Lupus in the Child’s Mind

Similar to the adult experience, children who have cognitive dysfunction as one of many active disease manifestations often have improvement or even resolution of cognitive abnormalities as other systemic features improve with treatment. For those patients who have cognitive abnormalities that do not prevent everyday function but are noted by family, school, or the patient, evaluation should include neurocognitive and psychiatric assessments.

Patients with cognitive abnormalities associated with major psychiatric diagnoses may require antidepressant or antipsychotic therapy possibly in conjunction with immunosuppressive therapy, as well as counseling. Other possible findings on neurocognitive testing such as attentional problems also can be addressed with medical and cognitive therapy. Children with SLE and a concern of intellectual decline or memory problems have an advantage over adult patients because they are routinely tested in school. It is important to compare previous academic standardized testing to current results, because differences may not be significant and concerns may be due to anxiety or a change in academic demands. Once the patient has an evaluation, the results can be shared with the school. By law, patients who have disabilities can request a 504 or individual education plan to improve school support, including services such as tutors, school psychological evaluations, and specific curricular plans worked out between the patient, parents, medical team, and school team.

Perhaps the greatest challenge for a child with SLE is how to negotiate their social environment. Each child has an individual set of social skills, family, friends, and unique disease features that require different levels of attention and intervention. Significant physical or behavioral changes can alter social acceptance. Education of family, peers, and school faculty is critical to improve social functioning; however, it is not always the desire of the patient and family. Successful reintegration into the social environment is a significant challenge and a unique skill of the pediatric rheumatology team.

Dr. Brunner is associate professor of pediatrics in the divisions of rheumatology and clinical epidemiology, and head of the Cincinnati Children’s Hospital Medical Center Lupus Center at the University of Cincinnati College of Medicine. Dr. Klein-Gitelman is associate professor of pediatrics and head of pediatric rheumatology at the Children’s Memorial Hospital at Northwestern University Feinberg School of Medicine in Chicago.

References

1. Hermosillo-Romo D, Brey RL. Neuropsychiatric involvement in systemic lupus erythematosus. Curr Rheumatol Rep. 2002; 4:337-344.
2. The American College of Rheumatology nomenclature and case definitions for neuropsychiatric lupus syndromes. Arthritis Rheum. 1999; 42:599-608.
3. Sibbitt WL, Jr., Brandt JR, Johnson CR, et al. The incidence and prevalence of neuropsychiatric syndromes in pediatric onset systemic lupus erythematosus. J Rheumatol. 2002; 29:1536-1542.
4. Hanly JG, Fisk JD, McCurdy G, Fougere L, Douglas JA. Neuropsychiatric syndromes in patients with systemic lupus erythematosus and rheumatoid arthritis. J Rheumatol. 2005; 32:1459-1466.
5. McLaurin EY, Holliday SL, Williams P, Brey RL. Predictors of cognitive dysfunction in patients with systemic lupus erythematosus. Neurology. 2005; 64:297-303.
6. Olfat MO, Al-Mayouf SM, Muzaffer MA. Pattern of neuropsychiatric manifestations and outcome in juvenile systemic lupus erythematosus. Clin Rheumatol. 2004; 23:395-399.
7. Harel L, Sandborg C, Lee T, von Scheven E. Neuropsychiatric manifestations in pediatric systemic lupus erythematosus and association with antiphospholipid antibodies. J Rheumatol. 2006; 33:1873-1877.
8. Luna B, Garver KE, Urban TA, Lazar NA, Sweeney JA. Maturation of cognitive processes from late childhood to adulthood. Child Dev. 2004; 75:1357-1372.
9. Wyckoff PM, Miller LC, Tucker LB, Schaller JG. Neuropsychological assessment of children and adolescents with systemic lupus erythematosus. Lupus. 1995; 4(3):217-220.
10. . Klein-Gitelman MS, Zelko F, Kress A, Hunter S, Wagner-Weiner L. Comparison of neuro-cognitive function in children with pediatric systemic lupus erythematosus (pSLE) and their peers—second year follow-up. Arthritis Rheum. 2002; p. S216.
11. . Brunner HI, Ruth NM, German A, et al. Initial validation of the pediatric automated neuropsychological assessment metrics for childhood-onset systemic lupus erythematosus. Arthritis Rheum. 2007;57:1174-1182.
12. Mortilla M, Ermini M, Nistri M, DalPozzo G, Falcini F. Brain study using magnetic resonance imaging and proton MR spectroscopy in pediatric onset systemic lupus erythematosus. Clin Exp Rheumatol. 2003; 21:129-135.
13. Moritani T, Hiwatashi A, Shrier DA, Wang HZ, Numaguchi Y, Westesson PL. CNS vasculitis and vasculopathy: Efficacy and usefulness of diffusion-weighted echoplanar MR imaging. Clin Imaging. 2004; 28(4):261-270.
14. Padovan M, Locaputo A, Rizzo N, Govoni M, Trotta F. The evaluation of neuropsychiatric lupus erythematosus by functional neuroimaging. Preliminary results [in Italian]. Reumatismo. 2004; 56:24-30.
15. DiFrancesco M, Holland S, Ris D, et al. Functional magnetic resonance imaging of cognitive function in childhood-onset systemic lupus erythematosus: A pilot study. Arthritis Rheum. 2007; 56:4151-4163.
16. Benseler, S. M., E. D. Silverman. Neuropsychiatric involvement in pediatric systemic lupus erythematosus. Lupus. 2007;16:564-571.