Learning disability and epilepsy. 2, a review of available outcome measures and position statement on development priorities

An interpretative model of early indicators of specific developmental dyslexia in preschool age: a comparative presentation of three studies in Greece

The detection of specific factors of the developmental dyslexia at an early stage, and the identification of the role of those factors responsible for its manifestation, is a fundamental area of study on dyslexia in the recent literature. The objective of the present study is to clarify that dysfunctions in the following specific domains contribute in a causal model to the occurrence of dyslexia at an early stage: phonological awareness, psychomotor ability (body shape, spatio-temporal orientation, grapho-motor ability and laterality), perception, memory, attention, prereading and prewriting skills. The results of three studies, --carried out in Greece--which revealed the above factors as main predictors of the early onset of Specific Developmental Dyslexia (SDD) and confirmed the importance of intervention methods to it, led us to the construction of the proposed, causal model. The findings of these three studies converge on the perspective that the understanding, diagnosis and treatment of dysfunctions in the above domains, from preschool age, enable the early and reliable prevention of future difficulties in the learning process of children.

Cognitive outcomes in children who present with a first unprovoked seizure

PURPOSE

To determine the long-term cognitive and educational outcomes in children prospectively identified at the time of a first unprovoked seizure.

METHODS

A cohort of children with a first unprovoked seizure was enrolled and followed for a mean of 15 years. Cognitive function and educational outcomes were determined 10 or more years after the first seizure via standardized neuropsychological tests, school records, and structured interviews. Children with symptomatic etiology were excluded from the analysis. When available, siblings of study subjects were recruited as normal controls. Primary educational outcome was defined as enrollment into special education services or grade repetition.

RESULTS

Twenty-eight percent of (43 of 153) of children with a single seizure and 40% (42 of 105) of children with epilepsy received special education service or repeated a grade (p = 0.05). There was a statistically significant trend in which the children with more seizures tended to require special education or repeat a grade more often (28% in single seizure group vs. 34% in 2-9 seizure group vs. 64% in ≥10 seizure group; p = 0.004). Of 163 subjects who completed neuropsychological testing, children with single seizures tended to score higher than children with epilepsy on Wide Range Achievement Test-3 (WRAT) reading (p = 0.08), Test of Non-Verbal Intelligence-II (TONI-II) (p = 0.02), and Wechsler Intelligence Scale for Children (WISC)/Wechsler Adult Intelligence Scale (WAIS) (p = 0.07). There was no statistically significant difference between children with a single seizure and sibling controls.

CONCLUSION

The results suggest that children with a single seizure represent a group that is distinctly different from children with epilepsy and are more similar to sibling controls. In contrast, even children with very mild epilepsy have significantly worse educational outcomes.

Sleepiness, on-task behavior and attention in children with epilepsy who visited a school for special education: a comparative study

Children with epilepsy are at risk for problems in daytime functioning. We assessed daytime sleepiness, on-task behavior and attention in 17 children (aged between 7 and 11 years) with epilepsy who visited a school for special education and compared these to 17 children from a control group who visited a regular school. Within the group of children with epilepsy, we explored whether behavioral and cognitive functioning varied across days of the week and times of the day. Data were collected during four consecutive school days. Children with epilepsy had more daytime sleepiness, less on-task behavior and less attention than controls. Furthermore, sleepiness and on-task behavior varied cross days of the week and times of the day, an effect that was not found in controls. Implications for educational practice are discussed.

Consensus guidelines into the management of epilepsy in adults with an intellectual disability

BACKGROUND

Epilepsy has a pervasive impact on the lives of people with intellectual disability and their carers. The delivery of high-quality care is impacted on by the complexity and diversity of epilepsy in this population. This article presents the results of a consensus clinical guideline process.

RESULTS

A Delphi process identified a list of priority areas for the development of evidence-based guidelines. All guidelines were graded and consensus on scoring was achieved across the guideline group.

CONCLUSION

There is a dearth of high-quality evidence from well-constructed studies on which to base guidance. However, the development of internationally derived consensus guidelines may further support the management of epilepsy in adults with an intellectual disability.

The psychosocial impact of epilepsy in adults with an intellectual disability

Epilepsy has a pervasive impact on the quality of life, and thus the psychosocial well-being, of adults with an intellectual disability. Social and economical well-being appears to be affected by an increase in restrictions on activities and thus social contact. The population has very high rates of challenging behaviors and of mental illness. It is likely that these have a significant impact on epilepsy management. When populations with and without epilepsy are controlled for level of ability, no difference in prevalence of behavior or mental illness is seen between the populations. Current knowledge is limited on crucial issues such as the long-term effect of seizure disorder on mental health, quality of life, and cognition.

Prevalence, patterns, service needs, and assessment of neuropsychiatric disorders among people with epilepsy in residential care: validation of the Neuropsychiatric Inventory as a caregiver-rated measure of neuropsychiatric functioning in epilepsy

We assessed 228 people with epilepsy (PWE) in the residential care setting using the Neuropsychiatric Inventory (NPI) and Brief Psychiatric Rating Scale (BPRS) as caregiver- and observer-rated instruments. There was a significant burden of psychopathology, about half of all subjects surveyed scoring positive on either or both instruments. Psychopathology as measured by the NPI and BPRS was significantly greater in cognitively impaired subjects than in those with intact cognitive function. The NPI was found to be a valid caregiver-rated measure of psychopathology in PWE, with a principal components analysis yielding a reliable and interpretable four-factor solution, psychosis, interictal dysphoric disorder, depression, and anxiety being identified. Mental health service needs were found to be considerable in this population, with a significant hidden burden of psychiatric comorbidity. As this population has ongoing service needs through the life span, further research is necessary.

Examining a community model of epilepsy care for people with learning disabilities

PURPOSE

To assess the use of specialised medical epilepsy services by people with learning disabilities (LD) and epilepsy in a community healthcare setting, to compare medical epilepsy care in this group to current management guidelines, and to contrast important outcomes with those achieved in different healthcare settings.

METHODS

Postal survey with a carer completed questionnaire addressed to all adults with epilepsy registered on an LD register in Sheffield, UK (n=442).

RESULTS

An analysis based on 225 returned questionnaires revealed that 22.7% of individuals with LD and epilepsy had been free of seizures for over 1 year. 95.1% were taking antiepileptic drugs (AEDs), 46.2% had had an EEG, and 41.3% a brain scan. 53.3% of diagnoses had been made by epilepsy experts, 38.7% of individuals with LD and epilepsy were under specialist review. Although patients with more severe epilepsy were more likely to be under specialist care, 60.6% of patients with ongoing seizures, 57.9% with major seizures and 68.7% of individuals taken to hospital with prolonged had no access to specialist advice.

CONCLUSION

The proportion of people with LD who achieved seizure-control in the described population was lower than in all previously reported studies of LD patient groups. The poor outcome in terms of seizure-control, the lack of access to the epilepsy specialist service, and the apparent under-utilisation of investigations indicate that there are grounds for serious concern about this community model of medical epilepsy care for people with LD.

The development and validation of the Epilepsy and Learning Disabilities Quality of Life (ELDQOL) scale

Few suitable instruments exist for use with people, especially children, with both epilepsy and learning disabilities. One such measure is the Epilepsy and Learning Disabilities Quality of Life scale (ELDQOL), which has recently undergone revision following feedback from relevant users. This article reports on the final psychometric testing phase of this scale. ELDQOL consists of 70 items covering seizure severity, seizure-related injuries, antiepileptic drug side effects, behavior, mood, physical, cognitive, and social functioning, parental concern, communication, overall quality of life, and overall health. Revalidation involved a qualitative phase, to ascertain users' opinions on the wording, coverage, and layout of the questionnaire, and a quantitative phase, to examine internal consistency, test-retest reliability, and validity. There is very good evidence of the reliability and validity of the final version of ELDQOL, making it a promising instrument for assessing quality of life in children/young adults with epilepsy and learning disabilities.

The Evaluation of Behavioral Disturbances in Epilepsy

The evaluation of behavioral disturbances in epilepsy is an area fraught with complexity. On the one hand, there are no instruments that have been developed specifically for the assessment of behavioral disturbances in epilepsy. On the other hand, the phenomenology and pathophysiology of behavioral disturbances in epilepsy are unique and defy conventional descriptions in the psychiatric literature. The vast majority of studies have used instruments that have not been validated for this purpose. Studies with a psychiatric orientation generally tend to employ unvalidated semistructured or structured tools except for the Structured Clinical Interview for DSM, which has been validated for epilepsy. Studies with a neurological orientation generally use screening questionnaires and interpret the results of these as diagnostic. Neither approach is valid and both generally fail to measure potential confounders, such as seizure frequency, seizure severity, temporality of seizure occurrence in relation to time of assessment, life events, disablement, quality of life, and other socioeconomic indicators. Furthermore, instruments are generally employed using cutoff scores that may not be valid for epilepsy populations; the emphasis is often on symptom severity rather than symptom multiplicity (or load), which may also have an impact on the patient's outcome. In addition, instruments that have a basis in psychiatric criteria as opposed to symptomatology have inherent pitfalls at the interface between epilepsy and behavior. These and other issues in evaluating behavioral disturbances in people with epilepsy are reviewed and some solutions for the future are proposed.

Exploring the evaluation of antiepileptic drug change in people with intellectual disabilities and high-frequency epileptic seizures: seizure control and sustained responsiveness to the environment

PURPOSE

Optimum antiepilepsy medication should be successful in reducing seizures with minimal adverse effects on the patient's ability to concentrate or general level of awareness. The purpose was to investigate the potential of a method of measuring responsiveness to environmental events as a means of reflecting awareness levels among people with intellectual disabilities undergoing review of medication for high-frequency epileptic seizures.

METHODS

Observations of 22 participants referred to a specialist clinic were conducted three times a month over a 5-month period following the initial baseline measures and clinical intervention. Behavioral responsiveness was measured by calculating the likelihood of appropriate activity occurring given the occurrence of staff interaction. This likelihood was represented by the statistic Yule's Q. Seizure frequency was also evaluated.

RESULTS

Participant responsiveness after drug review was similar to baseline indicating an absence of long-term adverse effects. Participants experienced a significant decrease in seizure frequency.

CONCLUSION

It was concluded that drug review led to seizure reduction while behavioral measurement confirmed no loss of responsiveness.

Pharmacological outcomes in people with mental retardation and epilepsy

The aim of this study was to examine prospective outcomes in mentally retarded people with epilepsy seen for the first time during 1998 until the end of 2001. Two hundred and fourteen patients (120 men, 94 women, aged 11-70 years [median 34 years]) were referred over this 4-year period. Median duration of follow-up was 18 months (range, 13-36 months). Seventeen (8%) had nonepileptic attacks only, 10 of whom were being treated with antiepileptic drugs (AEDs). The remaining 197 (92%) patients had epilepsy, the majority (n=151, 77%) presenting with focal seizures. A total of 22 patients were started on AED treatment, with seizure freedom for at least a year being achieved in 10 (45%). AED manipulation was undertaken in a further 136 patients, resulting in 59 (43%) becoming seizure-free. No relationship was found between extent of mental retardation and seizure control. There was no deterioration in mean caregiver scores rating sleep, appetite, alertness, and behavior. These findings suggest that AED therapy can result in seizure freedom in more than 40% of mentally retarded people with epilepsy without producing unacceptable toxicity.

Psychopathology in people with epilepsy and intellectual disability; an investigation of potential explanatory variables

OBJECTIVES

There are few studies on epilepsy and psychopathology in people with intellectual disability (mental retardation) despite epilepsy prevalence rates that are thirty times higher than in the general population. The aims of this study, therefore, were to identify reliable, epilepsy-specific predictors of psychiatric and behavioural disorder in these patients, and to investigate reliable predictors of carer stress.

METHODS

A database of 685 patients was compiled, from which 250 were randomly selected. Structured interviews were completed on 186 of these 250 patients (74%) (108 men, 78 women; mean age (SD) 35.5 (10.1)) comprising descriptive, clinical and functional components, and validated measures of psychopathology for which comparative data were available. Logistic and linear regression methods were used to identify predictors.

RESULTS

One-third of patients with epilepsy and intellectual disability met criteria for possible psychiatric disorder, particularly affective/neurotic disorder; twice the comparison rates for intellectual disability alone. Behavioural problem levels, however, were lower than population norms. Regression models explaining modest amounts of variance (R(2)< or =24%) suggested certain seizure phenomena (greater seizure severity, more seizures in past month, lesser tendency to loss of consciousness during seizures) as particular risk factors for psychiatric disorder. General disability factors such as level of intellectual, sensory or motor disability and side effects of medication, however, contributed more to explaining behavioural problems. Around half of the family carers reported significant stress, and one-third exhibited clinically significant anxiety symptoms. Younger carers were more stressed, and side effects from patients' medication also contributed to carer stress.

CONCLUSIONS

Although epilepsy in itself may be a risk factor for psychopathology in a minority of people with intellectual disability, some epilepsy-specific factors may predict psychiatric disorder. Behavioural problems need to be considered separately from psychiatric disorder because general factors, more closely associated with disability, are stronger predictors of their occurrence.

Perspectives on epilepsy in people with intellectual disabilities: comparison of family carer, staff carer and clinician score profiles on the Glasgow Epilepsy Outcome Scale (GEOS)

PURPOSE

Clinical practice with people with intellectual disability relies heavily upon caregiver report. Crucially, the carer's perspective may depend upon his or her relationship to the patient. We investigated similarities and differences within and between family and paid carers in their reports on the Glasgow Epilepsy Outcome Scale (GEOS), an instrument that quantifies concerns about epilepsy in this population [Epilepsia 42 (2001) 1043].

METHODS

GEOS forms were available on 186 patients (108 males; mean age 39 years) across 384 primary respondents (141 staff, 83 family, 160 clinicians) and independently completed secondary respondents (67 staff, 36 family). Data were analysed to consider levels of concern as rated bv staff carers, family members and clinicians, and also to consider inter-rater agreement on the concerns raised.

RESULTS

There were significant differences in the magnitude of concern on each sub-scale [concerns about seizures, treatment, caring and social impact; range of F(2,171)=9.5-64.7; all P<0.0001]. Post hoc testing revealed that family members scored all sub-scales more highly than staff carers or clinicians, and that staff carers scored more highly than clinicians on all but one sub-scale. Inter-rater agreement between family members was considerably higher (range of r=0.69-0.91) than between staff carers (r=0.30-0.47) across the GEOS sub-scales. Association between staff and family ratings was also modest (r< or = 0.39).

CONCLUSIONS

It is preferable for the same staff member to complete each administration of the GEOS because of inter-staff variability in reporting of concerns. Families provide a consistent, but more extreme, picture and clinicians generally underestimate the concerns of direct caregivers. However, content of concerns varies relatively little across respondents.

Patient's perspective on epilepsy: self-knowledge among Omanis

Improving patients' knowledge has been suggested to improve their symptoms and prognosis. Very little is known about epileptic patient's knowledge of their illness in cross-cultural settings. This pilot study investigated what Omani patients know about their disorder. Patients attending a tertiary hospital completed a structured knowledge questionnaire to elicit information pertaining to aetiology, safety, compliance with medication regimes, legal and employment issues concerning epilepsy.Although correctly endorsing issues related to their medication, this cross-cultural sample was found to have limited knowledge about their condition. In particular, most patients were unable to give accurate indications of epilepsy, neither were they able to give correct responses to questions pertaining to safety and compliance. There is a need for improving patient's knowledge. As with other chronic disorders, people with epilepsy in Oman should receive systematic health education about how to manage the condition most effectively.

Behavioral assessment in mentally retarded and developmentally disabled patients with epilepsy

Behavioral disturbance is common in many individuals with mental retardation. Its presence in those with coexisting epilepsy provides a further challenge to the individual, caretakers, and family members. In particular, concerns that antiepileptic medication is causing such behavioral disturbances are often raised. For the clinician, assessment is crucial to minimize morbidity by appropriately identifying the cause of the behavioral disturbance. The assessment should aim to delineate whether the disturbance is due to a direct effect of epilepsy, its treatment, social impact, or factors unrelated to the epilepsy. However, before being able to make this differentiation, the clinician needs to understand the behavior itself. Assessing behavior in people with mental retardation requires a multifactorial approach. These factors include an objective and reliable description of the behavior and an assessment of its function. Detailed description requires a functional analysis of behavior. Such analysis may indicate the behavior is associated with epilepsy treatment or represents a seizure disorder in itself. In the majority of cases, though, it is likely that any disturbance seen is independent of epilepsy or its management.

Adults with learning disabilities and epilepsy: knowledge about epilepsy before and after an educational package

The understanding individuals have about their epilepsy may influence the success with which that individual copes with his/her epilepsy. This paper presents the first evaluation of a video-assisted brief educational package for adults with mild learning disabilities and epilepsy ("Epilepsy and You"; Paul, 1996 21). Utilizing a deferred entry to treatment design to evaluate intervention effects eighteen subjects participated in the study. Their knowledge about epilepsy before and after training was assessed using a checklist of knowledge and the Epilepsy Knowledge Questionnaire-Revised for use with people with learning disabilities. Results demonstrated significant gains in knowledge which were durable over a short follow-up period (1 month). "Epilepsy and You" was found to be suitable for use with a wide range of individuals and subjects' opinions demonstrated they enjoyed taking part. This study is a preliminary investigation from which other research can develop. Therefore, criticisms and suggestions for further research have been made.

Development and validation of the Glasgow Epilepsy Outcome Scale (GEOS): a new instrument for measuring concerns about epilepsy in people with mental retardation

PURPOSE

To develop a measure for use with adults with epilepsy and mental retardation, capable of assessing both clinical and care concerns and of quantifying treatment outcomes.

METHODS

Extensive validational and other psychometric evaluation was undertaken, comprising initial scale development work with 48 carers and 46 health practitioners, followed by formal field testing on a sample of 186 patients, using 384 respondents (160 clinicians, 141 staff, 83 family). Recognised qualitative methods were applied to identify central themes, and psychometric procedures generated data on validity, reliability, and component structure.

RESULTS

A total of 1,007 items of concern was generated, which was reduced systematically to a representative set of 90 items. The GEOS-90 comprises four subscales: concerns about "seizures," "treatment," "caring," and "social impact," each explaining approximately 70% of variance. Subscales and factor scales had strong internal consistency (alpha > or = 0.82). Stepwise linear regression was applied to derive a short-form version with similar structure. Thirty-five items were retained (GEOS-35; alpha > or = 0.89). Both scales discriminated moderately on clinical variables (number of seizure types, mono- vs. polytherapy, seizure frequency; all values of p < 0.05) and demonstrated concurrent validity with interview ratings from the ELDQOL (p < 0.05).

CONCLUSIONS

The GEOS scales appear valid and reliable for use with clinical populations of people with mental retardation.

Epilepsy and intellectual disability

A Medline and Psychline literature review of epilepsy in people with intellectual disability was performed. The review has highlighted the importance of the impact of epilepsy on the lives of individuals and their families, affecting physical morbidity, leading to an increased mortality and increasing the care-giving burden. Interventions with a strong evidence base are mainly pharmacological with an increasing body of work on the novel antiepileptic drugs. Surprisingly little research exists into the quality of service provision for this population. The authors suggest three areas for future work: (1) an increasing application of research methodologies such as direct observation and qualitative studies into this field; (2) an exploration of the broad impact of treatment and (3) the possibility that epilepsy is a barrier to care provision.

Treatment of seizures in patients with learning disabilities

People with learning disabilities commonly have seizures. Combined electroencephalogram and video investigations improve diagnostic accuracy, while neuroimaging may indicate a role for surgery. When epilepsy is diagnosed, individually tailored care is necessary. Rational antiepileptic drug use is advocated, with emphasis upon the newer agents due to their better tolerability and ease of use. Regular clinical review will prevent over-medicating. Although an optimistic approach can now be adopted, future developments require a more solid evidence base together with a rationality to all aspects of care, including drug therapy, carer education, closer collaboration among specialists, and mutual skill awareness of all involved.

Epilepsy and learning disabilities--a challenge for the next millennium?

People with learning disabilities often have seizures in addition to other disorders. Precise diagnosis may be difficult, but accuracy can be improved using electroencephalographic and video investigations. Following the establishment of a diagnosis of epilepsy, individually tailored care is necessary taking into account other health, behavioural and therapeutic issues. Neuroimaging may indicate a need for surgery which should not be automatically excluded as a treatment option. Rational antiepileptic drug use is advised, with emphasis upon the newer agents due to their better tolerance and ease of use. A programme of regular review will prevent over-medicating. Drug therapy may be withdrawn in a seizure-free patient. Realistic goals should be established for each individual coupled with an optimistic approach to care. However, future developments require a solid evidence base combined with rationality in all aspects of management. The community learning disability epilepsy nurse specialist is the key health-care professional who can ensure that a learning disabled individual with epilepsy is able to take full advantage of all available services. Education, closer collaboration and the mutual recognition of skills will ensure more cohesive and comprehensive care for this disadvantaged patient population.

Learning disability and epilepsy. 1, towards common outcome measures

A major component of the population of people who have epilepsy are people with a learning disability. As a group, such individuals often have complex epilepsy which is refractory to treatment. Current available measures to assess the outcomes of therapeutic interventions in epilepsy are based on seizure frequency, seizure severity and quality-of-life measures, but have not been validated in people with a learning disability. Thus, we do not know if such measures of outcome serve the needs of this group. This review examines how able we are to assess the efficacy of our interventions to control epilepsy in people with learning disability. It is suggested that a standard data set is necessary as the basis of the assessment of any therapeutic intervention. Central components of this data set would encompass a definition of important characteristics of an individual, a description of their epilepsy and an assessment of the impact of their condition on both their own and their carer's health. The approach to obtaining this information should employ a methodology which can allow for environmental influences.