Psychiatric Annals

Mental Health Care in the Federal Bureau of Prisons 

Neuropsychologically Impaired Offenders: Considerations for Assessment and Treatment

George P Fowles, EdD, CRC

Abstract

The growth of clinical neuropsychology over the past 20 years has resulted in increasingly sophisticated methods of measuring brain behavior relationships in a quantitative manner. These methods are functionally rather than structurally or physiologically oriented and are particularly focused toward cognitive processes. Although far from conclusive as yet and suffering from various methodological and measurement deficiencies, a growing body of research is identifying offenders as a neuropsychologically unique population: unique not in the sense of particular pathology (obviously offenders are subject to the same various neuropathologies as the population at large) but rather in incidence and concentration of neuropsycho logical deficits. Learning disabilities and violence are two phenomena that have received particular attention both among juvenile and adult offenders. Particular focus has been on those deficits that are relatively mild, static, and chronic in nature and frequently of unclear etiology. Such deficits hold implications not only for the fundamental understanding of criminal behavior but also for the more practical concerns of the criminal justice system, including forensic decision making as well as correctional management and rehabilitation efforts.

HISTORICAL REVIEW

For decades, interest in determining a neurological component of criminal behavior has been high; however, attempts to establish such a relationship, particularly those based on physiological measures (EEG), have been frustrating and results have been conflicting and inconclusive.1 The numerous investigations of learning disabilities among juvenile and adult offender populations have generally supported a significantly higher incidence in offenders than in the population at large.2,3 A longitudinal study among a cultural subgroup found that children diagnosed as suffering from minimal brain dysfunction at age 10, as a group, had approximately six times as many contacts with police agencies by age 18 as did normal controls.4 Seizure disorders have been found to be three times as prevalent among incarcerated populations as among nonincarcerated middle-class populations.5 Several investigations have found that delinquents perform significantly poorer than nondelinquents on a variety of neuropsychological measures0*9 even after affording some control for race, educational background, and socioeconomic status.10 Within incarcerated populations, violent offenders have been found to display more severe deficits than nonviolent offenders.11'15

Although a variety of deficits have been observed, the most consistently reported deficits are those suggesting frontal lobe and left hemisphere dysfunction. The cognitive and behavioral correlates of such dysfunction include deficits in abstraction, concept formation, judgment, verbal fluency, academic skills, planning, problem solving, voluntary learning, and learning from experience. Diminished anxiety and inhibition and corresponding impulsiveness16 are frequently noted. Various etiologies have been proposed to explain these deficits including perinatal difficulties, childhood head and face trauma, child abuse,17 unattended chronic medical problems, malnutrition, early and ongoing drug abuse,18 and developmental delay of the frontal lobes.19

ASSESSMENT

The assessment of neuropsychological status of inmates in the correctional setting may take many forms depending on the purpose of the evaluation and the personnel conducting it. Ii is assumed that all new admissions to correctional facilities receive medical examinations, which include the taking of a medical history and at least a cursory neurological exam. It is at this point that individuals with known, acute, or severe neurologic conditions should be identified and treated or referred appropriately. However, a large number of individuals with milder neuropsychological deficits are not likely to display overt positive neurological signs or provide a remarkable medical history at the time of the initial exam, and thus their deficits will not be identified routinely.

It would be impractical to propose that all offenders receive a comprehensive neuropsychological test battery that may require eight or more hours of examination. Given the size of offender populations as well as limitations of correctional staff…

The growth of clinical neuropsychology over the past 20 years has resulted in increasingly sophisticated methods of measuring brain behavior relationships in a quantitative manner. These methods are functionally rather than structurally or physiologically oriented and are particularly focused toward cognitive processes. Although far from conclusive as yet and suffering from various methodological and measurement deficiencies, a growing body of research is identifying offenders as a neuropsychologically unique population: unique not in the sense of particular pathology (obviously offenders are subject to the same various neuropathologies as the population at large) but rather in incidence and concentration of neuropsycho logical deficits. Learning disabilities and violence are two phenomena that have received particular attention both among juvenile and adult offenders. Particular focus has been on those deficits that are relatively mild, static, and chronic in nature and frequently of unclear etiology. Such deficits hold implications not only for the fundamental understanding of criminal behavior but also for the more practical concerns of the criminal justice system, including forensic decision making as well as correctional management and rehabilitation efforts.

HISTORICAL REVIEW

For decades, interest in determining a neurological component of criminal behavior has been high; however, attempts to establish such a relationship, particularly those based on physiological measures (EEG), have been frustrating and results have been conflicting and inconclusive.1 The numerous investigations of learning disabilities among juvenile and adult offender populations have generally supported a significantly higher incidence in offenders than in the population at large.2,3 A longitudinal study among a cultural subgroup found that children diagnosed as suffering from minimal brain dysfunction at age 10, as a group, had approximately six times as many contacts with police agencies by age 18 as did normal controls.4 Seizure disorders have been found to be three times as prevalent among incarcerated populations as among nonincarcerated middle-class populations.5 Several investigations have found that delinquents perform significantly poorer than nondelinquents on a variety of neuropsychological measures0*9 even after affording some control for race, educational background, and socioeconomic status.10 Within incarcerated populations, violent offenders have been found to display more severe deficits than nonviolent offenders.11'15

Although a variety of deficits have been observed, the most consistently reported deficits are those suggesting frontal lobe and left hemisphere dysfunction. The cognitive and behavioral correlates of such dysfunction include deficits in abstraction, concept formation, judgment, verbal fluency, academic skills, planning, problem solving, voluntary learning, and learning from experience. Diminished anxiety and inhibition and corresponding impulsiveness16 are frequently noted. Various etiologies have been proposed to explain these deficits including perinatal difficulties, childhood head and face trauma, child abuse,17 unattended chronic medical problems, malnutrition, early and ongoing drug abuse,18 and developmental delay of the frontal lobes.19

ASSESSMENT

The assessment of neuropsychological status of inmates in the correctional setting may take many forms depending on the purpose of the evaluation and the personnel conducting it. Ii is assumed that all new admissions to correctional facilities receive medical examinations, which include the taking of a medical history and at least a cursory neurological exam. It is at this point that individuals with known, acute, or severe neurologic conditions should be identified and treated or referred appropriately. However, a large number of individuals with milder neuropsychological deficits are not likely to display overt positive neurological signs or provide a remarkable medical history at the time of the initial exam, and thus their deficits will not be identified routinely.

It would be impractical to propose that all offenders receive a comprehensive neuropsychological test battery that may require eight or more hours of examination. Given the size of offender populations as well as limitations of correctional staff and resources, this would simply be impossible. The value of conducting such evaluations would also be questionable due to limited treatment and training programs available to meet identified needs and the reluctance of many offenders to participate in programming that is available. Most correctional facilities do utilize some types of psychological and educational screening. Typically, this involves some combination of a clinical interview by a psychologist or psychiatrist, the administration of intellectual and personality measures, and academic achievement assessment by an education specialist. The clinician looking for gross pathology and the education specialist trying to assess an absolute academic level may overlook neuropsychological deficits. Nevertheless, given the increased incidence of deficits in the offender population and the possible implications of these deficits, it is recommended that intake evaluations be expanded to include some type of neuropsychological screening, at least in those settings where rehabilitative efforts are to be attempted.

Screening, by definition, implies brevity and something less than a complete evaluation. Unfortunately, considering the wide range of neuropsychological functions, the briefer the screening device the more questionable its validity. No single test has been developed that effectively discriminates between normals and those with brain dysfunction, and no one test can adequately describe the various deficits that can exist. Thus, if the clinician relies upon a single measure there is a high possibility of false negatives. Screening procedures should therefore attempt to assess, even if briefly, a variety of functions. A complete review of screening procedures is beyond the scope of this discussion, but general approaches have been described by numerous authors including a review by Berg, Franzen, and Wedding.20

One practical approach to screening is to use a technique proposed by Strub and Black in Menial Status Examination in Neurology.2* This is a structured, although not standardized, mental status examination that assesses a wide variety of cognitive functions. The examination may be administered in 15 to 20 minutes. Using the information obtained, the clinician should be able to determine whether more extensive neuropsychological evaluation is required. Unfortunately, since the exam is not standardized and is qualitative in nature, it requires considerable experience and expertise on the part of the examiner to use this approach reliably.

Another promising neuropsychological screening test battery is the Wysocki-Sweet screening battery.22 This battery is composed of seven existing tests, each of which have been found to be sensitive to brain dysfunction. The total battery takes slightly under one hour to administer. It also measures a wide variety of cognitive functions and has the additional advantage of standardized scoring. Initial evaluations of this battery employing decision rules correctly classified 68% of brain damaged subjects, 84% of schizophrenic patients as not brain damaged, and 100% of normal control subjects as normal. These figures suggest that the probability of identifying false positives is low, but there remains a considerable possibility of false negatives.

Both screening approaches can be augmented by the inclusion of the Shipley Institute of Living Scale25 in order to provide a measure of abstraction abilities and intelligence quotient (IQ). Although it adds an additional 20 minutes of examination time, it can be administered separately from the other tests in a group format. The original conceptual quotient (CQ) of this measure has recently been improved by including an age and education corrected abstraction quotient (AQ), which can reveal conceptual dysfunction. The limitation of this measure is that it should not be used with very low functioning individuals as it is highly dependent on verbal abilities.

There will be cases when a comprehensive neuropsychological battery should be administered. The Luria-Nebraska24 or HalsteadReitan25 are useful in determining relative strengths and deficits to allow for establishing a comprehensive rehabilitation program. These batteries are also useful in differentiating between functional and organic disorders. It is recommended that a complete comprehensive battery be administered in forensic evaluations when possible neurological involvement is suspected.

APPLICATION TO FORENSIC EVALUATIONS

Neuropsychological deficits, inasmuch as they affect cognitive abilities, hold obvious implications for forensic determinations involving competency to stand trial, criminal responsibility, and dangerousness. An evaluation of 15 death row inmates provided dramatic evidence for the need to include neuropsychological assessment in many forensic evaluations.26 Of the 15 inmates selected for the study solely on the basis of the imminence of their executions, all had histories of multiple severe head injuries; five had major neurological impairments including seizures, paralysis, and cortical atrophy; seven had histories of blackouts, dizziness, psychomotor epileptic symptoms, and numerous minor neurological signs. In five additional cases of suspected dysfunction, it was not possible to obtain complete neurological examinations. Ten cases were found to involve cognitive dysfunction as measured by psychological testing. Nine subjects suffered psychiatric symptoms during childhood and six were found to be chronically psychotic. Two additional subjects were thought to suffer from a bipolar mood disorder. Amazingly, these conditions were not raised during original trials, sentencing, or in the course of subsequent appeals.

The Federal Comprehensive Crime Control Act of 198427 permits verdicts of "not guilty by reason of insanity'1 on the basis of cognitive impairment, which requires evidence that the defendant was unable to appreciate the "nature and quality or wrongfulness of his acts at the time of the alleged offense." The competency to stand trial section of the law requires that the defendant be able to understand his legal situation and to assist an attorney in his own defense. Clearly, neuropsychological deficits could affect either of these issues. More specifically, deficits involving problems with concept formation, abstraction, and language, typically referred to as frontal lobe syndrome,28 hold major implications in assessment of these issues. Again, these are the deficits most frequently found in offender populations.

Although mild perceptual or motor problems, unless accompanied by deficits of higher functions, would not appear to impinge on these decisions in and of themselves, there are cases where more significant problems could have an impact. Although the volitional portion of the insanity defense has been removed from the current federal standards for criminal responsibility, neurologically based impulsivity may have implications in dangerous determinations. This, in turn, holds implications for involuntary commitment. Violent offenders have consistently displayed more severe neuropsychological and neurological deficits, particularly those involving the frontal and temporal lobes. Although no specific level, type, or constellation of deficits has been conclusively established to predict violence, a wide variety of neuropathotpgies have been associated with violent behavior29 and should be investigated as one potential factor in determination of dangerousness.

Given the gravity of these decisions as well as the inadequacy of many screening devices, it is recommended that cases involving any indication of significant brain dysfunction be administered a comprehensive neuropsychological battery. Zisken suggests a neuropsychological battery accompany neurologica] examination in forensic cases to more adequately describe the functional aspects of brain impairment.30

TRUTMENT

Within the correctional setting, treatment of the n eu ropsych o logically impaired offender may be considered in terms of institutional management, academic and vocational education, and psychotherapy. The previously described deficits have implications in each of these areas.

Inmates with neuropsychological impairment may pose particular problems for correctional administrators and custody staff. Their generally impulsive response style and inability to appreciate the consequences of their actions may lead to continuous conflict with institutional regulations. Similarly, their poor insight, impaired problem solving abilities, and inability to plan may not incline them to use their time constructively or engage in meaningful programs. Language difficulties may leave these individuals unable to follow complex instructions or read important written information such as handbooks, forms, and bulletins that could assist in their institutional adjustment.

The cumulative effect of these difficulties may result in frustration, withdrawal, or acting out; thus, they may tend to identify and associate with the more negative and antisocial elements of a correctional environment. These behaviors may elicit hostile and punitive reactions by staff. Unfortunately, such reactions are likely to be ineffective in changing the behavior of these individuals due to their inherent difficulties with both voluntary and experiential learning. In contrast, the management of these individuals should be effected through structure, both of their physical environment and their daily schedules.

Because they lack internal controls and problem solving abilities, these offenders tend to function best in environments that are routine and predictable. Authoritative approaches, both environmentally and interpersonally, should be avoided as they tend to elicit unnecessary hostile responses. Correctional line staff need information and education regarding behaviors associated with neuropsychological deficits and techniques for interacting with such individuals effectively. This information should be provided not only in a general sense, but also as it relates to specific individuals with clearly identified deficits.

These same cognitive and behavioral sequelae have implications for psychotherapeutic interventions. Particularly, conceptual deficits may prevent these individuals from being able to abstractly consider their situations. They have difficulty in appreciating causal relationships and thus have trouble considering the goal-directedness and consequential aspects of their behavior. Psychotherapeutic approaches with these offenders should be simple, specific, and behavioral, rather than insight oriented. Psychoeducational approaches may also be valuable in teaching problem solving, decision making, and social skills. Relaxation and anger control training may reduce impulsive behavior. In general, the clinician should be careful to avoid complex verbal interpretation, generalization, or focusing on temporally removed issues. The clinician cannot presume understanding on the part of the offender and should ask him to restate his perceptions of major issues. Treatment goals should be measured in small increments and gains should be frequently reinforced.

In addition to the primary cognitive deficits that must be accommodated in the process of psychotherapy, the therapist must also address overlying emotional and behavioral problems that the individual may have developed as protective mechanisms.31 The individual with neuropsychological impairment, whether fully or only vaguely aware of his limitations, has learned to avoid situations in which he is likely to fail. Such situations are aversive and anxiety provoking. Rather than face rhose situations, the individual may gravitate toward activities that he feels hold a higher probability of success. Unfortunately, these may include counterproductive responses such as aggressive and antisocial behavior. The therapist's role in addressing these issues is to: 1) educate the individual as to the nature of his deficits; 2) assist in the development of strategies to approach frightening yet productive activities; 3) provide support for such approaches; and 4) assist in the elimination of counterproductive behaviors through education and confrontation.

Academic and vocational training are major needs of the neuropsychologically impaired offender. It has been found that up to 50% of offenders in the United States cannot read at an age appropriate level.52 While attempts to establish a causal link between learning disabilities and delinquency have been inconclusive, the high incidence of learning disabilities among offender populations has been well documented. Lewis et al33 failed to find significant neurological differences between severely reading disabled delinquents and better reading delinquents, but did find that the poor readers were more likely to present psychiatric symptomatology and were more violent.

Likewise, Bryant et al " also failed to find differences in the frequency of learning disabilities between violent and nonviolent offenders, although the violent offenders displayed more neuropsychological impairment. Andrew34 assessed five theories of dyslexia among juvenile delinquents and found support for a left hemisphere dysfunction explanation. Severe conceptual deficits have also been noted among academic underachieving offenders, even after controlling for IQ. " Underlying neuropsychological deficits may also be aggravated by the generally poor educational histories noted among delinquent and offender populations. Likewise, vocational histories among offenders are notoriously poor.

Given the learning difficulties of offender populations, correctional education programs should be recognized as special education. Ideally, correctional educators should have specific training in learning disorders and be capable of prescriptive teaching. Teacher to student ratios should be small enough to enable the teacher to individually interact with the students, not only to address individualized deficits but aJso because these individuals respond better to active rather than passive learning methods. Small groups of similarly functioning individuals may reduce the embarrassment that has been so aversive in their educational histories. Computer assisted instruction also has the advantages of avoiding interpersonal embarrassment as well as sustaining attention and providing a sense of mastery for the individual.

As in psychotherapy, instructional approaches should be specific and employ a repetitive behavioral approach with frequent reinforcement, As the upper achievement levels of these individuals may be limited, even after considerable instruction, curriculum should not only include basic academics but should be oriented toward teaching daily living and survival skills which can be utilized immediately. A promising possibility that remains to be explored is the application of cognitive rehabilitation techniques employed with other neurological populations.56 These approaches focus more on the development of critical thinking skills as opposed to purely academic skills.

Neuropsychological deficits also hold implications for the selection of vocational goals and training. The cognitive, sensory, and motor skills assessed by neuropsychoiogical batteries are also the foundation of vocational aptitude. Unfortunately, many offenders in correctional settings select vocational goals and training on the basis of availability and subjective interest, without the benefit of vocational guidance or consideration of their neuropsychoiogical skills and deficits. In contrast to the academic approach of attacking the deficits, vocational rehabilitation attempts to capitalize on the individual's relative strengths.37 For example, an individual with left hemisphere dysfunction and accompanying verbal deficits should not be directed toward a highly verbal vocation but rather directed to tasks that capitalize on intact spatial abilities.

Conversely, individuals with right hemisphere associated spatial deficits should be directed to socially and verbally oriented jobs consistent with their overall level of intellectual functioning. If the individual's functioning level is very low, emphasis should be placed on developing prevocationaf work adjustment sJthis as opposed to specific vocational training. In addition to the cognitive deficits that impinge on vocational functioning, neuropsychoiogical deficits are also frequenuy accompanied by psychosocial problems that must also be addressed in the selection of the appropriate vocational goal.

Finally, correctional workers involved in the critical period of release, community re-entry, or parole need to be aware that documented neuropsychoiogical deficits may establish eligibility for vocational rehabilitation services. This agency can provide considerable services including further treatment, training, annd support for disabled offenders.

SUMMARY

The full nature and implications of brain dysfunction among offenders has yet to be investigated and established. Existing data, however, suggest it is a significant factor that needs to be addressed by the criminal justice system, particularly if rehabilitation remains a stated goal of correctional agencies. Unidentified neuropsychoiogical deficits treated inappropriately are likely to contribute to the further failure of rehabilitative efforts in a historically difficult population. Neuropsyehological assessment can provide valuable information that can be utilized by a wide variety of correctional personnel and that has applications from the courtroom through parole.

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10.3928/0048-5713-19881201-10

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