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Medical and psychological correlates in children with learning disabilities
February, 1971 T h e J o u r n a l o[ P E D I A T R I C S
273
Medical and psychological correlates in children Mth learning disabilities Data are presented on 100 children with learning and/or behavioral problems who were re[erred to a diagnostic and evaluation clinic because of suspected "minimal brain dysfunction." Each child received thorough medical and psychological examinations. Electroencephalograms were done on 88 of the children. A chi square interaction analysis was set up comparing the results o[ the neuroIogic examination, electroencephalogram, and final diagnosis. There was no significant relationship among any of these [actors, nor was there any combined or additive effect. The results indicate that the final diagnosis is more contingent upon symptomatology and psychological findings than upon any specific medical, neurologic, or eleetroencephaIographic findings. In view of the poor correlation of the neurologic examination and the electroencephalogram with the final diagnosis, there appears to be minimal utility in referring such children routinely [or these procedures.
Thomas J. Kenny, Ph.D., ~ and Raymond L. Clemmens, M.D. BALTI
IV[ O R E
~
MD.
R E M E D I A T I O N of learning problems is primarily an educational responsibility? However, school authorities finding themselves confronted with many academically and behaviorally handicapped children frequently look to the physician and/or psychologist for assistance in understanding the problems and in dealing with its nonpedagogic aspects. -~,8 This has commonly led to requests for neurologic consultations, electroencephalograms, and psychological examinations, presumably with the expectation that such information might clarify whether or not an individual child might be neurologically impaired. 4, ~ Prom the Department of Pediatrics, University o[ Maryland Medical School. ~"Reprlnt address: Department of Pediatrics, University o[ Maryland Hospital, Baltimore, Md. 21201.
The purposes of the present investigation were to evaluate the relative utility of the parts of the assessment process and to determine which factors are significantly involved in the diagnosis and treatment of the learning or behavioral problems that are usually associated with minimal brain dysfunction. METHOD
One hundred children were selected randomly from the files of the Central Evaluation Clinic for Children, University of Maryland Hospital; all had been seen for evaluation from 1964 to the present time. Twenty children were selected at each age level from 8 to 12 years. Sex, race, and socioeconomic background were randomized in the selection. VoI. 78, No. 2, pp. 273-277
274
The .Journal of Pediatrics February 1971
Kenny and CIemmens
Table I. Referral data No. of
Reason [or referral Behavior Learning and/or development Behavior and learning Learning and medical Medical only Total
children 31 15 40 8 6 100
To be included in the study, the child must have had a problem in behavior, learning, or development, the characteristics of which suggested to the referring agency the possibility of minimal brain dysfunction. A case study method was used to collect the data on each patient. These data included: (1) reason for referral, (2) source of referral, (3) psychological test data, (4) neurologic evaluation, (5) electroencephalographic findings, (6) family stability, (7) final diagnosis, and (8) recommendations. RESULTS
The study sample as selected was composed of 85 males and 15 females; there were 57 Caucasians and 43 Negroes in the group. Table I shows the referral background of the children. Seventy per cent of the group were referred from the school system, including teachers, principals, social workers, and psychologists. Medical sources referred another 24 per cent of the children. The majority had problems of behavior, or of behavior and learning. Twenty-nine per cent of the children were seen as possibly having a major medical problem such as slow development. The psychological evaluations indicated that the total group had a mean I.Q. of 80 and that the distribution of intelligence was bell shaped but shifted approximately 1 88 standard deviations to the left (Fig. 1). Thus half of the children scored below the low normal range of intelligence (I.Q. <
80). Eighty-nine children were administered the Bender-Gestalt test of visual motor perception. Over two thirds of the group (69
No. of
Source of referral School Medical Social agency Other
children 70 24 4 2
Total
100
per cent) had test results indicative of visual motor problems usually associated with neurologic dysfunction. Test performance was questionably suggestive of dysfunction in 19 per cent of the children. Only 12 per cent of the test results were interpreted as being normal. The achievement test results indicated general rather than specific areas of academic deficiency. Seventeen children had reading scores 6 months below the average of their other achievement scores, but spelling was 6 months below average in a similar number of children, and 11 children were significantly lower in arithmetic. A majority of this group, 75 per cent, were below age level in academic achievement, but over half of this group was functioning at a level equivalent to their mental age. The results of the medical evaluation are summarized in Table II. The neurologic examination was normal in 58 children and clearly abnormal in 4; in 38 subjects there was evidence of the so-called "soft" signs. G, 7 Of this last group, 12 children were found to have 3 or more soft signs, whereas 14 others had 2 signs, and the remaining 12 had a single finding. Thirty-five of the children were seen for examination by both a neurologist and a pediatrician. There was complete agreement between the 2 examiners in 25 instances; for one child there was 75 per cent agreement, and there was 50 per cent agreement with 3 subjects. In 4 instances, the neurologist considered the results of the examination to be negative, whereas the pediatrician found one soft sign; in 2 other children the neurologist's examination was negative and the pediatrician reported 2 soft signs.
Volume 78 Number 2
Learning disabilities in children
275
NUMBER 50 25 20 15 I0 5 0 below50
51-60
61-70
71-80
81-90
91-100 IO0-up
Fig. 1. I.Q. distribution. Table II. Medical finding NO. Of
Electroencephalogram Not done Normal 14/6 positive spikes Abnormal Specific (16) Nonspecific, diffuse ( 20) Total
children 12 34 18 36
100
The electroencephalographic studies produced a wide range of results with no single significant diagnostic pattern (Table II). One third of the children had records that were interpreted as being normal, whereas one third had records read as abnormal. Of the 36 abnormal records, 16 showed specific abnormalities, including spike foci, spike and wave complexes, or seizure discharges. The other 20 were considered "diffusely abnormal," including dysrhythmic backgrounds, slow activity, etc. Eighteen electroencephalographic records demonstrated 14 a n d / o r 6 per second positive spikes. The primary diagnoses are listed in Table III. Any child with an I.Q. of 79 or below was given a primary diagnosis of intellectual subnormality (by definition). Forty-two children had diagnoses involving minimal brain damage and brain damage plus emotional disturbance, whereas 10 children were considered to have primary psychiatric problems; the remaining child was found to be free of significant problems.
No. of
Neurologic findings Normal Abnormal--"IIard" signs Equivocal~"Soft" signs One (12) Two (14) Three or more (12) Total
children 58 4 38
100
A chi square interaction analysis was set up comparing the results of the electroencephalogram, the neurologic examination, and the final diagnosis. Fig. 2 presents the findings of this analysis. There was no significant relationship among any of the factors, nor was there any combined or additive effect. The parts of the medical evaluation did not significantly influence the diagnosis. The most usual recommendation by far was for educational adjustment or remediation. Medication was recommended for half of the children; a third of the group were referred for some type of psychological or psychiatric counseling. This last finding is not surprising in light of the characteristics of the child's environment (Table IV). Of the total group only 26 homes were considered without significant problems, whereas 47 families had overt psychiatric problems or an emotionally unstable environment. Nineteen of the children were living in homes with one parent, while another 11 were not living with either parent.
276
Kenny and Clemmens
The Journal o[ Pediatrics February 1971
B- ABNORMAL EEG
A-NORMAL EEG
DIAGNOSIS
.IZ lZ I I NORMAL ABNORMAL NORMAL ABNORMAL NEUROLOGICAL NEUROLOGICAL NEUROLOGICAL; NEUROLOGICAL
L Intellectual Subnormality ?.Minimal Brain damage
7
3. Psychiatric 4. Brain damage + psychiatric
9
IE;
12
43
2
4
3
14
4
I
B
0
I0
4
3
7
7
21
20
15
31
22
Chi Square factors; A-Normal EEG I Normal Neurological Examination
IN=88'
B- Abnormal EEG Abnormal Neurological Examination
I. Diagnosis * 1 2 Subjects were omitted due to lack of EEG's Chi Square attained = 8.21 (non-significanl} Chi Square .90 =14.68 , Degrees of Freedom =9
Fig. 2. Chi square analysis.
Table I I I . Results Primary diagnoses Intellectual subnormality (I.Q. under 80) Minimal brain damage Primary psychiatric Minimal brain damage + secondary emotional problems Other Total
No. of children 47
19 10 23 1 100
DISCUSSION The first annual report of the National Advisory Committee on Handicapped Children (January, 1968) defines learning disabilities as follows: "Children with special learning disabilities exhibit a disorder in one or more of the basic psychological processes involved in understanding or in using spoken or written languages. These may be manifested in disorders of listening, thinking, talking, reading, writing, spelling, or arithmetic. They include conditions which have been referred to as preeeptual handicaps, brain injury, minimal brain dysfunction, dyslexia, developmental aphasia, etc. They do
Recommendations Educational Medication Psychotherapy and/or counseling (parent and/or child) Occupational therapy, physical therapy, or speech therapy Other Total
No. o[ children 85 50 34
15 12 196
not include learning problems which are due primarily to visual, hearing, or motor handicaps, to mental retardation, emotional disturbance, or to environmental disadvantage."s The current study indicates that the children referred for a "complete evaluation" in a medical setting are at a high risk for learning problems. As a whole, the group stands at the fourteenth percentile in intelligence. The Bender-Gestalt findings also indicate that the group has a high risk for learning problems. On the face of this evidence, these children require extraordinary educational attention and techniques. This
Volume 78 Number 2
psychological information could have been available through the facilities of the school system prior to diagnostic and evaluation referral. Only 6 of the children studied were in special education at the time of referral. The diagnostic evaluation of children with learning disabilities has varied from one center to another and in the extreme has included an elaborate and time-consuming sequence of consultations and investigations? The approach that has been advocated seems to overemphasize the relevance of the medical aspects of the problem. T h e results of the present study indicate that extensive medical evaluations are relatively unrewarding. T h e results of this study indicate that the final diagnosis is more contingent upon symptomatology and the results of psychological studies than any specific medical, neurologic, or electroeneephalographic findings, since no significant commonality results from these findings. I t is appropriate to question whether medication could or should be given on the basis of symptomatology without extensive investigations. Psychiatrists have long recognized that medication could be prescribed safely on the basis of symptoms alone if the patient is followed carefully. 1~ It is apparent that the group of children described as having minimal brain dysfunction has been unwittingly expanded to inelude developmental variations and the fringes of atypical development that do not fit into the category of minimal brain damage; this includes many dull, borderline, and mildly retarded children. The findings further emphasize the point that if minimal brain dysfunction does exist, this is not in a vacuum and that environmental factors frequently coexist and complicate the problem. The child with minimal brain dysfunction is at high risk for having secondary emotional factors; an environment which is adequate to meet the needs of a "normal" child may be inadequate to meet the excessive environmental requirements of a child who is hyperactive, distractible, and has a short
Learning disabilities in children
277
Table IV. Family and environment* No. of
Environment
children Normal 26 One parent in home 19 Child not living with either parent 11 Overt emotional instability in home 47 Environmental deprivation 10 Total 113 *Foster care, 8; adopted, 4.
attention span. T h e diagnostic approach should be flexible enough to provide what is needed rather than following a rigidly prescribed and fixed set of investigations. REFERENCES
1. Fine, M.: Considerations in educating children with cerebral dysfunction, J. Learning Disabilities 3: 12, 1970. 2. Clemmens, R.: Minimal brain damage in children--an interdisciplinary problem, Children 8: 179, 1961. 3. Clemmens, R., and Glaser, K.: Specific learning disabilities, Clin. Pediat. 6: 481, 1967. 4. Clements, S. D.: Project Director Task Force I, Minimal brain dysfunction in children, National Institute of Neurologic Disease and Blindness, Monograph No. 3, 1966, United States Department of Health, Education, and Welfare. 5. Capute, A., Niedermeyer, E., and Richardson, F.: The electroencephalogram in children with minimal cerebral dysfunction, Pediatrics 41: 1104, 1968. 6. Kennard, M.: Value of equivocal signs in neurologie diagnosis, Neurology 10: 753, 1960. 7. Paine, R. S.: Contribution of neurology to the pathogenesis of hyperactivity in children, Clin. Proc. Child. Hosp. D. C. 19: 235, 1960. 8. Chalfont, J. C., and Scheffelin, M. A.: Central processing dysfunction in children: A review of research, National Institute of Neurologie Disease and Blindness, Monograph No. 9, 1969, p. 148. 9. Clements, S., and Peters, J.: Minimal brain dysfunction in the school age child, Arch, Gen. Psychiat. 6: 185, 1962. 10. Glaser, K., and Clemmens, R. L.: School failure, Pediatrics 35: 128, 1965. 11. Chess, S.: Diagnosis and treatment of the hyperactive child, New York J. Med. 60: 2379, 1960. 12. Laufer, M., and Denhoff, E.: I-Iyperkinetie behavior syndrome in children, J. PEI)IAT. 50: 463, 1957.
273
Medical and psychological correlates in children Mth learning disabilities Data are presented on 100 children with learning and/or behavioral problems who were re[erred to a diagnostic and evaluation clinic because of suspected "minimal brain dysfunction." Each child received thorough medical and psychological examinations. Electroencephalograms were done on 88 of the children. A chi square interaction analysis was set up comparing the results o[ the neuroIogic examination, electroencephalogram, and final diagnosis. There was no significant relationship among any of these [actors, nor was there any combined or additive effect. The results indicate that the final diagnosis is more contingent upon symptomatology and psychological findings than upon any specific medical, neurologic, or eleetroencephaIographic findings. In view of the poor correlation of the neurologic examination and the electroencephalogram with the final diagnosis, there appears to be minimal utility in referring such children routinely [or these procedures.
Thomas J. Kenny, Ph.D., ~ and Raymond L. Clemmens, M.D. BALTI
IV[ O R E
~
MD.
R E M E D I A T I O N of learning problems is primarily an educational responsibility? However, school authorities finding themselves confronted with many academically and behaviorally handicapped children frequently look to the physician and/or psychologist for assistance in understanding the problems and in dealing with its nonpedagogic aspects. -~,8 This has commonly led to requests for neurologic consultations, electroencephalograms, and psychological examinations, presumably with the expectation that such information might clarify whether or not an individual child might be neurologically impaired. 4, ~ Prom the Department of Pediatrics, University o[ Maryland Medical School. ~"Reprlnt address: Department of Pediatrics, University o[ Maryland Hospital, Baltimore, Md. 21201.
The purposes of the present investigation were to evaluate the relative utility of the parts of the assessment process and to determine which factors are significantly involved in the diagnosis and treatment of the learning or behavioral problems that are usually associated with minimal brain dysfunction. METHOD
One hundred children were selected randomly from the files of the Central Evaluation Clinic for Children, University of Maryland Hospital; all had been seen for evaluation from 1964 to the present time. Twenty children were selected at each age level from 8 to 12 years. Sex, race, and socioeconomic background were randomized in the selection. VoI. 78, No. 2, pp. 273-277
274
The .Journal of Pediatrics February 1971
Kenny and CIemmens
Table I. Referral data No. of
Reason [or referral Behavior Learning and/or development Behavior and learning Learning and medical Medical only Total
children 31 15 40 8 6 100
To be included in the study, the child must have had a problem in behavior, learning, or development, the characteristics of which suggested to the referring agency the possibility of minimal brain dysfunction. A case study method was used to collect the data on each patient. These data included: (1) reason for referral, (2) source of referral, (3) psychological test data, (4) neurologic evaluation, (5) electroencephalographic findings, (6) family stability, (7) final diagnosis, and (8) recommendations. RESULTS
The study sample as selected was composed of 85 males and 15 females; there were 57 Caucasians and 43 Negroes in the group. Table I shows the referral background of the children. Seventy per cent of the group were referred from the school system, including teachers, principals, social workers, and psychologists. Medical sources referred another 24 per cent of the children. The majority had problems of behavior, or of behavior and learning. Twenty-nine per cent of the children were seen as possibly having a major medical problem such as slow development. The psychological evaluations indicated that the total group had a mean I.Q. of 80 and that the distribution of intelligence was bell shaped but shifted approximately 1 88 standard deviations to the left (Fig. 1). Thus half of the children scored below the low normal range of intelligence (I.Q. <
80). Eighty-nine children were administered the Bender-Gestalt test of visual motor perception. Over two thirds of the group (69
No. of
Source of referral School Medical Social agency Other
children 70 24 4 2
Total
100
per cent) had test results indicative of visual motor problems usually associated with neurologic dysfunction. Test performance was questionably suggestive of dysfunction in 19 per cent of the children. Only 12 per cent of the test results were interpreted as being normal. The achievement test results indicated general rather than specific areas of academic deficiency. Seventeen children had reading scores 6 months below the average of their other achievement scores, but spelling was 6 months below average in a similar number of children, and 11 children were significantly lower in arithmetic. A majority of this group, 75 per cent, were below age level in academic achievement, but over half of this group was functioning at a level equivalent to their mental age. The results of the medical evaluation are summarized in Table II. The neurologic examination was normal in 58 children and clearly abnormal in 4; in 38 subjects there was evidence of the so-called "soft" signs. G, 7 Of this last group, 12 children were found to have 3 or more soft signs, whereas 14 others had 2 signs, and the remaining 12 had a single finding. Thirty-five of the children were seen for examination by both a neurologist and a pediatrician. There was complete agreement between the 2 examiners in 25 instances; for one child there was 75 per cent agreement, and there was 50 per cent agreement with 3 subjects. In 4 instances, the neurologist considered the results of the examination to be negative, whereas the pediatrician found one soft sign; in 2 other children the neurologist's examination was negative and the pediatrician reported 2 soft signs.
Volume 78 Number 2
Learning disabilities in children
275
NUMBER 50 25 20 15 I0 5 0 below50
51-60
61-70
71-80
81-90
91-100 IO0-up
Fig. 1. I.Q. distribution. Table II. Medical finding NO. Of
Electroencephalogram Not done Normal 14/6 positive spikes Abnormal Specific (16) Nonspecific, diffuse ( 20) Total
children 12 34 18 36
100
The electroencephalographic studies produced a wide range of results with no single significant diagnostic pattern (Table II). One third of the children had records that were interpreted as being normal, whereas one third had records read as abnormal. Of the 36 abnormal records, 16 showed specific abnormalities, including spike foci, spike and wave complexes, or seizure discharges. The other 20 were considered "diffusely abnormal," including dysrhythmic backgrounds, slow activity, etc. Eighteen electroencephalographic records demonstrated 14 a n d / o r 6 per second positive spikes. The primary diagnoses are listed in Table III. Any child with an I.Q. of 79 or below was given a primary diagnosis of intellectual subnormality (by definition). Forty-two children had diagnoses involving minimal brain damage and brain damage plus emotional disturbance, whereas 10 children were considered to have primary psychiatric problems; the remaining child was found to be free of significant problems.
No. of
Neurologic findings Normal Abnormal--"IIard" signs Equivocal~"Soft" signs One (12) Two (14) Three or more (12) Total
children 58 4 38
100
A chi square interaction analysis was set up comparing the results of the electroencephalogram, the neurologic examination, and the final diagnosis. Fig. 2 presents the findings of this analysis. There was no significant relationship among any of the factors, nor was there any combined or additive effect. The parts of the medical evaluation did not significantly influence the diagnosis. The most usual recommendation by far was for educational adjustment or remediation. Medication was recommended for half of the children; a third of the group were referred for some type of psychological or psychiatric counseling. This last finding is not surprising in light of the characteristics of the child's environment (Table IV). Of the total group only 26 homes were considered without significant problems, whereas 47 families had overt psychiatric problems or an emotionally unstable environment. Nineteen of the children were living in homes with one parent, while another 11 were not living with either parent.
276
Kenny and Clemmens
The Journal o[ Pediatrics February 1971
B- ABNORMAL EEG
A-NORMAL EEG
DIAGNOSIS
.IZ lZ I I NORMAL ABNORMAL NORMAL ABNORMAL NEUROLOGICAL NEUROLOGICAL NEUROLOGICAL; NEUROLOGICAL
L Intellectual Subnormality ?.Minimal Brain damage
7
3. Psychiatric 4. Brain damage + psychiatric
9
IE;
12
43
2
4
3
14
4
I
B
0
I0
4
3
7
7
21
20
15
31
22
Chi Square factors; A-Normal EEG I Normal Neurological Examination
IN=88'
B- Abnormal EEG Abnormal Neurological Examination
I. Diagnosis * 1 2 Subjects were omitted due to lack of EEG's Chi Square attained = 8.21 (non-significanl} Chi Square .90 =14.68 , Degrees of Freedom =9
Fig. 2. Chi square analysis.
Table I I I . Results Primary diagnoses Intellectual subnormality (I.Q. under 80) Minimal brain damage Primary psychiatric Minimal brain damage + secondary emotional problems Other Total
No. of children 47
19 10 23 1 100
DISCUSSION The first annual report of the National Advisory Committee on Handicapped Children (January, 1968) defines learning disabilities as follows: "Children with special learning disabilities exhibit a disorder in one or more of the basic psychological processes involved in understanding or in using spoken or written languages. These may be manifested in disorders of listening, thinking, talking, reading, writing, spelling, or arithmetic. They include conditions which have been referred to as preeeptual handicaps, brain injury, minimal brain dysfunction, dyslexia, developmental aphasia, etc. They do
Recommendations Educational Medication Psychotherapy and/or counseling (parent and/or child) Occupational therapy, physical therapy, or speech therapy Other Total
No. o[ children 85 50 34
15 12 196
not include learning problems which are due primarily to visual, hearing, or motor handicaps, to mental retardation, emotional disturbance, or to environmental disadvantage."s The current study indicates that the children referred for a "complete evaluation" in a medical setting are at a high risk for learning problems. As a whole, the group stands at the fourteenth percentile in intelligence. The Bender-Gestalt findings also indicate that the group has a high risk for learning problems. On the face of this evidence, these children require extraordinary educational attention and techniques. This
Volume 78 Number 2
psychological information could have been available through the facilities of the school system prior to diagnostic and evaluation referral. Only 6 of the children studied were in special education at the time of referral. The diagnostic evaluation of children with learning disabilities has varied from one center to another and in the extreme has included an elaborate and time-consuming sequence of consultations and investigations? The approach that has been advocated seems to overemphasize the relevance of the medical aspects of the problem. T h e results of the present study indicate that extensive medical evaluations are relatively unrewarding. T h e results of this study indicate that the final diagnosis is more contingent upon symptomatology and the results of psychological studies than any specific medical, neurologic, or electroeneephalographic findings, since no significant commonality results from these findings. I t is appropriate to question whether medication could or should be given on the basis of symptomatology without extensive investigations. Psychiatrists have long recognized that medication could be prescribed safely on the basis of symptoms alone if the patient is followed carefully. 1~ It is apparent that the group of children described as having minimal brain dysfunction has been unwittingly expanded to inelude developmental variations and the fringes of atypical development that do not fit into the category of minimal brain damage; this includes many dull, borderline, and mildly retarded children. The findings further emphasize the point that if minimal brain dysfunction does exist, this is not in a vacuum and that environmental factors frequently coexist and complicate the problem. The child with minimal brain dysfunction is at high risk for having secondary emotional factors; an environment which is adequate to meet the needs of a "normal" child may be inadequate to meet the excessive environmental requirements of a child who is hyperactive, distractible, and has a short
Learning disabilities in children
277
Table IV. Family and environment* No. of
Environment
children Normal 26 One parent in home 19 Child not living with either parent 11 Overt emotional instability in home 47 Environmental deprivation 10 Total 113 *Foster care, 8; adopted, 4.
attention span. T h e diagnostic approach should be flexible enough to provide what is needed rather than following a rigidly prescribed and fixed set of investigations. REFERENCES
1. Fine, M.: Considerations in educating children with cerebral dysfunction, J. Learning Disabilities 3: 12, 1970. 2. Clemmens, R.: Minimal brain damage in children--an interdisciplinary problem, Children 8: 179, 1961. 3. Clemmens, R., and Glaser, K.: Specific learning disabilities, Clin. Pediat. 6: 481, 1967. 4. Clements, S. D.: Project Director Task Force I, Minimal brain dysfunction in children, National Institute of Neurologic Disease and Blindness, Monograph No. 3, 1966, United States Department of Health, Education, and Welfare. 5. Capute, A., Niedermeyer, E., and Richardson, F.: The electroencephalogram in children with minimal cerebral dysfunction, Pediatrics 41: 1104, 1968. 6. Kennard, M.: Value of equivocal signs in neurologie diagnosis, Neurology 10: 753, 1960. 7. Paine, R. S.: Contribution of neurology to the pathogenesis of hyperactivity in children, Clin. Proc. Child. Hosp. D. C. 19: 235, 1960. 8. Chalfont, J. C., and Scheffelin, M. A.: Central processing dysfunction in children: A review of research, National Institute of Neurologie Disease and Blindness, Monograph No. 9, 1969, p. 148. 9. Clements, S., and Peters, J.: Minimal brain dysfunction in the school age child, Arch, Gen. Psychiat. 6: 185, 1962. 10. Glaser, K., and Clemmens, R. L.: School failure, Pediatrics 35: 128, 1965. 11. Chess, S.: Diagnosis and treatment of the hyperactive child, New York J. Med. 60: 2379, 1960. 12. Laufer, M., and Denhoff, E.: I-Iyperkinetie behavior syndrome in children, J. PEI)IAT. 50: 463, 1957.