Neglect in CMdren
Jose M. Ferro, MD,* Isabel Paviio Martins, MD,* and Luis Tkvora, MD'F

Three children developed neglect following right-hemispheric lesions. In the first, computed tomography (CT) demonstrated a striatoinsular infarction. In the second, CT revealed a large meningioma compressing the right hemisphere,
and in the third, C T revealed two intracerebral hemorrhages in the right posterior parietal and occipital lobes. Neglect
in these children produced a clinical picture comparable to that occurring in adults, but there was a rapid and complete
recovery. T h e paucity of reports of neglect in children may be a function of the rapid recovery, the phenomenon being
missed if not looked for in the acute stage. We conclude that, at least for children aged 6 years or more, the right
hemisphere is dominant for directed selective attention.
Ferro JM, Martins IP, TLvora L Neglect in children. Ann Neurol 15:281-284, 1984

In human adults neglect reflects a disturbance in the
spatial distribution of directed attention and has been
associated with lesions of the inferior parietal and dorsolatetal frontal lobes, cingulate and supplementary
motor gyrus, striatum, and thalamus C8, 101. These are
interconnected areas whose lesions, according to Heilman 187, interrupt a cortical-limbic-reticular loop that
mediates orienting responses and arousal to meaningful
stimuli presented in the contralateral hemispace.
In childhood neuropsychological studies of acquired
unilateral hemispheric lesions have focused mainly on
left hemispheric and language disturbances, and except
for a case briefly described by HCcaen 157, n o mention
of neglect is made in several other studies rl, 2, 8, 10,
117. We report three cases of neglect in children, induced by right hemispheric lesions.
Case Reports
Patient 1

A 6-year-old left-handed girl suddenly developed nonfluent
aphasia, left hemiparesis, and left hypesthesia for touch, pain,
and postural sensation. O n visual confrontation testing, a left
hemianopia was detected. She did not respond to threatening
gestures from the left side, and she failed to notice people
coming or talking to her from the left. Conjugate eye movements were full, both to verbal commands and pursuit. When
writing with her right hand, she demonstrated a typical spatial
dysgraphia. She neglected the left half of sentences or words,
and lines of writing showed variable degrees of inclination.
She tended to use only the right part of the paper, and she
separated letters by leaving blank spaces between them. Her
performance was slightly better on dictation than on copying.
Visuoconstructional ability was also impaired. O n Benton's
Visual Retention Test (form C) she often omitted or distorted the left peripheral figures. She also showed a typical

From the Departments of *Neurology and TNeurosurgery,
Neurobehavioral Unit, Centro de Escudos Egas Moniz, Hospital
Santa Maria, Lisbon, Portugal.

pattern of left visual inattention on a cancellation test. In this
test (Fig 1) the patient is asked to cross out all the lines drawn
in three rows on a sheet of paper placed in front of her.
Although she could always detect left unilateral somatic
stimulation, on simultaneous tactile stimulation she failed to
notice stimuli on the left. On a dichotic listening task (pairs of
nouns), she demonstrated a left-channel extinction.
A computed tomographic (CT) scan performed on the
sixth day of illness demonstrated a right paraventricular infarction involving the internal capsule and insula, and the
lentiform nucleus and a small area of white matter over it.
This lesion produced no perifocal edema or mass effect (Fig
2). Right carotid angiogram showed corkscrew irregularities
in the supraclinoid segment of the internal carotid artery and
in the proximal part of the middle and anterior cerebral arteries suggestive of fibromuscular dysplasia. Two weeks later
hemispatial neglect, as well as visual, auditory, and tactile
extinction, had disappeared. Aphasia was also improved.
Writing to dictation was better, but the patient still demonstrated spatial errors (confused lines) when reading sentences
aloud.

Patient 2
A 9-year-old boy with idiopathic thrombocytopenic purpura
was admitted to the hospital because of gum bleeding, generalized cutaneous petechiae, and ecchymoses. Platelet count
was 15,000 per cubic millimeter on admission and remained
low despite platelet transfusions and steroid therapy. Four
days later the patient had several generalized seizures, complained of headache and drowsiness, and vomited. Neurological examination disclosed a mild left-side weakness and sensory loss. Electroencephalogram showed right hemispheric
slowing, and computed tomographic (CT) scan demonstrated
two right intrahemispheric hemorrhages, one posterior
parietal and one occipital, associated with edema (Fig 3).
The patient was treated with anticonvulsant agents and

Received Apr 14, 1983, and in revised form Aug 8. Accepted for
publication Aug 13, 1983.
Address reprint requests to Dr Ferro, Neurobehavioral Unic, Centro
de Estudos Egas Moniz, 1600 Lsbon, Portugal.

281

Fig 2. Computed tomographic scan of patient 1, demonstrating
hypodense area in right hemisphere, involving the internal capsule and lenticular nucleus.

\

searching was normal. Mean simple visual reaction time was
26.1 f 3.5 (SD) ms for the right hand and 30.1 5 5.6 for the
left, a significant difference ( t = 3.32, p < 0.01), and on
Benton’s Judgment of Line Orientation Test (form V), the
patient scored 1 SD below the mean. C T scan showed a
residual hypodense right posterior parietal lesion.

/\

Patient 3

Fig 1 . Performance on cancellation tasks. (A)Patient 1; (B) patient 2; (C) patient 3. Patients failed to notice lines drawn on
the lejit half of the test sheet.

anticerebral edema medications and received repeated
platelet transfusions. Bleeding stopped, and on the next day
he became fully alert. Left-side weakness and hypesthesia
were less evident, but a crossing-out task performed at bedside disclosed left hemispatial inattention (see Fig 1). One
month after admission, findings on general neurological examination were normal. There was no extinction on simultaneous visual, tactile, or auditory stimulation. Performance
on dichotic listening tests, constructional tasks, cancellation
and line bisection tests, spontaneous drawing, and tactile

282 Annals of Neurology

Vol 15 No 3 March 1984

A 5-year-old right-handed boy was admitted to the hospital
because of vomiting, malaise, restlessness, and episodes of
nocturnal fecal and urinary incontinence that had started 15
days before. For five months the child had been less active,
showing no interest in playing or drawing. He had increasing
difficulty in dressing. Neurological examination revealed an
alert but easily fatigable child. Language was unimpaired.
Ocular fundi were normal. There was a slight
- left hemiparesis
and a left facial hypalgesia. The left plantar response was
extensor, and there was a moderate truncal ataxia and leftside deviation when walking.
He presented a severe visuospatial disability: his performance on Benton’s Visual Retention Test and his spontaneous drawing of a human figure were poor. He demonstrated
left hemispatial neglect on cancellation and line bisection
tasks (see Fig 1). His performance following simultaneous
tactile stimulation was normal. O n a task of repeated movements with both hands, the left hand tended gradually to
stop. O n a dichotic listening test he presented a left-channel
extinction.
A C T scan revealed a very large hyperdense mass occupying most of the right cranial cavity that enhanced homogeneously with contrast. The mass had almost collapsed the

Fig 3. First computed tomographic scan of patient 2. Note two
hyperdense areas in the right hemisphere,posteriorparietal and
occipital, associated with grade I1 edema.
right hemisphere and had produced marked midline shift (Fig

4).Right cerebral arteriography showed a medial displacement of the sylvian arteries by a relatively vascular mass. The
tumor, which proved to be a fibroblastic meningioma, was
removed in two stages. Two days before the second operation a bedside cancellation test no longer showed evidence of
neglect. Spontaneous drawing was still poor.
One month postoperatively muscle strength, sensory and
visual field findings, and performance on cancellation and line
bisection tests were normal. His performance on the Visual
Retention Test was improved. He still presented a leftchannel extinction o n dichotic listening tests but no extinction on simultaneous tactile or visual stimulation. The left
hand no longer stopped moving in a task requiring simultaneous hand movements.

Discussion
Neglect in these three children resembled that observed in adults with similarly localized lesions. All had
right hemispheric lesions. Although patient 1 was left
handed and her right hemisphere was probably dominant for language, she presented a typical “nondominant syndrome” consisting of left-side neglect, constructional apraxia, and spatial dysgraphia. In adult
sinistrals neglect is also much more common with right
than with left hemispheric lesions {G}. Lesion location
was also similar to that of lesions that produce neglect

Fig 4. Compated tomographic scan of patient 3, demonstrating a
vey large hyperdense mass occupying most of the right cranial
caiiity that enhanced homogeneously with contrast.

in adults [7, 9}. Occipital and posterior parietal lesions
(patient 2) are a well-established anatomical correlate
of neglect, and a few reports 13, 41 describe neglect
following striatal infarcts (as in patient 1).
In regard to the clinical signs, we note that o n the
visual modality all patients ignored stimuli in the left
hemispace, showing hemispatial neglect on a cancella-

Ferro et al: Neglect in Children

283

tion test. Patient 1 also showed left extinction on simultaneous tactile stimulation, and patients 1 and 3 a leftchannel extinction on a dichotic listening test. In
patient 1, whose lentiform lesion spared the geniculotemporal and the intertemporal pathways, this pattern can be interpreted as left auditory inattention.
The paucity of reports of neglect in children may
have several causes: (1) In series of childhood hemispheric lesions, in which hcmianopia has been a frequent finding, neglect could have been attributed to
visual field defects 11, 8, '91. (2) In other series of right
brain-damaged children, no tests for visual neglect are
mentioned 11, 2, 8, 10, 111. (13) Neglect in children
may be transient and show rapid recovery, and thus be
overlooked if not searched for during the acute stage.
Indeed, in our patients neglect was present only during
the acute stage and disappeared quickly. Recovery
from neglect was faster than that from aphasia. ( 4 ) It is
possible that the rarity of neglecr in children stems
from a lack of right hemispheric dominance for attention. In adults the right parietal lobe is said to attend to
both hemispaces, whereas the left parietal lobe attends
only to the right hemispace E7,91. If in children both
hemispheres were equipotential for attention and
could react to both hemispaces, unilateral lesions
would not cause the striking disturbance of attention
that occurs in adults. This interpretation is not supported by the present findings, however. At least for
children aged six years or more, the right hemisphere
appears dominant for directed selective attention.

284

Annals of Neurology

\'ol

15 No 3

March 1984

The authors thank Drs R. Morris and K. M. I-leilman for their most
helpful suggestions and criticism, and Maria de Fitirna Pereira for
typing the manuscript.

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