Neuropsychological testing of a child with bipolar disorder
Not only do the symptoms of a mood disorder impact a child’s ability to learn, but evidence is emerging that learning disabilities, attentional problems, and deficits in the area known as executive functions are a significantly associated feature of early-onset bipolar disorder.
A learning disability is assumed to be present when a child has a discrepancy between his or her ability and his or her achievement. This is typically documented when a student has a normal or high IQ, but is still two years behind his or classmates in academic learning. U.S. Public Law states that learning-disabled individuals are: “Those who have a disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, which disorder may manifest itself in imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculations.”
These are broad and rather non-inclusive definitions of learning disabilities which address mostly verbal disabilities and which fail to take into account the non-language domains and area of executive functions. A specific learning disability is a breakdown in one particular task area, whereas executive function deficits cut across many domains and impact all arenas of life—both academic and non-academic. Executive function deficits affect the student’s ability to organize, strategize, and plan, among other things. It is highly likely that deficits in the area of executive functions will not be apparent until schoolwork gets more complicated, requires more independent work, and more planning and strategizing. Therefore, unless a child is tested and identified as experiencing these deficits, the snowballing effect of problems in this area may not become apparent until middle school or early high school. If the child shuts down and refuses to do school work at this point, parents and therapists will look to medication failure and the thriving of hormones before thinking that it may be “silent” executive function deficits.
Therefore, children with bipolar disorder should be tested with a comprehensive battery of intelligence, academic, neuropsychological, and psychological tests. These tests identify area of strength and weakness and do much to explain present difficulties and warn of future difficulties as the academic work-load becomes more demanding and intense in the higher grades. The findings of these tests will guide remediation efforts, and are critical when developing the Individual Education Plan—the IEP.
Who Should Test and How Do You Find The Tester?
Children with bipolar disorder should be tested by a child neuropsychologist. This is a professional who has specific training and supervised experience in the assessment and treatment of patients with brain disorders, and disorders of the central nervous system. A neuropsychologist typically has a doctorate in psychology and two years of postdoctoral training within a neurological or neurosurgical setting (one year in a general setting; one in a children’s unit). These professionals are licensed by the state.
To find a neuropsychologist, speak with your child psychiatrist, pediatrician, or pediatric neurologist. Other health professionals, such as occupational therapists, physiotherapists, speech pathologists and special educators may also make referrals. Remember, you are looking for someone who does more than psychoeducational testing.
A comprehensive battery of tests can easily require eight hours of direct consultation, as well as additional hours for reviewing records, data analysis, and the preparation of a written report. The cost for such an assessment will run in the range of $2,400-$3,000. Some insurance companies may reimburse a portion of the fees, but many do not. It’s a good idea to call your insurance company for preauthorization.
The school’s assessment will not be a complete neuropsychological evaluation since most school psychologists are not licensed to administer and interpret the neuropsychological battery of tests. Some schools may accept the test results that you bring them and be heartened that a seasoned professional has pinpointed areas of difficulty. However, the IDEA does not require them to accept your professional’s findings. In the event the team does not consider the findings in an independent or outside assessment, you have the right to present your findings in a due process hearing. In such a case you will want to consult with a qualified education advocate or attorney. (See Mediation and Due Process).
The Battery of Tests:
A suggested battery of tests (including the battery that examines the domain of executive functions and that should be given to all children and adolescents with bipolar disorder) is listed and discussed in depth in The Bipolar Child, Revised Edition. For the purposes of this article, we will focus only on the executive function deficits that so many children with bipolar disorder are now suspected of having.
What Are Executive Functions?
The pre-frontal cortex and the frontal lobes which are (just in front of the motor strip), are the areas of the brain that coordinate speech, reasoning, problem solving, strategizing, working memory, attention, self-control, intention, motor sequencing, and other processes central to higher functioning. When all is well, an individual can plan, strategize, break a plan down into smaller tasks in order to aim for a goal, assess if the strategy is working or not and be flexible enough to change it (“shift set”), bring working memory to bear, and sustain attention and see the project through to the finish.
Illustration by Jackie Aher
for the Bipolar Child,
Revised Edition, 2002
Research is showing that children with attention-deficit disorder with hyperactivity, as well as those with Tourette’s syndrome, have deficits in the frontal lobes. It is now suspected that many children with bipolar disorder also have problems in the frontal lobes. When the prefrontal systems don’t work correctly, there is a major impact on the ability to pay attention, inhibit impulses, devise plans, carry them through, and alter them if needed.
The child with glitches in this area will appear distractible, impulsive and restless, and disorganized (things will be lost or forgotten; rooms will be a mess). The problem or problems in the domain of executive functioning, governed by the frontal lobes may account for the co-morbidity between ADHD and bipolar disorder, Tourette’s syndrome and Oppositional Defiant Disorder.
Working memory is often confusing to people who understand short-term memory and long-term memory. An excellent definition of working memory is provided by Dr. Leslie E. Packer: “When you hold new information in mind while you retrieve past information to apply to it, you are using your working memory. If I ask you a question, you keep the question in mind as you mentally search through your ‘memory files or folders’ to pull out the information you are looking for. But what if memory’s ‘filing system’ is a disorganized mess? You’d know that the information was ‘in there’ but it would take you longer to find it and you may not always find it in time.”
Working memory, then, involves the ability to hold data in short-term memory while manipulating it toward problem solving or sequencing it in a logical order.
Research studies using functional magnetic resonance imaging (fMRI) have examined working memory and found that as memory load grows heavier, activity increases in the front area of the brain. A key part of the prefrontal cortex and certain other brain areas stay active, impressing researchers that these areas are involved in the active maintenance of information in working memory.
Bipolar children also seem to have problems with working memory. This is not surprising since they seem to have some problem in the prefrontal cortex of the brain.
Executive functions also affect motor skills as the motor strip begins the frontal lobes. (If you think of the placement of a headband on the hair, imagine the motor strip there, and everything in front of it the frontal cortex. The prefrontal cortex is the layer of tissue just behind the forehead).
Almost all tasks—by definition—involve not only analysis, planning, monitoring, and adjustment of strategy, but also images and ideas which must be translated into sequenced motor acts. It is not uncommon for these children to have difficulties with fine motor skills (handwriting) and motor outflow (initiating action in space). This is the child who may appear lazy, unmotivated, and hopelessly disorganized. As one very bright boy put it: “Remote controls were made for people like me.”
Parents can read about the problems that executive function deficits can cause for a student at school at http://www.schoolbehavior.com/conditions_edf.htm. There are some excellent tips for educators and parents on how to better organize the child or adolescent. We particularly liked the picture of the backpack and its being labelled “Another black hole in space where papers and books disappear never to be seen again.”