Cognitive and Neuropsychological Functioning

in Children With Cerebral Palsy

Eileen B. Fennell, PhD, Thomas N. Dikel, PhD

ABSTRACT

This article reviews the extant literature on intellectual functioning in different subtypes of cerebral palsy. Following a
definition of the characteristics of each of three major cerebral palsy groups, typical neurologic and magnetic resonance
imaging findings are reported. More recent studies that examine the intellectual and neuropsychological functioning of
children within these classification groups are also reviewed. This review concludes that there remains a significant lack
of precise information about the impact of cerebral palsy on the intellectual, motor, and neuropsychological functioning
of children and that neuropsychological assessment can provide the necessary tools for such studies. (J Child Neurol
2001;16:58-63).

Baxl defined cerebral palsy as a disorder of movement and
posture resulting from a lesion of the immature brain. One
of a group of so-called &dquo;static encephalopathies,&dquo;z the brain
lesions producing the clinical symptoms are nonprogres-
sive. Clinically, however, the manifestations of cerebral palsy
may evolve over time, and secondary complications may
arise as the child ages from the motor and movement dis-
orders and the associated sensory impairments that are pre-
sent.3 Originally defined by Little in 1843 as arising from
difficult deliveries, cerebral palsy is now recognized to result
from a variety of prenatal, perinatal, and postnatal causes.
These include hypoxia-ischemia lesions, periventricular and
intraventricular hemorrhagic lesions, migrational defects
occurring early in fetal development, cerebrovascular mal-
formations, intrauterine infections, and central nervous sys-
tem infections.’ Birth asphyxia accounts for between 10% and
14% of cases of cerebral palsy, whereas congenital factors
account for about 50% of cases. 2,5 With the increased survival
of premature infants and the advances in neuroimaging,
more precise definitions of the cerebral lesions have led to
a better characterization of the differences in types and
locations of lesions in preterm and term infants who develop
Received Sept 15, 2000. Accepted for publication Sept 15, 2000.
From the Department of Clinical and Health Psychology, University of
Florida, Gainesville, FL.
Presented at the University of Florida Consensus Conference in Child
Neurology: Management of Spasticity, May 4-6, 2000.
Address correspondence to Dr Eileen B. Fennell, Department of Clinical
and Health Psychology, University of Florida, PO Box 100165, Gainesville,
FL 32610-0165. Tel: 352-265-0680, ext. 46893; fax: 352-265-0468; e-mail:
efennell@hp.ufl.edu.
cerebral palsy As Menkes and Sarnat note,’ with the decline
in neonatal mortality, there has been an increase in the inci-
dence of cerebral palsy ranging from 1 to 2 per 1000 births.22
The majority of these children are preterm infants with birth
weights of 2500 g or less: the lower the birth weight, the
greater the risk of cerebral palsy.
CLASSIFICATION OF THE CEREBRAL PALSIES
Cerebral palsy is most often classified according to the
clinical presentation of primary motor deficits, although
some children present with a mixed picture of clinical
deficits. The most commonly used classifications are
(1) spastic cerebral palsies, (2) extrapyramidal cerebral
palsies, and (3) hypotonic cerebral palsies.
SPASTIC CEREBRAL PALSY
Spastic cerebral palsy results from dysfunction in the cor-
ticospinal tracts leading to increased muscle tone, increased
or hyperreflexia, and the persistence of primitive reflexes.’
As a result of increased tone, contractures may develop in
the joints of the wrist, arm, ankles, hip, and knees. This group
of cerebral palsies accounts for between 66% and 82% of
cases reported in several surveys.3 Spastic cerebral palsies
are further subdivided into three groupings: spastic diple-
gia, spastic quadriplegia, and spastic hemiplegia.
Spastic diplegia is characterized by bilateral spasticity,
typically greater for the legs than the arms. The typical
magnetic resonance imaging (MRI) finding in spastic diple-
gia is periventricular leukomalacia with infarction in the

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vascular border zone of the internal capsule and thalamus.44
The lesion is thought to result from hypotensive perfusion of
these regions and occurs more commonly in preterm than in
term infants.’ Term infants with spastic diplegia manifest a
wider variety of MRI lesions, including periventricular leuko-
malacia, micropolygyria, and porencephaly, as well as nor-
mal MRIs.~ Seizures are fairly common in children with
spastic diplegia and are often generalized or focal seizures with
secondary generalization. Approximately 16% to 27% of chil-
dren with spastic diplegia will experience seizures.66
Spastic quadriplegia is the most severe form of bilateral
cerebral palsy with involvement of both upper and lower
extremities. MRI findings in preterm infants with spastic
quadriplegia typically involve severe periventricular leuko-
malacia. In term infants, cortical lesions are more common
and typically involve the parasagittal watershed distribution
of cerebral vessels.’ Cystic lesions and polymicrogyria have
also been identified in the MRIs of full-term infants, sug-
gesting that earlier adverse events affected normal prolifer-
ation and migrational processes in the developing brain.
Seizure disorders are common among these children, and men-
tal retardation is frequent among the more severely affected.
Spastic hemiplegia typically involves unilateral spasticity
of the arm and leg contralateral to the lesion with greater
involvement of the arm. Flexion contractures of the affected
limbs are often present. Many different pathologies have
been identified in spastic hemiplegia, although the etiology
is unknown in about one third of the cases.’ The most com-
mon etiologic factors identified include various intrauter-
ine insults including maternal hemodynamic disturbances,
placental emboli, anomalous fetal circulation, and maternal
infection.4 A variety of postnatal etiologies have also been
identified including bacterial meningitis, viral meningoen-
cephalitis, and vascular accidents. 3,4 Focal epilepsies and sen-
sory deficits may be present in the affected limb(s).6
EXTRAPYRAMIDAL CEREBRAL PALSY
This group of cerebral palsies, which accounts for between
5% and 22% of cases surveyed, is characterized by a variety
of abnormal motor patterns and postures that arise from
defective regulation of muscle tone and coordinated move-
ments.3 The pathology involves basal ganglia and extrapyra-
midal pathways. Sometimes referred to as dyskinetic cerebral
palsy, manifestations of the disorder include involuntary
athetoid movements of the limbs or dystonic posturing of the
trunk and limbs MRI findings may include bilateral basal
ganglia lesions arising from kernicterus or hypoxic-ischemic
damage. Epilepsy is not common among these children. A
wide range of intellectual abilities have been reported, with
4
many patients scoring within the normal ranges.4
HYPOTONIC CEREBRAL PALSY
This form of cerebral palsy is characterized by generalized
decreased muscle tone that persists from infancy beyond
age 3 years. The hypotonia is not the result of primary
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59
muscle or peripheral nerve diseases. Sometimes called
ataxic cerebral palsy, many children develop frank cerebellar
symptoms including incoordination, gait disturbances, and
impairments in rapid coordinated successive movements.’
The etiology of this form of cerebral palsy is unclear, with
some suggestion that it is the result of delayed development
of the cerebellum or in the maturation of type-1 and type-2
muscle fibers.3 Rarely is perinatal asphyxia identified as
causally related to the disorder. MRI findings, when present,
include a small cerebellum, enlarged ventricles, and gyral
atrophy. Children with this disorder often develop learning
disabilities.’ Although specific subtypes of learning dis-
abilities have not been described, in our experience, these
often involve deficits in motor programming for handwrit-
ing, attentional dysfunction, and slowed motor output,
which affects the child’s abilities on timed tests. Intellectual
functioning is rarely impaired among these children except
for lower scores on intelligence tests that are timed, such
as on the Performance Scale of the Wechsler Intelligence
Scale for Children (WISC-III).7 Finally, there are a smaller
number of children who manifest a mixed clinical picture
of both spasticity and extrapyramidal signs. The clinical
manifestations of these so-called &dquo;mixed cerebral palsies&dquo;
include increased reflexes, dystonia, and/or other extrapyra-
midal signs. Surveys estimate that approximately 13% of chil-
dren with cerebral palsy will present with this mixture of
clinical signs. ~ As a result, the MRIs of these children reflect
the varying etiologies and structural lesions that give rise
to the clinical picture.
COGNITIVE FUNCTIONING IN CEREBRAL PALSY
Given the heterogeneous nature of the clinical picture in cere-
bral palsy, it is difficult, if not impossible, to make satisfactory
generalizations about the relationship of cerebral palsy and
cognitive functioning. The literature representative of stud-
ies meant to pursue this issue is sparse and often does not
differentiate between types of cerebral palsy. Earlier
reviews8~9 have given broad estimates of the ranges of IQs
among these children. Estimates among these children of
the frequency of mental retardation, defined as IQ scores of
69 or below, range from 50% to 70%. We know, however, that
rates vary significantly between levels of cerebral palsy
and that levels of impairment vary within cerebral palsy sub-
type. Individuals with spastic quadriparesis are, in most
cases, severely intellectually impaired, whereas half of
hemiparetic children have IQs in the average range, and 18%
achieve scores over 100.1° In children with spastic diplegia,
there tends to be a general correlation between severity of
motor deficit and level of retardation.:3 In cases of extrapyra-
midal cerebral palsy, delayed or deficient language skills due
to dysarthric incoordination of muscles of language and
speech and significant gross motor handicaps can lead to
false underestimation of intelligence. In these cases, motor
function tends to be more impaired than cognition.3 Current
classification systems for cerebral palsy emphasize physical
impairment and classification, and definition of retardation
60
considers functional, or intellectual, limitations, disability,
and societal limitations without a clear understanding of
pathophysiology or the details of impairment.ll
INTELLIGENCE TESTING
A measured level of intelligence is generally assumed to pro-
vide an indication of the extent to which one has developed
the basic cognitive and academic skills required for success
in our culture. 12 In addition, a child’s intelligence can influ-
ence both general adaptation and the effectiveness of treat-
ment for cerebral palsy 13 ; data from intelligence testing can
be used to assess the efficacy of educational or intervention
programs and to provide indications of a child’s cognitive
progression or regression.
However, the use of standard measures of intelligence
for assessing children with cerebral palsy poses significant
challenges. Test results must be interpreted in the context
of the motor, speech, visual, and auditory difficulties that
may be present in children with cerebral palsy. Wechsler Per-
formance Scale subtests demand adequate vision and visual
discrimination, visual-motor coordination, gross and fine
motor skills, the ability to work quickly and efficiently, and
the ability to communicate responses to the examiner. Opto-
metric examinations of children with cerebral palsy and intel-
ligence within the average range (standard IQ scores
between 85 and 115) have demonstrated increased inci-
dence of strabismus, amblyopia, nystagmus, optic atrophy,
and significant refractive errors. 14 Visual impairment may also
be exacerbated by visual-perceptual difficulties, produc-
ing greater visual handicap than might be expected by visual
acuity and strabismus alone. 15 Articulatory impairment and
speech intelligibility were examined in subjects with cere-
bral palsy who were deemed to have adequate intelligence,
hearing, and ability to perform the required tasks. Results
identified characteristic dysarthric phonemic features such
as anterior lingual place inaccuracy, reduced precision of
fricative and affricate manners, and inability to achieve
extreme positions in vowel articulatory spaces Upper-
extremity motor impairment may interfere with the hand-
eye coordination and fine and gross motor skills that become
sequentially increasingly demanding within the Perfor-
mance Scale subtests.
Another major issue affecting consideration of cogni-
tion and cerebral palsy pertains to the split between Verbal
IQ and Performance IQ on Wechsler intelligence tests that
is often found in these children. In any assessment of intel-
ligence, the use of summary scores assumes measure of a
unitary ability. If this is not the case, the reported IQ serves
in a limited capacity, much as a midpoint or forced average
among a diverse array of strengths and weaknesses, that may
misrepresent the child’s level of functioning.’z~’7 Moreover,
intelligence testing generally presumes that individuals have
adequate coordination to accurately convey their nonver-
bal thinking abilities; violation of this assumption may
reduce the accuracy of the Wechsler Performance IQ as an
estimate of nonverbal thinking
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Ito et all&dquo; assessed 23 children with spastic diplegia
prior to and 2 years following entrance into school. After two
years of school, Wechsler Verbal IQs increased significantly,
but Wechsler Performance IQs did not change, thereby
increasing the Verbal-Performance split. Wechsler Verbal IQs
of children studying in standard classrooms increased sig-
nificantly more than those of children in special classes; how-
ever, mean Wechsler Performance IQ increases were greater
for children in special classes. Therefore, the increased
Verbal-Performance split was most pronounced for chil-
dren studying in ordinary classrooms. Interestingly, six chil-
dren with spastic quadriplegia were assessed for Wechsler
Verbal IQ. Although their Wechsler Verbal IQs were lower
than those of diplegic children prior to entry into school,
there were no differences after 2 years of schooling. 18
Laterality of lesion may also impact performance on intel-
ligence measures. On a battery of neuropsychological tests,
despite similar Wechsler Verbal IQs, right-hemiplegic children
performed significantly poorer than left-hemiplegic children
and sibling controls on measures of syntactic awareness
and repetition of semantically coherent material. 19 Another
study found that mild to moderate right hemiplegics (left
hemisphere impaired) demonstrated impaired acquisition for
drawings relative to control subjects.2° When comparing
children with right- and left-sided hemiplegia with age-
matched controls for verbal and nonverbal function, both
hemiplegic groups were relatively impaired in nonverbal
function.21 Although the right-hemiplegic group was more
impaired in verbal function than the left-hemiplegic or con-
trol groups, this impairment was evident only in the girls.
When compared to sibling controls, children with right- and
left-infantile hemiplegia demonstrated correlation between
left-hand impairment and poor arithmetic computational
skills.l9 The performance of right-hemiplegic children on
measures of syntactic awareness and repetition of seman-
tically coherent material was, despite similar Wechsler Ver-
bal IQ, significantly poorer than that of left-hemiplegic
children.
SEIZURES AND CEREBRAL PALSY
The presence of seizure disorder may be related to increased
risk for cognitive deficits. Vargha-Khadem and colleagues22
found that the scores of hemiplegic children on measures
of memory and IQ were not correlated with hemispheric lat-
eralization of lesion, and early cerebral damage to either
hemisphere tended to result in few and mild deficits. In
children with comorbid epilepsy, however, high incidence
and degree of deficit, unrelated to hemisphere of lesion, were
observed. An investigation of incidence of epilepsy in cere-
bral palsy found epilepsy in over 50% of patients, with
seizure onset generally less than 4 years post cerebral palsy
diagnosis.&dquo; Epilepsy was associated with increased intel-
lectual deterioration. In a more detailed review of the preva-
lence, nature, and prognosis of epilepsy in cerebral palsy,
38% of the 85 reviewed cerebral palsy cases had epilepsy.24
However, the patients most commonly affected had spastic

tetraplegia and diminished intellectual capacity. Zafeiriou
et al25 found overall prevalence rates of 36%, with increasing
incidence of epilepsy in hemiplegic (42%), tetraplegic (57%),
dystonic (81%), and atonic-diplegic (88%) patients. Seizure
onset occurred prior to the child’s first birthday in 70% of
children with cerebral palsy and epilepsy, and epilepsy was
found to be a major prognostic factor for mental retardation
and poor motor development. Onset in the first year was also
found in a majority of epileptic cerebral palsy patients, con-
stituting 42% of 323 cerebral palsy patients.26 Nearly 50% of
patients with spastic tetraplegia and hemiplegia had comor-
bid epilepsy, with lower incidence in patients with spastic
diplegia.
In some cases, electroencephalographic abnormalities
may be present in the absence of clinical signs. In a study
of 51 children with hemiparetic cerebral palsy, 80% had
electroencephalographic abnormalities; however, less than
50% showed clinical signs.2’ Children with congenital anom-
alies were found to have higher incidence and earlier onset
of epilepsy than children with perinatal insult. 28 Children with
term-type injuries were more likely to show these results
than children with preterm injuries. A study looking at
potential prognostic indicators of intelligence and seizures
in hemiparetic cerebral palsy found that anatomic abnor-
malities of commissural or association pathways or of cere-
bral cortex were associated with higher incidence of seizures
and abnormal intelligence.6
BRAIN IMAGING
Cranial MRI has been used to help determine etiologic fac-
tors in children with clinically documented motor delay. MRI
abnormalities were found in 77% of children diagnosed with
cerebral palSy.21 Etiologic association was established solely
from MRI in 23%, with 32% supporting suspected etiology.
In no case was myelination delay the sole abnormality, and
only 17% of the children with minor motor delay had abnor-
’
mal scans.
Brain imaging studies can be instructive in the devel-
opment of our understanding of the etiology of cerebral
palsy; however, imaging abnormalities may be more related
to visual-motor than cognitive abilities. Fedrizzi et al3° inves-
tigated correlation between Wechsler Full Scale, Verbal,
and Performance IQs and features of periventricular leuko-
malacia on MRI. The investigators found a significant Ver-
bal-Performance split, and periventricular leukomalacia
was detected in all of the 30 children (age 6 years, 8 months
to 14 years, 7 months). Severity of ventricular dilation,
degree and extent of white-matter reduction, involvement
of optic radiation, and thinning of posterior corpus callosum
were significantly correlated with Wechsler Full Scale and
Performance IQs. No correlation was observed, however,
between Wechsler Verbal IQ and any analyzed MRI fea-
tures. In addition, Feldman et a131 found correlation between
degree of motor disability and the extent of T 2-weighted MRI
white-matter signal abnormality, with no relation demon-
strated between cognitive outcome and degree of signal
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61
abnormality or sulcal prominence. However, Melhem et
a1,~2 in a chart review of children with spastic cerebral palsy
and MRI-documented periventricular leukomalacia, found
larger mean lateral ventricular volumes in cognitively
impaired groups relative to control groups and groups with-
out cognitive impairment. They also found significantly
larger lateral ventricular volumes in moderate and markedly
motor-impaired groups than in control or mild motor deficit
groups. A retrospective analysis of computed tomographic
(CT) examinations of 76 cerebral palsy children with no
severe intellectual deficit showed abnormalities in 63%; in
former preterm infants, that number rose to 88%.33 The CT
abnormalities were generally posterior, bilateral, and sym-
metric, often involving ventriculomegaly and affecting the
contours of the lateral ventricles.
Single photon emission computed tomography (SPECT)
was employed to evaluate cerebral perfusion impairment in
51 children, ages 6 months to 6 years, 11 months with man-
ifestations of cerebral palSy.31 Thalamic hypoperfusion was
detected in 50 children. Temporal lobe hypoperfusion was
found in 53%, basal ganglia in 41%, cerebellum in 39%, and
extratemporal cortices in 22%. On the basis of MRI, however,
only 7 patients showed thalamic abnormality (2 in basal gan-
glia and 5 in extratemporal cortices) and 1 showed cerebellar
atrophy. Rather, the major MRI findings were white-matter
changes and thinning of corpus callosum.
NEUROPSYCHOLOGICAL ASSESSMENT
Neuropsychological norm-reference testing provides a
valuable objective index of evaluation of both baseline
function and functional change over time. However, a
review of the literature demonstrates a paucity in neu-
ropsychologically based investigations of cognitive func-
tion and functioning in general relative to cerebral palsy.
The following studies provide examples of the utility of neu-
ropsychology in better understanding the functional impact
of cerebral palsy.
Kiessling and colleaguesl9 investigated differential hemi-
spheric function in hemiplegic cerebral palsy in a study
population of 8 children with right hemiplegia, 8 with left
hemiplegia, and 13 nearest-age normal siblings as a control
group. Their study involved neuropsychological measures
of semantic comprehension, expressive language function
(confrontation naming), syntactic awareness, ability to
repeat semantically coherent information, short-term mem-
ory, nonverbal reasoning, and academic skills (reading
recognition, spelling, and arithmetic problem solving).
Results indicated impaired function in right-hemiplegic (left
lateralized brain lesion) children on measures of syntactic
awareness and sentence repetition (high-level language
function), providing evidence for a lateralized neural sub-
strate of language ability, present at birth. The relationship
between extent and type of disability and measures of
degree of fine-motor (hand involvement) impairment demon-
strated significant correlation between hand impairment
and scores on syntactic awareness and sentence repetition
62
tasks. Although syntactic comprehension was impaired in
the right-hemiplegic group, receptive vocabulary was gen-
erally intact. Left-hand function (right-brain lesion)
correlated with math achievement scores, supporting the
idea that mathematical ability-math-estimating skills and
concepts of number and set-requires good visual-spatial
skills.
More recently, Craft and colleagues&dquo; studied alter-
ation in cognitive performance following selective dorsal
rhizotomy for treatment of spastic diplegic cerebral palsy.
Sixteen prematurely born, surgically treated children with
IQs over 80 were compared to 9 prematurely born children
who had not been treated with selective dorsal rhizotomy
and 24 healthy age- and sex-matched children recruited from
a local school. Cognitive ability was assessed 1 day pre-
operatively and 6 months postoperatively. Visual attention
was assessed by Posner et al’s covert orienting task
which has a valid-cue, simple orienting response condi-
tion and an invalid cue condition that involves inhibition,
disengagement, and redirection. Six additional measures of
cognitive function were taken from the Woodcock-Johnson
Psychoeducational Battery.37 Results showed significant
between-group differences in changes in visual attention
performance over time. Both cerebral palsy groups were
slower than the healthy children in both conditions at base-
line and follow-up assessments. No difference was shown
between the cerebral palsy groups at baseline for either con-
dition. At follow-up, there was no difference in perfor-
mance between the cerebral palsy groups on the valid cue
condition. On the invalid cue condition, however, the chil-
dren in the selective dorsal rhizotomy group were signifi-
cantly faster than the children in the nonoperated group,
indicating an improvement in significant aspects of atten-
tional functioning. On the Woodcock-Johnson subtests,
both cerebral palsy groups performed more poorly than the
healthy children on all measures, except memory for sen-
tences, on both test administrations. All children generally
showed improvement from the first to the second assess-
ment, with degree of improvement similar for all groups,
with one exception. Children in the selective dorsal rhizot-
omy group demonstrated substantially greater improve-
ment than children in the other groups on a measure of
visual-auditory associative learning. Through use of neu-
ropsychological testing, the investigators were able to
demonstrate distinct improvements in attentional and cog-
nitive (visual-auditory learning) functioning following selec-
tive dorsal rhizotomy over and above general improvement
in temperament or physical comfort.
In addition, Feldman and colleagues have studied lan-
guage ability related to prematurity, periventricular brain
injury, and cerebral palSy.31,31 Other investigators were able
to dissociate constructional dyspraxia from visual and visual-
perceptual impairments in preterm children with spastic
diplegia.11 As awareness of the utility of neuropsychological
measures grows, so, too, will the sophistication and preci-
sion of research conclusions and our knowledge base.
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CONCLUSION _
Clinicians and researchers are faced with complex issues
regarding the disposition of children with cerebral palsy.
Families, policy makers, and corporate interests want to
know what sort of life to expect for children with cerebral
palsy. Undoubtedly, a primary element in that equation is the
child’s cognitive ability. This review has indicated a general
lack of empirical research addressing these issues.
Most studies of cognitive effects of cerebral palsy have
reported either global IQ scores or vocational outcomes.
There is also a lack of studies attempting to examine the spe-
cific site of brain lesions in relation to associated neu-
ropsychological functioning. Although some recent studies
have described a variety of etiologic factors in the diagno-
sis of cerebral palsy, most have focused on premature and
low-birthweight infants with pre- and perinatal neurologic
lesions. Here, too, most report global estimates of IQ rather
than provide detailed information on memory, visual-spatial,
and language functioning, which would provide the basis for
developing specific remediation or accommodation strate-
gies for the child.
Future studies should attempt to more clearly delineate
the relationships between MRI of brain lesions and the
functional effects of those lesions on early, middle, and late
childhood neuropsychological functioning. Although it is
clear that different lesions are seen in different types of cere-
bral palsy, there remains a relative dearth of knowledge on
the developmental impact and functional expression of
these lesions beyond motor symptoms and IQ scores. Bet-
ter definition of these functional brain-behavior relationships
would allow us to better understand how to develop more
specific educational, psychological, and vocational inter-
ventions to enhance or maximize outcome. Attempts to
understand the cognitive correlates of cerebral palsy must
investigate and present results by subtype rather than as gen-
eralizations regarding cerebral palsy as a whole. We suggest
that neuropsychological assessment provides a rich his-
tory and solid empirical basis for such investigation.
Acknowledgment
This research was supported, in part, by the National Institutes of Health,
National Research Service Award T32HD027524 from the National Institute of
Child Health and Human Development.
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