Understanding neurodevelopmental trajectories and behavioral profiles in SCN1A-related epilepsy syndromes

BACKGROUND

A pathogenic variant in SCN1A can result in a spectrum of phenotypes, including Dravet syndrome (DS) and genetic epilepsy with febrile seizures plus (GEFS + ) syndrome. Dravet syndrome (DS) is associated with refractory seizures, developmental delay, intellectual disability (ID), motor impairment, and challenging behavior(1,2). GEFS + is a less severe phenotype in which cognition is often normal and seizures are less severe. Challenging behavior largely affects quality of life of patients and their families. This study describes the profile and course of the behavioral phenotype in patients with SCN1A-related epilepsy syndromes, explores correlations between behavioral difficulties and potential risk factors.

METHODS

Data were collected from questionnaires, medical records, and semi-structured interviews. Behavior difficulties were measured using the Adult/Child Behavior Checklist (C/ABCL) and Adult self-report (ASR). Other questionnaires included the Pediatric Quality of Life Inventory (PedsQL), the Functional Mobility Scale (FMS) and the Sleep Behavior Questionnaire by Simonds & Parraga (SQ-SP). To determine differences in behavioral difficulties longitudinally, paired T-tests were used. Pearson correlation and Spearman rank test were used in correlation analyses and multivariable regression analyses were employed to identify potential risk factors.

RESULTS

A cohort of 147 participants, including 107 participants with DS and 40 with genetic epilepsy with febrile seizures plus (GEFS + ), was evaluated. Forty-six DS participants (43.0 %) and three GEFS + participants (7.5 %) showed behavioral problems in the clinical range on the A/CBCL total problems scale. The behavioral profile in DS exists out of withdrawn behavior, aggressive behavior, and attention problems. In DS patients, sleep disturbances (β = 1.15, p < 0.001) and a lower age (β = -0.21, p = 0.001) were significantly associated with behavioral difficulties. Between 2015 and 2022, behavioral difficulties significantly decreased with age (t = -2.24, CI = -6.10 - -0.15, p = 0.04) in DS participants aging from adolescence into adulthood. A decrease in intellectual functioning (β = 3.37, p = 0.02) and using less antiseizure medications in 2022 than in 2015, (β = -1.96, p = 0.04), were identified as possible risk factors for developing (more) behavioral difficulties.

CONCLUSIONS

These findings suggest that, in addition to epilepsy, behavioral difficulties are a core feature of the DS phenotype. Behavioral problems require personalized management and treatment strategies. Further research is needed to identify effective interventions.

Behavioral difficulties and associated factors among the 'lost generation' of Syrian children and adolescents

Childhood and adolescence, vital in shaping adult life and society, are profoundly impacted during conflicts like Syria's devastating war. This study explores the prevalence of behavioral disorders in Syrian children and adolescents, examining the influence of war and family-related factors. This cross-sectional study was conducted on children aged 2-17 years at a children's outpatient clinic in Damascus, Syria. We assessed parents' quality of life, war and family-related factors, and behavioral difficulties through parental interviews using two questionnaires: the Arabic version of the Strengths & Difficulties Questionnaire (SDQ) and the brief Arabic version of the World Health Organization Quality of Life Questionnaire (WHOQOL-BREF). 74.67% of children aged 2-4 years and 61.29% of children aged 5-17 years were experiencing behavioral difficulties, with emotional difficulties being the most prevalent ones. Children exposed to kidnapping, family losses, lack of school enrollment, and those with parents having lower education, lower socioeconomic status, and poorer quality of life exhibited higher Total SDQ scores. The high prevalence of behavioral difficulties among children and adolescents in Syria is a major concern, with both direct and indirect war-related factors contributing to this issue.

The short- and longer-term effects of brief behavioral parent training versus care as usual in children with behavioral difficulties: study protocol for a randomized controlled trial

BACKGROUND

The access to and uptake of evidence-based behavioral parent training for children with behavioral difficulties (i.e., oppositional, defiant, aggressive, hyperactive, impulsive, and inattentive behavior) are currently limited because of a scarcity of certified therapists and long waiting lists. These problems are in part due to the long and sometimes perceived as rigid nature of most evidence-based programs and result in few families starting behavioral parent training and high dropout rates. Brief and individually tailored parenting interventions may reduce these problems and make behavioral parent training more accessible. This protocol paper describes a two-arm, multi-center, randomized controlled trial on the short- and longer-term effectiveness and cost-effectiveness of a brief, individually tailored behavioral parent training program for children with behavioral difficulties.

METHODS

Parents of children aged 2-12 years referred to a child mental healthcare center are randomized to (i) three sessions of behavioral parent training with optional booster sessions or (ii) care as usual. To evaluate effectiveness, our primary outcome is the mean severity of five daily ratings by parents of four selected behavioral difficulties. Secondary outcomes include measures of parent and child behavior, well-being, and parent-child interaction. We explore whether child and parent characteristics moderate intervention effects. To evaluate cost-effectiveness, the use and costs of mental healthcare and utilities are measured. Finally, parents' and therapists' satisfaction with the brief program are explored. Measurements take place at baseline (T0), one week after the brief parent training, or eight weeks after baseline (in case of care as usual) (T1), and six months (T2) and twelve months (T3) after T1.

DISCUSSION

The results of this trial could have meaningful societal implications for children with behavioral difficulties and their parents. If we find the brief behavioral parent training to be more (cost-)effective than care as usual, it could be used in clinical practice to make parent training more accessible.

TRIAL REGISTRATION

The trial is prospectively registered at ClinicalTrials.gov (NCT05591820) on October 24th, 2022 and updated throughout the trial.

A transdiagnostic data-driven study of children's behaviour and the functional connectome

Behavioural difficulties are seen as hallmarks of many neurodevelopmental conditions. Differences in functional brain organisation have been observed in these conditions, but little is known about how they are related to a child's profile of behavioural difficulties. We investigated whether behavioural difficulties are associated with how the brain is functionally organised in an intentionally heterogeneous and transdiagnostic sample of 957 children aged 5-15. We used consensus community detection to derive data-driven profiles of behavioural difficulties and constructed functional connectomes from a subset of 238 children with resting-state functional Magnetic Resonance Imaging (fMRI) data. We identified three distinct profiles of behaviour that were characterised by principal difficulties with hot executive function, cool executive function, and learning. Global organisation of the functional connectome did not differ between the groups, but multivariate patterns of connectivity at the level of Intrinsic Connectivity Networks (ICNs), nodes, and hubs significantly predicted group membership in held-out data. Fronto-parietal connector hubs were under-connected in all groups relative to a comparison sample and children with hot vs cool executive function difficulties were distinguished by connectivity in ICNs associated with cognitive control, emotion processing, and social cognition. This demonstrates both general and specific neurodevelopmental risk factors in the functional connectome.

Post-traumatic stress disorder (PTSD) symptoms in children with severe epilepsy

OBJECTIVES

To assess symptoms of post-traumatic stress disorder (PTSD) in children with severe epilepsy and the associations of trauma symptoms across age, comorbid symptoms, epilepsy-specific factors, parental resources, and psychopathology.

METHODS

Fifty children with severe epilepsy across three different age groups (0-5 yrs., 6-12 yrs., 13-18 yrs.) were assessed with developmental-sensitive and standardized PTSD assessment tools when hospitalized at the tertiary epilepsy center Filadelfia, Denmark. The Diagnostic Infant and Preschool Assessment (DIPA), the Darryl test, and the ITQ questionnaire were used to assess the three age groups, respectively.

RESULTS

Twenty-two percent of the overall sample met the criteria for PTSD, with a prevalence of symptoms increasing with age (6%, 28%, and 40%). Comorbid psychiatric symptoms in preschoolers were present in 81% of the children witnessing a high level of distress in this group. Behavioral difficulties were elevated across all three age groups, and 40% of the children with trauma symptoms had a parent with concurrent psychopathology.

CONCLUSION

To the authors' knowledge, this study is the first to assess trauma symptoms with standardized tests in children with more complicated epilepsies. Trauma symptoms in the group are high; however, there is a need for larger scale studies and research into trauma symptoms in children with more severe epilepsy than those assessable with the included assessment tools. The trauma perspective in severe childhood epilepsy might further clarify the complex associations of biological and contextual variables that affect the children's life quality and enable better preventative treatment options for this group.

Elevated lead levels in relation to low serum neuropeptide Y and adverse behavioral effects in preschool children with e-waste exposure

As a neurotoxicant, lead (Pb) primarily affects central nervous system, and particularly impacts developing brain. This study explores the associations of blood Pb level and children's behavioral health. A total of 213 preschool children aged 3-7 years old were recruited from Guiyu (the e-waste-exposed area) and Haojiang (the reference area). The behavioral health of children was assessed using the 'behavioral symptoms' subscale of the Strengths and Difficulties Questionnaire (SDQ). Results showed that there was a significant difference in percent of children categorized as "at risk" between Guiyu (48.2%) and Haojiang (13.9%) (p < 0.001). The blood Pb level of children in Guiyu was significantly higher than those in Haojiang (median: 5.19 μg/dL vs. 3.42 μg/dL, p < 0.001). The serum Neuropeptide Y (NPY) was significantly lower in Guiyu children than those in Haojiang. Spearman correlation analyses demonstrated that blood Pb levels was negatively correlated with NPY (r_s = -0.25, p < 0.001), but positively correlated with behavioral symptom scores; while serum NPY levels were negatively associated with behavioral symptom scores. Behavioral symptom scores were higher in children with blood Pb level ≥5.00 μg/dL (high) than those with blood Pb level < 5.00 μg/dL (low). After adjusting for confounding factors, children with lower NPY levels were at higher risk of having behavioral difficulties. In conclusion, Pb exposure in e-waste-exposed areas may lead to decrease in serum NPY and increase in the risk of children's behavioral problems. In addition, NPY may mediate the association between Pb exposure and behavioral difficulties.

EIF3F-related neurodevelopmental disorder: refining the phenotypic and expanding the molecular spectrum

BACKGROUND

An identical homozygous missense variant in EIF3F, identified through a large-scale genome-wide sequencing approach, was reported as causative in nine individuals with a neurodevelopmental disorder, characterized by variable intellectual disability, epilepsy, behavioral problems and sensorineural hearing-loss. To refine the phenotypic and molecular spectrum of EIF3F-related neurodevelopmental disorder, we examined independent patients.

RESULTS

21 patients were homozygous and one compound heterozygous for c.694T>G/p.(Phe232Val) in EIF3F. Haplotype analyses in 15 families suggested that c.694T>G/p.(Phe232Val) was a founder variant. All affected individuals had developmental delays including delayed speech development. About half of the affected individuals had behavioral problems, altered muscular tone, hearing loss, and short stature. Moreover, this study suggests that microcephaly, reduced sensitivity to pain, cleft lip/palate, gastrointestinal symptoms and ophthalmological symptoms are part of the phenotypic spectrum. Minor dysmorphic features were observed, although neither the individuals' facial nor general appearance were obviously distinctive. Symptoms in the compound heterozygous individual with an additional truncating variant were at the severe end of the spectrum in regard to motor milestones, speech delay, organic problems and pre- and postnatal growth of body and head, suggesting some genotype-phenotype correlation.

CONCLUSIONS

Our study refines the phenotypic and expands the molecular spectrum of EIF3F-related syndromic neurodevelopmental disorder.

Outdoor air pollution pregnancy exposures are associated with behavioral problems in China's preschoolers

There are mounting evidences indicated that maternal exposure to outdoor air pollutants in pregnancy affects children's neural development, but the researches on children's behavioral difficulties are seldom. We explored the association between maternal exposure to outdoor air pollution during different trimesters of pregnancy and the prevalence of behavioral difficulties among 657 preschool children aged 3-4 from three kindergartens in Wuhan, China. This is a cross-sectional study. Children's behavioral difficulties were assessed by the Strengths and Difficulties Questionnaire (SDQ) (reported by parents). Maternal exposure to outdoor air pollutants during pregnancy were estimated based on the daily average measured concentration levels from ground monitoring stations. Potential confounding factors including children-related, maternal, and socio-economic status (SES) were adjusted in the study. We calculated the prevalence of each type of behavioral difficulties and used binary logistic regression method to estimate the crude odds ratio (cOR), adjusted odds ratio (aOR), and corresponding 95% confidence intervals (95% CIs) for 1 μg/m³ increase in each air pollutant during every exposure window in single- and two-pollutant models. The prevalence of participants' total behavioral difficulties was 9.6%. In single-pollutant models, during full gestation, positive associations were observed between exposure to NO₂ (aOR = 1.204, 95% CI 1.042, 1.392), particle matter (PM)₁₀ (aOR = 1.070, 95% CI 1.018, 1.125), PM_2.5 (aOR = 1.095, 95% CI 1.021, 1.176) and total difficulties, exposure to PM₁₀ (aOR = 1.040, 95% CI 1.001, 1.081), PM_2.5 (aOR = 1.053, 95% CI 1.000, 1.109) and prosocial behavior, respectively. In the first trimester, exposure to SO₂ (aOR = 1.047, 95% CI 1.009, 1.086), NO₂ (aOR = 1.039, 95% CI 1.013, 1.066), PM₁₀ (aOR = 1.013, 95% CI 1.004, 1.023), and PM_2.5 (aOR = 1.016, 95% CI 1.004, 1.028) were all positively associated with total difficulties. The associations between second and third trimesters' exposure to all pollutants and outcomes were not statistically significant. However, in the two-pollutant models, second trimester exposure to PM_2.5 (aOR = 1.078, 95%CI 1.023, 1.137) was positively associated with total behavioral difficulties after adjusting for PM₁₀. Exposure to outdoor air pollutants SO₂, NO₂, PM₁₀, and PM_2.5 during pregnancy may be associated with behavioral difficulties, especially in the first trimester.

Autism spectrum disorder, social communication difficulties, and developmental comorbidities in Sturge-Weber syndrome

Sturge-Weber syndrome (SWS) is a neurocutaneous disorder characterized by the combination of a facial naevus flammeus and pial angioma, often associated with learning difficulties and/or epilepsy. Here, we report on the neuropsychological characteristics of a cohort of 92 children with SWS seen at a national referral center between 2002 and 2015. Almost a quarter (24%) had a diagnosis of autism spectrum disorder (ASD), with 45% overall having evidence of social communication difficulties (SCD). Autism spectrum disorder was more commonly seen in those individuals with bilateral angioma (p = 0.021). Significant behavioral difficulties were reported in 50% while 26% had difficulties with sleep. Difficulties with social communication, behavior, and sleep were closely associated with one another. They were not, however, significantly associated with markers of epilepsy severity and were noted to occur even in children without epilepsy. The prevalence of ASD/SCD, sleep difficulties, and behavioral disorders seen in SWS is high and reflects the complex needs of this group.