Determinants of Social Outcomes in Adults With Childhood-onset Epilepsy

Association of area deprivation index (ADI) with demographics and postoperative outcomes in pediatric brain tumor patients

PURPOSE

Although social determinants of health (SDOH) have been associated with adverse surgical outcomes, cumulative effects of multiple SDOH have never been studied. The area deprivation index (ADI) assesses cumulative impact of SDOH factors on outcomes. We analyzed the relationship between ADI percentile and postoperative outcomes in pediatric patients diagnosed with brain tumors.

METHODS

A retrospective, observational study was conducted on our consecutive series of pediatric brain tumor patients presenting between January 1, 1999, and May 31, 2022. Demographics and outcomes were collected, identifying SDOH factors influencing outcomes found in the literature. ADI percentiles were identified based on patient addresses, and patients were stratified into more (ADI 0-72%) and less (ADI 73-100%) disadvantaged cohorts. Univariate and multivariate logistic regression analyses were completed for demographics and outcomes.

RESULTS

A total of 272 patients were included. Demographics occurring frequently in the more disadvantaged group were Black race (13.1% vs. 2.8%; P = .003), public insurance (51.5% vs. 27.5%; P < .001), lower median household income ($64,689 ± $19,254 vs. $46,976 ± $13,751; P < .001), and higher WHO grade lesions (15[11.5%] grade III and 8[6.2%] grade IV vs. 8[5.6%] grade III and 5[3.5%] grade IV; P = .11). The more disadvantaged group required adjunctive chemotherapy (25.4% vs. 12.05%; P = .007) or radiation therapy (23.9% vs. 12.7%; P = .03) more frequently and had significantly greater odds of needing adjunctive chemotherapy (odds ratio [OR], 1.11; confidence interval [CI], 1.01-1.22; P = .03) in a multivariate model, which also identified higher WHO tumor grades at presentation (OR, 1.20; CI, 1.14-1.27; P < .001).

CONCLUSION

These findings are promising for use of ADI to represent potential SDOH disadvantages that pediatric patients may face throughout treatment. Future studies should pursue large multicenter collaborations to validate these findings.

Individualized Homeopathic Medicines as Adjunctive Treatment of Pediatric Epilepsy: A Double-Blind, Randomized, Placebo-Controlled Trial

INTRODUCTION

Epilepsy, one of the most common neurological diseases, contributes to 0.5% of the total disease burden. The burden is highest in sub-Saharan Africa, central Asia, central and Andean Latin America, and south-east Asia. Asian countries report an overall prevalence of 6/1,000 and that in India of 5.59/1,000. We examined whether individualized homeopathic medicines (IHMs) can produce a significantly different effect from placebos in treatment of pediatric epilepsy in the context of ongoing standard care (SC) using anti-epileptic drugs (AEDs).

METHODS

The study was a 6-month, double-blind, randomized, placebo-controlled trial (n = 60) conducted at the pediatric outpatient department of a homeopathic hospital in West Bengal, India. Patients were randomized to receive either IHMs plus SC (n = 30) or identical-looking placebos plus SC (n = 30). The primary outcome measure was the Hague Seizure Severity Scale (HASS); secondary outcomes were the Quality of Life in Childhood Epilepsy (QOLCE-16) and the Pediatric Quality of Life inventory (PedsQL) questionnaires; all were measured at baseline and after the 3rd and 6th month of intervention. The intention-to-treat sample was analyzed to detect group differences and effect sizes.

RESULTS

Recruitment and retention rates were 65.2% and 91.7% respectively. Although improvements were greater in the IHMs group than with placebos, with small to medium effect sizes, the inter-group differences were statistically non-significant - for HASS (F 1, 58 = 0.000, p = 1.000, two-way repeated measures analysis of variance), QOLCE-16 (F 1, 58 = 1.428, p = 0.237), PedsQL (2-4 years) (F 1, 8 = 0.685, p = 0.432) and PedsQL (5-18 years) (F 1, 47 = 0.000, p = 0.995). Calcarea carbonica, Ignatia amara, Natrum muriaticum and Phosphorus were the most frequently prescribed medicines. No serious adverse events were reported from either of the two groups.

CONCLUSION

Improvements in the outcome measures were statistically non-significantly greater in the IHMs group than in the placebos group, with small effect sizes. A different trial design and prescribing approach might work better in future trials.

TRIAL REGISTRATION

CTRI/2018/10/016027.

Whole-Genome Sequencing Among Kazakhstani Children with Early-Onset Epilepsy Revealed New Gene Variants and Phenotypic Variability

In Kazakhstan, there is insufficient data on genetic epilepsy, which has its own clinical and management implications. Thus, this study aimed to use whole genome sequencing to identify and evaluate genetic variants and genetic structure of early onset epilepsy in the Kazakhstani pediatric population. In this study, for the first time in Kazakhstan, whole genome sequencing was carried out among epilepsy diagnosed children. The study involved 20 pediatric patients with early onset epilepsy and no established cause of the disease during the July-December, 2021. The average age at enrolment was 34.5 months, with a mean age at seizure onset of 6 months. Six patients (30%) were male, and 7 were familial cases. We identified pathogenic and likely pathogenic variants in 14 (70%) cases, among them, 6 novel disease gene variants (KCNQ2, CASK, WWOX, MT-CO3, GRIN2D, and SLC12A5). Other genes associated with the disease were SCN1A (x2), SLC2A1, ARX, CACNA1B, PCDH19, KCNT1, and CHRNA2. Identification of the genetic causes in 70% of cases confirms the general structure of the etiology of early onset epilepsy and the necessity of using NGS in diagnostics. Moreover, the study describes new genotype-phenotypic correlations in genetic epilepsy. Despite certain limitations of the study, it can be concluded that the genetic etiology of pediatric epilepsy in Kazakhstan is very broad and requires further research.

Safety and efficacy of brivaracetam in children epilepsy: a systematic review and meta-analysis

Background

Epilepsy is one of the most common neurological diseases, affecting people of any age. Although the treatments of epilepsy are more and more diverse, the uncertainty regarding efficacy and adverse events still exists, especially in the control of childhood epilepsy.

Methods

We performed a systematic review and meta- analysis following the Cochrane Handbook and preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Four databases including PubMed, Embase, Web of Science and Cochrane library were searched. Studies reporting the use of brivaracetam monotherapy or adjuvant therapy in children (aged ≤18 years) were eligible for inclusion. Each stage of the review was conducted by two authors independently. Random-effects models were used to combine effect sizes for the estimation of efficacy and safety.

Results

A total of 1884 articles were retrieved, and finally 9 articles were included, enrolling 503 children with epilepsy. The retention rate of BRV treatment was 78% (95% CI: 0.64-0.91), the responder rate (reduction of seizure frequency ≥ 50%) was 35% (95% CI: 0.24-0.47), the freedom seizure rate (no seizure) was 18% (95% CI: 0.10-0.25), and the incidence rate of any treatment-emergent adverse events (TEAE) was 39% (95% CI: 0.09-0.68). The most common TEAE was somnolence, which had an incidence rate of 9% (95% CI: 0.07-0.12). And the incidence rate of mental or behavioral disorders was 12% (95% CI: 0.06-0.17).

Conclusion

Our systematic review and meta-analysis showed that BRV seemed to be safe and effective in the treatment of childhood epilepsy.

Could thalamic biochemical changes correlate to cognitive impairment in idiopathic generalized epilepsy?

Background

The thalamus is crucial in the development of idiopathic generalized epilepsy (IGE), which could lead to cognitive dysfunctions, according to data from neuropsychology and advanced neuroimaging investigations. This research aimed to measure the metabolic changes in the thalamus and to assess if could be contributed to cognitive impairment in IGE patients. Thirty IGE patients and thirty healthy volunteers with matched ages, genders, and educational levels participated in this cross-sectional case–control research. The IGE patients and controls were evaluated neuropsychologically using Intelligence Quotient (IQ) to assess general cognitive ability, Digit span for attention, Wechsler memory scale (WMS) for verbal memory, cube drawing test for visuospatial memory, Trail making test for executive functions, and Controlled Oral Word Association test (COWAT) for verbal fluency and quantitative multi-voxel MR spectroscopy (MRS) measurements of N-acetyl aspartate (NAA), choline (Cho), creatine (Cr), NAA/Cr, NAA/Cho and Cho/Cr ratios at 1.5 T scanner. The voxels were located over the right and left thalamus.

Results

The IGE patients showed worse cognitive performance in IQ, attention, executive function, and verbal and visuospatial memory domains compared to the controls. The IGE patients exhibited a significantly decrease NAA in the right thalamus (p = 0.004) and a lower NAA/Cr ratio in the left thalamus (p = 0.01). the mean thalamus NAA level exhibited a positive correlation with CDT (r = 0.45, p = P = 0.01), and WMS-R (r = 0.39, p = 0.03) and a negative correlation with trail-making A test (r = 0.42, P = 0.01).

Conclusions

it was concluded that IGE patients exhibited poor cognition which could be attributed to thalamic neurometabolic changes due to impaired thalamic cortical circuits.

Cognitive profiles in pediatric unilobar vs. multilobar epilepsy

OBJECTIVES

We aimed to determine how cognitive impairment relates to the extent of the presumed epileptogenic zone in pediatric focal epilepsies. We analyzed the cognitive functions in unilobar compared to multilobar focal epilepsy patients that underwent neuropsychological testing at a tertiary epilepsy center.

METHODS

We assessed cognitive functions of pediatric focal epilepsy patients with the German version of the Wechsler Intelligence Scales that measures full-scale IQ and subcategories. We assessed differences in IQ and epilepsy-related variables between unilobar and multilobar epilepsy patients.

RESULTS

We included 62 patients (37 unilobar, 25 multilobar), aged 10.6 ± 3.7 years. Full-scale IQ values were significantly higher in unilobar (93.6 ± 17.7, 95% CI 87.7-99.6) than in multilobar epilepsy patients (77.3 ± 17.2, 95% CI 69.3-85.0; p = 0.001). In all but one IQ subcategory (working memory), significantly higher values were measured in unilobar than in multilobar epilepsy patients. The proportion of unilobar epilepsy patients with severe cognitive impairment (8.3%) and below-average intelligence (30.5%) was lower compared to multilobar epilepsy patients (47.6% and 61.9%; p = 0.002 and p = 0.021, respectively). Epilepsy onset occurred earlier in multilobar (4.0 years, 95% CI 2.6-5.5, SD ± 3.4 years) than in unilobar epilepsy patients (7.0 years, 95% CI 5.5-8.5, SD ± 4.4 years, p = 0.008).

CONCLUSIONS

Pediatric multilobar epilepsy patients face more cognitive issues than unilobar epilepsy patients on average. Our findings should help to identify children and adolescents who are most at risk for impaired cognitive development. A limitation of our study is the simple division into unilobar and multilobar epilepsies, with no specific account being taken of etiology/epilepsy syndrome, which can have a profound effect on cognition.

Cognitive disorders in childhood epilepsy: a comparative longitudinal study using administrative healthcare data

OBJECTIVE

The study aimed to assess the risk of cognitive impairment in patients with epilepsy, the impact of age of epilepsy onset on cognition and the temporal relationship of epilepsy onset and intellectual impairment.

METHODS

This longitudinal study analyzed birth cohorts and followed-up children born 2005-2007 up to the age of ten using administrative healthcare data of about 8.9 million members insured by the statutory health insurance "BARMER" in Germany. We compared prevalence of cognitive impairment (ICD-code F7*) in children with epilepsy (ICD-code G40) to controls, and calculated relative risks by age groups at onset of epilepsy and assessed differences in relation to the temporal sequence of the diagnoses.

RESULTS

Of the 142,563 pre-pubertal children included in the analysis, 2728 (1.9%) had an epilepsy diagnosis within the first 10 years of life. 17.4% (475/2728) of children with epilepsy had a diagnosis of cognitive impairment compared to 1.7% (2309/139835) in controls. The relative risk for cognitive impairment compared to age-matched controls was 10.5 (95% CI 9.6, 11.6) and was highest in epilepsy cases with seizure manifestation within the first 2 years of life compared to older children. The prevalence of cognitive impairment before epilepsy diagnosis was slightly increased compared to controls, while it was increased by a factor of nine in children diagnosed with cognitive impairment in the year of onset of epilepsy or afterwards.

CONCLUSIONS

Pre-pubertal children with epilepsy have a ten-fold higher risk for intellectual impairment compared to age-matched controls. This risk inversely correlates with the age of epilepsy manifestation. Cognitive impairment was diagnosed after epilepsy manifestation in the majority of patients.

How Parents Cope with the Care of a Child with Epilepsy: Based upon Grounded Theory

Background

Parents of children with seizure face the complicated health issues of their children. Adaptation strategies of parents as major care providers impact not only their handling of stresses on themselves but also children's quality of life. This study investigated the adaptation processes of parents of children with seizure at two educational hospitals affiliated with Kerman University of Medical Sciences in Iran.

Methods

Twenty parents (15 mothers and 5 fathers), and three nurses were selected using purposive sampling method. Data was collected using qualitative semi-structured interviews and analyzed using the method suggested by Corbin and Strauss version 2008. The interviews were conducted until thematic saturation was achieved.

Results

The adaptation process had five phases: “Disbelief, Patience on what happened, change to preserve, acceptance of the current situation, and self- empowerment.” In summary, the parents of children with seizure had a 5-phase adaptation strategy. The core category achieved was “continued efforts of parents to restore calm.”

Conclusion

Properly assessing the stresses' resources on parents of children with seizure is necessary. Informing their adaptation strategies may help medical staff and social services to provide more targeted support and promote the balance of the family function.

Underutilization of epilepsy surgery: Part I: A scoping review of barriers

One-third of persons with epilepsy have seizures despite appropriate medical therapy. Drug resistant epilepsy (DRE) is associated with neurocognitive and psychological decline, poor quality of life, increased risk of premature death, and greater economic burden. Epilepsy surgery is an effective and safe treatment for a subset of people with DRE but remains one of the most underutilized evidence-based treatments in modern medicine. The reasons for this quality gap are insufficiently understood. In this comprehensive review, we compile known significant barriers to epilepsy surgery, originating from both patient/family-related factors and physician/health system components. Important patient-related factors include individual and epilepsy characteristics which bias towards continued preferential use of poorly effective medications, as well as patient perspectives and misconceptions of surgical risks and benefits. Health system and physician-related barriers include demonstrable knowledge gaps among physicians, inadequate access to comprehensive epilepsy centers, complex presurgical evaluations, insufficient research, and socioeconomic bias when choosing appropriate surgical candidates.

The History of Epilepsy: From Ancient Mystery to Modern Misconception

Epilepsy is an ancient disease, which has fascinated and frightened scientists and laymen alike. Before the working knowledge of the central nervous system, seizures were shrouded in mystery. In antiquity, this disease was accredited to gods and demonic possession, causing those with epilepsy to be feared and isolated. Epilepsy patients continued to face discrimination through the mid-20th century. This discrimination ranged from lack of access to health insurance, jobs, and marriage equality to forced sterilizations. Despite the strides that have been made, there are still many misconceptions globally regarding epilepsy. Studies show that patients with epilepsy in communities that understand the pathology and cause of seizures are generally more successful in social and educational environments. While there has been progress, there is more work which needs to be done to educate people across the globe about the pathology of epilepsy.

Risk factors, etiologies, and comorbidities in urban pediatric epilepsy

The Seizures and Outcomes Study in Children (SOS-KIDS) identifies risk factors, etiologies, and comorbidities in a pediatric epilepsy population in a major city with diversity in socioeconomic levels. A thorough understanding of the range of issues impacting children with epilepsy is critical to establishing treatment that will produce better health outcomes. SOS-KIDS is a cross-sectional cohort study of pediatric epilepsy patients who live in Washington D.C. and are evaluated at Children's National Hospital. Families were recruited at the time of the child's routine clinic appointment or inpatient visit. Information was extracted from participants' electronic medical records (EMR) and parent reports; participants were screened for comorbidities using standardized screening measures. Data were collected from 289 participants (47% female, 53% male), and mean age was 7.9 years (2 months to 17 years). Twenty-nine percent of participants had primary generalized epilepsy, 63% focal epilepsy, 0.3% combined generalized and focal epilepsy, and 8% could not be distinguished. There were a variety of epilepsy risk factors including prematurity (10%), intraventricular hemorrhage (7%), neonatal seizures (8%), and febrile seizures (17%). The most common etiologies were cerebral malformations (13%) and genetic disorders (25%). Numerous participants had documented comorbidities including developmental delay (56%), intellectual disability (20%), headaches (16%), attention-deficit hyperactivity disorder (23%), and autism (7%). Of participants aged six years and older, depression, and anxiety were reported in 5% and 6% within the EMR, 14% and 19% in parent surveys, and 22% and 33% with standardized screening measures. We identified a wide variety of risk factors and etiologies among urban pediatric epilepsy patients, with genetic and structural being the most common. Neurologic and psychiatric comorbidities were common, but the prevalence of several psychiatric disorders reported within the EMR was substantially lower compared to that found when using parent surveys and standardized screening measures.

Cognitive performance and behavior across idiopathic/genetic epilepsies in children and adolescents

We investigated the cognitive and behavioral profile of three distinct groups of epilepsies with a genetic background for intergroup differences: (1) idiopathic/genetic generalized epilepsies (IGE/GGE group); (2) idiopathic focal epilepsies (IFE group); and (3) epilepsies with proven or strongly suggested monogenic or structural/numeric chromosomal etiology (genetic epilepsies, GE group). Cognitive (total IQ and subcategories) and behavioral parameters (CBCL) were assessed at the tertiary epilepsy center of the University of Munich (Germany). We used ANOVA with post-hoc Bonferroni-correction to explore significant mean differences and Fisher’s exact test for significant proportional differences of intelligence impairment and behavioral problems. 126 (56 IGE/GGE, 26 IFE, 44 GE) patients were available. Total IQ was 89.0 ± 15.9 (95% CI 84.5–93.4) for IGE/GGE, 94.8 ± 18.1 (95% CI 87.3–102.3) for IFE and 76.4 ± 22.4 (95% CI 67.6–85.3) for GE (p = 0.001). The same trend was significant for all but one IQ subcategory. The rate of patients with an intelligence impairment (total IQ < 70) was higher for GE (40%) than for IGE/GGE (14%) and for IFE (7%) patients (p = 0.033). There were no significant differences between groups for behavior scores and behavioral problems. This study shows that the current ILAE classification of epilepsies with genetic etiology creates a heterogeneous group of patients with respect to cognitive performance but not behavior. These findings may help in further delineating epilepsies as regards cognitive performance, notwithstanding their closely related etiological classification.

Psychosocial and functional outcomes in young adults with childhood-onset epilepsy: a 10-year follow-up

AIM

To compare long-term psychosocial and functional outcomes of young adults with uncomplicated childhood-onset epilepsy (COE) to population norm controls utilizing a controlled prospective cohort study.

METHOD

Psychosocial and functional outcomes were assessed at 10-year follow-up. Fifty-three young adults (27 males, 26 females) with COE (n=21 remission; 18y 1mo-30y 9mo; mean age 23y 4mo [SD 3y 4mo]; mean age of epilepsy onset 12y [SD 3y 2mo]) were compared to 55 (23 males, 32 females) first-degree cousin controls (18y 5mo-29y 8mo; mean age 23y 6mo [SD 3y]). Seizure remission status and baseline comorbidities (attention-deficit/hyperactivity disorder [ADHD], depressive disorders, anxiety disorders, and academic problems) were examined as possible risk factors for significant differences in functional outcomes.

RESULTS

Poorer functional outcomes, indicated by patient rated cognition and overall disability, were evident among young adults with epilepsy compared to controls (all p<0.05). These difficulties were due to baseline comorbid ADHD and academic problems. Remission status was not related to measured cognition and overall disability.

INTERPRETATION

Psychosocial outcomes of young adults with COE were similar to controls. In contrast, functional outcomes were worse in epilepsy across cognition and overall disability. Baseline comorbid ADHD and academic problems were identified as risk factors at 10-year follow-up suggesting that these early recognized comorbidities at or near diagnosis have long-term impacts.

WHAT THIS PAPER ADDS

Young adults with childhood-onset epilepsy (COE) and controls have similar psychosocial outcomes 10 years after diagnosis. Young adults with COE report greater limitations in cognition and overall disability than controls. Baseline presence of attention-deficit/hyperactivity disorder and academic problems significantly affect cognitive and overall disability scores.

Safety and tolerability of adjunctive brivaracetam in children with focal seizures: Interim analysis of pooled data from two open-label trials

OBJECTIVE

To evaluate long-term safety and tolerability of adjunctive brivaracetam (BRV) in children with epilepsy.

METHODS

This was an interim analysis (cut-off March 15, 2017) of pooled data from two open-label, single-arm, multicentre trials. N01263 (NCT00422422) was a 3-week trial of BRV 0.8-4 mg/kg/day in patients (1 month-<16 years) with epilepsy. Patients who completed this trial could continue into a long-term follow-up trial (N01266, NCT01364597) which also directly enrolled patients (4-<17 years) with focal seizures. After dose-escalation, patients received BRV 1-5 mg/kg/day (maximum 200 mg/day) during long-term evaluation. Data are reported for patients aged 4 to <16 years with focal seizures.

RESULTS

The safety set comprised 149 patients: 34 from the initial trial (26 entered long-term trial) and 115 directly enrolled into the long-term trial. At the cut-off, 90 patients were receiving BRV (total exposure: 299.4 patient-years). Treatment-emergent adverse events (TEAEs) were reported by 140/149 (94.0%) patients, most commonly (≥20%) nasopharyngitis (24.8%), pharyngitis (22.1%), convulsion (21.5%), and pyrexia (20.1%). TEAEs considered drug-related by the investigator were reported by 56/149 (37.6%) patients, most commonly somnolence (6.0%). Two patients died; neither death was considered related to BRV. Mean changes from baseline in child behaviour rating scales were small; most patients remained in their baseline category.

CONCLUSION

In this pooled analysis of two open-label trials including long-term data, adjunctive BRV was generally well tolerated in children aged 4 to <16 years with focal seizures. These findings supported approval of BRV as a new therapy option for children aged ≥4 years with focal seizures.

Children with epilepsy demonstrate macro- and microstructural changes in the thalamus, putamen, and amygdala

PURPOSE

Despite evidence for macrostructural alteration in epilepsy patients later in life, little is known about the underlying pathological or compensatory mechanisms at younger ages causing these alterations. The aim of this work was to investigate the impact of pediatric epilepsy on the central nervous system, including gray matter volume, cerebral blood flow, and water diffusion, compared with neurologically normal children.

METHODS

Inter-ictal magnetic resonance imaging data was obtained from 30 children with epilepsy ages 1-16 (73% F, 27% M). An atlas-based approach was used to determine values for volume, cerebral blood flow, and apparent diffusion coefficient in the cerebral cortex, hippocampus, thalamus, caudate, putamen, globus pallidus, amygdala, and nucleus accumbens. These values were then compared with previously published values from 100 neurologically normal children using a MANCOVA analysis.

RESULTS

Most brain volumes of children with epilepsy followed a pattern similar to typically developing children, except for significantly larger putamen and amygdala. Cerebral blood flow was also comparable between the groups, except for the putamen, which demonstrated decreased blood flow in children with epilepsy. Diffusion (apparent diffusion coefficient) showed a trend towards higher values in children with epilepsy, with significantly elevated diffusion within the thalamus in children with epilepsy compared with neurologically normal children.

CONCLUSION

Children with epilepsy show statistically significant differences in volume, diffusion, and cerebral blood flow within their thalamus, putamen, and amygdala, suggesting that epilepsy is associated with structural changes of the central nervous system influencing brain development and potentially leading to poorer neurocognitive outcomes.

Identifying the trajectory of social milestones 15-20 years after epilepsy surgery: Realistic timelines for postsurgical expectations

OBJECTIVE

Patients often undertake epilepsy surgery with the expectation that it will lead to improvements in their social situation. Short- to medium-term research consistently points toward improvements in social outcomes; however, no study has mapped out postsurgical social timelines, particularly for longer-term (>15 years) outcomes.

METHODS

We recruited 39 patients who had undergone anterior temporal lobectomy (ATL) for drug-resistant temporal lobe epilepsy (TLE) between 1994 and 2002. The cohort (24 females) had a median age of 49 years (range 38-67), age of habitual seizure onset was 9.5 years (range 0.5-29 years), and age at surgery was 31 years (range 20-53). Patients were followed up for a median of 18.4 years postsurgery (IQR = 4.4). Using data obtained from semistructured interviews, we conducted a comprehensive qualitative analysis of patients' self-reported postsurgical social trajectories. Self-report questionnaires were used to assess mood and health-related quality of life (HRQOL) at the time of interview.

RESULTS

There was a common sequence of social milestone achievement, spanning 20 years postsurgery. Typically, patients first (re)gained their license, then attempted educational and vocational gains, followed by establishing long-term relationships and finally a family unit. Rare, intermittent seizures postsurgery did not appear to have detrimental effects on social trajectories. Those who experienced a reduction in seizures showed increased likelihood of attaining social milestones compared to those with ongoing seizures.

SIGNIFICANCE

Achieving social milestones after epilepsy surgery may take considerably longer than patients are expecting prior to surgery. The pattern of social milestone outcome resembled a process of psychosocial development. These findings have important implications for presurgical counseling and postsurgical rehabilitation.

Parent-child mentalizing in pediatric epilepsy

BACKGROUND

Child psychopathology involves inappropriate or biased attributions of others' mental states (mentalizing), and parents' assessment of their children's mentalizing significantly predicts the latter's psychosocial outcomes. Behavioral difficulties are frequent in children with epilepsy (CWE) yet biased mentalizing and parental accuracy in understanding their child's mental states reasoning have not been addressed.

METHODS

This study compared the performance of 34 CWE aged 9 to 16 years with 67 language age-matched controls on a biased mentalizing task. The task required children to infer on the mental states of peers in stories involving social scenarios. Responses were scored as positive, negative, or rational mentalizing attributions. To measure parental accuracy, a parent version was administered in the patient group that required a parent to identify their child's responses correctly. Relationships with the child's cognitive, behavioral, and epilepsy-related factors were examined.

RESULTS

Patients made greater negative mental states attributions compared with control children. This negative mentalizing bias was accurately identified by parents and was associated with children's behavioral problems. Parental accuracy was reduced for patients with lower cognitive abilities. Parents did not accurately identify an overly positive (OP) bias in their child's mental states attributions. Children's positive response bias correlated with their lower executive function (EF) skills. Epilepsy factors predicted cognitive deficits but not biased mentalizing or behavioral problems.

CONCLUSION

Biased mentalizing characterizes social cognition in CWE with behavioral problems. Further investigation of the mentalizing biases and parental awareness of children's mental states reasoning is required to fully understand the greater psychosocial and behavioral difficulties found in CWE.

Social outcomes for adults with a history of childhood-onset epilepsy: A systematic review and meta-analysis

OBJECTIVES

This review aimed to describe social outcomes in adulthood for people with a history of childhood-onset epilepsy and identify factors associated with these outcomes; focused on educational attainment, employment, income/financial status, independence/living arrangement, romantic relationships, parenthood, and friendships.

METHODS

A comprehensive search of MEDLINE, EMBASE, and PsycINFO was conducted, as well as forward and backward citation tracking. A total of 45 articles met inclusion criteria. Random effects meta-analyses were conducted, and subgroup analyses evaluated outcomes for people with epilepsy (PWE) with good prognosis (e.g., normal intelligence, 'epilepsy-only') and poor prognosis (e.g., intellectual disability, Dravet syndrome), and those who underwent epilepsy surgery in childhood.

RESULTS

Among all PWE, 73% (95% confidence interval [CI]: 64-82%) completed secondary school education, 63% (95%CI: 56-70%) were employed; 74% (95%CI: 68-81%) did not receive governmental financial assistance; 32% (95%CI: 25-39%) were in romantic relationships; 34% (95%CI: 24-45%) lived independently; 21% (95%CI:12-33%) had children, and 79% (95%CI: 71-87%) had close friend(s). People with epilepsy often fared worse relative to healthy controls. Among PWE with a good prognosis, a comparable number of studies reported similar/better outcomes relative to controls as reported poorer outcomes. The most consistent predictor of poorer outcomes was the presence of cognitive problems; results of studies evaluating seizure control were equivocal.

CONCLUSION

People with epilepsy with a good prognosis may show similar social outcomes as controls, though robust conclusions are difficult to make given the extant literature. Seizure control does not guarantee better outcomes. There is a need for more studies evaluating prognostic factors and studies with control groups to facilitate appropriate comparisons.

Socioeconomic Status and Pediatric Neurologic Disorders: Current Evidence

Socioeconomic status (SES) is an important risk factor for many neurological disorders and a determinant of health outcomes and quality of life, especially for individuals with neurologic disorders and developmental disabilities. This article focuses on the relationship between SES and pediatric epilepsy, cerebral palsy, autism spectrum disorder, and intellectual disability. Disparities in the prevalence and long-term impact of SES on functioning in persons with disabilities are observed worldwide. Clinicians can use the information presented in the article to target early identification and interventions for improving outcomes in populations most at risk for these disorders and for poor health, social, and economic outcomes.

Adherence to antiepileptic drugs in adolescents with epilepsy

INTRODUCTION

The aims of the current study were to identify patterns and predictors of adherence in adolescents with epilepsy over one year, as well as its impact on seizures and health-related quality of life (HRQOL).

METHODS

Forty-eight adolescents with epilepsy (M_age=14.8+1.5, 69% female, 73% White: NonHispanic) and their caregivers completed questionnaires assessing demographics, epilepsy knowledge, side effects, adherence barriers, family functioning, and HRQOL at quarterly clinic visits over one year. Adherence was monitored electronically via MEMS TrackCaps. Seizures were determined via chart review.

RESULTS

Baseline adherence was 86.05% and significantly decreased over 12months (b=-2.07, p<0.001). Higher adherence was predicted by higher socioeconomic status (SES) (b=0.04, p<0.05), more side effects (b=0.06, p<0.01), fewer caregiver-reported adherence barriers (b=0.18, p<0.05), and lower family conflict (b=-0.19, p<0.05). Change in adherence over 12months did not significantly predict HRQOL or seizures.

CONCLUSIONS

This is the first longitudinal study of objective adherence in adolescents with epilepsy. Given adolescence is a period of vulnerability during development, including declining adherence, caregivers are encouraged to continue collaborating with their adolescents around epilepsy management. Adherence barriers represent an ideal target for intervention and can be implemented in the clinic by frontline providers. Multidisciplinary care can address low SES (social work, financial advocates) and family conflict (psychologists, therapists) in patients with the ultimate goal of optimizing adherence and health outcomes.

Cognitive Disabilities and Long-term Outcomes in Children with Epilepsy: A Tangled Tail

Cognitive problems ranging from mild specific learning problems to profound intellectual disability (ID) are very common in children with epilepsy. For most affected patients there is good evidence that the cognitive problems are present at the onset of seizures and do not deteriorate over time. There is no evidence that a few seizures lead to cognitive deterioration. An exception may occur in children with epileptic encephalopathies, although this contention is not always easy to prove. ID is a strong predictor of intractable epilepsy, and the greater the degree of the ID the greater the risk of medication resistant epilepsy. It is not known if specific learning disorders are associated with more severe epilepsy. Rolandic epilepsy is unusual because possibly one-third of patients have transient cognitive and behavioral difficulties during the active phase but later have normal adult social outcome. More longitudinal studies with baseline and repeated cognitive assessments are needed to fully understand the relationship of cognitive problems to childhood onset epilepsy.

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.

Most Children With Epilepsy Experience Postictal Phenomena, Often Preventing a Return to Normal Activities of Childhood

BACKGROUND

After a seizure, individuals with epilepsy have reported diverse symptoms in the postictal period, especially motor and cognitive dysfunction. However, these phenomena have not been well characterized in children, and their impact on patient well-being is not understood. We hypothesized that in a subset of epilepsy patients, postictal symptoms would affect their ability to return to normal childhood activities.

METHODS

To test our hypothesis, a survey-based approach was used to characterize the type, frequency, and duration, as well as the impact of these symptoms on the ability of these children to return to their normal activities.

RESULTS

In this prospective study, data were analyzed from 208 patients seen in the pediatric neurology outpatient clinic at the Alberta Children's Hospital. We found that 86% (179 out of 208) of respondents reported postictal symptoms, with the most common symptom category being fatigue, sleepiness, and/or tiredness (90%; 161 of 179). The greatest impact resulted from weakness or being unable to move normally, which prevented 78% of those affected (71 of 91) from returning to normal activities after a seizure. Children who had focal seizures were more likely to experience postictal fatigue, sleepiness, or tiredness (P = 0.01; Bonferroni corrected), but no other postictal symptoms were significantly associated with a specific seizure type or epilepsy syndrome.

CONCLUSIONS

The results of this study further our understanding of the frequency, type, and duration of symptoms experienced in the postictal period and how these symptoms impact children with epilepsy. It is clear that postictal phenomena often occur after epileptic seizures and have a significant impact on the lives of children with epilepsy.

Treatment issues for children with epilepsy transitioning to adult care

This is the third of three papers that summarize the second symposium on Transition in Epilepsies held in Paris in June 2016. This paper focuses on treatment issues that arise during the course of childhood epilepsy and make the process of transition to adult care more complicated. Some AEDs used during childhood, such as stiripentol, vigabatrin, and cannabidiol, are unfamiliar to adult epilepsy specialists. In addition, new drugs are being developed for treatment of specific childhood onset epilepsy syndromes and have no indication yet for adults. The ketogenic diet may be effective during childhood but is difficult to continue in adult care. Regional adult epilepsy diet clinics could be helpful. Polytherapy is common for patients transitioning to adult care. Although these complex AED regimes are difficult, they are often possible to simplify. AEDs used in childhood may need to be reconsidered in adulthood. Rescue medications to stop prolonged seizures and clusters of seizures are in wide home use in children and can be continued in adulthood. Adherence/compliance is notoriously difficult for adolescents, but there are simple clinical approaches that should be helpful. Mental health issues including depression and anxiety are not always diagnosed and treated in children and young adults even though effective treatments are available. Attention deficit hyperactivity disorder and aggressive behavior disorders may interfere with transition and successful adulthood but these can be treated. For the majority, the adult social outcome of children with epilepsy is unsatisfactory with few proven interventions. The interface between pediatric and adult care for children with epilepsy is becoming increasingly complicated with a need for more comprehensive transition programs and adult epileptologists who are knowledgeable about special treatments that benefit this group of patients.