Epilepsy, intellectual disability, and living environment: a critical review

Using a picture-based book to support epilepsy care in clinical consultations for people with intellectual disabilities

BACKGROUND AND AIMS

People with intellectual disabilities are more likely to have epilepsy than the general population. A picture-based book, Getting on with Epilepsy, may help to improve their epilepsy management and quality of life. The present study aimed to explore how the book could be best used in routine clinical care.

METHODS

Twenty people with epilepsy and intellectual disabilities were video-recorded using the Getting on with Epilepsy book with a nurse or doctor. This was analysed using conversation analytic methods. Eighteen patients and five clinicians took part in interviews to explore their views on book use, which were thematically analysed. All data were then synthesised to form themes.

RESULTS

Three themes were identified which demonstrated the importance of (1) understanding the book depicted seizures (2) relating the book to the participants' experiences (3) using the book as an education and information tool. The themes highlighted the techniques and approaches that clinicians used to facilitate understanding. Some tensions and differences were noted between training and implementation in routine practice, particularly around prompts in themes 1 and 3 intended to correct or change participants' interpretation of the book.

CONCLUSIONS

The Getting on with Epilepsy book can be used in routine clinical practice to support people with intellectual disabilities and epilepsy. There was a balance between exploring patients' narratives and understanding with the need to convey clinical information, and this may also apply to the use of other accessible resources.

Clinical recommendations for conducting pediatric functional language and memory mapping during the phase I epilepsy presurgical workup

Objective: Pediatric epilepsy surgery effectively controls seizures but may risk cognitive, language, or memory decline. Historically, the intra-carotid anesthetic procedure (IAP or Wada Test) was pivotal for language and memory function. However, advancements in noninvasive mapping, notably functional magnetic resonance imaging (fMRI), have transformed clinical practice, reducing IAP's role in presurgical evaluations. Method: We conducted a critical narrative review on mapping technologies, including factors to consider for discordance. Results: Neuropsychological findings suggest that if pre-surgery function remains intact and the surgery targets the eloquent cortex, there is a high chance for decline. Memory and language decline are particularly pronounced post-left anterior temporal lobe resection (ATL), making presurgical cognitive assessment crucial for predicting postoperative outcomes. However, the risk of functional decline is not always clear - particularly with higher rates of atypical organization in pediatric epilepsy patients and discordant findings from cognitive mapping. We found little research to date on the use of IAP and other newer technologies for lateralization/localization in pediatric epilepsy. Based on this review, we introduce an IAP decision tree to systematically navigate discordance in IAP decisions for epilepsy presurgical workup. Conclusions: Future research should be aimed at pediatric populations to improve the precision of functional mapping, determine which methods predict post-surgical deficits and then create evidence-based practice guidelines to standardize mapping procedures. Explicit directives are needed for resolving conflicts between developing mapping procedures and established clinical measures. The proposed decision tree is the first step to standardize when to consider IAP or invasive mapping, in coordination with the multidisciplinary epilepsy surgical team.

Prevalence of epilepsy in autism spectrum disorders: A systematic review and meta-analysis

LAY ABSTRACT

Autistic individuals experience higher co-occurring medical conditions than the general population, and yet the estimates of autistic individuals with epilepsy are not updated. Co-occurrence of epilepsy in autistic individuals often aggravated cognitive impairment and increased the risk of poor long-term prognosis. Thus, an updated systematic review and meta-analysis was conducted to study the relevant articles published from inception to 2020, evaluate the prevalence of epilepsy in autistic individuals, and further explore the putative factors influencing the prevalence. A total of 66 studies from 53 articles were included in this study. The results showed that epilepsy is more common in autistic individuals than in the general population. The prevalence of epilepsy in autistic individuals in the clinical sample-based studies was higher than that in the population-based based cross-sectional or cohort studies. The prevalence of epilepsy in autistic adults was higher than that in autistic children. A significantly increased prevalence of epilepsy was detected in the autistic adolescent group (11-17 years old), and a higher trend of prevalence of epilepsy was observed in the autistic pre-school group (⩽ 6 -years-old) than that of the autistic school-aged group (7-10 years-old). The prevalence of epilepsy increased with age, female rate, and low intellectual function rate of autistic individuals. However, the human development index of countries was negatively associated with the pooled prevalence, which could be attributed to the different levels of awareness, diagnostic technologies, and autism-service support worldwide. About 1/10 autistic individuals also had epilepsy, which was common in the clinical setting, adolescents, adults, females, or patients with intellectual disability and less common in the country with high human development index. Thus, these findings provided critical and innovative views on the prevalence of epilepsy in autistic individuals and contributed to the targeted clinical management and preventive measures.

Autism Spectrum Disorder and Medical Cannabis: Review and Clinical Experience

Autism spectrum disorder (ASD) is a multifactorial, pervasive neurodevelopmental disorder defined by the core symptoms of significant impairment in social interaction and communication as well as restricted, repetitive patterns of behavior. In addition to these core behaviors, persons with ASD frequently have associated noncore behavioral disturbance (ie, self-injury, aggression), as well as several medical comorbidities. Currently, no effective treatment exists for the core symptoms of ASD. This review reports the available preclinical and clinical data regarding the use of cannabis and cannabidiol in the treatment of core symptoms, noncore symptoms and comorbidities associated with ASD. Additionally, we describe our clinical experience working with children and young adults with ASD who have used cannabis or cannabidiol. At present, preclinical and clinical data suggest a potential for therapeutic benefit among some persons with ASD and that it is overall well tolerated. Further research is required to better identify patients who may benefit from treatment without adverse effects.

In vitro changes in the proportion of protein-unbound-free propofol induced by valproate

PURPOSE

It has been reported that oral valproate (VPA) reduces the dose of propofol required for sedation. As  a potential reason for this, it is considered that VPA displaces serum protein-bound propofol and increases the proportion of protein-unbound-free propofol. To examine this hypothesis, the present in vitro study investigated the influence of VPA on the proportion of protein-unbound-free propofol in human serum samples.

METHODS

Serum samples were collected from 10 healthy volunteers, who were not taking any medication. VPA (final concentration: 0.05, 0.1 or 1 mg/mL) and propofol (final concentration: 1 or 5 µg/mL) were mixed with serum samples with normal (4.0 g/dL) or low (2.5 g/dL) albumin concentrations. Then, protein-unbound-free propofol was extracted from the samples, and its concentration was measured using high-performance liquid chromatography. We compared the proportion of protein-unbound-free propofol in each of the VPA-containing samples with that in serum samples without VPA (control).

RESULTS

In the serum samples with normal albumin concentrations, 1 mg/mL VPA significantly increased the proportion of protein-unbound-free propofol at 1 and 5 µg/mL propofol. Furthermore, in the serum samples with low albumin concentrations, the proportion of protein-unbound-free propofol was significantly increased by both 0.1 and 1 mg/mL VPA at propofol concentrations of 1 and 5 µg/mL.

CONCLUSION

VPA might increase the proportion of protein-unbound-free propofol in human serum via displacement reactions.

Primary care for people with an intellectual disability - what is prescribed? An analysis of medication recommendations from the BEACH dataset

BACKGROUND

People with intellectual disability (ID) experience a range of health disparities. Little is known about differential primary care prescribing patterns for people with and without ID.

AIM

To compare medications recommended by GPs at encounters where ID is recorded versus other encounters.

DESIGN & SETTING

Analysis of national Australian GP medication data from the Bettering the Evaluation and Care of Health (BEACH) programme, January 2003-December 2012 inclusive.

METHOD

Medication recommendations made at encounters where an ID-defining problem was recorded as a reason for encounter (RFE) and/or as a problem managed, were allocated to the 'ID group' (n = 563). These encounters were compared with all other encounters (the 'non-ID group', n = 1 004 095) during the study period. Following age-sex standardisation of ID group encounters, significant differences were determined by non-overlapping 95% confidence intervals (CIs).

RESULTS

Antipsychotics and anticonvulsants were recommended more frequently at ID group encounters than at non-ID group encounters. Antidepressant and anxiolytic recommendation rates did not differ between groups. Narcotic analgesic and antihypertensive recommendations were significantly lower at ID group encounters.

CONCLUSION

Higher rates of epilepsy and mental illness, and off-label use of some antipsychotics and anticonvulsants for behaviour management in people with ID, may have contributed to medication recommendations observed in this analysis. Lower narcotic analgesic recommendations at ID group encounters may relate to complex presentations and the nature of problems managed, while lower antihypertensive recommendations may indicate some potential omission of routine blood pressure measurement.

Quality of life predictors in patients with epilepsy and cognitive disabilities

Purpose We aimed to assess the QOL and its predictors in Bulgarian patients with refractory epilepsy (RE) and cognitive problems.

Methods We conducted a study based on questionnaires designed for people with intellectual disability (the stigma scale, the Glasgow Depression Scale, the Glasgow Anxiety Scale, the Glasgow Epilepsy Outcome Scale – GEOS-35) and a purposeful interview on clinical and social factors of 64 patients (50% men) with RE and cognitive problems.

Results The mean total score of the GEOS-35 was 76 ± 2.34 (an indicator of low QOL). On univariate analysis, the GEOS-35 total score was associated with seizure frequency and severity, stigma, depression, and anxiety. On multivariate regression analysis predictors of the GEOS-35 total score were anxiety, seizure severity, and stigma Р < 0.001 (F = 14.66). Regarding the GEOS-35 subscales, on multivariate regression analysis, we found that 1. Seizure severity, seizure type, and anxiety were predictors of “concerns about seizures” Р < 0.001 (F = 8.99); 2. Anxiety was the only predictor of “concerns about treatment” Р < 0.001 (F = 7.98); 3. Anxiety and seizure severity were predictors of “concerns about caring” Р < 0.001 (F = 12.12); and 4. Seizure severity and stigma were predictors of “concerns about social impact” Р < 0.001 (F = 18.31).

Conclusions We have affirmed the low QOL in patients with RE and cognitive problems and its clinical and social determinants. The results from our study prove the necessity of a multidisciplinary approach for quality of life improvement in these patients.

Low bone mineral density risk factors and testing patterns in institutionalized adults with intellectual and developmental disabilities

BACKGROUND

Adults with intellectual or developmental disability (ID/DD) have multiple risks for low bone mineral density (BMD) without formal guidelines to guide testing. We sought to identify risk factors and patterns of BMD testing among institutionalized adults with ID/DD.

METHODS

We evaluated risk factors for low BMD (Z-/T-score < -1) and patterns of BMD testing among adults with ID/DD receiving care at a state-run residential facility. Kruskal-Wallis, Fisher's exact and Pearson's chi-squared tests were used as appropriate.

RESULTS

Of the 140 eligible patients, only 44% ever had BMD testing of which 89% had low BMD. Median age at diagnosis was 42 years old. Individuals with low BMD were more likely to be older, non-weight bearing, Caucasian and have severe cognitive delay.

CONCLUSIONS

Adults with ID/DD in this facility had a high prevalence of low BMD. Further studies are needed to better characterize risk factors and inform screening within this high-risk population.

Wordless intervention for people with epilepsy and learning disabilities (WIELD): a randomised controlled feasibility trial

OBJECTIVE

To investigate the feasibility of a full-scale randomised controlled trial of a picture booklet to improve quality of life for people with epilepsy and learning disabilities.

TRIAL DESIGN

A randomised controlled feasibility trial. Randomisation was not blinded and was conducted using a centralised secure database and a blocked 1:1 allocation ratio.

SETTING

Epilepsy clinics in 1 English National Health Service (NHS) Trust.

PARTICIPANTS

Patients with learning disabilities and epilepsy who had: a seizure within the past 12 months, meaningful communication and a carer with sufficient proficiency in English.

INTERVENTION

Participants in the intervention group used a picture booklet with a trained researcher, and a carer present. These participants kept the booklet, and were asked to use it at least twice more over 20 weeks. The control group received treatment as usual, and were provided with a booklet at the end of the study.

OUTCOME MEASURES

7 feasibility criteria were used relating to recruitment, data collection, attrition, potential effect on epilepsy-related quality of life (Epilepsy and Learning Disabilities Quality of Life Scale, ELDQOL) at 4-week, 12-week and 20-week follow-ups, feasibility of methodology, acceptability of the intervention and potential to calculate cost-effectiveness.

OUTCOME

The recruitment rate of eligible patients was 34% and the target of 40 participants was reached. There was minimal missing data and attrition. An intention-to-treat analysis was performed; data from the outcome measures suggest a benefit from the intervention on the ELDQOL behaviour and mood subscales at 4 and 20 weeks follow-up. The booklet and study methods were positively received, and no adverse events were reported. There was a positive indication of the potential for a cost-effectiveness analysis.

CONCLUSIONS

All feasibility criteria were fully or partially met, therefore confirming feasibility of a definitive trial.

TRIAL REGISTRATION NUMBER

ISRCTN80067039.

"Sometimes, it just stops me from doing anything": A qualitative exploration of epilepsy management in people with intellectual disabilities and their carers

PURPOSE

Epilepsy affects 1 in 5 people with an intellectual disability (ID), but little is known about their experiences of living with epilepsy. A qualitative study was conducted to investigate the impact and management of epilepsy in people with ID.

MATERIALS AND METHODS

People with epilepsy and ID and their carers were invited to take part in semi-structured interviews. Eleven participants with ID and their carers were interviewed together, one participant with ID and their carer were interviewed separately, two interviews took place with the participant with ID only, and one interview took place with the carer only. The interviews were transcribed verbatim, coded, and analyzed thematically (dual independent coding for 30% of the transcripts).

RESULTS

Three themes emerged (participant characteristics, living with epilepsy, epilepsy management and information needs) which indicated the following: 1) diversity regarding health profiles, communication abilities, severity of epilepsy, perceived control of epilepsy, and support needs; 2) a reduction in severity and frequency of seizures for a sizeable proportion of participants through antiepileptic drugs; 3) the lifelong impact of epilepsy and related seizures on participants' activities and quality of life; 4) the perceived burden of epilepsy and difficulty managing the condition for a large proportion of participants; 5) high levels of satisfaction with epilepsy-related services and care; and 6) an overall lack of written accessible information about epilepsy.

CONCLUSIONS

This study has highlighted a significant impact of epilepsy and related seizures on the daily lives and quality of life of people with ID. Although a sizeable proportion of participants and their carers considered their epilepsy to be well controlled, the majority reported difficulties managing epilepsy and minimizing its impact on their wellbeing. Excluding care staff and the support provided by epilepsy clinics, the participants had not accessed any adapted self-management or information resources about epilepsy.

Effect of carbamazepine or phenytoin therapy on blood level of intravenously administered midazolam: a prospective cohort study

Dental treatment of intellectually disabled patients is frequently performed under general anesthesia or sedation. Many of these patients have epilepsy and are medicated with antiepileptic drugs (AEDs). Carbamazepine (CBZ) and phenytoin (PHT) are known to promote the metabolism of midazolam, and the blood levels of midazolam in patients medicated with CBZ or PHT may be different from those in healthy individuals. In this study, we clarified the influences of CBZ and PHT on the blood level of intravenously administered midazolam in patients medicated with CBZ or PHT. The subjects were divided into the following groups: not medicated with AEDs (control group), medicated with only CBZ or PHT (mono CBZ/PHT group), and medicated with CBZ or PHT or both and other AEDs (poly CBZ/PHT group). General anesthesia was achieved using midazolam, propofol, and remifentanil, and then the blood midazolam level was measured at 10, 30, and 60 min after intravenous midazolam administration. According to the results, the blood midazolam level was significantly lower in the mono and poly CBZ/PHT groups than in the control group. This finding suggests that intravenously administered midazolam may have a weaker effect in patients medicated with CBZ or PHT.

Does adherence to epilepsy quality measures correlate with reduced epilepsy-related adverse hospitalizations? A retrospective experience

In 2011, the American Academy of Neurology (AAN) established eight epilepsy quality measures (EQMs) for chronic epilepsy treatment to address deficits in quality of care. This study assesses the relationship between adherence to these EQMs and epilepsy-related adverse hospitalizations (ERAHs). A retrospective chart review of 475 new epilepsy clinic patients with an ICD-9 code 345.1-9 between 2010 and 2012 was conducted. Patient demographics, adherence to AAN guidelines, and annual number of ERAHs were assessed. Fisher's exact test was used to assess the relationship between adherence to guidelines (as well as socioeconomic variables) and the presence of one or more ERAH per year. Of the eight measures, only documentation of seizure frequency, but not seizure type, correlated with ERAH (relative risk [RR] 0.343, 95% confidence interval [CI] 0.176-0.673, p = 0.010). Among patients in the intellectually disabled population (n = 70), only review/request of neuroimaging correlated with ERAH (RR 0.128, 95% CI 0.016-1.009, p = 0.004). ERAHs were more likely in African American patients (RR 2.451, 95% CI 1.377-4.348, p = 0.008), Hispanic/Latino patients (RR 4.016, 95% CI 1.721-9.346, p = 0.016), Medicaid patients (RR 2.217, 95% CI 1.258-3.712, p = 0.009), and uninsured patients (RR 2.667, 95% CI 1.332-5.348, p = 0.013). In this retrospective series, adherence to the eight AAN quality measures did not strongly correlate with annual ERAH.

The relationship between living arrangement and adherence to antiepileptic medications among individuals with developmental disabilities

BACKGROUND

Non-adherence to antiepileptic drugs (AEDs) is associated with considerable morbidity and mortality in the general population but little is known about adherence in individuals with intellectual disability (ID).

METHOD

Using the records of a closed pharmacy billing system over a 30 month period, we examined the medication non-adherence rates for AEDs among 793 individuals with ID. We calculated the medication possession ratio (number of days each participant was in possession of an AED), and defined non-adherence as 25% or more of the exposure days without the possession of an AED. All participants studied had filled prescriptions for AEDs spanning at least 6 months.

RESULTS

Controlling for age and gender, we found non-adherence rates varied by living arrangement. Compared with those living in group homes, individuals with ID living in family homes or in semi-independent settings were significantly less adherent to AEDs (P < 0.0003).

CONCLUSION

Non-adherence to AEDs is a potential medical risk for individuals with ID that is significantly impacted by the type of community living arrangement.

Prognostic factors for outcome in pediatric probable lesional frontal lobe epilepsy with an unknown cause (cryptogenic)

The outcomes of children with cryptogenic seizures most probably arising from the frontal lobe are difficult to predict. We retrospectively collected data on 865 pediatric patients with epilepsy. In 78 patients with cryptogenic frontal lobe epilepsy, the age at first seizure was inversely correlated with the outcome, including the degree of intellectual disability/developmental delay (P = .002) and seizure frequency (P = .02) after adequate treatment. Intellectual disability was more prevalent in children with a first seizure at 0 to 3 years old (P = .002), and seizures were more frequent in those with a first seizure at 0 to 6 years old than at 7 to 16 years old (P = .026). For pediatric cryptogenic frontal lobe epilepsy, the age at first seizure is important and inversely correlated with outcome, including seizure frequency and intellectual disability.

Wordless intervention for epilepsy in learning disabilities (WIELD): study protocol for a randomized controlled feasibility trial

BACKGROUND

Epilepsy is the most common neurological problem that affects people with learning disabilities. The high seizure frequency, resistance to treatments, associated skills deficit and co-morbidities make the management of epilepsy particularly challenging for people with learning disabilities. The Books Beyond Words booklet for epilepsy uses images to help people with learning disabilities manage their condition and improve quality of life. Our aim is to conduct a randomized controlled feasibility trial exploring key methodological, design and acceptability issues, in order to subsequently undertake a large-scale randomized controlled trial of the Books Beyond Words booklet for epilepsy.

METHODS/DESIGN

We will use a two-arm, single-centre randomized controlled feasibility design, over a 20-month period, across five epilepsy clinics in Hertfordshire, United Kingdom. We will recruit 40 eligible adults with learning disabilities and a confirmed diagnosis of epilepsy and will randomize them to use either the Books Beyond Words booklet plus usual care (intervention group) or to receive routine information and services (control group). We will collect quantitative data about the number of eligible participants, number of recruited participants, demographic data, discontinuation rates, variability of the primary outcome measure (quality of life: Epilepsy and Learning Disabilities Quality of Life scale), seizure severity, seizure control, intervention's patterns of use, use of other epilepsy-related information, resource use and the EQ-5D-5L health questionnaire. We will also gather qualitative data about the feasibility and acceptability of the study procedures and the Books Beyond Words booklet. Ethical approval for this study was granted on 28 April 2014, by the Wales Research Ethics Committee 5. Recruitment began on 1 July 2014.

DISCUSSION

The outcomes of this feasibility study will be used to inform the design and methodology of a definitive study, adequately powered to determine the impact of the Books Beyond Words intervention to improve the management of epilepsy in people with learning disabilities.

TRIAL REGISTRATION

http://ISRCTN80067039 (Date of ISRCTN assignation: 23 April 2014).

The association between epilepsy and autism symptoms and maladaptive behaviors in children with autism spectrum disorder

Epilepsy is common in children with autism spectrum disorder (ASD) but little is known about how seizures impact the autism phenotype. The association between epilepsy and autism symptoms and associated maladaptive behaviors was examined in 2,645 children with ASD, of whom 139 had epilepsy, from the Simons Simplex Collection. Children with ASD and epilepsy had significantly more autism symptoms and maladaptive behaviors than children without epilepsy. However, after adjusting for IQ, only hyperactivity symptoms remained significantly increased (13% higher) in the epilepsy group. Among children with ASD without co-occurring intellectual disability, children with epilepsy had significantly more irritability (20% higher) and hyperactivity (24% higher) symptoms. This is the largest study to date comparing the autism phenotype in children with ASD with and without epilepsy. Children with ASD and epilepsy showed greater impairment than children without epilepsy, which was mostly explained by the lower IQ of the epilepsy group. These findings have important clinical implications for patients with ASD.

A qualitative study of carers' and professionals' views on the management of people with intellectual disability and epilepsy: a neglected population

Little attention has been paid to the specific needs of people with intellectual disability and epilepsy despite evidence of increased prevalence of epilepsy, increased risk of complex epilepsy, and heightened use of health services among this group. In an attempt to address this gap, an online international survey was undertaken inviting health professionals and caregivers, both paid and family members, to share their views on the adequacy and quality of available treatment. This paper reports on the responses obtained from 113 individuals from the UK and Ireland. Findings revealed that professionals and carers differ in their expectations of treatment and with regard to maximizing communication during consultations. In addition, findings suggested that the potential of consultations to provide information for carers, as well as to allay concerns, may not be realized. Rescue medications were viewed favorably; however, respondents expressed less satisfaction with routine medications. These findings may reflect a failure by professionals to appropriately transfer knowledge of these treatments.

Epilepsy and autism: neurodevelopmental perspective

Epilepsy and autism coexist in up to 20% of children with either disorder. Current studies suggest that a frequent co-occurring condition in epilepsy and autism is intellectual disability, which shows a very high prevalence in those with both autism and epilepsy. In addition, these recent studies suggest that early-onset seizures may index a group of infants at high risk for developing autism, usually with associated intellectual deficits. In this review we discuss recent advances in the conceptualization of shared anatomical and molecular mechanisms that may account for the coexistence of epilepsy, autism, and intellectual disability. A major contribution to our improved understanding of the relationship among these three phenotypes is the discovery of multiple genomic variants that cut across them as well as other neurobehavioral phenotypes. As these discoveries continue they are very likely to elucidate causal mechanisms for the various phenotypes and pinpoint biologic pathways that may be amenable to therapeutic interventions for this group of neurodevelopmental disorders.

A longitudinal study of epilepsy and other central nervous system diseases in individuals with and without a history of infantile autism

OBJECTIVE

To compare the prevalence and types of epilepsy and other central nervous system (CNS) diseases in a clinical sample of 118 individuals diagnosed as children with infantile autism (IA) with 336 matched controls from the general population.

METHODS

All participants were screened through the nationwide Danish National Hospital Register (DNHR). The average observation time was 30.3years (range 27-30years), and mean age at follow-up was 42.7years (range 27-57years).

RESULTS

Of the 118 individuals with IA, 29 (24.6%) were registered with at least one epilepsy diagnosis against 5 (1.5%) in the comparison group (p<0.0001; OR=21.6; 95% CI 8.1-57.3). Other CNS diseases occurred with low frequency in both groups and only cerebral palsy, unspecified (p=0.02) was significantly more frequent among participants with a history of IA.

CONCLUSIONS

Our study lends further support to the notion that epilepsy, but not other CNS diseases, is a common comorbid condition in IA. Low intelligence, but not gender, was a risk factor for epilepsy in IA.

Social skills: differences among adults with intellectual disabilities, co-morbid autism spectrum disorders and epilepsy

Assessing social skills is one of the most complex and challenging areas to study because behavioral repertoires vary depending on an individual's culture and context. However, researchers have conclusively demonstrated that individuals with intellectual disabilities (ID) have impaired social skills as well as those with co-morbid autism spectrum disorders (ASD) and epilepsy. However, it is unknown how these groups differ. Assessment of social skills was made with the Matson Evaluation of Social Skills for Individuals with Severe Retardation. One hundred participants with ID were matched and compared across four equal groups comprising 25 participants with ID, 25 participants with epilepsy, 25 participants with ASD, and 25 participants with combined ASD and epilepsy. When controlling for age, gender, race, level of ID, and hearing and visual impairments, significant differences were found among the four groups on the MESSIER, Wilks's Λ=.58, F(18, 257)=3.05, p<.01. The multivariate η(2) based on Wilks's Λ was .17. Significant differences were found on the Positive Verbal subscale, F(3, 96)=3.70, p<.01, η(2)=.10, Positive Non-verbal subscale, F(3, 96)=8.95, p<.01, η(2)=.22, General Positive subscale, F(3, 96)=7.30, p<.01, η(2)=.19, Negative Non-verbal subscale, F(3, 96)=5.30, p<.01, η(2)=.14, and General Negative subscale, F(3, 96)=3.16, p<.05, η(2)=.09. Based on these results, individuals with ID expressing combined co-morbid ASD and epilepsy had significantly more impaired social skills than the ID only or groups containing only a single co-morbid factor with ID (ASD or epilepsy only). Implications of these findings are discussed.

Description of environmental determinants of quality of life in children with intellectual disability in Japan using the Delphi technique

OBJECTIVES

The present study aimed to define the framework of an environment conducive to the well-being of children with intellectually disability (CID).

METHODS

A questionnaire composed of 31 items was developed through literature review. Then a 2-round Delphi survey was conducted with 3 different panels: health professionals (HPs), parents of CID, and teachers. The participants were asked to rate each item, select and rank the 10 most important items, and suggest additional ones.

RESULTS

A total of 71 participants responded to the first round: 24 HPs, 22 parents, and 25 teachers. In the second round the overall response rate was 83%. At the end of the exercise, 12 items reached global consensus, i.e., in all groups. Only 5 items were ranked as most important by all groups: attitudes of family members at home; attitudes of HPs and teachers; support from family members at home; support at school (classmates and teachers); and government policies. Nevertheless, the panelists' views diverged on the remaining items. Several additional elements were suggested.

CONCLUSIONS

The views of HPs, teachers, and parents are complementary for the improvement of quality of life (QOL) of CID. The present findings will be used as a basis for the development of an instrument to assess the living environment of CID.

Association of epilepsy and comorbid conditions

Comorbid health conditions are common among people with epilepsy. Proposed explanations for this association include the possibility that first, epilepsy (including its treatment) causes the comorbid condition; second, the comorbid condition (including its treatment) causes epilepsy; or third, a common pathogenic mechanism mediates the co-occurrence of epilepsy and the comorbid condition. It is unlikely that a single explanation will suffice for all of the epilepsy comorbid conditions. Determining the basis of the association between epilepsy and its comorbid conditions has important implications for diagnosis and management. In this paper, we discuss this issue in the context of five common epilepsy comorbid conditions: bone health and fractures, stroke, depression, migraine and attention-deficit hyperactivity disorder. Current findings, research limitations and future directions of research efforts are discussed.

Epilepsy in children with intellectual disability in Bosnia and Herzegovina: effects of sex, level and etiology of intellectual disability

The purpose of this study was to examine the occurrence of epilepsy in children with intellectual disability. An additional goal was to determine if there were statistical differences in the occurrence of epilepsy related to the sex, level and etiology of intellectual disability of children. The sample consisted of 167 children with intellectual disability attending two special education schools in Sarajevo, Bosnia and Herzegovina. The method for data collection was the examination of the children's medical records. A chi-square test was performed to determine if there were any significant differences in the occurrence of epilepsy among different categories of children with intellectual disability. Additionally, Phi coefficient and Cramer V coefficient were calculated to determine the strength of association. The occurrence of epilepsy in children with intellectual disability is high and certain etiological categories are associated with an even higher risk of epilepsy. The study confirmed a high occurrence of epilepsy in children with intellectual disability. Some psycho-educational implications of epilepsy were discussed and in the future there should be better cooperation between medical and educational institutions in treating the bio-psycho-social issues of a child with epilepsy.

Living environment of persons with severe epilepsy and intellectual disability: a prospective study

We studied a population with intellectual disability (ID) and epilepsy and analyzed aspects of the living environment. Using an epilepsy impact score (EPIEK, the Epilepsy Impact Scale Kempenhaeghe), we found that epilepsy is more severe in younger persons than in older persons until about age 60 years. Individuals with more adaptive behavior had less severe epilepsy. Compared with persons with ID, the subjects in this study had fewer sensory problems and many more mobility problems, and more often saw a general practitioner. We concluded that people with severe epilepsy and ID have, in some ways, the same needs as people with only ID, and yet, in other ways (development of adaptive skills and aspects of living environment), distinctly different needs.

Epilepsy in autism is associated with intellectual disability and gender: evidence from a meta-analysis

BACKGROUND

The association between epilepsy and autism is consistently reported, with a wide range of prevalence rates. This may be attributed to the heterogeneity of the samples with respect to age, comorbidity, sex, and intellectual disability (ID). We aimed to compare the prevalence of epilepsy 1) among autistic patients with ID versus autistic patients without ID and 2) among male versus female autistic patients.

METHODS

We reviewed all data available from published reports (1963-2006) on autism and epilepsy and conducted a meta-analysis of 10 and 14 studies, respectively, to assess the relative risk (RR) of epilepsy in autism according to ID and gender. The pooled groups included 2112 (627 with IQ > or = 70, 1485 with IQ < 70) and 1530 (1191 male, 339 female) patients, respectively.

RESULTS

There was a strong discrepancy in relative risk (RR) according to IQ, with more autistic patients with ID having epilepsy (RR = .555; 95% confidence interval [CI]: .42-.73; p < .001). The pooled prevalence of epilepsy was 21.5% in autistic subjects with ID versus 8% in autistic subjects without ID. There was a strong discrepancy in RR according to sex, favoring comorbidity of epilepsy in autistic girls (RR = .549; 95% CI: .45-.66; p < .001). The male:female ratio of autism comorbid with epilepsy was close to 2:1 whereas the male:female ratio of autism without epilepsy was 3.5:1.

CONCLUSIONS

The results of this meta-analysis indicate that risk for epilepsy in autism is a function of ID severity and distinguishes autism associated with epilepsy as a subgroup of autism by its male-female ratio.