Emotional functioning: Long-term outcomes after pediatric epilepsy surgery

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

PURPOSE

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

METHOD

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

RESULTS

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 Several additional depression screening measures met criteria for Tier 2 (CDI-2, BASC-2-Depression Scale, and CBCL Withdrawn/Depressed Scale).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

CONCLUSION

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

Surgery for Intractable Epilepsy in Pediatrics, a Systematic Review of Outcomes other than Seizure Freedom

To perform a systematic review evaluating reported outcomes for epilepsy surgery in pediatric patients with pharmacoresistant epilepsy beyond seizure control, including impact on quality of life, behavioral, neurocognitive outcomes as well as complications, and death. We reviewed articles from both EMBASE and MEDLINE/PubMed articles that met formal criteria (patients ≤18 years, those with intractable epilepsy, at least 5 patients in the case series, published in peer-reviewed journal). Each reviewer independently reviewed the articles and those with discrepancies were discussed and consensus was reached. Out of a total of 536 abstracts obtained from EMBASE and MEDLINE/PubMed searches combined with additional cross-referencing, a total of 98 manuscripts ultimately met all inclusion criteria. The manuscripts were divided into 3 outcomes categories: Quality of Life (16), Cognitive Outcomes (60), and Deficits and Complications (50). Several papers fell into more than 1 category. These were separated by surgical types and evaluated. We found that overall reporting in all domains was variable and inconsistent amongst the different studies. This systematic review highlights the lack of completeness in reporting outcomes and complications involving pediatric epilepsy surgery and discordant results. This underscores the importance of multicenter systematic prospective data collection in pediatric patients who undergo pediatric epilepsy surgery.

Long-term outcomes of children with drug-resistant epilepsy across multiple cognitive domains

AIM

To simultaneously evaluate long-term outcomes of children with drug-resistant epilepsy (DRE) across multiple cognitive domains and compare the characteristics of participants sharing a similar cognitive profile.

METHOD

Participants were adolescents and young adults (AYAs) diagnosed with DRE in childhood, who completed a comprehensive neuropsychological battery evaluating intelligence, memory, academic, and language skills at the time of surgical candidacy evaluation and at long-term follow-up (4-11y later). Hierarchical k-means clustering identified subgroups of AYAs showing a unique pattern of cognitive functioning in the long-term.

RESULTS

Participants (n=93; mean age 20y 1mo [standard deviation {SD} 4y 6mo]; 36% male) were followed for 7 years (SD 2y 4mo), of whom 65% had undergone resective epilepsy surgery. Two subgroups with unique patterns of cognitive functioning were identified, which could be broadly categorized as 'impaired cognition' (45% of the sample) and 'average cognition' (55% of the sample); the mean z-score across cognitive measures at follow-up was -1.86 (SD 0.62) and -0.23 (SD 0.54) respectively. Surgical and non-surgical patients were similar with respect to seizure control and their long-term cognitive profile. AYAs in the average cognition cluster were more likely to have better cognition at baseline, an older age at epilepsy onset, and better seizure control at follow-up.

INTERPRETATION

The underlying abnormal neural substrate and seizure control were largely associated with long-term outcomes across cognitive domains.

Longitudinal changes in emotional functioning following pediatric resective epilepsy surgery: 2-Year follow-up

OBJECTIVE

To examine longitudinal changes and predictors of depression and anxiety 2 years following resective epilepsy surgery, compared to no surgery, in children with drug-resistant epilepsy (DRE).

METHOD

This multicenter cohort study involved 128 children and adolescents with DRE (48 surgical, 80 nonsurgical; 8-18 years) who completed self-report measures of depression and anxiety at baseline and follow-up (6-month, 1-year, 2-year). Child demographic (age, sex, IQ) and seizure (age at onset, duration, frequency, site and side) variables were collected.

RESULTS

Linear mixed-effects models controlling for age at enrolment found a time by treatment by seizure outcome interaction for depression. A negative linear trend across time (reduction in symptoms) was found for surgical patients, irrespective of seizure outcome. In contrast, the linear trend differed depending on seizure outcome in nonsurgical patients; a negative trend was found for those with continued seizures, whereas a positive trend (increase in symptoms) was found for those who achieved seizure freedom. Only a main effect of time was found for anxiety indicating a reduction in symptoms across patient groups. Multivariate regressions failed to find baseline predictors of depression or anxiety at 2-year follow-up in surgical patients. Older age, not baseline anxiety or depression, predicted greater symptoms of anxiety and depression at 2-year follow-up in nonsurgical patients.

CONCLUSION

Children with DRE reported improvement in anxiety and depression, irrespective of whether they achieve seizure control, across the 2 years following surgery. In contrast, children with DRE who did not undergo surgery, but achieved seizure freedom, reported worsening of depressive symptoms, which may indicate difficulty adjusting to life without seizures and highlight the potential need for ongoing medical and psychosocial follow-up and support.

Seizure freedom improves health-related quality of life after epilepsy surgery in children

AIM

To determine whether epilepsy surgery improved health-related quality of life (HRQoL) and whether seizure freedom after surgery mediated the improvement in HRQoL.

METHOD

This multicenter cohort study compared HRQoL after epilepsy surgery to pharmacological management in children with drug-resistant epilepsy (DRE). HRQoL was measured using the Quality of Life in Childhood Epilepsy (QOLCE) questionnaire at baseline and 1-year follow-up. The mediator between treatment type and HRQoL was seizure freedom.

RESULTS

Two hundred and thirty-seven patients were recruited (surgery group: n=147 [92 males, 45 females]; pharmacological group: n=90 [53 males, 37 females]). Mean age at seizure onset was 6 years (SD 4y 4mo) in the surgical group and 6 years 1 month (SD 4y) in the pharmacological group. The odds ratio of seizure freedom was higher for the surgery versus pharmacological group (β=4.24 [95% confidence interval {CI}: 2.26-7.93], p<0.001). Surgery had no direct effect on total QOLCE score at 1-year (β=0.24 [95% CI -2.04 to 2.51], p=0.839) compared to pharmacological management, but had an indirect effect on total QOLCE that was mediated by seizure freedom (β=0.92 [95% CI 0.19-1.65], p=0.013), adjusting for baseline total QOLCE score. Surgery had a direct effect on improving social function (p=0.043), and an indirect effect on improving physical function (p=0.016), cognition (p=0.042), social function (p=0.012) and behavior (p=0.032), mediated by seizure freedom.

INTERPRETATION

Greater seizure freedom achieved through epilepsy surgery mediated the improvement in HRQoL compared to pharmacological management in children with DRE.

WHAT THIS PAPER ADDS

Seizure freedom is higher after pediatric epilepsy surgery compared to pharmacologically managed epilepsy. Surgery indirectly improves health-related quality of life (HRQoL) mediated by seizure freedom compared to pharmacological management. Surgery has a direct effect on improving social function relative to pharmacological management. Baseline HRQoL was an important predictor of HRQoL after treatment.

Parents' view of the cognitive outcome one year after pediatric epilepsy surgery

OBJECTIVES

The cognitive outcome of pediatric epilepsy surgery has mainly been examined on the basis of standardized tests. Here, we analyzed the outcome in six cognitive domains from the parents' view.

METHODS

Included were consecutive surgical pediatric patients whose parents filled-in a comprehensive questionnaire on cognitive problems in children and adolescents (Kognitive Probleme bei Kindern und Jugendlichen (KOPKIJ); Gleissner et al. 2006) at the preoperative baseline (T1) as well as twelve months thereafter (T2). All children also underwent standard neuropsychological assessments at T1 and T2.

RESULTS

Parents of 96 patients provided pre- and postoperative KOPKIJ data. Overall, 80% of the children became seizure-free at the follow-up. Group means indicated a strong positive effect of time on KOPKIJ and neuropsychological performance. We found postoperative improvements in five out of six cognitive domains (language, memory, executive functions, attention, school; unchanged: visuospatial abilities). Individually, improvements were twice as likely as declines. However, 33 patients (35%) experienced significant decline in at least one cognitive domain. Later onset of epilepsy resulted in better performance but had no effect on change scores. Seizure-free status, lower antiseizure drug load, and stronger drug reduction after surgery contributed to postoperative cognitive improvements as perceived by the parents; no other effects of clinical factors were obtained (e.g., localization/lateralization). Despite their similar outcome patterns, change scores as derived from parental ratings and neuropsychological assessment were not correlated.

CONCLUSIONS

Parents acknowledged the overall positive neurocognitive development after pediatric epilepsy surgery as previously shown by standardized tests. Seizure freedom and lower antiseizure drug load contributed to the beneficial cognitive outcome. Even if cognitive improvements outweighed declines, a risk for cognitive decline with impact on everyday functioning does exist.

Impact of resective surgery for pediatric drug-resistant epilepsy on emotional functioning

OBJECTIVE

The objective of the study was to evaluate emotional functioning following surgical and medical treatment in children with drug-resistant epilepsy (DRE; i.e., uncontrolled seizures despite treatment with ≥2 antiepileptic drugs [AED]).

METHOD

This prospective, longitudinal, multicenter study involved 128 children and adolescents (8-18 years) with DRE who were assessed for surgical candidacy; 48 went on to have surgery and 80 continued medical treatment. Participants completed child-validated self-report measures of anxiety and depression at baseline, 6, and 12 month follow-up. Standardized z-scores were calculated with higher scores indicative of greater symptoms.

RESULTS

At baseline, 16% and 22% of all patients reported elevated symptoms of depression and anxiety, respectively (i.e., z ≥ 1.00). Seizure freedom was higher in the surgical, compared with the medical, group at 6 (64 vs. 11%) and 12 month (77 vs. 24%) follow-up. Linear mixed effects models controlling for age found a main effect of time for both depression and anxiety; scores decreased over time for all patients. A main effect of seizure outcome was found for depression, but not anxiety; seizure freedom was associated with lower scores overall. There were no main effects of treatment or significant interactions. Multiple regression analyses found baseline mood predicted outcomes at 6 and 12 month follow-up; higher anxiety and depression scores at baseline were associated with higher scores at follow-up. Older age and greater number of AEDs at baseline was associated with higher depression scores at 12 month follow-up.

CONCLUSION

Overall, patients reported a reduction in anxiety and depressive symptoms over the first 12 months, irrespective of treatment, and baseline level of functioning was the best predictor of outcome. Despite more children achieving seizure freedom with surgery compared with medical treatment, surgery was not associated with better outcomes over time. It may be that changes in anxiety and depression require a longer time to emerge postsurgery; however, being seizure-free is associated with fewer depressive symptoms, irrespective of treatment type.

Behaviour outcomes in children with epilepsy 1 year after surgical resection of the ventromedial prefrontal cortex

Early damage to the ventromedial prefrontal cortex (VM) has been associated with impaired behavioural functioning in children without epilepsy, yet behaviour in children with epilepsy and VM lesions has not been investigated. The primary aim of this study was to examine behavioural outcomes in children with epilepsy emanating from the VM preoperatively and one year after epilepsy surgery compared to the general population and matched epilepsy controls. Behavioural outcomes were defined as comprising both problems and competencies (i.e. social, school and co-curricular performance). A secondary aim was to examine whether seizure outcome, number of antiepileptic drugs (AEDs), or age at surgery related to behavioural outcomes. Ratings on the Child Behavior Checklist were examined preoperatively and 1 year after surgery for 20 children with epilepsy who had undergone surgical resection of the VM (N = 10) or temporal lobe (TL, N = 10). VM and TL groups were comparable on Full Scale IQ (40-101), age of seizure onset (0.5-9.0 years), age at surgery (3.1-16.9 years), seizure laterality (5 left in each group), age at assessments, sex (3 female in VM group, 2 female in TL group) and seizure outcome (7 seizure free in VM group, 6 seizure free in TL group). The VM group had significantly elevated behaviour problems (i.e. withdrawn, thought, social and attention problems) and reduced competencies (i.e. social and school) compared to the general population before and after surgery. VM and TL cases did not differ on any behaviour problem scales pre or postoperatively and neither group showed significant change in functioning over time; however, VM patients had significantly lower total competence than TL patients postoperatively. A significant seizure outcome × time interaction was observed: children who were seizure free following surgery (collapsed across surgical site) showed an improvement in total behaviour problems and aggression at 1 year follow-up, whereas children with ongoing seizures showed a deterioration in these domains. In conclusion, VM lesions in children with epilepsy are associated with behavioural problems but their profile does not differ from that of children with temporal lobe epilepsy. These results are consistent with the concept that seizures arise from epileptogenic networks that may affect multiple cortical areas, even when onset is in a focal site.

Cognition in epilepsy: current clinical issues of interest

PURPOSE OF REVIEW

This review provides an update and summary of recent neuropsychological findings in epilepsy focusing on three major clinical topics among the many developments in the field. We will critically outline the current state with regard to cognition in new-onset epilepsies, social cognition in epilepsy, and the long-term outcome of epilepsy surgery and the cognitive outcomes of superselective surgical procedures.

RECENT FINDINGS

Current studies indicate that neuropsychological impairments are prevalent already at the onset of epilepsy and even before, social cognition (i.e., emotion recognition and theory of mind) is impaired in different epilepsy populations, the long-term outcome of epilepsy surgery is mostly characterized by a stable or even improved cognitive status, and superselective epilepsy surgeries are associated with a promising neuropsychological outcome.

SUMMARY

The high prevalence of cognitive deficits around epilepsy onset challenges the assumption that epilepsy is the major cause of cognitive problems and calls for early neuropsychological diagnostics. Social cognition seems to be a relevant domain that is not yet routinely considered in epilepsy. The cognitive long-term outcome of epilepsy surgery is mostly positive. Stereotactic thermocoagulation and gamma knife surgery appear to be cognitively safe procedures.

Academic Outcomes in Individuals With Childhood-Onset Epilepsy: Mediating Effects of Working Memory

OBJECTIVES

Academic difficulties are common in children with epilepsy, although little is known about the effect of various seizure-related and cognitive variables. Given that persistent seizures may negatively impact academics, and that working memory is predictive of academic abilities, we examined the effects of recent seizures and working memory on word reading, spelling, and arithmetic in pediatric epilepsy. We hypothesized that persistent seizures would be associated with lower working memory ability, which would in turn result in poorer academic performance.

METHODS

Our sample consisted of 91 children with epilepsy being treated at the Hospital for Sick Children in Toronto, Canada, who underwent neuropsychological testing between 2002 and 2009 to help determine surgical candidacy. Four to 11 years later, follow-up testing was conducted on both surgical (n=61) and non-surgical (n=30) patients. Seizure status was defined by the presence or absence of seizures within the preceding 12 months.

RESULTS

5000 bias-corrected bootstrap resamples with replacement were used to calculate the 95% confidence intervals (CIs) for the indirect effect of seizure status on academics through working memory, controlling for baseline academic functioning. Persistent seizures were associated with reduced working memory, which was in turn associated with lower reading (B=-4.64, 95% CI [-10.21, -1.30]), spelling (B=-7.09, 95% CI [-13.97, -2.56], and arithmetic scores (B=-8.04, 95% CI [-13.66, -3.58] at follow-up.

CONCLUSIONS

For children with intractable epilepsy, working memory deficits present a significant barrier to the development of academic skills. Working memory interventions may be a helpful adjunct to academic remediation in this population to facilitate academic progress. (JINS, 2017, 23, 594-604).

Surgical Management of Pediatric Epilepsy: Decision-Making and Outcomes

First-line treatment for epilepsy is antiepileptic drug and requires an interdisciplinary approach and enduring commitment and adherence from the patient and family for successful outcome. Despite adherence to antiepileptic drugs, refractory epilepsy occurs in approximately 30% of children with epilepsy, and surgical treatment is an important intervention to consider. Surgical management of pediatric epilepsy is highly effective in selected patients with refractory epilepsy; however, an evidence-based protocol, including best methods of presurgical imaging assessments, and neurodevelopmental and/or behavioral health assessments, is not currently available for clinicians. Surgical treatment of epilepsy can be critical to avoid negative outcomes in functional, cognitive, and behavioral health status. Furthermore, it is often the only method to achieve seizure freedom in refractory epilepsy. Although a large literature base can be found for adults with refractory epilepsy undergoing surgical treatment, less is known about how surgical management affects outcomes in children with epilepsy. The purpose of the review was fourfold: (1) to evaluate the available literature regarding presurgical assessment and postsurgical outcomes in children with medically refractory epilepsy, (2) to identify gaps in our knowledge of surgical treatment and its outcomes in children with epilepsy, (3) to pose questions for further research, and (4) to advocate for a more unified presurgical evaluation protocol including earlier referral for surgical candidacy of pediatric patients with refractory epilepsy. Despite its effectiveness, epilepsy surgery remains an underutilized but evidence-based approach that could lead to positive short- and long-term outcomes for children with refractory epilepsy.

Predictors of language skills in the long term after pediatric epilepsy surgery

OBJECTIVE

The objective of this study was to evaluate language skills in a heterogeneous cohort of patients who underwent or were considered for epilepsy surgery in childhood 4-11years earlier. The few existing studies that have evaluated cognitive function in the long term after surgery have examined intelligence and memory.

METHOD

Participants were 97 patients, of whom 61 underwent surgery. They completed standardized tests of picture naming, vocabulary, letter fluency, semantic fluency and intelligence at baseline and, on average, 7years later.

RESULTS

Among all patient groups, scores across language tasks were similar at baseline and follow-up. Language skills were largely independent of surgical status but were associated with seizure control. Seizure freedom and/or a longer proportion of life without seizures were associated with higher scores across all language tasks at follow-up. However, few patients showed meaningful improvements or deterioration at the individual level. Older age at epilepsy onset, higher IQ, and higher baseline scores were associated with higher follow-up scores on all language tasks. Localization and lateralization of epileptogenic foci and language lateralization were associated with higher scores on some language tasks at follow-up. Most of these variables were also predictive of change in scores over time on some of the language tasks.

SIGNIFICANCE

Language skills largely remained similar at baseline and follow-up. Seizure freedom was associated with a modest advantage at the group level, and no significant change at the individual level, suggesting an abnormal neural substrate or epileptic activity prior to seizure control may hinder the long-term capacity for improvement, even in the absence of seizure activity.

Academic skills in the long term after epilepsy surgery in childhood

OBJECTIVE

We evaluated the progression of academic skills in a cohort of patients who underwent, or were considered for, epilepsy surgery in childhood, four to eleven years before. The few existing studies that have evaluated cognitive function in the long term after surgery have examined intelligence and memory.

METHOD

Participants were 97 patients with childhood-onset intractable epilepsy; 61 had undergone resective epilepsy surgery. Participants completed standardized tests of reading, spelling, arithmetic, and intelligence at baseline and, on average, 7years after. Surgical patients were additionally assessed one year postsurgery.

RESULTS

At baseline and long-term follow-up, 61% and 69% of patients, respectively, scored at least one standard deviation below normative data in at least one academic domain. Evaluation of change over time while controlling for IQ showed that arithmetic scores were lower at long-term follow-up in comparison with those at baseline among all patient groups, whereas reading and spelling scores remained unchanged. Few advantages were associated with seizure control. Multiple regression analyses found that older age at surgery, cessation of antiepileptic medications, improved IQ, and low baseline scores were independently associated with improvement in some academic domains among all patient groups.

CONCLUSION

We found that arithmetic scores were lower at long-term follow-up, suggesting a lack of ongoing development or deterioration in skills. Reading and spelling scores remained stable suggesting that patients made gains in abilities at a rate expected for their increase in age; this finding contrasts with recent short-term outcome studies identifying significantly lower scores over time in these areas.

Development of intelligence 4 to 11 years after paediatric epilepsy surgery

OBJECTIVE

Little is known about the long-term intellectual outcomes following paediatric epilepsy surgery. Change is not likely within the first 2 years following surgery, and the few studies of longer term outcomes have yielded inconsistent results. This study addressed this issue by examining a large group of surgical and non-surgical patients at baseline and after 4-11 years.

METHODS

Participants were 97 patients (mean age 20.08 [SD: 4.44] years) with childhood-onset intractable epilepsy; 61 had undergone resective epilepsy surgery. Participants underwent neuropsychological testing with the age-appropriate Wechsler Intelligence Scale, generating Full Scale, Performance and Verbal IQs, and Working Memory and Processing Speed indices.

RESULTS

In total 54% of the surgical and 39% of the non-surgical patients were seizure free in the preceding 12 months (p > .05); however, surgical patients did achieve seizure freedom sooner and used fewer medications at follow-up. Surgical status was not associated with any cognitive domain. However, with the exception of processing speed, significant seizure status × time interaction effects were evident and seizure-free patients had higher scores at follow-up. Regression analyses additionally showed that low pre-operative scores were predictive of improvement overtime, whereas high pre-operative scores were predictive of high scores at follow-up.

INTERPRETATION

The results show similar intellectual outcomes for surgical and non-surgical paediatric patients. Four to 11 years after paediatric epilepsy surgery, seizure freedom, whether attained through epilepsy surgery or other means, was found to be associated with intellectual improvements. Seizure status and baseline scores were the most consistent predictors.