Assessment of Unilateral spatial neglect (USN) in children was described fairly
recently (Hécaen 1976). Few cases (Ferro et al. 1984, Johnston
unilateral spatial
neglect in children
using the Teddy Bear
Cancellation Test
Anne Laurent-Vannier* MD;
Mathilde Chevignard MD, Department of Rehabilitation for
Children with Acquired Brain Injury, Hôpital National de
Saint Maurice, St Maurice;
Pascale Pradat-Diehl MD, UPMC/INSERM 731 – Department
of Physical Medicine and Rehabilitation, Hôpital de la
Salpêtrière, Paris;
Geneviève Abada OT, Department of Rehabilitation for
Children with Acquired Brain Injury, Hôpital National de
Saint Maurice, St Maurice;
Maria De Agostini PhD, INSERM U 472, Villejuif, France.
*Correspondence to first author at Service de rééducation
des pathologies neurologiques acquises de l’enfant, Hôpital
National de Saint Maurice, 14 rue du Val d’Osne, 94415 Saint
Maurice Cedex, France.
E-mail: a.laurentvannier@hopital-saint-maurice.fr
The purpose of the study was to provide normative data for the
Teddy Bear Cancellation Test (TBCT) and to evaluate
prospectively the frequency of unilateral spatial neglect (USN)
in children with acquired brain injury (ABI). In the control
group (n=419; 218 males, 201 females; mean age 5y 1mo [SD 1y
4mo]; range 3 to 8y) omissions were rare and decreased with
age. A left displacement of the first three teddy bears cancelled
was observed with increasing age. This preferential left-to-right
cancelling strategy was interpreted as learned under the
influence of reading habits. The same test was used prospectively
in 41 children with ABI (24 males, 17 females; mean age 5y 5mo
[SD 2y]; range 3 to 8y) admitted to a paediatric rehabilitation
department specializing in acquired brain lesions. In patients
and controls, children under 6 years of age omitted more items
than older children. The localization of omissions was skewed
significantly to the left in children with right-sided lesions
compared with children with left-sided lesions. USN was
observed in seven patients with ABI. Left USN was found in
three of the 10 patients with right-sided ABI. Right USN was
present in two of the patients with 15 left-sided ABI and two of
the 16 patients with non-lateralized ABI. Left USN is frequent in
children after right-sided brain injury. The relatively high
incidence of right spatial neglect in children is discussed in
relation to the development of hemispheric specialization.
See end of paper for list of abbreviations.
120 Developmental Medicine & Child Neurology 2006, 48: 120–125
QUELLI Renata bassani - bassaniqre@gmail.com - CPF: 012.477.481-46
and Shapiro 1986, Ferro and Martins 1990, Thompson et al.
1991, De Agostini 1992, Manly 1997, Billingsley et al. 2002)
had been reported before recent articles demonstrating
neglect in 12 children with acquired brain injury (ABI;
Laurent-Vannier et al. 2003) and in a group of children with
perinatal brain lesions (Trauner 2003). Possible reasons for
the paucity of research on USN in children include its confu-
sion with hemianopia or dyslexia, and a lack of specific evalu-
ation tests. Only a few tasks have been designed specifically
to assess USN in children. Thompson et al. (1991) proposed
the Pre-school Measure of Unilateral Neglect, a bingo-type
game of line drawings of animals. Recently, Trauner (2003)
introduced another task to measure objectively neglect behav-
iour in infants, toddlers, and preschool children in which
children have to remove objects placed in front of them. The
order of object removal and the total time taken to remove all
objects are recorded on videotape. However, the equipment
required for this task precludes its widespread use in every-
day clinical practice.
In our clinical practice in a department specializing in chil-
dren with acquired brain lesions (Laurent-Vannier et al. 1998,
2000), USN appeared to be more frequent than described in
the literature. To study USN in children aged over 2 years, we
designed the Teddy Bear Cancellation Test (TBCT; [Test de
Barrage des Nounours] Laurent-Vannier et al. 2001, 2003). A
cancellation test was chosen because such tests are easy to
perform in clinical practice, and because cancellation tests
are known to detect USN in adults (Halligan et al. 1989,
Azouvi et al. 2002).
Therefore, the aims of the current study were: (1) to pro-
vide normative data for the TBCT and (2) to evaluate in a
prospective study the frequency of USN in children with ABI.
Method
MATERIAL
The TBCT was developed according to the same principles
as the Bells Test (Gauthier et al. 1989) for adults. A sheet of
paper (21×29.7cm) included different pictures of objects
that are of interest to children. The teddy bear was chosen as
the target because it is sex-neutral. Fifteen targets and 60 dis-
tractors were distributed proportionately in a pseudo-ran-
dom array in five columns. Each column was numbered from
1 to 5 from left to right (Figs 1a,b).
The examiner sat in front of the child and presented the
child with a sheet showing a teddy bear crossed out. The child
was then asked to cross out all the teddy bears. If the child
stopped before all the teddy bears were cancelled, the child was
asked once if the task had been finished. The task was com-
pleted when the child stopped or said he had finished.
The following variables were used: number of omissions
(out of 15), ‘location of omissions’ score (LO-S), and ‘loca-
tion of the first three teddy bears crossed out’ score
(START-S). LO-S was calculated according to the columns of
omitted items: –1 point for each omission in columns 1 and 2, 0
for omissions in column 3, and +1 for each omission in columns
4 and 5 (Figs 1a,b). This score reflects the lateralization of
omissions. START-S was calculated with the same method.
This score can range from –3 for three items crossed out on
the left side to +3 for three items crossed out on the right
side. Children with ABI exhibiting a pathological number of
 omissions (number of omissions ≥95th centile; see Table III)
and a LO-S ≥2 were considered to have USN.
Participants
CONTROL CHILDREN
Four hundred and nineteen children (218 males, 201 females;
mean age 5y 1mo [SD 1y 4mo]; range 3 to 8y), divided into
five age groups (Table I), underwent the TBCT. These age
groups encompassed three levels of nursery school and two
grades in primary school. Children were recruited in two dif-
ferent urban areas corresponding to high and low socio-
economic status (SES; two schools in the Paris area and two in
the suburbs). Handedness was defined by the hand used for
writing. Exclusion criteria were a history of previous neuro-
logical or psychiatric disorders, or children who had repeated
a grade more than once. Following the standard procedure,
school inspectors (Public National Education system) and
school principals gave their approval for pupils to participate
in the study. Parents and children gave their informed consent.
The children took the test at school in a quiet room.
CHILDREN WITH ACQUIRED BRAIN INJURIES
A prospective study was performed over one year in the
Department for Rehabilitation of Children with Acquired
Brain Injury at the Hôpital National de Saint Maurice, St
Maurice, France. Children were referred as soon as they
could leave the acute care department. Most of the patients
in this study came from the neurosurgery or neurology
departments at Necker Enfants Malades children’s hospital
in Paris, where they received care during the acute phase of
their treatment. Forty-one children with acquired brain
injuries (24 males, 17 females; mean age 5y 5mo [SD 2y];
range 3 to 8y) carried out the TBCT.
Most of the lesions (32/41) were traumatic. Location of
lesions was assessed by computerized tomography or mag-
netic resonance imaging. Children were divided into three
groups: two groups with right- or left-sided lesions exclusive-
ly or predominantly, and a group with non-lateralized lesions
(diffuse brain swelling, subarachnoid haemorrhage, or bilat-
eral lesions; Table II). Children with ABI were divided into
two age groups: under 6 years (n=22) and 6 to 8 years (n=19).
Clinical assessment was performed on admission and includ-
ed a thorough neurological examination to detect the pres-
ence or absence of motor or sensory deficits and hemianopia.
Depending on age, children also underwent cognitive tasks
such as drawing (spontaneous and copying) and placing
stickers on a blank sheet of paper. The TBCT was part of the
clinical assessment. Neglect behaviour in daily life was also
investigated through clinical observation of daily life activi-
ties such as moving, eating, and personal care. Thirty of the
41 children performed the TBCT in the first two weeks after
admission to the Department of Rehabilitation, mostly on the

Table I: Demographic characteristics of control children

Age groups, y:m n Mean age Males:Females, Right:Left SES,

(SD), y:m n handed, n High:Low, n

3:0– 3:11 92 3:5 (0.27) 45:47 70:22 49:43

4:0– 4:11 116 4: 6 (0.28) 62:54 100:16 57:59
5:0– 5:11 115 5:6 (0.27) 65:50 99:16 65:50
6:0– 6:11 47 6:5 (0.29) 24:23 42:5 18:29
7:0– 7:11 49 7:7 (0.46) 22:27 40:9 24:25

SES, socioeconomic status.

a b

Figure 1: (a) Teddy Bear Cancellation Test. (b) Location of target in five columns.

The Teddy Bear Cancellation Test Anne Laurent-Vannier et al. 121

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 day of admission. Some children admitted to the department
were awakening from coma or were agitated, so the test was
administered later. For three of 41 children, the test could not
be administered due to organizational difficulties.
Results
CONTROL CHILDREN
Table III gives the mean (SD) number of omissions, LO-S, and
START-S for control children. The number of omissions
decreased with age: analysis of variance (ANOVA; with age
groups, sex, handedness, and SES as explanatory variables)
revealed a significant effect only for age group (F=12.6;
degrees of freedom [df]=411; p<0.001). The number of omis-
sions in the 95th centiles ranged from two omissions at 3 years
to no omission at 7 years of age.
No significant effect was found for age group, sex, hand-
edness, or SES on LO-S.
START-S was found to be related to age group (F=3.66;
df=411; p<0.01). A left displacement of the first three teddy
bears cancelled was observed with increasing age. The effect of
SES on the starting score showed a tendency towards signifi-
cance (F=2.96; df=411; p=0.08): the score was negative in
both groups but greater for high (mean –0.51 SD 1.92) versus
low (mean –0.21, SD 1.98) SES.
CHILDREN WITH ACQUIRED BRAIN INJURIES
Children in the three lesion groups did not differ in terms of
age at lesion or at testing, sex, handedness, aetiology, or Verbal

Table II: Demographic and clinical characteristics of children with acquired brain injuries (n=41)

Characteristics Right lesions Left lesions Non-lateralized lesionsa

n 10 15 16
Age at lesion, mean (SD) y:m 5:6 (2:1) 5:5 (2:2) 5:7 (2:0)
Days since onset, mean (SD) 57.8 (71.1) 64.1 (77.4) 35.0 (36.6)
Males:Females, n 6:4 10:5 8:8
Right:Left handed, n 9:1 14:1 15:1
Aetiology, n
Traumatic brain injury 8 12 12
Tumours 2 1 0
Cerebrovascular disease 0 2 1
Infectious disease 0 0 3
Motor deficit, n 8 11 6
Sensory deficit, n 3 4 1
Hemianopia, n 2 2 2
Verbal IQ, mean (SD) 91.6 (16.7) 73.6 (19.9) 79.8 (9)
Performance IQ, mean (SD) 73.9 (13.7) 73.3 (14.6) 75.2 (15.3)
aDiffuse brain swelling, subarachnoid haemorrhage, or bilateral lesions.

Table III: Performance of control children in Teddy Bear Cancellation Test

Scoring variables Age groups

3y–3y 11mo 4y–4y 11mo 5y–5y 11mo 6y–6y 11mo 7y–7y 11mo

n 92 116 115 47 49
Omissions
Mean (SD) 0.61 (0.78) 0.24 (0.50) 0.20 (0.48) 0.13 (0.45) 0.02 (0.14)
Minimum 0 0 0 0 0
Maximum 3 2 2 2 1
95th centile 2 1 1 1 1
LO-S
Mean (SD) 0.09 (0.74) 0.03 (0.36) 0.03 (0.26) 0.06 (0.25) –0.02 (0.14)
Minimum –2 –1 –1 0 –1
Maximum 2 1 1 1 0
95th centile 2 1 1 1 0
5th centile –1 –1 0 0 0
START-S
Mean (SD) 0.04 (1.77) –0.32 (2.04) –0.34 (1.99) –0.45 (2.09) –1.22 (1.61)
Minimum –3 –3 –3 –3 –3
Maximum 3 3 3 3 3
95th centile 3 3 3 3 2
5th centile –2 –3 –3 –3 –3

LOS-S, location of omissions; START-S, location of first three teddy bears crossed out.

122 Developmental Medicine & Child Neurology 2006, 48: 120–125

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 or Performance IQ. They did differ in terms of the frequency not observed on the TBCT but right neglect was found in
of motor deficit (χ2=6.19; df=2; p<0.05; Table II). The mean daily life activities and other tasks: omission of the right eye
number of omissions, LO-S, and START-S for each lesion group on the spontaneous drawing of a face, omission of the right
are shown in Table IV. part of a drawing, and displacement of the drawing to the left
For the number of omissions, ANOVA (with lesion groups, in a copying task.
age groups, and sex as explanatory variables) revealed a sig- Eight other children exhibited a pathological number of
nificant effect of age (F=4.18; df=1; 36; p<0.05). Children omissions without pathological LO-S, or neglect behaviours
under 6 years omitted more items (mean 2.59 [SD 3.4]) than in other tasks. It can be speculated that these non-lateralized
children aged 6 to 8 years (mean 1.21 [SD 2.12]). No effect of omissions are related to attention disorders. A double disso-
lesion group or sex was found. ciation was found between neglect and hemianopia. In this
For the LO-S, a significant effect of lesion group was study, three children with neglect had no hemianopia, and
observed (F=3.88; df=2; 36; p=0.02). Post-hoc analyses (t- two children with hemianopia had no neglect (Table V).
test) revealed that the group with right-sided lesions signifi-
cantly differed from the group with left lesions (t=–2.44; Discussion
df=23; p<0.05) and from the group with non-lateralized The TBCT was simple to use for control children and those
lesions (t=–2.34; df=24; p<0.05). No significant effect was with ABI. The omission rate was very low in the controls and
found between left-sided and non-lateralized lesions. Only decreased with increasing age. In 95% of controls, no more
children in the right-sided lesion group had a negative LO-S, than two omissions were observed at 3 years and no omis-
indicating that their omissions were located on the left. No sions were recorded at over 6 years of age. Rousseaux et al.
effect of sex or age was found. (2001) examined cancellation strategies in adults. In the Bells
For the START-S, statistical analysis showed no significant
effect of lesion or age group. Nevertheless, in children with
right brain injury the mean START-S was positive, indicating a
Table IV: Performance of children with acquired brain injury
right to left strategy, whereas it was negative in the other two
in Teddy Bear Cancellation Test
groups (Fig. 2).
Fifteen children exhibited a pathological number of omis- Scoring Right lesions Left lesions Non-lateralized
sions. Eight of them exhibited lateralized omissions and so variables lesionsa
were considered to have USN. Seven out of those eight patients
(Table V) showed concordant USN in daily life activities and n 10 15 16
Omissions
in other tasks. Three children among the 10 with right lesions
Mean (SD) 3.3 (4.1) 1.9 (3.0) 1.1 (1.6)
exhibited left USN and four children (two of 15 with left lesions Minimum 0 0 0
and two of 16 with non-lateralized brain lesions) exhibited Maximum 10 9 5
right neglect. No age difference was found between groups LO-S
of children with left and right neglect (mean 4.3 [SD 2] and Mean (SD) –1.3 (2.3) 0.6 (1.6) 0.4 (1.4)
mean 4.9 [SD 2.5] respectively) whereas children with Minimum –6 –1 –1
neglect were younger than the others (mean 4.5 [SD 2] and Maximum 2 5 4
mean 6.9 [SD 1.9]; t=–2.04; df=39; p<0.05). START-S
Two children showed a dissociation between the results Mean (SD) 0.2 (2.7) –1.0 (1.9) –0.6 (2.2)
in the TBCT and the other tasks (see Method). The first child Minimum –3 –3 –3
Maximum 3 3 3
(male, 3y 4mo with non-lateralized lesions) had three omis-
sions with an LO-S of +2 but did not show neglect behaviour aDiffuse brain swelling, subarachnoid haemorrhage, or bilateral

in the other tasks or in daily life. In the second child lesions. LOS-S, location of omissions; START-S, location of first three
(female, 5y 10mo with non-lateralized lesions) neglect was teddy bears crossed out.

Table V: Characteristics of seven children with unilateral spatial neglect (USN) detected by both Teddy Bear Cancellation Test and
by other tasks sensitive to USN and in daily life activities

Patient number, Aetiology Lateralization Location of Hemianopia Hemiparesis Hypoesthesia Days Number LO-S START-S
sex, age at onset of lesion lesion since of
(y:m), handedness onset omissions

1. F, 3:6, R Tumour R Subcortical Yes Yes Yes 7 10 –4 3

2. M, 6:7, R Traumatic R Subcortical No Yes No 41 9 –3 3
3. M, 3:1, R Traumatic R Hemisphere Yes Yes Yes 249 9 –6 3
4. M, 3:8, R Tumour L Temporal Yes Yes No 80 5 4 –2
5. M, 3:2, R Traumatic L Frontotemporal No Yes Yes 21 9 5 –3
6. M, 3:11, R Traumatic NL Diffuse brain Missing No No 15 3 3 1
swelling data
7. M, 8:6, R Traumatic NL Diffuse brain No Yes No 21 5 2 –3
swelling

LO-S, location of omissions; START-S, location of first three teddy bears crossed out. M, male; F, female; R, right; L, left; NL, non-lateralized.

The Teddy Bear Cancellation Test Anne Laurent-Vannier et al. 123

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 Test they studied the location of the first item cancelled, and
observed that controls, either right- or left-handed and using
their left or right hand, started crossing out on the left side of
the sheet. The START-S used in this study, which takes into
account location of the first three cancellations, seems to
reflect better the cancellation strategy than considering only
the first item cancelled, as the effects of chance are reduced.
In the present study, the START-S demonstrated a leftward
displacement with increasing age. The youngest children did
not have a left-to-right cancellation strategy. As age increased,
the children, like adults, began cancelling from the left.
Reading habits have been shown to influence the exploration
of non-linguistic stimuli as well as visuo-spatial skills (Chokron
and De Agostini 1995, 2000). In the present study, the age-
dependent left-to-right cancellation strategy probably reflects a
learned process underlying visuo-spatial performance (Frith
1998). Consistent with this interpretation, children with a high
SES exhibited a tendency to present a more consistent left-to-
right strategy than children with a low SES (F=2.96; df=411;
p=0.08) We can assume that these children may have had the
opportunity to read earlier than the other children.
Twenty-six of the 41 children with brain injuries performed
the TBCT within the age-predicted range, indicating that brain
injury alone does not produce abnormal results. Fifteen of the
children with brain injuries exhibited a pathological number
of omissions. As in the controls, patients under 6 years of age
omitted more items than older children.
Half of the children with a pathological number of omis-
sions exhibited them in a non-lateralized way. This was inter-
preted as relating to attention disorders rather than USN.
Gauthier et al. (1989) had the same interpretation in adults.
The other half of these children exhibited a pathological num-
ber of omissions and lateralized omissions on the left or on
the right, which was interpreted as USN. Only two children
provided results in the TBCT that were not concordant with
performances in other tasks. Therefore, there is evidence to
0.5
0 USN may be more frequent in very young children (Laurent-
–0.5
–1
■ LOS-S
■ START-S
–1.5
–2
Right Left Non-laterized Controls
lesions lesions lesions
Figure 2: A negative location of omissions score (LO-S)
indicates that omissions are localized on left, and a
positive score on the right. A negative location of first three
teddy bears crossed out score (START-S) indicates that first
three teddy bears cancelled are located on left, and a
positive score on right. Children in right-sided lesions group
displayed a negative LO-S and a positive START-S. In left and
non-lateralized children with brain injuries and controls,
LO-S was positive and START-S was negative.
124 Developmental Medicine & Child Neurology 2006, 48: 120–125
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support the ability of the TBCT to detect USN. Nevertheless,
as for adults (Azouvi et al. 2002), a single test is not sufficient
to rule out or confirm the presence of neglect, and a battery
of tests is needed to prevent USN from being misdiagnosed.
Lateralized omissions have sometimes been attributed to
hemianopia. We observed a double dissociation between USN
and hemianopia. Consequently, hemianopia cannot explain
the lateralized omissions in the TBCT and cannot explain USN
behaviour (Halligan et al. 1990; Laurent-Vannier et al. 2001,
2003; Billingsley et al. 2002). USN has also been confused with
other disabilities such as dyslexia (Manly et al. 1997).
The cancellation strategy must also be considered. We
observed a right-to-left strategy in children with right brain
injury, and a left-to-right strategy in children with left brain
injury. Although a left-to-right strategy alone cannot detect
right USN, as it is also the strategy used by control children,
the presence of a right-to-left cancellation strategy could reveal
left USN in children with brain injury. In adults with left USN,
the right-to-left strategy, different from the normal strategy,
was the most sensitive measure in a battery assessing neglect
(Azouvi et al. 2002). In children, this abnormal strategy of
environmental exploration may persist long after the brain
lesion. It has been reported previously (Billingsley et al. 2002,
Laurent-Vannier et al. 2003, Trauner 2003) and interpreted
as persistent USN.
The second objective of this study was to assess the fre-
quency of USN in children with ABI. To our knowledge, this
is the first prospective study assessing USN frequency in chil-
dren with brain injury acquired after the pre- and perinatal
stage. Our findings suggest that the frequency of USN ranges
from 13% (in left and non-lateralized lesions) to 30% (in right
lesions). This study confirms our previous hypothesis that
left and right neglect are not rare in children (Laurent-
Vannier et al. 2003). However, USN does appear to be some-
what less frequent in children when comparing the current
results with a systematic review of published reports of
adults with cerebral stroke (Bowen 1999): left spatial neglect
was found in about 43% of adult patients with right brain
injury and in 21% of those with left brain injury.
In children as in adults, left USN appears to be more fre-
quent and probably more severe than right neglect. Right
Vannier et al. 2003, Trauner 2003). Contrasting with the mature
brain, one may speculate that a transition from bilateral to
lateralized representation of spatial awareness can occur dur-
ing the first years of life (Laurent-Vannier et al. 2003).
In adults (Azouvi et al. 2002, Buxbaum et al. 2004) and chil-
dren, USN induces severe disability in daily activities (Laurent-
Vannier et al. 2001, 2003), and can have a negative impact on
academic performance in reading, writing, and mathematics.
For this reason, it is important that USN be correctly diagnosed
so that adequate rehabilitation can be initiated at an early stage.
DOI:10.1017/S0012162206000260
Accepted for publication 26th April 2005.
Acknowledgements
We are especially indebted to Professor Harvey Levin for his most
valuable help. We thank the following therapists and students for
participating in data collection: Adeline Bizouard, Charlotte
Chambond, Carole David, Myriam Laurent-le Goff, Claire Léghu,
Clémence Mathat, Clarisse Meyer, and Emeraude Quevillon.
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List of abbreviations
ABI Acquired brain injury
LO-S Location of omissions
SES Socioeconomic status
START-S Location of the first three teddy bears crossed out
TBCT Teddy Bear Cancellation Test
USN Unilateral spatial neglect

International Symposium
Status Epilepticus in Infants and Young Children
Basic Mechanisms, Clinical Evaluation, Prognosis and Treatment

29–30 April 2006 at the Senri Hankyu Hotel, Osaka, Japan

Notification and Call for Papers

Further information about the Infantile Seizure Society, Japan and the meeting can be obtained from ISS-9 Secretariat,
Toshisaburo Nagai MD, PhD Osaka University, Graduate School of Child and Reproductive Health,
1–7, Yamadaoka Suita, Osaka, Japan
Tel: +00 81 565 0871, Fax: +00 81 6 6879 2531, E-mail: nagai-t@sahs.med.osaka-u.ac.jp

The Teddy Bear Cancellation Test Anne Laurent-Vannier et al. 125

QUELLI Renata bassani - bassaniqre@gmail.com - CPF: 012.477.481-46