Psychological Evaluation of Pediatric, Neurologic Lyme
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
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
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