Peds SAEs Flashcards

Question

9. You are asked to evaluate a 1-year-old patient who is not yet walking but is developmentally appropriate. Which reflex would you expect to find? (a) Asymmetric tonic neck (b) Symmetric tonic neck (c) Palmar grasp (d) Plantar grasp

Answer 1

(d) The asymmetric tonic neck reflex (ATNR) and symmetric tonic neck reflex (STNR) are usually integrated by 6 to 7 months. Palmar grasp disappears by 5 to 6 months. Plantar grasp is integrated when walking is achieved. The normal age of walking varies, but may be as late as 18 months.

Answer 2

(c) "Little league elbow," seen in throwing athletes with immature skeletons, is a conglomeration of different diagnostic entities caused by valgus and extension-overload. Medial epicondylar avulsion can frequently occur. Separation from 3--5mm can be managed nonsurgically. However, separations greater 5mm usually require surgery.

Answer 3

(d) Children with cerebral palsy often have weakness as part of their disorder. Treatments such as bracing, tendon lengthening or transfers, and medications such as botulinum toxin or intrathecal baclofen add to this weakness. Strengthening programs or functional training programs can help to strengthen weak muscles.

Answer 4

(a) The lack of coughing in a patient with neurologic impairment when presented with food may mean a normal swallow, but is more likely to mean silent aspiration. A normal videofluoroscopic swallowing study is unlikely in a patient with a TBI who is drooling and hoarse. Hoarseness may be a sign of reflux, but in a child with a TBI is more likely to mean vocal cord abnormality.

Answer 5

(b) Children who sustain cervical or high thoracic spinal cord injuries at an early age are at high risk of developing progressive scoliosis that requires surgical management.

Answer 6

(d) While this child is totally dependent for transfers, he only requires minimal support to sit upright and has no fixed deformities. Custom seating should be used for those with fixed deformities. A tilt-in-space frame should be used when children need to have their position in space changed frequently because of deformities or medical problems. While it is tempting to prescribe a wheelchair with a folding frame for a family who transports a child in a car rather than a van, the child will be better positioned using contoured seating and a rigid frame. At age 5 years, the size of frame needed will be able to be transported in a car even without folding. Adaptive strollers usually position the child in a reclined position and should be used as a backup to a wheelchair, which is not easily transported in an automobile, or for a child who can walk but periodically needs dependent mobility for fatigue or following seizures or for similar reasons.

Answer 7

(d) This patient illustrates the diagnostic dilemma of the floppy infant. Causes of this problem include central nervous system lesions (both brain and spinal cord), myopathies, neuropathies, and neuromuscular junction problems. This infant has had abnormalities since birth, which argues against infantile botulism. Kugelberg Welander syndrome (also known as spinal muscular atrophy type 3) has onset during childhood, as does Duchenne muscular dystrophy. Tetraplegic cerebral palsy often presents in infancy with floppiness and hyporeflexia, which later change to spasticity and hyperreflexia.

Answer 8

(b) The child with L5 myelodysplasia typically has late hip dislocation, calcaneus foot, hip flexion contractures, and may have either knee extension or flexion contractures, depending on whether quadriceps (L2-4) or hamstrings (L4-S1) are stronger. Gluteus medius (hip abductor, L4-S1) and hip adductors (L1-3) are innervated higher than L5 and are typically balanced in L5 myelodysplasia. Late hip dislocation is due to either unbalanced hip musculature or spinal deformities.

Answer 9

(a) A thoracolumbosacral orthosis is used for scoliosis having an apex at T9 or lower. A sternooccipital mandibular orthosis immobilizes the neck. A thermoplastic Minerva body jacket is also used for cervical immobilization. A cervicothoracolumbosacral orthosis such as the Milwaukee brace extends from the pelvic section to the neck ring and has been shown to correct scoliotic curves throughout that area.

Answer 10

(b) A comprehensive review of published English language studies on intrathecal baclofen (ITB) showed evidence of statistically significant improvement in upper and lower extremity tone with ITB use in children with cerebral palsy (CP). Other reported improvements with ITB in children with CP are either anecdotal or not substantiated by randomized controlled trials.

Answer 11

(c) The child is experiencing autonomic dysreflexia. The 90th percentile for blood pressure in an average sized 3-year-old girl is 103/62. A child with C5 tetraplegia would be expected to have even lower average blood pressure. Initial treatment consists of positioning the patient in an upright position and emptying the bladder. If this does not correct the problem, medications should be considered. If medications are needed, either nitropaste 2% or nifedipine may be used. For a child weighing 15kg the correct initial dose is 0.25 to 0.5 mg/kg/dose (3.75–7mg) of nifedipine or ½ inch of nitropaste.

Answer 12

(b) Problems of executive function include impairments in attention, memory, and abstract reasoning. While aphasia and low intelligence may be seen following traumatic brain injury (TBI), they are not problems of executive function. Agitation is usually seen early in recovery from TBI, at the Rancho Los Amigos stage 4. The full consequences of a TBI that occurs in a young child may not be seen until much later, at an age when the child is expected to have that skill. For example, problems in abstract reasoning in a child who had a TBI at age 5 may not be seen until the child reaches 9 or 10 years of age.

Answer 13

(d) A child with C6 ASIA class A spinal cord injury would be expected ultimately to independently self-feed, but not bathe, do lower extremity dressing, or perform bed mobility.

Answer 14

(a) Hypotonia in infants can be caused by many abnormalities, including cerebral lesions, spinal cord pathology, polyneuropathies, and myopathies. These electrodiagnostic findings are most consistent with congenital myotonic dystrophy.

Answer 15

(a) The Gross Motor Functional Measure (GMFM) evaluates motor changes over time in children with cerebral palsy. It includes activities in prone and supine positions, rolling, sitting, crawling, kneeling, standing, walking, running, and jumping. It does not measure the quality of motor performance.

Answer 16

(d) Seventy-five percent of lesions in spina bifida cystica (myelomeningocele) affect the lumbosacral spine. Ninety percent of children with spina bifida have hydrocephalus that requires a shunt for management.

Answer 17

(c) A mobile arm support or balanced forearm orthosis would enable the child with C5 ASIA A spinal cord injury (SCI) and weak arm muscles to move the arm through useful active range of motion and to position the hand for function. In patients with C5 SCI, these orthoses are typically combined with wrist extension splints or a universal or palmar cuff for feeding. A resting hand splint may be used at night to improve or maintain range of motion, but would interfere with daytime function. A short hand splint would not strengthen wrist extensor muscles, but may be useful to improve function.

Answer 18

(a) Given that his pulmonary function has not changed, the most likely cause for his shortness of breath is cardiac decompensation due to cardiomyopathy. Respiratory failure due to neuromuscular weakness would typically correspond to worsening of pulmonary function testing. Bacterial and aspiration pneumonia would both present with much more acute symptoms. Boys and men with Duchenne muscular dystrophy rarely get deep venous thromboses or pulmonary emboli. If left untreated, the patient will likely develop congestive heart failure from cardiomyopathy. The decreased cardiac output usually responds to treatment with digoxin and ACE-inhibitors.

Answer 19

Rooting and automatic walking reflexes are present at birth, and are integrated by 4 months of age. Posterior protective extension does not appear until 7 to 8 months of age. Plantar grasp is present at birth and not integrated until after independent walking occurs at approximately 12 months of age.

Answer 20

(a) Sucking and swallowing are well-coordinated at 34 weeks’ gestation. Because the infant’s tongue is more anterior than the adult’s, the tongue fills more of the oral cavity than in the adult. The larynx in the infant is high, about at the C2–3 level. Newborn infants are obligate nose breathers and oral breathing is not observed until 3 to 4 months of age.

Answer 21

(a) Fever in a child with a severe traumatic brain injury should be investigated and infections treated with appropriate antibiotics. In the absence of infection, the fever in central autonomic dysfunction is poorly responsive to nonsteroidal anti-inflammatory drugs. Baclofen may help to control the spasticity, but propranolol is more effective in controlling the hypertension, tachycardia, and hyperthermia.

Answer 22

(c) The Education for All Handicapped Children Act and the Individuals with Disabilities Education Act guarantee children with disabilities education in the least restrictive environment. They also guarantee necessary health care be provided in the school environment (eg, intermittent catheterization) but do not require medical care be provided.

Answer 23

(d) Muscle strengthening will not reduce the curve or prevent it from progressing and is not easily accomplished in 2-year-old children. Posterior or anterior spinal fusion is not indicated with a curve of this size and is to be avoided in a young child if at all possible. Spinal orthotics are used in young children with spinal muscular atrophy to improve sitting balance and to attempt to halt curve progression.

Answer 24

(b) The abnormal gene for Duchenne and Becker muscular dystrophy (DMD, BMD, respectively) is on the short arm of the X chromosome at position Xp21Reference. Both DMD and BMD are inherited Xlinked recessive diseases affecting primarily skeletal and myocardial muscles. Dystrophin is a large cytoskeletal protein in the subsarcolemmal lattice, the protein that stabilizes the plasma membrane during muscle contractions.Mutations in the dystrophin gene that result in a complete loss of dystrophin lead to the DMD phenotype. Mutations that cause a reduced, truncated, or dysfunctional form of dystrophin to be produced lead to the BMD phenotype. Both DMD and BMD are progressive myopathies, although DMD is much more severe and is universally fatal. BMD shows a similar pattern of muscle weakness to DMD but with later onset and much slower rate of progression.

Answer 25

(a) While scoliosis may occur in children with achondroplasia, it is less common than kyphosis, which begins in infancy. Spinal stenosis occurs frequently in individuals with achondroplasia, with 38 years being the average age of symptom onset. Low back pain is extremely frequent in adults with achondroplasia, but rare in children. Progressive kyphosis that occurs in infants and young children with achondroplasia is treated with a spinal orthosis.

Answer 26

(c) While boys with C5 spinal cord injury (SCI) may learn to perform bladder self-catheterization with assistive devices, girls do not. Level transfers require active elbow and wrist extension, which would not be present in a person with C5 SCI. Self-feeding with assistive devices such as a palmar band can usually be done by persons with C5 tetraplegia.

Answer 27

(a) An infant’s head is approximately 19% and each arm constitutes 9% of the total body surface area (TBSA). In adults and older children the head is approximately 9% of the TBSA

Answer 28

(d) The elbow is involved 90% of the time in juvenile rheumatoid arthritis (JRA), the temporomandibular and hip 50% each. The shoulder is involved about 8% of the time in early JRA and about 33% later

Answer 29

(b) Diazepam has lethargy and sleepiness as major side effects. Dantrolene works at the level of the muscle and often causes weakness, which can interfere with function. Oxybutynin relaxes the muscles of the bladder, not skeletal muscles.

Answer 30

(b) This patient presents with hypotonia, weakness, and hyperreflexia, a combination most commonly seen in central nervous system lesions such as cerebral palsy. A child with a neuromuscular disorder would not have hyperreflexia with the hypotonia and weakness. In severe cerebral palsy it is common to see early hypotonia with brisk reflexes that changes to hypertonia as the child gets older.

Answer 31

(b) Precocious puberty occurs in up to 50% of girls who sustain a severe traumatic brain injury (TBI) in early childhood. Diabetes insipidus is an early complication of TBI. While other endocrine abnormalities may occur, they are less common.

Answer 32

(a) The majority of clinical problems encountered in neuromuscular disease can be directly linked to skeletal muscle weakness. Studies indicate that what causes most of the functional problems and impairs quality of life for people with neuromuscular disease is muscle weakness.

Answer 33

(b) Intervention with submaximal exercise training in neuromuscular disease improves physical performance and increases muscle efficiency, and thus helps fight fatigue and improve quality of life. However, in children, the exercise program must be conducted in an enjoyable setting. Supervision is necessary to make sure the children do not play to exhaustion, which could produce muscle damage and overwork weakness.

Answer 34

(c) The exam describes typical findings in a boy with myopathy such as Duchenne muscular dystrophy (DMD). The earliest weakness in DMD is proximally in the gluteus maximus. The boy assumes a posture of lumbar lordosis to place the center of gravity posterior to the hip joint to prevent hyperflexion of the hip and thus a fall. Toe walking is a compensatory adaptation to knee extensor weakness.

Answer 35

(c) Grade 4 intraventricular hemorrhages in premature infants are most commonly associated with spastic diplegia.

Answer 36

(d) Arthrogryposis multiplex congenita (AMC) may be caused by a variety of conditions, but is usually not accompanied by spasticity. Thus botulinum toxin and baclofen are not indicated. Most club feet (equinovarus) in patients with AMC are resistant to conservative methods and require surgical releases.

Answer 37

(d) Children with cerebral palsy often have weakness as part of their disorder. Treatments such as bracing, tendon lengthening or transfers, and medications such as botulinum toxin or intrathecal baclofen add to this weakness. Strengthening programs or functional training programs can help to strengthen weak muscles.

Answer 38

(a) Autism is characterized by echolalia, inability to play reciprocally, and abnormal relationships with people. While children with mental retardation, cerebral palsy, and hearing impairment may have some of these features, they do not have all of them in the absence of autism.

Answer 39

(c) Poliomyelitis involves the anterior horn cells. During an acute infection, the virus is transported to the anterior horn cells followed by inflammation and loss of spinal and bulbar motor neurons.

Answer 40

(b) In normal newborn infants flexor tone predominates and hands are kept fisted. In prone position a normal newborn is able to turn the head to either side. The newborn has a rounded spine when placed in supported sitting

Answer 41

(a) The lack of coughing in a patient with neurologic impairment when he/she is presented with food may mean a normal swallow, but is more likely to mean silent aspiration. A normal videofluoroscopic swallowing study is unlikely in a patient with a traumatic brain injury (TBI) who is drooling and hoarse. Hoarseness may be a sign of reflux, but in a child with a TBI it is more likely to mean vocal cord abnormality.

Answer 42

(c) Recent studies by McDonald and by Bach showed that reduction of maximal expiratory force (MEF) to 40%–60% of normal in the 7- to 14-year-old age group was the first sign of respiratory muscle dysfunction in boys with Duchenne muscular dystrophy (DMD). The earlier and more severe decreases of MEF that are greater than the decreases in maximal inspiratory force, correspond to the clinically observed weakness of abdominal muscles, which like coughing are important in forced expiration. Vital capacity was not found to decrease until an average of 15–16 years. Low oxygen saturation is a late manifestation in DMD, developing after hypercapnia.

Answer 43

(a) The clinical picture is suggestive of a polyneuropathy. Patients with hereditary polyneuropathies may have feet with high arches. Electrodiagnostic studies including nerve conduction studies remain the most important first tests in the evaluation of polyneuropathy.

Answer 44

(d) Tethered cord is the most common cause of new onset spasticity in patients with myelodysplasia. Linear growth does not cause new spasticity. Symptoms of Chiari malformation include cranial nerve disorders and respiratory problems. Shunt malfunction may be associated with headaches, vomiting, eye muscle abnormalities, and sometimes abdominal symptoms.

Answer 45

(b) Deep venous thromboses (DVTs) which can be diagnosed by Doppler study usually occur in the first 3 months after spinal cord injury (SCI) and are rare in prepubertal children. In lower leg DVTs the foot and leg are usually swollen. Heterotopic ossification (HO), which can be detected by bone scan, occurs in about 3% of children with SCI and has onset an average of 14 months after injury. Heterotopic ossification most commonly involves the hip. Cellulitis is usually associated with skin lesions and usually involves a discrete area. A fracture is the most likely cause of swelling in this case and can be diagnosed by plain radiographs

Answer 46

(a) There are no large, randomized, controlled studies that show the long-term effects of any type of Ankle-Foot Orthosis (AFO) on function or contracture formation. Small studies have shown that both rigid and hinged AFOs improve gait efficiency by preventing plantar flexion.

Answer 47

(d) Children with juvenile rheumatoid arthritis are more likely to have systemic features, have large joints involved, and have cervical spine involvement. Adults with rheumatoid arthritis have joint destruction earlier.

Answer 48

(b) Children with myelodysplasia have deceptively good verbal facility that creates the impression of higher intellectual functioning than is found on formal testing (“cocktail party syndrome”). Children with cerebral palsy, autism, and muscular dystrophy do not typically demonstrate this finding.

Answer 49

(b) Hip subluxation is the most likely cause of knee pain in a child with T6 ASIA B SCI. Pain from hip pathology is often referred to the knee in children. While hip adductor spasticity contributes to subluxation or dislocation, the spasticity itself is not painful. Dysesthetic pain is usually generalized. An abnormal knee examination is usually found in a knee injury that causes pain.

Answer 50

(c) A basilar skull fracture is often associated with a permanent sensorineural hearing loss. Other traumatic brain injuries may be associated with hearing loss, but this is less common. All patients with basilar skull fracture should be assumed to have a hearing loss and have audiological evaluation as soon as possible.

Answer 51

(a) The typical “myopathic gait” seen in early Duchenne muscular dystrophy is caused by weakness of the gluteus maximus and quadriceps muscles. In order to maintain upright posture the child assumes the hyperlordotic stance. Contractures of the gastrocsoleus and iliopsoas muscles occur later in the disorder.

Answer 52

(d) Approximately 70% of children with hemiplegia have seizures. About 50% of children with tetraplegic cerebral palsy have seizures. Seizures are rare in children with diplegia or athetosis

Answer 53

(a) The 1-year-old child should be fit with a simple prosthesis which suspends securely and allows for growth. The knee joint should be added between 3 and 5 years. The SACH foot is most commonly prescribed because of its simple design and durability. All prostheses for growing children should incorporate a removable growth liner in the socket.

Answer 54

(c) These options all describe reflexes. (a) asymmetric tonic neck reflex, (b) palmar grasp, and (d) Moro are seen until a baby is about 6 months old. Protective extension or parachute reaction (c) does not appear until after 6 months.

Answer 55

(c) Spinal cord injury without obvious radiologic abnormality (SCIWORA) usually occurs in young children, is thought to be due to the relatively large head size and weak neck muscles, and motor abnormalities may not be apparent for up to several days. SCIWORA most commonly occurs in the cervical region.

Answer 56

(a) Because of growth and increasing weakness, a common sequela of motor neuron disease is scoliosis. It is important to provide adequate pelvic support with a firm seat to avoid hip asymmetry. If wheelchairs are too big, asymmetric spinal posture is encouraged. Slanted seats with pommels are useful to control extensor spasticity, which should not be an issue here. Seat backs should be high to help control spinal posture

Answer 57

(b) Scoliosis requiring surgery is a common complication seen in children who have had an spinal cord injury (SCI) at a young age. Increased lordosis in the absence of scoliosis is rarely seen. Deep venous thrombosis rarely occurs in young children and when it does occur it usually occurs soon after the SCI. Heterotopic ossification tends to occur soon after the SCI.

Answer 58

(b) Strong hip flexor and adductor muscles can overpower weak extensors and abductors. Acquired hip dislocation can be prevented in some cases by release of spastic hip flexors and adductors.

Answer 59

(b) Migraines do not typically occur only in the morning. Neck extensor tightness usually occurs before the loss of ambulation in boys with Duchenne muscular dystrophy, which usually occurs before the age of 15 years. Vision changes usually do not cause morning headaches. Hypercarbia results from hypoventilation during sleep and is an early sign of impending respiratory failure.

Answer 60

(c) Spastic diplegic cerebral palsy occurs most commonly in premature infants who have had an intraventricular hemorrhage during the neonatal period. Intrauterine stroke causes hemiplegia. Neonatal hyperbilirubinemia most commonly causes athetosis. Birth asphyxia is more commonly associated with spastic quadriplegic cerebral palsy.

Answer 61

(b) There are many studies about longterm outcomes of ambulation in children and adults with myelomeningocele. While many factors influence outcome, including intelligence, medical problems, and obesity, the best predictor of ambulation into adulthood is strong quadriceps function. Bowel and bladder continence has no relationship to ambulation.

Answer 62

(c) A child with C5 ASIA A spinal cord injury should eventually become independent in feeding, and in upper extremity dressing with assistive devices, in driving a power wheelchair, and in propelling a manual wheelchair short distances on level surfaces.

Answer 63

(d) Spinal muscular atrophy (SMA)is a term used to describe a group of inherited disorders characterized by weakness and muscle wasting due to degeneration of anterior horn cells of the spinal cord and brainstem motor nuclei. Three subtypes of autosomal recessive predominantly proximal SMA have been linked to chromosome 5q. The majority of cases of SMA type I present within the first 2 months of life with generalized hypotonia and symmetric weakness. Children typically sit only with support. Tongue fasciculations have been reported in 56%-61% of patients. Proximal muscles are weaker than distal.

Answer 64

(a) Any disorder that interferes with cerebral perfusion or oxygenation can cause further damage following traumatic brain injury. This includes hypotension, hypoxia, increased intracranial pressure because of cerebral edema, acute hydrocephalus, or space-occupying lesions. Midline shift or herniation may lead to infarction because of pressure or traction on cerebral vessels. Therefore, efforts are made to control intracranial pressure through fluid and electrolyte management, hyperventilation, and maintenance of normal blood pressure and oxygenation. Growing skull fractures result from the arachnoid protruding through a dural tear, producing a cyst that can contribute to a widening skull deficit, which usually requires operative repair. This is a complication of traumatic brain injury but not a secondary injury. Coup and contrecoup cerebral contusions and diffuse axonal injuries are examples of primary injury.

Answer 65

(b) Children with major burn injuries should be placed in positions that tend to prevent contractures. These include neck extension (no pillows); shoulders at 90° abduction and neutral rotation with elbows, wrists, hips, and knees extended; feet at neutral dorsiflexion, metacarpophalangeal joints at 70° to 90° flexion and finger interphalangeal joints in full extension.

Answer 66

(d) Most children with severe traumatic brain injury have dysphagia, incontinence, and agitation at some time during the recovery period. Central autonomic dysfunction (hypertension, hyperpyrexia, sweating, tachypnea, and rigidity) is associated with worse cognitive and motor outcomes a year or more after injury.

Answer 67

b) The most useful clinical criterion to distinguish Becker muscular dystrophy (BMD) from Duchenne muscular dystrophy (DMD) is the continued ability of the patient to walk into late teen-age years. Persons with BMD will typically remain ambulatory beyond 16 years. Outlier DMD cases generally stop ambulating between 13 and 16 years of age. Creatine kinase values cannot be used to differentiate DMD from BMD. Calf enlargement and the presence of Gowers’ sign are a nonspecific findings. Studies have shown significant overlap in the observed age at onset between DMD and BMD

Answer 68

(d) Cerebral palsy is the leading cause of childhood disability. The reported incidence is approximately 2-3 per 1,000 live births. The incidence of spina bifida is .5 per 1,000, of spinal muscular atrophy 1 in 25,000. The annual incidence for traumatic brain injury in children is 1-2 per 1,000. However, the great majority of cases are minor and result in no long-term disability. Approximately 15% of brain-injured children have moderate and severe injuries resulting in permanent impairment.

Answer 69

(c) Neck flexor weakness occurs during preschool years. Weakness is generalized but is predominantly proximal early in the disease course. Pelvic girdle weakness precedes shoulder girdle weakness by several years. Weakness progresses steadily. Quantitative strength testing is more sensitive than manual muscle testing.

Answer 70

(c) Terminal overgrowth at the transected end of a long bone is the most common complication after amputation in the skeletally immature child. It occurs most frequently in the humerus, fibula, tibia, and femur, in that order. The oppositional growth may be so vigorous that the bone pierces the skin. The treatment of choice is surgical revision.

Answer 71

(d) Although opiates should be considered the most important part of acute pain management nonopiates should be used when possible. As the needs become more chronic, other agents should be instituted to minimize the problems seen with opiates. Behavioral management and relaxation therapy should also be used when possible. Typically, the position of comfort for a burned child is the position that promotes deformity and, therefore, should be avoided. Garments are fitted later in the course of treatment.

Answer 72

(b) The lower limb deficient child should be fitted with a prosthesis when he or she is ready to pull up to a standing position, usually between 9 and 12 months. A knee joint is added between 3 and 5 years.

Answer 73

(d) In neonates and young infants, motor behavior is influenced by primitive reflexes because of the immature central nervous system. These reflexes gradually become suppressed. Concurrently, more sophisticated postural responses emerge. Obligatory persistent primitive reflexes are the earliest markers of abnormal neurologic maturation.

Answer 74

(c) A history of delay in communication development raises several diagnostic possibilities, including true language dysfunction or a motor dysfunction or significant hearing loss. Infants with hearing loss start to fall behind after 6-8 months of age, when learning of auditory-dependent vocalization begins. Oral motor dysfunction is often associated with cerebral palsy, most often spastic quadriparesis. Difficulty with drinking from a cup and difficulty with the introduction of solid food are early symptoms of oral motor dysfunction. Autism is a spectrum disorder with qualitative abnormalities in communication and in social and behavioral realms.

Answer 75

(c) Mental retardation is the most common serious associated disability in cerebral palsy. The overall incidence of mental retardation is approximately 30%-50%. Severe mental retardation is present in about one-half of the retarded group. Approximately one-third of cases have mild cognitive deficits. The greatest retardation is seen in rigid, atonic, and severe spastic quadriplegic cerebral palsy.

Answer 76

(a) Although there is considerable variability from case to case, outcome is primarily related to the severity of the injury.