. guage Disorders, Nortllwcstcrn University, Evnnston, Outline dingnostie criteria. Ill. 3 Beale Ong, M.D., consultar.t in pediatric neurology, A grant from the Easter Seal Research Foundation Neurological and Sensory Disease Service Program, to cover the expenses of the Committee members of U.S. Public Health Service, Washington, D.C. John E. Peters, M.D., professor of psychiatry, University Task Force I was awarded for administrative handling of Arkansas Medical Center, Little Rock, Ark. to George Washington University, Washington; D.C. Miss Jayne Shover, associate director, National Society The project director was appointed a consultant for Crippled Children and Adults, Inc., Chicago, Ill. (ex officio). to the National Institute of Neurological Diseases Sam D. Clement~, Ph. D., associate professor, Depart and Blindness. ments of Psychiatry and Pediatrics, UniverJity of Arkansas Medical Center, Little Rock, Ark.-projeet October 1, 1964, was the target date for the official director. laun.ching of the project. 4 ------ III. A Brief History of the Concept of Minimal Brain Dysfunction The literature on minimal brain dysfunction prior authors. As is the case with many pioneering works, to 1920 is sparse and is generally concerned with ob it represented the eSSenCe of 20 years of foregoing servations on individuals who sustained damage to the study. In the light of the subsequent expansion of brain after reaching adulthood. the concepts the study may appear fragmentary. Several early references describe "nervous condi Mindful of this, and perhaps anticipating reproving tions" in children which affect learning and behavior response, Strauss and Kephart acknowledged the need (1, 2). for alterations in theories and applications as new data Many papers appearing during the period between accumulated (29). the two World Wars can be considered as the descrip Nonetheless, few single volumes have been so in tive forerunners of certain aspects of minimal brain fluential in the production of fresh considerations in dysfunction. Of particular importance are the con the areas of pathology, diagnosis, education, and in tributions of Kramer and PoIlnow (3); Kahn and vestigation of children with learning and behavioral Cohen (4); Bender (5, 6); Goldstein and Scheerer disabilities. Xt refocused attention on the neglected (7); Goldstein (8); Orton (9). A large number of area of individual differences among children. It also references are devoted to the linkage between specific is an excellent illustration of the usefulness of col etiologic agents and resultant changes in behavior and laboration on a problem area. learning abilities (10-21). Since 1950, the literature has become increasingly 1;'he early work of Gesell and Amatruda (22); loaded with clinically oriented articles and studies of Werner and Strauss (23) ; Werner and Thuma (24); the disabilities under the general concept of minimal Werner and Weid (25); Strauss and Werner (26); brain dysfunction in children. Strauss (27) sets the stage for the concepts of brain The recent volume edited by Birch (30) i the com dysfunction in children and the child with minimal prehensive review of mental subnormality by Masland, brain dysfunction as they are presently constituted. Sarason, and Gladwin (31); and recent standard texts The c1as!:ic work of Strauss and Lehtinen (28) became of child psychology, neurology, pediatrics, and psy~ the first comprehensive presentation on the topic and chiatry obviate an extensive review of the literature is the reference most frequently cited by subsequent for this particular paper. 5 I • IV. Toward Clarification of Central Issues Several basic issues impede agreement on the COrl is contributing to the chief complaints about the child cepts of "brain dysfunction" and the tlchild with mini and to his clinical symptoms. mal brain dysfunction." They come from our If the "whole child" approach to diagnosis is incomplete knowledge of the human organism, our deemed essential to the earnest understanding of a communication failures, and our personal biases. Any "difficult" youngster, then equal weight, in terms of serious attempt at solution must at least acknowledge symptom antecedents and investigatory priority, must these issues. be given to both organicity and environment. THE ORGANIOITy-ENVIRONMENT OBSTACLE Although organicity is often recognized as a con One issue is the age-old dilemma: Organicity vs. trib1,ltor to symptomatology, it is frequently ignored in environment. This conflict, which is reminiscent of the final diagnosis of the child, and in the treatment the heredity-environment controversy, represents an planning, unless it is grossly obvious. The justification updating and expansion of its predecessor. offered is our inability to ascertain exactly the extent The concept of organicity has been broadened to of its contribution. include all factors which originate in or are inherent Two DIFFERING POINTS OF VIEW in pathology, including genetic variations, biochemical irregularities, perinatal brain insults, or the results of A second clouded issue reflects uncertainty regard illnesses and injuries sustained during the years critical ing the very existence of a condition such as "minimal for the normal development and maturation of the brain dysfunction" in the types of children with which central nervous system. we are dealing. For convenience, the extreme views Incl1,lded in the organicity concept is the proposition will be categorized and labeled according to the senti that any condition which alters normal functioning ments of their proponents. can manifest itself as learning and behavioral irregular 1. The purist point of view is that I'minimal brain ities. These irregularities depend upon such factors dysfunction" is in most instances an unproven pre as causes, loci of the assault, developmental stage of sumptive diagnosis. Therefore, the concept can have embryo, fetus, or child, and diffuseness or discreteness little meaning and acceptance until such time as our of the damage to the central nervous system (eNS). knowledge is greatly increased and our diagnostic The concept of environment would consider all skills remarkably refined. Brain dysfunctioning can factors related to the normal life experiences inherent only be inferted until physiologic, biochemical, or in the social-economic-cultul'al milieu of the individ structural alterations of the brain are demonstrated. .j ual) his interpersonal relationships, and his personal 2. The pragmatic case might be presented in the ~ psychological traumata and stresses. Included is an following manner: With our limited validated knowl appreciative regard for the part such elements could edge concerning relationships between brain and be play in the production of learning and behavioral havior, we must accept certain categories of deviant 1 irregularities. behavior, developmental dyscrasias, learning disabili Assuming agreement that the two ma.ior determi ties, and visual-motor-perceptual irregularities as valid nants of learning and behavior are organicity and indices of brain dysfunctioning. They represent neuro environment, the diagnostic team must determine, as !ogic signs of a most meaningful kind, and reflect dis accurately as possible, the amount of impairment each organized central nervous system functioning at the 6 - --_._------highest level. To· consider learning and behavior as fe'ctively and honestly as possible the large number of distinct and separate from other neurologic functions children who present chronic differences we feel are echoes a limited concept of the nervous system and of more related to organicity variables than others. its various levels of influence and integration. The above two views represent the extreme versions We cannot afford the luxury of waiting until causes of the situation. If clinicians' viewpoints could be can be unquestionably established by techniques yet to plotted, the result would most likely take on the shape be developed. We cannot postpone managing as ef- of a bimodal distribution with overiapping. 7 v. Nomenclature Nomenclature is essential to facilitate communica erroneous, too inclusive, or represent a "limited" tion. Its purpose is to engender mutual understand~ Straussian view. A proposal for the resolution of the ing. To this end, terminology must define accurately terminology problem was offered several years ago and, in so doing, distinguish clearly one condition from by Stevens and Birch (32). another. To be understood readily, the term must Over the years, the designation "brain-damaged" describe the condition. has been applied to most children determined to be The task of te~inology selection might be simpli in the "organic" classifications regardless of responsible fied if endorsement were required by one group only, agents or symptoms. Thus, if the major overt mani e.g., pediatric neurologists. In the case of children festations of a dysfunctioning brain appear in the with minimal dysfunction the designation must at motor areas (the cerebral palsies); sensory areas tempt to satisfy the diverse demands of at least four (visual or auditory impainnents); mentation or intel groups: lect (the mental subnormalities); or as seizures (the 1. The clinicians (usually involving several dis epilepsies) ; the "brain-damaged" label has frequently ciplines) who diagnose, outline, and execute treat been applied to the child, especially when related spe ment. cific learning and behavioral deviations accompany the 2. The researchers who are concerned with descrip other primary symptoms. This situation has given tive accuracy, validity, and preciseness of the eNS rise to the frequent complaint that the term has evolved deviations. into an all-embracing "wastebasket" designation. 3. Other professional groups who deal with the The problem compounds itself when one considers children and fulfill portions of the treatment plan, a partial list of other diverse characteristics which have e.g., educators. been attributed to brain variations: infantile autism; 4. Parents and others who are personally involved childhood schizophrenia; superior intellect; specific with the child. talents and abilities in music, art, language, athletics; Disagreement has developed over the use of the the aphasias; specific dyslexia; or early and superior term "minimal brain dysfunction" as either a diagnos reading ability. tic or descriptive deaignation. Historically, the terms In an attempt to establish a continuum of dysfunc "brain-crippled," "brain-injured," and "brain-injured tioning in any of the areas of brain function, and to dis child," were selected by Strauss, Werner, Lehtinen, tinguish severity of symptoms in one or a combination and others, to describe and account for particular of these areas, many later authors prefixed the adjective learning and behavioral aberrations in certain chil "minimal" to the terms "brain damage," "brain dys dren. Other writers, in contributing to or expanding functions," or "cerebral dysfunction." In the main, the concept or in describing the condition, used such these terms were used by their authors to describe transitional terms as "brain damage," "brain-damaged milder, borderline, or subclinical abnormal manifesta child," "brain dysfunction," or "cerebral dysfunction." tions of motor, sensory, or intellectual function, and to Judging from frequency of appearance in the indicate specific kinds of learning, thinking, and be literature, "brain damage" and "brain-damaged child" havioral sequelae. seem to be the most popular. Although these two Of major significance is the nse of "minimal brain terms are the most widely employed, most writers dysfunction" to designate a large group of children agree that they are unfortunate in that they connote whose neurologic impairment is "minhnal" (as on a specific demonstrable brain alterations, are unclear, continuum), subtly affecting learning and behavior, 8 without evident lowering of general intellectual Organic Brain Dysfunction (36) capacity. Minimal Brain Damage (38) Diffuse Brain Damage (39) Strauss and Lehtinen (28, p. 108 and p. 128) use the N europhrenia (40) terms "minor brain damage," and "minimal brain in Organic Drivenness (4) jury," for this same condition, stating: "Behavior Cerebral Dysfunction (41) and learning, it is now beginning to be recognized, may Organic Behavior Disorder (42) be affected by minimal brain injuries without apparent Choreiform Syndrome (43) Minor Brain Damage (28) lowering of the intelligence level." The volume by Minimal Brain Injury (28,44) Strauss and Kephart (29) is primarily devoted to this Minimal Cerebral Injury (22) group of youngsters. Gesell and Amatruda (22, p. Minimal Chronic Brain Syndromes (45) 240), U5ing the term "minimal cerebral injury," de Minimal Cerebral Damage (46) scribe the counterpart in infants and young children. Minimal Cerebral Palsy (47) Cerebral Dys-synchronization Syndrome These terms have been criticized by Birch (30, p. 5) . Yet the authors using "minimal brain damage" or Group II-Segment or Consequence "minimal brain dysfunctions" apparently have done so Hyperkinetic Behavior Syndrome (48) in an honest effort to characterize categories of chil Character Impulse Disorder (49) dren. These children are different in certain learn Hyperkinetic Impulse Disorder (50) Aggressive Behavior Disorder (51 ) ing and behavioral patterns, but when tested individ Psychoneurological Learning Disorders (52) ually and comprehensively achieve within the near Hyperkinetic Syndrome (53 and others) average, average, or above average ranges of intellec Dyslexia (54 and others) tual functioning. The vital implication is that educa Hyperexcitability Syndrome (43) tional programing and rehabilitation for tht 9 guage, memory, and control of attention, impulse, or mal brain dysfunction may exhibit these minor symp motor function. toms in varying degree and in varying combinations. Similar symptoms mayor may not complicate the Classification Guide, Brain Dysfunction Syndromes problems of children with cerebral palsy, epilepsy, mental retardation, blindness, or deafness. Minimal Major These aberrations may arise from genetic variations, (minor; mild) (severe) 1. Impairment of fine movement or 1. Cerebral palsies. biochemical irregularities, perinatal brain insults or coordination. other illnesses or injuries sustained during the years 2. Electroencephalographic abnor 2. Epilepsies. which are critical for the development and maturation malities wi thou t actual seizures, of the central nervous system, or from unknown causes. or possibly subclinical seizures The definition also allows for the possibility that which may be associated with fluctuations in behavior or intel early severe sensory deprivation could result in central lectual function. nervous system alterations which may be permanent. 3. Deviations in attention, <'ctivity 3. Autism and other During the school years, a variety of learning dis level, impulse control, and gross disorders of abilities is the most prominent manifestation of the affect. mentation and be condition which can be designated by this term. havior. 4. Specific ancI circumscribed per 4,. Mental subnormal The group of symptoms included under the term ceptual, intellectual, and mem ities. minimal brain dysfunction stems from disorders which ory deficits. may manifest themselves in severe form as a variety 5. Nonperipheral impairments of 5. Blindness, deafness, vision, hearing, haptics, and and severe apha of well-recognized conditions. The child with mini- speech. sias. 10 I VI. Symptomatology-Identification of the Child In a search for symptoms attributed to children with 5. Poor showing on group tests (intelligence and minimal brain dysfunctioning, over 100 recent publi achievement) a,1d daily classroom examinations cations were reviewed. which require reading. Many different terms were used to describe the 6. Characteristic subtest patterns on the Wechsler same symptom, e.g., excessive motor activity for age Intelligence Scale for Children, including "scat might be referred to as anyone of the following: ter" within both Verbal and Performance hyperactivity, hyperkinesis, organic driven ness, rest Scales; high Verbal-low Performance; low lessness, motor obsessiveness, fidgetiness, motor disinhi Verbal-high Performance. bition, or nervousness. B. Impairments of Perception and Concept-formation A large number of terms were too broad for other than limited value, e.g., "poor academic achieve 1. Impaired discrimination of size. ment"; others were more specific, e.g., "reading ability 2. Impaired discrimination of right-left and up- two grade levels below grade placement." A few are down. mentioned one time only, e.g., "inclined to have faint 3. Impaired tactile discriminations. ing spells." Others are too general (or judgmental) to 4. Poor spatial orientation. classify, e.g., "often good looking." Opposite char 5. Impaired orientation in time. acteristics are common: "physically immature for 6. Distorted concept of body image. age"-"physically advanced for age"; "fearless" 7. Impaired judgment of distance. "phobic"; "outgoing"-"shy"; "hyperactive"-Hhypo 8. Impaired discrimination of figure-ground. active." iJ. Impaired discrimination of part-whole. These examples represent some of the difficulties 10. Frequent perceptual reversals in reading and in encountered in developing a scheme for classification writing letters and numbers. of the symptoms, and indicate the variety of syn'dromes 11. Poor perceptual integration. Child cannot contained within the primary diagnosis of minimal fuse sensory impressions into meaningful entities. brain dysfunctioning. The following represents C. Specific Neurologic Indicators an attempt to classify some of the descriptive elements 1. Few, if any, apparent gross abnormalities. culled from the literature. 2. Many "soft," equivocal, or borderline findings. PRELIMINARY CATEGORIES OF SIGNS AND SYMPTOMS 3. Reflex assymetry frequent. 4. Frequency of mild visual or hearing impair- A. Test Performance Indicators ments. 1. Spotty or patchy intellectual deficits. Achieve 5. Strabismus. ment low in some areas; high in others. 6. Nystagmus. 2. Below mental age level on drawing tests (man, 7. High incidence of left, and mixed laterality house, etc.) • and confused perception of laterality. 3. Geometric figure drawings poor for age and 8. Hyperkinesis. measured intelligence. 9. Hypokinesis. 4. Poor perfonnance on block design and marble 10. General awkwardness. board tests. 11. Poor fine visual-motor coordination. 11 D. Disorders of SPeech and Communication 3. Poor emotional and impulse control. 1. Impaired discrimination of auditory stimuli. 4. Low tolerance for frustration. 2. Various categories of aphasia. 5. Reckless and uninhibited; impulsive then re 3. Slow language development. morseful. 4. Frequent mild hearing loss. J. Sleep Characteristics 5. Frequent mild speech irregularities. 1. Body or head rocking before faIlmg mto sleep. E. Disorders of Motor Function 2. Irregular sleep patterns in the young child. 1. Frequent athetoid, choreiform, tremulous, or 3. Excessive movement during sleep. rigid movements of hands. 4. Sleep abnormally light or deep. 2. Frequent delayed motor milestones. 5. Resistance to naps and early bedtime, e.g., seems 3. General clumsiness or awkwardness. to require less sleep than average child. 4. Frequent tics and grimaces. K. Relationship Capacities 5. Poor fine or gross visual-motor coordination. 1. Peer group relationships generally poor. 6. Hyperactivity. 2. Overexcitable in normal play with other chil 7. Hypoactivity. dren. F. Academic Achievement and Adjustment (Chief S. Better adjustment when playmates are limited to complaints about the child by his parents and one or two. teachers) 4. Frequently poor judgment in social and inter 1. Reading disabilities. personal situations. 2. Arithmetic disabilities. 5. Socially bold and aggressive. 3. Spelling disabilities. 6. Inappropriate, unselective, and often excessive 4. Poor printing, writing, or drawing ability. displays of affection. 5. Variability in performance from day to day 7. Easy acceptance of others alternating with with or even hour to hour. drawal and shyness. 6. Poor ability to organize work. 8. Excessive need to touch, cling, and hold on to 7. Slowness in finishing work. others. 8. Frequent confusion about instructions, yet suc L. Variations of Physical Development cess with verbal tasks. 1. Frequent lags in developmental milestones, e.g., G. Disorders of Thinking Processes motor, language, etc. 1. Poor ability for abstract reasoning. 2. Generalized maturational lag during e~rly school 2. Thinking generally concrete. years. 3. Difficulties in concept-formation. 3. Physically immature; or 4. Thinking frequently disorganized. 4. Physical development normal or advanced for 5. Poor short.-term and long-term memory. age. 6. Thinking sometimes autistic. 7. Frequent thought perseveration. M. Characteristics of Social Behavior H. Physical Characte;'istics 1. Soci~ i competence frequently below average for age a.ud measured intelligence. 1. Excessive drooling in the young child. 2. Behavior often inappropriate for situation, and 2. Thumb-sucking, nail-biting, head-banging, and consequences apparently not foreseen. teeth-grinding in the young child. 3. Food habits often peculiar. 3. Possibly negative and aggressive to authority. 4. Slow to toilet train. 4. Possibly antisocial behavior. 5. Easy fatigability. N. Variations of Personality 6. High frequency of enuresis. 1. Overly gullible and easily led by peers and older 7. Encopresis. youngsters. I. Emotional Chal'acteristics 2. Frequent rage reactions and tantrums when 1. Impulsive. crossed. 2. Explosive. 3. Very sensitive to others. 12 4. Excessive variation in mood and responsiveness 5. Disorders of attention (short attention span, from day to day and even hour to hour. distractibility, perseveration). 5. Poor adjustment to environmental changes. 6. Impulsivity. 6. Sweet and even tempered, cooperative and 7. Disorders of memory and thinking. friendly (most commonly the so-called hypo 8. Specific learning disabilities: kinetic child) . a. Reading. b. Arithmetic. O. Disol'dcl's of Attention and Concentration c. Writing. 1. Short attention span for age. d. Spelling. 2. Overly distractible for age. 9. Disorders of speech and hearing. 3. Impaired concentration ability. 10. Equivocal neurological signs and electro 4. Motor or verbal perseveration. encephalographic irregularities. 5. Impaired ability to make decisions, particularly The CCsigd' approach can serve only as a guideline from many choices. for the purpose of identification and diagnosis. Several authors note that many of the character The protea~ nature of the disability is the obvious istics tend to improve with the normal maturation of conclusion from the approach to symptomatology and the central nervous system. As the child matures, identification taken above. various complex motor acts and differentiations appear The situation, however, is not as irremediable as it or are more easily acquired. might appear. Order is somewhat salvaged by the Variability beyond that expected for age and meas fact that certain symptoms do tend to cluster to form ured intelligence appears throughout most of the signs recognizable clinical entities. This is particularly true and symptoms. This, of course, limits predictability of the "hyperkinetic syndrome," within the broader and expands misunderstanding of the child by his par context of minimal brain dysfunctioning. The ents, peers, teachers, and often the clinicians who work "hypokinetic syndrome," primary reading retardation, with him. and to some extent the aphasias, are other such Ten characteristics most (,ften cited by the various examples. authors, in order of frequen.:y : Recognition and acceptance of these specific symp 1. Hyperactivity. tom complexes as subcategories, within the general 2. Perceptual-motor impairments. category of minimal brain dysfunctioning, would 3. EmotionallabiIity. facilitate classification and the development of appro 4. General coordination deficits. priate management and education procedures. 13 VII. Diagnostic Evaluation and Criteria The purposes of the diagnostic evaluation are to cific intel'p~rsonal family dynamics, emotional demonstrate the existence or absence of minimal brain stresses, and traumata. dysfunction, to determine the causative factors of the 2. PHYSICAL EXAMINATION: past 0)' present environment responsible for this con a. General.-To evaluate general physical dition, to define the specific limitations of physical or status and to search for sYs'temic disease. The intellectual capabilities present, and thus to establish physical examination should be done as part of the basis for a logical program of medical and educa the current evaluation of the child, ;;md not ob tional remediation. tained at a previous time for some 01.;,';',," purpose, Diagnostic confusions have developed from a lack e.g., routine preschool checkup or in conj1,lr·di.on of recognition that differences e. 14 B. BEHAVIORAL ASSESSMENT private practice. Clinic orientation might emphasize 1. ACADEMIC HISTORY.--To involve child's teaching-training, service, or research. teachers and principal, with their observations 3. The diagnostic procedure-including such as regarding school behavior as well as academic pects as thoroughness and excellence, in terms of time, progress and achievement. The child's school number; and varieties of techniques and measures records: including samples of schoolwork and utilized and uni- or multiple-disciplinary approach. test results, should be available to the diagnostic Unfortunatdy, at the present time a lack of scien team. tific knowledge may make it impossible to provide a 2. PSYCHOLOGICAL EVALUATION.-The precise medkal or educational diagnosis. Resort must following items represent the core of the psycho be made to broad and imprecise diagnostic categories. logical evaluation: The development of multidisciplinary diagnostic pro a. Individual comprehensive assessment of in grams and the continuing increase of scientific knowl tellectual functioning. edge will do much to dispel these existing disturbing b. 1{easures of complex visual-motor-percep uncertainties. tual functioning. We are dealing with a complex and extensive work c. Behavioral observations in a variety of up. Few existing clinics are prepared to provide all !lettings. the services required by this group of children. There d. Additional indices of learning and behavior are great advantages in consolidation of effort and as indicated. concentration of facilities in a single environment. 3. LANGUAGE EVALUATION.-Detailed as A more detailed consideration of the means by sessment of speech and language behavior. To which these needs are to be met and of the specific include audiometric screening; assessment of ar management and educational programs which will be required is the subject of a further study to be ticulation, voice quality, and rate; and ~he ex pressive and receptive aspects of language. carried out by Task Force II of this mission. The 4. EDUCATIONAL EVALUATION.-An edu mission of this task force has been defined as follows: cational diagnostician should conduct detailed Task Force II will be responsible for consideration analyses of academic abilitics, including achieve of services including those necessary and desirable to ment assessment for details of levels and methods diagnose the medical and health-related problem and of sldll acquisition; e.g., reading, number con to identify the methods of determining educational cepts, spelling and writing. performance capability and ways of educa~jng afflicted children. The two aspects of the problem are educa A child has not had the benefit of a complete diag ti.:m, and medical and health-related services. nostic evaluation unless he has had both a medical and 1. Relative to the educational aspects of the prob a behavioral assessment. The medical evaluation is lem, the task force will concern itself with prob1ems ess.ential to prevent the development or continuation of educational identification! assessment and evalua of unsuspected disease processes. The behavioral as tion, teaching of children with minimal brain dys sessmemol'Qvides the basis for a logical u1"1.nagement function, educational techniques and methodologies and educational program. involved, preparation and certification of teachers, re Since various types of diagnosis are involved; a given sponsibility of the public school system for educating child may appropriately receive several diagnoses. these children, guidance of parents in managing chil Additional confusion sten" f;om the present lack of a dren at home, and public education as it relates to the multidisciplinary approach. 'fhe diagnosis which re introduction into society of children with minimal ceives emphasis may reflect a number of variables in brain dysfunction. cluding the following: 2. Relative to the medical and health-related as 1. The diagnostician-his discipline, trqining, ex pects, the task force will concern itself with methods perience, clinical talents; his knowledge and attitudes of identification of children with minimal brain dys regarding causes in the production of learning and be func.tion) diagnostic services required for obtaining havior problems in children. adequate knowledge of the child's ability to perform, 2. The diagnostic setting-academic or clinical; and the development of guidelines to be used by ap community child guidance center, community all propriate professional persons in conducting and carry purpose mental health clinic, medical center child ing out services necessary to proper management of psychiatry clinic> medical center pediatric clinic, or the child with minimal brain dysfunction. 15 ,llll. Bibliographies SECTION BIBLIOGRAPHIES 18. SHAFFER, J. A specific cognitive deficit observea 111 gonadal aplasia (Turner's syndrome), J. Clin. References 1 through 31 are cited in Section III, Psychol., XVIII: 403-406, 1962. A Brief History of the Concept of Brain Damage. 19. SHERM.\N, M., and BEVERLY, B. I. The factor of de terioration in children showing behavior difficulties 1. BURR, C. W. The nervous child, N.Y. Med. J., 114: after epidemic encephalitis, Arch. Neuro. Psychiat., 203, 1921. 10: 329-343, 1923. 2. MILES, R. S, Common nervous conditions of children. 20. THURSTON, D., MIODLeKAMP, J., and MASON, E. The Arch. Pediat., 38: 664,1921. late effects of lead poisoning, J. Pediat., 47: 413-423, 3. KRAMER, F., and POLLNOW, H. Uber eine hyperkin 1955. etische erkrankung im kindesalter, Monatschr. f. 21. WAOENHEIM, L. The effect of childhood disease on IQ Psychiat. u. NeuTo., 82: 1-40, 1932. variability, J. Consult. Psycho!., 18: 354, 1954. 4. KAHN, E., and COllEN, L. H. Organic driven ness-a 22. GESELL, A., and AMATRUDA, C. Developmental Diag brain-stem syndrome and an experience, N. Eng. J. nosis, Paul B. Hoeber, Inc., 1941. Med., 210: 748-756,1934. 5. BENDER, L. Psychological problems of children with 23. WERNER, H., and STRAUSS, A. Pathology of figure organic brain disease, Amer. J. Orthopsyehiat., 19: ground relation in the child, J. Abnorm. Soc. Psychol., 404-441, 1949. 36: 58-67,1941. 6. BENDER, L. Psychopathology of Children with Organic 24. WERNER, H., and THUMA, B. A deficiency in the per BraI .. Disorders. Charles C Thomas, 1959. ception of apparent motion in children with brain 7. GOLDSTEIN, K., and SOHEERER, M. Abstract and con injury, Amer. J. psychol., 55: 58-67, 1942. crete behavior, Psycho!. Monogr., 53: No.2, 1941. 25. WERNER, H., and WElD, A. The figure-ground syn 8. GOLDSTEIN, K. Aftereffects of Brain-Injuries in War. drome in the brain-injured child, Int. Record of Med. Grune and Stratton, 1942. Gener. Pract. Clinics, 169: 362-367, 1956. 9. ORTON, S. Reading, Writing, and Speech Problems in 26. STRAUSS, A. A., and WERNeR, H. Disorders of con Children. W. W. Norton & Co., 1931. ceptual thinking in the brain-injured child, J. Nerv. 10. BLAU, A. Mental changes following head trauma in Ment. Dis., 96: 153-172, 1942. children, Arch. Neurol. Psychiat., 35: 723-769,1937. 27. STRAUSS, A. A. Ways of thinking in brain-crippled 11. BONO, E. Postencephalitic, ordinary and extraordinary deficient children, Amer. J. Psychiat., 100: 639-647. children, J. Pediat., 1: 310-314, 1932. 1944. 12. HOHMAN, L. B. Postencephalitic behavior disorders in 28. ST\\AUSS, A. A., and LEHTINEN, L. Psychopathology children, Johns Hopkins Hosp. Bull., 33: 372-375, and Education of the Brain Injured Child. Grune 1922. & Stratton, 1947. Serves as vol. I. 13. JOHNSON, E. A study of psychological findings of 100 29. STRAUSS, A. A., and KEPHART, N. Psychopathology children recovering from purulent meningitis, J. Clin. a!ld Education of the Brain Injured Child: Vol. II, Psychol., 16: 55-58, 1960. Progress in Clinic and Theory. Grune & Stratton, H. LURIE, L. A., and LEVY, S. Personality changes and 1955. Cataloged under Strauss and Lehtinen. behavior disorders of children following pertussis 30. Brain Damage in Children-The Biological and Social report based on study of 500 problem children, Aspects, cd. by Herbert G. Birch. Williams and J.A.M.A., 120: 890-894,1942. Wilkins Co., 1964. 15. RllIlLANO, B. Infantile Autism-The Syndrome and 31. MASLAND, R., SARASON, S., and GLADWIN, T. Mental its Implications for a Neural Theory of Behavior. Subnormality. Basic Books, Inc., 1958. Appleton-Century-Croft, 1964. 16. MONEY, J. Cytogenetic and psychosexual incongruities References 32 through 59 are cited in Section V, with a note on space-form blindnessJ Am. J. Psychiat., Nomenclature. 119: 820-827, 1963. 17. PASAMANIOK, n., and KNOBLOOH, H. Brain damage 32. STEVENS, G.D., and BIROH,J. W. A proposal for clari and reproductive casualty, Amer. J. Orthopsychiat., fication of the tr.rminology used to describe brain-in 30: 299-305,1960. • jured children, Except. Children, 23: 346-349, 1957. 16 33. ANDERSON, C./ and PLYMATE, H. Management of the 56. RADINOVITOH, R., DREW, A., DE JONG, R., INORAM, W'I brain damaged ~dolescent, Amer. J. Orthopsychia., ;'\nd WITHEY, L. A research approat',h to reading re, 32: 492-501,1962. tar dation, Res. PubL Assoc. for Res. Nerv. Ment. 34. SILVER, A. Diagnosis and prognosis of behavior disC)rdcr Dis., 34: 363, 1954. associated with organic brain disease in children, J. 57. HERMANN, K. Reading Disability. Charles C Thom Insurance Med.1 6: 38-42,1951. as, Publishers, 1959. 35. BRADLEY, C. Characteristics and management of chil 58. WALTON, J., ELLIS, E., and COURT, S. Clumsy chilo dren with behavior problems associated with organic drcn: a $tudy of developmental apraxia and agnosia, brain damage. Pediatric Clinics of North America, Brain, 85: 603-612,1962. pp. 1049-1060, November 1957. 59. CLEMENTS, S. D., LEHTINEN, L. E., anel LUKENS, J. E. 36. DURI{S, H. The effect on learning of brain pathology. Children with minimal brain injury-a symposium. Except. Child., 24: 169-172,1957. National Society for Crippled Children and Adults, 37. CLEMENTS, S. D., and PETERS, J. E. Minimal brain Inc., 1964. dysfunctions in the school-age child, Arch. Gen. Psychiat., 6: 185-t97, 1962. References Not Cited in Article 38. CLEMMENS, R. Minimal brain damage in children 60. ANDERSON, C. M. Early Brain Injury, J. Amer. Wo an interdisciplinary problem, Children, 8: 179-183, men'i Med. Assoc. 11: 113-119, 1956. 1961. 61. ANDERSON, C. M., and PLYMATE, H. B. Management 39 .. DARYN, E. Problem1 of children with diffuse brain of the brain-damaged adolescent, Amer. J. Or tho. damage. Arch. Gen. Psychiat.) 4: 299-306, 196!. psychiat., 32: 492-501, 1962. 40. DOLL, E. A. Bchayior syndromes of CNS impairment, 62. BAKER, H. J. Intrcductioll to Exceptional Children. in The Exceptional Child, ed. by J. Magary and J. Macmillan Co., 1959. Eichorn, Holt, Rinehart, and Winston, Inc., 1960. 63. DAKWIN, R. M. Diagnostic approach to behavior dis. 41. LAUFElt, M. W. -Jerebral dysfunction and behavior dis orders in children, J. Amer. Women's Med. Assoc., orders in adolescents. Amer. J. Orthopsychiat., 32: 14: 786-791, 1959. 501-507,1962. 64. BAKWIN, It, and BAKWIN, R. M. Clinical manage. 42. MILMAN, D. Organic behavior disorder: behavior ment behavior disorders in children. W. B. Saun~ characteristics of brain-damaged children, A.M.A. J. ders Co., 1953. Diseases Child., 91: 521-528, 1956. 65. BELMONT,!., and BIRCH, H. G., KLEIN. D., and POL 43. PR£CHTL, H. F. R., and STEMMER, C. The choreiform LACK, M. Perceptual evidence of CNS dysfunction syndrome in children, Dev. Med. Child Neuro., 4: in schizophrenia, Arch. Gen. Psychi:lt., 10: 395-408, 119, 1962. 1964. 44. EISENDERO, L. Psychiatric implications of brain dam 66. BENTON, P. C. Organic behavior disorders in children, age in children, Psychiat. Quart.! 31: 72-92, 1957. J. Okla. State Med. Assoc., 54: 481-485, 1961. 45. PAINE, R. Minimal chronic brain syndromes in chil 67. BIROH. H. G. (ed.) ilrain Damage in Chil;::cen-the dren, Dev. Med. Child Neuro., 4: 21-27, 1962. Biological and Social Aspects, Williams and Wilkins 46. KNODLOCH, H., and PASAMANIOK, B. Syndrome of Co.,1964. minilual cerebral damage in infancy, J.A.M.A., 170: 68. CHESS, S. Diagnosis and treatment of the hyperactive 1384, 1959. child, N.Y. State J. Med., 60: 2379-2385, 1960. 47. WIOGLESWORTH, R. Minimal cerebral palsy, Cer. Pal. 69. CHILDERS, A. T. Hyperactivity in children having be null., 3: 293, 1961. havior disorders, Amer. J. Orthopsychiat" 5: 22i- 48. DENOFF, E., LAUFER, M., and HOLDEN, R. The syn 243, 1935. dromes of cerebral dysfunction, J. Okla. State Med. 70. CLARK, R. M. Language and behavior of children with Assoc .. 52: 360-366, 1959. un~uspected brain injury, Logos, 5: 22-24, 1962. 49. FROSCH, J., and WORTIS, S. A contribution to the 71. COHEN, L. Perception of reversible figures after brain nosology of the impulse disorders, Am. J. Psychiat., injury, Arch. Neuro. and Psychiat., 81: 765-7751 111: 132, 1954. 1959. 50. LAUFER, M., and DENHOFF, E. Hyperkinetic behavior 72. CROWELL, D. H. Children with brain patho!osy,.Clin· syndrome in children, J. Ped., 50: 463-474, 1957. ical Psychology of Exceptional Children, ed. Louttit, 51. MORRIS, H., ESCOLL, P., and WEXL£R, R. Aggressive C. M'I Harper, 1936. behavior disorders of childhood: a follow up study, 73. CRUICKSHANK, W. M., nONTZEN, F. A., RATZEllURY, Am. J. Psychiat., 112: 991,1956. F. H., and TMINIIAUSER, M. T. A Teaching Method 52. MVKELllUST, H., and Bosm:s, B. Psychoneurological for Brain Injured and Hyperactive Children. Syra learning disorders in children, Arch. Pediat., n: cuse University Press, 1961. 247-256, 1960. 74. DOLL, E. A. Neurophrenia, Amer. J. Psychiat., 108: 53. OUNST};D, C. The hyperkinetic syndrome in epileptic 5053,1951. children, Lancet, 2: 303-311, 1955. 75. DUNN, 1. M. Educable Mentally Retarded Children, 54. PARK,.G. Mirror and reversed reading, J. Pcdiat.) 42: Exceptional Children in the Schools; golt, Rinehart, 120-128, 1953. and Winston, 1963. 55. SILVER, A. A. nehavioral syndrome associated with 76. EISENBERG, L. Dynamic considerations underlying the brain damage in children, Pediatric Clinics of North management of the brain-damaged child, GP, 14~ America, pp. 687-698. 101-106, 1956. 17 77. ELIZUR, A. A combined test used for the diagnosis of 102. MYKELBUST, H. Training Aphasic Children, The Vol organic brain condition, Arch. Neuto. and Psychiat., ta Bureau. 81: 776-789, 1959. 103. MYKELBUST, H., and JOHNSON, D. Dyslexia in chil 78. EWALT, J. R. Organic behavior problems, Texas Re dren, Except. Children, 29: 15, 1962. ports <)n BioI. and Med., 3: 247-252, 1945. 104. NORTH, H. M. The nervous child, Med. J. of Aus 79. FOURAORE, M. H. Learning characteristics of brain-in tralia, 1: 612,1953. jured children, Except. Children, pp. 210-211, Jan 105. ORTON, S. Developmental Apraxia, Bull. Orton Sa uary 1958. ciety, IV: 1954. 80. FREIDUS, E. S. New approaches in special education 106. PACELLA, B. L. Behavior problems in children, Med. of the brain-injured child, New Jersey Assoc. for Clinics of No. Amer., 1948. Brain Injured Children. 107. PAINE, R. S. Contributions of neurology to the patho 81. GOLDBERG, H. K.. The ophthalmologist looks at the genesis of hyperactivity in children, Clin. Proceedings reading problem, Amer. J. Ophthalmology, 47: 67, of Children's Hospital, Washington, D.C., 19: 235, 1959. 1963. 82. GOLDBERG, H., MARSHALL, C., and SIMS, E. The role 108. PAINE, R. S. Symptomatology of unrecognized chronic of brain damage in congenital dyslexia, Am. J. Oph brain syndromes of children, J. Maine Med. Assoc., thalmology, 50: 586-590, 1960. 53: 84, 1962. 83. HAMMOND, J. E. Learning and behavior problems of 109. PAINE, R. S. Minimal chronic brain syndromes in children, Virginia Med. Monthly, 89: 379-385, 1962. children, Dev. Med. and Child Neuro., 4: 21, 1962. 84. INGRAM, T. T. S. A characteristic form of overactive 110. PREOHTL, H. F. R. The mother-child interaction in behavior in brain damaged children, J. Ment. Sci., babies with minimal brain damage t a follow up study), 102: 550-558, 1956. presented at Tavistock Study Group, London, Sept. 85. KALISlcI, L. Specific problems in arithmetic in the 5,1961. brain-injured child, Bull. Orton Soc., XI: 1961. 111. ROBB, P. Neurological aspects of reeding disabilities, 86. KALISKI, L. The brain-injured child-learning by liv in Reading for Effective Living, ed. by J. A. Figurel. ing in a structured setting, Amer. J. Ment. Def., 63: International Reading Association Conference Pro 688-695, 1963. ceedings, vol. 3, pp. 116-119, 1958. 87. KARLIN,!. W. Aphasias in children, Am. J. Diseases 112. RUSSELL, J. A. The hyperactive child, Am. J. Diseases of Children, 87: 752,1954. of Childreni 63: 94, 1942. 88. KENNARD, M. Value of equivocal signs in neurologic 113. SOHNEIDER, W. F. Psychiatric evaluation of the hy diagnosis, Neurology, 10: 1960. perkinetic child, J. Ped., 26: 559, 1945. 89. KENNARD, M. Behavior problems and the brain in 114. SOHROEDER, P. L. Behavior difficulties in (:hildren as jured child, Northwest Med., 58: 1535-1541, 1959. sociated :I'/ith the results of birth trauma, J.A.M.A., 90. KNOBEL, M. A syndromic approach to acting-out chil 92: 110, 1929. dren, Diseases of the Nerv. System, XX 1 (2): 80, 115. SOHWADE, E. D., and GEIGER, S. G. Abnormal elec 1959. troencephalographic findings in severe behavior dis 91. KNOBEL, M., WOLMAN, M. B.. , and MASON, E. Arch. orders, Diseases Nervous System, 17: 307, 1956. Gen. Psychiat., 1: 310-321, 1959. 116. SIEGEL, E. Helping the Brain Injured Child, N.Y. 92. KRuPp, G. R., and SOHWARTZBERG, B. The brain-in Assoc. for Brain Injured Children, HI6!' jured child-a challenge to social workcrs, Social 117. SILVER, A. A., and HAGIN, R. Specific reading dis Casework, February 1960. ability: Delineation of the syndrome and relation 93. LAUFER, M. W. Problems of cerebral dysfunctions, New York Assoc. for Brain-injured Children. ship to cerebral dominance, Comprehensive Psychiat., 94. LAUFER, M. W., DENHOFF, E., and SOLOMONS, G. Hy 1: 126,1960. perkinetic impulse disorder in children's behatr'or 118. STRAUSS, A. A., and WERNER, H. The mental or problems, Psychosom. Med., 19: 38, 1957. ganization of the brain injured mentally defective 95. LAWRENCE, M. M. Minimal brain injury in child child, Am. J. Psychiat., 97: 1194, 1941. psychiatry, Comprehensive Psychiat., 1: 360, 1960. 119. THELANDER, H. E., PHELPS, J. K., and KIRK, E. W. 96. LEVY, S. Postencephalitic behavior disorder-a for Learning disabilities associated with lesser brain dam gotten entity, a report of 100 cases, Am. J. Psychiat., age, J. Ped., 53: 405,1958. 115: 1062,1959. 120. TIMME, A. R. The choreiform syndrome, Calif. Med., 97. LEWIS, R. S., S'I'RAUSS, A. A., and LEHTINEN, L. E. 68: 1.';4J 1948 . . The other child, Grune and Stratton, 1960. 121. WOOD, NANOY E. Evaluation of language disorders in 98. LURIE, L. A. The medical appro~t:h to the study of children of school age, Speech and Language Therapy behavior disorders of children, Am. J. Psychiat., 91: with the Brain-Damaged Child, cd. Daley, Catholic 1379,1935. Univ. of America Press, 1962. 99. MoHuGH, E. E. The brain-injured child with im paired hearing, Laryngoscope, 71: 1034, 1961. 122. WOOD, N. E. Language disorders: Major barriers to 100. MILLER, B. J. A parent's view, The Child with Brain communication, School Life, June 1961. Damage, Assoc. for Aid of Crippled Children, 1959. 123. WORTIS, J. A note on the concept of the "brain-in 101. MONEY, J. (ed): Reading Disability-Progress and Re jured child," Am. J. Ment. Defic., 61: 204, 1956. search Needs in Dyslexia, The Johns Hopkins Press, 124. WYLLIE, W. G. Behavior prclblems and the backward 1962. child, Lancet, 224: 1247, 1933. 18 U.s. GOVERNMENT PRINTING OFFICE: 19760-214-634 ------~- .. --~ oi,' 1\ "I J I I Public Health Service Publication No. 1415 • i DHI:W Publication No.,(NIH) 76-349 " -- ~------