When a family is informed that their child has cerebral palsy, the physician should be prepared to discuss prognostic implications of this diagnosis. An almost immediate reaction of the parents is to ask, "What does this mean for my child's future? What can we expect? What will he be able to do?"
It is not easy to answer these questions in specific terms. At times, particularly during infancy and early childhood, one may have to defer giving a definite opinion until continuing observation provides important clues for predicting the outcome more accurately.
In the clinical judgment of prognosticating physical independence several considerations have to be weighed. Some of these reflect the anticipated severity of neuromuscular deficit while some are related to other areas of function. Among the signs and symptoms of motor dysfunction three specific considerations are helpful: (1) the clinical type of cerebral palsy,1 determined on the basis of distribution and nature of neurologic signs, (2) the pace of motor development, or length of delay in gross motor milestones, and (3) the evolution of infantile reflexes, or its persistent abnormalities.
In addition to the motor disability, accomplishments may be influenced by dysfunction in other areas - especially intellectual deficit, sensory impairment, emotional-social maladjustment, or other possible problems. For clarity of discussion, the significance and effect of these diverse factors will be discussed separately. However, it is their interaction that will determine the prognosis, and in the overall framework of development one must judge their cumulative influence.
THE CLINICAL TYPE OF CEREBRAL PALSY
The nature and distribution of neuromuscular impairment, which is the basis of clinical classification, provide a general guideline regarding the most likely functional limitations that the child will have to overcome. From clinical surveys2'3 and experience with long-term follow-up one can also draw some conclusions about the spectrum and probable frequency of functional accomplishments in each type.
It can be said that prognosis, from the viewpoint of physical function, is quite uniform in certain clinical types: favorable for children with hemiparesis and for the relatively rare cases with ataxia, but poor when the presenting sign is either rigidity or severe permanent hypotonia.2'4 On the other hand, there is a great diversity in the degree of motor handicap and outlook for physical independence among children with evidence of bilateral spasticity and/or athetosis.2,4
As a rule, all hemiplegic children walk eventually unless there is also a severe intellectual deficit.2,4,5 Early motor milestones are, generally, delayed by four to six months. In the majority of cases, walking is accomplished by two years, and only a few children begin to walk in the third year.4 In many instances a short leg brace is required, usually as a temporary corrective measure, but no other type of walking aid is necessary.
Hemiparetic children do experience difficulties with bimanual activities." The affected hand is used for assistive function to an extent that varies according to the degree of paresis and whether or not there is a cortical-sensory deficit. Approximately half of these children have signs of parietal-lobe syndrome with astereognosis and impairment of other cortical sensory modalities.7 Although this cannot be definitely detected until four or five years of age, a tendency of excessively neglecting the affected hand is an early, suspect sign. Parietal lobe syndrome is usually accompanied by a growth disturbance of the affected extremities,8 which may be an additional clue before reliable testing for cortical sensory deficit can be done.
Since most daily activities do not necessarily require bilateral hand use, children with hemiparesis should become self-sufficient in this respect. One may expect a delay in the age of attaining some adaptive skills, and the speed of performance may be slow. There are one-handed techniques - for example, to tie shoelaces or to cut meat - that can be taught to overcome the lack of bimanual dexterity if volitional hand function is poor.
Diplegic children have a bilateral neuromuscular deficit affecting primarily the lower extremities, and their most evident difficulties are related to locomotion.2,3 In spite of delayed development, more than half of these children progress to independent ambulation, and the majority walk by three years.4 An additional 20 per cent will require assistive devices, such as crutches, for ambulation all their life. Lower-extremity braces are often needed, particularly at a younger age either for support or for preventive purposes. Gait abnormalities range from minimal to markedly pathologic appearance.
About 15 per cent of diplegie children rely on using a wheelchair either because severe spastic paralysis makes crutch walking too exhaustive or because of some other associated problem, such as intellectual deficit. In most cases, there is no curtailment of arm and hand function. However, some children may have a slight neurologic impairment of the upper extremities, which can influence fine hand coordination and dexterity.2,3,6
Impairment of neuromuscular function is more extensive in spastic quadriparesis.2,3,6 It is in this group that one finds a large number of severely affected children; approximately 25 per cent require almost total care. From a physical standpoint,4,6 about one-third of children with spastic quadriparesis are mildly affected and have minimal or no limitations in walking, self-care, and other daily activities. Another one-third can walk only with assistive devices.
The majority of youngsters in the ambulatory group become independent walkers after three years of age.4 Of the remaining one-third who cannot walk, some attain independence from a wheelchair if upper-extremity function and/or intelligence are not significantly affected. Neurologic impairment of arms and hands and, consequently, the potential for independence in daily activities, vary considerably.2,3 Generally, however, one can expect that children who walk with or without crutches have adequate coordination of the upper limbs to become self-sufficient in other activities provided that they are not significantly retarded.
Three-fourths of the children with athetoid cerebral palsy walk independently.4 Only a few of those who do not have effective balance can control the extraneous arm movements well enough to use crutches. About half of the ambulatory children walk before three years. Dyskinesia interferes with hand coordination, and, even in case of a mild motor deficit, writing and other fine motor skills are usually difficult.1
Unlike most other types of cerebral palsy, athetoid cerebral palsy is characterized by neuromuscular dysfunction that may be more severe in the upper extremities than in the legs.2,3,6 There are some children who are able to walk but have considerable problems with hand function and need help with feeding, dressing, and similar tasks. Adaptive devices, such as a key guard for a typewriter or special holders for spoons and other implements may be useful in selected cases.
In the presence of spasticity and athetosis there is usually some neuromuscular deficit of all extremities, and functional limitations reflect the consequences of both spastic paralysis and dyskinetic incoordination.2,3,6 About half of these children walk, most of them after the age of three years.4 Motor control of the upper extremities is usually sufficient in children who walk, and independence in daily activities is expected unless there are additional handicapping complications. Most but not all wheelchair-confined patients require assistance in daily care.
AMBULATORY STATUS AND ONSET OF WALKING IN PRENATAL AND PERINATAL CEREBRAL PALSY
In spite of the rather slow early development, ultimate functional limitations are relatively mild in the ataxic type. Although they do so rather late, these children acquire the ability to walk.4,6,9 As cerebellar signs tend to decrease with age, hand coordination and self-sufficiency improve over the years.
The rigid and atonic types of cerebral palsy have a poor prognosis.3,6,10 Both physical and intellectual deficit are severe, and these children remain functionally dependent.
Table 1 shows the outcome of ambulation in different clinical types. While the age of walking varies by clinical type, the chances of achieving it decrease after four or five years in all instances and is unlikely after the age of eight. The onset of walking after four years suggests that unlimited ambulation is not a realistic expectation.
Consideration of the clinical type gives an approximate idea of the expected curtailment in physical function and of the possible range of achievements for each group in a general sense. However, it cannot be used for predicting the outcome in specific terms because there are considerable variations in the severity of neuromuscular disability and in coexistent nonmotor deficits, particularly in some clinical types.
THE PACE OF MOTOR DEVELOPMENT
From the viewpoint of neuromuscular dysfunction, one can consider the rate of gross motor development an indirect indicator of the extent of damage and of the remaining maturational potential. In particular, the age at which certain grossmotor milestones are accomplished is a useful sign to project future ambulatory status in diplegie, quadriparetic, athetoid, and spastic-athetoid cerebral palsy, where the outcome tends to be less uniform than in other clinical types.
Several longitudinal studies indicate that there is a significant correlation between sitting by two and four years and the potential for walking.2,4 In a survey of 359 prospectively followed population, 66 children were already walking at two years and an additional 111 by four years. Therefore, the potential of ambulation remained questionable for 293 children at the age of two and for 182 children when they were four years old. Correlation between the age of sitting and later ambulatory status is shown in Table 2. All 64 children who attained sitting by 24 months were able to walk eventually, but no child who remained nonambulatory sat at this age. However, only one-third of the children who were able to walk later had accomplished sitting by two years. AN eventual ambulators sat, at the latest, by 48 months, with the exception of three children who attained this milestone a few weeks after their fourth birthday. Sitting by four years was accomplished by 96 per cent of those who subsequently walked. In comparison, the incidence of sitting at that age was only 4 per cent in the nonambulatory group.
All the children who walked or sat by two years became community ambulators without limitations and required no assistive device. Only half of the group that attained sitting by three years achieved this level. On the other hand, all children who were sitting after three years could walk only with the aid of crutches or braces and had restrictions in functional ambulation.4
These findings indicate that sitting by 24 months or earlier has a virtually absolute correlation with ambulation in diplegie, quadriparetic, athetoid, and spastic-athetoid cerebral palsy. Lack of sitting by four years excludes the potential for walking with almost the same degree of predictive reliability. Furthermore, one can also project the quality and level of effectiveness in ambulation based on the age of sitting before or after two years.
Attainment of sitting as a prognostic sign of ambulation becomes more applicable and accurate with increasing age. Its limited usefulness before two years is demonstrated by the fact that more than half of the children who will walk in some fashion are not sitting by that age. Since the group of children who are nonsitters before the age of 24 months includes both potentially ambulatory and nonambulatory youngsters, other identifying characteristics would be needed to differentiate those who eventually walk from those who do not.
EVOLUTION OF INFANTILE REFLEXES
Primitive infantile reflex activity at birth and in infancy is a reflection of immaturity of the central nervous system.11-16 In parallel with the anatomic and functional maturation of neuronal structures, primitive reflexes are gradually inhibited and become integrated in coordinated movements under the influence of higher centers.
Extensive reviews of infantile reflex development demonstrated that this process follows an orderly sequence and timetable. Clinical observations also suggest that there is a chronologic association between the suppression of certain primitive reflexes and attainment of gross motor milestones. Abnormal reflex behavior, specifically persistence and/or hyperactivity, indicates damage to the central nervous system and is one of the characteristic signs of cerebral palsy.13,16,17 As a rule, the more severe the abnormalities the more serious the neuromuscular impairment. Thus, the evolution of primitive infantile reflexes could represent another set of clinical signs to assess the extent of expected neuromuscular disability and, thereby, assist in predicting functional outcome. Indeed, it has been suggested that persistence of tonic neck reflexes makes walking unlikely.2
Table 3 shows a description of selected infantile reflexes and the age at which they become suppressed or appear normally. The list is not complete, as it includes only those which are relevant to the topic of this discussion. It should be noted that there is some discrepancy in the literature regarding the normal age limits for some reflexes. This is related to differences in methods of examination and in terminology.
As noted earlier, primitive reflexes in cerebral palsy tend to persist beyond the expected age. In addition, there may be qualitative differences, in that reflex responses become hyperactive or, in extreme form, obligatory. This distinction will be further clarified, since it has both diagnostic and prognostic significance.
INCIDENCE OF SITTING AT TWO AND FOUR YEARS AND LATER AMBULATORY STATUS
INFANTILE REFLEX DEVELOPMENT
As seen in Table 3, the asymmetric tonic neck reflex fades when the infant is around six months old. Before this age, neck rotation in healthy infants may elicit a visible response of complete or partial "fencing position" or only tone changes consistent with that posture without overt alteration in extremin position.12 The response, however, is only transient, and the infant is able to initiate arm and leg movements in spite of continuing reflex stimulus. This is a nonobligatory response, which represents a normal phenomenon in the first half year of life. In contrast, an obligatory reflex is a visible response lasting more than 30 seconds, or one that the infant is unable to overcome as long as the stimulus is maintained.
Nonobligatory asymmetric tonic neck reflex after six months of age should be regarded with suspicion. It is suggestive of a maturational delay and of possible central nervous system damage, such as cerebral palsy. The pathologic significance and, consequently, the diagnostic value of a persistent nonobligatory asymmetric tonic neck reflex increase with age. An obligatory response, on the other hand, is considered abnormal at any age and can be an early sign of cerebral palsy.
In normal infants, symmetric tonic neck and tonic labyrinthine reflexes are usually more subtle than the asymmetric tonic neck and Moro reflex.12,16 Their influence tends to be manifested by alterations of tone rather than by consistent, overt postural changes. On testing the positive supporting reaction, it is often difficult to differentiate between reflex activity and voluntary attempt of weight bearing except in young infants.16,18 However, these reflexes gain particular importance as signs of abnormality because they are generally exaggerated, often to an obligatory level, and they may remain so for variable lengths of time following early insults to the central nervous system.4,11,12,16
Stimulated by these considerations, the author and her associate made a prospective longitudinal study to correlate reflex development with later ambulatory status in children with cerebral palsy.4 One of our particular aims was to explore whether these signs could assist in earlier prognostication of walking, preferably before the child was two years old, in clinical types with a wide range of functional outcome.
The survey included 164 children with spastic diplegie, quadriparetic, athetoid, and spasticathetoid cerebral palsy.4 All were first seen at or before 12 months of age. Length of follow-up ranged from two and one-half to 10 years, and at the time of data analysis the ambulatory status was known in all cases. Of the 164 children, 117 were already walking; these were between the ages of three and 11. The remaining 47, who were between the ages of eight and 11, did not ambulate and were not expected to do so.
Among these children were 109 who had not achieved sitting by the age of 12 months; 91 had not been able to sit at 18 months, and 79 could not sit at 24 months. These children served as the population for correlating prospectively recorded reflex behavior and known outcome of walking.
A number of primitive reflexes and undifferentiated movement patterns were noted. For the Moro reflex, presence or absence was observed. Asymmetric tonic neck, symmetric tonic neck, tonic labyrinthine reflexes, positive supporting reaction, and predominant extensor pattern of lower extremities in vertical suspension were noted. The latter is a characteristic posture indicating spasticity of the legs. These responses were scored as positive if they were obligatory. That is, a visible postural change was elicited by appropriate stimulus on repeated examination and the child was unable to move out of that position volitionally as long as the stimulus was imposed.
The results of data analysis showed there were considerable variations in the total group of nonsitters with respect to infantile reflex behavior, that these differences were consistent at every age selected for comparison, and that they correlated with future ambulation. These findings are shown in Table 4. There was a nearly universal obligatory persistence of the six primitive movement patterns at 12 and 18 months in almost all the children who never became ambulatory. Furthermore, in these patients often all six but at least three of the immature reflexes remained in evidence to an obligatory extent at 24 months. On the other hand, only a few of the children who eventually walked exhibited one or two of these reflexes in obligatory form at 12 months of age (five out of 88). Subsequently, even in these cases a gradual fading of obligatory reflex activity occurred. By 18 months only three children out of 65 retained not more than one or two of these signs, and at 24 months they coula not be elicited in obligate form in any of the potentially ambulatory patients.
CORRELATION OF PRIMITIVE REFLEX DEVELOPMENT AND OUTCOME OF AMBULATION
In this study, obligate nature of selected reflex responses was used as a criterion for prognostic purposes. However, it should be mentioned that persistent reflex abnormalities in cerebral palsy encompass a spectrum with qualitative differences ranging from an extreme obligatory state to a vestigial form. While the effect of the former is overwhelming and severely impedes voluntary motion, the latter may manifest itself only as a subtle influence on muscle tone but does not completely interfere with active movement control. More recently, infantile reflex testing has been formalized and validated as a quantitative examining tool.12 The method provides a description of several refined gradations for specific reflexes from slight to obligatory response and designates a scoring system for each level of activity. It may be expected that current long-term observations based on using this method of examination will yield deeper insight into the natural course of infantile reflex maturation in cerebral palsy and its prognostic value, possibly before 12 months of age.
In another independent study of locomotor prognosis in cerebral palsy, 73 nonambulatory children 10 months to four and one-half years of age were observed at two-to-six-month intervals.19 A one-point score was given for each of the following signs: presence of positive supporting reaction, asymmetric and symmetric tonic neck, Moro, neck-righting reflexes, and absence of the foot placement and parachute reactions (Table 3). Good and guarded prognosis was indicated by a score of zero and one, respectively, while children with scores of two or more had a poor chance of walking. There was a 95 per cent predictive reliability of these signs with children over one year of age.
As demonstrated by data from different sources, the chronologic evolution of infantile reflexes can provide a basis for predicting the probability of walking. These signs increase the accuracy of prognostication, especially, in clinical types with widely variable outcome. They are useful predictors before the achievement of sitting and between 12 to 24 months of age at the earliest.
In general, the more severe the neuromuscular dysfunction the greater the likelihood of an intellectual deficit. For this reason, in many instances when the child is retarded the motor deficit alone would severely limit the possibility of walking or independence in self-care. However, there are many exceptions, and when there is a discrepancy between mental ability and the degree of physical handicap the effect of these two factors can be rather complex.
Mild-to-moderate mental retardation increases the delay of gross-motor development. Of the 107 hemiplegic children who walked after two years (Table 1), all functioned in this range of intellectual ability; however, the relatively later ambulators did not include all educable-retarded hemiplegic youngsters. Among the spastic diplegic, quadriparetic, athetoid, and spastic-athetoid children, 83 per cent of those who walked between five and seven years were retarded. On the other hand, all children who walked under two years of age had normal or borderline intelligence. Severe to profound mental handicap associated with moderate or, as seen occasionally, with mild physical disability can change the prognosis from partial to complete dependence, including lack of ambulation. Adaptive development and ultimate level of function in activities of daily living are more adversely affected than walking ability when motor deficit is accompanied by mental retardation. However, if his physical limitations allow, a mildly retarded child should become independent in self-help skills.
The usual developmental screening tests must be used with caution to predict possible intellectual impairment when there is a physical handicap. Many test items at an early age require an intact motor system. Formal psychological assessment of mental ability is usually postponed until three or four years of age. Under these circumstances, appropriate language development is a sensitive indicator of good intellectual function, provided that there is no significant hearing deficit or severe dysarthria that would interfere with speech acquisition or production. The relative frequency of mental retardation is highest in rigid, atonic, and spastic quadriparetic cerebral palsy.2,3,6,10 These clinical types also have a higher incidence of more severe intellectual deficit. In comparison, mental impairment is less frequent, and it is usually mild in diplegie and hemiplegie cerebral palsy .2,3,5,6,20,21
Intelligence is least likely to be affected in athetosis caused by bilirubin encephalopathy with discrete basal ganglion lesions. Significant microcephaly and seizures were found to increase the likelihood of an associated intellectual deficit.2,22 There are some indications that the overall incidence of mental retardation in cerebral palsy is decreasing. This has been attributed to prevention of more severe anoxic brain damage by improved neonatal care.
OTHER ASSOCIATED DEFICITS
Dyspraxias, disturbances of central perceptual sensory processing, and deficits of intersensory integration may occur in any clinical type.22'26 Within the limitations of this article it should suffice to say that these invisible handicaps can interfere with learning and performing a wide variety of tasks, including basic self-care activities and scholastic skills, despite normal intelligence and regardless of the extent of motor disability. Learning problems may be further aggravated by organic behavior syndrome with true hyperkinesis or with milder disorder of attentiveness.
A severe abnormality of the visual system, such as blindness, when associated with physical deficit has a profound effect on development and accomplishments in both fine- and gross-motor function. Fortunately, retrolental fibroplasia, which had been the most frequent cause of this complication, has been in large measure eliminated. Homonymous hemianopia, seen in hemiplegie children, especially in association with parietal lobe syndrome, is well compensated for and does not represent a functional handicap. There is an increased incidence of refractory errors and strabismus in cerebral palsy. If undetected and untreated, they add to already existing functional difficulties.3,22,27,28
The ability to communicate is an invaluable asset for successful outcome.29,30 Since language acquisition is closely related to cognitive function, variable degrees of delay or deficit can be expected, particularly in retarded children with lower levels of intelligence. Aphasia may complicate an acquired insult to the dominant hemisphere after seven to eight years of age but these cases are rare. The implications of hearing loss for speech development and the necessity for early correction apply as they do in all children. However, clinicians must be aware of the increased frequency of auditory disorders, either peripheral or central,2,3,22,31 in cerebral palsy. High-frequency hearing loss, which most often accompanies bilirubin encephalopathy with athetosis may result in distorted production of some sounds but does not interfere with functional speech.2,3,32 Dysarthria may occur in athetosis and, less frequently, in spastic quadriparesis. It is caused by pseudobulbar palsy as a result of supranuclear spastic paralysis or athetoid incoordination affecting the lower cranial nerves.2,3 In mild cases there is faulty articulation of consonants, but speech is intelligible. Severe dysarthria, which sometimes precludes functional speech, is more often associated with athetosis and, on occasion, can occur when neuromuscular impairment is otherwise mild.3,6 A most significant advance in these cases is the use of nonverbal communication methods. It may consist of a language board with words, letters, or other symbols at which the child can point. There are also more sophisticated electronic communicators with instant visual display, some of which are the size of pocket calculators. The self-sufficiency provided by appropriately selected communication aids eliminates a great source of frustration for the child and for those around him. Interaction by means of these devices can range from a level necessary for simple daily needs to pursuit of scholastic and vocational interests.29 Drooling, seen in some cases of severe pseudobulbar palsy, is a socially embarrassing handicap.
While the child is young, parental and professional concern is focused on his outlook in walking, self-care, and, later, scholastic achievements. With passing years the emphasis is shifted to the question of what place he can ultimately occupy in society. Successful adaptation, defined as full utilization of all available functional assets, is contingent on personality development and emotional health.
Unfortunately, the life experience of many handicapped children is not optimally conducive to fostering a mature personality.33 The effect of having a handicapped child on family dynamics and the consequences of these events on child-rearing practices are well documented.34'39 Often, but not always by necessity, handicapped children also receive special attention from other persons in the outside world. It is understandable that these circumstances tend to perpetuate a dependent, selfcentered, and immature attitude. Data from vocational rehabilitation agencies indicate that this factor is responsible for a number of failures in gainful employment.30
It is virtually inevitable that children with a developmental disability lead a different life style from their nonhandicapped peers. That restrictions in peer contact, recreational, and other group activities can hamper the development of social skills need not be elaborated. The reported social isolation of some young adults with cerebral palsy40 often reflects their own feeling of inadequacy and lack of self-assurance.
The incidence of reactive emotional maladjustment is not related to the extent of handicap.41,42 In fact, children with mild physical disability and reasonably good intellectual function seem to be the group at the highest risk for serious problems and for what has been described as catastrophic reactions.2 This can be attributed, perhaps in part, to increased opportunities for competing in a nonhandicapped world for which they may be illprepared by earlier, more sheltered experiences. Conflicts and disappointments also arise when aspirations or parental expectations are at variance with realistic goals. Moreover, in spite of assurances for the legal rights of the handicapped, a societal attitude of stigma continues to linger that can create stressful, emotionally threatening situations.
Long-term studies from several countries indicate a 35 to 50 per cent vocational success rate among adults with cerebral palsy, including competitive and sheltered employment.2,3,30,43,44 Patients with diplegia, hemiplegia, or athetosis have the most favorable prospects.
Cerebral palsy is not a homogeneous disease entity. In addition to impairment of the motor system, organic deficits may affect other areas of function. Physical and intellectual abilities are the most significant organic factors that influence the prognosis, and fulfillment of maximal potential is fostered by a healthy and well-adjusted personality. Prediction of outcome is based on many considerations, and its accuracy increases with the unfolding of developmental trends in different areas of function and behavior.
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5. Perlstein, M. A., and Hood, P. N. Infantile spastic hemiplegia: intelligence, and age of walking and talking. Am. J. Ment. Defic. 61 (1957), 534.
6. Molnar, G. E., and Taft, L. T. Pediatric rehabilitation. I. Cerebral palsy and spinal cord injuries. Curr. Probi. Pediatr. 7 (1977), 3.
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14. Milani-Comparetti, A., and Gidoni, E. A. Pattern analysis of motor development and its disorders. Dev. Med. Child Neurol. 9 (1967), 625.
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17. Bobath, K. The motor deficit of patients with cerebral palsy, Clin. Dev. Med. (23). London: Spastics Society, 1972.
18. Hoskins, T. A., and Squires, ]. E. Developmental assessment: a test for gross motor and reflex development. Phys. Ther. 53 (1973), 117.
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21. Shotick, A. L. Mental retardation. In Cruickshank, W. M., supra, p. 421.
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25. Abercrombie, M. L. J. Perceptual and Visuomotor Disorders in Cerebral Palsy: A Review of the Literature. London: Spastics Society/ Heinemann, 1964.
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31. Nober, E. H. Auditory processing. In Cruickshank, W. M., supra, p. 223.
32. Hardy, W. G. Auditory deficits of the kernicterus child. In Swinyard, C. A., (ed.). Kernicterus and Its Importance m Cerebral Palsy. Springfield, Ill.: Charles C Thomas, 1957, p. 255.
33. Wortis, H. Z., and Cooper, W. The life experience of persons with cerebral palsy. Am. J. Phys. Med. 36 (1957), 328.
34. Hewett, S. The Family and the Handicapped Child. London: Allen and Unwin, 1970.
35. Barsch, R. H. The Parent of the Handicapped Child. Springfield, DJ.: Charles C Thomas, 1968.
36. McMichael, J. K. Handicap, A Study of Physically Handicapped Children and Their Families. Pittsburgh: University of Pittsburgh Press, 1971.
37. Shere, E. S., and Kastenbaum, R. Mother child interaction in cerebral palsy, environmental and psychosocial obstacles to cognitive development. Genetic Psychol. Monogr. 73 (1966), 255.
38. Shere, E. S. Patterns of child rearing in cerebral palsy, effects upon the child's cognitive development. Pediatr. Digest. 23 (1971), 28.
39. Färber, B. Family process. In Cruickshank, W. M., supra, p. 459.
40. Klapper, Z. S., and Birch, H. G. The relationship of childhood characteristics to outcome in young adults with cerebral palsy. Dev. Med. Child Neurol. 8 (1966), 645.
41. Freeman, R. D. Emotional reactions of handicapped children. Rehabii. Ut. 28 (1967), 274.
42. Freeman, R. D., Psychiatric problems in adolescents with cerebral palsy. Dev. Med. Chäd Neurol. 12 (1970), 64.
43. Hansen, E. Cerebral Palsy in Denmark. Copenhagen: Munksgaard, 1960.
44. Henderson, J. L. Cerebral palsy in Childhood and Adolescence. A Medical. Psychological and Social Study. Edinburgh: Livingstone, 1961.
AMBULATORY STATUS AND ONSET OF WALKING IN PRENATAL AND PERINATAL CEREBRAL PALSY
INCIDENCE OF SITTING AT TWO AND FOUR YEARS AND LATER AMBULATORY STATUS
INFANTILE REFLEX DEVELOPMENT
CORRELATION OF PRIMITIVE REFLEX DEVELOPMENT AND OUTCOME OF AMBULATION