Adolescent and caregiver experiences with epilepsy

Living with epilepsy in adolescence and young adulthood transitioning from pediatric to adult hospital services: A systematic review and meta-synthesis of qualitative studies

BACKGROUND

Transition is characterized by developing greater self-identity and growing independence, but adolescents dealing with chronic illnesses encounter health-related and situational changes during transition. Despite the many suggestions made in recent years, the shift from pediatric to adult care continues to pose difficulties for adolescents and young adults with epilepsy (AWE). The holistic perspective of AWE's experiences and needs during transition is not as well understood.

AIM

To synthesize the qualitative evidence related to AWE's experiences and needs transitioning from pediatric to adult hospital care.

METHODS

This systematic review adhered to the rigorous Joanna Briggs methodology for qualitative evidence synthesis. A comprehensive search was conducted across multiple databases, including PubMed, CINAHL, Scopus, Embase, PsycINFO, and ProQuest Dissertations & Theses Global, from their inception to April 2024. The findings were critically appraised and aggregated using meta-synthesis.

RESULTS

The search yielded a total of 3,985 studies, and twenty-one were included in the review. Two of the included studies were undertaken in a program where a transition clinic was established. The meta-synthesis reveals that the transition experience of AWE is more than a change from one clinic to another and is interwoven into a pattern of developmental, health-illness, situational, and organizational transition issues. Five synthesized findings were developed: 1) Feeling different from others and striving to address the impact of epilepsy in everyday life; 2) the transition from pediatric to adult care - a problematic intersection point; 3) the family's role - support or parental overprotectiveness 4) seeking knowledge and being familiar with epilepsy supported by healthcare professionals and technologies, and 5) development of independence and responsibility through involvement and support from healthcare professionals and parents.

CONCLUSION

During the transition from pediatric to adult hospital care, AWEs encounter a loss of familiarity, increased responsibility, and feelings of not belonging. Therefore, it is essential to create an environment where they can thrive beyond the limitations of their illness. Understanding, acceptance, and inclusivity should characterize this environment to support AWEs in facilitating the development of responsibility, independence, and confidence as they navigate transitions.

Pilot randomized controlled clinical trial of an adherence social norms intervention for adolescents with epilepsy

OBJECTIVE

Non-adherence to anti-seizure medications (ASMs) is common for adolescents with epilepsy, with potentially devastating consequences. Existing adherence interventions in epilepsy do not meet the unique challenges faced by adolescents. Leveraging social norms capitalizes on the increased importance of peer influence while simultaneously targeting the low motivation levels of many adolescents. The current study examined the feasibility, acceptability, and satisfaction of a social norms adherence intervention in adolescents with epilepsy.

METHODS

A pilot RCT of a mHealth social norms intervention was conducted with adolescents with epilepsy who demonstrated non-adherence (≤95% adherence) during baseline. Adolescents were randomized to either (1) mHealth social norms (reminders, individualized and social norms adherence feedback) or (2) control (reminders and individualized adherence feedback). Primary outcomes included feasibility, acceptability, and satisfaction. Exploratory outcomes included electronically monitored adherence, seizure severity, and health-related quality of life (HRQOL).

RESULTS

One hundred four adolescents were recruited (53% female; Mage = 15.4 ± 1.4 years; 81% White: Non-Hispanic; 5% Black, 10% Bi/Multiracial; 2% White: Hispanic; 1% Other: Hispanic; 1% Bi/Multiracial-Hispanic). Forty-five percent screen-failed due to high adherence, 16% withdrew, and 38% were randomized to treatment (n = 19) or control (n = 21). Recruitment (75%), retention (78%), and treatment satisfaction were moderately high. Engagement with the intervention was moderate, with 64% of participants engaging with intervention notifications. Exploratory analyses revealed that after controlling for COVID-19 impact, the social norms intervention group maintained higher adherence over time compared to the control group. Small to moderate effect sizes were noted for seizure severity and HRQOL between groups.

CONCLUSION

This pilot intervention appeared feasible and acceptable. Increases in adherence in the treatment versus control group were modest, but a future larger more adequately powered study is needed to detect effects. Notably, it appeared the COVID pandemic influenced adherence behaviors during our trial.

Depression and anxiety and their associated factors among caregivers of children and adolescents with epilepsy in three selected hospitals in Amhara region, Ethiopia: A cross-sectional study

Background

The prevalence rates of depression and anxiety are unforeseen among primary caregivers of patients with epilepsy. Little attention is being given to the problem in Ethiopia.

Objectives

This study aimed to assess the prevalence and associated factors of depression and anxiety among caregivers of children and adolescents with epilepsy in three selected hospitals in Amhara region, Ethiopia.

Methods

Institution-based cross-sectional study was conducted in Ethiopia from January 1-30/2021. Systematic sampling technique was used. The Public Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) questionnaires were used to measure depression and anxiety respectively. Binary logistic regression model was employed independently for both depression and anxiety. Variables with P-values <0.2 were taken to multivariate analyses. Variables with P-value <0.05 in the multivariate analyses were considered to have a statistical association with depression and anxiety.

Result

A total of 383 participants involved yielding a response rate of 90.5%. The prevalence of depression and anxiety were found to be 13.7% and 10.4% respectively. Being female (Adjusted Odds Ratio (AOR) = 1.21: 95% Confidence Interval (CI): 1.00, 3.82), being unmarried (AOR = 1.31; 95%CI: 0.32, 5.023), having history of chronic medical illness (AOR = 1.46; 95%CI: 1.07, 1.98), current seizure attack (AOR = 4.19; 95%CI: 1.36, 12.97), duration of care 6-11years (AOR = 1.80; 95%CI: 1.11, 7.58), duration of care > 11years (AOR = 6.90; 95%CI: 1.56, 30.49), moderate social support (AOR = 0.37; 95%CI: 0.13, 0.81), strong social support (AOR = 0.61; 95%CI: 0.22, 1.67) and currently use substance (AOR = 2.01;95%CI: 1.63, 6.46) were factors associated with depression. On the other hand, being unmarried (AOR = 1.47; 95%CI: 1.12, 1.93), current seizure attack (AOR = 1.81 with 95% CI = 1.28–2.54), able to read and write (AOR = 0.33; 95%CI: 0.14, 0.77), completed primary and secondary education (AOR = 0.54; 95%CI: 0.39, 0.76), current substance use (AOR = 1.466; 95%CI: 1.12, 1.93), being parent (AOR = 2.55; 95%CI: 1.31, 4.96), rural (AOR = 3.75; 95%CI: 1.40, 10.04) and grand mal type (AOR = 2.21; 95%CI: 1.68, 2.91) were factors associated with anxiety.

Conclusions

In our study, approximately one in fifteen and more than one in ten caregivers had depression and anxiety respectively. The result of this study suggested that healthcare providers need to pay more attention to the psychological well-being of all caregivers of children and adolescents with epilepsy.

Social brain networks: Resting-state and task-based connectivity in youth with and without epilepsy

Individuals with epilepsy often experience social difficulties and deficits in social cognition. It remains unknown how disruptions to neural networks underlying such skills may contribute to this clinical phenotype. The current study compared the organization of relevant brain circuits-the "mentalizing network" and a salience-related network centered on the amygdala-in youth with and without epilepsy. Functional connectivity between the nodes of these networks was assessed, both at rest and during engagement in a social cognitive task (facial emotion recognition), using functional magnetic resonance imaging. There were no group differences in resting-state connectivity within either neural network. In contrast, youth with epilepsy showed comparatively lower connectivity between the left posterior superior temporal sulcus and the medial prefrontal cortex-but greater connectivity within the left temporal lobe-when viewing faces in the task. These findings suggest that the organization of a mentalizing network underpinning social cognition may be disrupted in youth with epilepsy, though differences in connectivity within this circuit may shift depending on task demands. Our results highlight the importance of considering functional task-based engagement of neural systems in characterizations of network dysfunction in epilepsy.

Just In Time: Challenges and Opportunities of First Aid Care Information Sharing for Supporting Epileptic Seizure Response

There are over three million people living with epilepsy in the U.S. People with epilepsy experience multiple daily challenges such as seizures, social isolation, social stigma, experience of physical and emotional symptoms, medication side effects, cognitive and memory deficits, care coordination difficulties, and risks of sudden unexpected death. In this work, we report findings collected from 3 focus groups of 11 people with epilepsy and caregivers and 10 follow-up questionnaires. We found that these participants feel that most people do not know how to deal with seizures. To improve others' abilities to respond safely and appropriately to someone having seizures, people with epilepsy and caregivers would like to share and educate the public about their epilepsy conditions, reduce common misconceptions about seizures and prevent associated stigma, and get first aid help from the public when needed. Considering social stigma, we propose design implications of future technologies for effective delivery of appropriate first aid care information to bystanders around individuals with epilepsy when they experience a seizure.

The development of a social norms adherence intervention for adolescents with epilepsy

INTRODUCTION

Adherence is suboptimal in adolescents with epilepsy. Social norms comparison (i.e., feedback about someone else's behavior related to one's own behavior) strategies may be beneficial in improving medication adherence. Using a novel model of behavioral intervention development, the aim of the current study was to create a social norms intervention for adolescents with epilepsy via focus groups and usability studies.

METHODS

A focus group, individual interviews, short-term usability, and extended usage testing studies were conducted. Across all study phases, content and images of intervention components were displayed to participants as mock-ups in PowerPoint slide decks. After each phase, updated iterations were shown to participants to refine the intervention. Several questionnaires were completed by adolescents and caregivers to characterize the samples.

RESULTS

Twelve adolescents participated in the focus group/individual interviews and usability studies. The final Behavioral Economic Adherence for Teens (BEAT) intervention consists of a text messaging system and a graphical user interface. General feedback indicated the need for simplicity and ease of use regarding obtaining the graphical messages (e.g., no extra login and passwords); engaging visual images; and weekly comparisons of a target patient's medication adherence to other adolescents' performance. The average system usability system (SUS) rating was 88.3 + 3.8.

CONCLUSIONS

Our final intervention had high usability ratings and was perceived as engaging and easy to understand. An important next step is to test the BEAT intervention in a Phase 2 randomized trial.

Pharmacological Considerations When Transitioning the Care of Epilepsy Patients from Pediatric to Adult Epilepsy Centers

There is scarce evidence in review of the available literature to support a clear and superior model for the transition of care for epilepsy patients from pediatric to adult centers. Anecdotally, there is a common perception that families are reluctant to make this change and that the successful transition of care for epilepsy can be a challenge for patients, families, and physicians. As part of the effort to prepare the patient and family for the adult model of care, several treatment issues should be addressed. In this article, we discuss the specific challenges for physicians in transition of care for epilepsy patients from a pharmacological standpoint, which include differences in metabolism and pharmacodynamics that can impact tolerability or efficacy of antiepileptic medications, lifestyle changes affecting medication compliance and seizure control, acquired adult health conditions necessitating new medications that may result in adverse drug interactions, and adult neurologists' potential lack of familiarity with certain medications typically used in the pediatric epilepsy population. We offer this as a guide to avoid one of the many possible pitfalls when epilepsy patients transition to adult care.

Allocation of Treatment Responsibility in Adolescents With Epilepsy: Associations With Cognitive Skills and Medication Adherence

Objectives

To describe allocation of treatment responsibility (ATR) in adolescents with epilepsy, investigate associations between cognitive skills and ATR, and examine whether ATR for antiepileptic drugs (AEDs) predicted electronically monitored adherence.

Method

Sixty adolescents with epilepsy and their caregivers completed the Allocation of Treatment Responsibility Scale and a battery of self-report measures. Medical chart review data and electronically monitored AED adherence were collected for 1 year. Descriptive data assessed ATR for caregivers and adolescents; multivariate hierarchical regressions tested associations between variables.

Results

ATR for labs and clinic appointments was greatest for caregivers, while ATR for AEDs was more likely to be shared between caregiver and adolescent. Poorer attention was associated with greater caregiver responsibility for AEDs. Greater caregiver responsibility for AEDs was associated with higher electronically monitored adherence over 12 months.

Conclusions

In adolescents with epilepsy, caregivers are responsible for most treatment tasks, although responsibility for taking medication was shared with the adolescent. Greater caregiver responsibility for medication results in better long-term AED adherence. ATR is an important construct that warrants further attention in research and clinical practice, especially in the context of transition and health outcomes in pediatric epilepsy.

Prevalence and Associated Factors of Mental Distress among Caregivers of Patients with Epilepsy in Ethiopia: A Cross-Sectional Study Design

Background

Caregiving to individuals with mental illness is a broad responsibility, including not only practical help and care but also emotional support. Cross-sectional studies in different localities suggested a significant burden of mental distress among caregivers of patients with epilepsy, but we are not aware about the condition in Ethiopia. Therefore, the aim of the current study is to assess the prevalence and associated factors of mental distress among caregivers of patients with epilepsy in Ethiopia.

Methods

An institutional based cross-sectional study was conducted in Neuropsychiatric Department of Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia. Using systematic random sampling technique, 409 caregivers participated in the study. Data was collected by face to face interview using standardized and validated Kessler Psychological Distress Scale (K-10) to assess mental distress. Descriptive, bivariate, and multivariate logistic regression models were used for analysis. Adjusted Odd Ratio (AOR) with 95% Confidence Interval (CI) was used to show the odds, and P-value < 0.05 was considered as statistically significant.

Results

The mean age of respondents was 43.3 years with standard deviation of ±11.4 years. Two hundred eighteen (53.3%) of the respondents were male. The prevalence of mental distress was found to be 27.1% with 95% CI [22.6-31.1]. Relationship with patient of being mother [AOR: 5.67, 95% CI: (1.68-13.70)], father [AOR: 4.42, 95% CI: (1.25-12.58)], wife/husband [AOR: 10.59, 95% CI: (2.43-14.19)], and child [AOR: 5.37, 95% CI: (1.27-12.69)]; caring for young person below 20 years of age [AOR: 4.00, 95% CI: (1.43-11.21)]; poor social support [AOR: 7.26, 95% CI: (3.60-14.65)]); and experienced stigma [AOR: 3.03, 95% CI: (1.63-5.66)] were statistically and significantly associated factors of mental distress among caregivers of patients with epilepsy.

Conclusion and Recommendation

We found a lower prevalence of mental distress among caregivers of patients with epilepsy compared to other low- and middle-income settings. Being caring for young patients, being parents to the patient, poor social support, and stigma were statistically significant associated factors of mental distress among caregivers. Therefore, appropriate psychosocial interventions are warranted to be designed and implemented emphasizing the aforementioned associated factors.

Tuberous sclerosis complex: Concerns and needs of patients and parents from the transitional period to adulthood

INTRODUCTION

Transitioning into adulthood and from pediatric services to adult healthcare are both challenging processes for young adults with rare chronic disorders such as tuberous sclerosis complex (TSC) and their parents. Adult healthcare systems are often less family-oriented and lack multidisciplinary care and experience with TSC, which can result in increased health risks and morbidity. Patient-driven data on care needs are necessary to optimize support for this vulnerable patient group.

AIM

The aim of this study was to explore the concerns and care needs of young adult patients with TSC in medical, psychological, and socioeconomical domains.

METHOD

A qualitative study was performed using semistructured interviews with 16 patients (median age: 21years; range: 17 to 30) and 12 parents. Concerns and care needs were organized using the International Classification of Functioning, Disability, and Health (ICF).

RESULTS

Main concerns involved mental and physical health, participation, self-management skills, family planning, and side effects of medications. Patients expressed the need for multidisciplinary care that is well-informed, easily accessible, and focused on the patient as a whole, including his/her family. Parents reported high stress levels.

CONCLUSION

The current study provides patient-driven information, allowing recommendations to facilitate the (transition of) care for young adults with TSC. In addition to seizures, tumor growth, and TSC-associated neuropsychiatric disorders (TAND), more attention is needed for concerns and care needs specific to the transitional period, participation, and environmental factors. Adult healthcare providers should offer expert multidisciplinary care for adult patients with TSC, including attention for parental stress.

Quality of life and level of burden in primary caregivers of patients with epilepsy: Effect of neuropsychiatric comorbidity

BACKGROUND

Few studies are focused on the quality of life (QOL) of primary caregivers and the effects of the clinical variables of epilepsy and patient psychiatric comorbidity on primary caregivers.

PURPOSE

Our main objective was to describe QOL and level of burden (LB) in caregivers of people with epilepsy (PWE) at a tertiary-care hospital in Mexico City. A secondary purpose was to determine if LB and QOL were different between caregivers of patients with neuropsychiatric comorbidity and caregivers of patients without neuropsychiatric comorbidity.

METHODS

One hundred and fifty-one caregivers of PWE were assessed with the short version of the World Health Organization Quality of Life (WHOQOL) scale (WHOQOL-BREF) and the Zarit Burden Interview. Patients' clinical and demographic data, along with their psychiatric histories, were collected.

RESULTS

One hundred and twelve patients had psychiatric comorbidity. The mean LB score of the caregivers was 26.25±16.28. The mean scores for the WHOQOL-BREF domains were as follows: physical health, 47.8±10.7; psychological health, 55.4±11.5; social relationships, 47.23±18.6; and environment, 48.7±11.6. The caregivers of patients with psychiatric comorbidity had lower scores in the domains of psychological health (p=0.034) and social relationships (p=0.029) compared with caregivers of PWE without comorbidity. On adjusted multivariate analysis, aggressiveness (p=0.008), age at onset of epilepsy (p=0.02), and years with epilepsy (p=0.01) were associated with higher caregiver LB scores; higher caregiver years of education were associated with better psychological health (p=0.002) and more years with epilepsy (p=0.03) with lower QOL scores.

CONCLUSION

Aggressive behavior was the psychiatric comorbidity most clearly associated with lower QOL and higher LB. Longer duration of epilepsy was related to higher burden and lower QOL. More years of education of the caregiver were associated with better QOL. We found no significant correlation between seizure control and QOL or LB.

Measurement in pediatric epilepsy self-management: A critical review

Given the paucity of information available regarding self-management, the aims of this paper are to synthesize the literature on factors associated with and measures to assess self-management in pediatric epilepsy.

INCLUSION CRITERIA

youth birth to 18 years with a seizure disorder or an epilepsy diagnosis and/or their caregivers, published 1985-2014 in English, and conducted in countries with a very high human development index. The review was conducted in 6 phases: (1) identification of bibliographical search criteria and databases; (2) abstract assessment; (3) full article review; (4) organization of final citations into categories; (5) identification of predictors, potential mediators/moderators, and outcomes associated with self-management factors and categorization of factors as influences, processes, or behaviors across individual, family, community, and health care domains; and (6) critique of self-management instrument studies. Twenty-five studies that evaluated factors associated with self-management were identified. Individual and family-focused factors were the most commonly studied predictors of self-management, with psychosocial care needs and self-efficacy for seizure management identified as key factors associated with pediatric epilepsy self-management. Few studies have included mediator and moderator analyses. Measures of adherence were the most commonly used outcome. There has been a predominant focus on pediatric epilepsy influences and processes that are modifiable in nature, potentially at the expense of evidence for the role of community and health systems in pediatric epilepsy self-management. The 6 self-management instrument tools reported scientific rationale and good psychometric properties. Results highlight several key modifiable cognitive and behavioral targets for skills development: adherence, self-efficacy for seizure management, attitudes toward epilepsy, and family variables. Moving forward, a comprehensive pediatric epilepsy self-management model, well-validated measures of self-management behaviors, mediator/moderator designs to examine the complex relationships between predictors and pediatric epilepsy self-management outcomes, and studies examining the community and health care domains of self-management are necessary.

Epilepsy: Transition from pediatric to adult care. Recommendations of the Ontario epilepsy implementation task force

The transition from a pediatric to adult health care system is challenging for many youths with epilepsy and their families. Recently, the Ministry of Health and Long-Term Care of the Province of Ontario, Canada, created a transition working group (TWG) to develop recommendations for the transition process for patients with epilepsy in the Province of Ontario. Herein we present an executive summary of this work. The TWG was composed of a multidisciplinary group of pediatric and adult epileptologists, psychiatrists, and family doctors from academia and from the community; neurologists from the community; nurses and social workers from pediatric and adult epilepsy programs; adolescent medicine physician specialists; a team of physicians, nurses, and social workers dedicated to patients with complex care needs; a lawyer; an occupational therapist; representatives from community epilepsy agencies; patients with epilepsy; parents of patients with epilepsy and severe intellectual disability; and project managers. Three main areas were addressed: (1) Diagnosis and Management of Seizures; 2) Mental Health and Psychosocial Needs; and 3) Financial, Community, and Legal Supports. Although there are no systematic studies on the outcomes of transition programs, the impressions of the TWG are as follows. Teenagers at risk of poor transition should be identified early. The care coordination between pediatric and adult neurologists and other specialists should begin before the actual transfer. The transition period is the ideal time to rethink the diagnosis and repeat diagnostic testing where indicated (particularly genetic testing, which now can uncover more etiologies than when patients were initially evaluated many years ago). Some screening tests should be repeated after the move to the adult system. The seven steps proposed herein may facilitate transition, thereby promoting uninterrupted and adequate care for youth with epilepsy leaving the pediatric system.

An Analysis of a Novel, Short-Term Therapeutic Psychoeducational Program for Children and Adolescents with Chronic Neurological Illness and Their Parents; Feasibility and Efficacy

The purpose of this intervention was to develop a therapeutic psycho-educational program that improves quality of life in children and adolescents who are experiencing chronic neurological illness, including epilepsy, and their parents, and to analyze the intervention's feasibility and efficacy and participants' satisfaction. Participants were eight children (n = 8) and adolescents and their parents; participating children were experiencing chronic neurological illness with psychological comorbidity; children with intellectual impairment were excluded (IQ < 80). The program was carried out weekly for four sessions. In each of the 4 weeks, children's session content addressed self, emotion, coping skills, and finishing up, respectively; and parents' session content targeted family dynamic and emotional intervention, coping skills, childcare and education, and finishing up, respectively. Clinical psychologists administered psychological assessments (viz., Child Behavior Checklist, Pediatric Quality of Life Inventory, Parenting Stress Index, Beck Depression Inventory, Children's Depression Inventory, and Revised Children's Manifest Anxiety Scale) at pre- and post-intervention, and administered satisfaction surveys following the intervention. Participants' opinions about the program's necessity, contents, and process, and participants' overall program satisfaction were analyzed. Parents and children reported high levels of satisfaction with the program. Externalizing behavioral problems, anxiety/depression, and emotional functioning from quality of life showed improvement after the intervention. Although not statistically significant, total child stress trended downward from pre- to post-intervention. A four-session structured therapeutic psycho-educational program for children and adolescents with chronic neurological illness and their parents was successfully implemented, showing good compliance and high satisfaction and efficacy.

Preliminary feasibility and efficacy of text messaging and application-based adherence interventions in adolescents with epilepsy

OBJECTIVE

Few interventions have been developed to improve treatment adherence in adolescents with epilepsy. The purpose of this study was to test the feasibility and acceptability of text messaging and application-based interventions to improve adolescent antiepileptic drug adherence. It was hypothesized that these interventions would improve adherence and would be feasible and acceptable to adolescents and their caregivers.

METHODS

Twenty-five adolescents (mean age=15.7; 52% males) and caregivers were randomized to one of five interventions for one month: 1) adolescent text only, 2) adolescent and caregiver text plus communication, 3) adolescent application only, 4) adolescent and caregiver application plus communication, and 5) epilepsy application for adolescents only. Questionnaires were completed at baseline, posttreatment, and 1-month follow-up. The primary outcome measure was electronically monitored adherence.

RESULTS

Results indicated high levels of baseline adherence that contributed to minimal adherence improvements. Adolescents and caregivers reported that text messaging and application-based interventions were feasible and acceptable.

SIGNIFICANCE

These data highlight that technology-focused adherence interventions are feasible but should likely be targeted to those with demonstrated nonadherence in future clinical trials.

Social Behavioral Problems and the Health-Related Quality of Life in Children and Adolescents with Epilepsy

OBJECTIVE

The purpose of this study was to investigate the impact of specific behavioral problems on the health-related quality of life (HRQOL) in children and adolescents with epilepsy.

METHODS

Children and adolescents with epilepsy (n=92; age range=6-17 years) and their mothers completed questionnaires about behavioral problems, HRQOL, socio-demographics, and epilepsy-related variables. To determine significant predictor variables of the HRQOL, the stepwise regression analyses and partial correlations were performed to adjust for other behavioral problems and covariates.

RESULTS

The analyses revealed that an increase in social behavioral problems and delinquent behavior was associated with a decrease in the HRQOL. Lower levels of maternal education and the number of antiepileptic drugs were also associated with a decline in the HRQOL; the HRQOL and social behavioral problems remained significantly correlated after adjusting for maternal education level, number of antiepileptic drugs, and non-social behavioral problems.

CONCLUSION

Parents and practitioners should provide intervention if behavioral problems, particularly social behavioral problems, are observed in children or adolescents with epilepsy.

Evaluation of a multidisciplinary epilepsy transition clinic for adolescents

INTRODUCTION

The main goal of the transition clinic is to explore and optimize medical issues during transition from adolescence to adulthood, and to ease the transition into adult care. However, only limited data on the process and outcomes of transitional care in clinical practice are available.

OBJECTIVE

To describe the process and outcomes of an Epilepsy Transition Clinic in a tertiary referral center in The Netherlands.

METHODS

Data were collected from patients with epilepsy (aged 15-25 years), who visited the transition clinic between March 2012 and September 2014.

RESULTS

The Epilepsy Transition Clinic is staffed with a multidisciplinary team including a neurologist/epileptologist, clinical neuropsychologist, a social worker and an educationalist/occupational counselor, all with knowledge of paediatric and adult medical and developmental issues. In total, 117 patients with epilepsy were included in the analysis. After consultation, 89 patients received a diagnostic work-up (76.1%), change in AED prescription (n = 64, 54.7%), or consultation/tailored advice (n = 73, 62.4%). In fourteen patients (12.0%) the epilepsy diagnosis was changed. Nineteen patients (16.2%) had complete epilepsy remission for over one year. Forty-three patients (36.8%) were referred to adult care.

CONCLUSION

This study describes a multidisciplinary epilepsy transition clinic staffed by a neurologist/epileptologist, neuropsychologist, a social worker and an educationalist/occupational counselor. Diagnostic work-up and evaluation of psychosocial and educational/vocational status during adolescence are strongly recommended.

Economic evaluation of a behavior-modifying intervention to enhance antiepileptic drug adherence

Between 35% and 50% of patients with epilepsy are reported to be not fully adherent to their medication schedule. We aimed to conduct an economic evaluation of strategies for improving adherence to antiepileptic drugs. Based on the findings of a systematic review, we identified an implementation intention intervention (specifying when, where, and how to act) which was tested in a trial that closely resembled current clinical management of patients with epilepsy and which measured adherence with an objective and least biased method. Using patient-level data, trial patients were matched with those recruited for the Standard and New Antiepileptic Drugs trial according to their clinical characteristics and adherence. Generalized linear models were used to adjust cost and utility in order to estimate the incremental cost per quality-adjusted life-year (QALY) gained from the perspective of the National Health Service in the UK. The mean cost of the intervention group, £1340 (95% CI: £1132, £1688), was marginally lower than that of the control group representing standard care, £1352 (95% CI: £1132, £1727). Quality-adjusted life-year values in the intervention group were higher than those in the control group, i.e., 0.75 (95% CI: 0.70, 0.79) compared with 0.74 (95% CI: 0.68, 0.79), resulting in a cost saving of £12 (€15, US$19) and with the intervention being dominant. The probability that the intervention is cost-effective at a threshold of £20,000 per QALY is 94%. Our analysis lends support to the cost-effectiveness of a self-directed, implementation intention intervention for improving adherence to antiepileptic drugs. However, as with any modeling dependent on limited data on efficacy, there is considerable uncertainty surrounding the clinical effectiveness of the intervention which would require a substantive trial for a more definitive conclusion.

Transition to adult medical care for adolescents with epilepsy

INTRODUCTION

During transition to adult medical care, the adolescent with epilepsy is especially prone to emotional, mental, physical, and social developmental difficulties, leading to stigma and poor psychosocial and socioeconomic outcome in the long term.

OBJECTIVES

The aim of this review is twofold: to describe the psychosocial and medical transition from adolescence to adulthood and to evaluate the most effective model for transitional services in adolescents with epilepsy.

METHODS

We searched PubMed for quantitative and qualitative data about transition from adolescence to adulthood in patients with epilepsy.

RESULTS

A total of 49 articles were retrieved. We reviewed personal, psychosocial, and medical issues during transition and their long-term individual and societal consequences. Identifying risk factors for poor transition can lead to appropriate interventions for patients and their family. Although the concept of multidisciplinary transition care for adolescents with epilepsy is widely recognized, only a few transition clinics have been established. There is lack of evidence for their quality and cost-effectiveness.

CONCLUSION

In addition to medical problems, more attention should be paid to the risk of psychosocial problems during transition from pediatric to adult care. The implementation of transition care for adolescents with epilepsy is considered beneficial; however, its effectiveness should be further investigated.

An examination of the Allocation of Treatment Responsibility scale in adolescents with epilepsy

The purpose of the current study was to examine the psychometric properties of the adapted Allocation of Treatment Responsibility (ATR) scale and the distribution of tasks related to oral medication and clinic and laboratory visits in a sample of adolescents with epilepsy. Adolescents with epilepsy (N = 50; ages 13-17 years) and their caregivers completed the adapted ATR and a measure of medication management. Internal consistency for the adapted ATR was strong (total and subscale range: 0.75-0.97). Validity was partially supported by significant correlations between adolescent age and ATR oral medication responsibility for both respondent measures. Allocation of Treatment Responsibility total scores were not associated with adherence to medications and clinic appointments. Initial findings are promising and have important implications for assessing the distribution of treatment responsibility among adolescents with epilepsy and their families.

Systematic review of epilepsy self-management interventions integrated with a synthesis of children and young people's views and experiences

AIM

To determine the effectiveness of epilepsy self-management interventions and explore the views and experiences of medication and seizures by children and young people.

BACKGROUND

Experiencing seizures and side-effects from anti-epileptic medicines have negative impacts on children and young people managing their epilepsy. Children commonly experiment with not taking epilepsy medication as prescribed and engage in unhealthy lifestyles. DESIGN/REVIEW METHODS: Mixed-method systematic review with theory development. Cochrane quantitative methods and thematic synthesis of qualitative and survey evidence.

DATA SOURCES

Eight databases were searched from earliest dates to July 2013.

RESULTS

Nineteen studies were included. Meta-analysis was not possible. Zero of nine intervention studies showed improvement in anti-epilepsy medication adherence. Skill-based behavioural techniques with activities such as role play and goal setting with young people increased epilepsy knowledge and seizure self-management (small effects). Intervention studies were methodologically weak and no studies reported if improvement in self-management was sustained over time. Synthesis of nine qualitative and one mixed-method studies generated six themes encapsulating anti-epilepsy medication and epilepsy effects. There was a lack of fidelity between intervention programme theories and what children and young people found difficult with medication self-management and managing the effects of epilepsy.

CONCLUSION

Children and young people knowingly and/or unknowingly take risks with their epilepsy and give reasoned explanations for doing so. There are no effective interventions to change epilepsy medication adherence behaviours. There is an urgent need for more innovative and individually tailored interventions to address specific challenges to epilepsy self-management as identified by children and young people themselves.

Life quality and health in adolescents and emerging adults with epilepsy during the years of transition: a scoping review

AIMS

The aims of this study were to (1) search the literature in order to identify the challenges facing adolescents and emerging adults with epilepsy; and (2) categorize these issues within both the framework of the International Classification of Functioning, Disability and Health (ICF) and an empirical model of quality of life (QOL) in childhood epilepsy.

METHOD

We systematically searched PsycINFO, Ovid MEDLINE and Web of Science for studies reporting on QOL and health identified in people with epilepsy aged 12 to 29 years. Studies were limited to those that were published in the last 20 years in English, presenting the patient perspective. Data were extracted and charted using a descriptive analytical method. Identified issues were classified according to the ICF and QOL frameworks.

RESULTS

Fifty four studies were identified. Another 62 studies with potentially useful information were included as an addendum. The studies highlight a range of psychosocial issues emphasizing peer acceptance, social isolation, and feelings of anxiety, fear, and sadness.

INTERPRETATION

The ICF and QOL constructs represent useful starting points in the analytical classification of the potential challenges faced by adolescents with epilepsy. Progress is needed on fully classifying issues not included under these frameworks. We propose to expand these frameworks to include comorbidities, impending medical interventions, and concerns for future education, employment, marriage, dignity, and autonomy.

Caregiver burden in epilepsy: determinants and impact

Aim. Caregiver burden (CB) in epilepsy constitutes an understudied area. Here we attempt to identify the magnitude of this burden, the factors associated with it, and its impact to caregiver quality of life (QOL). Methods. 48 persons with epilepsy (PWE) underwent video-EEG monitoring and their caregivers completed questionnaires providing demographic, disease-related, psychiatric, cognitive, sleep, QOL, and burden information. Results. On regression analysis, higher number of antiepileptic drugs, poorer patient neuropsychological performance, lower patient QOL score, and lower caregiver education level were associated with higher CB. Time allocated to patient care approximated but did not attain statistical significance. A moderate inverse correlation between CB and caregiver QOL physical component summary score and a stronger inverse correlation between CB and caregiver QOL mental component summary score were seen. Conclusion. In a selected cohort of PWE undergoing video-EEG monitoring, we identified modest degree of CB, comparable to that reported in the literature for other chronic neurological conditions. It is associated with specific patient and caregiver characteristics and has a negative effect on caregiver QOL.

The effect of epilepsy surgery on caregiver quality of life

PURPOSE

Epilepsy surgery has been shown to improve patient quality of life (QOL). Little is known about its effect on caregiver QOL.

METHODS

The study population comprised of 26 persons with epilepsy (PWE) who underwent long term video EEG monitoring at Massachusetts General Hospital for presurgical evaluation along with 16 caregivers. The PWE completed epilepsy directed QOL (QOLIE-31) and psychological (Beck depression-BDI and anxiety inventory-BAI) questionnaires before and after surgery. Their participating caregivers completed generic health related QOL (SF36v2) and disease burden (Zarit caregiver burden inventory-ZCBI) questionnaires before and after surgery. Demographic data for all participants and disease/surgery related data for the PWE were collected. Statistical analysis was performed to compare PWE and caregiver QOL before and after surgery.

RESULTS

Mean patient age was 37 years. Most (77%) suffered from symptomatic partial epilepsy for approximately 18 years prior to surgery, averaging 4 seizures per month and 2.2 antiepileptic drugs (AEDs). 78% of them underwent an anterior temporal lobectomy and the rest extra-temporal resections. On follow up at approximately 9 months, 69% had a surgical outcome of Engel class I, 23% of class II and 8% class IV. Postoperatively, the PWE remained on average on 1.9 AEDs. There was a statistically significant improvement for both the aggregate QOLIE-31 score and all its subscales (except for medication effects) as well as the BAI scores. 96% of the PWE felt that the decision to go through surgery was worthwhile. Mean caregivers age was 47 years. Half of them were spouses to the PWE and the majority of the rest their parents. 50% of them stated that their overall time devoted to patient's care decreased after surgery and 50% that it remained unchanged. The mental component scale (SF36v2, MCS) of caregiver QOL showed statistically significant improvement. ZCBI score and the physical component scale of their QOL (SF36v2, PCS) did not significantly vary before and after surgery. 75% of caregivers deemed their QOL better post surgery vs 19% similar. 94% of the caregivers felt that the decision to go through surgery was worthwhile.

CONCLUSIONS

Successful epilepsy surgery has a positive impact not only to patient QOL but also to their caregiver. To the best of our knowledge, this is the first pilot study to systematically address the impact of epilepsy surgery on caregivers providing additional support to epilepsy surgery as the optimal treatment modality in carefully selected patients. These findings call for further investigation on the caregiver quality of life in epilepsy and for its inclusion in the treatment plan and quality indicators for epilepsy surgery.

Treatment adherence among adolescents with epilepsy: what really matters?

Treatment adherence is often suboptimal among adolescents with epilepsy. However, knowledge is lacking regarding factors that affect adherence. Empirical studies and theories of human development suggest that self-management skills, self-efficacy, and sense of control are related to adherence. Eighty-eight adolescents with epilepsy, and their parents, completed standardized measures assessing epilepsy knowledge and expectations, treatment self-management, sense of control, and self-efficacy. Better self-reported parent adherence was correlated with greater epilepsy knowledge/expectations (p<0.001) and more medications (p = 0.042). Better self-reported adolescent adherence was correlated with fewer siblings (p = 0.003) and higher adolescent epilepsy knowledge/expectations (p<0.001). Greater adolescent epilepsy knowledge/expectations correlated with parent self-reported adherence (p<0.001), Powerful others locus of control (p = 0.008), and adolescent/parent discordance regarding epilepsy knowledge/expectations (p<0.001). Interventions that enhance adolescent's knowledge of epilepsy and their treatment plan, while ensuring that teens and parents are in agreement with regard to epilepsy treatment, might contribute to better adherence.

Psychiatric concerns in pediatric epilepsy

Pediatric epilepsy is a common, chronic, and challenging physical illness for children and their families. This article provides a medical overview and discusses the cognitive functioning and psychosocial adjustment as well as the psychiatric management for children and adolescents with pediatric epilepsy. The management of these children involves establishing a collaborative health care approach, evaluating academic functioning, considering psychotherapy, and managing psychopharmacologic treatment. A thorough understanding of the biopsychosocial concerns in pediatric epilepsy can enable medical providers and mental health clinicians to promote resiliency and adaptation in children and their families facing troubling seizure disorders.

Self-reported and parent-reported quality of life of children and adolescents with new-onset epilepsy

PURPOSE

To investigate the self-reported quality of life (QOL) of children and adolescents with new-onset epilepsy and explore parent's perceptions of their child's QOL and the impact of epilepsy on the family.

METHODS

As part of the Standard and New Antiepileptic Drug (SANAD) trial, 248 children (aged 8-15 years) with new-onset epilepsy and their parents completed batteries of QOL measures. Children completed the KINDL and subscales of the QOLIE-AD-48. Parental questionnaires included the Rutter Parent Scales, Adverse Events Profile, and subscales of the Child Health Questionnaire.

KEY FINDINGS

Compared with published norms, children with epilepsy had significantly poorer QOL across multiple domains compared with healthy children and children with asthma. Parents, particularly of younger children and those with other long-term health problems, were affected by their child's health or behavior, which affected their emotional well-being and time for their own needs.

SIGNIFICANCE

Children with new-onset epilepsy, particularly those with comorbid conditions, are at risk of reduced QOL at the time of diagnosis. It is important that children with epilepsy and their families are assessed for psychosocial problems so that early intervention can be undertaken.

Patterns of nonadherence to antiepileptic drug therapy in children with newly diagnosed epilepsy

CONTEXT

Because of epilepsy's common occurrence, the narrow therapeutic and safety margins of antiepileptic medications, and the recognized complications of medication nonadherence in adults with epilepsy, identifying the rates, patterns, and predictors of nonadherence in children with epilepsy is imperative. The onset and evolution of antiepileptic drug nonadherence in children with newly diagnosed epilepsy remains unknown.

OBJECTIVES

To identify and characterize trajectories of adherence in children with newly diagnosed epilepsy over the first 6 months of therapy and to determine sociodemographic and epilepsy-specific predictors of adherence trajectories.

DESIGN, SETTING, AND PATIENTS

Prospective, longitudinal observational study of antiepileptic drug adherence in a consecutive cohort of 124 children (2-12 years old) with newly diagnosed epilepsy at Cincinnati Children's Hospital Medical Center. Patients were recruited from April 2006 through March 2009, and final data collection occurred in September 2009.

MAIN OUTCOME MEASURE

Objective adherence measured using electronic monitors.

RESULTS

Fifty-eight percent of children with newly diagnosed epilepsy demonstrated persistent nonadherence during the first 6 months of therapy. Group-based trajectory models identified 5 differential adherence patterns (Bayesian information criterion = -23611.8): severe early nonadherence (13%; 95% confidence interval [CI], 8%-20%), severe delayed nonadherence (7%; 95% CI, 3%-12%), moderate nonadherence (13%; 95% CI, 8%-20%), mild nonadherence (26%; 95% CI, 19%-34%), and near-perfect adherence (42%; 95% CI, 33%-50%). The adherence pattern of most patients was established by the first month of therapy. Socioeconomic status was the sole predictor of adherence trajectory group status (χ(4)(2) = 19.3 [n = 115]; P < .001; partial r(2) = 0.25), with lower socioeconomic status associated with higher nonadherence.

CONCLUSION

Five trajectory patterns were identified that captured the spectrum of nonadherence to antiepileptic drugs among children with newly diagnosed epilepsy; the patterns were significantly associated with socioeconomic status.

Commentary: Pediatric epilepsy: a good fit for pediatric psychologists

While there are an abundance of pediatric neuropsychologists working with youth with epilepsy (YWE), other subspecialty psychologists have played minimal roles in clinical and research endeavors in pediatric epilepsy. Thus, the purpose of this commentary was to describe (a) the needs of YWE due to the intermittent nature of seizures and difficulties with disease management, (b) increased risk for psychosocial comorbidities, (c) limited access to care, and (d) provide recommendations for how pediatric psychologists can become involved in the clinical care and research activities for YWE.

Development and reliability of a correction factor for parent-reported adherence to pediatric antiepileptic drug therapy

PURPOSE

Study aims were (1) to document and examine associations between parent-report and electronic monitoring (EM) of pediatric antiepileptic drug (AED) adherence, (2) to determine the sensitivity and specificity of parent-reported adherence, and (3) to develop a correction factor for parent-reported adherence.

METHODS

Participants included 111 consecutive children with new-onset epilepsy (M(age) = 7.2 ± 2.0; 61.3% male; 75.8% Caucasian) and their primary caregivers. AED adherence was electronically monitored for 3 months prior to the 4-month clinic follow-up visit. Parent-reported adherence captured adherence 1-week prior to the clinic visit. For specificity/sensitivity analyses of parent-reported adherence, cut points of 50%, 80%, and 90% were used with electronically monitored adherence calculated 1-week prior to the clinic visit as the reference criterion.

KEY FINDINGS

Electronically monitored adherence (80.3%) was significantly lower than parent-reported adherence (96.5%; p < 0.0001) 1-week prior to the clinic visit, but both were significantly correlated (rho = 0.46, p < 0.001). The 90% parent-reported adherence cut point demonstrated the most sensitivity and specificity to electronically monitored adherence; however, specificity was still only 28%. A correction factor of 0.83 was identified as a reliable adjustment for parent-reported adherence when compared to electronically monitored adherence.

SIGNIFICANCE

Although EM is the gold standard of adherence measurement for pediatric epilepsy, it is often not clinically feasible to integrate it into routine clinical care. Therefore, use of a correction factor for interpreting parent-reported adherence holds promise as a reliable clinical tool. With reliable adherence measurement, clinicians can provide adherence interventions with the hope of optimizing health outcomes for children with epilepsy.

Development and validation of the Pediatric Epilepsy Medication Self-Management Questionnaire

Study aims were to describe the development and validation of a Pediatric Epilepsy Medication Self-Management Questionnaire (PEMSQ) for caregivers of children 2-14 years. It was expected that PEMSQ scales would have 1) factors with high internal consistency (e.g., Cronbach's alpha>0.70) and 2) moderate associations with adherence and seizures. Participants included caregivers of 119 children with epilepsy (M(age)=7.2 yrs, 36% female, 72% Caucasian) who completed the PEMSQ, demographics questionnaire, and AED adherence was assessed (e.g., electronic monitors, self-report). Factor analysis was conducted and internal consistency and construct validity were assessed. The final PEMSQ is 27 items with four scales (Epilepsy and Treatment Knowledge and Expectations, Adherence to Medications and Clinic Appointments, Barriers to Medication Adherence, and Beliefs about Medication Efficacy) accounting for 88% variance. Cronbach's alphas ranged from 0.68-0.85. Significant associations were found between PEMSQ scales, adherence, and seizures. The PEMSQ represents the first self-management measure validated for caregivers of children with epilepsy, with clinical and research utility.

Psychiatric concerns in pediatric epilepsy

Pediatric epilepsy is a common, chronic, and challenging physical illness for children and their families. This article provides a medical overview and discusses the cognitive functioning and psychosocial adjustment as well as the psychiatric management for children and adolescents with pediatric epilepsy. The management of these children involves establishing a collaborative health care approach, evaluating academic functioning, considering psychotherapy, and managing psychopharmacologic treatment. A thorough understanding of the biopsychosocial concerns in pediatric epilepsy can enable medical providers and mental health clinicians to promote resiliency and adaptation in children and their families facing troubling seizure disorders.