Neurobehavioral comorbidities in children with active epilepsy: a population-based study

Learning difficulties in Japanese schoolchildren with focal epilepsy

BACKGROUND

Children with epilepsy often show some degree of cognitive impairment. In this study, we investigated their learning skills to clarify the characteristics of the difficulties related to learning in Japanese-speaking children with focal epilepsy.

METHODS

The study included 13 boys and 17 girls of mean age 9.7 years (standard deviation 2.61; range 6-14 years) with focal epilepsy and a normal magnetic resonance brain scan. None of the patients had any other neurological disorder.

RESULTS

Twenty-two children had "learning difficulties", i.e., an intellectual disability or low scores on a learning abilities task. Significant differences were found in age (P = 0.030), age at onset of epilepsy (P = 0.033), and electroencephalographic findings, as well as between bilateral vs. unilateral (P = 0.028) and right-localized vs. left-localized or bilateral (P = 0.014) involvement between subjects with and without learning difficulties. Seven (88%) of eight children with low scores on a learning abilities task showed abnormalities in reading speed.

DISCUSSION

More than half of Japanese-speaking children with focal epilepsy need learning assistance. This finding points to a need for learning support in children with focal epilepsy regardless of language. Measurement of reading speed is useful in children with learning difficulties to identify those who require early intervention.

Screening for functional gastrointestinal disorders in children with epilepsy

BACKGROUND AND AIM

We aimed to examine the frequency of functional gastrointestinal disorders (FGIDs) among pediatric patients with epilepsy and the association of FGIDs with epilepsy characteristics.

MATERIAL AND METHODS

Patients with epilepsy aged between 4 and 18 years old were enrolled. Age- and sex-matched healthy children were taken as the control group. Children with cerebral palsy, history of abdominal surgery, gastrointestinal disorders, medication affecting gastrointestinal system motility, recent gastrointestinal infection, and those on the ketogenic diet were excluded from the study. Rome IV symptom-based criteria were used to screen FGIDs. Frequencies of FGIDs were compared between patients with epilepsy and controls. Additionally, epilepsy type, seizure frequency, and antiepileptic drug (AED) requirements were also compared between patients with and without FGIDs.

RESULTS

During the study period, 78 children [41 girls, age between 4 and 17 years, mean ± standard deviation (SD): 11.5 ± 4.3 years] with epilepsy were included in the study. The mean age at epilepsy onset was 7.8 ± 3.7 years, and mean disease duration was 5.1 ± 3.9 years. The most common epilepsy type was focal (74.3%), followed by generalized (25.7%). There was at least one of the FGIDs in 26 children in the patient group and 15 children in the control group (33.3% vs. 19.2%, p < 0.001). The most common FGID in the patient group was irritable bowel syndrome (IBS), which was significantly higher than the control group. While aerophagia and rumination syndrome were not seen in either group, cyclic vomiting syndrome was seen only in the patient group. When the patients with and without FGIDs were compared, there was no difference between the groups in terms of epilepsy type, frequency of seizure, type, and the number of drugs used.

CONCLUSIONS

We found that children with epilepsy have a higher prevalence of FGIDs when compared with age- and sex-matched healthy controls. Our results suggest that children with epilepsy, especially complaining of gastrointestinal symptoms, should be screened for FGIDs.

Self-reported quality of life and degree of youth-parent agreement: A long-term follow-up of childhood-onset epilepsy

OBJECTIVE

To prospectively delineate self-reported health-related quality of life (HRQOL) of adolescents and young adults (AYAs) 8 and 10 years after an epilepsy diagnosis and evaluate the degree of AYA-parent agreement in ratings of AYA's HRQOL.

METHODS

Data came from the Health-Related Quality of Life in Children with Epilepsy Study (HERQULES), a 10-year longitudinal study of children, aged 4-12 years, with newly diagnosed epilepsy. Epilepsy-specific HRQOL was self-reported by AYA 8 and 10 years after diagnosis and by parents at multiple time points throughout the 10-year follow-up. Measurers of HRQOL over time were analyzed using a linear mixed-effect model approach. AYA-parent agreement was evaluated using intraclass correlation coefficient (ICC) and Bland-Altman plots.

RESULTS

A total of 165 AYAs participated at long-term follow-up. There was considerable heterogeneity among AYA's HRQOL, and as a group, there was no significant change in HRQOL from the 8- to 10-year follow-up. Household income at the time of diagnosis, seizure control at follow-up, and a history of emotional problems (anxiety/depression) were independent predictors of HRQOL at follow-up. AYA-parent agreement on AYA's HRQOL was moderate (ICC 0.62, 95% CI 0.51-0.71), although considerable differences were observed at the individual level. AYA-parent agreement varied with AYA's and parent's age, seizure control, and family environment.

SIGNIFICANCE

In the long-term after a diagnosis of epilepsy, AYAs report stable HRQOL over time at the group level, although notable individual differences exist. Seizure control, anxiety/depression, and family environment meaningfully impact AYA's long-term HRQOL. AYA and parent reports on HRQOL are similar at the group level, although they cannot be used interchangeably, given the large individual differences observed.

A conundrum of West syndrome, behavioural problems and parental expressed emotions: a case report

West syndrome (WS) is the most common epileptic syndrome in infancy characterised by epileptic spasms, hypsarrhythmia and neurodevelopmental problems. Epileptic spasms remain in many ways a conundrum, and the ideal intervention, as well as how to screen patients to provide optimal care and certainly its genetic cause, remains puzzling. It is important to screen infants for early recognition and intervention to achieve the optimal outcome. We hereby discuss the approach to management of a boy aged 4½ years old with WS and behavioural problems and of parental expressed emotions.

Subcortical nuclei volumes are associated with cognition in children post-convulsive status epilepticus: Results at nine years follow-up

PURPOSE

The purpose of the present study was to investigate the relationship between subcortical nuclei volume and cognition in children with post-convulsive status epilepticus (CSE).

METHODS

Structural T1-weighted magnetic resonance imaging (MRI) scans (Siemens Avanto, 1.5 T) and neuropsychological assessments (full-scale intelligence quotient (FSIQ) and Global Memory Scores (GMS)) were collected from subjects at a mean 8.5 years post-CSE (prolonged febrile seizures (PFS), n = 30; symptomatic/known, n = 28; and other, n = 12) and from age- and sex-matched healthy controls (HC). Subjects with CSE were stratified into those with lower cognitive ability (LCA) (CSE+, n = 22) and those without (CSE-, n = 48). Quantitative volumetric analysis using Functional MRI of the Brain Software Library (FSL) (Analysis Group, FMRIB, Oxford) provided segmented MRI brain volumes. Univariate analysis of covariance (ANCOVA) was performed to compare subcortical nuclei volumes across subgroups. Multivariable linear regression was performed for each subcortical structure and for total subcortical volume (SCV) to identify significant predictors of LCA (FSIQ <85) while adjusting for etiology, age, socioeconomic status, sex, CSE duration, and intracranial volume (ICV); Bonferroni correction was applied for the analysis of individual subcortical nuclei.

RESULTS

Seventy subjects (11.8 ± 3.4 standard deviation (SD) years; 34 males) and 72 controls (12.1 ± 3.0SD years; 29 males) underwent analysis. Significantly smaller volumes of the left thalamus, left caudate, right caudate, and SCV were found in subjects with CSE+ compared with HC, after adjustment for intracranial, gray matter (GM), or cortical/cerebellar volume. When compared with subjects with CSE-, subjects with CSE+ also had smaller volumes of the left thalamus, left pallidum, right pallidum, and SCV. Individual subcortical nuclei were not associated, but SCV was associated with FSIQ (p = 0.005) and GMS (p = 0.014). Intracranial volume and etiology were similarly predictive.

CONCLUSIONS

Nine years post-CSE, SCV is significantly lower in children who have LCA compared with those that do not. However, in this cohort, we are unable to determine whether the relationship is independent of ICV or etiology. Future, larger scale studies may help tease this out.

An Overview of Anxiety Disorders and Depression in Children with Epilepsy: A Literature Review

Comorbid psychiatric disorders in children with epilepsy have long been a subject of medical literature. Many studies conducted by pediatric neurologists, neurosurgeons, psychiatrists, and psychologists have revealed that psychiatric disorders, including anxiety disorders and depression, are frequently seen in children and adolescents with epilepsy. Due to various etiologies behind epilepsy, causes, manifestation, and treatment of anxiety and depression all have unique aspects. We think there are multiple reasons behind anxiety disorders and depression in children with epilepsy, varying from the physiological nature of the epilepsy itself to the environmental factors such as family, parenting, and social status. In this article, we aim to review the causes, risk factors, and management of anxiety disorders and depression in children with epilepsy.

Double stigma in mental health: epilepsy and mental illness

BACKGROUND

Epilepsy and mental illness share similar problems in terms of stigma, as a result of centuries of superstition, ignorance and misbeliefs. Stigma leads not only to discrimination and civil and human rights violations but also to poor access to healthcare and non-adherence or decreased adherence to treatment, ultimately increasing morbidity and mortality. Despite continuous efforts in fighting stigma in these conditions, there is very limited knowledge on the phenomenon of double stigma, meaning the impact of having two stigmatised conditions at the same time.

AIMS

To discuss double stigma in mental health with special reference to epilepsy.

METHOD

Articles were identified through searches in PubMed up to 31 October 2019 using the search terms 'epilepsy', 'psychiatric disorders', 'stigma' and additional material was identified from the authors' own files and from chosen bibliographies.

RESULTS

Double stigma is gaining attention for other stigmatised medical conditions, such as HIV, however, the literature on epilepsy is almost non-existent and this is quite astonishing given that one in three people with epilepsy have a lifetime diagnosis of a psychiatric condition. Felt (perceived) stigma and psychiatric disorders, particularly depression, create a vicious circle in epilepsy maintaining both, as depression correlates with stigma and vice versa as well as epilepsy and depression serving as bidirectional risk factors. This phenomenon has no geographical and economic boundaries as similar data have been reported for low-income and high-income countries.

CONCLUSIONS

Governments and policymakers as well as health services, patients' organisations, families and the general public need to be aware of the phenomenon of double stigma in order to develop campaigns and interventions tailored for these patients.

Intravenous dexmedetomidine sedation for magnetoencephalography: A retrospective study

BACKGROUND

Magnetoencephalography (MEG) plays a preponderant role in the preoperative assessment of patients with drug-resistant epilepsy (DRE). However, the magnetoencephalography of patients with drug-resistant epilepsy can be difficult without sedation and/or general anesthesia. Our objective is to describe our experience with intravenous dexmedetomidine as sedation for magnetoencephalography and its effect, if any, on the ability to recognize epileptic spikes.

METHODS

In this retrospective study, we reviewed the records of 89 children who presented for Magnetoencephalography/electroencephalography (EEG) scans between August of 2008 and May of 2015. Data analyzed included demographics and the frequency of epileptic spikes. Sedated magnetoencephalography recordings were compared to nonsedated video-electroencephalography (vEEG) recordings in the same patients to determine the impact of dexmedetomidine.

RESULTS

Spike frequency between magnetoencephalography with sedation and video-electroencephalography without sedation was compared in 85 patients. Magnetoencephalography and video-electroencephalography were considered clinically concordant in 80 patients (94.1%) and discordant in 5 patients (5.9%), all with less spikes during Magnetoencephalography. The median (range) bolus dose of dexmedetomidine was 2 (1-2) mcg/kg. The median (range) infusion rate of dexmedetomidine was 2 (0.5-4) mcg/kg/h. All patients experienced reductions in heart rate after administration of dexmedetomidine; these reductions were statistically, but not clinically, significant.

CONCLUSIONS

Our results suggest that dexmedetomidine-based protocol provides reliable sedation in children undergoing MEG scanning because of the high success rate, limited interictal artifacts, and minimal impacts on spike frequency.

Behavioral phenotypes of childhood idiopathic epilepsies

OBJECTIVE

To characterize the presence and nature of discrete behavioral phenotypes and their correlates in a cohort of youth with new and recent onset focal and generalized epilepsies.

METHODS

The parents of 290 youth (age = 8-18 years) with epilepsy (n = 183) and typically developing participants (n = 107) completed the Child Behavior Checklist for children aged 6-18 from the Achenbach System of Empirically Based Assessment. The eight behavior problem scales were subjected to hierarchical clustering analytics to identify behavioral subgroups. To characterize the external validity and co-occurring comorbidities of the identified subgroups, we examined demographic features (age, gender, handedness), cognition (language, perception, attention, executive function, speed), academic problems (present/absent), clinical epilepsy characteristics (epilepsy syndrome, medications), familial factors (parental intelligence quotient, education, employment), neuroimaging features (cortical thickness), parent-observed day-to-day executive function, and number of lifetime-to-date Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) diagnoses.

RESULTS

Hierarchical clustering identified three behavioral phenotypes, which included no behavioral complications (Cluster 1, 67% of epilepsy cohort [n = 122]), nonexternalizing problems (Cluster 2, 11% of cohort [n = 21]), and combined internalizing and externalizing problems (Cluster 3, 22% of cohort [n = 40]). These behavioral phenotypes were characterized by orderly differences in personal characteristics, neuropsychological status, history of academic problems, parental status, cortical thickness, daily executive function, and number of lifetime-to-date DSM-IV diagnoses. Cluster 1 was most similar to controls across most metrics, whereas Cluster 3 was the most abnormal compared to controls. Epilepsy syndrome was not a predictor of cluster membership.

SIGNIFICANCE

Youth with new and recent onset epilepsy fall into three distinct behavioral phenotypes associated with a variety of co-occurring features and comorbidities. This approach identifies important phenotypes of behavior problem presentations and their accompanying factors that serve to advance clinical and theoretical understanding of the behavioral complications of children with epilepsy and the complex conditions with which they co-occur.

Trajectories of quality of life 10 years following a diagnosis of epilepsy in childhood

OBJECTIVE

This study estimated trajectories of health-related quality of life (HRQOL) over a 10-year period among children newly diagnosed with epilepsy. We also modeled the characteristics of children, parents, and families associated with each identified trajectory.

METHODS

Data came from the HERQULES (Health-Related Quality of Life in Children With Epilepsy Study), a Canada-wide prospective cohort study of children (aged 4-12 years) with newly diagnosed epilepsy. Parents reported on their children's HRQOL at diagnosis, and at 0.5-, 1-, 2-, 8-, and 10-year follow-ups using the Quality of Life in Childhood Epilepsy Questionnaire-55. Trajectories of HRQOL were identified using latent class growth models. Characteristics of children, parents, and families at the time of diagnosis that were associated with each trajectory were identified using multinomial logistic regression.

RESULTS

A total of 367 children were included. Four unique HRQOL trajectories were identified; 11% of the cohort was characterized by low and stable scores, 18% by intermediate and stable scores, 35% by intermediate scores that increased then plateaued, and 43% by high scores that increased then plateaued. Absence of comorbidities, less severe epilepsy, and better family environment (greater satisfaction with family relationships and fewer family demands) at the time of diagnosis were associated with better long-term HRQOL trajectories. Although the analyses used estimates for missing values and accounted for any nonrandom attrition, the proportion of children with poorer HRQOL trajectories may be underestimated.

SIGNIFICANCE

Children with new onset epilepsy are heterogenous and follow unique HRQOL trajectories over the long term. Overall, HRQOL improves for the majority in the first 2 years after diagnosis, with these improvements sustained over the long term.

Optimising Evidence-Based Psychological Treatment for the Mental Health Needs of Children with Epilepsy: Principles and Methods

There are potent evidence-based psychological treatments for youth with mental health needs, yet they are rarely implemented in clinical practice, especially for youth with mental health disorders in the context of chronic physical illness such as epilepsy. Implementation science, the study of the translation of research into practice, can promote the uptake of existing effective interventions in routine clinical practice and aid the sustainable integration of psychological treatments with routine health care. The aim of this report was to use four implementation science methods to develop a version of an existing effective psychological treatment for mental health disorders [the Modular Approach to Treatment of Children with Anxiety, Depression or Conduct Problems (MATCH-ADTC)] for use within paediatric epilepsy services: (a) literature search; (b) iterative focus groups underpinned by normalisation process theory; (c) Plan-Do-Study-Act methods; and (d) qualitative patient interviews. Findings: Three modifications were deemed necessary to facilitate implementation in children with both mental health disorders and epilepsy. These were (a) a universal brief psychoeducational component addressing the relationship between epilepsy and mental health; (b) supplementary, conditionally activated interventions addressing stigma, parental mental health and the transition to adulthood; and (c) additional training and supervision. The intervention needed relatively little alteration for implementation in paediatric epilepsy services. The modified treatment reflected the scientific literature and the views of clinicians and service users. The multi-method approach used in this report can serve as a model for implementation of evidence-based psychological treatments for children with mental health needs in the context of other chronic illnesses.

Psychiatric Comorbidities in People With Epilepsy

Purpose of Review

To review the latest evidence concerning the epidemiology, clinical implications, and management of psychiatric disorders in epilepsy.

Recent Findings

People with epilepsy have a 2-5 times increased risk of developing any psychiatric disorder, and 1 in 3 patients with epilepsy have a lifetime psychiatric diagnosis. Psychiatric comorbidities represent a poor prognostic marker as they have been associated with a poor response to treatment (drugs and surgery), increased morbidity, and mortality. Validated screening instruments are available for mood and anxiety disorders in adults as well as attention-deficit hyperactivity disorder in children with epilepsy.

Summary

All patients with epilepsy should be routinely screened for psychiatric disorder at the onset and at least once a year. Patients with epilepsy and their relatives should be informed of the risk of mental health problems and the implications.

Cognitive functioning in a representative cohort of preschool children with febrile seizures

AIM

To analyse cognitive functioning in 4-5-year-old children who had experienced febrile seizures (FS) and to assess the importance of complex, recurrent and early vs late onset FS.

METHODS

The sample consisted of 73 children, screen positive for FS, drawn from the general child population of 4-year-old children attending their health check-up at child healthcare centres in Gothenburg, Sweden. They were assessed as regards general cognitive ability, visual memory and attention and were contrasted with age norms and with results obtained in 20 children without FS from the same healthcare centres.

RESULTS

Of the 73 children, two had a previously diagnosed intellectual disability (ID) (one mild, one moderate) and two further children tested within the study had results corresponding to mild ID. Children with early onset of FS (before age 12 months)-who often had recurrent FS-had lower full-scale, verbal and processing speed IQ than those who had later onset of FS.

CONCLUSION

Children with early onset of FS and particularly those with recurrent FS may be at increased risk for poorer verbal and processing speed functioning and therefore at risk of developing cognitive, executive dysfunctions. They would probably benefit from neuropaediatric and neuropsychological follow-up.

Psychosocial and functional outcomes in young adults with childhood-onset epilepsy: a 10-year follow-up

AIM

To compare long-term psychosocial and functional outcomes of young adults with uncomplicated childhood-onset epilepsy (COE) to population norm controls utilizing a controlled prospective cohort study.

METHOD

Psychosocial and functional outcomes were assessed at 10-year follow-up. Fifty-three young adults (27 males, 26 females) with COE (n=21 remission; 18y 1mo-30y 9mo; mean age 23y 4mo [SD 3y 4mo]; mean age of epilepsy onset 12y [SD 3y 2mo]) were compared to 55 (23 males, 32 females) first-degree cousin controls (18y 5mo-29y 8mo; mean age 23y 6mo [SD 3y]). Seizure remission status and baseline comorbidities (attention-deficit/hyperactivity disorder [ADHD], depressive disorders, anxiety disorders, and academic problems) were examined as possible risk factors for significant differences in functional outcomes.

RESULTS

Poorer functional outcomes, indicated by patient rated cognition and overall disability, were evident among young adults with epilepsy compared to controls (all p<0.05). These difficulties were due to baseline comorbid ADHD and academic problems. Remission status was not related to measured cognition and overall disability.

INTERPRETATION

Psychosocial outcomes of young adults with COE were similar to controls. In contrast, functional outcomes were worse in epilepsy across cognition and overall disability. Baseline comorbid ADHD and academic problems were identified as risk factors at 10-year follow-up suggesting that these early recognized comorbidities at or near diagnosis have long-term impacts.

WHAT THIS PAPER ADDS

Young adults with childhood-onset epilepsy (COE) and controls have similar psychosocial outcomes 10 years after diagnosis. Young adults with COE report greater limitations in cognition and overall disability than controls. Baseline presence of attention-deficit/hyperactivity disorder and academic problems significantly affect cognitive and overall disability scores.

Impact of epilepsy training on school teachers and counselors: An intervention study in Lebanon

This study aimed to evaluate the immediate impact of an epilepsy training through the administration of a questionnaire (in Arabic) before and immediately after the intervention in Lebanese public and private schools. This project is part of an awareness campaign applied to 3 groups of teachers and counselors and consisted of a pretest, a unified conference and a posttest. The statistical analysis used the McNemar and Stuart Maxwell tests (statistical significance level of 0.05). 73 participants completed the questionnaires. The majority were female (68.5%), aged less than 39 years (57%) and familiar with epilepsy. A positive impact of the training was found regarding the effect of epilepsy on schooling, seizures manifestations, psychological effects, seizure first aid and the possibility of curing epilepsy with surgery. Most of our participants recognized that children with epilepsy have a comparable IQ to others. They did not exhibit a discriminatory attitude against people with epilepsy in terms of the direct attitude towards them, employment or marriage. This is one of few studies done worldwide demonstrating an immediate positive effect of epilepsy training among school teachers. Future research should be undertaken to develop robust training models to destigmatize epilepsy.

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An epilepsy training in Lebanese schools had an immediate positive impact.

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In total 73 teachers and counselors completed the pre and posttest questionnaires.

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Participants didn't exhibit a discriminatory attitude against people with epilepsy.

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Participants recognized that children with epilepsy have a comparable IQ to others.

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Training improved awareness on seizure first aid and epilepsy cure by surgery.

Neuropsychological group rehabilitation on neurobehavioral comorbidities in children with epilepsy

Neurobehavioral comorbidities, particularly attention-deficits, are common in children with epilepsy (CWE). Neurobehavioral problems are manifested in school performance, peer relations, and social competence. Although the high prevalence of these comorbid behavioral problems is fully recognized, there remains to be a lack of studies on the interventions targeted for CWE. A manualized neuropsychological group intervention, Rehabilitation of EXecutive Function and ATtention (EXAT) has been developed for school-aged children (aged 6-12 years) with executive function (EF) and attention-deficits. This study aimed to explore the effects of EXAT on parent- and teacher-rated attention and behavior problems in CWE compared with children with the diagnosis of attention-deficit hyperactivity disorder (ADHD) and children with no formal diagnosis but prominent deficits in EF and attention. Forty-two children attending in neuropsychological group rehabilitation EXAT between the years 2006 and 2017 participated in this retrospective registry study. The CWE group consisted of 11 children, the ADHD group with 16 children, and EF/attention group consisted of 15 children with EF attention and/or problems without diagnosis of ADHD. The CWE group did not differ from the other two study groups (ADHD and no formal diagnosis) before the EXAT intervention. This indicates that attention problems in CWE are similar to those with diagnosed ADHD. The results were promising for applying structured multilevel intervention for CWE and neurobehavioral comorbidities. Lack of group differences between the groups participating EXAT suggests similar intervention effects between CWE, ADHD, and those with less severe EF and attention problems. In parent ratings, intervention effects were higher in hyperactivity and oppositional behavior for children with attention problems and without epilepsy. Parents in the CWE group reported no effects except for one subscale related to hyperactivity. However, teachers reported consistently positive intervention effects for both inattention and hyperactivity-impulsivity along with anxiety and emotional lability. The results suggest that neurobehavioral comorbidities in CWE could be targeted in neuropsychological group intervention. In conclusion, CWE seem to benefit from interventions and behavior modification techniques first developed for children with ADHD.

Epigenome-wide association study of seizures in childhood and adolescence

The occurrence of seizures in childhood is often associated with neurodevelopmental impairments and school underachievement. Common genetic variants associated with epilepsy have been identified and epigenetic mechanisms have also been suggested to play a role. In this study, we analyzed the association of genome-wide blood DNA methylation with the occurrence of seizures in ~ 800 children from the Avon Longitudinal Study of Parents and Children, UK, at birth (cord blood), during childhood, and adolescence (peripheral blood). We also analyzed the association between the lifetime occurrence of any seizures before age 13 with blood DNA methylation levels. We sought replication of the findings in the Generation R Study and explored causality using Mendelian randomization, i.e., using genetic variants as proxies. The results showed five CpG sites which were associated cross-sectionally with seizures either in childhood or adolescence (1-5% absolute methylation difference at p_FDR < 0.05), although the evidence of replication in an independent study was weak. One of these sites was located in the BDNF gene, which is highly expressed in the brain, and showed high correspondence with brain methylation levels. The Mendelian randomization analyses suggested that seizures might be causal for changes in methylation rather than vice-versa. In conclusion, we show a suggestive link between seizures and blood DNA methylation while at the same time exploring the limitations of conducting such study.

Epilepsy

Epilepsy is considered a disease characterized by an underlying predisposition to seizures as well as neurobiologic, cognitive, psychologic, and social consequences. It is the most frequent chronic neurologic condition of childhood, affecting 0.5%-1% of children worldwide. It comprises a variety of disorders with many different etiologies, consequently affecting management and outcome. Although the great majority of children have epilepsies that are self-limited and have a good prognosis, it is nevertheless very well recognized that epileptic activity (be it seizures or interictal discharges) can be particularly deleterious to the developing brain acting as a disruptor to normal developmental function. Indeed, epilepsy and neurocognitive and behavioral disorders very frequently coexist, and it can be challenging to understand if there is causality or if they are all the reflection of the underlying brain disorder. Hence, accurate phenotypic and etiologic diagnosis is of utmost importance as it will not only guide decision making with regard to choice of treatment but also enable management of expectations concerning outcome. The current chapter aims to provide a general overview of the fast evolving and vast field of childhood epilepsy from its definition and epidemiology, to its diagnostic challenges, management, and outcome.

Cognition, Behavior, and Psychosocial Effects of Seizures in the Developing Brain

Epilepsy, a complex neurological disorder of recurrent seizures, is associated with significant impacts on the developing brain. Patients commonly face multiple comorbidities, including debilitating effects on cognition, behavior, and psychiatric outcomes. These conditions can be a source of great distress for patients that may even be greater than the burden of epilepsy itself. Here we investigate the relationship between seizures and the development of these comorbidities, specifically cognition, memory, learning, behavior, and psychiatric disorders. We first delineate the current research methodology in clinical and basic science that is employed to study the impact of epilepsy and seizures. We then explore neurobiological mechanisms underlying the development of seizures and cognitive and behavioral outcomes. Potential avenues of intervention to best support individuals and optimize their neurodevelopmental progress are also highlighted.

Factors for cognitive impairment in adult epileptic patients

OBJECTIVE

To analyze factors for cognitive impairment in epileptic patients.

METHODS

A total of 257 epileptic patients completed clinical memory scale (CMS) and 70 of them were further surveyed with mini-mental state examination (MMSE), Montreal cognitive assessment (MoCA), digital symbol test (DSy), verbal fluency test, digit span test (DSp), Hamilton anxiety scale (HAMA) and Hamilton depression scale (HAMD). Monadic linear related analysis and multiple stepwise regression analysis were performed to evaluate the potential factors for cognitive impairment.

RESULTS

Educational level was correlated with scores of cognitive tests (p < .01), with a difference between the junior high school group and senior high school group (p < .01 or p < .05). Seizure frequency was negatively correlated with CMS scores (p < .01), with a difference between the group with a seizure frequency of less than once a year and other groups (p < .01). The kind of antiepileptic drugs (AEDs) was negatively correlated with CMS scores (p < .01), with a difference between the single-drug group and the group taking more than two kinds of AEDs (p < .01). Depression scores were negatively correlated with MMSE, MoCA, DSy, DSp (p < .01 or p < .05), disease duration negatively with DSy (p < .01), and age negatively with MoCA (p < .05). Seizure type was correlated with DSy, and general seizure fared worse in the tests than other seizure types (p < .05).

CONCLUSION

Educational level, seizure frequency, kinds of AEDs and depression can affect the cognitive function of epileptic patients. High educational level, good seizure control, single-drug treatment and healthy psychological state are protective factors for cognitive function of epileptic patients.

Attention-deficit hyperactivity disorder in adults with epilepsy

PURPOSE

We investigated the prevalence of attention-deficit hyperactivity disorder (ADHD) in adult people with epilepsy (PWE). We hypothesized that ADHD is common among adult PWE and, some clinical factors may be associated with ADHD.

METHODS

In this cross-sectional study, 200 adult PWE referred to our neurology clinic at Shiraz, Iran were recruited (consecutively sampled). Validated Persian versions of Adult ADHD Self-Report Scale (ASRS v1.1) and Addenbrooke's Cognitive Examination-Revised (ACE-R) tests were used. We performed univariate analyses and also a logistic regression analysis.

RESULTS

Eighty-two patients (41%) were male, and 118 (59%) were female. Seventy patients (35%) had a positive screen for ADHD. There was a significant association between cognitive function and the prevalence of positive screening for ADHD in the whole group; 19 (18%) of the patients with a normal cognition, 23 (42%) of those with mild impairment, and 28 (70%) of those with severe cognitive impairment screened positive for ADHD (p = 0.0001). One hundred and five patients had normal cognition and were studied separately. Nineteen patients (18%) had screened positive for ADHD. Attention-deficit hyperactivity disorder was not associated with any of the tested variables in these patients.

CONCLUSION

About one-fifth of adults with epilepsy and normal cognitive function may have a positive screen for ADHD. Routine screening of all PWE for early detection and appropriate management of ADHD would be a reasonable approach.

Current behavioral health and cognitive screening practices in pediatric epilepsy

PURPOSE

Initiatives such as the Epilepsy Learning Healthcare System continue to advocate for standardized care and shared outcome data. Therefore, the current project aim was to gather information from epilepsy healthcare professionals, behavioral health professionals in particular, regarding their behavioral health and cognitive screening practices in pediatric patients with epilepsy. Information obtained will be used to assist in the development of new educational programs and platforms in the American Epilepsy Society (AES) and to inform the development of guidelines for behavioral healthcare of patients with pediatric epilepsy.

SURVEY INFORMATION

Twenty-five AES members representing 25 unique epilepsy programs across the United States participated in the survey. Findings are described in terms of three focus areas: (1) Systems, (2) Assessment, and (3) Intervention. Over 80% of respondents surveyed reported that they do conduct formal screenings, most commonly to determine if further evaluation is indicated (81%), inform treatment decisions (57.1%), and for developmental surveillance (33.3%). Assessment methods were fairly evenly split between nonstandardized informal questions (50%) and evidence-based broadband measures, with the Behavior Assessment System for Children (BASC), 2nd or 3rd Editions (40%) most commonly used. If behavioral health concerns are identified, referrals are often made for psychotherapy (48% in-house; 80% community-based), psychiatry (68% in-house; 48% community-based), and cognitive testing (88% neuropsychological testing; 36% for psychoeducational testing). Thirty-two percent refer for psychotropic medication management.

CONCLUSION

According to this survey, a number of epilepsy centers and clinics incorporate behavioral health screening; however, there is significant variability in assessments/measures used, who is administering them, and their purpose in the trajectory of treatment. These findings emphasize the need for standardization across centers in order to most effectively provide comprehensive care for youth with epilepsy.

Assessing feasibility of routine identification tools for mental health disorder in neurology clinics

OBJECTIVE

We aimed to test the feasibility of using an online parent-completed diagnostic assessment for detecting common mental health disorders in children attending neurology clinics. The assessment does not require intervention by a mental health professional or additional time in the clinic appointment.

SETTING

Two parallel and related screening studies were undertaken: Study 1: Tertiary paediatric neurology clinics. Study 2: Secondary and tertiary paediatric neurology clinics.

PATIENTS

Study 1: 406 Young people aged 7-18 attending paediatric neurology clinics. Study 2: 225 Young people aged 3-18 attending paediatric epilepsy clinics.

INTERVENTIONS

Parents completed online versions of the Strengths and Difficulties Questionnaire (SDQ) and Development and Well-being Assessment (DAWBA).

MAIN OUTCOME MEASURES

We investigated: the willingness of families to complete the measures, proportion identified as having mental health disorders, time taken to complete the measures and acceptability to families and clinicians.

RESULTS

The mean total difficulties score of those that had completed the SDQ fell in the 'high' and 'very high' ranges. 60% and 70% of the DAWBAS completed met criteria for at least one DSM-IV disorder in study 1 and 2 respectively. 98% of the parents reported that the screening methods used were acceptable.

The psychopharmacology of epilepsy

Epilepsy affects 1% of the world's population and is defined as two or more unprovoked seizures. Psychiatric conditions (depression, psychosis, anxiety, and attention deficit hyperactivity disorder (ADHD)) may coexist and are linked to negative seizure outcomes and poorer quality of life. There is an increasing body of evidence to suggest a bidirectional relationship between epilepsy and psychiatric disorders, which may imply shared pathophysiologic mechanisms. Extensive research has examined neurobiologic and neuroanatomic substrates for this association revealing some interesting similarities. Psychiatric disorders in people with epilepsy often go underdiagnosed and undertreated, due to fears of exacerbating psychiatric symptoms or provoking seizures, which may cause delays in optimal management. This chapter covers psychiatric conditions in epilepsy largely focusing on depressive disorders and psychotic disorders. Anxiety and ADHD in association with epilepsy are also discussed. Epidemiology, pathophysiologic mechanisms, and pharmacotherapies used to treat epilepsy and psychiatric disorders are also covered.

Parent reported health related quality of life (HRQoL) and behaviour in young people with epilepsy before and two years after epilepsy surgery

PURPOSE

The aim of this study was to compare parent-reported Health Related Quality of Life (HRQoL) and behaviour of young people before (baseline) and two years after paediatric epilepsy surgery (follow-up).

METHODS

The parents of 107 children who underwent epilepsy surgery completed surveys focussing on different aspects of child HRQoL and behaviour at baseline and follow-up. Parents of children with multiple disabilities (n = 27) completed five additional questions focussing on child HRQoL. Changes in scores between baseline and follow-up were compared using Wilcoxon signed-rank tests. Factors associated with changes in scores were analyzed using linear regression.

RESULTS

HRQoL and behaviour were significantly improved at follow-up (p < 0.001). HRQoL was also significantly improved for children with multiple disabilities (p = 0.003). Factors independently associated with improvement in HRQoL on multivariable analysis were lower baseline scores (p < 0.001), seizure-free status (p < 0.001) and improvement in behaviour (p = 0.022). Factors independently associated with improvement in behaviour were higher baseline difficulties (p < 0.001), reduction in antiepileptic drug (AED) usage, (p < 0.001), seizure-free status (p = 0.04), younger age (p = 0.03), and improvements in HRQoL (p = 0.028).

CONCLUSION

Parent rated HRQoL and behaviour had improved two years after epilepsy surgery. Seizure freedom was associated with both improvements in HRQoL and behaviour. Additionally, a reduction in AED usage contributed to reduced behavioural difficulties. All children undergoing epilepsy surgery should undergo assessment of HRQoL and behaviour at baseline and follow-up.

One-third of school-aged children with cerebral palsy have neuropsychiatric impairments in a population-based study

AIM

To describe motor function and associated impairments, particularly autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD), in school-aged children with cerebral palsy (CP).

METHODS

Population-based study of all children with CP born 1999-2006 from the county of Västra Götaland, Sweden; 264 children (141 males, 123 females). Information was obtained from the CP Register of western Sweden (data collected at 4-8 years of age) and all medical records at 10-17 years of age.

RESULTS

Cerebral palsy was spastic in 76%, dyskinetic in 17% and ataxic in 7% of all children. Sixty-three per cent were independent walkers. Associated impairments were present in 75%. Vision was impaired in 19%, hearing in 8% and speech in 54%. Intellectual disability (ID) was present in 53% and epilepsy in 41%. ID had increased from 42% to 53% since preschool-age. Neuropsychiatric impairments were present in 32% of the children; ASD in 18%; and ADHD in 21%. All impairments, except for ASD and ADHD, increased with more severe motor impairment.

CONCLUSION

Three in four school-aged children with CP have associated impairments, underscoring the need to broadly assess every child. The high rate of ASD and ADHD points to the importance of in-depth studies of such impairments in CP.

Antibiotic Exposure in the First Year of Life and the Risk of Attention-Deficit/Hyperactivity Disorder: A Population-Based Cohort Study

Early childhood antibiotic exposure induces changes in gut microbiota reportedly associated with the development of attention-deficit/hyperactivity disorder (ADHD). We conducted a population-based cohort study to examine the association between antibiotic use in the first year of life and ADHD risk. We included children born in Manitoba, Canada, between 1998 and 2017. Exposure was defined as having filled 1 or more antibiotic prescriptions during the first year of life. ADHD diagnosis was identified in hospital abstracts, physician visits, or drug dispensations. Risk of developing ADHD was estimated using Cox proportional hazards regression in a high-dimensional propensity score-matched cohort (n = 69,738) and a sibling cohort (n = 67,671). ADHD risk was not associated with antibiotic exposure in the matched-cohort (hazard ratio = 1.02, 95% confidence interval: 0.97, 1.08) or in the sibling cohort (hazard ratio = 0.96, 95% confidence interval: 0.89, 1.03). In secondary analyses of the matched cohort, ADHD risk increase was observed in those exposed to 4 or more antibiotic courses or a duration longer than 3 weeks. These associations were not observed in the sibling cohort. We concluded that antibiotic exposure in the first year of life does not pose an ADHD risk on a population level.

Seizure frequency, healthcare resource utilisation and mortality in childhood epilepsy: a retrospective cohort study using the THIN database

OBJECTIVE

To understand the association of seizure frequency with healthcare resource utilisation (HCRU) and mortality in UK children with epilepsy (CWE).

DESIGN

Retrospective cohort study.

SETTING

Routinely collected data in primary care from The Health Improvement Network UK database.

PATIENTS

CWE ≥1 and<18 years of age with a record of seizure frequency were included in mortality analyses from 2005 to 2015 and HCRU analyses from 2010 to 2015.

MAIN OUTCOME MEASURES

Frequency of HCRU contacts during the year following latest seizure frequency and mortality (descriptive and Cox proportional hazards regression) from first record of seizure frequency.

RESULTS

Higher seizure frequency was related to increased HCRU utilisation and mortality. In negative binomial regression, each category increase in seizure frequency related to 11% more visits to general practitioners, 35% more inpatient admissions, 15% more outpatient visits and increased direct HCRU costs (24%). 11 patients died during 12 490 patient-years follow-up. The unadjusted HR of mortality per higher category of seizure frequency was 2.56 (95% CI: 1.52 to 4.31). Adjustment for age and number of prescribed anti-epileptic drugs at index attenuated this estimate to 2.11 (95% CI: 1.24 to 3.60).

CONCLUSION

Higher seizure frequency is associated with greater HCRU and mortality in CWE in the UK. Improvement in seizure control may potentially lead to better patient outcomes and reduced healthcare use.

Sleep disorders and behavioral disorders in Jamaican children with epilepsy: A case-control study

Children with epilepsy (CWE) are more likely to have sleep and behavioral disorders. With differences in reports, the aim was to evaluate sleep and behavior in Jamaican CWE and determine any association with epilepsy-related variables. Children with epilepsy were identified along with age and gender-matched controls from the University Hospital of the West Indies and the Bustamante Hospital for Children. Written informed consent was obtained followed by the completion of questionnaires assessing sleep, behavior, and background of both cases and controls. Parents of 61 children (26 cases and 35 controls) participated in the study. There was no difference in sleep scores or frequency of sleep disorders between cases and controls (p > 0.05). Children with epilepsy had worse scores than controls in peer problems (3.85 vs 2.32, p < 0.01), internal problems (7.42 vs 4.71, p < 0.01), and total behavioral problem (16.27 vs 12.09, p < 0.01). When compared with controls, CWE had a higher frequency of abnormal peer problems (66% vs 32%, p < 0.05) and emotional problems score (42% vs 15%, p < 0.05). Children with learning difficulty were three times more likely to have abnormal behavioral score Odds Ratio (OR) = 3.818, p < 0.05). Jamaican CWE have similar sleep scores to their healthy peers but have a higher frequency of peer and emotional problems.

Establishing clinical cutoffs for the PedsQL™ Epilepsy Module

OBJECTIVE

The purpose of the present study was to establish clinical cutoffs for the PedsQL Epilepsy Module scales by dichotomizing scores into normative or impaired. We predicted that these cutoffs would be useful in identifying children at greater risk for impairments in health-related quality of life (HRQOL) including those who exhibit effects of ongoing seizures, antiepileptic drugs (AEDs), and polytherapy.

METHODS

Two hundred and thirty-seven youth (2-18 years old) and their caregivers were recruited from five tertiary care hospitals across the United States. Caregivers and youth (5 years and older) completed the parent- or self-report versions of the PedsQL Epilepsy Module. Caregivers also completed measures of behavior and mood, AED side effects, and executive functioning in children. Clinical cutoffs were calculated in two ways: anchor-based (receiver operating characteristic (ROC) curve) and distribution-based (0.5 standard deviation (SD)). Medical characteristics were abstracted from the medical chart. t-Tests and chi-square tests were used to determine whether children's HRQOL classified as normative or impaired in epilepsy quality of life differed on seizure freedom, AED side effects, and polytherapy.

RESULTS

The final clinical cutoffs were as follows for each PedsQL Epilepsy Module subscale (caregiver and child): Impact (Parent = 60.7; Child = 64.39), Cognitive (Parent = 38.11; Child = 50.97), Executive Functioning (Parent = 46.65; Child = 57.15), Sleep (Parent = 42.07; Child = 43.90), and Mood/Behavior (Parent = 54.14; Child = 53.30). Youth with more severe AED side effects, ongoing seizures, and/or on polytherapy were more likely to have impaired quality of life across domains.

CONCLUSION

Clinical cutoffs extend this instrument's utility in surveilling common psychosocial comorbidities, tracking changes in functioning over time, and informing clinical decision-making in youth with epilepsy including recommendations for additional assessment and intervention by a range of health providers serving youth with epilepsy (YWE).

The role of task-based neural activation research in understanding cognitive deficits in pediatric epilepsy

Children with epilepsy can experience significant cognitive dysfunction that can lead to academic underachievement. Traditionally believed to be primarily due to the effects of factors such as the chronicity of epilepsy, medication effects, or the location of the primary epileptogenic lesion;, recent evidence has indicated that disruption of cognition-specific distributed neural networks may play a significant role as well. Specifically, over the last decade, researchers have begun to characterize the mechanisms underlying disrupted cognitive substrates by evaluating neural network abnormalities observed during specific cognitive tasks, using task-based functional magnetic resonance imaging (fMRI). This targeted review assesses the current literature investigating the relationship between neural network abnormalities and cognitive deficits in pediatric epilepsy. The findings indicate that there are indeed neural network abnormalities associated with deficits in executive function, language, processing speed, and memory. Overall, cognitive dysfunction in pediatric epilepsy is associated with a decrease in neural network activation/deactivation as well as increased recruitment of brain regions not typically related to the specific cognitive task under investigation. The research to date has focused primarily on children with focal epilepsy syndromes with small sample sizes and differing research protocols. More extensive research in children with a wider representation of epilepsy syndromes (including generalized epilepsy syndromes) is necessary to fully understand these relationships and begin to identify underlying cognitive phenotypes that may account for the variability observed across children with epilepsy. Furthermore, more uniformity in fMRI protocols and neuropsychological tasks would be ideal to advance this literature.

Should pediatric neurologists play a role in the management of the most common psychiatric comorbidities in children with epilepsy? Practical considerations

Child neurologists should provide initial care for the mental health problems of children and adolescents with epilepsy. Attention deficit hyperactivity disorder (ADHD), autism spectrum disorders are common comorbidities of childhood epilepsy. The psychotropic drugs used to treat mental health disorders can be safely employed in children with seizures. Child neurologists can diagnose common behavioral problems, should be comfortable with first-line agents to treat common psychiatric illnesses, and should recognize when support from psychologists or child and adolescent psychiatrists is needed. This article is part of the Special Issue "Obstacles of Treatment of Psychiatric Comorbidities in Epilepsy".

Autism, ADHD and parent-reported behavioural difficulties in young children with epilepsy

PURPOSE

To provide data on the prevalence of Autism Spectrum Disorder (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), and parent reported behaviour difficulties in young children with epilepsy, and to compare results with children with neurodisability (neurodevelopmental/neurological difficulties) without epilepsy.

METHOD

Children with epilepsy (1-7 years, n = 48) and children with neurodisability (1-7 years, n = 48) matched for gender, chronological and developmental age underwent psychological assessment. Parents completed measures of behaviour including the Strengths and Difficulties Questionnaire (SDQ). DSM-5 diagnoses of ASD and ADHD were made at consensus case conferences. Factors associated with child behaviour were analysed using linear regression.

RESULTS

Of the children with epilepsy, 18% met ASD criteria and 40% met ADHD criteria (corresponding figures in the non-epilepsy group were 41% and 27%). A large proportion (76%-78%) in both groups scored in the at-risk range on the SDQ and frequently had difficulties across multiple behavioural domains. Children with epilepsy had more concerns expressed regarding attention and mood. None of the epilepsy factors were significantly associated with scores on the behavioural measures.

SIGNIFICANCE

Young children with epilepsy had a very high level of parent reported behavioural difficulties and a high risk for ADHD and ASD highlighting the need for comprehensive multidisciplinary assessment. Behavioural concerns were not greater than for other children with non-epilepsy related neurodisability with the exception of attention and mood. Epilepsy related factors were not associated with child behaviour, suggesting that seizures per se do not confer a unique risk for behavioural difficulties.

Valproic acid potently inhibits interictal-like epileptiform activity in prefrontal cortex pyramidal neurons

Valproic acid has a long-standing reputation of effectively treating the symptoms of not only epilepsy but also psychiatric conditions. In the latter, the exact mechanism by which valproate exerts its effect remains unclear. In this study, epileptiform bursts were recorded from pyramidal neurons in the prefrontal cortex (the brain region thought to be involved in psychiatric disorders) using the patch-clamp technique. An extracellular solution with no magnesium ions and elevated potassium levels that is known to induce epileptiform activity in vitro was used. Because of their short durations, the epileptiform bursts were regarded as interictal-like epileptiform activity, which is believed to be involved in cognitive impairment. Interictal discharges occur in many neuropsychiatric disorders as well as in healthy population. Epileptic activity in prefrontal cortex pyramidal neurons was potently inhibited by two therapeutic concentrations of valproic acid (20 μM and 200 μM). Moreover, valproate suppressed spontaneous excitatory postsynaptic potentials. Epileptiform bursts were fully inhibited by NMDA receptor antagonist, which suggests that epileptiform activity is driven by NMDA receptors. The inhibition of excitability in prefrontal cortex pyramidal neurons by valproate was also shown. This study shows that it is possible to evoke NMDA-dependent epileptiform activity in prefrontal cortex pyramidal neurons in vitro. We suggest that the prefrontal cortex is a good region for studying the influence of drugs on interictal epileptiform activity.

Epidemiology of children with epilepsy at a tertiary referral centre in South Africa

PURPOSE

This retrospective observational hospital-based study assessed the characteristics of children with epilepsy in a sub-Saharan African tertiary service over a 10-year period.

METHODS

Children with a primary or secondary diagnosis of epilepsy seen during the study period were identified from the departmental database. Demographic and clinical data were collected from the database and available medical records.

RESULTS

Of 4701 children managed in the neurology service, 2407 children (51%) had epilepsy. The 2017 International League Against Epilepsy Classification of the Epilepsies was used to ascribe seizure and epilepsy type, epilepsy syndrome diagnosis and aetiologic categories. Forty-three percent of children had seizure onset before age one year. Focal Epilepsy occurred in 48% of the cohort (n = 1145). Twenty-five percent had an epilepsy syndrome diagnosis. Most children (54%) had epilepsy of unknown aetiology. Among those with underlying non-genetic aetiologies (33%), sequelae of intracranial infections, perinatal insults and structural brain malformations were most prevalent. Motor disability was present in 24% of children. Seventy-four percent had at least one associated motor disability, intellectual or learning disability, developmental delay or psychiatric comorbidity.

CONCLUSION

Epilepsy is common in sub-Saharan Africa. Many affected children have avoidable aetiologies. Compared to data from similar hospital-based studies in poorly resourced and resource-equipped settings, our cohort had a higher proportion of seizure onset below the age of one year and a greater number of infectious aetiologies, which is similar to population-based studies reported in sub-Saharan Africa. The presence of comorbidities is significant and demands greater advocacy for services for these children.

Executive functioning in children with epilepsy: Genes matter

Pediatric epilepsy has emerged as a chronic medical disease with a characteristic behavioral and cognitive phenotype, which includes compromised executive functioning (EF) and attention-related deficits. However, considerable interindividual variability exists; children often display very different or even opposite outcomes, and some children are more likely than others to develop neurocognitive problems in the face of similar individual and disease-related problems. The factors responsible for this interindividual variability are still largely unknown, but we do know that some genetic factors render the developing brain more susceptible to damage or traumatic experiences than others. Dopamine availability has a neuromodulatory function in the prefrontal cortex (PFC) and especially affects EF. Dopamine availability relates to polymorphisms in the gene encoding catechol-O-methyltransferase (COMT Val158Met), which in turn is affected by the methylation state of its promoter. Allelic variation of the methylenetetrahydrofolate reductase (MTHFR C677T) gene, alters methylation and may influence the methylation state of the COMT promoter. Given this, we tested the hypothesis that these polymorphisms interact in children with epilepsy, and that variability in allelic expression is associated with variability in cognitive phenotype. Executive function was tested directly and indirectly (parent-rated) in 42 children between 5 and 12 years of age. The MTHFR T allele carriers performed worse than MTHFR homozygous CC carriers on indirect EF, and a significant decline was observed when T allele carriers had at least one met allele of the COMT gene, especially on Working Memory. Direct EF was significantly compromised in COMT Val/Val carriers where reduced dopamine availability seems to confer a higher risk in a test that requests a high degree of executive attention and planning. This finding suggests that in children with epilepsy, genes that influence methylation and dopamine availability affect PFC-related EF. Therefore, we should consider genetic vulnerability as a polygenic risk, which might predispose for a particular phenotype and include specific genetic signatures as part of each patient's behavioral and cognitive profile from the moment that we start to take care of the child.

Intelligence and memory outcomes within 10 years of childhood convulsive status epilepticus

Long-term intelligence and memory outcomes of children post convulsive status epilepticus (CSE) have not been systematically investigated despite evidence of short-term impairments in CSE. The present study aimed to describe intelligence and memory outcomes in children within 10 years of CSE and identify potential risk factors for adverse outcomes. In this cohort study, children originally identified by the population-based North London Convulsive Status Epilepticus in Childhood Surveillance Study (NLSTEPSS) were prospectively recruited between July 2009 and February 2013 and invited for neuropsychological assessments and magnetic resonance imaging (MRI) scans. Full-scale intelligence quotients (FSIQs) were measured using the Wechsler Abbreviated Scales of Intelligence (WASI), and global memory scores (GMS) was assessed using the Children's Memory Scale (CMS). The cohort was analyzed as a whole and stratified into a prolonged febrile seizures (PFS) and non-PFS group. Their performance was compared with population norms and controls. Regression models were fitted to identify predictors of outcomes. With a mean of 8.9 years post-CSE, 28.5% of eligible participants were unable to undertake testing because of their severe neurodevelopmental deficits. Children with CSE who undertook formal testing (N = 94) were shown to have significantly lower FSIQ (p = 0.001) and GMS (p = 0.025) from controls; the PFS group (N = 34) had lower FSIQs (p = 0.022) but similar memory quotients (p = 0.88) with controls. Intracranial volume (ICV), developmental delay at baseline, and active epilepsy at follow-up were predictive of long-term outcomes in the non-PFS group. The relationship between ICV and outcomes was absent in the PFS group despite its presence in the control and non-PFS groups. Post-CSE, survivors reveal significant intelligence and memory impairments, but prognosis differs by CSE type; memory scores are uncompromised in the PFS group despite evidence of their lower FSIQ whereas both are compromised in the non-PFS group. Correlations between brain volumes and outcomes differ in the PFS, non-PFS, and control groups and require further investigation.

Parent-reported symptoms of ADHD in young people with epilepsy before and two years after epilepsy surgery

The aim was to compare parent-reported symptoms of attention-deficit/hyperactivity disorder (ADHD) before (baseline) and two years after pediatric epilepsy surgery (follow-up). The parents of 107 children who underwent epilepsy surgery completed surveys including the Conners 10-item scale at baseline and follow-up. Changes in scores between baseline and follow-up were compared using paired sample t-test. Factors associated with changes in scores were analyzed using linear regression. Features of ADHD were significantly reduced at follow-up (p < 0.001). Items with the greatest reduction were items focusing on core aspects of the diagnostic criteria for ADHD. Fewer children were in the at-risk range for ADHD on the Conners 10-item scale at follow-up but this did not reach statistical significance (49% vs. 43%; p = 0.481). Factors independently significantly associated with improvement in ADHD symptoms on multivariable analysis were higher baseline scores (p < 0.001), seizure-free status (p = 0.029), and right-sided surgery (p = 0.031). Children who undergo epilepsy surgery have a high rate of ADHD symptoms. Parent-rated symptoms of ADHD improved at 2-year follow-up after epilepsy surgery. All children undergoing epilepsy surgery should undergo assessment for ADHD at baseline and follow-up.

Neurobehavioral problems in children with early-onset epilepsy: A population-based study

PURPOSE

Neurobehavioral problems (i.e., cognitive impairment/behavior problems) are a major challenge in childhood epilepsy. Yet there are limited data in children with early-onset epilepsy (CWEOE; onset ≤4 years), the period in which the incidence of childhood epilepsy is highest. This study aimed to determine the prevalence, spectrum, and risk factors for neurobehavioral problems CWEOE.

METHODS

This prospective, population-based, case-controlled study identified children with newly diagnosed early-onset epilepsy in South East Scotland using active multisource capture-recapture surveillance (May 2013 - June 2015). The CWEOE and controls completed an age-appropriate neurobehavioral assessment battery across seven domains: general cognitive ability (GCA), adaptive behavior, externalizing, internalizing, executive functioning, social functioning, and Autism Spectrum Disorder (ASD) risk.

RESULTS

Fifty-nine CWEOE were identified with an ascertainment of 98% (95% confidence interval [CI] 94, 103). Forty-six (78% [95% CI 65.9, 86.6]) CWEOE (27 male, median age 25.5, range 1-59, months) and 37 controls (18 male, median age 31.5, range 3-59, months) consented for study entry. The CWEOE were similar to controls in gender, age, prematurity, and family history of psychopathology, but not socioeconomic status (Fisher's exact test [FET] < .001). Neurobehavioral assessments were carried out a median of 2.97 (Interquartile range [IQR] 1.51-4.95) months post epilepsy diagnosis. More CWEOE (63% [95% CI 48.6, 75.5]) had neurobehavioral problems compared with controls (27% [95% CI 15.4, 43.0]); p < 0.01. This observation was independent of socioeconomic status. Multidimensional problems were prevalent in CWEOE with 43% having two or more different domain-level problems; GCA impairment, adaptive behavior, internalizing, social functioning, and ASD risk were particularly marked. Risk factors varied by domain.

DISCUSSION

This novel study using comprehensive psychometric assessments found that neurobehavioral problems in CWEOE were detectable, common, and multidimensional. The degree of cooccurrence implies that problems are the norm, and multidimensional screening should be considered at epilepsy onset. The findings could aid policy development on health and educational provision in CWEOE.

How can transition to adult care be best orchestrated for adolescents with epilepsy?

Objective evidence is limited for the value of transition programs for youth with chronic illness moving from pediatric to adult care; however, such programs intuitively "make sense". We describe the strengths and weaknesses of a variety of transition programs from around the world for adolescents with epilepsy. Consequences of poorly organized transition beyond suboptimal seizure control may include an increased risk of sudden unexpected death in epilepsy (SUDEP), poor psychological and social outcome, and inadequate management of comorbidities. The content of transition programs for those with normal intelligence differs from those with intellectual disability, but both groups may benefit from an emphasis on sporting activities. Concerns that may interfere with optimal transition include lack of nursing or social work services, limited numbers of adult neurologists/epileptologists confident in the treatment of complex pediatric epilepsy problems, institutional financial support, and time constraints for pediatric and adult physicians who treat epilepsy and the provision of multidisciplinary care. Successful programs eventually need to rely on a several adult physicians, nurses, and other key healthcare providers and use novel approaches to complex care. More research is needed to document the value and effectiveness of transition programs for youth with epilepsy to persuade institutions and healthcare professionals to support these ventures.

Developments in depression in epilepsy: screening, diagnosis, and treatment

INTRODUCTION

Depression is one of the most frequent comorbidities in epilepsy affecting between 17% and 22% of patients, but it is still underdiagnosed and undertreated. Areas covered: This paper discusses recent advances about screening, diagnosis, and treatment of depression in epilepsy taking into account the heterogeneity of clinical scenarios where depression can occur. Expert opinion: A number of screening instruments are now validated for adults with epilepsy, and their psychometric properties are discussed but the NDDI-E is the most practical and cost-effective. Challenges in diagnosing depression in epilepsy are discussed including reasons for the atypical features of mood disorders in epilepsy. Psychological treatments and/or SSRIs are indicated, but the level of evidence is still low. Even if there is no reason to hypothesise that internationally accepted guidelines of treatment of depression outside epilepsy may not be valid, rigorous studies are needed in order to have proper outcome measures. Epilepsy centers should have well-defined care pathways for depression in order to provide access to mental health support when needed.

Global development and adaptive behaviour in children with early-onset epilepsy: a population-based case-control study

AIM

There are limited population-based data on global development and adaptive behaviour in children with early-onset epilepsy. The aims of this study were: (1) to identify the prevalence of deficits in global development and adaptive behaviour experienced by children with early-onset epilepsy; (2) to identify factors associated with such deficits; and (3) to compare the relationship between measures of neurodevelopment in the group with epilepsy to a group without epilepsy who had other neurological or neurodevelopmental difficulties.

METHOD

The Sussex Early Epilepsy and Neurobehaviour study is a prospective, community-based study involving children (1-7y) with epilepsy. We undertook comprehensive psychological assessment with participants, including measures of global development and adaptive behaviour. We compared the children with epilepsy with a sex, age, and developmentally-matched group of children without epilepsy who had neurodevelopmental or neurological difficulties using correlation matrices.

RESULTS

Forty-eight children (91% of the eligible population) with epilepsy underwent assessment. Seventy-one per cent of children displayed delayed global development (<2SD) and 56% showed significant deficits (<2SD) in adaptive behaviour. Our analysis revealed that non-white ethnicity and use of polytherapy were independently associated with decreased scores on measures of global development and adaptive behaviour. The correlations between measures of developmental functioning were higher in children with epilepsy than in those without.

INTERPRETATION

Children with early-onset epilepsy frequently have difficulties with global development and adaptive behaviour. The higher correlations between neurodevelopmental measures in children with epilepsy suggest that the profile in children with epilepsy is different. This may have significant implications for both neuropathology and interventions.

WHAT THIS PAPER ADDS

Children with early-onset epilepsy are at significant risk of intellectual disability. Developmental impairment is associated with use of polytherapy but not with any seizure parameters. Developmental profiles in young children with epilepsy differ from other conditions.

Autism spectrum disorders: autistic phenotypes and complicated mechanisms

BACKGROUND

Autism spectrum disorder (ASD), a pervasive developmental neurological disorder, is characterized by impairments in social interaction and communication, and stereotyped, repetitive patterns of interests or behaviors. The mechanism of ASDs is complex, and genetic components and epigenetic modifications play important roles. In this review, we summarized the recent progresses of ASDs focusing on the genetic and epigenetic mechanisms. We also briefly discussed current animal models of ASD and the application of high-throughput sequencing technologies in studying ASD.

DATA SOURCES

Original research articles and literature reviews published in PubMed-indexed journals.

RESULTS

Individuals with ASDs exhibit a set of phenotypes including neurological alteration. Genetic components including gene mutation, copy-number variations, and epigenetic modifications play important and diverse roles in ASDs. The establishment of animal models and development of new-generation sequencing technologies have contributed to reveal the complicated mechanisms underlying autistic phenotypes.

CONCLUSIONS

Dramatic progress has been made for understanding the roles of genetic and epigenetic components in ASD. Future basic and translational studies should be carried out towards those candidate therapeutic targets.

Medication treatment for attention-deficit/hyperactivity disorder and the risk of acute seizures in individuals with epilepsy

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) affects 10%-30% of individuals with epilepsy, yet concerns remain regarding the safety of ADHD medication in this group. The objective of this study was to examine the risk of acute seizures associated with ADHD medication in individuals with epilepsy.

METHODS

A total of 21 557 individuals with a seizure history born between 1987 and 2003 were identified from Swedish population registers. Within this study population, we also identified 6773 youth (<19 years of age) who meet criteria for epilepsy, and 1605 youth with continuous antiepileptic drug (AED) treatment. ADHD medication initiation and repeated medication periods were identified from the Swedish Prescribed Drug Register between January 1, 2006 and December 31, 2013. Acute seizures were identified via unplanned visits to hospital or specialist care with a primary seizure discharge diagnosis in the Swedish National Patient Register during the same period. Conditional Poisson regression was used to compare the seizure rate during the 24 weeks before and after initiation of ADHD medication with the rate during the same 48 weeks in the previous year. Cox regression was used to compare the seizure rate during ADHD medication periods with the rate during nonmedication periods. Comparisons were made within-individual to adjust for unmeasured, time?constant confounding.

RESULTS

Among 995 individuals who initiated ADHD medication during follow-up, within-individual analyses showed no statistically significant difference in the rate of seizures during the 24 weeks before and after medication initiation, compared to the same period in the previous year. In the full study population 11 754 seizure events occurred during 136 846 person-years and 1855 individuals had at least one ADHD medication period. ADHD medication periods were associated with a reduced rate of acute seizures (hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.57-0.94), compared to nonmedication periods within the same individual. Similar associations were found in youth with epilepsy and continuous AED treatment, when adjusting for AEDs, and across sex, age, and comorbid neurodevelopmental disorders.

SIGNIFICANCE

We found no evidence for an overall increased rate of acute seizures associated with ADHD medication treatment among individuals with epilepsy. These results suggest that epilepsy should not automatically preclude patients from receiving ADHD medications.