Epilepsy in children with attention-deficit/hyperactivity disorder

Attention deficit hyperactivity disorder in children with epilepsy: a multicenter cross-sectional analysis in China

BACKGROUND

The diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) comorbid with epilepsy have been insufficiently addressed in China. We conducted a study in China to investigate the current status, diagnosis, and treatment of ADHD in children to further our understanding of ADHD comorbid with epilepsy, strengthen its management, and improve patients' quality of life.

METHODS

We carried out a multicenter cross-sectional survey of children with epilepsy across China between March 2022 and August 2022. We screened all patients for ADHD and compared various demographic and clinical factors between children with and without ADHD, including gender, age, age at epilepsy onset, duration of epilepsy, seizure types, seizure frequency, presence of epileptiform discharges, and treatment status. Our objective was to explore any possible associations between these characteristics and the prevalence of ADHD.

RESULTS

Overall, 395 epilepsy patients aged 6-18 years were enrolled. The age at seizure onset and duration of epilepsy ranged from 0.1-18 to 0.5-15 years, respectively. Focal onset seizures were observed in 212 (53.6%) patients, while 293 (76.3%) patients had epileptiform interictal electroencephalogram (EEG) abnormalities. Among the 370 patients treated with anti-seizure medications, 200 (54.1%) had monotherapy. Although 189 (47.8%) patients had ADHD, only 31 received treatment for it, with the inattentive subtype being the most common. ADHD was more common in children undergoing polytherapy compared to those on monotherapy. Additionally, poor seizure control and the presence of epileptiform interictal EEG abnormalities may be associated with a higher prevalence of ADHD.

CONCLUSIONS

While the prevalence of ADHD was higher in children with epilepsy than in normal children, the treatment rate was notably low. This highlights the need to give more importance to the diagnosis and treatment of ADHD in children with epilepsy.

The diagnosis of ADHD in children and adolescents with epilepsy: a scoping review

Attention-deficit hyperactivity disorder (ADHD) is often diagnosed in children and adolescents with epilepsy, but clear clinical guidelines on how to make this diagnosis are still lacking. Without these guidelines, there is no consensus between specialists on how to proceed when assessing children with epilepsy for ADHD, which can negatively impact the quality of care being offered to this population. As a first step toward gaining more specific clinical guidelines, this scoping review was aimed at documenting the tools and procedures used to diagnose ADHD in children and adolescents with epilepsy over time and at determining whether the diagnoses were made in accordance with clinical guidelines and recommendations. The literature search was conducted using PsycINFO, PubMed, and CINAHL. Studies were included if conducted with children and adolescents aged between 4 and 18 years with epilepsy being evaluated for ADHD. Studies were clustered according to their publication date and the reported diagnostic procedures were identified. Forty-nine out of 3854 records were included. Results highlight discrepancies between how ADHD was diagnosed in reviewed studies and clinical guidelines or recommendations. Indeed, most studies did not use a multi-method and multi-informant approach when diagnosing ADHD in children with epilepsy, with no improvement over time. Future studies aimed at diagnosing ADHD in children and adolescents should ensure that they are following clinical guidelines and recommendations, in addition to adapting their diagnostic procedures to the presence of any neurological comorbidities, such as epilepsy.

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.

Factor associated with the occurrence of epilepsy in autism: a systematic review

This systematic review aimed to identify factors significantly associated with the occurrence of epilepsy in autistic individuals and to consider the impact of study quality on findings. Electronic databases were systematically searched on October 2nd, 2020 and records retrieved were limited to those published from 2000 onwards. Study quality was categorised as 'good', 'moderate' or 'weak'. Fifty-three studies were included and in studies where the prevalence of epilepsy was reported (n = 257,892), 18,254 (7%) had co-occurring epilepsy. Intellectual disability/cognitive impairment was the most commonly reported risk factor associated with occurrence of epilepsy in autistic individuals. The evidence supporting other, potentially relevant factors was weak and inconsistent and requires further evaluation. Only 9/53 studies were considered 'good' quality.

Epilepsy and Attention Deficit Hyperactivity Disorder: Connection, Chance, and Challenges

Comorbidities are common in children with epilepsy, with nearly half of the patients having at least one comorbidity. Attention deficit hyperactivity disorder (ADHD) is a psychiatric disorder characterized by hyperactivity and inattentiveness level disproportional to the child’s developmental stage. The burden of ADHD in children with epilepsy is high and can adversely affect the patients’ clinical outcomes, psychosocial aspects, and quality of life. Several hypotheses were proposed to explain the high burden of ADHD in childhood epilepsy; the well-established bidirectional connection and shared genetic/non-genetic factors between epilepsy and comorbid ADHD largely rule out the possibility of a chance in this association. Stimulants are effective in children with comorbid ADHD, and the current body of evidence supports their safety within the approved dose. Nonetheless, safety data should be further studied in randomized, double-blinded, placebo-controlled trials. Comorbid ADHD is still under-recognized in clinical practice. Early identification and management of comorbid ADHD are crucial to optimize the prognosis and reduce the risk of adverse long-term neurodevelopmental outcomes. The identification of the shared genetic background of epilepsy and ADHD can open the gate for tailoring treatment options for these patients through precision medicine.

Interventions for ADHD in children & adolescents with epilepsy: A review and decision tree to guide clinicians

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common pediatric epilepsy comorbidities. Treating ADHD in the context of epilepsy can be overwhelming for parents and clinicians. Current frontline treatment for ADHD is stimulant medication. However, some parents of pediatric patients with epilepsy have concerns about adding additional medication to their child's epilepsy regimen and/or about adverse effects of stimulant medication. Non-medication ADHD treatments including psychosocial interventions and ketogenic diet have also shown success in improving ADHD symptoms. Our focused review provides an easy-to-use guide for clinicians on ADHD interventions and combinations of interventions for pediatric patients with epilepsy and ADHD. Our guide includes information from 8 electronic databases for peer-reviewed, English language studies of psychosocial treatments for youth with epilepsy and ADHD. One hundred eight studies were selected based on inclusion criteria (21 systematic reviews, 12 meta-analyses, 8 literature reviews, 6 population surveys, 31 clinical trials, 20 cross-sectional studies, and 10 retrospective reviews). Results indicated that stimulant medication is a frontline treatment for ADHD symptoms in youth with epilepsy, with important caveats and alternatives.

Non-mental diseases associated with ADHD across the lifespan: Fidgety Philipp and Pippi Longstocking at risk of multimorbidity?

Several non-mental diseases seem to be associated with an increased risk of ADHD and ADHD seems to be associated with increased risk for non-mental diseases. The underlying trajectories leading to such brain-body co-occurrences are often unclear - are there direct causal relationships from one disorder to the other, or does the sharing of genetic and/or environmental risk factors lead to their occurring together more frequently or both? Our goal with this narrative review was to provide a conceptual synthesis of the associations between ADHD and non-mental disease across the lifespan. We discuss potential shared pathologic mechanisms, genetic background and treatments in co-occurring diseases. For those co-occurrences for which published studies with sufficient sample sizes exist, meta-analyses have been published by others and we discuss those in detail. We conclude that non-mental diseases are common in ADHD and vice versa and add to the disease burden of the patient across the lifespan. Insufficient attention to such co-occurring conditions may result in missed diagnoses and suboptimal treatment in the affected individuals.

Society for Developmental and Behavioral Pediatrics Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is the most common childhood neurodevelopmental disorder and is associated with an array of coexisting conditions that complicate diagnostic assessment and treatment. ADHD and its coexisting conditions may impact function across multiple settings (home, school, peers, community), placing the affected child or adolescent at risk for adverse health and psychosocial outcomes in adulthood. Current practice guidelines focus on the treatment of ADHD in the primary care setting. The Society for Developmental and Behavioral Pediatrics has developed this practice guideline to facilitate integrated, interprofessional assessment and treatment of children and adolescents with "complex ADHD" defined by age (<4 years or presentation at age >12 years), presence of coexisting conditions, moderate to severe functional impairment, diagnostic uncertainty, or inadequate response to treatment.

ADHD and epilepsy-related QoL in youth with epilepsy

OBJECTIVE

Pediatric epilepsy and attention-deficit/hyperactivity disorder (ADHD) present a cumulative vulnerability to youth, particularly in the domains of executive function (EF) and quality of life (QoL). The aim of this study was to explore the relationships between EF and epilepsy-specific QoL in youth with epilepsy (YWE) who also have ADHD.

METHODS

Youth with epilepsy aged 5-18 years and caregivers participated in a large multi-site national validation of the PedsQL™ Epilepsy Modules. YWE and their caregivers were asked to complete measures of epilepsy-specific QoL, ADHD symptoms, and EF. Previous ADHD diagnosis was reported by caregivers as well as abstracted from the medical record.

RESULTS

Caregiver and YWE reports of current ADHD symptoms significantly predicted all epilepsy-specific QoL domains. Suboptimal QoL was reported for those YWE whose ADHD symptoms were above the clinical threshold compared to YWE whose ADHD symptoms were within the average range. Results were similar for YWE with a documented ADHD vs no ADHD diagnosis. In addition, poorer metacognition and behavioral regulation EF was associated with lower epilepsy-specific QoL for both YWE with ADHD and without ADHD diagnosis. However, in YWE with ADHD, effect sizes were consistently larger for behavioral regulation compared to metacognition across epilepsy-specific QoL domains, with behavioral regulation accounting for 50% of the variance in each of the EF and mood QoL domains.

SIGNIFICANCE

Addressing ADHD symptoms, epilepsy-specific, QoL, and EF as part of routine epilepsy care may promote optimal outcomes for YWE with ADHD as well as relieve burden on the healthcare system.

Clinical and neuropsychological characteristics of children with epilepsy and attention-deficit/hyperactivity disorder

OBJECTIVES

This study aimed to explore the clinical and neuropsychological characteristics-cognition, behavior, parenting-related stress, and sleep-of children with epilepsy, attention-deficit/hyperactivity disorder (ADHD), or both.

METHODS

We retrospectively reviewed the electronic medical records of 33 children with epilepsy and ADHD, 113 with epilepsy alone, and 294 with ADHD alone. The children were required to complete the Advanced Test of Attention (ATA), and their parents completed the ADHD Rating Scale (ARS), Child Behavior Checklist (CBCL), Children's Sleep Habits Questionnaire (CSHQ), Disruptive Behavior Disorder (DBD) Scale (DBD), Social Responsiveness Scale (SRS), and Parenting Stress Index-Short Form (PSI-SF).

RESULTS

Auditory Commission Errors made during the ATA were higher in children with epilepsy and ADHD than in those with epilepsy alone. On the SRS, all the subscales except Social Awareness were significantly higher in children with epilepsy and ADHD or ADHD alone than in those with epilepsy alone. The Oppositional Defiant and Conduct Disorder subscales on DBD, Attention Problems, and Aggressive Behaviors on CBCL were significantly higher in children with both epilepsy and ADHD than in those with epilepsy alone. The Parent-Child Dysfunctional Interaction subscales on the PSI-SF were significantly greater in children with both epilepsy and ADHD than in those with epilepsy alone. The subscales on the CSHQ did not significantly differ between children with both epilepsy and ADHD and those with epilepsy alone.

CONCLUSIONS

In children with epilepsy, comorbid ADHD was associated with negative effects on response inhibition, aggressive behavior, and parenting-related stress.

ADHD and ADHD-related neural networks in benign epilepsy with centrotemporal spikes: A systematic review

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) and benign epilepsy with centrotemporal spikes (BECTS or rolandic epilepsy) present with a very high level of comorbidity. We aimed to review the existing literature focusing on two aspects: the possible role of epileptic activity in the damage of ADHD-related neural networks and the clinical approach to patients presenting with both conditions.

MATERIAL AND METHODS

A systematic review was performed using Sapienza Library System and PubMed. The following search terms have been considered: attention networks, ADHD, attention systems, rolandic epilepsy, benign epilepsy with centrotemporal spikes, centrotemporal spikes epilepsy, and focal epilepsy in children. The target population consisted of patients under 18 years of age diagnosed with either BECTS and ADHD or healthy controls.

RESULTS

Nine case-control and cohort studies have been selected. The reported prevalence of ADHD in patients with BECTS was around 60%. No clinical correlation was found between the medical records and the presence of ADHD in patients with BECTS, if not due to febrile convulsion (FC). One study showed higher levels of bilateral discharges in patients with severe ADHD. The negative influence of the age at onset of seizures was demonstrated on attention but not on intelligence quotient (IQ). Moreover, the frequency of seizures and the occurrence of discharges during nonrapid eye movement (NREM) sleep were correlated to attention impairment. From a neurobiological point of view, functional connectivity in patients with BECTS and ADHD appears to be disrupted. Two studies reported a specific impairment in selective visual attention, while one study underlined a decreased activation of the dorsal attention network (DAN). Two different studies found that patients with BECTS and comorbid ADHD presented with altered thickness in their magnetic resonance imaging (MRI) scans in the cortical and subcortical regions (including the frontal lobes, lingual-fusiform cortex, cuneus and precuneus, limbic area and pericalcarine cortex among others). This might explain the cognitive and behavioral symptoms such as poor selective visual attention, speech disturbance, and impulsivity.

CONCLUSIONS

Despite BECTS being considered to have a relative benign course, many studies have documented cognitive and/or behavioral problems in patients diagnosed with this type of epilepsy. In particular, children affected by rolandic epilepsy should receive a complete neuropsychological evaluation at seizure onset considering the high rate of comorbidity with ADHD. A further investigation of the common pathogenic substrate is desirable to better orientate the clinical and therapeutic interventions applied.

Role of inflammation in childhood epilepsy and ADHD comorbidity

Epilepsy is a heterogeneous disorder that is not limited to experiencing seizures but also includes multiple neuropsychiatric squeal (i.e. attention-deficit/hyperactivity disorder (ADHD), depression and anxiety) that adversely impact a child quality of life. However, the underlying mechanism linking both disorders is not yet thoroughly explored. Our objective was to assess pro-inflammatory cytokines levels in children with seizure controlled epilepsy and explore the association between pro-inflammatory cytokines and the co-occurrence of ADHD in such children. A cross-sectional study included 50 children with controlled epilepsy for at least one year, in addition to 30 neurotypical children as controls. All children were assessed by the Conner parent scale for ADHD. Serum interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) levels were measured and correlated to clinical data. In the present study, 23 out of 50 children with epilepsy also had ADHD (46%). Children with ADHD have been found to have a significantly lower age of onset, longer duration of epilepsy, and a higher serum level of IL-6 and TNF-α than those without ADHD. The Conner's parent rating scale overall total score yielded significant negative correlations with the age of onset of epilepsy and a significant positive correlation with the duration of epilepsy and pro-inflammatory cytokine levels. In addition to active seizures, the presence of elevated circulating inflammation markers may be associated with increased frequency of ADHD in children with epilepsy aged 6-14 years.

Neuropsychiatric Aspects of Epilepsy

This article reviews common and clinically important neuropsychiatric aspects of epilepsy. Comorbidities are common, underdiagnosed, and powerfully impact clinical outcomes. Biological, psychological, and social factors contribute to the associations between epilepsy and neuropsychiatric disorders. Epidemiologic studies point to a bidirectional relationships between epilepsy and neuropsychiatric disorders. People with epilepsy are more likely to develop certain neuropsychiatric disorders, and those with these disorders are more likely to develop epilepsy. This relationship suggests the possibility of shared underlying pathophysiologies. We review the neuropsychiatric impact of antiseizure medications and therapeutic options for treatment. Diagnosis and treatment involve close collaboration among a multidisciplinary team.

Natural and forced neurogenesis in the adult brain: Mechanisms and their possible application to treat neurological disorders

Neural stem cells (NSCs) in the adult hippocampus generate new neurons via a process referred to as neurogenesis, supporting cognitive functions. Since altered neurogenesis has been reportedly associated with several diseases such as epilepsy, the molecular basis of NSC activity is an important focus in the study of neurogenesis. Furthermore, facilitation of neurogenesis in the injured brain would be an ideal approach to replenish lost neurons for damage recovery. However, natural neurogenesis by endogenous NSCs in the adult brain is insufficient for complete recovery after severe injury. Recent advances in understanding forced neurogenesis from brain-resident non-neuronal cells by direct reprogramming and clearing hurdles to achieve it have improved the ability to replace damaged neurons in the brain. In this review, we describe molecular mechanisms underlying natural and forced neurogenesis, and discuss future directions for treatments of diseases in the central nervous system.

Cognitive functioning in a representative cohort of preschool children with febrile seizures

AIM

To analyse cognitive functioning in 4-5-year-old children who had experienced febrile seizures (FS) and to assess the importance of complex, recurrent and early vs late onset FS.

METHODS

The sample consisted of 73 children, screen positive for FS, drawn from the general child population of 4-year-old children attending their health check-up at child healthcare centres in Gothenburg, Sweden. They were assessed as regards general cognitive ability, visual memory and attention and were contrasted with age norms and with results obtained in 20 children without FS from the same healthcare centres.

RESULTS

Of the 73 children, two had a previously diagnosed intellectual disability (ID) (one mild, one moderate) and two further children tested within the study had results corresponding to mild ID. Children with early onset of FS (before age 12 months)-who often had recurrent FS-had lower full-scale, verbal and processing speed IQ than those who had later onset of FS.

CONCLUSION

Children with early onset of FS and particularly those with recurrent FS may be at increased risk for poorer verbal and processing speed functioning and therefore at risk of developing cognitive, executive dysfunctions. They would probably benefit from neuropaediatric and neuropsychological follow-up.

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.

Overview on Emotional Behavioral Testing in Rodent Models of Pediatric Epilepsy

Psychiatric and cognitive disturbances are the most common comorbidities of epileptic disorders in children. The successful treatment of these comorbidities faces many challenges including their etiologically heterogonous nature. Translational neurobehavioral research in age-tailored and clinically relevant rodent seizure models offers a controlled setting to investigate emotional and cognitive behavioral disturbances, their causative factors, and potentially novel treatment interventions. In this review, we propose a conceptual framework that provides a nonsubjective approach to rodent emotional behavioral testing with a focus on the clinically relevant outcome of behavioral response adaptability. We also describe the battery of neurobehavioral tests that we tailored to seizure models with prominent amygdalo-hippocampal involvement, including testing panels for anxiety-like, exploratory, and hyperactive behaviors (the open-field and light-dark box tests), depressive-like behaviors (the forced swim test), and visuospatial navigation (Morris water maze). The review also discusses the modifications we introduced to active avoidance testing in order to simultaneously test auditory and hippocampal-dependent emotionally relevant learning and memory. When interpreting the significance and clinical relevance of the behavioral responses obtained from a given testing panel, it is important to avoid a holistic disease-based approach as a specific panel may not necessarily mirror a disease entity. The analysis of measurable behavioral responses has to be performed in the context of outcomes obtained from multiple related and complementary neurobehavioral testing panels. Behavioral testing is also complemented by mechanistic electrophysiological and molecular investigations.

Methods in Electrode Implantation and Wiring for Long-Term Continuous EEG Monitoring in Rodent Models of Epilepsy and Behavioral Disturbances

Rodent seizure models that pathologically and behaviorally recapitulate age-tailored epileptic disorders are used by us and others to advance our understanding of the chronobiology and mechanisms of epileptic seizure emergence and their comorbidities and to investigate potential novel treatment strategies. Obtaining prolonged continuous electroencephalogram (EEG) tracings over months is essential in this line of translational research, particularly to assess the relation between electrographic changes and the development of seizures and their various psychiatric and cognitive comorbidities in models where seizures gradually emerge over weeks following brain insults. Here we describe our approach to electrode implantation and wiring in order to successfully obtain high-quality continuous EEG tracings in rats for prolonged periods. A detailed stepwise methodological description is provided with a special focus on the details that help most in avoiding notorious pitfalls such as premature EEG cable disconnections and a poor signal to noise ratio.

Children and adolescents with epilepsy in rehabilitation centers: A French prospective transversal study

INTRODUCTION

The reason why some children and adolescent with epilepsy (CAWE) still challenge the "inclusive" educative policy needs to be explored.

METHODS/PATIENTS

We conducted a transversal study in French medical, social, and educative rehab centers (MSERCs) dedicated to CAWE to describe the profile of 263 centers-involved (CI)-CAWE. Centers-involved CAWE were prospectively followed from September 2012 to August 2013. Medical, social, and educative rehab centers were dichotomized according to their care-provider agreement (i.e., CAWE of "moderate" (M) vs. "severe" (S) conditions). Clinical factors known to impact clinical outcome and quality of life (QoL) in epilepsy and four disabling conditions at risk to impact school life (i.e., cognitive and psychiatric/behavioral disorders, risk of physical hazards (i.e., refractory seizures with unpredictable loss of tone and/or awareness), and one or more seizure/week) were evaluated. The electronic chart of the French collaborative database (namely GRENAT) was used for data collection allowing comparison with the profile of 731 "normally integrated and schooled" (NIS)-CAWE extracted from GRENAT and matching for generation (i.e., born between 1988 and 2006).

RESULTS

Centers-involved CAWE's profile was found, after adjustment, to be associated with clinical factors and disabling conditions reflecting the poorest clinical outcome and health-related quality of life (HR-QoL) (all p < 0.001). A cutoff of two disabilities/child highly discriminated NIS-CAWE vs. CI-CAWE. Centers-involved CAWE of S-MSERCs were the most severe (all p < 0.001), and the type of cognitive disability (i.e., intellectual disability (ID) vs. specific learning disorders (SLD)) highly paralleled the types of MSERCs (S vs. M). Using a parent-informant questionnaire, the number of disabilities/child was found to correlate with both the evaluation of the impact of epilepsy (r = 0.47, p < 0.001) and the HR-QoL (r = 0.37, p < 0.001). A satisfactory social life was reported (83.8%) even after S vs. M dichotomization (77.2% vs. 94.7%; p < 0.001).

CONCLUSION

Multiple disabilities rather than epilepsy per se challenge the inclusive educative policy. Evaluation of disabilities could be the missing bridge to optimize this policy and understand its limits.

Epilepsy

Epilepsy is considered a disease characterized by an underlying predisposition to seizures as well as neurobiologic, cognitive, psychologic, and social consequences. It is the most frequent chronic neurologic condition of childhood, affecting 0.5%-1% of children worldwide. It comprises a variety of disorders with many different etiologies, consequently affecting management and outcome. Although the great majority of children have epilepsies that are self-limited and have a good prognosis, it is nevertheless very well recognized that epileptic activity (be it seizures or interictal discharges) can be particularly deleterious to the developing brain acting as a disruptor to normal developmental function. Indeed, epilepsy and neurocognitive and behavioral disorders very frequently coexist, and it can be challenging to understand if there is causality or if they are all the reflection of the underlying brain disorder. Hence, accurate phenotypic and etiologic diagnosis is of utmost importance as it will not only guide decision making with regard to choice of treatment but also enable management of expectations concerning outcome. The current chapter aims to provide a general overview of the fast evolving and vast field of childhood epilepsy from its definition and epidemiology, to its diagnostic challenges, management, and outcome.

Prevalence of Epilepsy and Inter-Ictal Epileptiform Discharges in Children with Autism and Attention-Deficit Hyperactivity Disorder

OBJECTIVE

To study the prevalence of epilepsy and Inter-ictal epileptiform discharges (IED) in children with Autism spectrum disorder (ASD) and Attention-deficit hyperactivity disorder (ADHD), and the factors associated with occurrence of epilepsy in these children.

METHODS

Children between 6 and 12 y attending the Child Development Centre of a tertiary-care institute in India were evaluated for ASD and ADHD as per Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Childhood Autism Rating Scale was used to assess ASD severity, and Conner's Rating Scales were used to sub-classify children with ADHD. Intelligence quotient was assessed if not assessed in the previous 1 y. History of seizures was taken, and electroencephalography was done in all children. Epilepsy was diagnosed and classified according to International League Against Epilepsy.

RESULTS

Of the 130 children enrolled (90 ASD, 40 ADHD), 56 (43%) had epilepsy and 55 (42.3%) had IED. The proportion of both epilepsy and IED was higher among ASD (both 45.5%) as compared to ADHD (37.5% and 35%), although not statistically significant. Among children with ASD, epilepsy was common in those with severe ASD (P < 0.001), and IED were more common in those with IQ <80 (P = 0.047). There were no significant differences between occurrence of epilepsy/IED and subtypes of ADHD.

CONCLUSIONS

The high prevalence of epilepsy and IED among children with ASD and ADHD emphasizes the need for guidelines for identifying and diagnosing epilepsy in this group. This will ensure appropriate management and improve patient outcomes.

Methods in Emotional Behavioral Testing in Immature Epilepsy Rodent Models

Pediatric epilepsy is associated with prominent comorbid psychiatric and cognitive disturbances. Neurobehavioral testing is employed to characterize the cognitive and emotional behavioral derangements that accompany seizures in age-tailored and clinically relevant immature rodent seizure models. In addition to dissecting the causes of the etiologically multifaceted psychiatric and cognitive comorbidities of the epilepsies, neurobehavioral panels are essential in investigating potential neuroprotective strategies, especially during neurodevelopment. Here we describe a battery of behavioral testing panels that we tailored to our rodent seizure models with prominent amygdalo-hippocampal involvement. The panels include the open field and light-dark box tests for exploratory, hyperactive, and anxiety-like behaviors, the forced swim test for depressive-like behaviors, the Morris water maze for visuospatial navigation, and the modified active avoidance test for emotionally relevant learning and acquisition of adaptive behaviors. The behavioral laboratory setup and the employed methodologies are reviewed in details, with a special focus on the potential pitfalls that should be avoided.

Ectopic neurogenesis induced by prenatal antiepileptic drug exposure augments seizure susceptibility in adult mice

Recent clinical studies suggest that environmental insults, such as valproic acid (VPA) exposure, in utero can have adverse effects on brain function of the offspring in later life, although the underlying mechanisms of these impairments remain poorly understood. By focusing on the property of neural stem/progenitor cells (NS/PCs) residing in the adult hippocampus, we identified the mechanism of increased seizure sensitivity in prenatally VPA-exposed adult mice. Furthermore, we found that voluntary exercise can overcome the adverse effects through normalizing VPA-induced transcriptome alterations in NS/PCs. We believe that our study provides insights for further understanding and developing treatment strategies for neurological disorders induced by prenatal environmental insults.

Epilepsy is a neurological disorder often associated with seizure that affects ∼0.7% of pregnant women. During pregnancy, most epileptic patients are prescribed antiepileptic drugs (AEDs) such as valproic acid (VPA) to control seizure activity. Here, we show that prenatal exposure to VPA in mice increases seizure susceptibility in adult offspring through mislocalization of newborn neurons in the hippocampus. We confirmed that neurons newly generated from neural stem/progenitor cells (NS/PCs) are integrated into the granular cell layer in the adult hippocampus; however, prenatal VPA treatment altered the expression in NS/PCs of genes associated with cell migration, including CXC motif chemokine receptor 4 (Cxcr4), consequently increasing the ectopic localization of newborn neurons in the hilus. We also found that voluntary exercise in a running wheel suppressed this ectopic neurogenesis and countered the enhanced seizure susceptibility caused by prenatal VPA exposure, probably by normalizing the VPA-disrupted expression of multiple genes including Cxcr4 in adult NS/PCs. Replenishing Cxcr4 expression alone in NS/PCs was sufficient to overcome the aberrant migration of newborn neurons and increased seizure susceptibility in VPA-exposed mice. Thus, prenatal exposure to an AED, VPA, has a long-term effect on the behavior of NS/PCs in offspring, but this effect can be counteracted by a simple physical activity. Our findings offer a step to developing strategies for managing detrimental effects in offspring exposed to VPA in utero.

Adult ADHD and Comorbid Somatic Disease: A Systematic Literature Review

OBJECTIVE

To systematically review, synthesize, and appraise available evidence, connecting adult ADHD with somatic disease.

METHOD

Embase, Psychinfo, and Medline databases were searched for studies published from 1994 to 2015 addressing adult ADHD and somatic comorbidity. Somatic conditions were classified according to International Classification of Diseases (ICD-10) codes. Levels of evidence were graded as inconclusive, tentative, or well documented.

RESULTS

Most of the 126 studies included in the qualitative synthesis were small and of modest quality. Obesity, sleep disorders, and asthma were well-documented comorbidities in adult ADHD. Tentative evidence was found for an association between adult ADHD and migraine and celiac disease. In a large health registry study, cardiovascular disease was not associated with adult ADHD.

CONCLUSION

There are few large systematic studies using standardized diagnostic criteria evaluating adult ADHD and somatic comorbidities. Significant associations are found between adult ADHD and several somatic diseases, and these are important to consider when assessing and treating either adult ADHD or the somatic diseases.

Attention Deficit Hyperactivity Disorder and Associated Cognitive Dysfunction in Pediatric Epilepsy

Attention deficit hyperactivity disorder (ADHD) is the most common neuropsychiatric comorbidity associated with childhood epilepsy, affecting about a third of children with epilepsy. In contrast, ADHD in the general population occurs in 4%-12% of school-aged children. The cause of this association remains unclear. It is likely that common mechanisms underlie the vulnerability for both executive deficits and epileptogenesis. There are characteristics unique to children with ADHD and epilepsy. The inattentive type of ADHD is more prevalent than the combined presentation in children with epilepsy, while the combined type is more common in the general population. Interestingly, there is an equal sex distribution of ADHD in patients with epilepsy, while in the general population, ADHD is 3-7 times more prevalent in boys. Specific features of ADHD seen in different epilepsy syndromes are frequently associated with executive deficits. Early screening of ADHD symptoms in children with epilepsy is essential, as timely interventions can improve academic and social function and outcomes. The mainstays of therapy include behavioral interventions and pharmacotherapy, with evidence demonstrating that stimulants are both safe and effective in children with ADHD and epilepsy.

Parent- and Teacher-Reported Symptoms of ADHD in School-Aged Children With Active Epilepsy: A Population-Based Study

OBJECTIVE

Provide data on the distribution of parent- and teacher-reported symptoms of ADHD in childhood epilepsy and describe coexisting cognitive and behavioral disorders in children with both epilepsy and ADHD.

METHOD

Eighty-five (74% of those eligible) children (5-15 years) in a population-based sample with active epilepsy underwent psychological assessment. The ADHD Rating Scale-IV (ADHD-RS-IV) scale was completed by parents ( n = 69) and teachers ( n = 67) of participating children with an IQ > 34. ADHD was diagnosed with respect to Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.).

RESULTS

Parents reported significantly more symptoms of ADHD than teachers ( p < .001). Symptoms of inattention were more commonly reported than symptoms of hyperactivity-impulsivity ( p < .001). Neurobehavioral comorbidity was similar in those with ADHD and non-ADHD with the exception of oppositional defiant disorder (ODD) and developmental coordination disorder (DCD), which were more common in those with both epilepsy and ADHD.

CONCLUSION

Symptoms of ADHD are very common in childhood epilepsy but prevalence is influenced by informant.

Cognitive and neurodevelopmental comorbidities in paediatric epilepsy

Cognitive and behavioural comorbidities are often seen in children with epilepsy, and are more common and severe in refractory epilepsy. These comorbidities are associated with worse quality of life, increased behavioural and language problems and worse social skills, all of which adversely affect long-term psychosocial functioning. To enable early intervention and therapy, children and teens with epilepsy should be periodically screened for cognitive comorbidities. The location of the epileptic focus can, to a certain degree, predict the type(s) of comorbidity; however, the spectrum of disability is often broad, presumably because focal perturbations can cause network dysfunction. Comorbidities often result from underlying structural or functional pathology that has led to seizures. In selected cases, therapy targeting the underlying cause, such as the ketogenic diet for GLUT1 deficiency syndromes, may be remarkably effective in ameliorating both seizures and cognitive concerns. In many cases, however, cognitive impairment persists despite seizure control. In epileptic encephalopathies, frequent seizures and/or interictal epileptiform abnormalities exacerbate neurocognitive dysfunction, owing to synaptic reorganization or impaired neurogenesis, or to other effects on developing neural circuits, and prompt initiation of effective antiepileptic therapy is essential to limit cognitive comorbidities.

The Safety of Atomoxetine for the Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: A Comprehensive Review of Over a Decade of Research

Atomoxetine is a noradrenergic reuptake inhibitor prescribed for attention-deficit/hyperactivity disorder (ADHD) that first gained approval in the USA in 2002 and has been authorized in 97 countries worldwide. The aim of this paper is to comprehensively review publications that addressed one or more of seven major safety topics relevant to atomoxetine treatment of children and adolescents (aged ≥6 years) diagnosed with ADHD. While the review focuses on children and adolescents, publications in which data from patients aged >18 years and from 6 to 18 years were analyzed in the same dataset were included. Using a predefined search strategy, including agreement of two reviewers when selecting papers, reduced the potential for bias. Using this process, we identified 70 eligible papers (clinical trials, epidemiological studies, and case reports) across the seven topics. We also referred to the European Summary of Product Characteristics (SPC) and US label. We found 15 papers about suicidality, three about aggression/hostility, seven about psychosis/mania, six about seizures, seven about hepatic effects, 29 about cardiovascular effects, and 28 about growth and development. The main findings (i.e., those from the largest and most well-conducted studies/analyses) are as follows. A large register-based study of pediatric and adult patients (6818 received atomoxetine) calculated a hazard ratio of 0.96 for suicide-related events during treatment with atomoxetine, and a meta-analysis of 23 placebo-controlled studies (N = 3883), published in 2014, found no completed suicides and no statistically significant association between atomoxetine and suicidality. The frequency of aggression/hostility was not statistically significantly higher with atomoxetine, e.g., experienced by 1.6 % (N = 21/1308) of atomoxetine-treated patients versus 1.1 % (N = 9/806) of placebo-treated patients in one meta-analysis. Symptoms of psychosis and mania were mainly observed in patients with comorbid bipolar disorder/depression. Based on spontaneous reports, during a 2-year period when 2.233 million adult and pediatric patients were exposed to atomoxetine, the reporting rate for seizures was 8 per 100,000 patients. In the manufacturer's database, atomoxetine was a "probable cause" of three hepatic adverse events (AEs) (all reversible hepatitis), and 133 hepatic AEs had possible confounding factors and were "possibly related" to atomoxetine, during 4 years when atomoxetine exposure had reached about 4.3 million patients. Rare cases of severe liver injury are described in the US label and European SPC; a case requiring liver transplantation is described in the US label. In a comprehensive review of a clinical trials database (N = 8417 received atomoxetine), most pediatric patients experienced modest increases in heart rate and blood pressure, and 8-12 % experienced more pronounced changes (≥20 bpm, ≥15 to 20 mmHg). However, in three long-term analyses (≥2 years), blood pressure was within age norms, and few patients discontinued due to cardiovascular AEs. As described in the European SPC, QT interval prolongation is uncommon, e.g., in an open-label study, 1.4 % of 711 children and adolescents had prolonged QTc intervals (≥450 ms in males, ≥470 ms in females) that were not clinically significant at ≥3 years of treatment with atomoxetine. The European SPC warns about potential QT interval prolongation in patients with a personal or family history, or if atomoxetine is administered with other drugs that potentially affect the QT interval. Decreases in growth (weight and height gain) occurred and were greatest in patients of above average weight and height, but appeared to recover over 2-5 years of atomoxetine treatment. In conclusion, suicidality, aggression/hostility, psychosis, seizures, liver injuries, and prolonged QT interval are uncommon or rare in children and adolescents treated with atomoxetine, based on data from the predefined search and from the European SPC. Overall, the data that we assessed from our search do not suggest that associations exist between atomoxetine and suicidality or seizures. The data also suggest that an association may not exist between atomoxetine and aggression/hostility. While atomoxetine may affect the cardiovascular system, the data suggest these effects are not clinically significant in most patients. Reductions in growth appear to be reversible in the long term.

Behavioral and Movement Disorders due to Long-Lasting Myoclonic Status Epilepticus Misdiagnosed as ADHD in a Patient With Juvenile Myoclonic Epilepsy: Electroclinical Findings and Related Hemodynamic Changes

Epilepsy and attention-deficit/hyperactivity disorder (ADHD) likely share common underlying neural mechanisms, as often suggested by both the evidence of electroencephalography (EEG) abnormalities in ADHD patients without epilepsy and the coexistence of these 2 conditions. The differential diagnosis between epilepsy and ADHD may consequently be challenging. In this report, we describe a patient presenting with a clinical association of "tics" and behavioral disorders that appeared 6 months before our first observation and had previously been interpreted as ADHD. A video-EEG evaluation documented an electroclinical pattern of myoclonic status epilepticus. On the basis of the revised clinical data, the EEG findings, the good response to valproate, the long-lasting myoclonic status epilepticus, and the enduring epileptic abnormalities likely causing behavioral disturbances, the patient's symptoms were interpreted as being the expression of untreated juvenile myoclonic epilepsy. The EEG-functional magnetic resonance imaging study revealed, during clinical generalized spike-and-wave and polyspike-and-wave discharges, positive blood oxygen level-dependent (BOLD) signal changes bilaterally in the thalamus, the prefrontal cortex (Brodmann area 6, supplementary motor area) and the cerebellum, and negative BOLD signal changes in the regions of the default mode network. Such findings, which are typical of BOLD changes observed in idiopathic generalized epilepsy, may also shed light on the anatomofunctional network underlying ADHD.

[Formula: see text]Differences in memory functioning between children with attention-deficit/hyperactivity disorder and/or focal epilepsy

Prior research has shown that attention-deficit/hyperactivity disorder (ADHD) and epilepsy are frequently comorbid and that both disorders are associated with various attention and memory problems. Nonetheless, limited research has been conducted comparing the two disorders in one sample to determine unique versus shared deficits. Hence, we investigated differences in working memory (WM) and short-term and delayed recall between children with ADHD, focal epilepsy of mixed foci, comorbid ADHD/epilepsy and controls. Participants were compared on the Core subtests and the Picture Locations subtest of the Children's Memory Scale (CMS). Results indicated that children with ADHD displayed intact verbal WM and long-term memory (LTM), as well as intact performance on most aspects of short-term memory (STM). They performed worse than controls on Numbers Forward and Picture Locations, suggesting problems with focused attention and simple span for visual-spatial material. Conversely, children with epilepsy displayed poor focused attention and STM regardless of the modality assessed, which affected encoding into LTM. The only loss over time was found for passages (Stories). WM was intact. Children with comorbid ADHD/epilepsy displayed focused attention and STM/LTM problems consistent with both disorders, having the lowest scores across the four groups. Hence, focused attention and visual-spatial span appear to be affected in both disorders, whereas additional STM/encoding problems are specific to epilepsy. Children with comorbid ADHD/epilepsy have deficits consistent with both disorders, with slight additive effects. This study suggests that attention and memory testing should be a regular part of the evaluation of children with epilepsy and ADHD.

Attention-deficit/hyperactivity disorder symptoms in adults with self-reported epilepsy: Results from a national epidemiologic survey of epilepsy

OBJECTIVE

To assess symptoms of attention-deficit/hyperactivity disorder (ADHD) and their impact among adults with epilepsy from a large community-based survey.

METHODS

Adults who self-reported epilepsy were sent a postal survey including the Adult ADHD Self-Report Scale version 6 (ASRS-6), Physicians Health Questionnaire (PHQ-9), Generalized Anxiety Disorder Assessment 7 (GAD-7), and questions about seizure frequency and number of antiepileptic drugs (AEDs) during the preceding 3 months. Individuals with ASRS-6 scores >14 were classified as ASRS+, and those with lower scores as ASRS-. Outcome measures included the Quality of Life in Epilepsy Inventory 10 (QOLIE-10), Quality of Life and Enjoyment and Satisfaction Questionnaire (Q-LES-Q), and the Sheehan Disability Scale (SDS). The relationship of ADHD symptoms to quality of life outcomes was modeled hierarchically, with linear regression controlling for sociodemographic covariates, comorbid depression and anxiety, seizure frequency, and number of AEDs.

RESULTS

Among 1,361 of respondents with active epilepsy, 18.4% (n = 251) were classified as ASRS+ and at risk for ADHD. Compared to ASRS- cases, ASRS+ individuals were more likely to have elevated depression and anxiety scores as well as greater seizure frequency and more AED use (p < 0.05 for all). Modeling results comparing ASRS+ and ASRS- cases, controlling for all covariates, indicated that ASRS+ cases had lower quality of life (Beta [β] = -3.07, 95% confidence interval [CI] -4.19 to -1.96) and worse physical (β = -0.048 95% CI -0.076 to -0.020) and social functioning (β = -0.058, 95% CI -0.081 to -0.035) on the Q-LES-Q, and increases in family (β = 1.57, 95% CI 1.09-2.05), social (β = 1.68, 95% CI 1.20-2.16), and work-related disability (β-1.86, 95% CI 1.27-2.46).

SIGNIFICANCE

ADHD symptoms occur in nearly one of five adults with epilepsy, and are associated with increased psychosocial morbidity and lowered QOL. Future studies should clarify the nature and causes of ADHD symptoms in adults with epilepsy.

Spectrum of attention deficit hyperactivity disorders (ADHD) among Sudanese children with epilepsy

Epilepsy is commonly encountered in children with attention deficit hyperactivity disorder (ADHD). This study aims to determine the spectrum of ADHD among Sudanese children with epilepsy. The study was conducted at the Epilepsy and Neurodisabilities Outpatient Clinic for Children at Saad Abu Elila University Hospital, Khartoum, Sudan during the period January - July 2013. All patients with epilepsy who presented to the clinic during the study period were assessed for ADHD using psychometric questionnaire. According to the interpretation guide, the degree of probability of ADHD was identified. Out of 720 patients with epilepsy 77(10.6%) were identified as having ADHD. Of these 50 (19.50%) patients had a high probability of having ADHD, 29 (37.70%) above average, 29 (37.70%) average and 4 (5.20%) had low ADHD spectrum.

Reappraisal of abnormal EEG findings in children with ADHD: on the relationship between ADHD and epileptiform discharges

INTRODUCTION

Attention-deficit hyperactivity disorder is suggested to be closely related to epilepsy. A recent large-scale study revealed that ADHD in children is often accompanied by epilepsy. In Japan, methylphenidate (MPH) as a sustained-action tablet and atomoxetine (ATX) became commercially available as medications for children recently. Since then, the number of prescriptions of both medicines has increased rapidly. Methylphenidate, as a psychostimulant, has been a source of concern because of the perceived lowered threshold for convulsions in children. Based on this background, reappraisal of EEG findings in children with ADHD is important in order to detect indications of potential comorbid epilepsy and to investigate the developmental mechanisms of the neurophysiological manifestations in patients with ADHD.

MATERIAL AND METHOD

EEG findings in children newly diagnosed with ADHD and their relationship with clinical findings were investigated. The author evaluated 208 patients with ADHD newly diagnosed between 2008 and 2013. Of these, there were 145 patients for whom EEG findings were obtained along with a clinical follow-up for at least three months. Patients with IQ<70 were excluded in order to obtain a homogenous group of patients with ADHD. The male-to-female ratio was 130:15, and the age range was between 5 years, 9 months and 19 years, 9 months, with mean age of 11 years, 4 months.

RESULTS

The results revealed that about half (48.3%) of the children with ADHD had abnormal EEG findings and that 22.1% of them had epileptiform discharges. Patients without comorbidity of autism spectrum disorder (ore homogenous group with ADHD) were especially likely to show abnormal EEG findings (51.0%) including epileptiform discharges (24.5%). Afebrile seizures, that is, epileptic seizures, occurred in a boy three days after commencement of administration with MPH as a sustained-action tablet. In four patients with a past history of epilepsy, neither relapse of EEG abnormality nor epileptic seizures were observed during the follow-up period.

CONCLUSION

There was to be a significantly close relationship between ADHD and epileptiform discharges. Therefore, in patients with ADHD, it is important to obtain more precise information about seizures and presence of epilepsy from the personal and family histories, as well as to undertake a thorough EEG examination.

Children diagnosed with attention deficit disorder and their hospitalisations: population data linkage study

Examine the hospital admission risk in young children who are subsequently diagnosed with attention deficit hyperactivity disorder (ADHD). We conducted a population-based, record linkage study. Records of all non-Aboriginal children under 18 years who met the DSMIV/ICD10 criteria for ADHD and prescribed stimulant medication in Western Australia between 2003 and 2007 (n = 11,902) were linked to two other health data systems-the hospital morbidity data system and the midwives notification system (MNS). The non-ADHD reference population (n = 27,304) was randomly selected from the MNS. Compared with controls, children under 4 years who subsequently were diagnosed and treated for ADHD were 70% [odds ratio (OR) 1.70; 95% confidence intervals (CI) 1.62-1.77] more likely to be admitted to hospital under 4 years of age. There was an increased risk for injury or poison (OR 1.73; 95% CI 1.59-1.88), respiratory disease (OR 1.49; 95% CI 1.40-1.59), ear disease (OR 2.03; 95% CI 1.86-2.21), infectious diseases (OR 1.68; 95% CI 1.53-1.85) and neurological conditions (OR 2.03; 95% CI 1.68-2.44). Admissions under 4 years of age for head injuries, burns, poisons, all other injuries, diseases of the tonsils and adenoids, asthma and early infections were all more common amongst children subsequently diagnosed with and treated for ADHD. There is significant early hospital morbidity for children subsequently diagnosed with ADHD. Multiple aetiologies and causal pathways need to be considered where some of these may include early infections, inflammatory conditions, epilepsy and injuries. Future studies should look at which of these conditions may be on the causal pathway or likely early markers for ADHD.

Managing the risks of ADHD treatments

Pharmacotherapy of attention deficit-hyperactivity disorder (ADHD) is a well-established and effective treatment modality. However, ADHD medications are not without side effects. Understanding the prevalence of adverse events and effective management of risks associated with stimulants and other medications used to treat ADHD is central to broad applicability and effective treatment. This review discusses the literature on the prevalence of adverse events and management strategies employed. We searched online MEDLINE/PubMed and Cochrane databases for articles using several keywords relating to adverse events associated with ADHD medication management. We discuss the relevant data on the significance and prevalence of side effects and adverse events, highlight recent updates in the field, and suggest approaches to clinical management.

Are children affected by epileptic neuropsychiatric comorbidities?

Childhood-onset epilepsy is associated with psychiatric and cognitive difficulties and with poor social outcomes in adulthood. Some antiepileptic drugs adversely affect behavior in susceptible children with easy-to-control or refractory epilepsies, contributing to a high risk of psychological and psychiatric disturbance. Studies had demonstrated that patients with benign rolandic epilepsy and absence epilepsy had more aggressive behavior, depression, and anxiety disorders than control children. Psychiatric comorbidities are strongly associated with a poor long-term health-related quality of life in childhood-onset epilepsy, which suggests that comprehensive epilepsy care must include screening and long-term treatment for these conditions, even if seizures remit.

Comparing stimulant effects in youth with ADHD symptoms and epilepsy

To retrospectively examine response to stimulant treatment in patients with epilepsy and ADHD symptoms as predicted by seizure freedom for six months, use of methylphenidate (MPH) versus amphetamine (AMP) preparations, cognitive level, and medical records were searched for patients under the age of 18 with epilepsy and ADHD symptoms treated with MPH or AMP (n=36, age=10.4 ± 3.5; male=67%). "Responders" had a CGI-improvement score of ≤ 2 and did not stop medication because of adverse effects. "Worsened" patients discontinued medication because of agitation/emotional lability. Seizure freedom did not predict treatment response. Lower cognitive level was associated with increased rate of worsening (p=0.048). No patients who were seizure-free at the start of the medication trial experienced an increase in seizures. Of the patients having seizures at the start of trial, one patient on MPH and two patients on AMP had increased seizures during the trial. Seizures returned to baseline frequency or less after stimulant discontinuation or anticonvulsant adjustment. Methylphenidate was associated with a higher response rate, with 12 of 19 given MPH (0.62 ± 0.28 mg/kg/day) compared with 4 of 17 given AMP (0.37 ± 0.26 mg/kg/day) responding (p=0.03). Methylphenidate treatment and higher cognitive level were associated with improved treatment outcome, while seizure freedom had no clear effect. Confidence in these findings is limited by the study's small, open-label, and uncontrolled design.

Epilepsy in a large cohort of children diagnosed with attention deficit/hyperactivity disorders (ADHD)

PURPOSE

The knowledge about possible relationships between ADHD and epilepsy is largely based on small samples of ADHD patients and on cohorts with epilepsy. There is insufficient information about the clinical characteristics of epilepsy among children diagnosed with ADHD. The aim of this study was to investigate the prevalence and characteristics of epilepsy in a large, unselected cohort of children with ADHD.

METHODS

We conducted a retrospective chart-review of children with ADHD who were evaluated in our clinic between the years 2000 and 2005. We compared age, sex, disorders of psychological development, cognitive level, pharmacological treatment for ADHD, initial response to treatment and ADHD subtype with and without epilepsy. In addition, we compared our data with data from a Norwegian study in a large general pediatric population.

RESULTS

Of 607 children with ADHD (age 6-14 years; 82.4% males); 14 (2.3%) had a history of epilepsy, and 13 of these had active epilepsy. This is a higher occurrence than expected in the general pediatric population (0.5%). The majority of our patients had mild (an easily treated) epilepsy and they were more likely to be seizure free (79%) compared to the patients with epilepsy in general pediatric population. The ADHD patients with and without epilepsy did not differ regarding age, gender, disorders of psychological development, IQ level<85 or ADHD subtype. The patients had been diagnosed with epilepsy on average 1.8 years before the ADHD assessment. All patients with epilepsy were treated with methylphenidate (MPH), and initial response to MPH was achieved in 85.7%.

CONCLUSION

The epilepsy diagnosis preceded the ADHD diagnosis, and was found in a significantly higher rate than would be expected in the general pediatric population. The majority of patients had mild epilepsy and ADHD-Combined Inattentive/Hyperactive-Impulsive Subtype. All cases with epilepsy and ADHD were treated with MPH, with initial response achieved in 86%.

Prevalence of epilepsy and attention-deficit hyperactivity (ADHD) disorder: a population-based study

Epilepsy and attention-deficit hyperactivity disorder (ADHD) were reported to co-occur at rates higher than expected for coincidental findings. This study investigated the prevalence of both disorders in community-based primary care practice. The central database of the second-largest health maintenance organization in Israel was searched for all children aged 6 to 13 years (n = 284 419; 51.5% males) diagnosed as having ADHD according to the physicians' records and/or the filling of at least 10 prescriptions for antiepileptic medications according to pharmacy records. The prevalence of epilepsy in the total population was 5 out of 1000 children, and the prevalence of ADHD was 12.6%. More than one-fourth (27.7%) of the epileptic children were also diagnosed as having ADHD. On multivariate analysis, children with ADHD had almost twice the risk of epilepsy than children without ADHD. This study supports hospital-based findings of a strong interrelationship between ADHD and epilepsy. The high rate of ADHD in Israeli children warrants further investigation.

A cohort study of the risk of seizures in a pediatric population treated with atomoxetine or stimulant medications

PURPOSE

Stimulant medications used for treating attention deficit hyperactivity disorder (ADHD) can be associated with an increased risk of seizures. Atomoxetine is a non-stimulant medication approved for treating ADHD. This retrospective cohort analysis evaluated risk of seizures among pediatric patients naïve to ADHD medication therapy, with exposure to atomoxetine relative to stimulant medications.

METHODS

Among members of a large US health plan from 1/1/2003 to 12/31/2006, aged 6-17 years, we identified initiators of atomoxetine or stimulants with no evidence of prior study drug use. We created study cohorts using propensity score matching within 6-month calendar blocks. The outcome was a seizure event in the 6-month follow-up period verified through medical record review. Relative risks (RR) based on current use of each study drug adjusted for baseline covariates were calculated using Poisson regression. We estimated hazard ratios from Cox proportional hazards models for the comparison of atomoxetine to stimulants based on initial cohort assignment.

RESULTS

We matched 13,398 initiators of atomoxetine to 13,322 initiators of stimulants. We identified 97 seizure events. After adjustment, current atomoxetine therapy was associated with a non-statistically significant 28% lower risk of seizure compared to current stimulant therapy (RR 0.72; 95%CI 0.37, 1.38). The adjusted RR of seizure with atomoxetine compared to stimulants based on initial cohort assignment was 0.90 (95%CI 0.54, 1.49).

CONCLUSIONS

These results do not support an increase in the risk of seizure with atomoxetine therapy. The risk of seizure was not significantly different between pediatric patients taking atomoxetine compared with those taking stimulants.

Elevated rates of ADHD in mothers of children with comorbid ADHD and epilepsy

OBJECTIVES: To describe the prevalence of ADHD in mothers of children with comorbid ADHD and epilepsy (ADHD+E) and to compare ADHD symptoms in mothers with (Fam(+)) and without (Fam(-)) additional relative(s) with epilepsy. PATIENTS & METHODS: Mothers (n = 16) of children with ADHD+E were assessed by the Kiddie Schedule for Affective Disorders and Schizophrenia for School Age Children ADHD module and the ADHD Rating Scale IV. Information was collected on the presence (Fam(+)) or absence (Fam(-)) of first- or second-degree relatives with epilepsy in the sample. RESULTS: A total of 50% of mothers met the DSM-IV criteria for ADHD. ADHD was more prevalent in Fam(+) mothers (80%) compared with Fam(-) mothers (36%; p = 0.14). Fam(+) mothers had more current hyperactivity symptoms than Fam(-) mothers (p = 0.002), higher current ADHD severity (p = 0.02) and higher ADHD Rating Scale IV hyperactivity scores (p = 0.008). CONCLUSION: The prevalence of ADHD in mothers of children with ADHD+E is elevated in this pilot study, suggesting that ADHD symptoms in children with epilepsy and their mothers reflects shared familial genetic or environmental risks, potentially resulting in a higher prevalence of both disorders among family members. This is a pilot study and larger controlled studies are warranted.

Disengagement and inhibition of visual-spatial attention are differently impaired in children with rolandic epilepsy and Panayiotopoulos syndrome

We assessed voluntary orientation and reorientation of visuospatial attention in 313 healthy 6- to 22-year-old participants, 30 children suffering from benign epilepsy with centrotemporal spikes (BECTS) and 13 children with Panayiotopoulos syndrome (PS). The developmental section highlights the late development of reorienting skills. Only children with BECTS-R showed a strong tendency toward a rightward bias in attentional orientation. Additionally, a unilateral deficit of disengagement characterizes the patients with BECTS-R and comorbid ADHD. Right rolandic spikes seem to aggravate subclinical reorienting difficulties. Finally, children with PS failed to diffuse inhibition, except in the nearest area outside the attentional focus. This deficit could be attributed to the typical occipital-to-frontal spreading of the spikes in PS. By showing distinct attentional deficiencies according to the epileptic syndrome and the epileptic focus lateralization in BECTS, the results provide new evidence for alterations of attentional mechanisms by interictal epileptic activity, which probably contribute to learning difficulties.

The sleep phenotypes of attention deficit hyperactivity disorder: the role of arousal during sleep and implications for treatment

About 25-50% of children and adolescents with attention-deficit hyperactivity disorder (ADHD) experience sleep problems. An appropriate assessment and treatment of such problems might improve the quality of life in such patients and reduce both the severity of ADHD and the impairment it causes. According to data in the literature and to the overall complexity of the interaction between ADHD and sleep, five sleep phenotypes may be identified in ADHD: (i) a sleep phenotype characterized mainly by a hypo-arousal state, resembling narcolepsy, which may be considered a "primary" form of ADHD (i.e. without the interference of other sleep disorders); (ii) a phenotype associated with delayed sleep onset latency and with a higher risk of bipolar disorder; (iii) a phenotype associated with sleep disordered breathing (SDB); (iv) another phenotype related to restless legs syndrome (RLS) and/or periodic limb movements; (v) lastly, a phenotype related to epilepsy/or EEG interictal discharges. Each sleep phenotype is characterized by peculiar sleep alterations expressed by either an increased or decreased level of arousal during sleep that have important treatment implications. Treatment with stimulants is recommended above all in the primary form of ADHD, whereas treatment of the main sleep disorders or of co-morbidities (i.e. bipolar disorders and epilepsy) is preferred in the other sleep phenotypes. All the sleep phenotypes, except the primary form of ADHD and those related to focal benign epilepsy or focal EEG discharges, are associated with an increased level of arousal during sleep. Recent studies have demonstrated that both an increase and a decrease in arousal are ascribable to executive dysfunctions controlled by prefrontal cortical regions (the main cortical areas implicated in the pathogenesis of ADHD), and that the arousal system, which may be hyperactivated or hypoactivated depending on the form of ADHD/sleep phenotype.