Psychiatric aspects of epileptic children and adolescents

Tolerability of atomoxetine for treatment of pediatric attention-deficit/hyperactivity disorder in the context of epilepsy

To examine atomoxetine's tolerability in patients with epilepsy, we reviewed medical records of all patients with epilepsy who were treated with atomoxetine in a tertiary care pediatric psychopharmacology practice. Twenty-seven patients (10.1 ± 4.2 years, 63% male) with an average seizure frequency at baseline of 7 ± 24 per month (median: 0, range: 0-90) were found. Symptoms of attention-deficit/hyperactivity disorder in twenty-five patients (92.5%) had previously not responded to stimulants. Atomoxetine, average dose 35.2 ± 24.4 mg, was given for a median of 26 weeks (range: 4-141). Seventeen patients (63%) discontinued atomoxetine due to: inadequate response (n=7, 26%), worsening behavior such as increased irritability/activation (n = 7, 26%), nonadherence (n=1, 4%), emerging psychotic-like symptoms (n=1, 4%), and appetite decrease and tremor (n=1, 4%). There were no discontinuations because of seizure exacerbation. Atomoxetine dose, epilepsy etiology, seizure type, and comorbid psychiatric disorders did not predict discontinuation. No safety problems of sufficient magnitude to preclude prospective studies of atomoxetine in children with epilepsy were found.

Epilepsy impact on aspects of school life of children from different cultural populations in Thrace, Greece

Epilepsy influences the school life of children. The aims of this study were to (1) assess absenteeism and participation in sports activities, (2) investigate whether parents inform school and children inform their classmates, and (3) determine which factors influence these school aspects. Children from both Christian and Muslim families were enrolled and different cultural variables were prospectively documented. A total of 62 children with epilepsy (mean age: 10.2+/-3.3 years, range: 6-18) participated in the present study. Univariate analysis and multivariate logistic regression models were used to explore potential factors that could influence school life. Absenteeism was correlated with shorter disease duration, severity, lower parental educational level, and knowledge of epilepsy. Age>12 was associated with nonparticipation in activities. Schools were informed by 84% of families, and classmates, by 22.6% of children. In conclusion, better knowledge of epilepsy resulted in fewer missed school days. The majority of children did not discuss their disease, and children from the two populations with different religions did not differ significantly in the school aspects examined. These findings suggest a probable positive effect of educational programs on the issue of daily school life.

Psychopathology and psychological adjustment in children and adolescents with epilepsy

BACKGROUND

Epilepsy is the most common chronic neurological illness in childhood and adolescence, and this condition may increase the risk of psychopathology at these ages.

DATA SOURCES

A literature review, including MEDLINE and PsychLIT database, was made covering the period of 1966-2007. Research studies were included if they were concerned with children suffering from epilepsy and measures of psychopathology.

RESULTS

Studies found a more elevated rate of psychological and psychiatric disorders, both behavioral and emotional, in these samples compared to general population or children with other chronic conditions. The problems presented in children and adolescents with epilepsy are quite similar to those in general population with a slight increase of hyperkinetic and attention problems likely related to both direct brain damage and anticonvulsant treatment. There is no evidence of psychotic disorders and/or specific personality traits associated with epilepsy at these ages.

CONCLUSIONS

Family factors, specially those related to psychopathology in other family members and parent-child relationships, appear to have stronger influence on children psychopathology than illness factors themselves. Some guidelines are provided in order to improve future research.

Communication deficits in pediatric complex partial seizure disorder and schizophrenia

Based on findings that, like schizophrenic children, children with complex partial seizure disorder have illogical thinking, this study examined whether or not these same epileptic subjects had other thought processing impairments found in schizophrenic children. Compared to normal children (N = 38), both the epileptic (N = 27) and schizophrenic children (N = 31) underutilized discourse (cohesive) devices that make speech coherent. The severity of the discourse deficits and formal thought disorder of the schizophrenic children was associated with age, but not with IQ scores. Age, IQ, and seizure-related, not behavioral variables, were associated, however, with the severity of the discourse deficits of the epileptic subjects. The study' findings suggest that measures of impaired thought processing and communication in schizophrenic children could be a model to study the developmental impact of complex partial seizure disorder in middle childhood. The clinical implications of the study's findings are discussed.

The relationship of neuropsychological functioning to adaptation outcome in adolescents with spina bifida

Adolescents with spina bifida (SB) vary in their ability to adapt to the disease, and it is likely that numerous risk and protective factors affect adaptation outcomes. The primary aim was to test neuropsychological impairment, exemplified herein by executive dysfunction, as a risk factor in the Ecological Model of Adaptation for Adolescents with SB. Specific hypotheses were that: (1) executive functioning predicts the adaptation outcome of functional independence in adolescents with SB; (2) executive functioning mediates the impact of neurological severity on functional independence; and (3) family and adolescent protective factors are related to functional independence and moderate the relationship between executive functioning and functional independence. Forty-three adolescents aged 12-21 years completed neuropsychological measures and an interview that assessed risk, adolescent and family protective factors, and functional independence. Age, level of lesion, executive functioning, and the protective factor adolescent activities were significantly correlated with the functional independence outcome. In hierarchical regression analysis, the model accounted for 61% of the variance in functional independence outcomes. Executive functioning mediated the impact of neurological severity on functional independence.

Parents of children with enduring epilepsy: predictors of parenting stress and parenting

OBJECTIVE

The goals of the work described here were (1) to predict parenting stress and parenting from stressors, resources, and parental coping behaviors in parents of children with epilepsy, and (2) to determine whether parenting stress mediates the effects of these predictors on parenting.

METHODS

Participants were 91 parents of children with epilepsy (mean age of children=8 years, 5 months). Parental perceptions of stressors, resources, parental coping behaviors, parenting stress, and parenting were assessed by means of questionnaires. Regression analyses were used to analyze the unique and combined power of the predictors to predict parenting stress and parenting. Sobel tests were used to identify the mediational role of parenting stress.

RESULTS

Evidence was found for direct effects of stressors, resources, and coping behaviors on parenting stress and parenting, with relatively large effects for stressors. The mediational role of parenting stress was largest in the domain of parental behavioral control.

CONCLUSIONS

In the context of pediatric epilepsy, parenting stress mediates both disruptive and resilient family factors for their effects on parenting. Parents of children with epilepsy may benefit from parent training programs that, to reduce parenting stress, address epilepsy education, the management of difficult child temperament, building social support networks, and the modification of inadequate parental coping behaviors.

Epilepsy and family expressed emotion: Results of a prospective study

PURPOSE

To verify the emotional components expressed by the relatives of adult patients with a diagnosis of epilepsy, and whether they are related to adjustment to the illness and the course of the illness over time.

METHODS

We studied a consecutive sample of 43 outpatients suffering from epilepsy and 43 key relatives using the Camberwell Family Interview (CFI), with the expressed emotion (EE) of the relatives being rated at baseline (T0). EE refers to a construct representing some key aspects of interpersonal relationships: the relatives were assigned to the high-EE group if they scored 3 or more on the emotional over involvement (EOI) scale, or showed hostility, or made 6 or more critical comments. The patients were clinically evaluated at baseline and for 1 year of appropriate treatment by an epileptologist who was blinded to the EE ratings. They also completed STAI XI, STAI X2 and Beck's Depression Inventory at baseline.

RESULTS

Twenty-six relatives (60%) were rated as showing a high degree of EE. In the 12-month follow-up study, high EE and high EOI were found to be associated with a significantly higher seizure frequency than that recorded for the patients living in low-EE households (p<0.05). The patients from households assessed as reflecting a high degree of criticism showed poor drug compliance (p<0.01), whereas those with relatives assessed as having a high degree of warmth showed better clinical and pharmacological compliance (p<0.01). High family criticism scores also correlated with higher study entry levels of depression (p<0.05) and trait and state anxiety (p<0.05) among the patients.

CONCLUSIONS

The study findings highlight the impact of particular components of the family emotional climate on the clinical course and psychological adjustment of patients with epilepsy.

Family factors and psychopathology in children with epilepsy: a literature review

PURPOSE

From a social interactional and ecological framework, studies were reviewed that (1) compared family factors in children with epilepsy with those in children from normative groups, healthy children, children with a chronic illness, or siblings; and (2) examined the relationship between distinct family factors and child psychopathology.

RESULTS

Compared with control groups, families with a child with epilepsy generally fare worse on the whole range of family factors, indicating lower parent-child relationship quality, more depression in mothers, and problems with family functioning. Significant associations were apparent between distinct family factors, especially parental psychological control, parental attributions about epilepsy, and family members' satisfaction with family relationships, and psychopathology in children with epilepsy.

CONCLUSION

Future childhood epilepsy research might benefit from the examination of the simultaneous contribution of distinct family factors to child psychopathology, within a broad multifactorial framework that also includes neurological and medication factors.

Development and validation of the Subjective Awareness of Neuropsychological Deficits Questionnaire for Children (SAND-C)

Although lowered awareness of abilities has been associated with poorer outcome in adults with neurological compromise, a dearth of research exists examining whether lowered awareness exists in younger populations. Using findings from recent literature and expert opinion, a 47-item Subjective Awareness of Neuropsychological Deficits Questionnaire for Children (SAND-C) was created to assess awareness of cognitive functioning in 6 domains (attention, psychomotor, visual-spatial, language, memory, and executive functioning). Confirmatory factor analysis (CFA) of the SAND-C was conducted on a sample consisting of 365 healthy children and 48 children with epilepsy. The SAND-C was found to have strong reliability. Factor analysis confirmed the a priori 6 factor model, but the 6-factor model was only marginally better than a more parsimonious 1-factor solution. Post-hoc exploratory factor analyses indicate that the SAND-C may measure more constructs for adolescents than for younger children. The difference between younger and older children may reflect developmental changes in metacognitive awareness and abstraction about their own abilities.

Psychopathology in Children with Epilepsy: A Meta-Analysis

OBJECTIVE

To examine the types and severity of psychopathology in children with epilepsy.

METHODS

A series of meta-analyses were conducted to review 46 studies, including 2,434 children with epilepsy.

RESULTS

Effect sizes were medium to large for comparisons with children from the general population, which indicates that children with epilepsy are at increased risk for psychopathology, including internalizing and externalizing behavior problems. Comparisons with children with another chronic illness revealed small to medium effect sizes, indicating that psychopathology in children with epilepsy may partly be attributed to chronicity of the disease. Attention problems, thought problems, and social problems proved to be relatively specific to epilepsy. Comparisons with siblings suggested that psychopathology in children with epilepsy may be associated with family factors, especially where behavioral disorders appear to be more generic.

CONCLUSIONS

Clinicians should consider both neurological and psychosocial factors, including the family system, when treating psychopathology in children with epilepsy.

Behavioral aspects of chronic illness in children and adolescents

Despite the detail that is provided on the potential negative outcomes of children and families who have chronic illnesses, most of these families show admirable resilience. Most children adjust to their illnesses within 1 year and most families achieve healthy stable functioning with accommodations for the illness. The challenge of adjusting to a chronic illness can provide an excellent opportunity for a child or adolescent to master crucial skills, such as emotion regulation and problem-solving. Mastery of these skills can engender strong self-esteem and confidence. As our knowledge about the predictive factors for positive behavioral outcomes increases, the pediatrician can be in the position to minimize the negative behavioral aspects of chronic illness and facilitate adjustment. Attention to the behavioral aspects of chronic illness in the three critical areas of psychosocial adjustment of the patient, adjustment of the family, and adherence to regimens, allows pediatricians to play a crucial role in prevention, early identification, and early interventions. We hope that the material that is included in this review provides a starting point for clinicians to understand and to begin to assess these critical factors in chronic illness in children and adolescents.

The confluence of mental, physical, social, and academic difficulties in middle childhood. II: developing the Macarthur health and Behavior Questionnaire

OBJECTIVES

(1) To evaluate the psychometric properties of the MacArthur Health and Behavior Questionnaire (HBQ) in two studies of 4- to 8-year-old children and (2) to explore the empirical and theoretical implications of HBQ-based study findings.

METHOD

Samples of children were recruited from (1) mental health clinics (n = 53) and community schools (n = 67) for a case-control study in three research sites and (2) a Wisconsin-based community cohort study of families and work, comprising children with high levels of internalizing and/or externalizing behavior problems and asymptomatic children (N = 122). Combinations of mothers, fathers, and teachers completed the HBQ at one or two time points in four geographically and culturally distinctive settings.

RESULTS

Assessment of HBQ reliability showed high test-retest stability and cross-informant agreement. The instrument discriminated strongly and significantly among symptom groups (i.e., high internalizing, high externalizing, high both, and low both) and showed moderate to large effect sizes for between-group differences. Substantial covariance was also found among the HBQ mental, physical, social, and academic problem subscales.

CONCLUSIONS

The HBQ is a reliable and valid parent- and teacher-report instrument for assessing multiple dimensions of health and dysfunction in middle childhood and for identifying children on whom more intensive diagnostic procedures may be warranted. Confluences among the four health dimensions suggest phenomenological and perhaps etiological commonalities among traditionally partitioned childhood difficulties and suggest possible artificiality in the conventional distinction between pediatric and child psychiatric morbidities.

Coping with the challenge of transition in older adolescents with epilepsy

Chronic illnesses, such as epilepsy, have been shown to have detrimental effects on both psychological adjustment and coping behaviour. Using the process model of coping, these effects were investigated in a patient group of 36, 16-21 year olds with epilepsy and a control group of 31 of their peers. Participants completed a postal questionnaire containing measures of psychological adjustment (self-esteem, affect, self-efficacy) and an adolescent coping questionnaire. Comparison of the two groups showed that the patient group exhibited significantly more non-productive coping than the control group. The control group exhibited significantly more problem solving coping and displayed significantly more problem solving bias than the patient group. No significant differences were found between the patient and control group on measures of psychological adjustment. However, psychological adjustment was found to be associated with coping response in the patient but not the control group.

Antiepileptic drugs: affective use in autism spectrum disorders

Antiepileptic drugs are widely administered to individuals with autistic spectrum disorders. There are several reasons for the use of antiepileptic drugs in autistic spectrum disorders, including the high incidence of epilepsy in these individuals, the anecdotal reports suggesting an improvement of communication and behavior in autistic subjects with epileptic discharges, and the increased awareness that some disruptive behaviors may be manifestations of an associated affective disorder. In this study, data on the current use of antiepileptic drugs in the treatment of autism, and on the association of affective disorders with epilepsy and autism, are reviewed. The evidence supporting the hypothesis that there may be a subgroup of autistic children with epilepsy and affective disorders that preferentially respond to antiepileptic drugs is still very preliminary, and further investigations with double-blind controlled studies are needed. Although the role of antiepileptic drugs at the present time is not established, there is evidence that autism, epilepsy, and affective disorders commonly co-occur, and that they may share a common neurochemical substrate, which is the common target of the psychotropic mechanism of action of different antiepileptic drugs.

Psychosexual development in adolescents with chronic medical illnesses

The author provides a literature review and developmental formulation, with the goal to assist clinicians working with medically ill adolescents with psychosexual issues. MEDLINE and PsychINFO database searches of English-language medical journal articles published between 1986 and 1997 for articles related to medical illness and psychosexual development in adolescence were done. The author found that little systematic research on the psychosexual implications of medical illnesses for adolescents has been undertaken, but existing studies suggest that psychosexual development is negatively affected by medical illness. A three-phase model of adolescent psychosexual development is presented, with specific psychosexual tasks associated with each phase. Impediments to progressing through adolescent psychosexual phases due to medical conditions are identified, and case examples are provided. The author concludes that clinicians working with adolescents with medical conditions should attend to the possibility of psychosexual impediments in these adolescents and use developmentally appropriate methods for assessing and treating these difficulties when they arise.

Adolescents with active or inactive epilepsy or asthma: a comparison of quality of life

PURPOSE

We compared quality of life (QOL) in youth with inactive or active epilepsy with that of a similar sample of youth with asthma. We explored 19 different dimensions in three domains (psychological, social, and school) and also determined differences related to illness severity and gender.

METHODS

Subjects were 228 adolescents (117 with epilepsy and 111 with asthma). Data were collected from clinic records and from the adolescents, their mothers, and their teachers through questionnaires and structured interviews. Data were analyzed by analysis of covariance.

RESULTS

The analysis with all 19 QOL variables indicated a significant difference between the total asthma and the total epilepsy samples (multivariate F = 3.36, p = 0.0001). Further evaluation reflected differences between the epilepsy group and the asthma group on 13 of the 19 QOL variables. When active and inactive epilepsy and asthma groups were compared, youth with active epilepsy were faring worse than all other groups in 10 areas. Moreover, youth with inactive epilepsy were faring worse than those with inactive asthma in four areas. Illness severity and sex differences were more strongly related to QOL in the epilepsy sample than in the asthma sample. Sex-severity interactions suggested that girls with high seizure severity were most at risk for QOL problems.

CONCLUSIONS

Youth with active epilepsy generally had the poorest QOL. Severe seizures and female sex were associated with more problems. Sex-severity interactions should be explored in future research.

The etiology of psychiatric symptoms in patients with systemic lupus erythematosus

The purpose of this review was to explore the probable etiologies of psychiatric problems in patients with SLE. Although instances of psychosis generally are attributed to disease pathophysiology, the precise mechanism for this problem remains speculative. The etiology of non-psychotic psychiatric complaints is even less clear. Overall, it is likely that psychiatric complaints in patients with SLE are attributable to numerous factors including acquired brain dysfunction, organ system dysfunction, iatrogenic effects of corticosteroid treatment, learning history, psychosocial stressors, and current coping strategies. Additional research is needed to explore the bi-directional, synergistic, and dynamic interactions among diverse physiological and psychological variables as they impact an individual's psychiatric status.

Communication deficits in children undergoing temporal lobectomy

OBJECTIVE

To examine formal thought disorder and discourse (cohesive) devices that make speech coherent prospectively in seven children, aged 5.7 to 16.7 years, before and after temporal lobectomy for intractable cut points determined from sensitivity and specificity analyses of formal thought disorder and discourse measures in 22 children with complex partial seizure disorder and 45 normal children.

RESULTS

Before surgery, the mean illogical thinking and discourse scores of the surgical candidates were in the pathological range. After a mean postoperative follow-up period of 15.1 months, their illogical thinking (but not their discourse scores) decreased significantly to the normal range.

CONCLUSIONS

These preliminary findings are discussed in terms of the possible role of postsurgical changes in seizure control, behavior, antiepileptic drugs, cognition, and prefrontal function.

Learning disorders and delinquency

Learning disorders of various types are relatively common, and the reaction of the affected child can lead to social problems. The higher the children's intelligence the more frustrated they can become. Lack of self-esteem can cause unacceptable behaviour in trying to counteract this, and boost the child's confidence. There is evidence that learning disabilities are prevalent among those who are delinquent. Theories suggest this may be due directly to the learning difficulties, or to failure at school, starting a series of events leading to delinquency, or to the idea that those with learning difficulties are treated differently, especially when it comes to legal proceedings. Epilepsy can easily lead to learning disorders; particularly if the temporal lobes are involved, there are associated emotional disorders, or side effects of treatment. Also this association is often found amongst children with attention deficit disorders. If the link between learning disorders and delinquency is recognised there is considerable scope for prevention.