Seven months before this neuropsychological testing, J.C. was running when he slipped and struck the left anterior portion of his head on a corner of a building. He did not lose consciousness, and although dazed for several minutes and mildly confused for about two hours, he did not seek medical attention. He seemed to recover routinely, except for experiencing severe headaches.

About one month postinjury he also developed spells of dizziness. At first he felt he could live with these problems, but his school grades began to deteriorate, and he felt that he was not able to concentrate as well as he had before and had developed memory problems. He therefore decided to seek medical attention. The neurological evaluation and neuropsychological testing was not done until about seven months postinjury. Although the neurological examination was entirely normal, J.C. demonstrated significant neuropsychological deficits.

On the WAIS, J.C. earned a VIQ of 101 (exceeding about 53% of the normative sample), a PIQ of 107 (exceeding about 68%) and a FSIQ of 104 (exceeding about 61%).

The scaled scores for the Verbal subtests indicate that there was a moderate degree of variability. Even though J.C. performed well on Information, Comprehension, and Digit Span (scaled scores of 11 on each of these subtests), he earned scores of 9 on Similarities and Vocabulary and a score of only 7 on Arithmetic. The Performance subtests were consistently done at a somewhat better level, with the range of scaled scores extending from 10 to 12.

It is apparent that one could not be confident that the scores on the WAIS reflected acquired impairment to any significant extent. It was also quite possible that the variability, which occurred especially among the Verbal subtests, was within the range of normal variation.

Despite these relatively normal IQ values, J.C. showed clear evidence of impairment on the neuropsychological evaluation. He earned a GNDS score of 39, a value that is indicative of mild neuropsychological impairment. The highest GNDS score in our initial validational sample of non-brain-damaged subjects was 34 (Reitan & Wolfson, 1988). In our sample of 20 mild head-injured persons referred for clinical evaluation, a GNDS score of 39 fell at the 42.5 percentile, indicating that J.C. was a little more impaired generally than the average for our subjects in this group.

The other four most sensitive measures in the HRB also tended to show evidence of impairment. The consistency of J.C.’s deficits, even though generally mild, was revealed by the Impairment Index of 1.0. He performed very poorly on the Category Test (72 errors) and on the Localization component of the TPT (0). However, he was able to demonstrate quickness, alertness, and flexibility in his thought processes, at least when dealing with certain types of tasks, by requiring only 59 seconds to complete Part B of the Trail Making Test.

With four of the five most sensitive measures clearly falling in the range characteristic of brain-damaged subjects, it definitely appeared that J.C. had sustained a degree of brain-related impairment. As would be inferred from the Impairment Index, J.C. tended to do somewhat poorly on most of the tests.

Lateralizing findings, implicating both the left and right cerebral hemispheres, tended to support the indications of mild impairment of brain functions. Although J.C. had mixed lateral dominance, the fact that he wrote with his left hand would predispose him toward performing unimanual tasks somewhat better with his left hand than with his right.

On the Tactual Performance Test, however, he showed relatively little improvement on the second trial (right hand) as compared with the first trial (left hand), improving from a score of 7.9 minutes to a score of 7.1 minutes. His ability to complete the task on the third trial (both hands) in only 3.5 minutes clearly indicates that he was capable of improving with practice. The relatively poor performance with the right hand as compared with the left hand may therefore have some significance for implicating the left cerebral hemisphere.

A more striking indication, however, was derived from testing for tactile finger localization. J.C. made 5 mistakes in 20 trials with his right hand, but only 1 mistake with his left hand, a finding that definitely deviates from normal expectancy and implicates the left cerebral hemisphere.

We did not conclude that J.C. had any definite symptoms of dysphasia, but from a clinical point of view, it should be noted that he had a little difficulty with simple reading. When asked to read, He is a friendly animal, a famous winner of dog shows, J.C. read, "He is a friendly animal and a famous winner of a dog show." When asked to read, Place left hand to right ear, J.C. read, "Please—Place left hand to right ear." These mistakes in reading are probably not a sufficient basis to classify J.C. as having dyslexia, but they are consistent with the other indications of left cerebral hemisphere impairment.

Some of J.C.’s other performances implicated the right cerebral hemisphere. Although ambidextrous, the fact that J.C. wrote with his left hand would suggest that he probably should be somewhat faster in finger tapping speed with his left hand than with his right. However, his speed (48 taps) was identical with both hands. J.C.’s performance on grip strength was more striking. He was able to register 44.0 kg with his right hand, but only 41.5 kg with his left hand.

J.C. had some trouble copying simple spatial configurations. His first drawing of the cross was within normal limits, but the examiner had him repeat the task because he had performed slowly and seemed to be having difficulty. On his second attempt he performed more poorly than he had initially, clearly failing to estimate the full extension of the upper extremity.

If one inspects his drawing of the key carefully, additional indications of problems dealing with spatial configurations become apparent. The handle was somewhat small, but the difficulty J.C. had in achieving symmetry of the notches in the stem close to the handle represented a more significant error. Although he carefully drew in the notches on the upper part of the stem, he did not achieve a symmetrical representation on the lower part of the stem. He made the same type of mistake in his drawing of the "teeth." A failure to achieve symmetry can readily be observed by comparing the upper part of the "teeth" just below the "nose" on the left side as compared with the area just below the stem on the right side. While a casual observation of the drawing might suggest that the performance was within normal limits, a close inspection reveals the difficulties noted above, which are quite characteristic of persons with right cerebral damage.

In summary, J.C.’s test results almost certainly indicate cerebral impairment, with both general and more specific (lateralizing) indicators. It is not surprising that J.C. had noticed deterioration of his school work, difficulty with concentration, and problems with memory.

The MMPI also yielded some deviant results. It would be difficult to be fully confident that J.C.’s results would have been normal even without having sustained a head injury, but it is likely that the elevations, at least in part, were associated with and derived from his cognitive impairment.

The results of the HRB make it perfectly clear that J.C. had not followed the usual pattern of recovery in cases of mild head injury, i.e., mild initial deficits and a full recovery in one to three months. At the time of this examination, seven months postinjury, J.C. showed very clear and serious indications of neuropsychological impairment.