The relationship of seizure focus with depression, anxiety, and health-related quality of life in children and adolescents with epilepsy

Influence of Epilepsy Characteristics on the Anxiety Occurrence

The presence of anxiety in individuals with epilepsy significantly influences their medical treatment and quality of life and often goes unrecognized or untreated, posing a challenge to differential diagnosis. The study aimed to investigate the influence of epilepsy characteristics on anxiety. The research involved 155 patients with generalized and focal drug-sensitive [DSE] and drug-resistant [DRE] epilepsy. Hamilton anxiety rating scale [HAS] was used to assess the symptoms of anxiety at three time points [baseline, 12, and 18 months]. DSE patients exhibited significantly lower HAM-A scores than patients with DRE at the initial visit [p = 0.000] after 12 [p = 0.000] and 18-month follow-up [p = 0.000]. Focal DRE patients presented higher HAM-A scores than focal DSE patients in the initial visit [p = 0.000] after 12 [p = 0.000] and 18 months [p = 0.000]. Medication responsiveness, seizure type, and illness duration emerged as significant anxiety predictors [p = 0.000]. After 18 months of follow-up, significant contributors to anxiety were drug responsivity and illness duration [p = 0.000]. The occurrence of anxiety in epilepsy patients is most significantly influenced by well-controlled epilepsy and a positive response to medication.

EEG changes induced by meditative practices: State and trait effects in healthy subjects and in patients with epilepsy

The effect of meditation on brain activity has been the topic of many studies in healthy subjects and in patients suffering from chronic diseases. These effects are either explored during meditation practice (state effects) or as a longer-term result of meditation training during the resting-state (trait). The topic of this article is to first review these findings by focusing on electroencephalography (EEG) changes in healthy subjects with or without experience in meditation. Modifications in EEG baseline rhythms, functional connectivity and advanced nonlinear parameters are discussed in regard to feasibility in clinical applications. Secondly, we provide a state-of-the-art of studies that proposed meditative practices as a complementary therapy in patients with epilepsy, in whom anxiety and depressive symptoms are prevalent. In these studies, the effects of standardized meditation programs including elements of traditional meditation practices such as mindfulness, loving-kindness and compassion are explored both at the level of psychological functioning and on the occurrence of seizures. Lastly, preliminary results are given regarding our ongoing study, the aim of which is to quantify the effects of a mindfulness self-compassion (MSC) practice on interictal and ictal epileptic activity. Feasibility, difficulties, and prospects of this study are discussed.

[The relationship between immunological and psychopathological characteristics in patients with focal epilepsy depending on the profile of interhemispheric asymmetry]

OBJECTIVE

To identify the possible influence of cellular immunity parameters and neurobiological variables (frequency of seizures of various semiotics and their severity) on comorbid psychopathological symptoms depending on the profile of interhemispheric asymmetry in patients with focal forms of epilepsy.

MATERIAL AND METHODS

The study included 92 patients with epilepsy (38 men, 54 women, mean age 38.7+8.45 years). Focal temporal lobe epilepsy was diagnosed in 36 patients, focal frontal lobe epilepsy in 16 patients, and temporal-frontal lobe epilepsy in 40 patients. For each type of seizure, severity was assessed according to the National Seizure Severity Scale (NHS3). The mental status of patients was assessed using the SCL-90 self-report questionnaire. The Annette scale was used to assess the profile of interhemispheric asymmetry. The number of different clusters of lymphocytes was studied, including the number of T-lymphocytes (CD3+), T-helpers (CD3+CD4+), T-cytotoxic (CD3+CD8+), T-NK (natural killers CD3+CD16+CD56+), B-lymphocytes (CD3-CD19+), as well as immunoregulatory index (CD4/CD8 ratio). In order to identify any possible relationships between neurobiological and immune variables, on the one hand, and the SCL-90 constructs, on the other hand, a separate correlation analysis of Spearman ranks within the left-handed group and the right-handed group was carried out.

RESULTS

We revealed the differences between groups of patients with epilepsy with right and left profiles of hemispheric asymmetry regarding the relationship between the frequency of seizures, their severity and accompanying psychopathological variables, on the one hand, and between immunity indices and psychopathological constructs, on the other hand. It has been established that neurobiological and immune variables in left-handers can determine the psychopathological structure of the comorbid mental disorder.

CONCLUSION

Prediction of concomitant psychopathological syndromes in patients with epilepsy on the basis of clinical data and data on immunity is quite possible, but only in left-handed patients.

Key predictors of epilepsy-specific health-related quality of life (HRQOL) in youth with epilepsy

PURPOSE

Epilepsy-specific health-related quality of life (HRQOL) is an important outcome in youth with epilepsy (YWE). The PedsQL™ Epilepsy Module is the only caregiver-proxy and youth self-report epilepsy-specific HRQOL measure that can be used with youth 2-25 years. Multiple factors affect HRQOL, including epilepsy-specific characteristics, comorbid mental and behavioral health concerns, as well as sociodemographic factors. However, we have not yet examined the cumulative impact of these factors on epilepsy-specific HRQOL in YWE using the PedsQL™ Epilepsy module.

METHOD

Youth with epilepsy (n = 281) and their caregivers completed questionnaires focused on sociodemographic factors (e.g., youth biological sex and age), mood/anxiety and behavior symptoms (i.e., Behavioral Assessment Scale for Children - Second Edition; BASC-2, Parent Rating Scale), epilepsy characteristics [e.g., seizure frequency, number of anti-seizure medications (ASMs), ASM side effects, and years since diagnosis], and the PedsQL™ Epilepsy module (subscales: Impact, Cognitive Functioning, Executive Functioning, Sleep, and Mood/Behavior).

RESULTS

Hierarchical linear regressions were conducted to examine caregiver-proxy and youth self-reported factors that affect epilepsy-specific HRQOL. Results indicate the strongest key shared predictors of HRQOL in YWE, for both youth and caregiver informants, were mental and behavioral health symptoms. For instance, caregiver-proxy report of YWE HRQOL indicated BASC-2 Externalizing (p < 0.05), Behavioral Symptoms (p < 0.01), and Adaptive Skills (p < 0.001) explained 58 % of the variance in youth Cognitive Functioning HRQOL, while youth self-report of HRQOL indicated that BASC-2 Externalizing (p < 0.01), Behavioral Symptoms (p < 0.05), and Adaptive Skills (p < 0.001) contributed only 36 % of the variance in Cognitive Functioning HRQOL above and beyond the variance explained by sociodemographic and epilepsy-specific characteristics. Similar results were noted for Executive Functioning HRQOL domain, wherein caregiver-proxy report of YWE HRQOL indicated BASC-2 Internalizing (p < 0.01), Behavioral Symptoms (p < 0.001) and Adaptive Skills (p < 0.001) explained 65 % of variance in Executive Functioning, whereas youth self-report of Executive Functioning HRQOL indicated that caregiver-proxy BASC-2 Internalizing (p < 0.001) and Behavioral Symptoms (p < 0.01) explained 34 % of the variance in Executive Functioning HRQOL, above and beyond the variance explained by sociodemographic and epilepsy-specific characteristics. Unique mental and behavioral health predictors of YWE HRQOL were also found for both caregiver-proxy and youth self-report.

CONCLUSIONS

Given the integral role of mental and behavioral health symptoms in epilepsy-specific HRQOL, it is critical to address mental and behavioral health symptoms preventatively and proactively to provide YWE with the most optimal health plan, including good seizure control, minimal ASM side effects, and the best possible HRQOL.

Neighborhood disadvantage and health-related quality of life in pediatric epilepsy

INTRODUCTION

While several demographic and epilepsy-specific characteristics are associated with diminished HRQoL in children and adolescents with epilepsy, prior investigations have failed to incorporate and address the influence of broader social contextual factors on functional outcomes. To address this gap, the purpose of the current study was to investigate the role of neighborhood disadvantage on HRQoL, including the extent to which familial and seizure-specific risk factors are impacted.

METHODS

Data included parental ratings on the Quality of Life in Childhood Epilepsy (QOLCE) questionnaire for 135 children and adolescents with epilepsy, and the Area Deprivation Index (ADI) to measure neighborhood disadvantage. Bivariate correlations were conducted to identify significant associations with neighborhood disadvantage, followed by a three-stage hierarchical multiple regression to predict HRQoL. Follow-up binary logistic regressions were used to determine the risk conferred by neighborhood disadvantage on sociodemographic, seizure-specific, and HRQoL factors.

RESULTS

Moderate associations between neighborhood disadvantage and familial factors, including parental psychiatric history and Medicaid insurance, were identified, while disadvantage and greater seizure frequency were marginally associated. Neighborhood disadvantage independently predicted HRQoL, and was the sole significant predictor of HRQoL when familial factors were incorporated. Children with epilepsy living in disadvantaged areas were four times more likely to have diminished HRQoL, five times more likely to live with a parent with a significant psychiatric history, and four times more likely to reside with a family receiving Medicaid insurance.

CONCLUSIONS

These results highlight the importance of identifying high-risk groups, as the cumulative burden of social context, familial factors, and seizure-specific characteristics contribute to lower HRQoL in pediatric epilepsy which disproportionately affects patients from lower-resourced backgrounds. Potentially modifiable factors such as parental psychiatric status exist within the child's environment, emphasizing the importance of a whole-child approach to patient care. Further exploration of disadvantage in this population is needed to better understand these relationships over time.

Health-related quality of life in children with epilepsy: a concept analysis

PURPOSE

This study aimed to conduct a concept analysis of health-related quality of life in children with epilepsy to promote conceptual clarification and facilitate mutual understanding of the concept.

METHODS

Walker and Avant's concept analysis method was adopted.

RESULTS

Health-related quality of life in children with epilepsy consists of six attributes: health status, inner strength, close relationships, resource-rich community, social acceptance, and changeability. According to the ecological system paradigm, these attributes are structured into five dimensions: organism, microsystem, macrosystem, exosystem, and chronosystem. These dimensions provide a comprehensive approach to the relationship between children with epilepsy and their environment. Epilepsy and interactions with multilevel ecological systems that are directly and indirectly related to children with epilepsy precede the concept, followed by positive and negative affective responses.

CONCLUSION

The findings of this study may support effective communication in various practice settings, thereby contributing to the health and well-being of children with epilepsy, as well as the development and expansion of interventions to improve their health-related quality of life.

Behavioral health screening in pediatric epilepsy: Which measures commonly used in the United States are 'good enough'?

PURPOSE

To improve evidence-based implementation of behavioral health screening measures in pediatric epilepsy care, guidance is needed in the selection and interpretation of evidence-based screening measures. Therefore, the goals of this project were to (1) evaluate the clinical utility and psychometric properties of screening instruments frequently used in the United States (US) for anxiety, depression, and behavior problems in youth with epilepsy (YWE), and (2) provide guidance around selection and interpretation of these behavioral health screening measures.

METHOD

The critique was conducted in three phases: (1) identification of articles based on search criteria; (2) full review of articles for eligibility assessment; (3) evaluation of screening measures and organization into Tiers. Nine behavioral health measures frequently used to screen for anxiety, depression, and disruptive behaviors in the US were selected for evaluation. PubMed, CINAHL, Medline, and APA databases were searched using the following search terms: [target area] + [screening measure] + epilepsy + children [youth], [adolescents]. Inclusion/exclusion criteria for articles were as follows: (1) focused on YWE, (2) written in English, and (3) conducted in the US. Once articles were selected, Hunsley and Mash's criteria were used to evaluate and categorize the screening measures' psychometric properties, which have clear relevance to clinical practice. Measures were also classified into three tiers by the level of validation according to established evidence-based criteria.

RESULTS

Forty-one unique papers were identified through the literature search and assessed as eligible. Evaluation of screening measures revealed only two psychometrically sound measures that met criteria for Tier 1, the NDDI-E-Y and the Pediatric NeuroQoL-Depression, both depression screening measures. Several additional depression screening measures met criteria for Tier 2 (CDI-2, BASC-2-Depression Scale, and CBCL Withdrawn/Depressed Scale). Anxiety screening measures have not been validated in pediatric epilepsy and thus only met the criteria for Tier 2 (BASC-2 Anxiety Scale, CBCL DSM-IV Oriented Anxiety Problems Scale, MASC). Similarly for disruptive behaviors, two measures met Tier 2 criteria (BASC-2 Externalizing Problems Index, CBCL Externalizing Problems Index).

CONCLUSION

Strides have been made in the validation of behavioral health screening measures for YWE; however, continued research in this area is necessary to validate existing psychometrically sound measures and to develop and evaluate epilepsy-specific measures in the pediatric epilepsy population.

Evaluation of sleep habits, sleep chronotype, and quality of life in children with drug-resistant epilepsy in Turkey

BACKGROUND/AIM

Drug-resistant epilepsy (DRE) is a condition that affects sleep habits and the quality of life of children unfavorably. The aim of our study was to evaluate the relationship of sleep habits and sleep chronotype with the quality of life and behavioral problems in children with DRE.

MATERIALS AND METHODS

In our study, 2-11-year-old children, who were either healthy or diagnosed with DRE, were evaluated. A sociodemographic data form was filled out to evaluate the general characteristics of children. The Children's Sleep Habits Questionnaire (CSHQ) and the Children's Chronotype Questionnaire (CCTQ) for sleep habits, the Pediatric Quality of Life Inventory (PedsQL) for the quality of life, and the Aberrant Behavior Checklist (ABC) for behavioral problems were filled out through face-to-face interviews with parents.

RESULTS

Thirty children with DRE and 31 healthy children were included in our study. Statistically significant differences were found in children with DRE compared to the control group in terms of the total and the subscale scores of CSHQ, including sleep onset delay, sleep duration, sleep anxiety, parasomnias, and sleep-disordered breathing (p < 0.001). There were no significant differences between the groups in terms of CCTQ total scores and sleep patterns (p > 0.05). Significant differences were found in PedsQL total and subscale scores, and ABC scores in children with DRE compared to the control group (p < 0.001). Children's Sleep Habits Questionnaire, PedsQL, and ABC scores were significantly correlated with each other in children with DRE.

CONCLUSIONS

Our results have shown that sleep habits and the quality of life are poor in children with DRE. Our study has shown that sleep disturbances, quality of life, and behavioral problems are strongly associated with each other in DRE. The recognition and appropriate treatment of sleep disturbances are important for improving the quality of life in children with DRE.

Behavioral phenotypes of pediatric temporal lobe epilepsy

OBJECTIVE

A broad spectrum of emotional-behavioral problems have been reported in pediatric temporal lobe epilepsy (TLE), but with considerable variability in their presence and nature of expression, which hampers precise identification and treatment. The present study aimed to empirically identify latent patterns or behavioral phenotypes and their correlates.

METHODS

Data included parental ratings of emotional-behavioral status on the Behavior Assessment System for Children, 2nd Edition (BASC-2) of 81 children (mean age = 11.79, standard deviation [SD] = 3.93) with TLE. The nine clinical subscales were subjected to unsupervised machine learning to identify behavioral subgroups. To explore concurrent validity and the underlying composition of the identified clusters, we examined demographic factors, seizure characteristics, psychosocial factors, neuropsychological performance, psychiatric status, and health-related quality of life (HRQoL).

RESULTS

Three behavioral phenotypes were identified, which included no behavioral concerns (Cluster 1, 43% of sample), externalizing problems (Cluster 2, 41% of sample), and internalizing problems (Cluster 3, 16% of sample). Behavioral phenotypes were characterized by important differences across clinical seizure variables, psychosocial/familial factors, everyday executive functioning, and HRQoL. Cluster 2 was associated with younger child age, lower maternal education, and higher rate of single-parent households. Cluster 3 was associated with older age at epilepsy onset and higher rates of hippocampal sclerosis and parental psychiatric history. Both Cluster 2 and 3 demonstrated elevated family stress. Concurrent validity was demonstrated through the association of psychiatric (i.e., rate of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) disorders and psychotropic medication) and parent-rated HRQoL variables.

SIGNIFICANCE

Youth with TLE present with three distinct behavioral phenotypes that correspond with important clinical and sociodemographic markers. The current findings demonstrate the variability of behavioral presentations in youth with TLE and provide a preliminary framework for screening and targeting intervention to enhance support for youth with TLE and their families.

Temporal Lobe Epilepsy and Psychiatric Comorbidity

Most focal seizures originate in the temporal lobe and are commonly divided into mesial and lateral temporal epilepsy, depending upon the neuronal circuitry involved. The hallmark features of the mesial temporal epilepsy are aura, unconsciousness, and automatisms. Symptoms often overlap with the lateral temporal epilepsy. However, the latter present a less evident psychomotor arrest, frequent clones and dystonic postures, and common focal to bilateral tonic–clonic seizures. Sclerosis of the hippocampus is the most frequent cause of temporal lobe epilepsy (TLE). TLE is among all epilepsies the most frequently associated with psychiatric comorbidity. Anxiety, depression, and interictal dysphoria are recurrent psychiatric disorders in pediatric patients with TLE. In addition, these alterations are often combined with cognitive, learning, and behavioral impairment. These comorbidities occur more frequently in TLE with hippocampal sclerosis and with pharmacoresistance. According to the bidirectional hypothesis, the close relationship between TLE and psychiatric features should lead to considering common pathophysiology underlying these disorders. Psychiatric comorbidities considerably reduce the quality of life of these children and their families. Thus, early detection and appropriate management and therapeutic strategies could improve the prognosis of these patients. The aim of this review is to analyze TLE correlation with psychiatric disorders and its underlying conditions.

The Role and Mechanism of AMIGO3 in the Formation of Aberrant Neural Circuits After Status Convulsion in Immature Mice

Leucine rich repeat and immunoglobulin-like domain-containing protein 1 (Lingo-1) has gained considerable interest as a potential therapy for demyelinating diseases since it inhibits axonal regeneration and myelin production. However, the results of clinical trials targeted at Lingo-1 have been unsatisfactory. Amphoterin-induced gene and open reading frame-3 (AMIGO3), which is an analog of Lingo-1, might be an alternative therapeutic target for brain damage. In the present study, we investigated the effects of AMIGO3 on neural circuits in immature mice after status convulsion (SC) induced by kainic acid. The expression of both AMIGO3 and Lingo-1 was significantly increased after SC, with levels maintained to 20 days after SC. Following SC, transmission electron microscopy revealed the impaired microstructure of myelin sheaths and Western blot analysis showed a decrease in myelin basic protein expression, and this damage was alleviated by downregulation of AMIGO3 expression. The ROCK/RhoA signaling pathway was inhibited at 20 days after SC by downregulating AMIGO3 expression. These results indicate that AMIGO3 plays important roles in seizure-induced damage of myelin sheaths as well as axon growth and synaptic plasticity via the ROCK/RhoA signaling pathway.

The Utility of the Test of Memory Malingering Trial 1 in Differentiating Neurocognitive, Emotional, and Behavioral Functioning in a Pediatric Concussion Population

OBJECTIVE

In concussion populations, suboptimal task engagement detected by performance validity tests (PVTs) has been associated with poorer neuropsychological scores and greater post-concussive symptoms (PCS). This study examined if Pass/Fail status on the Test of Memory Malingering-TOMM Trial 1-differentiated the neurocognitive, emotional, and behavioral profile of pediatric patients with concussion.

METHOD

This study utilized archival data from 93 patients (mean age = 14.56 and SD = 2.01) with a history of concussion who were assessed at ~5-6 weeks post-injury (mean days = 40.27 and SD = 35.41). Individuals were divided into "Pass" and "Fail" groups based on TOMM Trial 1 performance. The testing battery included ACT, CPT-II and III, HVLT-R, WJ-III and IV ACH, ImPACT, BASC-2, and BRIEF.

RESULTS

The overall pass rate on Trial 1 was 70% (mean = 46.04 and SD = 4.55). Findings suggested that a passing score on Trial 1 may be associated with adequate performance across the remaining two trials of the TOMM. The Fail group scored significantly lower across attention, memory, and processing speed measures when compared with the Pass group. On rating scales, significantly more concerns were endorsed with the Fail group for attention and executive functioning relative to the Pass group. Parents generally endorsed significantly more concerns for executive functioning when compared with their children's self-reported symptoms. There was a trend for the Fail group to report more PCS; however, they did not significantly differ from the Pass group for depression, anxiety, or somatization.

CONCLUSIONS

This study highlights the importance of utilizing PVTs when evaluating concussion recovery.

Executive function and depressed mood are independently disruptive to health-related quality of life in pediatric temporal lobe epilepsy

OBJECTIVE

Youth with temporal lobe epilepsy (TLE) are at increased risk of depressive features and diminished health-related quality of life (HRQOL). To assist in the development of future behavioral interventions for youth with TLE, the current study explored potential pathways by which executive functioning (EF) and depressive features impinge upon HRQOL in the context of psychosocial and seizure-specific factors.

METHODS

Data included parental ratings on the Behavior Assessment System for Children (BASC-2), Behavior Rating Inventory of Executive Function (BRIEF), and the Quality of Life in Childhood Epilepsy (QOLCE) questionnaires for 82 children (Age = 11.99, SD = 3.80) with TLE. Observed path analysis was used to simultaneously investigate the determinants of HRQOL in pediatric TLE. Indirect effects were evaluated with bootstrap analyses.

RESULTS

Both executive dysfunction and depressive features were negatively linked to child HRQOL, and, furthermore, EF and HRQOL were indirectly connected by depressive features. In addition, depressive features were linked to lower EF, current antiepileptic drug (AED) regimen, and the presence of hippocampal sclerosis. Diminished EF was linked to parental psychiatric history and family stress; EF mediated the relationship of parental psychiatric history and family stress on both depressive features and diminished HRQOL. Finally, a more complicated AED regimen and higher HRQOL were indirectly connected by depressive features.

CONCLUSION

This study underscores the importance of child depressive features and EF along with environmental and epilepsy-specific factors on HRQOL in pediatric TLE.

Language in childhood epilepsy: A systematic review and meta-analysis

The abnormal brain activity associated with childhood epilepsy can have an impact on the developmental trajectory of cognitive processes, like language, in this population. However, there is variation in how researchers study language ability in children with epilepsy and the findings that are reported (no differences vs. a significant difference). The current systematic review and meta-analysis uses data from 13 available studies to consider the magnitude of language differences in children with epilepsy compared to their typically developing peers. Seizure classification, age of onset, component of language measured, and instrument used to measure language were all considered as potential moderators of differences in language skill. The results indicate a significant large effect size for language deficits in children with epilepsy compared to their peers. Seizure classification partially, but not fully, accounts for the variability in effect size. In addition, effect sizes differ relative to component of language measured; effect sizes were greatest in magnitude for semantic language and verbal fluency, and minimal for syntax, but only when including all studies of children with epilepsy, regardless of seizure classification. These findings differ when considering language component in children with generalized or focal seizures only. The data reported here also indicate distinct differences in effect size depending on type of instrument used to measure one aspect of language, verbal fluency.

The Correlation of Family Resilience with Sleep Quality and Depression of Parents of Children with Epilepsy

PURPOSE

The present study aims to investigate the correlation between family resilience, sleep quality, and depression in parents of children with epilepsy.

DESIGN AND METHODS

The parents of 157 children with epilepsy were assessed using the shortened Chinese version of the Family Resilience Assessment Scale (FRAS-SC) to measure the resilience level of families of children with epilepsy. The Pittsburgh Sleep Quality Index (PSQI) was used to determine the sleep quality of the subjects. The Self-Rating Depression Scale (SDS), a self-rating scale for evaluating depression, was used.

RESULTS

The FRAS-SC total score was 97.9 ± 9.0. The PSQI total score was 6.41 ± 3.79, and the detection rate of sleep disorders was 37.6%. The SDS total score was 51.63 ± 10.73, and the detection rate of moderate-severe depressive symptoms was 21.6%. The FRAS-SC total score and all items (except USR) were negatively correlated with the PSQI total score (P < .05). The FRAS-SC total score and all items were significantly and negatively correlated with the SDS total score (P < .01). The degree of explanation of family resilience for sleep quality and depression was 3.5% and 14.9%, respectively.

CONCLUSIONS

The higher the level of family resilience, the better sleep quality and the less depression the parents of children with epilepsy will get.

PRACTICAL IMPLICATIONS

Relevant intervention measures based on family resilience will help to improve the sleep quality of parents of children with epilepsy and alleviate depression. And then improve the family's ability to care for children with epilepsy.

The Ketogenic Diet for the Treatment of Mood Disorders in Comorbidity With Epilepsy in Children and Adolescents

The ketogenic diet, used for over a century as an alternative therapy for the control of drug-resistant seizures in both children and adults, has recently drawn increasing interest in various neurological or psychiatric disorders other than epilepsy. In particular, there are a few preliminary studies in mood and neurodevelopmental disorders such as anxiety, depression and autism spectrum disorders. Mood disorders in comorbidity with epilepsy are commonly seen in adolescents and young adults both at the onset and during the course of the epileptic disorder. The rationale for the use of the ketogenic diet is based on the potential mood stabilizing effects through level modifications of metabolites such as dopamine and serotonin and the regulation of GABA/glutamatergic neurotransmission, mitochondrial function and oxidative stress. In this review, epilepsies with a higher risk of mood disorders in adolescents will be considered. A brief overview of the various types of ketogenic diet that can currently be offered to young patients in order to improve palatability and compliance with the diet, is also included. The efficacy and tolerability of the ketogenic diet options for the treatment of mood disorders, with or without drug therapy including mood stabilizers and antidepressant drugs, are as well discussed.

Psychiatric Comorbidities in Pediatric Epilepsy

PURPOSE OF REVIEW

Psychiatric comorbidities are close to 5-times higher in children and youth with epilepsy (CYE) compared to general population. With epilepsy being one of the most common neurological disorders in children, we provide a timely review of psychiatric issues in CYE.

RECENT FINDINGS

A meta-analysis found a pooled prevalence of anxiety in 18.9% and depression in 13.5% of CYE. Attention deficit hyperactivity disorder (ADHD) is 2.5 to 5.5 times higher in CYE compared to healthy counterparts. Recent evidence highlights that behavioral adverse effects may lead to discontinuation of anti-epileptic drugs (AEDs) in more than 10% of CYE. Up to 70% CYE shows elevation in baseline psychological symptoms after AED initiation. Identifying psychiatric symptoms can be easily accomplished by the routine use of psychiatric screening instruments in CYE clinics, which is associated with improved health-related quality of life (HRQOL). Psychoeducation is a key component for any visit with CYE. There is some evidence of the effectiveness of behavioral psychological interventions for CYE. There are no therapeutic trials of psychotropics in CYE, but treatment recommendations based on the experience in adults with epilepsy and general population are applicable. Early diagnosis and management of psychiatric comorbidities leads to improvement in HRQOL of CYE. This requires routine screening and a multidisciplinary teamwork.

The Humanistic and Economic Burden of Pediatric Focal Seizures in the United States

OBJECTIVE

To better understand the humanistic and economic burden of focal seizures in children 2-12 years old.

METHODS

We conducted a targeted literature review by searching MEDLINE for English-language publications reporting on children 2-12 years old with focal seizures published in the United States since 2008.

RESULTS

Thirty-five publications were included. Incidence of focal seizures was 23.2 to 47.1 per 100,000 children per year; prevalence was 2.0 per 1,000 children, and ranged from 1.6 - 2.6 per 1,000 in patients of any age. Life expectancy was 47.3-61.8 years among children 3-12 years old. Patients took several antiepileptic drugs and experienced frequent seizures, sleep disorders, mood disorders, migraine, and seizure-related injuries (eg, bone fractures, sprains, open wounds). Children with focal seizures scored below average on cognitive assessments and up to 42%, 16%, and 19% had depression, anxiety, and attention-deficit disorder, respectively. Patients of any age had about 10 outpatient visits (2 epilepsy-related), 2 inpatient visits (less than 1 epilepsy-related), and 24 procedures (1 epilepsy-related) per year. Medication adherence was low: only half of pediatric patients maintained ≥90% adherence over 6 months. Annual total health care costs among patients of any age ranged from $18,369 - 38,549; first-year total health care costs for children were $19,883.

CONCLUSIONS

Incidence and prevalence of focal seizures is high and the humanistic and economic burdens are significant. Future studies focused exclusively on children with focal seizures are needed to more precisely describe the burden. We also suggest further research and implementation of methods to improve medication adherence as an approach to lessen burden on these young patients.

Prognostic role of Mini-Mental State Pediatric Examination (MMSPE) on neuropsychological functioning

OBJECTIVE

The aim of this study was to evaluate the ability of the Mini-Mental State Pediatric Examinations (MMSPE) in the individuation of neuropsychological impairments.

METHOD

MMSPE was administered to 60 children attending a primary or lower secondary school suffering from neurological diseases, admitted to our neuropsychology services. All children performed both a MMSPE examination and a neuropsychological evaluation. Results of neuropsychological evaluation and MMSPE were dichotomized. Positive predictive value (PPV), negative predictive value (NPV), and accuracy were also calculated.

RESULTS

The diagnostic performance of MMSPE showed a good overall accuracy (0.83, CI 95% 0.64-0.91), NPV (0.81, CI 95% 0.73-1.00), PPV (0.87, CI 95% 0.68-0.94), specificity (0.91, CI 95% 0.81-1.00), sensitivity (0.74, CI 95% 0.57-0.90), and odds ratio of 28.5 (CI 95% 6.6-123), p < 0.001.

CONCLUSIONS

MMSPE has a good prognostic ability in predicting neuropsychological problems in the context of different neurological pediatric diseases. We suggest that this instrument could greatly improve pediatric clinical practice in identifying high-risk children.

Internalizing symptoms in intractable pediatric epilepsy: Structural and functional brain correlates

Internalizing disorders (i.e., depression and anxiety) are common comorbidities in people with epilepsy. In adults with epilepsy, comorbid depression or anxiety is associated with worse seizure control and reduced quality of life, and may be linked to specific neural biomarkers. Less is known about brain correlates of internalizing symptoms in pediatric populations. In the current study, we performed a retrospective analysis of 45 youth between the ages of 6 and 18 years old with intractable epilepsy. Individuals were evaluated for internalizing symptoms on the Child Behavior Checklist (CBCL) and underwent magnetic resonance (MR) and fluorodeoxyglucose (FDG)-positron emission tomography (PET) imaging as part of the clinical evaluation for surgical treatment of epilepsy. Forty-two percent of patients experienced clinically significant internalizing symptoms based on parent report. Compared with individuals who scored in the normal range, youth with clinical levels of internalizing problems showed overall reductions in cortex volume, as well as widespread reductions in cortical thickness and functional activation in the bilateral occipital/parietal lobe, left temporal regions, and left inferior frontal cortex on MR and PET scans. There were no group differences in amygdala or hippocampus volumes, nor other patient- or illness-related variables such as age, sex, or the type, lateralization, or duration of epilepsy. Results suggest that high rates of internalizing disorders are present in youth with refractory epilepsy. Multifocal reductions in cortical thickness and function may be nonspecific risk factors for clinically meaningful internalizing symptoms in youth with chronic epilepsy. As such, the presence of broad cortical thinning and reduced glucose uptake upon radiological examination may warrant more focused clinical evaluation of psychological symptoms.

Behavioural changes in dogs with idiopathic epilepsy

BACKGROUND

Breed-specific and broader cohort studies have shown behavioural changes in dogs following the onset of idiopathic epilepsy (IE).

METHODS

A cross-sectional, case-control questionnaire study was carried out to strengthen this body of evidence. Owners of eight breeds of dog completed an online questionnaire about their dogs' behaviour; once for control dogs and twice for dogs with IE, for both pre-IE and post-IE onset behaviour.

RESULTS

Ninety-six (24.74 per cent) dogs with IE and 292 (75.26 per cent) age and breed-matched control dogs met the inclusion criteria. Control dogs had significantly higher 'Trainability' scores than dogs with IE (P=0.04). After IE, dogs had significantly higher 'Dog-Directed Fear or Aggression' (P=0.02), 'Non-Social Fear' (P=0.01), 'Attachment/Attention-Seeking Behaviour' (P=0.04), 'Attention-Deficit' (P=0.02) and significantly lower 'Trainability' (P=0.02) than prior to the onset of IE. Medication status did not significantly affect any behavioural factor, but drug-resistant dogs had significantly less 'Trainability' than drug-responsive (P=0.04) and partially drug-responsive dogs (P=0.03).

CONCLUSION

Behavioural differences related to cognitive function are seen between dogs with IE and controls. Behavioural changes related to anxiety, attention and cognition are seen in dogs following the onset of IE. The ability to clinically define and diagnose behavioural comorbidities in dogs is much needed from both a clinical and research perspective.

Executive functioning in children with epilepsy: Genes matter

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

Assessment and Management of Depression and Anxiety in Children and Adolescents with Epilepsy

Anxiety and depression in children and adolescents with epilepsy are common comorbidities which place a significant burden on patients and families and complicate the clinical management of epilepsy. This paper presents a narrative review on the aetiology, phenomenology, assessment, and management of depression and anxiety among paediatric patients with epilepsy. The recognition of affective comorbidity in paediatric epilepsy is limited at present, and the contributory role of antiepileptic medication towards such comorbidity must be considered by clinicians.

Executive Dysfunction and Depression in Pediatric Temporal Lobe Epilepsy: The Contribution of Hippocampal Sclerosis and Psychosocial Factors

OBJECTIVES

Temporal lobe epilepsy (TLE) has been identified as a risk factor for increased depression features in children and adolescents; however, less is known regarding specific neurocognitive predictors of depression in this population above and beyond seizure-specific and sociodemographic factors.

METHODS

The study included 62 patients with TLE (64% male) aged 8 to 16 years (M=12.62; SD=2.26) who underwent comprehensive neuropsychological evaluation.

RESULTS

Correlation analyses revealed significant association between patient depression and WCST Total Perseverations, BRIEF Behavioral Regulation Index (BRI) and family stress. Perseverative errors on the WCST and the BRI were found to significantly predict depression features in youth with TLE. Patient performance on WCST was also found to fully mediate the significant relationship between hippocampal sclerosis (HS) and depression in pediatric TLE. Finally, logistic regression indicated HS in the presence of TLE was associated with a four-fold risk of clinically significant depression ratings.

CONCLUSIONS

The current findings offer strong support for the relationship between executive function (EF) and depression in pediatric TLE. Also, as HS is not modifiable, these findings suggest EF intervention may be a potential modality for improving health-related quality of life (HRQOL) in youth with TLE. (JINS, 2018, 24, 606-616).

Symptoms of anxiety and depression and family's quality of life in children and adolescents with epilepsy

INTRODUCTION

We studied children and adolescents with epilepsy (CAWE) and their families to evaluate symptoms of anxiety and depression, quality of life (QoL), and their correlations with epilepsy characteristics.

MATERIAL AND METHODS

The study included 326 (52.5% females) 8 to 18years old CAWE. Anxiety and depression were assessed with the "Self-administered psychiatric scales for children and adolescents" (SAFA), and family's QoL with the parents' report "Impact of Epilepsy on QoL" (IEQoL).

RESULTS

The CAWE exhibiting abnormal (T≥70) scores were 8.0% in the anxiety scale, 9.2% in the depression scale, and 4.6% in both scales. Social anxiety was the predominant anxiety symptom, while irritable mood and desperation were the most frequent symptoms of depression. Depressive symptoms were associated with parents' complaint of higher worries about the child's condition and future and lower well-being of the family. Severity and duration of the epilepsy and polypharmacy were independent from abnormal scores of anxiety and depression, but were associated with parents' worries about the child's condition and family's well-being.

CONCLUSIONS

Anxiety and depression in CAWE are independent from the characteristics of the disease but are correlated to the lower well-being of the family. A search of these emotional problems is recommended for better care of the patients and their families.

The influence of endophenotypic, disease-specific, and environmental variables on the expression of anxiety in pediatric epilepsy

Children and adolescents with epilepsy often show higher rates of anxiety, which carries an increased risk for reduced health-related quality of life (HRQOL). The current study assessed the role of parental psychiatric history (i.e., anxiety, depression, and/or bipolar disorder) on the rate of anxiety features in youth seen in a tertiary epilepsy clinic. Data included parental ratings on the Behavior Assessment System for Children (BASC-2) and the Quality of Life in Childhood Epilepsy (QOLCE) questionnaire for 180 children and adolescents (mean age=11.40, SD=3.98). Our results identified clinically elevated anxiety ratings in nearly half the sample (47%) with previous psychiatric history endorsed by 48% of parents. The effect of parental psychiatric history on youth anxiety was found to be significant and associated with a threefold increase in the rate of youth anxiety features. This risk increased to fourfold in refractory epilepsy, and the impact of family psychiatric history is greater in adolescent females and in families that report higher levels of stress. In those families who reported no psychiatric history, anxiety was best predicted by epilepsy-specific factors above and beyond sociodemographic factors. Parental psychiatric history was also identified as a significant risk factor for diminished patient HRQOL, even after accounting for seizure control. These findings highlight the impact of family and epilepsy factors on psychological functioning and offer further support for the strong relationship between parental adjustment and child outcome in pediatric epilepsy.

Akt Inhibitor Perifosine Prevents Epileptogenesis in a Rat Model of Temporal Lobe Epilepsy

Accumulating data have revealed that abnormal activity of the mTOR (mammalian target of rapamycin) pathway plays an important role in epileptogenesis triggered by various factors. We previously reported that pretreatment with perifosine, an inhibitor of Akt (also called protein kinase B), abolishes the rapamycin-induced paradoxical increase of S6 phosphorylation in a rat model induced by kainic acid (KA). Since Akt is an upstream target in the mTOR signaling pathway, we set out to determine whether perifosine has a preventive effect on epileptogenesis. Here, we explored the effect of perifosine on the model of temporal epilepsy induced by KA in rats and found that pretreatment with perifosine had no effect on the severity or duration of the KA-induced status epilepticus. However, perifosine almost completely inhibited the activation of p-Akt and p-S6 both acutely and chronically following the KA-induced status epilepticus. Perifosine pretreatment suppressed the KA-induced neuronal death and mossy fiber sprouting. The frequency of spontaneous seizures was markedly decreased in rats pretreated with perifosine. Accordingly, rats pretreated with perifosine showed mild impairment in cognitive functions. Collectively, this study provides novel evidence in a KA seizure model that perifosine may be a potential drug for use in anti-epileptogenic therapy.