Childhood epilepsy and ADHD comorbidity in an Indian tertiary medical center outpatient population

The diagnosis of ADHD in children and adolescents with epilepsy: a scoping review

Attention-deficit hyperactivity disorder (ADHD) is often diagnosed in children and adolescents with epilepsy, but clear clinical guidelines on how to make this diagnosis are still lacking. Without these guidelines, there is no consensus between specialists on how to proceed when assessing children with epilepsy for ADHD, which can negatively impact the quality of care being offered to this population. As a first step toward gaining more specific clinical guidelines, this scoping review was aimed at documenting the tools and procedures used to diagnose ADHD in children and adolescents with epilepsy over time and at determining whether the diagnoses were made in accordance with clinical guidelines and recommendations. The literature search was conducted using PsycINFO, PubMed, and CINAHL. Studies were included if conducted with children and adolescents aged between 4 and 18 years with epilepsy being evaluated for ADHD. Studies were clustered according to their publication date and the reported diagnostic procedures were identified. Forty-nine out of 3854 records were included. Results highlight discrepancies between how ADHD was diagnosed in reviewed studies and clinical guidelines or recommendations. Indeed, most studies did not use a multi-method and multi-informant approach when diagnosing ADHD in children with epilepsy, with no improvement over time. Future studies aimed at diagnosing ADHD in children and adolescents should ensure that they are following clinical guidelines and recommendations, in addition to adapting their diagnostic procedures to the presence of any neurological comorbidities, such as epilepsy.

Attention-deficit/hyperactivity disorder in children with epilepsy: A systematic review and meta-analysis of prevalence and risk factors

OBJECTIVE

To evaluate the prevalence of and risk factors for attention-deficit/hyperactivity disorder (ADHD) in children with epilepsy (CWE).

METHODS

We conducted a systematic search in PubMed and Embase for the meta-analysis. The pooled prevalence of ADHD was calculated using a random-effects model; subgroup analyses were performed to explore heterogeneity. We collected raw data from articles reporting potential risk factors, which were included in the subsequent risk factor analysis.

RESULTS

Forty-six articles met the inclusion criteria for the meta-analysis, which showed a pooled ADHD prevalence of 30.7% in CWE, with a predominance of the inattentive subtype of ADHD; the heterogeneity of prevalence was related to population source/study setting (clinic based, community based, or database based) and method of ADHD diagnosis (with or without clinical review). Risk factors for ADHD in epilepsy included younger age, intellectual/developmental disabilities, a family history of epilepsy, earlier epilepsy onset, absence epilepsy, more frequent seizures, and polytherapy; In contrast, risk factors such as sex, generalized epilepsy or seizures, epilepsy etiology, and electroencephalogram abnormalities were not significantly associated with the occurrence of ADHD.

SIGNIFICANCE

The prevalence of ADHD in CWE is high and several potential risk factors are associated with it. This study contributes to a better understanding of ADHD in epilepsy for screening and treatment.

PLAIN LANGUAGE SUMMARY

This systematic review summarizes the prevalence of attention-deficit/hyperactivity disorder (ADHD) occurring in children with epilepsy and analyses the risk factors for comorbid ADHD in epilepsy. By reviewing 46 articles, we concluded that the overall prevalence of ADHD in children with epilepsy was 30.7% and that intellectual/developmental disabilities were the most significant risk factor for combined ADHD in children with epilepsy. This study provides a wealth of information on comorbid ADHD in epilepsy, which will help clinicians identify and treat potential ADHD in children with epilepsy in a timely manner.

Attention-deficit hyperactivity disorder in adults with epilepsy: An indirect relationship with suicide risk

PURPOSE

Studies on attention-deficit hyperactivity disorder (ADHD) are scarce in adults with epilepsy. This study aimed to investigate the risk factors for ADHD and determine whether ADHD is directly associated with the risk of suicide in adults with epilepsy.

METHODS

ADHD was assessed using the Structured Clinical Interview for the DSM-5 Disorders Clinical Version. The Mini International Neuropsychiatric Interview (MINI) Plus 5.0.0, Neurological Disorders Depression Inventory for Epilepsy (NDDIE), and Generalized Anxiety Disorder-7 (GAD-7) were also used. Suicide risk was defined as a MINI suicidality score of ≥ 1. Stepwise logistic regression and mediation analyses were conducted.

RESULTS

Of the 157 adults with epilepsy, 19 (12.1 %) were diagnosed with ADHD, including inattentive (5.7 %), hyperactive (3.8 %), and combined (2.5 %) types. Thirty-two subjects (20.4 %) had a risk of suicide. ADHD was insignificantly associated with any epilepsy-related factors. The diagnosis of ADHD was not associated with suicide risk independent of NDDIE ≥ 14 and GAD-7 ≥ 7. Mediation effects of ADHD on suicidality using NDDIE ≥ 14 (odds ratio [OR] 2.850, 95 % confidence interval [CI] 1.398-5.811, p = 0.004) or GAD-7 ≥ 7 (OR 3.240, 95 % CI 1.537-6.828, p = 0.002) were statistically significant, with the proportion mediated being 84.5 % or 92.0 % of the total ADHD effect, respectively. These models were adjusted for age, sex, and composite epilepsy severity scores.

CONCLUSIONS

ADHD was diagnosed in 12.1% of adults with epilepsy and was not associated with any epilepsy-related factors. ADHD was indirectly associated with the risk of suicide resulting from depression and anxiety in adults with epilepsy.

Comorbidity of epilepsy and attention-deficit/hyperactivity disorder: a systematic review and meta-analysis

Epilepsy and attention-deficit/hyperactivity disorder (ADHD) are common neurological and neuropsychiatric disorders, respectively, that can exist as comorbidities. However, the degree of comorbidity between both disorders has never been quantified based on a systematic review with meta-analysis. We performed a systematic search of the literature in Embase, PubMed, PsychINFO and the Cochrane Library on June 20, 2022. In a meta-analysis of 63 studies with a total sample size of 1,073,188 individuals (172,206 with epilepsy and 900,982 with ADHD) from 17 countries, the pooled prevalence of ADHD in epilepsy was 22.3% (95% CI 20.3-24.4%). The highest pooled prevalence was 12.7% (95% CI 9-17.1%) for ADHD-I subtype, whereas the pooled prevalence of epilepsy in ADHD was 3.4% (95% CI 2.53-4.21%). However, substantial heterogeneity in comorbidity rates was observed and partially attributed to the following factors: sample size, sample specification, geographical variations and diagnostic methods. Our study highlights the need for increased awareness of this diagnostic co-occurrence, and research is warranted to elucidate the underlying pathophysiological mechanisms.

Attention deficit hyperactivity disorder in patients with seizures: Functional seizures vs. epilepsy

BACKGROUND

We investigated the rates of positive screening for attention deficit-hyperactivity disorder (ADHD) in adults with seizures [i.e., focal epilepsy vs. idiopathic generalized epilepsy (IGE) vs. functional seizures (FS)]. We hypothesized that the rates of positive screening for ADHD are different between these three groups of patients.

METHODS

This was a cross sectional study. Patients, 19 to 55 years of age, with a diagnosis of IGE, focal epilepsy or FS were investigated at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from September 2022 until January 2023 and during their follow-up visits. We used the validated Persian version of Adult ADHD Self-Report Scale (ASRS v1.1)15 to investigate and screen for ADHD in these patients.

RESULTS

Forty patients with focal epilepsy, 40 with IGE, and 40 with FS were included. Attention deficit-hyperactivity disorder (ADHD) screening was positive in 35% of patients with FS, in 30% of those with focal epilepsy (compared with FS, p = 0.633), and in 10% of patients with IGE (compared with FS, p = 0.007).

CONCLUSION

Adult patients with functional seizures and those with focal epilepsy are at a high risk of self-reporting experiences that could be characteristic of ADHD. Screening tools [e.g., Adult ADHD Self-Report Scale (ASRS v1.1)] are useful to help clinicians address seizure comorbidities such as ADHD. However, a clinical diagnosis of ADHD should be ascertained in a patient with positive screening.

Epilepsy and attention-deficit/hyperactivity disorder in children and adolescents: An overview of etiology, prevalence, and treatment

Epilepsy and attention-deficit/hyperactivity disorder (ADHD) are closely connected and commonly seen in both children and adults. Each of the disorders has major psychosocial and quality of life (QOL) effects, and their co-occurrence makes coping even more challenging for both the patients and their families. Moreover, an adverse effect of some anti-seizure medications can potentially induce or exacerbate symptoms of ADHD on the one hand, while some ADHD medications may increase seizure risk on the other. The combination of proper diagnosis and appropriate treatment may improve or even prevent many of the complications associated with these conditions. The objectives of this review are to present the complex relationship between epilepsy and ADHD, looking into the pathophysiological, anatomical, and functional perspectives along with the psychosocial and QOL influences and the recommended treatment approaches in accordance with the latest literature.

Shared genetics and causality underlying epilepsy and attention-deficit hyperactivity disorder

The prevalence of attention deficit hyperactivity disorder (ADHD) in patients with epilepsy was much higher than prevalence in general population, and vice versa. The mechanisms underlying comorbid ADHD and epilepsy remained largely unknown. Here, we systematically analyzed the genetic correlation, causality, shared genetics and specific trait related tissues by using linkage disequilibrium score regression (LDSC), two sample Mendelian randomization (TwoSampleMR), bivariate causal mixture model (MiXeR), conjunctional false discovery rate (conjFDR) and LDSC applied to specifically expressed genes based on genome wide association studies (GWASs) data of ADHD and epilepsy. We found that ADHD had significant positive genetic association with epilepsy. Two-sample Mendelian randomization analysis with genome wide significant single nucleotide polymorphisms (SNPs) as instrument variables suggested a positively causal effect of ADHD on epilepsy. Using MiXeR, which estimates the total amount of shared variants, we observed 1 K causal variants overlapped between ADHD and epilepsy. At conjFDR <0.05, ADHD shared 2 distinct genomic loci with Epilepsy. Further disease-relevant tissues analysis showed that cortex, substantia nigra, amygdala and hippocampus were both associated with ADHD and epilepsy. Our results suggested that ADHD was genetically correlated with epilepsy, which might be due to the fact that they shared common pathogenic sites and tissues origin.

Co-morbidity of attention deficit hyperactivity disorder among children with seizure disorders at University of Gondar referral hospital Ethiopia (2016)

Attention deficit hyperactivity disorder is a disorder in which a person is unable to control behavior due to difficulty in processing neural stimuli, accompanied by an extremely high level of motor activity. The prevalence is much higher ranging from 8 to 77% among children with seizure disorders than in the general population. When attention deficit hyperactivity disorder presents in children with seizure disorder, it makes the treatment complicated and the prognosis poor. Hence, understanding the magnitude of attention deficit hyperactivity disorder and associated factors would be important to have a policy intention towards these people and to design appropriate interventions. Therefore, the current study was conducted to determine the comorbidity of attention deficit hyperactivity disorder and associated factors in children with seizure disorders. A hospital-based cross-sectional study was conducted by taking 260 children who have follow ups in the pediatric seizure clinic. The systematic random sampling technique was used to recruit participants. A structured, pretested and interviewer-administered questionnaire which included questions on associated factors and standard disruptive behavioral disorder rating scale was used to collect data. Data were coded, entered and cleaned by using the Epi-Data version 3.1 and exported to SPSS version 20 for further analysis. The multivariate binary logistic regression was used to check the association between independent and dependent variables. Variables with significant associations were identified based on adjusted odds ratio, with a 95% CI and p-value of < 0.05 will be considered as statistically significant. The prevalence of attention deficit hyperactivity disorder among epileptic children was found to be 115 (44.2%),with a confidence interval of (38.1–50.5),out of which only 3 (2.6%) were detected as having mental health problems by the clinician. The predominant subtype was inattentive type 96 (61.1%). Factors significantly associated with attention deficit hyperactivity disorder were male sex (AOR = 2.70 CI 1.46–4.97), family history of seizure disorder (AOR = 2.42 CI 1.26–4.65), family history of mental illnesses (AOR = 4.14 CI 1.76–9.68), sudden onset of the seizure (AOR = 2.37 CI 1.32–4.27), and uncontrolled seizure (AOR = 2.55 CI 1.41–4.61). Attention deficit hyperactivity disorder was common among children with seizure disorders in the study area. Male sex, sudden onsets of seizure, family history of seizure, and that of other psychiatric disorders as well as uncontrolled seizures were factors that increased the odds of attention deficit hyperactivity disorder. Therefore, interventions that would address such factors would help to overcome further complications.

Role of inflammation in childhood epilepsy and ADHD comorbidity

Epilepsy is a heterogeneous disorder that is not limited to experiencing seizures but also includes multiple neuropsychiatric squeal (i.e. attention-deficit/hyperactivity disorder (ADHD), depression and anxiety) that adversely impact a child quality of life. However, the underlying mechanism linking both disorders is not yet thoroughly explored. Our objective was to assess pro-inflammatory cytokines levels in children with seizure controlled epilepsy and explore the association between pro-inflammatory cytokines and the co-occurrence of ADHD in such children. A cross-sectional study included 50 children with controlled epilepsy for at least one year, in addition to 30 neurotypical children as controls. All children were assessed by the Conner parent scale for ADHD. Serum interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) levels were measured and correlated to clinical data. In the present study, 23 out of 50 children with epilepsy also had ADHD (46%). Children with ADHD have been found to have a significantly lower age of onset, longer duration of epilepsy, and a higher serum level of IL-6 and TNF-α than those without ADHD. The Conner's parent rating scale overall total score yielded significant negative correlations with the age of onset of epilepsy and a significant positive correlation with the duration of epilepsy and pro-inflammatory cytokine levels. In addition to active seizures, the presence of elevated circulating inflammation markers may be associated with increased frequency of ADHD in children with epilepsy aged 6-14 years.

Attention-deficit hyperactivity disorder in adults with epilepsy

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Seizures in children with epilepsy and attention-deficit/hyperactivity disorder

BACKGROUND

Epilepsy is an important disorder that is sometimes accompanied by inattention problems. This study explored the features of seizures in children with epilepsy, with or without attention-deficit/hyperactivity disorder (ADHD).

METHODS

Between January 2017 and January 2018, data records of children with epilepsy aged 5-18 years admitted to hospital were retrospectively collected. SPSS 17.0 was used for analyses and P < 0.05 was accepted as significant.

RESULTS

Of 301 patients with epilepsy, 32 of them had ADHD. Median age at diagnosis of epilepsy in the epilepsy + ADHD group was lower than in the epilepsy alone group (6 vs 8 years; z = -2.989, P = 0.003). The two groups were similar in terms of duration of epilepsy, seizure types and features of complicated versus non-complicated epilepsy, number of anti-epileptic drugs (AED) used (for all, P > 0.05). The epilepsy + ADHD group had a significantly higher prevalence of intellectual disability (31.3% vs 12.6%; χ² (1) = 7.9, P = 0.014) and specific learning disorder (12.5% vs 1.9%; χ² (1) = 11.1, P = 0.009) than the epilepsy alone group (χ² (1) = 11.1, P = 0.009). ADHD medication use was identified in 68.8% of children in the epilepsy + ADHD group.

CONCLUSION

Attention-deficit-hyperactivity disorder was identified in 11.8% of 5-18-year-old children (32/301) with epilepsy in a 1 year period. ADHD is more frequent in children with epilepsy in childhood (5-11 years of age). Epilepsy diagnosis is more frequent in younger children with ADHD. Children with epilepsy and ADHD, also have a significantly higher prevalence of intellectual disability and specific learning disorder. Younger children diagnosed with epilepsy should be carefully monitored for ADHD.

Gender and psychiatric disorders in children with epilepsy. A meta-analysis

OBJECTIVE

The objective of the study was to assess the influence of gender on psychiatric disorders in children with epilepsy (CWE).

METHOD

A systematic review of the literature on risk factors for psychiatric disorder in CWE published between 2004 and June 2018 was undertaken. Studies including data on gender that permitted the calculation of a risk ratio (RR) were included in the meta-analysis. A meta-regression was conducted to examine the contribution of setting of the survey and the inclusion of learning disabilities.

RESULTS

Thirty-nine papers were included in the review. The male/female RR in CWE for Attention Deficit Hyperactivity Disorder (ADHD) was 1.49 (Confidence Interval (CI): 1.24-1.79), autistic spectrum disorder (ASD) 1.67 (CI: 1.47 to 1.90), anxiety 1.00 (CI: 0.90-1.12), and depression 0.93 (CI 0.41-2.09). More boys than girls had ADHD and ASD, but in relative terms, the RR male/female was lower in CWE than the RR in the general population reported in other studies. Meta-regression indicated that the inclusion of children with intellectual disability (mental retardation) or the setting (community vs hospital) did not have a significant impact.

CONCLUSION

Compared with girls in the general population, girls with epilepsy seem to be at a higher risk of being diagnosed with ADHD/ASD as the gender ratio is more equal. This could be related to differences in the assessment of CWE and/or a shared pathogenesis between psychiatric conditions and epilepsy.