Psychological Evaluation of Pediatric, Neurologic Lyme Disease

by Dr. Fallon

Background. Children with Lyme disease may experience cognitive difficulties that interfere with school performance. Studies have demonstrated deficits in the areas of attention, memory, language and reasoning in adult subjects.[1-4] Other studies have explored the nature and extent of cognitive or academic dysfunction in children with Lyme disease,[5-8] though little attention has been directed toward the development of educational programs to deal with the issue. Marian Rissenberg, PhD, of Columbia Presbyterian College of Physicans & Surgeons, New York, presented a talk on the neuropsychological evaluation of children with Lyme disease. Dana Leonardi, MA, has been an integral part of this research.

Methods. In this pilot study, Dr. Rissenberg evaluated 8 children aged 7 to 13 years (mean, 9.1) with physical, cognitive, and emotional symptoms related to Lyme disease who had neuropsychological evaluation, including academic testing early and again later in the course of their antibiotic treatment. Physical symptoms reported at the initial evaluation (E1) included fatigue, joint pain headaches and irritability. Also reported were difficulties with schoolwork, concentration, and memory; sleep disturbance; sensory sensitivity; mood swings; impulsivity; depressed mood; anxiety; motor tics; word retrieval difficulty; balance problems; and temper outbursts.

Results. Dr. Rissenberg's results indicated that at the time of E1, even after completing from 1 to 5 months of high-dose antibiotic treatment, children had significant cognitive deficits. As a group, the subjects had a significant discrepancy between Verbal and Performance IQ, and a significantly deficient Performance IQ. There was a significant degree of inter-subtest variability on the WISC-III, with scores ranging from the 20th to 93rd percentile. Scores were lowest on tests sensitive to speed of processing, visual scanning, sequencing, and causal reasoning. Deficits were noted on 2 attention tasks, one sensitive to visual scanning and sustained attention and the other to auditory tracking. While there were no statistically significant memory deficits evident at E1, the data suggest that delayed recall of both verbal and visual material is deficient. On tests of language function, performance was deficient on a task requiring production of sentences containing a given word. On academic measures, half the S's were behind grade expectation in 2 measures of reading comprehension, as well as spelling. Most S's were above grade expectation in Basic Reading, Mathematics Reasoning and Numerical Operations. Reading skills were more advanced than math skills.

At E2, following 10 to 32 months (mean, 17) of additional antibiotic therapy, all subjects reported significant improvement of physical and emotional symptoms, with only 1 having continued headaches and another having sleep disturbance. Five experienced improvement in cognitive and academic difficulties, though 4 continued to have some cognitive complaints and 5 continued to have some emotional issues. Two continued to have both cognitive and emotional symptoms, and 1 had both physical and emotional symptoms.

Results from repeat administration of the WISC-III at E2 revealed significant improvement in Verbal and Performance IQ, with less of a spread between the two. Full Scale IQ and the Perceptual Organization Index also showed significant improvement. Marked improvement in performance was shown on those subtests that were deficient at E1, specifically Picture Arrangement, Comprehension, Object Assembly, and Coding, as well as Arithmetic. This strongly supports the notion that these deficits were secondary to Lyme disease and that their improvement is attributable to antibiotic treatment. Visual scanning and sustained attention improved, while auditory tracking showed less improvement. Performance on sentence production improved. Significant improvement was noted on the Verbal Immediate Memory Index and the General Memory Index of the CMS. Short-term memory impairment is no longer apparent. Gains were made in academic achievement in all areas, with the exception of Numerical Operations (paper and pencil calculations). However, even with 6 S's dropping an average of 1 year and 3 months, only 2 fell below their expected GE. Gains were demonstrated on 3 separate measures of reading comprehension and on reading speed and accuracy. Scores on tests of mathematical calculations and fund of general and word knowledge declined. This is interpreted as reflecting a decreased rate of learning and a widening of the gap between children with Lyme disease and their healthy peers over the course of the study.

Implications. Dr. Rissenberg noted that the results provide preliminary support for broadening the CDC diagnostic criteria, extending antibiotic treatment in children, and conducting careful neuropsychological evaluation and educational monitoring. Development of educational programs for the identification, accommodation, and remediation of Lyme disease-related academic difficulties is critical as the numbers of children with the disease increases. Lyme disease-related cognitive deficits represent acquired, as opposed to developmental, learning disabilities and attentional disorders. Educational services and modifications should include, when necessary, reduction of homework, extended time for tests, provision of classroom notes and course outlines, instruction in organizational, time management, and study skills strategies, availability of abridged or tape-recorded books, shortened schoolday, and home instruction. Support may be necessary even after treatment for Lyme disease has been completed. Education of teachers and other school personnel regarding the educational impact of Lyme disease, as well as resources for parents, must be available. Dr. Rissenberg noted that further study is needed, using larger groups and more stringent controls, of the cognitive and academic functioning, physical and psychiatric symptomatology, and treatment response in children with Lyme disease.

References

  1. Halperin JJ, Luft BJ, Anand AK, et al. Lyme neuroborreliosis: central nervous system manifestations. Neurology. 1989;39:753-759. 
  2. Kaplan RF, Meadows ME, Vincent LC, Logigian EL, Steere AC. Memory impairment and depression in patients with Lyme encephalopathy: comparison with fibromyalgia and non-psychotically depressed patients. Neurology. 1992;42:1263-1267. 
  3. Logigian EL, Kaplan RF, Steere AC. Chronic neurologic manifestations of Lyme disease. N Engl J Med. 1990;323,1438-1444. 
  4. Rissenberg M, Chambers S. Neuropsychological Deficits in Chronic Lyme Disease. Paper presented at the annual meeting of the American Psychiatric Association; 1996. 
  5. Adams WV, Rose CD, Eppes SC, Klein JD. Long-term cognitive effects of Lyme disease in children. Appl Neuropsychol. 1999;6:39-45. 
  6. Bingham PM, Galetta SL, Athreya B, Sladky J. Neurologic manifestations in children with Lyme disease. Pediatrics. 1995;96:1053-1056. 
  7. Bloom BJ, Wyckoff PM, Meissner HC, Steere AC. Neurocognitive abnormalities in children after classic manifestations of Lyme disease. Pediatr Infect Dis J. 1998;17:189-196. 
  8. Tager FA, Fallon BA, Keilp J, Rissenberg M, Liebowitz MR. A controlled study of cognitive deficits in children with chronic Lyme disease (in press). 

Suggested Reading

  • Adams WV. Cognitive effects of Lyme disease in children. Pediatrics. 1994;94:185-189. 
  • Athreya BH, Rose CD. Lyme disease. Current Problems in Pediatrics. 1996;26:189-207. 
  • Belman AL, Coyle PK, Roque C, et al. MRI findings in children infected by Borrelia burgdorferi. Pediatr Neurol. 1999;8:428-431. 
  • Belman AL, Iyer M, Coyle PK, Dattwyler R. Neurologic manifestations in children with North American Lyme disease. Neurology. 1993;43:2609-2614. 
  • Christen HJ. Lyme neuroborreliosis in children. Ann Med. 1996;28:235-240. 
  • Cohen MJ. Manual for the Children's Memory Scale. San Antonio, Tex: The Psychological Association; 1997. 
  • Coyle PK. Neurologic Lyme disease. Semin Neurol. 1992;12:200-208. 
  • Eppes SC, Klein JD, Caputo GM, Rose CD. Physician beliefs, attitudes, and approaches toward Lyme disease in an endemic area. Clin Pediatr. 1994;33:130-134. 
  • Fallon BA, Das S, Plutchok JJ, Tager F, Liegner K, Van Heertum R. Functional brain imaging and neuropsychological testing in Lyme disease. Clin Infect Dis. 1997;25(suppl 1):S51-S63. 
  • Fallon BA, Kochevar JM, Gaito A, Nields JA. The underdiagnosis of neuropsychiatric Lyme disease in children and adults. Psychiatr Clin North Am. 1998;21:693-703. 
  • Fallon BA, Das S, Plutchok JJ, et al. Functional brain imaging and neuropsychological testing in Lyme disease. Clin Infect Dis. 1997;25(suppl 1):S57-63. 
  • Fallon BA, Nields JA. Lyme disease: a neuropsychiatric illness. Am J Psychiatry. 1994;151:157-183. 
  • Fallon BA, Nields JA, Parsons B, et al. Psychiatric manifestations of Lyme borreliosis. J Clin Psychiatry. 1993;54:263-268. 
  • Fallon BA, Schwartzberg M, Bransfield R, et al. Late-stage neuropsychiatric Lyme borreliosis. Differential diagnosis and treatment. Psychosomatics. 1995;36:295-300. 
  • Feder HM, Gerber MA, Cartter ML, Sikand V, Krause PJ. Prospective assessment of Lyme disease in a school-aged population in Connecticut. J Infect Dis. 1995;171:1371-1374. 
  • Feder HM, Hunt MS. Pitfalls in the diagnosis and treatment of Lyme disease in children. JAMA, 1995;274:66-68. 
  • Garcia-Monco et al. Borrelia burgdorferi in the central nervous system. J Infect Dis. 1990;161:1187-1193. 
  • Gaudino EA, Coyle PK, Krupp L.B. Post-Lyme syndrome and chronic fatigue syndrome: neuropsychiatric similarities and differences. Arch Neurol, 1997;54:1372-1376. 
  • Gerber MA, Shapiro ED, Burke GS, Parcells VJ, Bell GL. Lyme disease in children in southeastern Connecticut. N Engl J Med. 1996;335:1270-1274. 
  • Issakainen J, Gnehm HE, Lucchini GM, Abinden R. Value of clinical symptoms, intrathecal specific antibody production and PCR in CSF in the diagnosis of childhood Lyme neuroborreliosis. Klin Paediatr. 1996;208:106-109. 
  • Krupp et al. Cognitive functioning in late Lyme borreliosis. Arch Neurol. 1991;48:1125-1129. 
  • Logiglian EL. Chronic neurologic manifestations of Lyme disease. N Engl J Med. 1990;323:1438-1444. 
  • Miller et al: Lyme borreliosis of the central nervous system in children. Infection. 1991;19:273-278. 
  • Pachner AR. The triad of neurologic manifestations of Lyme disease. Neurology. 1985;35:47-53. 
  • Pachner AR, Duray P, Steere AC. Central nervous system manifestations of Lyme disease. Arch Neurol. 1989;46:790-795. 
  • Preac-Mursic et al. First isolation of Borrelia burgdorferi from an Iris biopsy. J Clin Neuro-Ophthalmol. 1999;3:155-161. 
  • Pietrucha D. Neurologic manifestations of Lyme disease in children [abstract]. Ann Neurol. 1990;28:464. 
  • Raucher et al. Pseudotumor cerebri and Lyme disease: a new association. J Pediatr. 1985;107:831-834. 
  • Smith J. Neuro-ocular Lyme borreliosis. Neurol Clin. 1991;9:35-53. 
  • Shapiro ED, Seltzer EG. Lyme disease in children. Semin Neurol. 1997;17:39-44. 
  • Weschler D. Manual for the Wechsler Intelligence Scale for Children-Third Edition, San Antonio, Tex: The Psychological Corporation; 1991. 

 

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