Behavioral disorders in pediatric epilepsy: unmet psychiatric need

PURPOSE

This study examined the relation between psychiatric diagnosis and mental health services in children with epilepsy and the associated demographic, cognitive, linguistic, behavioral, and seizure-related variables.

METHODS

The Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS), the Child Behavior Checklist, the Test of Language Development, and the Wechsler Intelligence Scale for Children-Revised (WISC-R) were administered to 114 children, aged 5 to 16 years, with either complex partial seizures (CPS) or primary generalized with absence (PGE, petit mal). A Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) diagnosis and information regarding mental health services were derived from the K-SADS.

RESULTS

Although approximately 60% of the subjects had a DSM-IV psychiatric diagnosis, >60% received no mental health treatment. Absence of mental health care was associated with younger age, less parental education, limited number of antiepileptic drugs (AEDs; i.e., one or none), and higher verbal IQ. In addition, children with PGE and a single psychiatric diagnosis were less likely to have a history of mental health treatment.

CONCLUSIONS

This is the first study to demonstrate unmet mental health need in a large sample of children with CPS and PGE. The study's findings suggest that parents and clinicians should be aware of the mental health needs of children with epilepsy, particularly if they have one or more of the identified risk factors.

Hyperventilation-induced high-amplitude rhythmic slowing with altered awareness: a video-EEG comparison with absence seizures

PURPOSE

Hyperventilation-induced high-amplitude rhythmic slowing (HIHARS) in children may be associated with clinical episodes of altered awareness. The presence of automatisms has been proposed as a distinguishing feature that helps to differentiate absence seizures from nonepileptic causes of decreased responsiveness. This retrospective, controlled, video-EEG study compared the clinical characteristics of episodes of HIHARS with loss of awareness with those of absence seizures.

METHODS

The database of a tertiary Children's Hospital was searched for patients studied between April 1993 and April 1997 who had at least one episode of HIHARS with loss of awareness. The absence control group was obtained by selecting the next patient, after an HIHARS study subject, who met the following criteria: (a) had at least one absence seizure occurred during hyperventilation in the EEG recording, and (b) had a diagnosis of idiopathic generalized epilepsy. The video-EEG and medical histories of all patients were reviewed and summarized.

RESULTS

We reviewed video-EEG recordings of 77 episodes of HIHARS with loss of awareness from 22 children and 107 absence seizures during hyperventilation from 22 children. Eye opening and eyelid flutter were seen more frequently in absence seizures, whereas fidgeting, smiling, and yawning occurred more frequently during HIHARS episodes. Arrest of activity, staring, and oral and manual automatisms were observed in both groups.

CONCLUSIONS

Automatisms are common in both HIHARS and absence seizures. Yawning, smiling, and particularly fidgeting occur more commonly and eye opening and eyelid flutter less commonly in HIHARS. However, episodes of HIHARS with loss of awareness clinically mimic absence seizures, and these conditions can be distinguished reliably only by EEG.

Familial association of neuropsychological traits in patients with generalized and partial seizure disorders

To investigate familial effects of neuropsychological deficits associated with seizure disorders, we studied 65 families, in which 1 member had epilepsy. The disorders included childhood absence epilepsy (CAE), juvenile myoclonic epilepsy (JME) and temporal lobe epilepsy (TLE). Age-appropriate tests were administered to assess sustained attention, encoding and verbal memory, executive and focused attention and attentional flexibility/impulsivity. CAE probands attained lower scores than other probands in visual sustained attention and the ability to focus on and execute a visual-motor task. Scores of the unaffected relatives tended to fall between those of the probands and the controls. JME relatives had lower scores than other relatives in tests of visual and auditory sustained attention and attentional flexibility, and showed greater variability in response time. Behavioral information of this type may aid in the specification and differentiation of genetic linkages in affected families.

Cognitive function in adolescents and young adults in complete remission from benign childhood epilepsy with centro-temporal spikes

Benign childhood epilepsy with centrotemporal spikes (BECTS) is a frequent, benign childhood epilepsy with a good prognosis. However, neuropsychological deficits have been reported during its active phase. In this study, we evaluate the long-term neuropsychological consequences of this reputedly benign epilepsy, particularly the relation between paroxysmal abnormalities and cerebral language lateralization. The neuropsychological outcomes concerning both overall cognitive and lateral hemispheric functions were studied in twenty-three adolescents and young adults in total recovery from BECTS, in thirty-three controls without any significant past neurological history and in ten adolescents and young adults with complete resolution of generalized idiopathic epilepsy (childhood absence epilepsy or CAE). Language lateralization was evaluated using classical neuropsychological procedures (dichotic listening tasks, dual-task procedure). No difference was seen in the three populations with respect to overall cognitive function: memory, language and the executive functions. Although the Performance IQ was lower in patients in remission from CAE, the results were within normal limits. However, qualitative analysis of the dual-task procedure suggested a different organizational pattern for cerebral language in adolescents and young adults in remission from BECTS as compared to controls and patients in remission from CAE. The different organization in cerebral pattern in BECTS patients appeared to be related to the initial epileptic focus as determined by the EEG and/or the sleep-recording. We discuss the relationship between the presence of paroxysmal anomalies in childhood and subtle functional lateralized hemispheric abnormalities in adulthood.

The ovarian hormones and absence epilepsy: a long-term EEG study and pharmacological effects in a genetic absence epilepsy model

In the first experiment, the relationship between the phase of the estrous cycle and the number of spontaneously occurring spike-wave discharges was investigated in WAG/Rij rats, a model for generalized absence epilepsy. The electroencephalogram (EEG) was continuously recorded for 96 h in eight rats chronically equipped with cortical EEG electrodes. A circadian pattern emerged for the number of spike-wave discharges: a nadir during the first hours of the light period, and an acrophase during the first hours of the dark period. This daily maximum was increased at proestrus day compared with the other days of the cycle, when the plasma level of progesterone is enhanced specifically at these hours of this day. This suggests that progesterone enhances spike-wave discharges. There was no difference in the first few hours of the light period in the number of spike-wave discharges between proestrus and the three other days, suggesting that estradiol has no effect on spike-wave discharges. In the second study, the effects of the systemic administration of progesterone and 17 beta-estradiol on spike-wave discharges and spontaneous behavior were investigated. It was shown that progesterone (20 and 30 mg/kg) but not estradiol (0.17-1.5 mg/kg) increased the number and total duration of spike-wave discharges. On the other hand, injection of RU 38486 (10 and 30 mg/kg), an antagonist of intracellular progesterone receptors, had no effect on spike-wave discharges and did not block the stimulatory effect of progesterone. The antagonist of 17 beta-estradiol tamoxifen (1 and 3 mg/kg) did not evoke alterations in the number or duration of spike-wave discharges. Our results indicate that progesterone aggravates spike-wave discharges, but is not mediated through intracellular receptors. Since progesterone is rapidly metabolized in the brain to the positive modulator of GABA(A) receptor allopregnanolone, which increases spike-wave discharges in WAG/Rij rats, it is possible that the epileptiformic effects of progesterone are mediated through this metabolite.

Measures of psychopathology in children with complex partial seizures and primary generalized epilepsy with absence

OBJECTIVE

This investigation examined psychopathology in 48 children with complex partial seizures (CPS), 39 children with primary generalized epilepsy with absence (PGE), and 59 nonepileptic children, aged 5 to 16 years, by comparing the Child Behavior Checklist (CBCL) and the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS).

METHOD

The CBCL was completed by parents and the K-SADS was administered to both parent and child.

RESULTS

The CBCL identified psychopathology in 26% and the K-SADS in 51% of the CPS and PGE patients (kappa = 0.32). The CPS and PGE groups had significantly higher mean CBCL scores, as well as higher rates of psychiatric diagnoses and symptoms of psychopathology, compared with the nonepileptic group. However, the CPS and PGE groups did not differ in these measures. Within each patient group, Full Scale IQ, but not seizure control, was associated with these measures of psychopathology.

CONCLUSION

These findings suggest that the K-SADS identifies more children with psychopathology than the CBCL in children with CPS and PGE.

[Effect of dopamine enriched ganglion xenografts from the immature CNS of Helix aspersa L. snail on the learning time during acquisition of an operant food-procuring reflex in WAG/RIJ rats]

Xenografts from the ganglia of a newborn terrestrial snail Helix aspersa L. were implanted into the right parietal area of the brain cortex of WAG/Rij rats with absence epilepsy. Rats with implanted xenografts were trained for reaching a food ball from a tube (reaching test). It was shown that the mean duration of each leaning stage and total time necessary for acquisition of the instrumental conditioning (till the learning criterion) were shorter in animals with xenografts than in control groups of animals.

Neuropsychological assessment in children with absence epilepsy

OBJECTIVE

To define cognitive deficits in children with absence epilepsy.

BACKGROUND

Cognitive deficits have often been reported in children with epilepsy, but have rarely been characterized in patients with a specific epileptic syndrome.

METHODS

Detailed neuropsychological testing was carried out on 16 right-handed children with absence epilepsy with similar clinical and EEG findings, and the findings were compared to 16 well-matched right-handed children without absence epilepsy.

RESULTS

The authors found lower scores of measures of general cognitive functioning and visuospatial skills in patients with absence epilepsy, as compared to controls. Memory disturbances were also detected in absence epilepsy patients, with selective involvement of nonverbal memory and delayed recall. In contrast, verbal memory and language skills were relatively preserved. Patients whose seizures began at an earlier age seemed to have more severe cognitive deficits.

CONCLUSION

Language skills tend to be relatively well preserved in children with generalized epilepsy, with more dysfunction seen in global terms rather than specific lateralizing deficits. Patients with absence epilepsy seem to show a similar neurocognitive profile that may be a reflection of the underlying epilepsy syndrome.

Acute cognitive effects of nonconvulsive difficult-to-detect epileptic seizures and epileptiform electroencephalographic discharges

This study compares the acute cognitive effects of short nonconvulsive seizures with the effects of interictal epileptiform electroencephalographic (EEG) discharges in children. The study is a prospective, standardized, nonrandomized, and open clinical comparative study. Eligible patients were included when they had (a) unclear seizures and fluctuations in cognitive performance and (b) frequent epileptiform EEG discharges in a recent EEG. All children were assessed with EEG/video (Brainlab) simultaneously with computerized neuropsychologic testing (FePsy) assessing motor speed/alertness, mental speed/attention, and memory function. Eleven patients with short nonconvulsive seizures during cognitive testing were included and compared with 11 matched patients with interictal epileptiform EEG discharges during cognitive testing but without seizures. Patients included in both groups had a reconfirmed diagnosis of epilepsy. Cognitive performance for both groups was compared. Statistical analysis showed significant correlations between the number of seizures (during cognitive testing) and impaired alertness and between the duration of the ictal period and memory impairment. Interictal epileptiform EEG discharges do not have an additional independent effect on cognitive function. The results demonstrate the accumulating cognitive effect of seizures and illustrate that frequent seizures, even when these are short in duration and with subtle symptomatology, can have a substantial impact on daily life and can lead to state-dependent learning impairment. Alertness and short-term memory appeared to be the functions that are most vulnerable for the acute effects of seizures.

No, some types of nonconvulsive status epilepticus cause little permanent neurologic sequelae (or: "the cure may be worse than the disease")

Nonconvulsive status epilepticus (NCSE) is characterized by a cognitive or behavioral change which lasts for at least 30 minutes, with EEG evidence of seizures. Although there is little argument that generalized nonconvulsive status epilepticus (GNSE) does not cause lasting deficits, there is still debate regarding the morbidity of complex partial status epilepticus (CPSE). Because the EEG is used for diagnosis, a strong argument can be made that NCSE is significantly under-recognized and diagnosed. Furthermore, since the documented cases of permanent neurologic sequelae are few, the potential permanent morbidity from CPSE may be significantly exaggerated. The literature indicates that comatose patients have a poor prognosis largely as a result of comorbid conditions and coma, whereas lightly obtunded or slightly confused patients with NCSE have little or no sequelae. Patients with NCSE may suffer (hypotension and respiratory suppression) from iatrogenic 'aggressive' treatment with intravenous anti-epileptic drugs (IV-AEDs), and the findings in the literature indicate that subjects treated with benzodiazepines may have a worse prognosis. The clinician must balance the potential but rare neurologic morbidity associated with NCSE against the not infrequent morbidity caused by IV-AEDs. Better stratification of the level of consciousness and comorbid conditions is needed when evaluating outcomes so as to clearly distinguish among the deficits due to: comorbid conditions; the effects of treatment and the effects of status epilepticus (SE) proper.

Psychopathology in pediatric complex partial and primary generalized epilepsy

Structured psychiatric interviews were administered to 60 children with complex partial seizure disorder (CPS), 40 children with primary generalized epilepsy with absences (PGE), and 48 control children, aged 5 to 16 years. Significantly more patients with epilepsy had psychiatric diagnoses compared with the control children. There were no statistically significant differences, however, in the number of patients with CPS and PGE with psychiatric diagnoses. Other than a schizophrenia-like psychosis found only in the patients with CPS, the two groups of patients had similar psychiatric diagnoses. The presence of psychopathology was related to significantly lower IQ scores and socioeconomic status, but not to seizure-related factors. These findings suggest that the psychopathology of children with CPS and PGE reflects different subtle neuropsychological deficits.

Long-term psychosocial outcome in typical absence epilepsy. Sometimes a wolf in sheeps' clothing

OBJECTIVES

To determine whether young adults in whom typical absence epilepsy has been diagnosed in childhood have greater psychosocial difficulties than those with a non-neurologic chronic disease and to decide which seizure-related factors predict poor psychosocial outcome.

DESIGN

Population-based, inception cohort study.

SETTING

The only tertiary care pediatric hospital in the province of Nova Scotia.

PATIENTS

All children in whom typical absence epilepsy or juvenile rheumatoid arthritis (JRA) was diagnosed between January 1, 1997, and December 31, 1985, who were aged 18 years or older at follow-up in March 1994 to April 1995. Patients with typical absence epilepsy were identified from centralized electroencephalographic records for Nova Scotia, and those with JRA were identified from discharge diagnoses from the only children's hospital in Nova Scotia.

MAIN OUTCOME MEASURE

Patients participated in a structured interview that assessed psychosocial function.

RESULTS

Fifty-six (86%) of the 65 patients with absence epilepsy and 61 (80%) of the 76 patients with JRA participated in the interview. The mean age of the patients at the interview was 23 years. Terminal remission occurred in 32 (57%) of the patients with typical absence epilepsy but in only 17 (28%) of the patients with JRA. Factor analysis identified 5 categories of outcome: academic-personal, behavioral, employment-financial, family relations, and social-personal relations. Patients with typical absence epilepsy had greater difficulties in the academic-personal and in the behavioral categories (P < .001) than those with JRA. Those with ongoing seizures had the least favorable outcome. Most seizure-related factors showed minimal correlation with psychosocial functioning.

CONCLUSION

Young adults with a history of typical absence epilepsy, particularly those without remission of their seizures, often have poor psychosocial outcomes, considerably worse than those with JRA.

Behavioral descriptors that differentiate between seizure and nonseizure events in a pediatric population

The diagnosis and treatment of epilepsy relies heavily on descriptions of behavioral changes noted during seizure episodes. A pilot study was completed to determine the frequency of occurrence of behaviors commonly associated with seizures in a pediatric population (n = 153). Caretakers of the children (ages = 4 months to 19 years) were asked to respond to a checklist containing 40 behavioral descriptors. Thirteen descriptors were found to differentiate between seizure and nonseizure events. Twelve of these behaviors were endorsed significantly more frequently by caretakers of children with seizures including the following: does not remember what happened, moves mouth funny, drools, jerking/twitching, becomes stiff, changes in breathing, stares off, bites or chews tongue, eyes look glassy, will not respond, mumbles or slurs words, and eyes or head turn to one side. One behavior, fidgets in seat, was significantly more associated with nonseizure episodes. The behavioral descriptors may be presented in a checklist format or incorporated within a clinical interview in primary care settings for initial screening of children with possible seizure disorders.

Psychogenic seizures: video telemetry observations in 27 patients

Psychogenic seizures are unusual during the first decade of life. To compare the clinical features of psychogenic seizures in young children with those of teenagers, the long-term electroencephalographic and video monitoring studies of all patients younger than 18 years of age with recorded episodes diagnosed as psychogenic seizures were reviewed from a single hospital during the past 7 years. The 27 patients were divided into 2 age groups: group A, 6-9 years (n = 5), and group B, 10-17 years (n = 22). All patients had habitual episodes recorded during monitoring. Although the adolescents displayed clinical patterns similar to adult patients with psychogenic seizures, the children demonstrated a clinical pattern characterized mainly by prolonged staring and unresponsiveness. The most common behaviors in the adolescent group were tremor (45%), intermittent stiffening (41%), and out-of-phase movements of the extremities (36%). Fifteen percent of the patients had a history of seizures. This study suggests that young children with psychogenic seizures have clinical profiles different from that of teenagers.

Interictal aggression in epilepsy: the Buss-Durkee Hostility Inventory

Adult patients with left, right, or bilateral temporal lobe epilepsy or absence epilepsy, and normal controls completed the Buss-Durkee Hostility Inventory (BDHI), a standardized questionnaire of aggressive tendencies. Patients with left temporal lobe seizure foci scores higher on the Suspicion scale than did other patients or controls (p < 0.05). Factor analysis scale scores identified three factors: hostile feelings, covert aggression, and overt aggression. The groups differed on their pattern of factor scores (p < 0.01): patients with left temporal lobe epilepsy scored higher than other groups on hostile feelings, normal controls scored higher on Covert aggression, and bitemporal patients scores higher on Overt aggression. Patients with absence seizures did not differ from controls. Lateralization of the seizure focus in patients with temporal lobe epilepsy may alter expression of aggressive behavior.

Epilepsy with myoclonic absences

The cases are described of eight children, five of them girls, who had epilepsy with myoclonic absences. The mean age of onset was 4.9 years. Brief episodes of loss of awareness with bilateral clonic jerking of the upper limbs were associated with rhythmic 3 cycles/second spike-wave discharges on electroencephalogram. Generalised tonic-clonic or astatic seizures, or both, also occurred in seven patients. All now have learning difficulties, and seven have behavioural problems. Conventional treatment for absences was effective in only two children. Of six patients treated with lamotrigine, five have improved substantially, but only one is in sustained complete remission. One recently diagnosed patient continues to have frequent myoclonic absences. As the response to treatment and long term outcome are much poorer, it is important to differentiate myoclonic absences from typical childhood absence epilepsy.

Verbal and visual memory impairment in children with epilepsy

Verbal and visual memory performances were evaluated in 60 epileptic children and 60 normal control subjects with Signoret's Memory Battery scale. Eighteen patients had idiopathic generalized epilepsy and 42 had partial epilepsy, mostly of the temporal (n = 28) and frontal (n = 10) lobes. Memory scores were statistically lower in epileptics than in controls and significant differences were found within each group: (1) children with idiopathic generalized epilepsy had a slight depression of visual memory; (2) memory disorder was more severe in partial epilepsy; and (3) children with left and right temporal lobe epilepsy had marked memory deficits related to hemispheric specialization.

Social adjustment in young adults with absence epilepsies

A long-term follow-up of 58 young adults, aged 18-27 years, with persisting absence epilepsies since childhood or early adolescence, was performed to assess psychosocial outcome and the patients' own concept of their epilepsy. They were well adjusted in the areas of family status and employment, but had more unqualified jobs as compared with a reference group. They were also inclined to lead very regular lives in a way that led to social isolation. At least one of the following factors was considered by 74% of the group to have been affected by their epilepsy: schooling, occupation, routines of daily life, relations with friends, leisure time activities, and housing, this was independent of whether or not they had achieved seizure control. In treating absence epilepsies, it is important that one considers psychosocial aspects, even if a medically satisfying result with seizure control is obtained.

'Phantom' typical absences, absence status and experiential phenomena

We present a case of mild typical absences (phantom absences) culminating in absence status and generalized tonic-clonic seizures. The patient has recorded his experience during an episode of absence status and provides a rare insight into a mind temporarily clouded by whirling thoughts and muffled responses. This case is important as it demonstrates the pitfalls which may hinder the diagnosis of this unusual condition.

Evaluation of pseudoseizures. A psychiatric perspective

Two subgroups of patients with psychogenic pseudoseizures were identified among 20 neurology patients referred for consultation to rule out pseudoseizures. Patients with pseudo complex partial seizures were found to have primarily dissociative symptoms with guilt-laden bereavement as an important precursor. Patients with pseudo grand mal type seizures appeared to have developed their illness in the context of longstanding personality traits. Diagnostic and prognostic implications of these findings are discussed.

Effects of loreclezole on epileptic activity and on EEG and behaviour in rats with absence seizures

The antiepileptic profile of loreclezole, a new putative antiepileptic compound, has been determined in rats of the WAG/Rij strain, a genetic model of generalized absence epilepsy. In addition, the effects of 0, 5, 10 and 20 mg/kg loreclezole on the spectral content of the background EEG and on spontaneous behaviour of rats were investigated. Both the number of spike-wave discharges and their total duration dose-dependently decreased following administration of loreclezole. Furthermore, the behaviour of the animals was not markedly influenced and significant changes in the background EEG were not noticed after administration. These data suggest that the broad-spectrum antiepileptic loreclezole can be a valuable new drug in the treatment of absence epilepsy.