Increased frequency of rolandic spikes in ADHD children

Evaluation of the Behavioral Effect of Psychostimulants in Children with Autism Spectrum Disorder: A Cross-Sectional Study

BACKGROUND

 Autism spectrum disorder (ASD) is often accompanied by comorbid conditions such as attention deficit hyperactivity disorder and epilepsy. In this context, patients are often treated with psychostimulants in an attempt to control behavioral symptoms. This study aims to understand the behavioral effects of psychostimulants in children with ASD and investigate if interictal epileptiform discharges on electroencephalogram (EEG) can act as a modifying factor in this behavior.

METHODS

 Sixty-eight patients with ASD who were being accompanied in the Department of Child and Adolescent Psychiatry of the Centro Hospitalar Universitário de São João and had previously done an EEG assessment answered a questionnaire regarding their behavioral response to psychostimulants.

RESULTS

 In total, 47.4% of patients reported improved agitation, 56.1% enhanced concentration, and 8.8% improved sleep. Conversely, 28.1% experienced worsened agitation, 15.8% worsened concentration, and 17.5% worsened sleep. The remaining reported no alterations. The age of diagnosis correlated significantly with improved agitation, with a higher diagnosis age being associated with a higher probability of improvement. Extended-release methylphenidate and genetic variations were significantly associated with worsening of agitation. Regarding speech, 86% exhibited no changes, while 14% showed alterations, mostly, 87.5%, characterized as negative. For other behavioral alterations, 45.6% reported negative changes, 3.5% reported positive changes, and 50.9% reported no additional alterations. Female gender was significantly associated with other negative behavioral changes. A significant correlation was found between treatment duration and the probability of improvement in agitation, concentration, and other behavioral changes.

Neurocognitive effects and electrophysiological findings in ADHD and self-limiting centrotemporal spike wave epilepsy (SeLECTS) - A prospective tertiary care study

OBJECTIVE

The study aimed to determine the prevalence of attention deficit hyperactivity disorder (ADHD) in patients with self-limiting epilepsy with centrotemporal spike wave (SeLECTS), as well as the electroclinical features associated with this comorbid condition and the neurocognitive effects using psychometric tests. Additionally, we analysed the electrophysiological findings and neurocognitive status of patients with ADHD to estimate the prevalence of epilepsy and neurocognitive effects in the ADHD population and evaluate their clinical features.

METHOD

The study included patients diagnosed with SeLECTS and ADHD who were matched for age and gender. Electrophysiological tests, psychometric tests, demographic and clinical characteristics of SeLECTS patients aged 7-13 years and ADHD patients of similar age were analysed. The study examined electrophysiological and psychometric tests, as well as demographic and clinical characteristics. Both groups underwent testing using the Wechsler Intelligence Scale for Children (WISC-R), Stroop Colour and Word Test (SCWT), and EEG (Electroencephalogram). The SeLECTS group also underwent the Bender Visual-Motor Gestalt Test.

RESULTS

No significant relationship was found between the SeLECTS and ADHD groups in terms of age and gender. The rate of epileptiform discharge in EEG findings without a diagnosis of epilepsy was 5.6 % (n = 2) in the ADHD group. The rate of ADHD in the SeLECTS group was 28 % (n = 11). Although all subsections of the WISCR test were higher in the ADHD patient group than in the SeLECTS patient group, only verbal IQ and total IQ showed a significant difference. No significant differences were found between the completion times, error rates, and correction averages of the SCWT sections in both groups. There was no significant correlation found between the performance IQ, verbal IQ, and total intelligence scores in either the isolated SeLECTS patient group or the SeLECTS + ADHD patient group (p > 0.05). However, it is worth noting that verbal IQ was below normal in both groups and slightly lower in the SeLECT + ADHD group. Additionally, the mean SCWT completion time was significantly longer in the SeLECT + ADHD group than in the isolated SeLECTS group. However, no significant difference was found in the Bender Gestalt Visual Motor Perception Test. In the psychometric analyses comparing the isolated SeLECTS, SeLECT + ADHD, and ADHD patient groups, the SCWT completion times were significantly longer in the SeLECT + ADHD group than in the other two groups. The verbal IQ score was significantly higher in the ADHD group than in the other two groups.

CONCLUSION

In conclusion, although SeLECTS is commonly considered a benign form of epilepsy, our study found a high rate of comorbidity with ADHD. This condition has a negative impact on verbal intelligence and sustained attention, highlighting the importance of a complete neuropsychological evaluation at the stage of epilepsy diagnosis. It is crucial not to overlook the possibility of an ADHD diagnosis.

Do psychotropic drugs cause seizures?

Patients with epilepsy often present with concurrent psychiatric disorders, posing unique challenges for healthcare providers. This review explores the intricate relationship between psychiatric comorbidities, epilepsy, and psychotropic medications to inform clinical decision-making. The bidirectional association between epilepsy and psychiatric conditions complicates treatment, with psychiatric symptoms preceding or following seizure onset. The review discusses the seizure risks associated with antidepressants, CNS stimulants, and antipsychotics, shedding light on both historical perspectives and recent empirical evidence. Antidepressants, particularly tricyclic antidepressants (TCAs), are known to pose seizure risks, while newer agents like selective serotonin reuptake inhibitors (SSRIs) exhibit lower incidences and even potential anticonvulsant effects. Contrary to common beliefs, CNS stimulants used in attention-deficit/hyperactivity disorder (ADHD) treatment show efficacy without significantly increasing seizure risk. However, the association between ADHD and seizures warrants careful consideration. Among antipsychotics, clozapine stands out for its heightened seizure risks, especially during titration and at high doses, necessitating close monitoring and individualized approaches. Understanding the nuanced seizure risks associated with different psychotropic medications is crucial for optimizing patient care and minimizing iatrogenic seizures in this vulnerable population. By recognizing the complexities of psychiatric comorbidities in epilepsy and considering the unique challenges they pose, healthcare providers can make informed decisions to enhance patient safety and treatment outcomes. This review offers practical insights to guide clinicians in navigating the intricate landscape of managing psychiatric comorbidities in patients with epilepsy.

How the Spreading and Intensity of Interictal Epileptic Activity Are Associated with Visuo-Spatial Skills in Children with Self-Limited Focal Epilepsy with Centro-Temporal Spikes

This paper investigates brain-behaviour associations between interictal epileptic discharges and cognitive performance in a population of children with self-limited focal epilepsy with centro-temporal spikes (SeLECTS). Sixteen patients with SeLECTS underwent an extensive neuropsychological assessment, including verbal short-term and episodic memory, non-verbal short-term memory, attentional abilities and executive function. Two quantitative EEG indices were analysed, i.e., the Spike Wave Index (SWI) and the Spike Wave Frequency (SWF), and one qualitative EEG index, i.e., the EEG score, was used to evaluate the spreading of focal SW to other parts of the brain. We investigated associations between EEG indices and neuropsychological performance with non-parametric Spearman correlation analyses, including correction for multiple comparisons. The results showed a significant negative correlation between (i) the awake EEG score and the Block Tapping Test, a visuo-spatial short-term memory task, and (ii) the sleep SWI and the Tower of London, a visuo-spatial planning task (pcorr < 0.05). These findings suggest that, in addition to the usual quantitative EEG indices, the EEG analysis should include the qualitative EEG score evaluating the spreading of focal SW to other parts of the brain and that neuropsychological assessment should include visuo-spatial skills.

Self-limited childhood epilepsies are disorders of the perisylvian communication system, carrying the risk of progress to epileptic encephalopathies-Critical review

"Sleep plasticity is a double-edged sword: a powerful machinery of neural build-up, with a risk to epileptic derailment." We aimed to review the types of self-limited focal epilepsies..."i.e. keep as two separate paragraphs" We aimed to review the types of self-limited focal epilepsies: (1) self-limited focal childhood epilepsy with centrotemporal spikes, (2) atypical Rolandic epilepsy, and (3) electrical status epilepticus in sleep with mental consequences, including Landau-Kleffner-type acquired aphasia, showing their spectral relationship and discussing the debated topics. Our endeavor is to support the system epilepsy concept in this group of epilepsies, using them as models for epileptogenesis in general. The spectral continuity of the involved conditions is evidenced by several features: language impairment, the overarching presence of centrotemporal spikes and ripples (with changing electromorphology across the spectrum), the essential timely and spatial independence of interictal epileptic discharges from seizures, NREM sleep relatedness, and the existence of the intermediate-severity "atypical" forms. These epilepsies might be the consequences of a genetically determined transitory developmental failure, reflected by widespread neuropsychological symptoms originating from the perisylvian network that have distinct time and space relations from secondary epilepsy itself. The involved epilepsies carry the risk of progression to severe, potentially irreversible encephalopathic forms.

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.

Guanfacine inhibits interictal epileptiform events and sodium currents in prefrontal cortex pyramidal neurons

BACKGROUND

Guanfacine (an alpha-2A receptor agonist) is a commonly used drug with recognized efficacy in the treatment of attention deficit hyperactivity disorder (ADHD). This study aimed to assess the effects of guanfacine on short-lasting (interictal) epileptiform discharges in cortical neurons. Moreover, we assessed the effects of guanfacine on voltage-gated sodium currents.

METHODS

We conducted patch-clamp recordings in prefrontal cortex pyramidal neurons obtained from young rats. Interictal epileptiform events were evoked in cortical slices in a zero magnesium proepileptic extracellular solution with an elevated concentration of potassium ions.

RESULTS

Interictal epileptiform discharges were spontaneous depolarisations, which triggered action potentials. Guanfacine (10 and 100 µM) inhibited the frequency of epileptiform discharges. The effect of guanfacine on interictal events persisted in the presence of alpha-2 adrenergic receptor antagonist idazoxan. The tested drug inhibited neuronal excitability. Tonic NMDA currents were not influenced by guanfacine. Recordings from dispersed neurons showed that the tested drug (10 and 100 µM) inhibited persistent and fast inactivating voltage-gated sodium currents.

CONCLUSIONS

This study shows that guanfacine inhibits interictal discharges in cortical neurons independently of alpha-2A adrenergic receptors. This effect may be mediated by voltage-gated sodium currents. Inhibition of interictal activity by guanfacine may be of clinical importance because interictal events often occur in patients with ADHD and may contribute to symptoms of this disease.

Diagnostic utility of specific abnormal EEG patterns in children for determining epilepsy phenotype and presence of structural brain abnormalities

Objective

Estimate sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of EEG findings: centrotemporal spikes, photoparoxysmal response, asymmetric photic driving, and asymmetric sleep spindles, for epilepsy phenotype and presence of structural brain abnormalities.

Methods

In this case-control study we reviewed children referred for EEG over a 4-year period, with at least one of centrotemporal spikes, photoparoxysmal response, asymmetric photic driving, or asymmetric sleep spindles. This cohort was analyzed in combination with a research database of pediatric patients with seizures.

Results

Centrotemporal spikes had 100% sensitivity for childhood epilepsy with centrotemporal spikes or atypical childhood epilepsy with centrotemporal spikes, but lower specificity (70%) and PPV (58%). Photoparoxysmal response had high specificity (92%) and NPV (92%) for genetic generalized epilepsy. Asymmetric photic driving had low sensitivity for structural brain abnormalities (17%), with specificity 80%. In contrast, asymmetric sleep spindles had much higher sensitivity and specificity, 44% and 97%, respectively.

Conclusions

Although centrotemporal spikes are classically associated with childhood epilepsy with centrotemporal spikes, these discharges are seen in other conditions. Photoparoxysmal response is highly indicative of a genetic generalized epilepsy, though may be seen in other epilepsy phenotypes. Relative attenuation of sleep spindles is a more reliable indicator of structural brain malformation than asymmetric photic driving.

Significance

The quantitative diagnostic utility of EEG findings should be considered when incorporating these results into clinical decision-making.

Relationship between Attention Deficit Hyperactivity Disorder and epilepsy: a literature review

Background

Attention Deficit Hyperactivity Disorder (ADHD) is a prevalent neurological disorder. ADHD has been linked to epilepsy.

Main body

ADHD was found to be present in 30–40% of epileptic children. Researchers have developed numerous theories to explain how and why ADHD and epilepsy coexist. Whether ADHD and epilepsy symptoms are caused by co-occurring psychiatric disorders or by the temporary effects of epileptic discharges or by antiepileptic medicines is critical to consider. Diagnosis and treatment of individuals with ADHD and epilepsy are complicated and challenging from the clinical base.

Conclusions

Comorbidity between ADHD and epilepsy is still challenging to understand. The two diseases have a bidirectional link, so the association may not be coincidental. A disputable point is whether co-occurring ADHD and epilepsy symptoms represent a comorbid psychiatric disorder or are the epileptic discharges’ temporary effects, and are they related to antiepileptic drugs (AEDs). It is recommended to follow up with children with epilepsy or ADHD as they may develop comorbidity after a while.

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

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

Executive functioning in children with self-limited epilepsy with centrotemporal spikes: a systematic review and meta-analysis

Self-limited epilepsy with centrotemporal spikes (ECTS) is one of the most frequent focal epilepsies amongst children. Because remission usually occurs before 16 years old and patients present infrequent clinical manifestation, ECTS was considered benign for a long time. Despite the reports on cognitive deficits associated with ECTS in the last years, knowledge about the condition's specific executive function domains (inhibitory control, working memory, cognitive flexibility, verbal fluency, and higher-order executive functions) is still lacking. The following systematic review was conducted according to PRISMA guidelines. The PubMed and Scopus databases and gray literature were searched according to the following eligibility criteria: (1) original articles published in peer-review journals; (2) studies that present assessment of children with ECTS; and (3) studies with an available assessment of the executive function of the participants. A total of 43 studies (1179 patients and 1086 healthy controls) met the inclusion criteria. Data from 19 studies were extracted, and meta-analysis methods were used to compare results in the three main executive function domains and verbal fluency. The study quality was measured through the Newcastle-Ottawa Scale (NOS) and the evidence quality with the GRADEpro tool. Results and conclusions: The present systematic review is the first to gather information about executive functioning in children with ECTS. According to the meta-analyses, children with ECTS show weaker performances when compared with a control group in inhibitory control, cognitive flexibility, and verbal fluency. However, because the quality of evidence was classified as very low, caution is needed when interpreting the strength of the results.

Do Psychotropic Drugs Cause Epileptic Seizures? A Review of the Available Evidence

Psychiatric comorbidities in patients with epilepsy are common. A bidirectional relationship has been well described where not only patients with epilepsy have a higher prevalence of psychiatric comorbidities but also patients with primary psychiatric disorders are at an increased risk of developing seizures. The aim of this review is to highlight the complex relationship between epilepsy and common psychiatric disorders and to answer the question whether psychotropic medications are proconvulsant by reviewing the preclinical and clinical literature. The evidence shows that the majority of psychotropic medications are not proconvulsant when used in therapeutic doses with the exception of a subset of medications, mainly bupropion IR and certain antipsychotic drugs such as clozapine. An effective treatment of psychiatric comorbidities in patients with epilepsy must consider not only the potential therapeutic effect of the drug, but also its potential iatrogenic effects on the seizure disorder.

Methylphenidate for attention problems in epilepsy patients: Safety and efficacy

Children with attention deficit hyperactivity disorder (ADHD) have an increased risk of seizures, and children with epilepsy have an increased prevalence of ADHD. Adults with epilepsy often have varying degrees of attentional dysfunction due to multiple factors, including anti-seizure medications, frequent seizures, interictal discharges, underlying lesions, and psychiatric comorbidities. Currently, there are no approved medications for the treatment of epilepsy-related attentional dysfunction. Methylphenidate (MPH) is a stimulant, FDA-approved for the treatment of ADHD, and often used for ADHD in the setting of pediatric epilepsy. Large database and registry studies indicate safety of MPH in children with ADHD and epilepsy, with no significant effect on seizure frequency. Small single-dose and open-label studies suggest efficacy of MPH in adults with epilepsy-related attention deficits. Methylphenidate represents a possible treatment for attentional dysfunction due to epilepsy, but large, randomized, placebo-controlled, double-blinded studies are needed.

Modulation of locomotor behaviors by location-specific epileptic spiking and seizures

INTRODUCTION

Epilepsy is a debilitating neurological condition characterized by spontaneous seizures as well as significant comorbid behavioral abnormalities. In addition to seizures, epileptic patients exhibit interictal spikes far more frequently than seizures, often, but not always observed in the same brain areas. The exact relationship between spiking and seizures as well as their respective effects on behavior are not well understood. In fact, spiking without overt seizures is seen in various psychiatric conditions including attention-deficit hyperactivity disorder.

METHODS

In order to study the effects of spiking and seizures on behavior in an epileptic animal model, we used long-term video-electroencephalography recordings at six cortical recording sites together with behavioral activity monitoring. Animals received unilateral injections of tetanus toxin into either the somatosensory or motor cortex.

RESULTS

Somatosensory cortex-injected animals developed progressive spiking ipsilateral to the injection site, while those receiving the injection into the motor cortex developed mostly contralateral spiking and spontaneous seizures. Animals with spiking but no seizures displayed a hyperactive phenotype, while animals with both spiking and seizures displayed a hypoactive phenotype. Not all spikes were equivalent as spike location strongly correlated with distinct locomotor behaviors including ambulatory distance, vertical movements, and rotatory movement.

CONCLUSIONS

Together, our results demonstrate relationships between brain region-specific spiking, seizures, and behaviors in rodents that could translate into a better understanding for patients with epileptic behavioral comorbidities and other neuropsychiatric disorders.

Drug Treatment of Epilepsy Neuropsychiatric Comorbidities in Children

There is increasing recognition that epilepsy can be associated with a broad spectrum of comorbidities. While epileptic seizures are an essential element of epilepsy in children, there is a spectrum of neurological, mental health and cognitive disorders that add to the disease burden of childhood epilepsy resulting in a decreased quality of life. The most common comorbid conditions in childhood epilepsy include depression, anxiety, autism spectrum disorders, sleep disorders, attention deficits, cognitive impairment, and migraine. While epilepsy can result in comorbidities, many of the comorbidities of childhood have a bi-directional association, with the comorbid condition increasing risk for epilepsy and epilepsy increasing the risk for the comorbid condition. The bidirectional feature of epilepsy and the comorbidities suggest a common underlying pathological basis for both the seizures and comorbid condition. While recognition of the comorbid conditions of pediatric epilepsies is increasing, there has been a lag in the development of effective therapies partly out of concern that drugs used to treat the comorbid conditions could increase seizure susceptibility. There is now some evidence that most drugs used for comorbid conditions are safe and do not lower seizure threshold. Unfortunately, the evidence showing drugs are effective in treating many of the childhood comorbidities of epilepsy is quite limited. There is a great need for randomized, placebo-controlled drug trials for efficacy and safety in the treatment of comorbidities of childhood epilepsy.

The association between ADHD and physical health: a co-twin control study

Attention-deficit/hyperactivity disorder (ADHD) has been associated with increased risk for physical comorbidity. This study used a twin cohort to investigate the association between physical diseases and phenotypic variations of ADHD. A twin cohort enriched for ADHD and other neurodevelopmental conditions were analysed. The Attention Problems subscale of the Child Behavior Checklist/Adult Behavior Checklist (CBCL/ABCL-AP) was used to measure the participants’ severity of ADHD symptoms. Physical health issues were obtained with a validated questionnaire and were tested in relation to ADHD symptom severity in a co-twin control model. Neurological problems were significantly associated with a diagnosis of ADHD. A conditional model for the analysis of within-twin pair effects revealed an inverse association between digestive problems and the severity of ADHD symptoms, after adjusting for co-existing autism spectrum disorder and ADHD medications. Our findings suggest that individuals with ADHD are susceptible to neurological problems, why a thorough neurological check-up is indicated in clinical practice for this population. In addition, health conditions of digestive system could be considered as a non-shared environmental factor for behavioral phenotypes in ADHD. It supports the possible role of gut-brain axis in the underpinnings of ADHD symptoms, at least for a subgroup of individuals with certain genetic predisposition.

Evaluation of psychiatric comorbidity in attention-deficit hyperactivity disorder with epilepsy: A case-control study

OBJECTIVE

Attention deficit/hyperactivity disorder (ADHD) is a developmental disorder caused by structural and functional brain abnormalities as well as genetic and environmental factors. ADHD symptoms are commonly observed in individuals with epilepsy. A few studies have reported a pattern of behavioral problems in children with combined epilepsy and ADHD. We aimed to evaluate comorbid behavioral problems and mental health concerns among children with epilepsy with ADHD and without ADHD including autism spectrum disorder, anxiety, depression, somatic problems, oppositional defiant disorder, and conduct disorder.

METHODS

A total of 100 children aged between 6 and 11 years were recruited and categorized into 1 of 5 groups (20 child/group): (1) epilepsy, (2) epilepsy with ADHD, (3) ADHD with electroencephalogram (EEG) changes, (4) ADHD without EEG changes, and (5) healthy control. The scales used in our study included the Childhood Autism Spectrum Test (CAST) to screen autism spectrum conditions and related social and communication conditions, Conners' Parent Rating Scale (CPRS) to assess ADHD and other comorbid behavioral and social-emotional difficulties, and Children Behavior Checklist (CBCL) to evaluate behavior problems.

RESULTS

The CAST scale score showed no significant difference among the studied groups. Regarding the Conners-3 scale, the combined type of ADHD was predominant in the ADHD with EEG changes group and the ADHD with epilepsy group, while hyperactive ADHD was predominant in the ADHD without EEG changes group. The ADHD with EEG changes group and the ADHD with epilepsy group had equally high clinical rating scores for CBCL in internalizing and externalizing problems. There was a significant difference in the profile of all Diagnostic and Statistical Manual of Mental Disorders (DSM-5) scales of CBCL among the studied groups.

CONCLUSION

This is the first study to use EEG in patients with ADHD in comparison with epilepsy. ADHD with epilepsy is closely related to ADHD with EEG changes regarding psychiatric comorbidity in terms of anxiety, depression, somatic problems, oppositional defiance problems, and conduct problems.

Inhibiting Epileptiform Activity in Cognitive Disorders: Possibilities for a Novel Therapeutic Approach

Cognitive impairment is a common and seriously debilitating symptom of various mental and neurological disorders including autism, attention deficit hyperactivity disorder, multiple sclerosis, epilepsy, and neurodegenerative diseases, like Alzheimer's disease. In these conditions, high prevalence of epileptiform activity emerges as a common pathophysiological hallmark. Growing body of evidence suggests that this discrete but abnormal activity might have a long-term negative impact on cognitive performance due to neuronal circuitries' remodeling, altered sleep structure, pathological hippocampo-cortical coupling, and even progressive neuronal loss. In animal models, epileptiform activity was shown to enhance the formation of pathological amyloid and tau proteins that in turn trigger network hyperexcitability. Abolishing epileptiform discharges might slow down the cognitive deterioration. These findings might provide basis for therapeutic use of antiepileptic drugs in neurodegenerative cognitive disorders. The aim of our review is to describe the data on the prevalence of epileptiform activity in various cognitive disorders, to summarize the current knowledge of the mechanisms of epileptic activity in relation to cognitive impairment, and to explore the utility of antiepileptic drugs in the therapy of cognitive disorders. We also propose future directions for drug development and novel therapeutic interventions targeting epileptiform discharges in these disorders.

Clinical and electroencephalographic features of benign childhood epilepsy with centrotemporal spikes comorbidity with attention-deficit hyperactivity disorder in Southwest China

PURPOSE

This study was conducted to analyze the clinical and electroencephalographic (EEG) features of attention-deficit hyperactivity disorder (ADHD) in children with benign partial epilepsy with centrotemporal spikes (BECTS) in Southwest China, to address the question of what the risk factors are for patients with BECTS who suffer from ADHD.

METHODS

Overall 118 right-handed children with BECTS were included from two medical centers. Of them, 29 patients were with diagnosed ADHD according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) at baseline, and the remaining were considered as typical BECTS. Clinical and EEG characteristics were collected at baseline and follow-up endpoint of one year. All the patients completed an eight-hour video-electroencephalogram (VEEG) without sedation at those two time points using a digital system with international 10-20 array electrode placement. At the follow-up endpoint, we also evaluated the intelligence level of all patients using the Wechsler Intelligence Scale for Children-IV (WISC-IV). Multivariate logistical regression model was performed to assess the risk factors of ADHD in BECTS patients.

RESULTS

Compared with typical BECTS, patients with BECTS-ADHD had an earlier age of onset, a longer disease course and tended to have lower intelligence quotient (IQ) scores. Their epileptiform discharges were more likely to diffuse to one or both hemispheres, and a higher percentage of patients with BECTS-ADHD patients needed multitherapy to control seizures. Multivariate analysis showed that age of onset, disease course, intelligence score, number of antiepileptic drugs (AEDs), and bilateral or diffusing discharges were independently associated with the occurrence of ADHD in patients with BECTS (p < .05). Additionally, we found that delayed diagnosis (37.3%) and nonadherence to treatment (16.1%) were the main reasons of a long disease course.

CONCLUSION

Benign partial epilepsy with centrotemporal spikes with ADHD has the characteristics of early age of onset, long course of disease and low intelligence score. In addition, the epileptiform discharges of BECTS-ADHD were prone to be bilateral or diffuse, and polypharmacological treatment is also common in this group.

Dlg4 and Vamp2 are involved in comorbid epilepsy and attention-deficit hyperactivity disorder: A microarray data study

OBJECTIVE

Children with epilepsy exhibit a significantly higher risk for attention-deficit hyperactivity disorder (ADHD), which is often associated with lower quality of life. In this study, we aimed to identify molecular mechanisms associated with both epilepsy and ADHD.

MATERIALS AND METHODS

Gene expression profiles of GSE12457 and GSE47752 were downloaded from the gene expression omnibus (GEO) database. Differentially expressed genes (DEGs) were separately screened in epilepsy and ADHD samples and compared with controls. Weighted gene coexpression network analysis (WGCNA) was used to identify candidate modules associated with the two disorders. Functional annotation and analysis of hub genes and molecular complex detection (MCODE) was also performed.

RESULTS

Three modules closely related to epilepsy and ADHD were screened using WGCNA; DEGs in this module were involved in the synaptic vesicle cycle, axon and neuron regeneration, and neurotransmission. The Dlg4 and Vamp2 genes were selected as common candidate factors in epilepsy and ADHD pathogenesis.

CONCLUSION

Dlg4 and Vamp2 could play essential roles in comorbidity between epilepsy and ADHD.

Sleep and Epilepsy Link by Plasticity

We aimed to explore the link between NREM sleep and epilepsy. Based on human and experimental data we propose that a sleep-related epileptic transformation of normal neurological networks underlies epileptogenesis. Major childhood epilepsies as medial temporal lobe epilepsy (MTLE), absence epilepsy (AE) and human perisylvian network (PN) epilepsies - made us good models to study. These conditions come from an epileptic transformation of the affected functional systems. This approach allows a system-based taxonomy instead of the outworn generalized-focal classification. MTLE links to the memory-system, where epileptic transformation results in a switch of normal sharp wave-ripples to epileptic spikes and pathological high frequency oscillations, compromising sleep-related memory consolidation. Absence epilepsy (AE) and juvenile myoclonic epilepsy (JME) belong to the corticothalamic system. The burst-firing mode of NREM sleep normally producing sleep-spindles turns to an epileptic working mode ejecting bilateral synchronous spike-waves. There seems to be a progressive transition from AE to JME. Shared absences and similar bilateral synchronous discharges show the belonging of the two conditions, while the continuous age windows - AE affecting schoolchildren, JME the adolescents - and the increased excitability in JME compared to AE supports the notion of progression. In perisylvian network epilepsies - idiopathic focal childhood epilepsies and electrical status epilepticus in sleep including Landau-Kleffner syndrome - centrotemporal spikes turn epileptic, with the potential to cause cognitive impairment. Postinjury epilepsies modeled by the isolated cortex model highlight the shared way of epileptogenesis suggesting the derailment of NREM sleep-related homeostatic plasticity as a common step. NREM sleep provides templates for plasticity derailing to epileptic variants under proper conditions. This sleep-origin explains epileptiform discharges' link and similarity with NREM sleep slow oscillations, spindles and ripples. Normal synaptic plasticity erroneously overgrowing homeostatic processes may derail toward an epileptic working-mode manifesting the involved system's features. The impact of NREM sleep is unclear in epileptogenesis occurring in adolescence and adulthood, when plasticity is lower. The epileptic process interferes with homeostatic synaptic plasticity and may cause cognitive impairment. Its type and degree depends on the affected network's function. We hypothesize a vicious circle between sleep end epilepsy. The epileptic derailment of normal plasticity interferes with sleep cognitive functions. Sleep and epilepsy interconnect by the pathology of plasticity.

Transient Cognitive Impairment in Epilepsy

Impairments of the dialog between excitation and inhibition (E/I) is commonly associated to neuropsychiatric disorders like autism, bipolar disorders and epilepsy. Moderate levels of hyperexcitability can lead to mild alterations of the EEG and are often associated with cognitive deficits even in the absence of overt seizures. Indeed, various testing paradigms have shown degraded performances in presence of acute or chronic non-ictal epileptiform activity. Evidences from both animal models and the clinics suggest that anomalous activity can cause cognitive deficits by transiently disrupting cortical processing, independently from the underlying etiology of the disease. Here, we will review our understanding of the influence of an abnormal EEG activity on brain computation in the context of the available clinical data and in genetic or pharmacological animal models.

Benign epilepsy with centrotemporal spikes - Current concepts of diagnosis and treatment

Benign epilepsy with centrotemporal spikes (BECTS) is the most common focal epilepsy of the childhood and also one of the best known. It has a proclivity to start at a particular age and remit spontaneously before adolescence. Majority of patients may avoid long-term treatment, because of the mild course and very good outcome. Only few patients may present cognitive deficits if the proper treatment is not implied. BECTS is a part of heterogeneous group of syndromes that consists of Landau-Kleffner Syndrome (LKS), Continuous Spike-and-Wave during Sleep (CSWS) and Atypical benign partial epilepsy (ABPE). These syndromes may be also a result of various trajectories that BECTS may evolve to. Disease is suggested to have genetic origins, as some patients have relatives with different types of epilepsy. The discovery of the pathogenic mechanism of the disease and implementation of targeted therapy belong to the main challenges in the treatment of these patients.

The influence of EEG-detected nocturnal centrotemporal discharges on the expression of core symptoms of ADHD in children with benign childhood epilepsy with centrotemporal spikes (BCECTS): A prospective study in a tertiary referral center

Benign childhood epilepsy with centrotemporal spikes (BCECTS) is the most frequent benign focal epilepsy in childhood. Although it is described as a benign epilepsy syndrome, many studies have revealed that a significant number of patients have some degree of neuropsychological impairment. Thirty-two patients with BCECTS aged 6-11years were included in the study. All patients (without any antiepileptic or psychiatric medication) underwent all-night EEG monitoring and complex neuropsychological testing to diagnose the presence of core symptoms of attention-deficit/hyperactivity disorder (ADHD). The spike index (number of spikes per minute) on awake and asleep EEG, age at seizure onset, family history of epilepsy, and perinatal risks were correlated with the results of neuropsychological testing. Of the 32 patients, 21 patients (65.6%) fulfilled the criteria for ADHD diagnosis. Children who were younger at epilepsy onset demonstrated lower IQ and higher attention deficit (P=0.004) and higher impulsivity (P=0.016). The occurence of epileptiform discharges on nocturnal EEG was positively related to higher attention deficit and higher impulsivity. The findings are discussed in terms of how interictal discharges in the centrotemporal region during sleep affect the development of cognitive functions in children during critical epochs of neuropsychological development.

The Rise and Fall and Rise of Linkage Analysis as a Technique for Finding and Characterizing Inherited Influences on Disease Expression

For many years, family-based studies using linkage analysis represented the primary approach for identifying disease genes. This strategy is responsible for the identification of the greatest number of genes proven to cause human disease. However, technical advancements in next generation sequencing and high throughput genotyping, coupled with the apparent simplicity of association testing, led to the rejection of family-based studies and of linkage analysis. At present, genetic association methods, using case-control comparisons, have become the exclusive approach for detecting disease-related genes, particularly those underlying common, complex diseases. In this chapter, we present a historical overview of linkage analysis, including a description of how the approach works, as well as its strengths and weaknesses. We discuss how the transition from family-based studies to population comparison association studies led to a critical loss of information with respect to genetic etiology and inheritance, and we present historical and contemporary examples of linkage analysis "success stories" in identifying genes contributing to the development of human disease. Currently, linkage analysis is re-emerging as a useful approach for identifying disease genes, determining genetic parameters, and resolving genetic heterogeneity. We posit that the combination of linkage analysis, association testing, and high throughput sequencing provides a powerful approach for identifying disease-causing genes.

Attention Deficit Hyperactivity Disorder and Associated Cognitive Dysfunction in Pediatric Epilepsy

Attention deficit hyperactivity disorder (ADHD) is the most common neuropsychiatric comorbidity associated with childhood epilepsy, affecting about a third of children with epilepsy. In contrast, ADHD in the general population occurs in 4%-12% of school-aged children. The cause of this association remains unclear. It is likely that common mechanisms underlie the vulnerability for both executive deficits and epileptogenesis. There are characteristics unique to children with ADHD and epilepsy. The inattentive type of ADHD is more prevalent than the combined presentation in children with epilepsy, while the combined type is more common in the general population. Interestingly, there is an equal sex distribution of ADHD in patients with epilepsy, while in the general population, ADHD is 3-7 times more prevalent in boys. Specific features of ADHD seen in different epilepsy syndromes are frequently associated with executive deficits. Early screening of ADHD symptoms in children with epilepsy is essential, as timely interventions can improve academic and social function and outcomes. The mainstays of therapy include behavioral interventions and pharmacotherapy, with evidence demonstrating that stimulants are both safe and effective in children with ADHD and epilepsy.

Considerations for ADHD in the child with epilepsy and the child with migraine

INTRODUCTION

Attention Deficit Hyperactivity Disorder (ADHD) is a common comorbid condition in children with epilepsy and migraine. Treatment of ADHD in children with epilepsy or migraine is essential but clinicians may overlook symptoms of ADHD and avoid appropriate use of medications that may reduce symptoms of ADHD without compromising treatment of epilepsy or migraine. Areas covered: PubMed was searched for articles on ADHD and epilepsy or migraine. Key papers were reviewed for additional articles. Areas of interest were: epidemiology, etiological factors, and treatment with emphasis on therapy. Expert commentary: Stimulant medication, especially methylphenidate, appears to be safe and effective in the treatment of ADHD in children with epilepsy or migraine. Unfortunately, data is limited with very few controlled trials of methylphenidate and very limited information on the use of amphetamines or non-stimulant drugs.

The effects of risk factors on EEG and seizure in children with ADHD

Attention-deficit hyperactivity disorder (ADHD) is one of the most commonly seen developmental disorders in childhood. Its etiology, however, is not well known even though bio-psycho-social reasons have been thought to play a big role. The aims of this retrospective study are to identify the risk factors of ADHD in patients diagnosed with ADHD in childhood, analyze the relationship between clinical symptoms and risk factors to which they were exposed and determine their effects on prospective electrophysiological findings. Longitudinal cohort study of all children with ADHD treated at Ankara University Medical University during 2007-2012, with follow-up to ascertain risk factors and seizure and EEG abnormalities outcome. Multinominal univariate logistic regression analysis was used to calculate adjusted risk ratios (RRs) and 95% confidence intervals (CIs) for associations. Epileptiform discharges were found in 32 (22.9%) of the 140 ADHD patients. Of these, 71.9% had focal epileptiform discharges and 28.1% had generalized epileptiform discharges. The focal epileptiform discharges were most prevalent from the rolandic area. Among the 140 patients, 20 (14.3%) had a previous history of seizure, and all twenty had epileptiform discharges on EEG whereas none of the patients who had normal EEG had a seizure history. The rates of epileptiform discharges were significantly related to gestational age and asphyxia (RR: 1.8, 95% CI 0.3, 9.3; RR: 9.6, 95% CI 2.3, 40, respectively), whereas the rates of epilepsy were related to asphyxia but not gestational age. History of asphyxia and prematurity do seem to increase the risk of EEG abnormality in patients with ADHD. Modification of these environmental risk factors by evidence-based prevention programs may help to decrease the burden of ADHD.

Methylphenidate, cognition, and epilepsy: A double-blind, placebo-controlled, single-dose study

OBJECTIVE

To evaluate the potential efficacy of immediate-release methylphenidate (MPH) for treating cognitive deficits in epilepsy.

METHODS

This was a double-blind, randomized, single-dose, 3-period crossover study in patients with epilepsy and chronic cognitive complaints comparing the effects of placebo and MPH 10 and 20 mg given 1 week apart. Cognitive outcome was evaluated on the basis of an omnibus z score calculated from performance on the Conners Continuous Performance Test 3 (ability to discriminate between target and nontarget stimuli [d'] and hit reaction time standard deviation), Symbol-Digit Modalities Test, and Medical College of Georgia Paragraph Memory Test. Adverse events and seizure frequency were monitored. An open-label follow-up is reported elsewhere.

RESULTS

Thirty-five adult patients with epilepsy participated, of whom 31 finished. Demographics included the following: mean age = 35.3 years (range 20-62 years), 13 men and 18 women, and baseline seizure frequency of 2.8 per month. Epilepsy types were focal (n = 24), generalized (n = 6), or unclassified (n = 1). Mean epilepsy duration was 12.5 years. A statistically significant performance benefit was present at both 10-mg (p = 0.030) and 20-mg (p = 0.034) MPH doses. No seizures were associated with either MPH dose. Adverse effects leading to withdrawal included cognitive "fogginess" (n = 1 on 20 mg), anxiety/agitation (n = 1 on 10 mg), and tachycardia (n = 1). One participant was lost to follow-up after one 20-mg dose without side effect.

CONCLUSIONS

This single-dose study suggests that MPH may be effective in ameliorating some cognitive deficits in patients with epilepsy. Additional studies are required.

CLINICALTRIALSGOV IDENTIFIER

NCT02178995.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that single doses of MPH improve cognitive performance on some measures of attention and processing speed in patients with epilepsy and cognitive complaints.

The Many Faces of Elongator in Neurodevelopment and Disease

Development of the nervous system requires a variety of cellular activities, such as proliferation, migration, axonal outgrowth and guidance and synapse formation during the differentiation of neural precursors into mature neurons. Malfunction of these highly regulated and coordinated events results in various neurological diseases. The Elongator complex is a multi-subunit complex highly conserved in eukaryotes whose function has been implicated in the majority of cellular activities underlying neurodevelopment. These activities include cell motility, actin cytoskeleton organization, exocytosis, polarized secretion, intracellular trafficking and the maintenance of neural function. Several studies have associated mutations in Elongator subunits with the neurological disorders familial dysautonomia (FD), intellectual disability (ID), amyotrophic lateral sclerosis (ALS) and rolandic epilepsy (RE). Here, we review the various cellular activities assigned to this complex and discuss the implications for neural development and disease. Further research in this area has the potential to generate new diagnostic tools, better prevention strategies and more effective treatment options for a wide variety of neurological disorders.

A microRNA-328 binding site in PAX6 is associated with centrotemporal spikes of rolandic epilepsy

Objective

Rolandic epilepsy is a common genetic focal epilepsy of childhood characterized by centrotemporal sharp waves on electroencephalogram. In previous genome‐wide analysis, we had reported linkage of centrotemporal sharp waves to chromosome 11p13, and fine mapping with 44 SNPs identified the ELP4‐PAX6 locus in two independent US and Canadian case–control samples. Here, we aimed to find a causative variant for centrotemporal sharp waves using a larger sample and higher resolution genotyping array.

Methods

We fine‐mapped the ELP4‐PAX6 locus in 186 individuals from rolandic epilepsy families and 1000 population controls of European origin using the Illumina HumanCoreExome‐12 v1.0 BeadChip. Controls were matched to cases on ethnicity using principal component analysis. We used generalized estimating equations to assess association, followed up with a bioinformatics survey and literature search to evaluate functional significance.

Results

Homozygosity at the T allele of SNP rs662702 in the 3′ untranslated region of PAX6 conferred increased risk of CTS: Odds ratio = 12.29 (95% CI: 3.20–47.22), P = 2.6 × 10⁻⁴ and is seen in 3.9% of cases but only 0.3% of controls.

Interpretation

The minor T allele of SNP rs662702 disrupts regulation by microRNA‐328, which is known to result in increased PAX6 expression in vitro. This study provides, for the first time, evidence of a noncoding genomic variant contributing to the etiology of a common human epilepsy via a posttranscriptional regulatory mechanism.

An integrated feature ranking and selection framework for ADHD characterization

Today, diagnosis of attention deficit hyperactivity disorder (ADHD) still primarily relies on a series of subjective evaluations that highly rely on a doctor’s experiences and intuitions from diagnostic interviews and observed behavior measures. An accurate and objective diagnosis of ADHD is still a challenge and leaves much to be desired. Many children and adults are inappropriately labeled with ADHD conditions, whereas many are left undiagnosed and untreated. Recent advances in neuroimaging studies have enabled us to search for both structural (e.g., cortical thickness, brain volume) and functional (functional connectivity) abnormalities that can potentially be used as new biomarkers of ADHD. However, structural and functional characteristics of neuroimaging data, especially magnetic resonance imaging (MRI), usually generate a large number of features. With a limited sample size, traditional machine learning techniques can be problematic to discover the true characteristic features of ADHD due to the significant issues of overfitting, computational burden, and interpretability of the model. There is an urgent need of efficient approaches to identify meaningful discriminative variables from a higher dimensional feature space when sample size is small compared with the number of features. To tackle this problem, this paper proposes a novel integrated feature ranking and selection framework that utilizes normalized brain cortical thickness features extracted from MRI data to discriminate ADHD subjects against healthy controls. The proposed framework combines information theoretic criteria and the least absolute shrinkage and selection operator (Lasso) method into a two-step feature selection process which is capable of selecting a sparse model while preserving the most informative features. The experimental results showed that the proposed framework generated the highest/comparable ADHD prediction accuracy compared with the state-of-the-art feature selection approaches with minimum number of features in the final model. The selected regions of interest in our model were consistent with recent brain–behavior studies of ADHD development, and thus confirmed the validity of the selected features by the proposed approach.

Clinical Impact of Epileptiform Discharge in Children With Attention-Deficit/Hyperactivity Disorder (ADHD)

The aim of this study was to investigate the prevalence and clinical significance of epileptiform discharges in patients with attention-deficit/hyperactivity disorder (ADHD). The authors retrospectively reviewed 180 children who were diagnosed with ADHD and had an electroencephalography (EEG) recording. Epileptiform discharges were found in 29 (16.1%) of 180 patients with ADHD. Of these, 15 (8.3%) had generalized epileptiform discharges and 14 (7.7%) had focal epileptiform discharges. The focal epileptiform discharges were most prevalent from the frontal (5/14) and rolandic area (5/14). Among the 29 patients with epileptiform discharges and ADHD, 5 patients had previous history of epilepsy and 4 patients developed epilepsy later, whereas none of the normal EEG group developed epilepsy. The authors suggest that interictal epileptiform discharges appear to be associated with seizure occurrence in children with ADHD and might reflect maturational pathophysiology overlapping with epilepsy.

When Is EEG Indicated in Attention-Deficit/Hyperactivity Disorder?

The authors investigated the parameters for predicting epileptiform abnormalities in a group of children diagnosed with attention-deficit/hyperactivity disorder (ADHD). The sample consisted of 148 subjects aged between 6 and 13 (8.76 ± 1.26; 25.7% female) years. Subtypes of ADHD and comorbid psychiatric disorders were defined according to DSM-IV criteria. The Wechsler Intelligence Scale for Children-Revised was applied to all patients. Most of the subjects (89.2%) had wakefulness and sleep electroencephalography examinations lasting about one hour. The authors found out that the coexistence of speech sound disorder (odds ratio [OR] 3.90, 95% confidence interval [CI]: 1.61-9.48) and higher Digit Span test performance (OR 1.24, 95% CI: 1.06-1.44) predicted the presence of accompanying epileptiform abnormalities. The prevalence of epileptiform abnormalities was 26.4%, and they were frequently localized in the frontal (41%) and centrotemporal (28.2%) regions. Higher percentage of speech sound disorder co-occurrence (64%) in subjects with rolandic spikes suggests that epileptiform abnormalities associated with ADHD can be determined genetically at least in some cases. Pathophysiology of epileptiform abnormalities in ADHD might have complex genetic and maturational background.

Should epileptiform discharges be treated?

To evaluate the impact of epileptiform discharges (EDs) that do not occur within seizure patterns--such as spikes, sharp waves or spike waves--on cognitive function and to discuss the circumstances under which treatment of EDs might be considered. Methods used in this article is "Review of the literature". EDs may disrupt short-term cognition in humans. Frequent EDs for a prolonged period can potentially impair long-term cognitive function in humans. However, there is conflicting evidence on the impact of EDs on long-term cognitive outcome because this relationship may be confounded by multiple factors such as underlying etiology, seizures, and medication effects. Limitations of existing studies include the lack of standardized ED quantification methods and of widely accepted automated spike quantification methods. Although there is no solid evidence for or against treatment of EDs, a non-evidence-based practical approach is suggested. EDs in otherwise asymptomatic individuals should not be treated because the risks of treatment probably outweigh its dubious benefits. A treatment trial for EDs may be considered when there is cognitive dysfunction or regression or neurologic symptoms that are unexplained by the underlying etiology, comorbid conditions, or seizure severity. In patients with cognitive or neurologic dysfunction with epilepsy or EDs, treatment may be warranted to control the underlying epileptic syndrome. EDs may cause cognitive or neurologic dysfunction in humans in the short term. There is conflicting evidence on the impact of EDs on long-term cognitive outcome. There is no evidence for or against treatment of asymptomatic ED.

Resting-state oscillatory dynamics in sensorimotor cortex in benign epilepsy with centro-temporal spikes and typical brain development

Benign Epilepsy with Centro-Temporal Spikes (BECTS) is a common childhood epilepsy associated with deficits in several neurocognitive domains. Neurophysiological studies in BECTS often focus on centro-temporal spikes, but these correlate poorly with morphology and cognitive impairments. To better understand the neural profile of BECTS, we studied background brain oscillations, thought to be integrally involved in neural network communication, in sensorimotor areas. We used independent component analysis of temporally correlated sources on magnetoencephalography recordings to assess sensorimotor resting-state network activity in BECTS patients and typically developing controls. We also investigated the variability of oscillatory characteristics within focal primary motor cortex (M1), localized with a separate finger abduction task. We hypothesized that background oscillations would differ between patients and controls in the sensorimotor network but not elsewhere, especially in the beta band (13-30 Hz) because of its role in network communication and motor processing. The results support our hypothesis: in the sensorimotor network, patients had a greater variability in oscillatory amplitude compared to controls, whereas there was no difference in the visual network. Network measures did not correlate with age. The coefficient of variation of resting M1 peak frequency correlated negatively with age in the beta band only, and was greater than average for a number of patients. Our results point toward a "disorganized" functional sensorimotor network in BECTS, supporting a neurodevelopmental delay in sensorimotor cortex. Our findings further suggest that investigating the variability of oscillatory peak frequency may be a useful tool to investigate deficits of disorganization in neurodevelopmental disorders.

Altered attention networks in benign childhood epilepsy with centrotemporal spikes (BECTS): A resting-state fMRI study

It is noteworthy that some children with benign childhood epilepsy with centrotemporal spikes (BECTS) show attention problems despite their favorable seizure outcome. Resting-state functional magnetic resonance imaging (fMRI) is a method widely used to detect brain network alterations in neuropsychiatric diseases. We used resting-state functional magnetic resonance imaging (fMRI) to investigate specific brain networks related to attention deficit in children with BECTS. Resting-state fMRI was performed in patients with BECTS with ADHD (n=15) and those with BECTS without ADHD (n=15) and in healthy controls (n=15). Unbiased seed-based whole-brain functional connectivity analysis was used to study the connectivity pattern of three resting-state networks, including the ventral attention network (VAN) and the dorsal attention network (DAN) and the default mode network (DMN). Patients with BECTS with ADHD displayed decreased functional connectivity in the DAN compared with other two groups, while patients with BECTS without ADHD showed increased functional connectivity in the DAN. Moreover, we found increased functional connectivity in the VAN and in the DMN in patients with BECTS with or without ADHD when comparing with controls. These results showed that the newly-diagnosed children with BECTS displayed brain activity alterations in the ventral and dorsal attention networks. The difference in the extent of impairment in the dorsal attention network of patients with BECTS with ADHD and patients with BECTS without ADHD may lead to improved understanding of the underlying neuropathophysiology and treatment of BECTS with ADHD and BECTS without ADHD.

Cognitive function in childhood epilepsy: importance of attention deficit hyperactivity disorder

Background and Purpose

To determine how cognitive function is related to epilepsy classification and comorbid attention deficit hyperactivity disorder (ADHD) in children with newly diagnosed epilepsy of genetic or unknown etiology.

Methods

The medical records of children aged 6-16 years with newly diagnosed epilepsy of genetic or unknown etiology were reviewed retrospectively. The Korean Education Development Institute-Wechsler Intelligence Scale for Children and the Comprehensive Attention Test were used to evaluate intelligence and attention/executive function, respectively.

Results

The data of a total of 149 children, 103 with focal seizures and 46 with generalized seizures, were reviewed. The prevalence of ADHD was 49.2% (59 out of 120 examined patients), and ADHD patients exhibited significantly worse auditory selective attention, flanker test results, and spatial working memory. Patients with generalized seizures exhibited significantly worse auditory selective and sustained attention than patients with focal seizures. In patients with generalized seizures, sustained attention, flanker test findings, and spatial working memory were found to be affected by ADHD, and auditory selective and sustained attention were significantly worse in patients with benign childhood epilepsy with centrotemporal spikes and ADHD than in their counterparts without ADHD.

Conclusions

Cognitive processes are affected by seizure type and comorbid ADHD. Proper characterization of these neuropsychiatric impairments may allow earlier intervention during the disease course.

Key issues in addressing the comorbidity of attention deficit hyperactivity disorder and pediatric epilepsy

Attention deficit hyperactivity disorder (ADHD) is a common comorbidity of epilepsy encountered by clinicians. However, relatively little information is available to guide optimal diagnostic and treatment strategies. Differentiating ADHD from effects of epilepsy requires careful history taking and emphasis upon characteristic symptoms and course of illness. Rating scales for ADHD are well validated and may aid clinical management. Use of antiepileptic drugs may cause cognitive or behavioral side effects yet may improve behavior in some cases. Historically, clinicians have been hesitant to treat ADHD comorbidity for fear of lowering the seizure threshold. However, an aggregate of recent evidence now suggests that stimulants may be well tolerated and effective for ADHD comorbid with epilepsy. Studies that further clarify pathophysiology and treatment outcomes are needed in order to enhance clinical efficacy and quality of life for this population.

Cognitive correlates of interictal epileptiform discharges in adult patients with epilepsy in China

OBJECTIVE

Learning difficulties or cognitive impairment has been observed in many patients with epilepsy. Evidence from neurophysiologic and functional neuroimaging suggests that epileptic seizures and/or epileptiform activity can be the dominant factors inhibiting specific brain areas. However, most previous studies were focused on cognitive performance in children. In this study, we analyzed a new cohort of adult patients with frequent interictal epileptiform discharges (IEDs).

METHODS

Data from 67 adult patients with epilepsy were reviewed. Electroencephalography (EEG)-video recording and cognitive testing were performed, and the IED index was estimated as a percentage assigned to one of four categories (<1%, 1-10%, 10-50%, and >50%) during either wakefulness or sleep. Correlations of cognitive test results and clinical characteristics of IED categories were analyzed. The effects of the frequency, duration, location, and sleep-wake cycles of IEDs on cognition (intelligence and memory capacity) were analyzed.

RESULTS

Patients with an IED index >10% showed impaired performance on the Chinese Wechsler Adult Intelligence Scale (WAIS-RC) and the Chinese Wechsler Memory Scale (WMS). This effect was detected independently from other IED frequencies and other IED-related variables, such as duration, distribution, and location. The impact of waking or sleeping IEDs was of equal importance in contributing to impaired WAIS-RC and WMS performance.

CONCLUSION

An IED frequency of more than 10% in both waking and sleeping EEGs is associated with impaired cognitive performance in adult patients. However, whether patients with a high IED frequency but low seizure frequency will benefit from antiepileptic treatment should be examined in future studies.

EEG improvements with antiepileptic drug treatment can show a high correlation with behavioral recovery in children with ADHD

We investigated the relationship between neuropsychological disturbance, assessed using the global assessment of functioning (GAF) and the ADHD-rating scale (ADHD-RS), paroxysmal EEG abnormalities, and treatment with valproate sodium (VPA) in children with both attention deficit hyperactivity disorder (ADHD) and paroxysmal abnormality (PA). Participants with ADHD but without obvious epilepsy were recruited between April 1, 2003 and March 31, 2008. Paroxysmal abnormality was scored by measuring the spike frequency. Of 46 children, 16 showed PA; 3 of the 16 were excluded because no follow-up EEG was available. The EEG improved with VPA treatment in 5 of 8 patients with frontal PA and 3 of 5 patients with rolandic PA. While 83.3% of the patients with improvements in both assessments had frontal PA, only 16.7% had rolandic PA. The patients with frontal PA showed a significantly higher correlation between PA frequency and improvement in ADHD-RS compared with those with rolandic PA. In this study of children with ADHD, EEG improvement with antiepileptic drug treatment showed a high correlation with behavioral improvements as shown by ADHD-RS and GAF scores. However, this was not a population-based study, and the relative importance of detecting and treating PA in ADHD has yet to be determined.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Practitioner review: current best practice in the management of adverse events during treatment with ADHD medications in children and adolescents

BACKGROUND

Medication is an important element of therapeutic strategies for ADHD. While medications for ADHD are generally well-tolerated, there are common, although less severe, as well as rare but severe adverse events AEs during treatment with ADHD drugs. The aim of this review is to provide evidence- and expert-based guidance concerning the management of (AEs) with medications for ADHD.

METHODS

For ease of use by practitioners and clinicians, the article is organized in a simple question and answer format regarding the prevalence and management of the most common AEs. Answers were based on empirical evidence from studies (preferably meta-analyses or systematic reviews) retrieved in PubMed, Ovid, EMBASE and Web of Knowledge through 30 June 2012. When no empirical evidence was available, expert consensus of the members of the European ADHD Guidelines Group is provided. The evidence-level of the management recommendations was based on the SIGN grading system.

RESULTS

The review covers monitoring and management strategies of loss of appetite and growth delay, cardiovascular risks, sleep disturbance, tics, substance misuse/abuse, seizures, suicidal thoughts/behaviours and psychotic symptoms.

CONCLUSION

Most AEs during treatment with drugs for ADHD are manageable and most of the times it is not necessary to stop medication, so that patients with ADHD may continue to benefit from the effectiveness of pharmacological treatment.

Prevalence of epilepsy and attention-deficit hyperactivity (ADHD) disorder: a population-based study

Epilepsy and attention-deficit hyperactivity disorder (ADHD) were reported to co-occur at rates higher than expected for coincidental findings. This study investigated the prevalence of both disorders in community-based primary care practice. The central database of the second-largest health maintenance organization in Israel was searched for all children aged 6 to 13 years (n = 284 419; 51.5% males) diagnosed as having ADHD according to the physicians' records and/or the filling of at least 10 prescriptions for antiepileptic medications according to pharmacy records. The prevalence of epilepsy in the total population was 5 out of 1000 children, and the prevalence of ADHD was 12.6%. More than one-fourth (27.7%) of the epileptic children were also diagnosed as having ADHD. On multivariate analysis, children with ADHD had almost twice the risk of epilepsy than children without ADHD. This study supports hospital-based findings of a strong interrelationship between ADHD and epilepsy. The high rate of ADHD in Israeli children warrants further investigation.