Relationship of cognitive function and adjustment difficulties among children and adolescents with dissociative disorder

Introduction

Dissociative disorder is a common childhood psychiatric disorder encountered in Indian clinical practice. Several epidemiological and clinical studies conducted in India have found that condition is very common with a prevalence rate as high as 31% among inpatients and 15% among outpatients.[1] The most common dissociative symptoms in India among children and adolescents are dissociative convulsions while motor weakness, amnesia, and aphonia are less commonly seen.[234]

Literature has shown a positive association between stressful life events and adjustment difficulties with subsequent dissociative symptoms.[56] Children with dissociative disorder seem to lack adequate strategy to deal with these stressors effectively.[78] The unresolved psychological conflict is then converted to physical symptoms which gain social acceptance and protect the child from conflict or painful memory.[9] Particularly, Indian culture discourages direct expression of emotional distress, and the physical symptoms are more common way of expression.[10] Stressors in children and adolescents with dissociative disorder may include day-to-day problems such as difficulties in school or family relationships, fights, scolding and punishment, some frightening experiences, educational difficulties, sibling rivalry, sexual abuse, and adjustment problem with peers.[1011121314] Children with dissociative disorder also seem to have temperament characteristics of low activity, low emotionality, low rhythmicity, low attentivity, and low threshold of responsiveness.[151617]

Although dissociation by definition affects cognition, very few studies have used neuropsychological measures to examine dissociative phenomena in children. Cognitive functioning has been reported as a major vulnerability factor in causing ineffective coping with stress.[18] Among cognitive factors, both above-average and below-average intelligence has been cited as a factor in the etiology of dissociative disorder.[12] Cromer et al.[19] had examined the attentional correlates of dissociation in childhood. Consistent with the adult literature, higher levels of childhood dissociation were associated with deficits in tasks requiring inhibition, but not with tasks requiring primarily planning.[19] Similar findings suggest that a failure to inhibit previous responses might contribute to the pathological memory manifestations of dissociation.[20] Other studies also suggest that individuals showing higher levels of dissociation had more executive difficulties, and greater deficiencies in tasks of memory for context-dependent verbal material and visuospatial working memory.[212223]

Though there are studies on identifiable psychosocial stressors and cognitive functioning among children and adolescents with dissociative disorder, no studies have attempted to know the relationship of cognitive functions with adjustment difficulties. Understanding the relationship of cognitive functions with adjustment difficulties may help in identifying key vulnerabilities and enabling focused intervention strategies for the varied profile of children with dissociative disorders. Thus, the present study was conducted to assess the cognitive functioning and adjustment difficulties among children and adolescents with dissociative disorder and to look for association between these domains.

Methods

Results

A total of 56 patients were offered participation, out of which completed assessments were available in 50 patients. Four patients and/or their parents declined to participate while two left the study before the assessments could be completed. The demographic and clinical characteristics of the included patients are shown in Table 1. The ratio of females to males in this population was 1.5. A majority of the children belonged to nuclear family from rural background and were irregular in going to school. Dissociative convulsion was the most common dissociative phenomenology observed, and 17 participants had more than one type of dissociative symptoms. Comorbid psychiatric diagnosis was present in 50% of the sample, with somatoform disorders being the most common psychiatric comorbidity observed (36% of the sample).

Table 1 Demographic characteristics (n=50)

The mean IQ of the sample was 90.6 as per MISIC, with 7 participants having IQ between 70 and 79 (borderline intelligence), 18 participants between 80 and 89 (dull average), 23 between 90 and 109 (average), and one each between 110–119 and 120–129, respectively (above average and superior). The verbal IQ was higher than performance IQ (94.1 ± 11.6 vs. 87.1 ± 10.8), but the difference was not significantly significant. The distribution of IQ scores across the various domains of MISIC is shown in Figure 1. The cognitive measures of the sample are shown in Table 2. The maximum difficulty was observed in verbal working memory (N-back 2) and sustained attention as 38% and 66% of the sample had abnormal scores for N-back 2 and color cancelation task.

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Figure 1

Malin's Intelligence Scale for Indian Children scores. Domain wise scores and full-scale scores. DF-DB: Digit forward digit backward, IQ: Intelligence quotient, MISIC: Malin's Intelligence Scale for Indian Children

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Table 2 Cognitive measures (n=50)

The adjustment difficulties in various domains were transformed into scores. The average adjustment difficulties score in the family domain was 22.9, school domain was 29.3, health domain was 33.1, and domain of self was 36.0. The correlation between various domains of adjustment and tests of cognition is depicted in Table 3. Lower IQ was associated with poor adjustment in school (Spearman r = −0.367, P = 0.020). Abnormal scores in MDT delayed recall was associated with poor adjustment in school (r = −0.369, P = 0.019) and overall adjustment (r = −0.325, P = 0.041). Finally, abnormality in sustained attention as per CCT was associated with poorer adjustment in health domains (r = 0.402, P = 0.010).

Table 3 Correlation of adjustment domains with cognitive functions (n=50)

Discussion

The present study explores the relationship of dissociative symptoms and cognitive functions in children and adolescents with dissociative disorders. The ratio of males to females was similar to literature from elsewhere,[16] reflecting greater number of girls suffer from dissociation as compared to boys. The most common phenomenon of dissociation observed was dissociative convulsions, which is again the most common form of dissociation in the region and this specific age group.[3410] Somatoform disorders were the most common comorbid disorders, suggesting that in many cases, psychological conflicts are dealt simultaneously through defenses of dissociation and somatization.

The study suggests that the mean IQ of the sample was below the population norms, with greater deficit in performance aspects of intelligence. Previous literature suggests that children with dissociation have poor cognitive ability which results in ineffective coping with stress.[12] The findings on the block design and object assembly tests imply that visuoconstructive and visual organization abilities are impaired. This suggests that ability for analysis, synthesis, gestalt perception, and reasoning ability are impaired. Poorer cognitive resources in these domains may translate into poor coping skills to handle demands of various stresses.

The present study suggests that children had comparatively greater difficulty in verbal working memory (N-back test) as compared to verbal retention and recall (RAVLT). This suggests that the participants found it difficult to inhibit previous response. This finding is similar to a previous study which suggests that a failure to inhibit previous responses might contribute to the pathological memory manifestations of dissociation.[20] It has also been seen that childhood dissociation was associated with deficits in tasks requiring inhibition but not with tasks requiring primarily planning and strategy.[19] A high proportion of children had scored abnormally in the color cancelation task involving selective attention. Previous studies suggest that dissociation was associated with lower sustained attention and varied between low and high dissociation.[22]

The present study suggests that greatest difficulties in adjustment were occurring in the domain of self. This suggests that personality factor has tremendous role in coping in these children in day to day life. Similar finding had been reported in different studies throughout review of literature.[151617] Lower IQ scores were significantly associated with the poor adjustment in school manifested in features such as poor academic performance and strained relationship with peers and teachers. Literature from elsewhere suggests that lower IQ has been associated with difficulties in adjustment to school environment.[2930] Poor visual learning and memory were associated with school maladjustment as well as overall adjustment difficulty. Possibly, visual memory holds special significance in planning and executing tasks, which would be quite helpful in efficient execution of day to day activities. Sustained attention abnormalities were associated with adjustment to the domain of health. This possibly could be attributed to exposure to health hazards among those who could not sustain attention. This exemplified by increased rates of falls and other minor injuries among children with attention deficit hyperkinetic disorder as compared to controls.[3132]

The findings of the study should be contextualized in terms of the strengths and limitations. The strength of the study includes assessing for the 1^st time the relationship of cognitive function and adjustment domains in children and adolescents with dissociative disorder. Various cognitive domains were assessed using standard methodology. The limitations of the study include recruitment of a sample of convenience from a tertiary care center. Limited sample size precluded assessment of influence of different moderator variables on the adjustment and cognitive functioning. The adjustment was assessed through self-report of the participants, and further attempts to validate the same through proxy measures were not utilized. The study represents cross-sectional assessment and cannot comment on the changes in the relationship of cognitive functioning and adjustment over a period.

Conclusion

The study suggests that cognitive impairments and associated adjustment difficulties should be addressed in children and adolescents with dissociative disorder. Appropriate and timely intervention addressing cognitive deficits and related identifiable adjustment difficulties may possibly change the outcome of dissociative children, by improving adjustment to psychosocial stressors. Further studies are required in larger and control matched sample to consolidate the results of the present study. Future studies may look into association between cognitive function and adjustment difficulties over time using a longitudinal design so that natural evolution of the symptoms of dissociation in the context of interplay of cognition and stress can be clearly elucidated.