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Verbal and nonverbal skill

discrepancies in hydrocephalic
children
a b
Jack M. Fletcher , David J. Francis , Nora M.
c a
Thompson , Bonnie L. Brookshire , Timothy P. Bohan
a a b
, Susan H. Landry , Kevin C. Davidson & Michael E.
d
Miner
a
Department of Pediatrics , University of Texas Medical
School at Houston ,
b
University of Houston ,
c
Southwest Neuropsychiatric Institute ,
d
Division of Neurosurgery , Ohio State University ,
Published online: 04 Jan 2008.

To cite this article: Jack M. Fletcher , David J. Francis , Nora M. Thompson ,

Bonnie L. Brookshire , Timothy P. Bohan , Susan H. Landry , Kevin C. Davidson &
Michael E. Miner (1992) Verbal and nonverbal skill discrepancies in hydrocephalic
children, Journal of Clinical and Experimental Neuropsychology, 14:4, 593-609, DOI:
10.1080/01688639208402847

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 Journal of Clinical and Experimental NeuropsycholOgy 016&8634/92/1404-0593%3.00
1992,Vol. 14, NO.4, pp. 593-609 Q Swets & Zeitlinger

Verbal and Nonverbal Skill Discrepancies in

Hydrocephalic Children*

Jack M. Fletcher
Department of Pediatrics, University of Texas Medical School at Houston

David J. Francis
University of Houston
Downloaded by [Carnegie Mellon University] at 11:42 13 January 2015

Nora M. Thompson
Southwest Neuropsychiatric Institute

Bonnie L. Brookshire, Timothy P. Bohan, Susan H. Landry

Department of Pediatrics, University of Texas Medical School at Houston

Kevin C. Davidson
University of Houston

Michael E. Miner
Division of Neurosurgery, Ohio State University

ABSTRACT

This study evaluated a large sample (N = 90) of 5- to 7-year-old children with hy-
drocephalus caused by aqueductal stenosis or prematurity-intravenmcdar hemorrhage
or associated with spina bifida. Comparison groups of normal controls, children
with spina bifida and no shunt, and premature children with no hydrocephalus were
also evaluated. Comparison of skill discrepancies at two occasions separated by 1
year revealed that hydrocephalic children, as a group, showed poorer nonverbal
than verbal skills on measures from the McCanhy Scales of Children’s Abilities,

* Supported in part by NINDS grant #NS25368, “Neurobehavioral Development of

Hydrocephalic Children.”
We wish to thank John P. Laurent, M.D., William R, Cheek, M.D., and W. Daniel Williamson,
M.D. of the Baylor College of Medicine, Judy Locke, R.N., B.S.N., Spina Bifida Program
of the Texas Children’s Hospital, Houston, Texas, Derek A. Bruce, M.D.and Frederik H.
Sklar, M.D. of The University of Texas Southwestern Medical School-Dallas, Stephen A.
Fletcher, D.O. of The Univesity of Texas Medical School at Houston, and Robert I.
Clayton, M.D. and Arthur E. Marlin, M.D. of The University of Texas Health Science
Center-San Antonio, for permitting access to their patients for this study, and Linda
Kimbrough for study coordination and manuscript preparation.
Address reprint requests to: Jack M. Fletcher, Ph.D., Department of Pediatrics, MSB
3.136, The University of Texas Medical School at Houston, 6431 Fannin, Houston, TX
77030, USA.
Accepted for publication: November 4, 1991.
 594 JACK M.FLETCHER ET AL.

the WISC-R. and composites of neuropsychological skills. No discrepancies in

verbal-nonverbal memory were found nor were any discrepancies attributable to
etiology or motor demands of the tasks. Consistent with current hypotheses con-
cerning the role of the cerebralwhite matter in cognitive development. these results
show that hydrocephalic children in this age range generally have poorer development
of nonverbal cognitive skills relative to their language development.

The relationship of early childhood hydrocephalus and cognitive development is

poorly understood. Most children who develop hydrocephalus early in develop-
ment are not mentally deficient (Dennis et al., 1981; Fletcher & Levin, 1988).
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However, children with hydrocephalus typically demonstrate reductions in their

overall level of cognitive development (Dennis et al., 1981; Donders, Canady, &
Rourke, 1990; Raimondi & Soare. 1974; Soare & Raimondi, 1977; Tew &Laurence,
1975; Wills, Holmbeck, Dillon, & McLone, 1990). What is unclear is whether
hydrocephalus is associated with discrepancies in the development of language
versus nonverbal cognitive skills (e.g., perceptual matching, visual-motor
processing). Most studies addressing the question of discrepant development of
verbal and nonverbal skills have used measures of psychometric intelligence
(Fletcher & Levin, 1988). These studies generally showed lower scores on a
Performance measure of IQ than on a Verbal measure (e.g., Dennis et al., 1981;
Raimondi & Soare, 1974). Unfortunately, many other studies addressing this
question were restricted to poorly described samples of children, which either
failed to control for etiologies or were restricted to certain etiologies of hydro-
cephalus (especially spina bifida).
One of the most systematicstudies of psychometric intelligencein hydrocephalic
children varying in etiology (Dennis et al., 1981) compared VIQ and PIQ scores
from the Wechsler Intelligence Scale for Children-Revised (WISC-R; Wechsler,
1974) in three prenatal congenital and three postnatal acquired etiologies. The
largest discrepancies occurred in children with congenital etiologies (aqueductal
stenosis, spina bifida); children with postnatal etiologies showed average but
comparable scores on VIQ and PIQ measures. However, a more recent study by
the present authors (Thompson et al., 1991) did not find significantly discrepant
Verbal-Perceptual-Performance scores on the McCarthy Scales of Children’s
Abilities (McCarthy, 1972) in children with hydrocephalus secondary to spina
bifida and prematurity. In addition, Thompson et al. (1991) suggested that the
presence of lower PIQ scores may reflect the motor requirements of the WISC-R
and other comparable instruments. Neither Dennis et al. (1981) nor Thompson et
al. (1991) included comparison groups of children similar in etiology but untreated
for hydrocephalus. In addition, Thompson et al. (1991) did not include an aqueductal
stenosis group; and Dennis et al. (1981) included very few children with prematurity
and hydrocephalus. Because the psychometric measures and ages of the children
were also different, it is not surprising that different results were obtained.
Etiology-based differences in the cognitive development of hydrocephalic
children and interactions between verbal and nonverbal cognitive skills are both
 VERBAL-NONVERBAt 595

pertinent to an understanding of the biological correlates of cognitive develop-

ment in brain-injured children. Three principal etiologies of early hydrocephalus
are aqueductal stenosis (AS), spina bifida (SB), and prematurity (P-Hyd). All
three etiologies can lead to hydrocephalus, but they are also associated with
other congenital neuropathological anomalies that may have an influence on
development. Children with AS do not reabsorb cerebrospinal fluid (CSF) ad-
equately due to blockage of the normal CSF circulatory pattern at the aqueduct of
Sylvius. AS is often accompanied by abnormalitiesof the corpus callosum, hcluding
partial agenesis (Barkovich, 1990). SB is a defect in neural tube closure repre-
senting a broad category of disorders that result from anomalous closure of the
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neural tube. Many children are born with an obvious spinal defect, represented
by a myelomeningocele or meningocele, at the caudal end of the neural tube.
Cranial anomalies are multiple but generally include the Arnold-Chiari malfor-
mation, which introduces a barrier to CSF outflow from the ventricular system to
the subarachnoid space. SB is also often associated with corpus callosum defects
(Just, Swartz, Ludwig, Ermert, & Thelen, 1990).
These congenital abnormalities result from early disruptions in neuro-
embryogenesis, occurring between approximately the fourth and sixteenth weeks
(Barkovich, 1990). The presence of multiple anomalies indicates that there was a
prolonged, rather than a brief, disruption in neuroembryogenesis during the first
mmester and the early part of the second trimester. In contrast, noncommunicating
hydrocephalus develops in some premature infants due to blockage of CSF
reabsorptive mechanisms. The hemorrhages in the germinal matrix and parenchyma
lead to destruction of the brain and may result in the development of porencephalic
cysts. Specific neurological deficits may depend upon the laterality and severity
of the hemorrhages and the resulting porencephalic cyst. Since these destructive
lesions occur in what would normally be the late second and early third trimester
(Volpe, 1989), P-Hyd infants have late gestational disruptive lesions rather than
the early gestational anomalies that are seen in patients with SB and AS. Corpus
callosum abnormalitiesmay be present in the P-Hyd children because the destructive
lesion producing the hemorrhage and hydrocephalus may destroy the corpus
callosum. Abnormalities in the corpus callosum may also be related to stretching
and thinning of the corpus callosum as the ventricles enlarge (i.e., as the hydro-
cephalus worsens). However, hydrocephalus and premature birth are abnormal
events that occur in what is generally an otherwise normal brain.
If the effects of hydrocephalus per se are to lower nonverbal skills (Dennis et
al., 1981; Rourke, 1989), then hydrocephalic children without other neuro-
pathological lesions should present with preservation of verbal skills and impairment
of nonverbal skills. This may be particularly apparent in AS children, where the
major abnormalities are often restricted to the CSF obstruction that leads to
hydrocephalus and the corpus callosum anomalies. In contrast, SB and P-Hyd
can be considered spectrum disorders because of the variable presentation of
other CNS anomalies that have a diffuse effect on the CNS. The effect of these
other CNS anomalies may be to reduce verbal skills to the level of nonverbal
 5% JACK M.FLETCHER ET AL.

skills. Hence, AS children should be more likely to show verbal-nonverbal dis-

crepancies whereas SB and P-Hyd children are more likely to show comparable
development of verbal and nonverbal skills. These findings would represent an
interaction of etiology, presence or absence of hydrocephalus, and verbal and
nonverbal skills.
The present study provided a systematic test of these hypotheses in three
etiologies of hydrocephalus with comparison groups. Children were of similar
age, and the assessment of verbal and nonverbal development extended beyond
traditional assessments of psychometric intelligence.
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METHODS

Subjects
The design of this study involved (a) two-group comparisons of three etiologies of hydro-
cephalus (SB-shunt, prematurity-hydrocephalus,and AS) with comparison groups addressing
treatment and handicap effects (SB-no shunt, p r e m d t y - n o hydrocephalus, and normals);
and (b) comparisons across the three etiologies of hydrocephalus. All children were initially
recruited for a longitudinal study at the ages of 60-84 months over a 2-year period,
representing a thorough combing of the Houston-Galveston metropolitan area and sup-
plementation from San Antonio and Dallas. Most children were followed 1 year later,
with additional subjects entering the study to increase sample size.
Children were included in the hydrocephalus groups based on standard clinical d e f i -
tions and procedures for establishing diagnosis, including magnetic resonance imaging,
medical record review, and neurologic examination. Children who presented with hydro-
cephalus not secondary to dysraphic anomalies, prematurity, or AS were excluded. In
addition, any hydrocephalic child with additional complications, including meningitis.
other neurological anomaly (e.g., trauma, tumor, or stroke), uncontrolled epilepsy, primary
sensory loss (deafness, blindness), severe behavioral disorder (e.g.. autism, childhood
psychosis), or evidence of abuse or neglect, was excluded. Single or multiple shunt revi-
sions did not exclude a child from study. Subjects were also required to have either a
Verbal or Perceptual-Performance IQ on the McCarthy Scales of Children’s Abilities
(McCarthy, 1972) above 69 to avoid spurious results, since the relationship of VIQ and
PIQ changes with overall level of intelligence as a property of the test (Dennis et al.,
1981; Matarazzo, 1972).
The SB-shunt (SB-S) group consisted of 19 meningomyeloceles and 1 meningocele,
all of whom were shunted for hydrocephalus. The SB-no shunt (SB-nos) comparison
group (n = 13) consisted of 4 meningomyeloceles, 4 meningoceles, 3 spinal lipomas, and
2 children with disastomyelia. Although these children were recruited with the understanding
that they were all nonhydrocephalic, a careful review of medical records and, in 10 cases
(excluding two spinal lipoma and one disastomyelia cases), concurrent MFU of the brain,
revealed ventricular enlargement in two meningomyelocelesand two meningoceles. Hence,
this group did not uniformly represent a nonhydrocephalic comparison group. To maintain
sample size, these cases were not eliminated and were kept in a nonshunted SB compari-
son group. None of these cases demonstrated more than mild hydrocephalus.
The prematurity-hydrocephalus group (P-Hyd) consisted of 20 children with a history
of Grade III (n = 12) and Grade IV (n = 8 ) intraventricular hemorrhage (NH). Eight of
these children were shunted and the other 12 had received medication treatment for
progressive hydrocephalus shortly after birth. In this group, hydrocephalus was defined as
a Grade 111 or IV IVH persisting for at least 3 weeks after admission, with evidence of
 VERB AL-NONVERBAL 597

progressive ventricular dilation requiring treatment. In the nonshunted P-Hyd children,

concurrent MRI of the brain demonstrated mild to moderate hydrocephalus in 7 of the 10
cases who consented to the imaging study, The prematurity-no hydrocephalus (P-noHyd)
comparison group consisted of 16 children who never developed progressive ventricular
dilation and were never treated for hydrocephalus. Some of these children had Grade I ( n
= 1) and Grade I1 (n = 6) IVH. Thirteen of these cases received MRI; 12 were read as
normal and one revealed areas of increased density in the white matter unrelated to
prematurity and of questionable significance. These two groups were comparable in birth
weight and length of gestation, seventy of respiratory illness, and length of hospitalization.
No child was included with a history of severe bronchopulmonary dysplasia, significant
pulmonary immaturity, or severe retrolental fibroplasia.
The AS group consisted of 8 children with a history of congenital hydrocephalus for
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which they were shunted. In each case, concurrent MRI was consistent with AS. Normal
children ( n = 13) were siblings ( n = 5), cousins ( n = 2). or were recruited from parents who
had a SB or premature child not eligible for the study ( n = 6). This approach to recruitment
prevented the selection of a markedly different group of normals in terms of demographic
characteristics. Any child meeting the exclusionary criteria for the hydrocephalic groups
was not included. All normal children demonstrated complete absence of acquired neu-
rological disorder, including normal MRI in 12 cases.

Table 1 summarizes demographic data at the time of the initial recruitment (Year l),

Table 1. Demographic Characteristics of Follow-Up Year 1 Sample (N = 90).

Variable Group

Aqueductal
Spina Bifida Premature Stenosis Normal
Shunt NoShunt Hyd NoHyd Shunt

N 20 13 20 16 8 13
Age (mos.)
M 74.4 77.0 76.7 73.4 73.2 77.0
SD 4.3 5.4 5.0 5.10 6.4 4.6
SES (%)
Low (4-5) 60 23 40 31 37 39
Middle (3) 20 23 15 31 13 23
High (1-2) 20 54 45 38 50 38
Gender (%)
Male 30 38 45 56 75 69
Female 70 62 55 44 25 31
Race (%)
White 65 84 80 63 62 84
Black 10 0 5 24 25 0
Hispanic 20 8 10 13 13 16
Other 5 8 5 0 0 0
McCarthy
GCI
M 76.0 103.7 90.0 100.6 93.8 102.5
SD 10.8 16.8 24.3 7.6 18.1 14.9
 598 JACK M.FLETCHER ET AL.

revealing patterns that parallel the epidemiology of the disorders. Chi-square analyses
across the six groups and in the three two-group comparisonswere not statistically significant
(p > .05), although some trends are apparent. In particular, there is a trend for more
females and fewer Blacks in both SB groups. However, these trends are consistent with
the epidemiology of SB (Wiswell, Tuttle, Northam, & Simonds, 1990). All comparisons
of hydrocephalus groups with their respective comparison group show no sociodemographic
differences.
Sample sizes were varied across groups. Children with SB and no treatment for hydro-
cephalus and children with AS are rare and proved difficult to recruit, particularly in the
narrow age range used for this study. To increase sample size, we accepted additional
children who were too old for the initial assessment, but in the correct age range for the
second yearly follow-up of the initial groups. There were 11 children in Year 1 who did
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not receive Year 2 evaluations, and 11 children who were added in Year 2. An analysis of
the demographic variables in Table 1 for total cohort at Year 2 yielded no statistically
significant differences. No more than three Year 1 subjects were lost per group, but there
was a tendency to lose hydrocephalic subjects with larger discrepancies showing lower
nonverbal scores.

Cognitive Assessments
Each child received the McCarthy Scales of Children’s Abilities (McCarthy, 1972), a
battery of neuropsychological tests, and in Year 2, the WISC-R (Wechsler, 1974). Five
comparisons of discrepant abilities were made. The McCarthy Verbal and Perceptual-
Performance standard scores and the WISC-R VIQ and PIQ represented the first two
comparisons. For the third comparison, neuropsychological tests were used to create
composites of verbal and nonverbal cognitive abilities, reducing the number of dependent
variables for analysis. The verbal composite was created by averaging age-based standard
scores on the Auditory Analysis Test (Rosner & Simon, 1971), Rapid Automatized Nam-
ing (Denckla & Rudel, 1974). Word Fluency (Gaddes & Crockett. 1974), Word Finding
Test (Dennis, Hendrick, Hoffman, & Humphreys, 1987), and the Opposite Analogies,
Fluency, and Vocabulary subtests of the McCarthy. These tests represent a language
construct that is not contaminated with some of the less clearly language-based subtests of
the McCarthy and WISC-R. Similarly. a nonverbal composite was created by averaging
age-based standard scores on the Recognition-Discrimination Test (Saw & Fletcher, 1982).
Beery Visual-Motor Integration (Beery, 1982), and Judgement of Line Orientation Test
(Lindgren & Benton, 1980). The fourth comparison was on the verbal and nonverbal
selective reminding tests (Buschke, 1973; Fletcher, 1985). Finally, many hydrocephalic
children have primary motor handicaps. The fifth comparison addressed the role of motor
demands in tasks assessing nonverbal skills (e.g.. WISC-R PIQ). The nonverbal tasks
were averaged into composites representing motor-free spatial skills (Recognition-Dis-
crimination. Judgement of Line Orientation) and motor-based spatial skills (Beery VMI).
All composites were averages of scores standardized with M = 100 and SD = 15 based on
available normative data.

RESULTS

To provide the largest possible sample size and to address the replicability of the
analyses, results are presented separately for the Year 1 (N= 90) and Year 2 (N=
90)fOllOW-upS.
Tables 2 and 3 present means and standard deviations for Years 1 and 2,
respectively. To address the hypotheses of interest, a multivariate approach to
repeated measures ANOVA was used (O’Brien & Kaiser, 1985). Each compari-
 VERBAL-NONVERBAL 599

Table 2. Means and Standard Deviations for Verbal-Nonverbal Variables (M= 100; SD
= 15) by Groups for Year 1 (N = 90).
~

Variable Group

Aqueductal
Spina Bifida Premature Stenosis Normal
Shunt NoShunt Hvd NOH yd Shunt

N 20 13 20 16 8 13

McCarthy
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Verbal
M 85.1 101.6 96.0 99.3 99.8 100.8
SD 12.9 15.8 15.9 11.1 16.6 9.7
Perceptual-
Performance
M 78.1 105.9 89.7 106.2 88.4 106.7
SD 16.8 17.4 24.3 7.6 18.0 11.9
Composites
Verbal
M 82.2 104.4 95.5 99.2 97.5 100.8
SD 14.1 15.1 14.0 12.1 19.7 12.2
Nonverbal
M 71.0 100.6 83.3 97.4 83.7 102.4
SD 19.8 8.7 23.1 7.0 14.6 10.2
Memory*
Verbal
M 90.8 104.3 104.7 98.8 90.2 101.5
SD 8.9 10.8 19.6 14.S 7.6 10.6
Nonverbal
M 83.3 99.1 92.5 99.2 92.1 91.8
SD 12.5 22.9 15.7 19.3 21.6 12.8

Motor
Motor-Free Spatial
M 62.0 100.4 78.9 94.1 81.7 100.0
SD 30.6 9.8 28.2 11.4 16.6 13.3
Motor-Baed Spatial
M 79.9 100.8 87.6 100.7 85.7 104.9
SD 12.2 10.0 19.3 5.0 14.2 9.0

*Sample sizes vary slightly because some children were not able to complete the nonver-
bal memory task.
 600 JACK M.FLETCHER ET AL.

Table 3. Means and Standard Deviations for Verbal-Nonverbal Variables (A4= 100. SD
= 15) by Groups for Year 2 (N= 90).

Variable Group

Aqueductal
Spina Bifida Premature Stenosis Normal
Shunt NoShunt Hyd NoHyd Shunt

N 19 13 17 15 8 17
Age (mos.)
M 87.56 88.37 88.57 86.47 88.04 90.57
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SD 3.57 7.31 5.82 5.42 8.69 5.67

McCarthy
Verbal
M 84.7 101.3 94.4 101.8 96.3 109.1
SD 14.4 17.2 17.4 13.9 16.5 10.1
Perceptual-
Performance
M 82.5 107.2 95.5 107.0 82.8 112.1
SD 14.8 13.0 21.7 10.8 18.5 11.5
WISC-R*
Verbal
M 88.2 111.3 98.1 103.7 104.7 116.1
SD 15.1 15.3 18.1 7.7 19.2 11.2
Performance
M 82.6 110.3 97.8 110.3 88.0 112.9
SD 19.2 12.4 21.4 14.5 18.8 12.0
Composites
Verbal
M 83.5 95.8 93.5 99.0 91.9 103.7
SD 16.1 19.4 12.5 10.6 20.4 7.3
Nonverbal
M 80.2 98.1 86.2 97.0 81.0 102.0
SD 10.4 8.2 17.4 8.6 12.0 9.5
Memory
Verbal
M 82.8 96.6 87.8 97.8 86.9 98.0
SD 9.2 9.8 14.6 20.7 11.6 12.3
Nonverbal
M 78.6 95.4 81.7 103.3 81.7 99.2
SD 20.0 20.1 18.8 19.6 30.0 24.0
Motor
Motor-Free Spatial
M 78.3 96.1 85.9 94.9 80.8 100.0
SD 11.7 13.0 18.4 15.8 16.2 15.0
Motor-Based Spatial
M 81.6 100.0 90.0 99.1 81.2 104.0
SD 12.3 8.2 17.0 6.7 14.2 7.7
* Sample sizes vary slightly because the WISC-R was not obtained on some subjects.
 VERBAL-NONVERBAL 601

son contained two between-subjects factors, Etiology (3 levels) and Hydrocephalus

(2 levels), and one within-subjects factor, Task, which was treated as a repeated
measure. Significant interactions involving Hydrocephalus and Etiology (Hy-
drocephalus by Etiology; Hydrocephalus by Etiology by Task) were followed by
two single degree-of-freedom contrasts, each tested at .OW2 to control for the
number of comparisons. The first contrast tested whether the effect of hydro-
cephalus in the AS group was different from the average e f f v t of hydrocephalus
in the other two etiology groups. The second single degree-of-freedom contrast
tested whether hydrocephalus interacted with Etiology in the SB and IVH groups.
We hypothesized that both contrasts would be significant, indicating that the
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effects of hydrocephalus varied across the range of etiologies, and that these
differential effects were not simply the result of including a normal group. In
addition, it was expected that Task differences would interact with Etiology, and
possibly with the Etiology by Hydrocephalus interaction. These interactions would
indicate that the degree of discrepancy in verbal-nonverbal skills was different
for the three etiologies of hydrocephalus. However, if interactions of Task oc-
curred only in relationship to the Hydrocephalus factor, then the presence of
hydrocephalus would be related to skill discrepancies regardless of etiology.
Post hoc comparisons involved tests of simple interaction effects, simple effects,
simple-simple effects, and pairwise comparisons where applicable. The general
strategy followed is outlined in Maxwell and Delaney (1990). To control Type I
error, the Bonfenoni adjustment was employed to maintain alpha at .05 throughout
post hoc analyses for the overall effect being decomposed. Although age differ-
ences were not significant, age varied across etiology groups, so that this variable
was treated as a covariate.

McCarthy and WISC-R

In Year 1, the multivariate approach to repeated measures for McCarthy Verbal
and Perceptual-Performance scales did not yield a significant Etiology by Hy-
drocephalus by Task or Hydrocephalus by Etiology interaction, F < 1. However,
< .OO01.
the Hydrocephalus by Task interaction was significant, F(1,83) = 1 8 . 6 9 , ~
The interaction is depicted in Figure 1, which shows that all three hydrocephalus
groups had lower McCarthy Perceptual-Performance than Verbal scores relative
to the three comparison groups, who had comparable Perceptual-Performance
and Verbal scores.
Similar findings were obtained in the Year 2 McCarthy scores evaluation.
Again, the Hydrocephalus by Etiology by Task interaction was not significant,
F(2, 83) = 1.34, p < .27. However, the Hydrocephalus by Task interaction was
significant, F(1,82) = 10.28,p < .003. Relative to Year 1 findings, Year 2 results
were not as uniform for the hydrocephalus groups with Table 3 showing discrep-
ancies on the McCarthy predominantly in the AS group. However, the Hydro-
cephalus by Etiology interaction was not significant ( p < .17).
Similar results were obtained for the Year 2 WTSC-R comparison. The 3-way
interaction was not significant, F c 1, but the Hydrocephalus by Task interaction
 602 JACK M.FLETCHER ET AL.

110

105

100

95
W
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U
0
% 90

a5

en

7s
Verbal Perceptual- P e J f ~ m e n ~ e

McCARTHYSCAE

Fig. 1. Verbal and Perceptual-Performance Scale scores by Group, showing that

hydrocephalic children, regardless of etiology, have lower Perceptual-Perform-
ance scores relative to Verbal scores than non-hydrocephalicchildren, who do not
show skill discrepancies.

was significant, F(1.78) = 4.49,p c .04.The pattern of results was similar to the
McCarthy, showing larger differences in the AS group. Again, the Hydrocepha-
lus by Etiology interaction was not significant (p < .09).

Verbal-nonverbal composites
The MANOVA for the verbal-nonverbal composites yielded comparable results
to the McCarthy and WISC-R analyses. The 3-way interaction was not significant
at Year 1 or Year 2, F < 1. Again, the Hydrocephalus by Task interaction was
significant for Year 1, F(l,83) = 1 4 . 3 0 , <
~ .0003,and Year 2, F(1, 83) = 5 . 2 6 , p
< .02. There was no evidence of Hydrocephalus by Etiology interactions. As a
group, hydrocephalic children had lower nonverbal than verbal scores.
 VERBAL-NONVERBAL 603

Verbal-nonverbal memory
The MANOVA for the memory comparison yielded a significant 3-way interaction
at Year 1. F(2, 75) = 4 . 3 1 , ~< .02. Follow-up of this interaction with the single
degree-of-freedom contrasts yielded no significant effects at the .025 level. In-
spection of means in Table 2 showed a trend for the SB-S, P-Hyd, and normal
groups to have poorer nonverbal than verbal memory scores. However, the lower
scores in the normals made these findings difficult to interpret, particularly in
relationship to the AS group. :n Year 2, there were no significant interactions of
Task with Etiology or Hydrocephalus, F < 1. The main effect of Group was sig-
nificant, F(5, 83) = 23.96, p < .0001, but profiles were similar. Children with
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hydrocephalus obtained lower scores on both measures of memory than did the
comparison groups, with no evidence of discrepancy between verbal and nonver-
bal tasks.

Motor-free-motor-based
The final analysis addressed the role of the motor demands of the nonverbal
tasks, comparing a composite of spatial skills with no copying component and a
visual-motor component. There was no significant :3-way interaction, F(2, 83) =
2.65, p < .08.Moreover, as Table 2 shows, the SB-S and P-Hyd groups scored
lower on the motor-free tasks. Hence, the discrepancy in nonverbal processing
cannot be attributed to motor demands of the tasks. In Year 2, there were no
interactions involving Task with Hydrocephalus or Etiology, F < 1. In general,
children with hydrocephalus in this study had lower scores on both nonverbal
measures, so demands for motoric functioning (copying) did not explain the
observed discrepancies in verbal and nonverbal skills.

Treatment effects
Since treatment was confounded in the SB-S, SB-nos, and P-Hyd groups, addi-
tional analyses were conducted to examine relationships of etiology and treatment
(shunt, medication). For these analyses, hypotheses concerning interactions of
Etiology (SB, prematurity), Treatment (shunt, no shunt) and Task (Verbal,
Nonverbal) were evaluated on tasks showing discrepancies in hydrocephalic
cases.
Table 4 presents means and standard deviations for these analyses. For the
McCarthy, significant Task by Treatment interactions were apparent for Year 1,
F(1, 39) = 12.74, p < .001, and Year 2, F(1, 34) = 5.81, p < .03. Relative to
hydrocephalic children treated only with medication, inspection of means and
standard deviations in Table 4 shows that the shunted cases (collapsed across
etiology) had lower Perceptual-Performance scores than Verbal scores. Similar
findings were apparent for the Year 2 WISC-R scores, F ( 1 , 33) = 4.31, p < .05.
For composite scores, interactions of Task and Treatment were also found at
Year 1, F(1, 39) = 8.82, p < .006, and Year 2, F(1, 34) = 3.90, p c .06. As Table
4 shows, shunted children in both etiologies had larger discrepancies. To evalu-
ate if the results in Table 4 were explainable by the tendency to shunt children in
 604 JACK M.FLETCHER ET AL.

Table 4. Means and Standard Deviations for Verbal-Nonverbal variables (M= 100; SD =
15).

Group

Spina Bifida Prematurity

Variable Shunt Medication Shunt Medication
Year 1 2 1 2 1 2 1 2

N 20 19 4 3 8 6 12 11

McCarthy
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Verbal
M 85.1 84.7 97.7 95.5 89.3 88.0 100.4 98.0
SD 12.9 14.4 25.3 30.0 12.3 11.5 17.0 19.5
Perceptual-
Performance
M 78.1 82.5 106.0 98.5 69.4 76.0 103.2 106.1
SD 16.8 14.8 22.8 22.7 10.8 16.9 21.2 16.1
WISC-R
Verbal
M - 88.2 - 108.0 - 95.2 - 99.6
SD - 15.1 - 29.5 - 22.3 - 16.4
Performance
M - 82.6 - 105.3 - 78.3 - 108.5
SD - 19.2 - 6.7 - 18.4 - 14.5
Composites
Verbal
M 82.2 83.5 99.1 84.7 87.2 85.7 99.1 97.7
SD 14.1 16.1 21.2 35.5 13.7 6.3 99.1 13.2
Nonverbal
M 71.0 80.2 98.4 93.8 63.0 74.4 98.4 98.5
SD 19.8 10.4 22.7 17.8 17.5 14.4 8.7 11.6

the right hemisphere, Etiology by Shunt-side by Task analyses were conducted

(Right n = 29; Left n = 8). There were no significant interactions, main effects, or
trends involving side of shunt.

DISCUSSION

These results demonstrate that hydrocephalus per se is associated with discrep-

ancies in verbal and nonverbal cognitive skills, with nonverbal skills being lower.
The results do not indicate that hydrocephalic children have “normal” verbal
skills - only that their nonverbal skills are more poorly developed than their
verbal skills. Unlike Dennis et al. (1981), differences attributable to etiology
were not statistically significant. However, like Dennis et al. (1981), an inspec-
 VERB AL-NONVERBAL 605

tion of means (Tables 2 and 3) revealed larger discrepancies in verbal and nonverbal
skills in the AS group, with smaller discrepancies in children with etiologies
reflecting SB and prematurity. This is especially apparent in Year 2, when the
children were more comparable (on average) in age to Dennis et al. (1981). There
were major differences in the design of Dennis et al. (1981) and the present
study. The present study was prospectively conducted in a narrower age range.
Sample sizes were larger for most groups, and comparison groups untreated for
hydrocephalus were also included. Dennis et al. (1981) did not find differences
due to etiology on absolute measures of verbal and nonverbal cognitive skills.
Differences were apparent only on a within-group difference score, which was
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directly addressed in our study by testing interactions involving Task. This in-
teraction was not directly tested in Dennis et al. (1981), probably because of
sample size limitations. However, our statistical approach may not have had
sufficient power to detect interactions with etiology, reflecting the small size of
the AS group (n=8). This analysis warrants replication with a larger sample of
AS patients.
Unlike our first study (Thompson et al., 198l), we found interactions of
hydrocephalus per se with verbal and nonverbal discrepancies. In addition, these
discrepancies did not reflect motor demands of the nonverbal tasks. This latter
finding can be attributable to the more sophisticated measurement of spatial
skills in the current study. Thompson et al. (1991) only employed the Recognition-
Discrimination Test (RD). This task, which involves simple matching of geometric
designs, may not be sensitive to the spatial processing problems of hydrocephalic
children. In contrast, the Judgement of Line Orientation Test (JLO) used in the
curren. study may be more sensitive than RD to spatial processing deficits.
Studies in adults using evoked potential and regional cerebral blood flow meth-
odologies have shown that performance on the JLO is primarily mediated by the
right hemisphere (Deutsch, Bourbon, Papanicolaou, Br Eisenberg, 1988). Similarly,
Papanicolaou, DiScenna, Gillespie, and Aram (1990) found that the K O consistently
produced lower amplitudes in evoked potentials fiom the right hemisphere in
children with unilateral cerebral insults. Hence, the JLO, which is a more complex
visual-spatial task than RD, may be more sensitive to spatial processing deficits
in adults and children with brain impairment.
The interactions of hydrocephalus and verbal-nonverbal performance in this
study are not necessarily inconsistent with Thompson et al. (1991), who only
addressed etiology differences, not average effects of hydrocephalus. Since AS
subjects show larger verbal-nonverbal discrepancies, adding the AS group may
have been sufficient to detect an interaction in this study. There are also signifi-
cant sampling differences reflected by the lower Year 2 McCarthy GCI of the
SB-S group in the current study (M = 78.6, SD = 20.10) versus Thompson et d.(A4
= 95, SD = 11.8). Thompson et al. (1991) included 4 unshunted children in the
SB group, which should increase intellectual levels in the SB group relative to
those in the current SB-S group, all of whom were shunted. The children in
Thompson et al. (1991) were also comparable in age to subjects during Year 2 of
 606 JACK M.FLETCHER ET AL.

the present study, where discrepancies on the McCarthy Scales were less appar-
ent in the current study (see Table 3). Again, investigation of etiology differences
in larger samples is clearly needed. Of particular interest is the possibility of
differential growth effects: this will be addressed in the longitudinal study when
collection of a third follow-up has been completed.
The basis for verbal-nonverbal discrepancies undoubtedly extends beyond
the etiology of the hydrocephalus. The reductions in verbal skills in the SB-Sand
P-Hyd groups may reflect the higher frequency of other brain anomalies in these
groups. In the SB-S group, the Arnold-Chiari malformation and oculomotor
defects may be relevant ponders et al., 1990);in the P-Hyd group, the significant
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hypoxic insult in conjunction with hydrocephalus may reduce the possibility of

reorganization of CNS functions early in development. However, even severity
of hydrocephalus may be related to discrepancies in skill development because
of maximal effects on cerebral white matter tracts. Bendarsky and Lewis (1990)
found that increases in the size of the left lateral ventricle correlated with lower
verbal skills in young P-Hyd children, but that study did not thoroughly assess
nonverbal cognitive skills. In a study of a subset of the SB and AS children in the
current study, quantitative MRI measures of the left lateral ventricles and left
internal capsule correlated significantly with verbal skill measurements (Fletcher
et al., 1991).However, nonverbal skills correlated with internal capsule measures
from both hemispheres. This finding is important because measurements of pro-
jection fiber tracts may more directly reflect the degree to which the brain was
distended by hydrocephalus early in development. Shunting reduces ventricle
size, so that measurements of the ventricles may have little relationship with
initial severity of hydrocephalus.
Magnetic resonance imaging (MRI) of the brain in the children of the current
study also reveals considerablepathology involving the commissural tracts (Fletcher
et al., 1991). In AS and SB children, partial agenesis and hypoplasia (thinning
but no agenesis) occurred in virtually all children. There was a clear tendency for
children with intact corpora callosa to have higher levels of intellectual functioning
regardless of etiology. In addition, correlating the size of the corpus callosum
frommidsagittal MRI measurement revealed higher correlations with nonverbal
skills relative to verbal skills (Fletcher et al., 1991). Rourke (1989) hypothesized
that nonverbal skills deficits could occur because of impairment of white matter
in the right hemisphere (due, for example, to hydrocephalus), or inefficient
intrahemispheric connectivity (due, for example, to the corpus callosum abnor-
malities). Our findings are consistent with these hypotheses.
The basis for the null results on the memory comparison is not clear. There
are two possibilities. First, the measures may have been rather too difficult in the
age range employed in this study. Some hydrocephalic children were simply not
able to perfom the nonverbal task and were not included in these analyses. Other
children obtained extremely low scores near the basal level of the tasks. Longitudinal
follow-up of the sample, which is in progress, will help evaluate this possibility.
A second possibility is that disorders of the cerebral white matter are associated
 VERBAL-NONVERBAL 607

with more general reductions in higher-order skills such as memory and prob-
lem-solving. Severely head-injured children do not show discrepancies in per-
formance on the Verbal and Nonverbal Selective Reminding tests (Gilliam, Fletcher,
Levin, & Ewing-Cobbs, 1988). However, children with post-CNS irradiation for
leukemia do show poorer nonverbal memory performance (Copeland et al., 1985).
Both of these latter disorders principally (but not exclusively) involve multi-
focal lesions of the cerebral white matter and show other evidence for poorer
development of nonverbal processing skills (Fletcher & Copeland, 1988). Additional
research in larger samples is needed to address the basis for these findings.
A final comment concerns the confounding of hydrocephalus and its treatment
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in the SB and premature groups. We had hoped to develop a group of children

with SB and no hydrocephalus analogous to the P-noHyd group. However,
careful review of medical records and concurrent MRI in the SB group made it
clear that some children had mild to moderate hydrocephalus and had been treated
nonsurgically for hydrocephalus earlier in their development. In theory, these
children could have constituted a separate group, but the sample size was not
sufficient. Because children in the P-Hyd group had also received both shunts
and/or medication for hydrocephalus, we chose to compare treatment effects in
these two etiology groups to obtain sufficiently large cell sizes for statistical
analysis. These results showed that children who received shunts had larger
discrepancies in verbal and nonverbal scores. Of particular interest are the dif-
ferences within the premature group, where only the shunted children show a
discrepancy. The unshunted group obtained scores similar to the P-noHyd group.
In retrospect, it may have been more reasonable to compare shunted children
with SB or prematurity, since shunted hydrocephalics tend to show discrepan-
cies. Also, early ventricular dilation in the SB-noS and P-Hyd groups does not
seem to be associated with skill discrepancies.
On the surface, these findings could be taken to imply that shunting “causes”
poorer nonverbal scores. A more likely explanation is that children are shunted
when their hydrocephalus becomes severe and life-threatening, so that shunted
children have brains that have been more drastically impaired by hydrocephalus.
Indeed, morphometric evaluation of ventricle size in Fletcher et al. (1991) showed
no differences in shunted and unshunted SB children, both of whom had larger
ventricles relative to controls. Hence, as Rourke (1989) suggested, severity of
hydrocephalus early in development and prior to when the children in this study
were assessed, along with the corpus callosum abnormalities, may well have a
greater impact on the development of nonverbal ski’lls.

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