--Janice Papolos and Demitri F. Papolos, M.D.
How many times have we all jotted
down a list to take with us to the supermarket? Even a simple vertical column
of ordinary household items requires more than we realize. We scan areas of
the house and pull from memory different food stuffs or supplies that need to
be replenished or replaced: refrigerator (need milk, butter, juice); cabinets
(we’re out of sandwich bags and sponges); canisters (need coffee and tea);
laundry room (need detergent and bleach); dinner (….. good question).
All this information requires a flow of memory, organization, and planning.
Most of us do this part of the task spontaneously and routinely.
Now we need to create that list on
paper. As automatic as it seems, writing simple words like “coffee,”
“sandwich,” and “juice,” requires a call-up of a sequence
of letters and shapes for each word—spelling--and an ability to manipulate
the pen or pencil in order to encode the letters. During the physical act of
jotting down a list, we control several muscle groups to keep the writing tool
flowing in a direction—moving vertically, horizontally, and in a circular
fashion (rotary movement). Fine motor coordination is key as we stimulate certain
muscle groups, inhibit others, and balance, flex, and contract movements. We
don’t punctuate the list, write it in a creative way, grab the attention
of a reader, or develop a theme and add flourish and detail to our assertions.
A list is just a list.
Now that you realize the abilities
this simple column calls for, think of a child who has graphomotor problems
so that he or she writes letters in a laborious, illegible manner; who has sequencing
problems so that spelling is greatly below par; and who has memory challenges
so that the missing items or ingredients aren’t summoned easily to mind
(or kept in working memory long enough to write them down). A shopping list
becomes a whole new order of accomplishment, demanding effort even at this rudimentary
level.
There are no statistics, but it is
estimated by some psychiatrists and neuropsychycologists who treat and test
children with bipolar disorder, that at least half of these children have disorders
of written expression. The numbers may even be higher.
The problem for some children is
language-based (and may co-exist with dyslexia); for others it is a motor outflow
difficulty; and for many children with bipolar disorder, the problem may be
a severe difficulty in organizing thoughts, relinquishing original ideas and
reformulating them; and marshaling the energy and attention to complete the
task. Any one of these problems will make writing a demand that will most likely
be resisted—very vehemently, and with increasing frustration and anger.
What Happens When a Child
Has to Write
According to Hilary J. Luttinger,
MA, clinical research director of the Department of Medicine at Elmhurst Hospital
Center and Mount Sinai School of Medicine in New York:
Writing is a complex task requiring
the mastery and integration of a number of subskills. The process of writing
connects cognition, language, and motor skills. Some children have difficulty
in one aspect of the process, such as producing legible handwriting or spelling
(dysgraphia), while others have difficulty organizing and sequencing their
ideas. Difficulties in one area can delay skill development in the other areas.
Another layer of writing must develop
as a child moves into higher grades. Dr. Mel Levine, in A Mind At A Time,
writes that a student must “respond productively to the call for excellent
language skill, rich idea development, and the arrangement of ideas and facts
in a logical manner.” “In some cases,” he adds, “that
call goes unanswered.”
What are some of the reasons
that call goes unanswered, especially for children with bipolar disorder?
In addition to a motor and sequencing
difficulty, a child with bipolar disorder may also have difficulties with the
mechanics of writing (periods, commas, and capitals may be very late to arrive
in any written product), working memory, intention (let’s get it done),
and sustained attention. In a hypomanic state, the thoughts may race and ideas
pour out faster than the motor or organizational controls; conversely, in a
depressed phase, there may be a slow-down of thought and a paucity of ideas.
We spoke with Dr. Dana Luck, a neuropsychologist
in New York City and she explained:
Writing is a directed task and
very different from speaking. Verbally, we can all mention thoughts, circle
around them, move off in different directions, and hopefully get to the point
somewhere along the way. Writing, however, is much slower and very much more
precise. It is straight processing and it is a task of drafting, and re-drafting,
revision, elaboration and polishing. Children with bipolar disorder often
have such poor frustration tolerance, and very often have a very negative
reaction to the demand that they write.
Dr. Luck went on to say:
If a student has trouble self-monitoring,
if she or he can’t regulate a flow of ideas and can’t pace him
or herself, than each piece of the task that is uncompleted becomes a stress,
and the stresses begin to accumulate until the student simply shuts down and
refuses to even attempt the task.
Many of these processes that are
called upon when a child writes are in the domain of what is called executive
functioning. It is increasingly being recognized that a significant number of
children with bipolar disorder have deficits in the realm known as executive
functioning.
Executive Function Deficits
“Executive functioning”
refers to a cluster of mental control abilities, including skills such as the
capacity to plan ahead, choose and implement strategies, and organize one’s
thinking and actions. Executive functions also include abilities such as maintaining
awareness of what one is doing and staying on task, controlling one’s
impulses, and monitoring the quality of one’s own performance and making
adjustments if necessary.
Executive functioning is performed
by the advanced parts of the brain—the frontal lobes and the pre-frontal
cortex. Actually, brain imaging has shown that the frontal lobes may be divided
into seventeen or more subregions, each responsible for a slightly different
kind of work that the human performs. So a problem anywhere in this area will
impact the way a child approaches and performs any task.
A Deeper Look at the Executive
Functions Critical to the Writing Process
Whenever a human being approaches
a problem or a project, he or she must recruit the following executive functions:
- Analyze the problem
- Plan and implement the strategy
- Anticipate problems
- Organize the way the strategy
will be accomplished (break it down into its components and effectively assign
a time segment for each sub-strategy to be accomplished)
- Monitor the progress and assess
whether the plan is working
- Remain flexible and reformulate
the plan of attack if the monitoring and assessment process shows it not to
be working
- Reassess the new strategy that
has been implemented
- Follow the adjusted plan through
to the finish
As one can see, strategizing, organizing,
marshaling intention into movement, flexibility (changing the approach when
it is recognized that the original strategy isn’t working), and constant
monitoring are crucial to the completion of any task— and especially to
writing and editing an essay, a book report, or piece of narrative writing.
Working memory (also governed by
the frontal lobes and a significant part of executive functioning), is crucial
to the writing process also.
Working Memory
Working memory involves the ability
to hold data in short-term memory while manipulating it toward problem-solving
or sequencing it in a logical order. As Dr. Mel Levine writes in A Mind
at a Time:
(Many) kids have writing difficulty
that stems from weaknesses related to active working memory, the part of memory
that allows them to keep track of immediately relevant memory while doing
a task. These students tend to forget aspects of the writing tasks while they
are writing. For example, while trying to decide if they need a comma or a
colon, they may lose track of ideas for the next sentence.
He brings the point home when he
says:
Writing requires more memory than
just about anything else a student is asked to do in school. Writers need
to simultaneously retrieve spelling, punctuation, capitalization, letter formation
rules, vocabulary and content information, transitions and connections, and
all the other ingredients of written output.
Writing is an enormous academic strain
for some students, especially those with graphomotor dysfunctions or significant
weaknesses in attention, working memory, and organization of thought.
Graphomotor Dysfunctions
When you look at a child’s
handwriting on a piece of paper and see letters poorly formed, a difficulty
with the spatial organization of the letters and words on the page, and heavy
line pressure, you can quickly realize that the child is having difficulty in
the graphomotor domain. This area of disability is called dysgraphia—a
glitch between motor memory and its connection to the fingers.
As we mentioned earlier, a sequence
of visualization and tiny, precise muscle movements translate the thought of
a word into its written subunits (letters) that come together to make that word,
that are grouped with other words to make sentences.
All this, plus strong working memory,
sequencing, organization, and sustained attention go into the writing process before creativity and mature character development enter the picture.
Children with bipolar disorder are often extremely creative verbally, and would
be on paper also, if they didn’t often suffer difficulties in the skills
that must precede creativity in the writing process.
No wonder children with these problems
refuse to write, or produce very little on the written page. If they do write,
they “dumb down” the output. Small wonder, then, that teachers and
parents (and the children themselves) don’t realize how smart or even
gifted they might be. Parents find themselves increasingly anxious, frustrated,
and angry at the child who puts off any written assignment until the last minute.
They may first try to motivate the child, and when this doesn’t do the
trick, negative feelings quickly arise as evenings and weekends go sour—or
worse. This is exhausting and demoralizing for the child and the parent. Because
writing is a part of every school day, every subject, and most homework assignments,
it is important to find out what is really going on to impede the writing process
for the student.
Most early and significant learning
disorders in the area of written expression will be expressed by the second
or third grade (the graphomotor difficulties may be noticed earlier), so it
is very important to intervene early when some of the remediation process is
age-appropriate. For instance, a very young student will think nothing of using
a multisensory approach and sculpting letters in the air or using graph paper;
a fifth grader will sneer and become negative before you can explain the purpose
of the exercise.
What Tests Would Reveal These
Areas of Weakness In Written Expression?
There are many tests that can be
administered to determine which areas of the writing process are problematic
for a child, and each educational psychologist or neuropsychologist will use
those based on his or her training and clinical experience. However, most evaluators
on a child study team in a school system will rely on the following battery
of tests:
Written Language Assessments
The Woodcock-Johnson Psychoeducational
Battery—Revised is a norm-referenced test for ages three to eighty. Among
other skills, it yields samples of dictation and writing.
The Wechsler Individual Achievement
Test (WIAT-II) is a measurement tool used to gauge achievement skills and to
help diagnose learning disabilities for preschool children through adults.
Tests of Written Language (TOWL)
—The TOWL-3 is a written language assessment tool used with individuals
ages 7 and-a-half to 17. It measures expressive skills in written language including:
use of established rules for punctuation, capitalization, and spelling; the
use of serviceable syntactic and semantic structures; and the ability to write
logical, coherent and sequenced written products.
Tests of Sustained Attention
Tests that measure sustained attention
are recommended also. Two that are widely used are the Connor Continuous Performance
Tests and the Tests of Variable Attention (the TOVA). Both examine attention
over a long period—fourteen to twenty-two and a half minutes—and
are performed on a computer. These tests measure discrete aspects of attentional
functioning. One or the other is frequently administered.
Tests of Executive Functions
The WISC-IV, the newest version of
the well-known intelligence test, has some subtests that reveal executive function
deficits. But more comprehensive tests (typically administered and interpreted
by neuropsychologists) include:
The Wisconsin Card Sort
Tower Of Hanoi
Tower of London
Trails A & B
Stroop Color and Word Test
Another set of tests that a neuropsychologist
may administer is to assess executive motor skills. While almost all tasks involve
analysis, planning, monitoring, and possible adjustments of strategy (all executive
functions controlled by the frontal lobes and pre-frontal cortex), many images
and ideas must be translated into sequenced motor acts. These activities most
likely involve the pre-frontal cortex and the motor cortex—the strip that
begins the frontal lobes. Writing is very much a task of motor sequencing.
Tests that measure executive motor
skills include:
Luria Test of Praxis
Fine Motor Coordination
Purdue Pegboard or the Grooved Pegboard
Hallstead-Reitan Finger Tapping Test
Because explanations of the above
tests are beyond the purview of this newsletter, readers might want to read
more detail in Chapter 11 of The Bipolar Child, Revised.
What Is the Process of Remediation?
The remediation process will depend
on the areas of difficulty that are impacting the child’s written expression.
If the problem is a dysgraphia, and
the child is having trouble recalling the shape of letters (encoding) and sequencing
them on to paper in a legible fashion, then a multi-sensory approach that is
rehearsed and repetitive will help a great deal. A n occupational therapist
or a special education teacher may use a special pencil to encourage proper
pencil grip, help a child align his or her arms and body in order to write,
and use graph paper, or a paper with raised lines, to help the child recognize
where to place and how to space letters. There are also slant boards that help
the child work at a vertical surface as this promotes the development of proper
hand and wrist position and keeps the paper from sliding. This and a foot stool
will help the child’s body from collapsing and his or her head from getting
too close to the paper.
Special paper and slant boards are
usually available in teacher supply stores. Therapro is a wonderful Web site
that sells slant boards, pencil grips, and interesting products to promote better
writing for youngsters. Visit their Web site at http://www.theraproducts.com.
Difficulties with spelling and the
mechanics of writing such as capitalization and punctuation will also require
a systematic, structured, and constantly rehearsed routine. Both the occupational
services that help remediate dysgraphia and the remediation of poor mechanics
of writing should take place two-to-three times a week and must be written into
an Individual Education Plan (an IEP).
Along with special services, an IEP
should list a number of accommodations or modifications to the scholastic demands
placed on a child with written expression difficulties. These are excerpted
from “The Educational Issues of Children With Bipolar Disorder”
on the Web site of the Juvenile Bipolar Research Foundation at http://www.jbrf.org/edu_forums/accomodations.html and are used with permission:
I. Writing Disabilities or
Dysgraphia
Symptom: Student
writes in a slow and effortful manner. The mechanics of writing such as capitalization,
using periods or commas and proper syntax, are haphazard and slow to appear.
Accommodations:
- Teach and encourage the student
to use a keyboard in class and to complete all assignments.
- Assign a scribe to write longer
or timed writing assignments.
- Allow student to tape record classes.
Do not penalize quality of note-taking or assume the student is not taking
it all in aurally.
- Provide paper copies of notes
to the student.
- Allow extra time for assignments.
- Assign a scribe for important
tests, or allow the student to give his answers orally.
- Do not penalize the student for
handwriting or spelling errors.
- Have the parents investigate voice
recognition software, such as “Dragon Naturally Speaking ” (also
available on http://www.dyslexic.com).
- Have the parent investigate the
QuickLink Pen. This is a hand-held electrical scanner that allows a student
to scan relevant sentences or paragraphs from books, newspapers and articles
and to transfer the information to a computer where the notes are printed
for the student, bypassing laborious note-taking. Available at http://www.donjohnston.com.
II. ATTENTIONAL AND ORGANIZATIONAL
DIFFICULTIES
Symptom: Student
has difficulty staying on task and paying attention for any length of time.
Student is very fidgety in the classroom.
Accommodations:
- Seat the student close to the
teacher where the teacher can get student’s attention.
- Schedule frequent breaks.
- Offer choices, such as going to
a study carrel in the library or to a quiet area outside the classroom.
- Assign a study-buddy (use the
phrase study-partner for an older student). The students can focus each other
and acquire strategies for learning from each other.
Symptom: The student
is disorganized and often misplaces needed books and materials. The student
often forgets to bring home assignments and/or fails to turn in work.
Accommodations:
- Use a “travel folder.”
This is a pocket portfolio that has necessary papers to complete on the left-hand
side (mark this “To Do”) and all completed homework is transferred
to the right-hand side (mark this “Completed”).
- Give the student a planner book
and have teacher check that daily assignments are recorded properly.
- Email or fax parents a list of
assignments and news of upcoming projects or tests.
- Have teacher or aide give the
student a prompt before leaving school: “What do I need to do tonight
and what materials would I need to accomplish it ? I need: my coat, my recorder,
my math book, my study sheet for French, my planner, my lunch box, my travel
folder (French sheet is there...).” The teacher or aide could photocopy
lists of materials and clothing and have student check items off as they are
put in the bag. Student must be taught to pack backpack to return to school
the same way with a prompt such as “What do I need for school today?”
(A parent has to help out here.)
- Provide a second set of textbooks
for the home work area.
- Teach the student to number assignments
in the order in which they should be done before beginning a homework session
(thus they will focus and begin a mode of strategy). Have the student start
with an assignment that is short and easy, but avoid saving the hardest or
longest assignment for last. Have the student estimate how much time it will
take to complete each assignment and measure the estimates against the actual
time (these students have difficulty with time management). Have them use
a stopwatch to assign chunks of time to each step of a study plan which will
help move them on to the next step.
- Teach the student to preview questions
at the end of each chapter to focus him or her on important concepts. The
student should also preview photos, captions, and headings throughout the
chapter before reading and when reviewing for a test.
- Color-code subject folders and
notebooks to match textbooks. For instance, if the math text is orange, place
an orange strip of tape on the math folder and notebook so that student can
quickly locate and assemble all materials needed for math. If school requires
the books to be covered, color coordinate the books and folders.
- If the student uses a locker,
teach him or her to place all morning text books, notebooks, and folders on
top shelf of locker, and all afternoon materials on lower or bottom shelf.
This will help organize the student and ensure that he or she goes to class
with the correct materials. Have the student (with the help of an assistant
if necessary) clean out locker at least once a week. Schedule that cleanup
on Fridays to ensure that P.E. clothes and needed materials arrive home for
weekend use.
One additional note: Children in
elementary school onward will be given city-and state-wide exams that use prompts
in the writing sections (the children are supposed to use the prompt as a jumping
off point and compose a narrative story that is interesting and rich in detail).
This is a major stumbling block for children with disorders of written expression.
While researching this newsletter, we came across a truly valuable book by Barbara
Mariconda called The Most Wonderful Writing Lessons Ever. It deconstructs
the entire process and helps children and adults understand the building blocks
that make up good narrative writing. Though the book is advertised for grades
2-4, it is used in high schools, and teachers and parents will find this book
particularly helpful.
In Conclusion
Because the writing process is so
integral to every subject in school, it is easy to see that a child struggling
with written expression will find the entire day torturous and humiliating.
In the late afternoon and evening—typically difficult times for children
with bipolar disorder—the child will feel especially burdened as he or
she anticipates the frustration, fatigue, and failure that will accompany any
homework assignments that require written work.
Children with bipolar disorder are
coping with so many other difficulties…. If parents and teachers watch
mindfully for any struggle in the area of written expression, and move quickly
to begin remediation and to institute accommodations, they can significantly
lessen that burden. Early and sympathetic intervention will make a tremendous
difference—in the early years, and in the vastly more complicated and
difficult years of middle school and high school.
We’ll write again soon. Meantime
we wish you and your families peaceful summer days, and, as always, we look
forward to hearing from you.
All best,
Janice Papolos and Demitri Papolos,
M.D.
The authors wish to thank Dr. Dana
Luck, and Karen Williams for their contributions to this newsletter.
Bibliography
Luck, Dana. Telephone Interview
of May 23, 2004.
Levine, Mel. A
Mind At A Time. New York: Simon & Schuster, 2002.
Papolos D. and J. The Bipolar
Child, Revised. New York: Broadway Books, 2002.
Web site of the Juvenile Bipolar
Research Foundation (http://www.jbrf.org).
Latest News: (New on the
JBRF Web site)
The Juvenile Bipolar Research Foundation
(JBRF) has been seeking families throughout the nation who have two or more
children diagnosed with early-onset bipolar disorder for an affected sib pair
genetic study. Since August of 2003, over 400 such sibling pairs have been identified
and the researchers are very grateful to all of the parents who have responded.
If you are a new subscriber to this newsletter, have two or more children diagnosed
with the disorder, and would like to know more about this study, please contact
Janice Papolos at jpapolos@jbrf.org for more information. To read an FAQ about this study, please visit JBRF’s
Web site at http://www.jbrf.org.
JBRF is launching a new program for
researchers and clinicians called the Expert
Diagnostic Workshop. This is an online colloquium whose intent is to foster
a consensus as to which symptoms and behaviors should define the diagnosis of
bipolar disorder in children. To read an FAQ explaining the importance and organization
of the EDW, please visit the JBRF Web site.
www.bipolarchild.com
