ADHD-related symptoms, emotional/behavioral problems, and physical conditions in Taiwanese children with epilepsy

Attention-deficit/hyperactivity disorder in children with epilepsy: A systematic review and meta-analysis of prevalence and risk factors

OBJECTIVE

To evaluate the prevalence of and risk factors for attention-deficit/hyperactivity disorder (ADHD) in children with epilepsy (CWE).

METHODS

We conducted a systematic search in PubMed and Embase for the meta-analysis. The pooled prevalence of ADHD was calculated using a random-effects model; subgroup analyses were performed to explore heterogeneity. We collected raw data from articles reporting potential risk factors, which were included in the subsequent risk factor analysis.

RESULTS

Forty-six articles met the inclusion criteria for the meta-analysis, which showed a pooled ADHD prevalence of 30.7% in CWE, with a predominance of the inattentive subtype of ADHD; the heterogeneity of prevalence was related to population source/study setting (clinic based, community based, or database based) and method of ADHD diagnosis (with or without clinical review). Risk factors for ADHD in epilepsy included younger age, intellectual/developmental disabilities, a family history of epilepsy, earlier epilepsy onset, absence epilepsy, more frequent seizures, and polytherapy; In contrast, risk factors such as sex, generalized epilepsy or seizures, epilepsy etiology, and electroencephalogram abnormalities were not significantly associated with the occurrence of ADHD.

SIGNIFICANCE

The prevalence of ADHD in CWE is high and several potential risk factors are associated with it. This study contributes to a better understanding of ADHD in epilepsy for screening and treatment.

PLAIN LANGUAGE SUMMARY

This systematic review summarizes the prevalence of attention-deficit/hyperactivity disorder (ADHD) occurring in children with epilepsy and analyses the risk factors for comorbid ADHD in epilepsy. By reviewing 46 articles, we concluded that the overall prevalence of ADHD in children with epilepsy was 30.7% and that intellectual/developmental disabilities were the most significant risk factor for combined ADHD in children with epilepsy. This study provides a wealth of information on comorbid ADHD in epilepsy, which will help clinicians identify and treat potential ADHD in children with epilepsy in a timely manner.

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.

Childhood Physical Health and Attention Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis of Modifiable Factors

Although neurobiologic and genetic factors figure prominently in the development of attention deficit/hyperactivity disorder (ADHD), adverse physical health experiences and conditions encountered during childhood may also play a role. Poor health is known to impact the developing brain with potential lifelong implications for behavioral issues. In attempt to better understand the relationship between childhood physical health and the onset and presence of ADHD symptoms, we summarized international peer-reviewed articles documenting relationships between a select group of childhood diseases or health events (e.g., illnesses, injuries, syndromes) and subsequent ADHD outcomes among children ages 0-17 years. Drawing on a larger two-phase systematic review, 57 longitudinal or retrospective observational studies (1978-2021) of childhood allergies, asthma, eczema, head injury, infection, or sleep problems and later ADHD diagnosis or symptomatology were identified and subjected to meta-analysis. Significant associations were documented between childhood head injuries, infections, and sleep problems with both dichotomous and continuous measures of ADHD, and between allergies with dichotomous measures of ADHD. We did not observe significant associations between asthma or eczema with ADHD outcomes. Heterogeneity detected for multiple associations, primarily among continuously measured outcomes, underscores the potential value of future subgroup analyses and individual studies. Collectively, these findings shed light on the importance of physical health in understanding childhood ADHD. Possible etiologic links between physical health factors and ADHD are discussed, as are implications for prevention efforts by providers, systems, and communities.

Onset of Inattention and Hyperactivity in Children and Adolescents With Epilepsy 6 months After the Diagnosis

OBJECTIVE

Complete or major symptoms of ADHD are often present in epilepsy. This study evaluated inattention and hyperactivity symptoms over the first 6 months in newly diagnosed pediatric epilepsy without comorbid ADHD.

METHOD

Children and adolescents with newly diagnosed epilepsy were followed for 6 months after starting antiseizure medications. The Nisonger Child Behavior Rating Form (NCBRF), Adverse Event Profile (AEP), and the Revised Wechsler Intelligence Scale for Children were used.

RESULTS

There was a marked increase in attention difficulties while a moderate increase in hyperactivity levels. AEP scores, changes in non-verbal aspects of intelligence, levels of hyperactivity at the follow-up, and attention at baseline were significant predictors for inattention. In contrast, only levels of hyperactivity at the baseline and inattention at the follow-up were significant predictors for hyperactivity.

CONCLUSION

Significant inattention and hyperactivity levels originated 6 months after the diagnosis of epilepsy and starting antiseizure medication.

Autistic Traits and Cyberbullying Involvement Mediated by Psychopathologies and School Functions in a Nationally Representative Child Sample

Cyberbullying has become an international concern among youth with autistic traits in the digital age. It draws the attention of professionals in mental health and education due to its potentially severe psychosocial and academic impacts. However, there is limited knowledge about the mediators for these associations. This study investigated whether school dysfunction and comorbid psychopathologies mediated the link between autistic traits and cyberbullying. We used a nationally representative sample of 9,483 students (9-14 years of age). The instruments included the Social Responsiveness Scale for autistic traits; the Cyberbullying Experiences Questionnaire for cyberbullying victimization and perpetration; the Swanson, Nolan, and Pelham, version IV for inattention, hyperactivity/impulsivity, and oppositional behaviors; the Child Behavior Checklist for anxiety/depression; and the Social Adjustment Inventory for Children and Adolescents for impaired school functions. Multiple mediation models were used for statistical analyses. The results showed that the 1-year prevalence rates of pure victims, pure perpetrators, and bully-victims of cyberbullying were 7.9 percent, 2.4 percent, and 5.7 percent, respectively. Cyberbullying victimization and perpetration were positively associated with autistic traits, school dysfunction, and comorbid psychopathologies. The associations between autistic traits and cyberbullying victims and bully-victims were significantly mediated by school dysfunction and hyperactivity/impulsivity (only for bully-victims), independent of sex and age. Our results suggest that early identification and intervention of these difficulties may mitigate the risks of cyberbullying. ClinicalTrials.gov ID: NCT02707848.

Comorbidity of epilepsy and attention-deficit/hyperactivity disorder: a systematic review and meta-analysis

Epilepsy and attention-deficit/hyperactivity disorder (ADHD) are common neurological and neuropsychiatric disorders, respectively, that can exist as comorbidities. However, the degree of comorbidity between both disorders has never been quantified based on a systematic review with meta-analysis. We performed a systematic search of the literature in Embase, PubMed, PsychINFO and the Cochrane Library on June 20, 2022. In a meta-analysis of 63 studies with a total sample size of 1,073,188 individuals (172,206 with epilepsy and 900,982 with ADHD) from 17 countries, the pooled prevalence of ADHD in epilepsy was 22.3% (95% CI 20.3-24.4%). The highest pooled prevalence was 12.7% (95% CI 9-17.1%) for ADHD-I subtype, whereas the pooled prevalence of epilepsy in ADHD was 3.4% (95% CI 2.53-4.21%). However, substantial heterogeneity in comorbidity rates was observed and partially attributed to the following factors: sample size, sample specification, geographical variations and diagnostic methods. Our study highlights the need for increased awareness of this diagnostic co-occurrence, and research is warranted to elucidate the underlying pathophysiological mechanisms.

Increased prevalence of inattention-related symptoms in a large cohort of patients with congenital heart disease

The objective of this study is to assess the prevalence and risk factors for attention-deficit hyperactivity disorder (ADHD) in a large cohort of patients with congenital heart disease (CHD). Patients (n = 695) with CHD who were aged 6-15 years and visited the outpatient clinics in our hospital from June 2015 to May 2017 were enrolled. Their medical records were collected, and the Chinese version of the Swanson, Nolan, and Pelham rating scale (SNAP-IVc) and a questionnaire about neuropsychiatric care-seeking behavior were completed by parents and counselors. Of the 695 patients, the overall prevalence of ADHD was 12.4%, including 3.2% for the combined subtype, 6.8% for the inattentive-predominant subtype, and 2.4% for the hyperactivity/impulsive-predominant subtype. Only the inattention-predominant subtype was significantly more prevalent than in the general population. The prevalence of the inattention-predominant subtype was highest in the patients with cyanotic CHD, high severity index, and in those who had received surgery or cardiopulmonary bypass. Multivariate regression analysis indicated that the risk factors for inattention-related symptoms included postoperative seizure and previous cardiopulmonary bypass (odds ratio: 3.22 and 3.82; P = 0.027 and < 0.001, respectively). Only 58.7% of the patients with probable ADHD ever sought neuropsychiatric care, and only 27% regularly attended neuropsychiatric clinics. The inattention-predominant subtype of ADHD was more prevalent in our CHD patients, especially in those with cyanotic CHD, higher disease severity index, and in those who had undergone a surgical intervention. The percentage of patients receiving regular neuropsychiatric clinic follow-up was low.

Gender and psychiatric disorders in children with epilepsy. A meta-analysis

OBJECTIVE

The objective of the study was to assess the influence of gender on psychiatric disorders in children with epilepsy (CWE).

METHOD

A systematic review of the literature on risk factors for psychiatric disorder in CWE published between 2004 and June 2018 was undertaken. Studies including data on gender that permitted the calculation of a risk ratio (RR) were included in the meta-analysis. A meta-regression was conducted to examine the contribution of setting of the survey and the inclusion of learning disabilities.

RESULTS

Thirty-nine papers were included in the review. The male/female RR in CWE for Attention Deficit Hyperactivity Disorder (ADHD) was 1.49 (Confidence Interval (CI): 1.24-1.79), autistic spectrum disorder (ASD) 1.67 (CI: 1.47 to 1.90), anxiety 1.00 (CI: 0.90-1.12), and depression 0.93 (CI 0.41-2.09). More boys than girls had ADHD and ASD, but in relative terms, the RR male/female was lower in CWE than the RR in the general population reported in other studies. Meta-regression indicated that the inclusion of children with intellectual disability (mental retardation) or the setting (community vs hospital) did not have a significant impact.

CONCLUSION

Compared with girls in the general population, girls with epilepsy seem to be at a higher risk of being diagnosed with ADHD/ASD as the gender ratio is more equal. This could be related to differences in the assessment of CWE and/or a shared pathogenesis between psychiatric conditions and epilepsy.

Attention-deficit hyperactivity disorder and suicidality: The mediating effects of psychiatric comorbidities and family function

OBJECTIVE

To explore the association between Attention-Deficit Hyperactivity Disorder ("ADHD") and suicidality in children. Mediating effects of family function and psychiatric co-morbidities were also explored.

METHODS

This is a national representative cross-sectional survey of school-based sample of 4739 children aged 7-15. Logistic regression was used to assess the excess risks of suicidality (i.e., suicidal ideation, suicide plan, and suicide attempts) in 412 children with ADHD. Serial multiple mediator models were conducted to assess the mediating effects of family function and psychiatric comorbidities.

RESULTS

The prevalence of suicidality in children with ADHD was approximately 20% in Taiwan. After adjusting for potential confounders, the risk of suicidality among children with ADHD was approximately four times higher than among non-ADHD children [(adjusted Odds Ratio ["OR"] = 3.82, 95% Confidence Interval ("CI") (2.73, 5.34)] for suicidal ideation, adjusted OR = 4.18, 95% CI (2.57, 6.80) for suicide plan and adjusted OR = 4.45, 95% CI (1.99, 9.93) for suicide attempts. The mediating effects of anxiety/depression and conduct problems were about 20% and 8%, respectively, across all suicide outcomes. The mediating effects of family function were around 6-7% for suicidal ideation and 16-18% for suicide plan and suicide attempts. The effects of ADHD on suicidality, in general, remained after considering the mediating roles of family function and psychiatric comorbid conditions.

CONCLUSIONS

Children with ADHD are at a high risk of suicide. Although the family function and psychiatric co-morbidities partially mediate this association, ADHD in itself is a potent suicide risk factor and should be an important target for suicide prevention.

Factors associated with behavioral problems and cognitive impairment in children with epilepsy of Kinshasa, Democratic Republic of the Congo

BACKGROUND

Behavioral problems and cognitive impairment are common in children with epilepsy (CWE). In sub-Saharan Africa, little is known about these comorbidities particularly their relationships with socioeconomic features. The goal of this study was to identify clinical and socioeconomic factors associated with behavioral problems and cognitive impairment in CWE of Kinshasa (Democratic Republic of the Congo).

METHODS

This cross-sectional hospital-based study had included 104 CWE aged 6 to 17years. Behavioral problems were assessed by the child behavior checklist. The Wechsler nonverbal scale of ability was used to assess cognitive impairment.

RESULTS

At least one behavioral problem was found in 34.6% of CWE. Internalized problems were increasing with father's age (p=0.034). Externalized problems were increasing with the decreased of mother's age (p=0.009) and with a previous antiepileptic treatment (p=0.032). Total behavioral problems were increasing with a previous antiepileptic treatment (p=0.029). Cognitive impairment was present in 73.3% of CWE. It was more common in boys (p=0.013), and it was increasing with a low household daily expenses (p=0.034), with a previous antiepileptic treatment (p=0.041), with an early onset of epileptic seizures (p=0.042), and with a high frequency of epileptic seizures (p=0.011).

CONCLUSION

Behavioral problems and cognitive impairment are common in CWE. Multivariate analysis has shown that behavioral problems were associated with socioeconomic features only. Contrariwise, cognitive impairment was associated with both socioeconomic factors and clinical features. There is a need of more studies to improve knowledge of these comorbidities in the sub-Saharan Africa context.

The Mandarin version of the Kiddie-Schedule for Affective Disorders and Schizophrenia-Epidemiological version for DSM-5 - A psychometric study

BACKGROUND/PURPOSE

Changes of diagnostic coverage and criteria for psychiatric disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published in 2013 cause a need for updating the Kiddie-Schedule for Affective Disorders and Schizophrenia-Epidemiological version (K-SADS-E). This study examined the preliminary psychometric properties, including inter-rater reliability, and convergent and divergent validity of the modified K-SADS-E for DSM-5.

METHODS

A national survey of a school-based sample of 3242 students in grade 3, 5, and 7 from 44 schools was conducted in Northern, Central, and Southern Taiwan. Psychiatric diagnoses were made by the K-SADS-E interviews. Clinical questionnaires for attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and emotional and behavioral problems were examined using the Chinese version of the Swanson, Nolan, and Pelham IV scale, Social Responsiveness Scale, and Child Behavior Checklist.

RESULTS

The K-SADS-E showed satisfactory inter-rater reliability (prevalence adjusted bias adjusted kappa = 0.80-1.00) among eight interviewers. The diagnoses of K-SADS-E demonstrated good convergent and divergent validity with most corresponding clinical questionnaires.

CONCLUSION

Our finding suggests that the K-SADS-E is a reliable and valid instrument for diagnosing child and adolescent psychiatric disorders based on DSM-5. Further study will examine the sensitivity, specificity, and test-retest reliability of the K-SADS-E in clinical and community samples.

Parent-child discrepancies in the report of adolescent emotional and behavioral problems in Taiwan

The majority of studies on parent-child discrepancies in the assessment of adolescent emotional and behavioral problems have been conducted in Western countries. It is believed that parent-adolescent agreement would be higher in societies with a strong culture of familism. We examined whether parent-adolescent discrepancies in the rating of adolescent emotional and behavioral problems are related to parental and family factors in Taiwan. Participants included 1,421 child-parent pairs of 7^th-grade students from 12 middle schools in Northern Taiwan and their parents. We calculated Pearson’s correlation coefficients to assess the relationship between parental (Child Behavior Checklist, CBCL) and adolescent (Youth Self Report, YSR) report of emotional/behavioral problem syndromes. Regression models were used to assess parent-adolescent differences in relation to parental psychopathology and family factors. We found that parent-adolescent agreement was moderate (r = 0.37). Adolescents reported higher symptom scores than their parents (Mean Total Problem Score: CBCL: 20.79, YSR: 33.14). Parental psychopathology was related to higher parental ratings and better informant agreement. Parents with higher socioeconomic status (SES) tended to report lower scores for adolescent problem syndromes, resulting in higher levels of disagreement. Greater maternal care was related to higher parent-adolescent agreement. Based on our study findings, we conclude that familism values do not seem to improve parent-child agreement in the assessment of adolescent problem syndromes. The finding that higher SES was related to increased discrepancies speaks to the need to explore the culture-specific mechanisms giving rise to informant discrepancies.

Comorbidity of childhood epilepsy

Epilepsy in children is occasionally associated with variable comorbidities although the frequency of such comorbidity is often difficult to determine. They can be divided into three categories: neurological, psychological, and physical comorbidities. The goal of the present review is to discuss the reported comorbidities of epilepsy in children. The possible mechanisms and associated risk factors-including the effect of seizure frequency and seizure control, types of epilepsy, age of seizure onset, duration of illness, and the possible detrimental effect of antiepileptic drugs-will be described.