Attention deficit hyperactivity disorder (ADHD) in childhood epilepsy

Evaluation of Branched-Chain Amino Acids in Children with Autism Spectrum Disorder and Epilepsy

Autism spectrum disorder (ASD) and epilepsy run hand-to-hand in their pathophysiology. Epilepsy is not an uncommon finding in patients with ASD. The aim of the present study was to identify the metabolic abnormalities of BCAAs (leucine, isoleucine, and valine) in children with ASD with and without seizures in comparison with neurotypical controls. Also, this study aimed to investigate the presence of epileptiform discharges on electroencephalography (EEG) in ASD patients and to describe the types and frequency of seizures observed. The study included 90 children aged 2-7 years, 30 of whom were diagnosed with both ASD and epilepsy. The other 30 children were diagnosed as ASD without epilepsy, and a comparable 30 normally developed children served as a control group. The groups were matched by age and gender. All patients were referred to the Autism Disorders Clinic for interviews and examinations. The Childhood Autism Rating Scale (CARS) was applied to all study participants to assess the degree of autism. The present study results show that all types of seizures may be identified in ASD children. The median serum levels of BCAAs were lower in ASD children with and without epilepsy than in neurotypical controls. This opens the door for discussion about new etiologies and better categorizations of ASD based on genotype and genetic abnormalities detected. More studies with larger samples are needed to understand ASD better and to more reliable evaluate the association between ASD, EEG changes, seizures, and BCAAs.

Epilepsy and Attention Deficit Hyperactivity Disorder: Connection, Chance, and Challenges

Comorbidities are common in children with epilepsy, with nearly half of the patients having at least one comorbidity. Attention deficit hyperactivity disorder (ADHD) is a psychiatric disorder characterized by hyperactivity and inattentiveness level disproportional to the child’s developmental stage. The burden of ADHD in children with epilepsy is high and can adversely affect the patients’ clinical outcomes, psychosocial aspects, and quality of life. Several hypotheses were proposed to explain the high burden of ADHD in childhood epilepsy; the well-established bidirectional connection and shared genetic/non-genetic factors between epilepsy and comorbid ADHD largely rule out the possibility of a chance in this association. Stimulants are effective in children with comorbid ADHD, and the current body of evidence supports their safety within the approved dose. Nonetheless, safety data should be further studied in randomized, double-blinded, placebo-controlled trials. Comorbid ADHD is still under-recognized in clinical practice. Early identification and management of comorbid ADHD are crucial to optimize the prognosis and reduce the risk of adverse long-term neurodevelopmental outcomes. The identification of the shared genetic background of epilepsy and ADHD can open the gate for tailoring treatment options for these patients through precision medicine.

Interventions for ADHD in children & adolescents with epilepsy: A review and decision tree to guide clinicians

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common pediatric epilepsy comorbidities. Treating ADHD in the context of epilepsy can be overwhelming for parents and clinicians. Current frontline treatment for ADHD is stimulant medication. However, some parents of pediatric patients with epilepsy have concerns about adding additional medication to their child's epilepsy regimen and/or about adverse effects of stimulant medication. Non-medication ADHD treatments including psychosocial interventions and ketogenic diet have also shown success in improving ADHD symptoms. Our focused review provides an easy-to-use guide for clinicians on ADHD interventions and combinations of interventions for pediatric patients with epilepsy and ADHD. Our guide includes information from 8 electronic databases for peer-reviewed, English language studies of psychosocial treatments for youth with epilepsy and ADHD. One hundred eight studies were selected based on inclusion criteria (21 systematic reviews, 12 meta-analyses, 8 literature reviews, 6 population surveys, 31 clinical trials, 20 cross-sectional studies, and 10 retrospective reviews). Results indicated that stimulant medication is a frontline treatment for ADHD symptoms in youth with epilepsy, with important caveats and alternatives.

Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is the most prevalent neurobehavioral disorder in childhood. The major components of this disorder are developmentally inappropriate levels of inattention and hyperactivity/impulsivity, which result in functional impairment in 1 or more areas of academic, social, and emotional function. In addition to the propensity for children to have some compromise of academic and emotional function, children with ADHD also have a higher frequency of co-occurring learning, cognitive, language, motor, and mental health disorders. Similarly, children with developmental disorders have a higher risk of co-occurring ADHD. The diagnosis of ADHD can be ascertained by a review of the risks for the condition, consideration of masquerading conditions, a careful history and physical examination, and the recognition of co-occurring disorders. The signs and symptoms of co-occurring disorders and the management of ADHD differ across early childhood, middle childhood, and adolescence. Management is largely limited to behavioral and pharmacologic interventions, and it favors behavioral strategies in early childhood, pharmacologic and behavioral strategies in middle childhood, and pharmacologic interventions in adolescence. This article offers an approach to the evaluation, presentation, and management of ADHD with a focus on guiding primary care pediatricians.

Non-mental diseases associated with ADHD across the lifespan: Fidgety Philipp and Pippi Longstocking at risk of multimorbidity?

Several non-mental diseases seem to be associated with an increased risk of ADHD and ADHD seems to be associated with increased risk for non-mental diseases. The underlying trajectories leading to such brain-body co-occurrences are often unclear - are there direct causal relationships from one disorder to the other, or does the sharing of genetic and/or environmental risk factors lead to their occurring together more frequently or both? Our goal with this narrative review was to provide a conceptual synthesis of the associations between ADHD and non-mental disease across the lifespan. We discuss potential shared pathologic mechanisms, genetic background and treatments in co-occurring diseases. For those co-occurrences for which published studies with sufficient sample sizes exist, meta-analyses have been published by others and we discuss those in detail. We conclude that non-mental diseases are common in ADHD and vice versa and add to the disease burden of the patient across the lifespan. Insufficient attention to such co-occurring conditions may result in missed diagnoses and suboptimal treatment in the affected individuals.

Pharmacokinetic drug interactions between antiseizure medications and drugs for comorbid diseases in children with epilepsy

Introduction: Nearly 80% of children with epilepsy have one or more chronic comorbidities that require specific drug treatments in several cases. Drug-drug interactions (DDIs) between antiseizure medications (ASMs) and all other drugs (NON-ASMs) used to treat comorbid diseases may have serious consequences.Areas covered: All potential DDIs between 27 ASMs and all NON-ASMs used for oral chronic treatment of those disorders most often comorbid with epilepsy in children were searched for drug compendia. Clinical evidence of the identified DDIs was also searched in the literature. Forty-eight drugs have been identified as potential DDIs with at least one ASM. Most important DDIs are between some ASMs and omeprazole and pantoprazole (drugs for gastrointestinal disorders), ibuprofen and cyclobenzaprine (drugs for musculoskeletal disorders), loratidine, lumacaftor/ivacaftor, montelukast, and theophylline (drugs for respiratory system), levothyroxine, liothyronine and several corticosteroids (systemic hormonal preparations), almotriptan, dihydroergotamine, ergotamine, and several antipsychotics, antidepressants and anxiolytics (drugs for nervous diseases). Clinical evidence of the predicted DDIs was found in a minority of cases.Expert opinion: Treatment of children with epilepsy should be decided considering treatment of both seizures and comorbid diseases and aimed at minimizing the risk of DDIs between ASMs and NON-ASMs.

Experimental Models for the Discovery of Novel Anticonvulsant Drugs: Focus on Pentylenetetrazole-Induced Seizures and Associated Memory Deficits

Epilepsy is a chronic neurological disorder characterized by irregular, excessive neuronal excitability, and recurrent seizures that affect millions of patients worldwide. Currently, accessible antiepileptic drugs (AEDs) do not adequately support all epilepsy patients, with around 30% patients not responding to the existing therapies. As lifelong epilepsy treatment is essential, the search for new and more effective AEDs with an enhanced safety profile is a significant therapeutic goal. Seizures are a combination of electrical and behavioral events that can induce biochemical, molecular, and anatomic changes. Therefore, appropriate animal models are required to evaluate novel potential AEDs. Among the large number of available animal models of seizures, the acute pentylenetetrazole (PTZ)-induced myoclonic seizure model is the most widely used model assessing the anticonvulsant effect of prospective AEDs, whereas chronic PTZ-kindled seizure models represent chronic models in which the repeated administration of PTZ at subconvulsive doses leads to the intensification of seizure activity or enhanced seizure susceptibility similar to that in human epilepsy. In this review, we summarized the memory deficits accompanying acute or chronic PTZ seizure models and how these deficits were evaluated applying several behavioral animal models. Furthermore, major advantages and limitations of the PTZ seizure models in the discovery of new AEDs were highlighted. With a focus on PTZ seizures, the major biochemicals, as well as morphological alterations and the modulated brain neurotransmitter levels associated with memory deficits have been illustrated. Moreover, numerous medicinal compounds with concurrent anticonvulsant, procognitive, antioxidant effects, modulating effects on several brain neurotransmitters in rodents, and several newly developed classes of compounds applying computer-aided drug design (CADD) have been under development as potential AEDs. The article details the in-silico approach following CADD, which can be utilized for generating libraries of novel compounds for AED discovery. Additionally, in vivo studies could be useful in demonstrating efficacy, safety, and novel mode of action of AEDs for further clinical development.

In the eye of the beholder: Using a multiple-informant approach to examine the mediating effect of cognitive functioning on emotional and behavioral problems in children with an active epilepsy

PURPOSE

Childhood epilepsy is often associated with cognitive impairments and psychosocial problems. However, it is not clear which factors mediate symptom severity and child's resilience. Emotional and behavioral problems have been associated with various home and school environments, suggesting that information collected may vary depending on both context and informant. In this study we examined the mediating effect of child's cognitive functions on the association between child and epilepsy-related factors and psychosocial problems. Additionally, the differences in psychosocial problems reported by various informants (parents, teachers) in different school settings were explored.

METHODS

Participants were 155 children with epilepsy (50 % girls), age range 5-18 years who completed a brief neuropsychological battery. Parents completed the Child Behavior Checklist (CBCL) and teachers completed the corresponding Teacher's Rating Form (TRF), to assess a child's emotional and behavior problems.

RESULTS

The cognitive profile of the sample was within average to low-average range. Parents and teachers both reported high levels of emotional and behavioral problems, and teachers reported relatively higher levels of symptoms. A mediation effect of cognition on the association between child and epilepsy-related factors (i.e., number of antiseizure medications and illness duration) and child's emotional and behavioral problems was evident only for teachers' reports.

CONCLUSIONS

The results emphasize that the complex interactions between epilepsy, cognition and psychosocial outcomes are perceived differently in diverse contexts by different informants. The incongruities in informants' perceptions regarding the role of cognition in child's psychological state should be acknowledged and incorporated when planning effective educational and rehabilitation interventions for children with epilepsy.

Treatment of Children and Adolescents with Epilepsy with Atomoxetine

OBJECTIVE

The objective of this study was to assess the effectiveness and safety of atomoxetine in Korean children and adolescents with epilepsy.

METHODS

We retrospectively reviewed the electronic medical records of 105 children and adolescents with epilepsy treated with atomoxetine. Effectiveness was measured with the Clinical Global Impressions-Severity (CGI-S) and/or Clinical Global Impressions-Improvement (CGI-I) scales at baseline, and after 4 and 12 weeks. We defined response to atomoxetine as a CGI-I score less than three at week 12. Safety was evaluated at each visit, based on clinical assessment by a child and adolescent psychiatrist and reports from participants or their caregivers.

RESULTS

In total participants (n=105), 33 (31.4%) showed a response to treatment: a significant decrease in CGI-S scale score was observed over 12 weeks of atomoxetine treatment. The most common adverse event (AE) was decreased appetite (n=16, 15.2%), and life-threatening AEs were not observed. Seizure aggravation due to atomoxetine was observed in 7.6% (n=8) of total participants, and one of them discontinued atomoxetine.

CONCLUSION

Our results provide preliminary evidence of the effectiveness and safety of atomoxetine in children and adolescents with epilepsy.

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.

Prevalence of Epilepsy and Inter-Ictal Epileptiform Discharges in Children with Autism and Attention-Deficit Hyperactivity Disorder

OBJECTIVE

To study the prevalence of epilepsy and Inter-ictal epileptiform discharges (IED) in children with Autism spectrum disorder (ASD) and Attention-deficit hyperactivity disorder (ADHD), and the factors associated with occurrence of epilepsy in these children.

METHODS

Children between 6 and 12 y attending the Child Development Centre of a tertiary-care institute in India were evaluated for ASD and ADHD as per Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Childhood Autism Rating Scale was used to assess ASD severity, and Conner's Rating Scales were used to sub-classify children with ADHD. Intelligence quotient was assessed if not assessed in the previous 1 y. History of seizures was taken, and electroencephalography was done in all children. Epilepsy was diagnosed and classified according to International League Against Epilepsy.

RESULTS

Of the 130 children enrolled (90 ASD, 40 ADHD), 56 (43%) had epilepsy and 55 (42.3%) had IED. The proportion of both epilepsy and IED was higher among ASD (both 45.5%) as compared to ADHD (37.5% and 35%), although not statistically significant. Among children with ASD, epilepsy was common in those with severe ASD (P < 0.001), and IED were more common in those with IQ <80 (P = 0.047). There were no significant differences between occurrence of epilepsy/IED and subtypes of ADHD.

CONCLUSIONS

The high prevalence of epilepsy and IED among children with ASD and ADHD emphasizes the need for guidelines for identifying and diagnosing epilepsy in this group. This will ensure appropriate management and improve patient outcomes.

Behavior problems in children with epilepsy and attention-deficit hyperactivity disorder in Central China

In this study, we aimed to evaluate the prevalence of attention-deficit hyperactivity disorder (ADHD) in children with epilepsy in Central China and compare the behavioral problems in children with epilepsy combined with and without ADHD. Children with epilepsy aged between 6 and 16 years were recruited for this study. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria were administered for the diagnosis of ADHD and ADHD subtype in children with epilepsy. Children Behavior Checklist (CBCL) was administered by trained research assistants to evaluate children's behavior problems. Among 206 children diagnosed as having epilepsy, 51 had ADHD symptoms. Among them, 52.1% (29/51) were inattentive subtype (ADHD-I), 13.73% (7/51) were hyperactive/impulsive subtype (ADHD-HI), and 29.41% (15/51) were combined subtype (ADHD-C). Children with epilepsy and ADHD had significantly higher scores on attention problems, rule-breaking behavior, and aggressive behavior subscales (P < 0.01). Our results showed that children with epilepsy exhibited a significantly higher rate of ADHD compared with controls in Central China, with a predominant inattentive subtype. Children with epilepsy and ADHD showed more behavior problems such as attention-deficit, delinquent, and aggressive behaviors compared with children with epilepsy only.

Executive and behavioral functioning in pediatric frontal lobe epilepsy

OBJECTIVE

Epilepsy, as a chronic and neurological disease, is generally associated with an increased risk for social and emotional behavior problems in children. These findings are mostly derived from studies on children with different epilepsy types. However, there is limited information about the associations between frontal lobe epilepsy (FLE) and cognitive and behavioral problems. The aim of this study was to examine relationships between FLE and executive and behavioral functioning reported by parents and teachers.

MATERIAL AND METHODS

Teachers and parents of 32 children (18 boys, 14 girls, mean age 9; 2 years ±1;6) with a confirmed diagnosis of FLE completed the Behavioral Rating Inventory of Executive Function (BRIEF), the Child Behavior Checklist (CBCL), and Teacher Report Form (TRF).

RESULTS

About 25 to 35% of the parents and teachers rated children in the abnormal range of the main scales of the BRIEF, CBCL, and TRF. Teachers tend to report more metacognition problems, whereas parents tend to report more behavior regulation problems. Children with left-sided FLE showed more problems than children with bilateral or right-sided FLE. The whole range of executive dysfunctioning is linked to behavioral dysfunctioning in FLE, but ratings vary across settings and informants. The epilepsy variables age of onset, lateralization, drug load, and duration of epilepsy had only a small and scattered contribution.

CONCLUSION

Ratings on the BRIEF, CBCL, and TRF are moderately to highly correlated, suggesting a (strong) link between executive and behavioral functioning. Subtle differences between parents and teachers ratings suggest different executive function demands in various settings.

The Challenge of Pharmacotherapy in Children and Adolescents with Epilepsy-ADHD Comorbidity

Epilepsy is common in children and adolescents where its prevalence is 3.2-5.5/1000. About one-third of patients also have attention deficit hyperactivity/impulsivity disorder (ADHD). The possible relationship between epilepsy and ADHD is still unclear, and ADHD symptoms (such as inattention, hyperactivity, behavioral disturbances) are frequently considered as adverse effects of antiepileptic drugs (AEDs). The literature was searched for data on the behavioral effects of AEDs. Phenobarbital is the most frequently reported medication to induce symptoms of ADHD, followed by topiramate and valproic acid. Phenytoin seems to exert modest effects, while for levetiracetam there are contrasting data. Lacosamide induces some beneficial effects on behavior; carbamazepine and lamotrigine exert favorable effects on attention and behavior. Gabapentin and vigabatrin have limited adverse effects on cognition. Oxcarbazepine, rufinamide, and eslicarbazepine do not seem to aggravate or induce ADHD symptoms, whereas perampanel can lead to a high incidence of hostile/aggressive behavior, which increases with higher dosages. Information about the behavioral effects of ethosuximide, zonisamide, tiagabine, pregabalin, stiripentol, and retigabine is still limited. Because ADHD significantly affects the quality of life of epilepsy patients, the clinical management of this neuropsychiatric disorder should be a priority. Methylphenidate is effective most children and adolescents with ADHD symptoms and comorbid epilepsy, without a significant increase of seizure risk, although data are still limited with few controlled trials.

Attention profiles in childhood absence epilepsy compared with attention-deficit/hyperactivity disorder

OBJECTIVE

This study aimed to compare the attention profiles of subjects with childhood absence epilepsy (CAE) to those of children with attention-deficit/hyperactivity disorder (ADHD) and controls.

METHOD

We retrospectively reviewed the medical records of 20 children (age 7.2 ± 1.6 years, 5 boys) in whom CAE was diagnosed at the Department of Pediatric Neurology of Asan Medical Center, Seoul, Korea. ADHD and control subjects were selected from children who visited the Department of Pediatric Psychiatry and were confirmed as having or not having ADHD based on Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version (K-SADS-PL). The 20 children with CAE, 20 with ADHD and 20 controls completed the Advanced Test of Attention (ATA), which is a computerized continuous performance task.

RESULTS

The CAE subjects without ADHD showed increased Omission errors (p=.013) on the visual ATA and Response time (p=0.044) on the auditory ATA than the controls, although these differences did not remain significant after multiple comparison correction. The CAE subjects without ADHD had significantly decreased Response time variability on the visual ATA than the ADHD group (p<0.001). The CAE subjects with comorbid ADHD showed increased Commission errors (p=0.020) and Response time variability (p=0.016) on the visual ATA and increased Commission errors (p=0.022) on the auditory ATA than the CAE subjects without ADHD, although statistical significance disappeared after multiple comparison adjustments.

CONCLUSION

These findings suggest that selective attention is impaired in children with CAE and comorbid ADHD contributes to further impairment of sustained attention and response inhibition.

Attention-Deficit Hyperactivity Disorder (ADHD) in Epilepsy and Primary ADHD: Differences in Symptom Dimensions and Quality of Life

PURPOSE

We aimed to (1) compare quality of life (QOL) among children with epilepsy, epilepsy and attention-deficit hyperactivity disorder (ADHD), and primary ADHD and (2) compare ADHD symptom dimensions and subtypes between children with epilepsy-ADHD and primary ADHD.

METHODS

A total of 140 children; 53 with epilepsy, 35 with epilepsy-ADHD, and 52 with primary ADHD were included. KINDL-R (quality of life measure), Turgay DSM-IV Disruptive Behavior Disorders Rating Scale (T-DSM-IV-S), and Conners' Parent Rating Scale (CPRS) were completed. Neurology clinic charts were reviewed for epilepsy-related variables.

RESULTS

Children with epilepsy-ADHD had the lowest (poorest) KINDL-R total scores. Epilepsy-ADHD group had more inattentiveness symptoms, whereas primary ADHD group had more hyperactivity/impulsivity symptoms. The frequencies of ADHD combined and inattentiveness subtypes were 60% and 40% in children with epilepsy-ADHD and 80.7% and 19.3% in children with primary ADHD, respectively ( P = .034).

CONCLUSION

ADHD in epilepsy is associated with a significantly poor quality of life and predominantly inattentiveness symptoms.

Parent- and Teacher-Reported Symptoms of ADHD in School-Aged Children With Active Epilepsy: A Population-Based Study

OBJECTIVE

Provide data on the distribution of parent- and teacher-reported symptoms of ADHD in childhood epilepsy and describe coexisting cognitive and behavioral disorders in children with both epilepsy and ADHD.

METHOD

Eighty-five (74% of those eligible) children (5-15 years) in a population-based sample with active epilepsy underwent psychological assessment. The ADHD Rating Scale-IV (ADHD-RS-IV) scale was completed by parents ( n = 69) and teachers ( n = 67) of participating children with an IQ > 34. ADHD was diagnosed with respect to Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.).

RESULTS

Parents reported significantly more symptoms of ADHD than teachers ( p < .001). Symptoms of inattention were more commonly reported than symptoms of hyperactivity-impulsivity ( p < .001). Neurobehavioral comorbidity was similar in those with ADHD and non-ADHD with the exception of oppositional defiant disorder (ODD) and developmental coordination disorder (DCD), which were more common in those with both epilepsy and ADHD.

CONCLUSION

Symptoms of ADHD are very common in childhood epilepsy but prevalence is influenced by informant.

Seizure-related variables are predictive of attention and memory in children with epilepsy

Children with epilepsy (CWE) are at greater risk for cognitive deficits and behavioral difficulties than are typically developing healthy children, and particular epileptic symptoms and treatments may contribute to this risk. The current study examined the relationships between four seizure-related variables and attention and memory functioning in a sample of 207 CWE (ages 6-16) using both neurocognitive and parent/teacher-report measures. Sociodemographic, medical, and neuropsychological data were collected from patients' medical charts in a retrospective fashion. Hierarchical multiple regressions were performed with sociodemographic variables (age, gender, race) entered as step one and seizure-related variables (number of anti-epileptic drugs [AEDs], EEG laterality, EEG lobe of focus, lifetime seizure duration) entered as step two. Results indicated that seizure-related variables were consistently predictive of poor cognitive performances above and beyond sociodemographic variables, although only minimally predictive of parent/teacher-reports. A longer duration of seizure burden and greater number of AEDs were robust predictors of performances on most cognitive measures. These findings indicate that CWE with long lifetime seizure durations and multiple AEDs are at risk for inefficiencies in attention and memory. Knowledge of this risk will allow treating providers greater accuracy and precision when planning medical treatment and making recommendations to families.

Sleep problems in pediatric epilepsy and ADHD: The impact of comorbidity

AIMS

Attention-deficit hyperactivity disorder (ADHD) is a frequent comorbidity in pediatric epilepsy. Although sleep problems are commonly reported in both children with primary ADHD and epilepsy, those with epilepsy-ADHD comorbidity have not been well studied. This study aimed to compare sleep problems among three groups of children: 1) children with epilepsy, 2) children with epilepsy and ADHD (epilepsy-ADHD), and 3) children with primary ADHD.

METHODS

53 children with epilepsy, 35 children with epilepsy-ADHD, and 52 children with primary ADHD completed the Children's Sleep Habits Questionnaire (CSHQ). Neurology clinic charts were reviewed for the epilepsy-related variables. ADHD subtypes were diagnosed according to the DSM-IV.

RESULTS

Children with epilepsy-ADHD had the highest CSHQ total scores, while children with primary ADHD had higher scores than those with epilepsy. Besides the total score, epilepsy-ADHD group differed from the primary ADHD and epilepsy groups with higher CSHQ subscores on sleep onset delay and sleep anxiety. The frequency of moderate-severe sleep problems (CSHQ>56) was 62.9% in children with epilepsy-ADHD, while it was 40.4% and 26.4% in children with primary ADHD and epilepsy, respectively. CSHQ total scores were not different between ADHD subtypes in both children with epilepsy-ADHD and those with primary ADHD. None of the epilepsy-related variables were found to be associated with CSHQ scores.

DISCUSSION

Epilepsy-ADHD is associated with a significantly poor sleep quality which is beyond that of primary ADHD and epilepsy.

Sleep-Related Disorders in Children with Attention-Deficit Hyperactivity Disorder: Preliminary Results of a Full Sleep Assessment Study

BACKGROUND AND METHODS

We present the preliminary results of a prospective case-control sleep study in children with a diagnosis of attention-deficit hyperactivity disorder (ADHD). A deep sleep assessment including sleep questionnaires, sleep habits, a video-polysomnographic recording with full high-density electroencephalography (EEG) and cardiorespiratory polygraphy, multiple sleep latency test, and 1-week actigraphic recording were performed to verify whether children with ADHD may be classified into one of the following five phenotypes: (1) hypoarousal state, resembling narcolepsy, which may be considered a "primary" form of ADHD; (2) delayed sleep onset insomnia; (3) sleep-disordered breathing; (4) restless legs syndrome and/or periodic limb movements; and (5) sleep epilepsy and/or EEG interictal epileptiform discharges.

RESULTS

Fifteen consecutive outpatients with ADHD were recruited (two female, mean age 10.6 ± 2.2, age range 8-13.7 years) over 6 months. The narcolepsy-like sleep phenotype was observed in three children, the sleep onset insomnia phenotype was observed in one child, mild obstructive sleep apnea was observed in three children, sleep hyperkinesia and/or PLMs were observed in five children, while IEDs and or nocturnal epilepsy were observed in three children. Depending on the sleep phenotype, children received melatonin, iron supplementation, antiepileptic drugs, or stimulants.

CONCLUSIONS

Our study further highlights the need to design an efficient sleep diagnostic algorithm for children with ADHD, thereby more accurately identifying cases in which a full sleep assessment is indicated.

Effects of a ketogenic diet on ADHD-like behavior in dogs with idiopathic epilepsy

OBJECTIVES

Epilepsy in humans and rodent models of epilepsy can be associated with behavioral comorbidities including an increased prevalence of attention-deficit/hyperactivity disorder (ADHD). Attention-deficit/hyperactivity disorder symptoms and seizure frequency have been successfully reduced in humans and rodents using a ketogenic diet (KD). The aims of this study were (i) to describe the behavioral profile of dogs with idiopathic epilepsy (IE) while on a standardized nonketogenic placebo diet, to determine whether ADHD-like behaviors are present, and (ii) to examine the effect of a ketogenic medium chain triglyceride diet (MCTD) on the behavioral profile of dogs with idiopathic epilepsy (IE) compared with the standardized placebo control diet, including ADHD-like behaviors.

METHODS

A 6-month prospective, randomized, double-blinded, placebo-controlled, crossover dietary trial comparing the effects of the MCTD with a standardized placebo diet on canine behavior was carried out. Dogs diagnosed with IE, with a seizure frequency of at least 3 seizures in the past 3months (n=21), were fed the MCTD or placebo diet for 3months and were then switched to the alternative diet for 3months. Owners completed a validated behavioral questionnaire to measure 11 defined behavioral factors at the end of each diet period to report their dogs' behavior, with three specific behaviors hypothesized to be related to ADHD: excitability, chasing, and trainability.

RESULTS

The highest scoring behavioral factors in the placebo and MCTD periods were excitability (mean±SE: 1.910±0.127) and chasing (mean±SE: 1.824±0.210). A markedly lower trainability score (mean±SE: 0.437±0.125) than that of previously studied canine populations was observed. The MCTD resulted in a significant improvement in the ADHD-related behavioral factor chasing and a reduction in stranger-directed fear (p<0.05) compared with the placebo diet. The latter effect may be attributed to previously described anxiolytic effects of a KD.

CONCLUSIONS

These data support the supposition that dogs with IE may exhibit behaviors that resemble ADHD symptoms seen in humans and rodent models of epilepsy and that a MCTD may be able to improve some of these behaviors, along with potentially anxiolytic effects.

Behavioral and Movement Disorders due to Long-Lasting Myoclonic Status Epilepticus Misdiagnosed as ADHD in a Patient With Juvenile Myoclonic Epilepsy: Electroclinical Findings and Related Hemodynamic Changes

Epilepsy and attention-deficit/hyperactivity disorder (ADHD) likely share common underlying neural mechanisms, as often suggested by both the evidence of electroencephalography (EEG) abnormalities in ADHD patients without epilepsy and the coexistence of these 2 conditions. The differential diagnosis between epilepsy and ADHD may consequently be challenging. In this report, we describe a patient presenting with a clinical association of "tics" and behavioral disorders that appeared 6 months before our first observation and had previously been interpreted as ADHD. A video-EEG evaluation documented an electroclinical pattern of myoclonic status epilepticus. On the basis of the revised clinical data, the EEG findings, the good response to valproate, the long-lasting myoclonic status epilepticus, and the enduring epileptic abnormalities likely causing behavioral disturbances, the patient's symptoms were interpreted as being the expression of untreated juvenile myoclonic epilepsy. The EEG-functional magnetic resonance imaging study revealed, during clinical generalized spike-and-wave and polyspike-and-wave discharges, positive blood oxygen level-dependent (BOLD) signal changes bilaterally in the thalamus, the prefrontal cortex (Brodmann area 6, supplementary motor area) and the cerebellum, and negative BOLD signal changes in the regions of the default mode network. Such findings, which are typical of BOLD changes observed in idiopathic generalized epilepsy, may also shed light on the anatomofunctional network underlying ADHD.

Effect of learning disabilities on academic self-concept in children with epilepsy and on their quality of life

Academic self-concept could significantly affect academic achievement and self-confidence in children with epilepsy. However, limited attention has been devoted to determining factors influencing academic self-concept of children with epilepsy. We aimed to analyze potentially significant variables (gender, frequency of seizures, duration of epilepsy, intellectual disability, learning disability and attention deficit hyperactivity disorder) in relation to academic self-concept in children with epilepsy and to additional domains of their quality of life. The study group consisted of 182 children and adolescents aged 9-14 years who completed the SPAS (Student's Perception of Ability Scale) questionnaire determining their academic self-concept and the modified Czech version of the CHEQOL-25 (Health-Related Quality of Life Measure for Children with Epilepsy) questionnaire evaluating their health-related quality of life. Using regression analysis, we identified learning disability as a key predictor for academic-self concept of children with epilepsy. While children with epilepsy and with no learning disability exhibited results comparable to children without epilepsy, participants with epilepsy and some learning disability scored significantly lower in almost all domains of academic self-concept. We moreover found that children with epilepsy and learning disability have significantly lower quality of life in intrapersonal and interpersonal domains. In contrast to children with epilepsy and with no learning disability, these participants have practically no correlation between their quality of life and academic self-concept. Our findings suggest that considerable attention should be paid to children having both epilepsy and learning disability. It should comprise services of specialized counselors and teaching assistants with an appropriate knowledge of epilepsy and ability to empathize with these children as well as educational interventions focused on their teachers and classmates.

Comorbidity of childhood epilepsy

Epilepsy in children is occasionally associated with variable comorbidities although the frequency of such comorbidity is often difficult to determine. They can be divided into three categories: neurological, psychological, and physical comorbidities. The goal of the present review is to discuss the reported comorbidities of epilepsy in children. The possible mechanisms and associated risk factors-including the effect of seizure frequency and seizure control, types of epilepsy, age of seizure onset, duration of illness, and the possible detrimental effect of antiepileptic drugs-will be described.

[Formula: see text]Differences in memory functioning between children with attention-deficit/hyperactivity disorder and/or focal epilepsy

Prior research has shown that attention-deficit/hyperactivity disorder (ADHD) and epilepsy are frequently comorbid and that both disorders are associated with various attention and memory problems. Nonetheless, limited research has been conducted comparing the two disorders in one sample to determine unique versus shared deficits. Hence, we investigated differences in working memory (WM) and short-term and delayed recall between children with ADHD, focal epilepsy of mixed foci, comorbid ADHD/epilepsy and controls. Participants were compared on the Core subtests and the Picture Locations subtest of the Children's Memory Scale (CMS). Results indicated that children with ADHD displayed intact verbal WM and long-term memory (LTM), as well as intact performance on most aspects of short-term memory (STM). They performed worse than controls on Numbers Forward and Picture Locations, suggesting problems with focused attention and simple span for visual-spatial material. Conversely, children with epilepsy displayed poor focused attention and STM regardless of the modality assessed, which affected encoding into LTM. The only loss over time was found for passages (Stories). WM was intact. Children with comorbid ADHD/epilepsy displayed focused attention and STM/LTM problems consistent with both disorders, having the lowest scores across the four groups. Hence, focused attention and visual-spatial span appear to be affected in both disorders, whereas additional STM/encoding problems are specific to epilepsy. Children with comorbid ADHD/epilepsy have deficits consistent with both disorders, with slight additive effects. This study suggests that attention and memory testing should be a regular part of the evaluation of children with epilepsy and ADHD.

Reappraisal of abnormal EEG findings in children with ADHD: on the relationship between ADHD and epileptiform discharges

INTRODUCTION

Attention-deficit hyperactivity disorder is suggested to be closely related to epilepsy. A recent large-scale study revealed that ADHD in children is often accompanied by epilepsy. In Japan, methylphenidate (MPH) as a sustained-action tablet and atomoxetine (ATX) became commercially available as medications for children recently. Since then, the number of prescriptions of both medicines has increased rapidly. Methylphenidate, as a psychostimulant, has been a source of concern because of the perceived lowered threshold for convulsions in children. Based on this background, reappraisal of EEG findings in children with ADHD is important in order to detect indications of potential comorbid epilepsy and to investigate the developmental mechanisms of the neurophysiological manifestations in patients with ADHD.

MATERIAL AND METHOD

EEG findings in children newly diagnosed with ADHD and their relationship with clinical findings were investigated. The author evaluated 208 patients with ADHD newly diagnosed between 2008 and 2013. Of these, there were 145 patients for whom EEG findings were obtained along with a clinical follow-up for at least three months. Patients with IQ<70 were excluded in order to obtain a homogenous group of patients with ADHD. The male-to-female ratio was 130:15, and the age range was between 5 years, 9 months and 19 years, 9 months, with mean age of 11 years, 4 months.

RESULTS

The results revealed that about half (48.3%) of the children with ADHD had abnormal EEG findings and that 22.1% of them had epileptiform discharges. Patients without comorbidity of autism spectrum disorder (ore homogenous group with ADHD) were especially likely to show abnormal EEG findings (51.0%) including epileptiform discharges (24.5%). Afebrile seizures, that is, epileptic seizures, occurred in a boy three days after commencement of administration with MPH as a sustained-action tablet. In four patients with a past history of epilepsy, neither relapse of EEG abnormality nor epileptic seizures were observed during the follow-up period.

CONCLUSION

There was to be a significantly close relationship between ADHD and epileptiform discharges. Therefore, in patients with ADHD, it is important to obtain more precise information about seizures and presence of epilepsy from the personal and family histories, as well as to undertake a thorough EEG examination.

Memory in children with epilepsy: a systematic review

PURPOSE

Research suggests an increased risk for cognitive impairment in childhood epilepsy with memory being one area of cognition most likely to be affected. Understanding the prevalence and predictors of memory difficulties may help improve awareness of the difficulties and allow efficacious supports to be put in place.

METHOD

A systematic review was carried out using the search terms 'memory', 'children' and 'epilepsy' in the database PUBMED. Eighty-eight studies met inclusion criteria. The review focuses on comparisons of memory scores of children with epilepsy and controls, and comparison of memory scores of children with epilepsy to normative scores. Predictors of memory impairment and the effect of surgery on memory functioning are also reviewed.

RESULTS

The majority (78%) of studies reviewed revealed that children with epilepsy scored lower than controls and normative scores on measures of memory. Post-surgery, memory scores were reported to improve in 50% of studies. Predictors of memory impairment included a greater number of AEDs used, younger age of onset, increased seizure frequency and longer duration of epilepsy.

CONCLUSION

Children with epilepsy have a high frequency of memory impairments. However, the exact prevalence of difficulties is not clear due to the lack of population-based data. Most studies have not controlled for IQ and thus it is unclear if difficulties are always related to global cognitive difficulties. There is need for future population-based studies and studies focussing on the neurobiology of memory problems in children with epilepsy.

Are children affected by epileptic neuropsychiatric comorbidities?

Childhood-onset epilepsy is associated with psychiatric and cognitive difficulties and with poor social outcomes in adulthood. Some antiepileptic drugs adversely affect behavior in susceptible children with easy-to-control or refractory epilepsies, contributing to a high risk of psychological and psychiatric disturbance. Studies had demonstrated that patients with benign rolandic epilepsy and absence epilepsy had more aggressive behavior, depression, and anxiety disorders than control children. Psychiatric comorbidities are strongly associated with a poor long-term health-related quality of life in childhood-onset epilepsy, which suggests that comprehensive epilepsy care must include screening and long-term treatment for these conditions, even if seizures remit.

Mutation of Elfn1 in mice causes seizures and hyperactivity

A growing number of proteins with extracellular leucine-rich repeats (eLRRs) have been implicated in directing neuronal connectivity. We previously identified a novel family of eLRR proteins in mammals: the Elfns are transmembrane proteins with 6 LRRs, a fibronectin type-3 domain and a long cytoplasmic tail. The recent discovery that Elfn1 protein, expressed postsynaptically, can direct the elaboration of specific electrochemical properties of synapses between particular cell types in the hippocampus strongly reinforces this hypothesis. Here, we present analyses of an Elfn1 mutant mouse line and demonstrate a functional requirement for this gene in vivo. We first carried out detailed expression analysis of Elfn1 using a β-galactosidase reporter gene in the knockout line. Elfn1 is expressed in distinct subsets of interneurons of the hippocampus and cortex, and also in discrete subsets of cells in the habenula, septum, globus pallidus, dorsal subiculum, amygdala and several other regions. Elfn1 is expressed in diverse cell types, including local GABAergic interneurons as well as long-range projecting GABAergic and glutamatergic neurons. Elfn1 protein localises to axons of excitatory neurons in the habenula, and long-range GABAergic neurons of the globus pallidus, suggesting the possibility of additional roles for Elfn1 in axons or presynaptically. While gross anatomical analyses did not reveal any obvious neuroanatomical abnormalities, behavioural analyses clearly illustrate functional effects of Elfn1 mutation. Elfn1 mutant mice exhibit seizures, subtle motor abnormalities, reduced thigmotaxis and hyperactivity. The hyperactivity is paradoxically reversible by treatment with the stimulant amphetamine, consistent with phenotypes observed in animals with habenular lesions. These analyses reveal a requirement for Elfn1 in brain function and are suggestive of possible relevance to the etiology and pathophysiology of epilepsy and attention-deficit hyperactivity disorder.

The impact of methylphenidate on seizure frequency and severity in children with attention-deficit-hyperactivity disorder and difficult-to-treat epilepsies

AIM

Difficult-to-treat epilepsies and attention-deficit-hyperactivity disorder (ADHD) often co-occur. Because of concerns about the use of stimulants in children with this comorbidity, the impact of ADHD treatment on seizure frequency and severity is not known. This pilot study evaluated the safety and efficacy of methylphenidate in this population.

METHOD

After a 3 month period in which antiepileptic drugs were adjusted, 22 patients recruited from a specialist outpatient clinic for severe epilepsy (16 males, six females; mean age 11 y 2 mo, SD 3 y 2 mo) received methylphenidate for 3 months in an open label, non-controlled trial; four with generalized or multifocal (symptomatic/cryptogenic) epilepsy, one with generalized (idiopathic) epilepsy, 17 with partial (symptomatic/cryptogenic) epilepsy; five with partial seizures only, 17 with primarily or secondarily generalized seizures). Epilepsy, ADHD symptoms, and side effects were assessed using the Swanson, Nolan, and Pelham Questionnaire, the Child Behavior Checklist, the Hague Seizure Severity Scale, and the Side Effects Rating Scale.

RESULTS

Methylphenidate significantly improved ADHD. After 3 months of treatment, 73% of patients no longer had clinically significant symptoms. Methylphenidate also reduced seizure severity (9-point median decrease on the Hague Seizure Severity Scale). Seizure frequency increased in four out of 22 patients, but only one patient withdrew from the study for this reason. Most patients experienced no major side effects.

INTERPRETATION

These data are among the first showing that low doses of methylphenidate are safe and effective to treat ADHD symptoms in patients with difficult-to-treat epilepsies. Randomized controlled trials are needed to replicate the findings.

Externalizing and tantrum behaviours in children with ASD and ADHD compared to children with ADHD

OBJECTIVE

Compare rates of externalizing in children with autism spectrum disorder (ASD) and attention deficit/hyperactivity disorder (ADHD) symptoms to children with ADHD.

METHOD

Parents/caregivers of 85 children with ASD and/or ADHD were surveyed about their children's behaviours using the Autism Spectrum Disorders-Comorbidity for Children and the Autism Spectrum Disorders-Behaviour Problem for Children.

RESULTS

Specific main effects analyses were then conducted. Children with ASD exhibited a higher number of externalizing (F(1, 83) = 83.34, p < 0.001) and tantrum behaviours (F(1,83) = 781.86, p < 0.001) than children without ASD.

CONCLUSIONS

ASD exacerbates the externalizing symptoms of ADHD during childhood. This study adds to the literature on the importance of assessing for a wide-range of possible behaviour problems in children presenting with ADHD symptomatology. The implications of these findings are discussed in the context of other research.

Epilepsy in a large cohort of children diagnosed with attention deficit/hyperactivity disorders (ADHD)

PURPOSE

The knowledge about possible relationships between ADHD and epilepsy is largely based on small samples of ADHD patients and on cohorts with epilepsy. There is insufficient information about the clinical characteristics of epilepsy among children diagnosed with ADHD. The aim of this study was to investigate the prevalence and characteristics of epilepsy in a large, unselected cohort of children with ADHD.

METHODS

We conducted a retrospective chart-review of children with ADHD who were evaluated in our clinic between the years 2000 and 2005. We compared age, sex, disorders of psychological development, cognitive level, pharmacological treatment for ADHD, initial response to treatment and ADHD subtype with and without epilepsy. In addition, we compared our data with data from a Norwegian study in a large general pediatric population.

RESULTS

Of 607 children with ADHD (age 6-14 years; 82.4% males); 14 (2.3%) had a history of epilepsy, and 13 of these had active epilepsy. This is a higher occurrence than expected in the general pediatric population (0.5%). The majority of our patients had mild (an easily treated) epilepsy and they were more likely to be seizure free (79%) compared to the patients with epilepsy in general pediatric population. The ADHD patients with and without epilepsy did not differ regarding age, gender, disorders of psychological development, IQ level<85 or ADHD subtype. The patients had been diagnosed with epilepsy on average 1.8 years before the ADHD assessment. All patients with epilepsy were treated with methylphenidate (MPH), and initial response to MPH was achieved in 85.7%.

CONCLUSION

The epilepsy diagnosis preceded the ADHD diagnosis, and was found in a significantly higher rate than would be expected in the general pediatric population. The majority of patients had mild epilepsy and ADHD-Combined Inattentive/Hyperactive-Impulsive Subtype. All cases with epilepsy and ADHD were treated with MPH, with initial response achieved in 86%.

Reliability of early cortical auditory gamma-band responses

OBJECTIVE

To evaluate the test-retest reliability of event-related power changes in the 30-150 Hz gamma frequency range occurring in the first 150 ms after presentation of an auditory stimulus.

METHODS

Repeat intracranial electrocorticographic (ECoG) recordings were performed with 12 epilepsy patients, at ≥1-day intervals, using a passive odd-ball paradigm with steady-state tones. Time-frequency matching pursuit analysis was used to quantify changes in gamma-band power relative to pre-stimulus baseline. Test-retest reliability was estimated based on within-subject comparisons (paired t-test, McNemar's test) and correlations (Spearman rank correlations, intra-class correlations) across sessions, adjusting for within-session variability. Reliability estimates of gamma-band response robustness, spatial concordance, and reproducibility were compared with corresponding measurements from concurrent auditory evoked N1 responses.

RESULTS

All patients showed increases in gamma-band power, 50-120 ms post-stimulus onset, that were highly robust across recordings, comparable to the evoked N1 responses. Gamma-band responses occurred regardless of patients' performance on behavioral tests of auditory processing, medication changes, seizure focus, or duration of test-retest interval. Test-retest reproducibility was greatest for the timing of peak power changes in the high-gamma range (65-150 Hz). Reliability of low-gamma responses and evoked N1 responses improved at higher signal-to-noise levels.

CONCLUSIONS

Early cortical auditory gamma-band responses are robust, spatially concordant, and reproducible over time.

SIGNIFICANCE

These test-retest ECoG results confirm the reliability of auditory gamma-band responses, supporting their utility as objective measures of cortical processing in clinical and research studies.

Mental health problems in Nigerian children with epilepsy: associations and risk factors

Epilepsy is the most common neurological disorder affecting children, and the greatest burden of childhood epilepsy is found in the developing countries of the world. Behavioral problems are reported to occur more frequently in children with epilepsy, but there are limited studies on the pattern of behavioral problems in children living with epilepsy in sub-Saharan Africa. Eighty-four consecutive cases of epilepsy aged ≥5 years seen at the pediatric neurology clinic of the University College Hospital, Ibadan, Nigeria over a period of 9 months were screened for behavioral problems using the Rutter A2 scale. Behavioral problems were found in 39 (46.6%) of 84 subjects and occurred more frequently in males. Presence of associated learning difficulties (OR 5.13, 95% CI 1.61-16.36) and being diagnosed with epilepsy within 6 months of the onset of the first epileptic seizure (OR 4.54, 95% CI 0.073-0.69) independently predicted psychopathology in the cases studied. Emotional and behavioral problems are common in Nigerian children with epilepsy. There is a need for effective mental health services for children with epilepsy in order to optimize outcomes.

Childhood epilepsy and autism spectrum disorders: psychiatric problems, phenotypic expression, and anticonvulsants

Epilepsy and autism spectrum disorders (ASDs) frequently co-occur during childhood, however, the characteristics of psychiatric or behavioural problems in these children remains largely unknown. This article contributes to these discussions by reporting on the prevalence and presentation of psychiatric or behavioural problems in children with epilepsy and ASDs, as well as on the use of anticonvulsants in these children. The current evidence suggests that children with epilepsy and ASDs may present with a distinct clinical profile, with a greater number of developmental difficulties, and a more severe expression of the ASD phenotype that can not solely be accounted for by level of intellectual functioning. Positive effects of anticonvulsants on behavioural symptoms associated with ASDs were also reported, though pharmacoresistance and a lack of clear treatment guidelines may contribute to an elevated risk of adverse side effects. In relation to clinical presentation and management there is a need for careful consideration of potential interaction effects between disorder specific factors (e.g., age of seizure onset/ASD diagnosis), cognitive characteristics (e.g., intellectual functioning, memory), and psychosocial variables (e.g., coping strategies). Ultimately however, many conclusions are tentative and this review highlights the need for more empirically validated research on children with epilepsy and ASDs.

The sleep phenotypes of attention deficit hyperactivity disorder: the role of arousal during sleep and implications for treatment

About 25-50% of children and adolescents with attention-deficit hyperactivity disorder (ADHD) experience sleep problems. An appropriate assessment and treatment of such problems might improve the quality of life in such patients and reduce both the severity of ADHD and the impairment it causes. According to data in the literature and to the overall complexity of the interaction between ADHD and sleep, five sleep phenotypes may be identified in ADHD: (i) a sleep phenotype characterized mainly by a hypo-arousal state, resembling narcolepsy, which may be considered a "primary" form of ADHD (i.e. without the interference of other sleep disorders); (ii) a phenotype associated with delayed sleep onset latency and with a higher risk of bipolar disorder; (iii) a phenotype associated with sleep disordered breathing (SDB); (iv) another phenotype related to restless legs syndrome (RLS) and/or periodic limb movements; (v) lastly, a phenotype related to epilepsy/or EEG interictal discharges. Each sleep phenotype is characterized by peculiar sleep alterations expressed by either an increased or decreased level of arousal during sleep that have important treatment implications. Treatment with stimulants is recommended above all in the primary form of ADHD, whereas treatment of the main sleep disorders or of co-morbidities (i.e. bipolar disorders and epilepsy) is preferred in the other sleep phenotypes. All the sleep phenotypes, except the primary form of ADHD and those related to focal benign epilepsy or focal EEG discharges, are associated with an increased level of arousal during sleep. Recent studies have demonstrated that both an increase and a decrease in arousal are ascribable to executive dysfunctions controlled by prefrontal cortical regions (the main cortical areas implicated in the pathogenesis of ADHD), and that the arousal system, which may be hyperactivated or hypoactivated depending on the form of ADHD/sleep phenotype.

Health inequalities experienced by children and young people with intellectual disabilities: a review of literature from the United Kingdom

This literature review aimed to synthesize evidence on the prevalence and determinants of health conditions and impairments among children and young people with intellectual disability in the United Kingdom. Several databases were systematically searched for studies conducted with children under the age of 18 living in the United Kingdom and published in 2010-11. Evidence from a 2002 and a 2010 literature review on health inequalities among individuals of all ages with intellectual disability was also reviewed. We conclude there is an increased prevalence of a number of health conditions and impairments among children with intellectual disability and evidence that these health inequalities are associated with several preventable environmental determinants.