Pediatric Multiple Sclerosis: What we know and where are we headed?

Epilepsy and demyelination: Towards a bidirectional relationship

Demyelination stands out as a prominent feature in individuals with specific types of epilepsy. Concurrently, individuals with demyelinating diseases, such as multiple sclerosis (MS) are at a greater risk of developing epilepsy compared to non-MS individuals. These bidirectional connections raise the question of whether both pathological conditions share common pathogenic mechanisms. This review focuses on the reciprocal relationship between epilepsy and demyelination diseases. We commence with an overview of the neurological basis of epilepsy and demyelination diseases, followed by an exploration of how our comprehension of these two disorders has evolved in tandem. Additionally, we discuss the potential pathogenic mechanisms contributing to the interactive relationship between these two diseases. A more nuanced understanding of the interplay between epilepsy and demyelination diseases has the potential to unveiling the molecular intricacies of their pathological relationships, paving the way for innovative directions in future clinical management and treatment strategies for these diseases.

Quantitative Meta-analyses of Cognitive Abilities in Children With Pediatric-onset Multiple Sclerosis

Pediatric-onset multiple sclerosis (POMS), is the manifestation of multiple sclerosis in individuals before 18 years of age. About a third of children with POMS show some form of lower cognitive performance. The purpose of this study is to examine using quantitative meta-analyses the effect size of altered performance between children with and without POMS on overall intelligence quotient (IQ), information processing speed, and language functions. We searched the literature for studies that reported scores on cognitive tests administered to children with and without POMS. Studies were systematically reviewed using PRISMA guidelines. We analyzed data from 14 studies that examined 1283 children with and without POMS when cognitive categories consisted of five or more studies. Effect sizes, publication bias and potential confounds were considered. Significant cognitive differences are revealed for all categories with the strongest effect observed for overall IQ. A moderate effect is observed for information processing speed, and small effects for verbal fluency and verbal memory. Cognitive abilities present differently in children with POMS and a better understanding of this manifestation will inform intervention and remediation tools that can improve clinical and educational practice for the benefit of children with POMS.

Interval Timing in Pediatric Multiple Sclerosis: Impaired in the Subsecond Range but Unimpaired in the One-Second Range

Background: For adult multiple sclerosis (MS) patients, impaired temporal processing of simultaneity/successiveness has been frequently reported although interval timing has been investigated in neither adult nor pediatric MS patients. We aim to extend previous research in two ways. First, we focus on interval timing (instead of simultaneity/successiveness) and differentiate between sensory-automatic processing of intervals in the subsecond range and cognitive processing of intervals in the one-second range. Second, we investigate whether impaired temporal information processing would also be observable in pediatric MS patients' interval timing in the subsecond and one-second ranges.

Methods: Participants were 22 pediatric MS patients and 22 healthy controls, matched for age, gender, and psychometric intelligence as measured by the Culture Fair Test 20-R. They completed two auditory interval-timing tasks with stimuli in the subsecond and one-second ranges, respectively, as well as a frequency discrimination task.

Results: Pediatric MS patients showed impaired interval timing in the subsecond range compared to healthy controls with a mean difference of the difference limen (DL) of 6.3 ms, 95% CI [1.7, 10.9 ms] and an effect size of Cohen's d = 0.830. The two groups did not differ significantly in interval timing in the one-second range (mean difference of the DL = 26.9 ms, 95% CI [−14.2, 67.9 ms], Cohen's d = 0.399) or in frequency discrimination (mean difference of the DL = 0.4 Hz, 95% CI [−1.1, 1.9 Hz], Cohen's d = 0.158).

Conclusion: The results indicate that, in particular, the sensory-automatic processing of intervals in the subsecond range but not the cognitive processing of longer intervals is impaired in pediatric MS patients. This differential pattern of results is unlikely to be explained by general deficits of auditory information processing. A tentative explanation, to be tested in future studies, points to subcortical deficits in pediatric MS patients, which might also underlie deficits in speech and visuomotor coordination typically reported in pediatric MS patients.

[Methodological issues of cognitive impairment studies in pediatric multiple sclerosis patients]

The article provides a review of the characteristics of cognitive impairment in multiple sclerosis (MS) and methods for its assessment in children. The features of the most frequently used neuropsychological batteries, with consideration of specifics of cognitive impairment in MS, and data on assessment of a state of cognitive functions obtained using neuropsychological tests are presented. The authors also discuss the issue of a long-term impact of the disease on a state of cognitive functions. Clinical factors, which can lead to cognitive impairment (type of multiple sclerosis, age at manifestation, number of relapses), are described.

Families' Experience of Pediatric Onset Multiple Sclerosis

This study interviewed parents to understand families' experience with pediatric onset multiple sclerosis (POMS), which make up 2.7% to 10.5% of all MS cases. 21 sets of parents of children with a confirmed diagnosis of POMS were recruited from two pediatric MS centers. Families experienced stress from the uncertainty prior to diagnosis, anxiety over symptoms and possible progression of the disease, frustrations with the uncertain effects of disease-modifying treatments (DMTs), and difficulties with injections. Families had to cope with cognitive and physical effects of POMS at school, decisions about expectations and independence for the child, and extra demands POMS placed on the family. Most parents reported benefitting from support from physicians, the National Multiple Sclerosis Society, and the MS community. Families had benefitted from DMTs, and, despite the stresses, most had adapted successfully to the illness. Advice from interviewees to other parents and recommendations for improving family support are presented.

Cognitive Impairment in Multiple Sclerosis: A Review of Neuropsychological Assessments

Of the more than two million people worldwide with multiple sclerosis, 40% to 65% experience cognitive impairment, many of them early in the course of the disease. Cognitive impairment has been found in patients with all subtypes of multiple sclerosis. Because both pharmacologic and nonpharmacologic interventions may improve patients' brain function, cognitive assessment should be a routine part of the clinical evaluation. Traditional paper-and-pencil neuropsychological tests and batteries can help detect and monitor patients' cognitive problems. Computerized cognitive batteries also show promise. Controversy continues over which test is most reliable at assessing cognitive impairment in both everyday clinical practice and research. Each battery has possible disadvantages, such as practice effects, poor sensitivity and specificity, and questionable applicability to multiple sclerosis. Based on our review of the literature, we describe the tests that are currently being used or that might be used in assessing cognitive deficits in patients with multiple sclerosis, and we summarize the strengths and limitations of each.

"It feels like wearing a giant sandbag." Adolescent and parent perceptions of fatigue in paediatric multiple sclerosis

AIM

Fatigue is one of the most common and disabling symptoms of paediatric MS, associated with depressed mood, impaired school performance and lower quality of life. Fatigue in children and adolescents with MS (caMS) is poorly understood, and effective treatments for fatigue are currently lacking. No qualitative studies have previously examined fatigue in caMS. Thus, the objectives were (a) to explore experiences of fatigue in paediatric MS and (b) to gain insight into how caMS and their parents respond to and manage fatigue.

METHODS

In-depth semi-structured qualitative interviews were conducted with 15 caMS and 13 of their parents, either face-to-face or via telephone. Inductive thematic analysis was primarily used, incorporating elements of grounded theory.

RESULTS

Five key themes were identified in the data. Participants described mentally and physically exhausting fatigue, which they perceived as uncertain and uncontrollable. Parents expressed concern about caMS' well-being and future because of fatigue, whilst caMS discussed the implications of disclosure or non-disclosure of fatigue to peers and teachers. An additional overarching theme addressed participants' emotional responses to fatigue. Participants stressed the need for better guidance on fatigue management.

INTERPRETATION

This study provides a unique insight into the experience and management of fatigue in paediatric MS from the perspective of both caMS and parents. Some findings echoed experiences of fatigue in other populations, whilst new factors in paediatric MS also emerged. Fatigue management interventions involving caMS, parents and teachers should be developed and implemented in clinical practice.

Understanding fatigue in paediatric multiple sclerosis: a systematic review of clinical and psychosocial factors

AIM

Fatigue in children and adolescents with multiple sclerosis (caMS) is currently poorly understood. This review aimed to provide greater insight into this area and direction for future research by evaluating evidence of associations between fatigue and clinical, psychological, and social factors in caMS.

METHOD

Studies were identified by searching online databases, hand-searching reference lists, and requesting unpublished literature from key authors. Studies that examined fatigue in relation to at least one clinical, psychological, or social factor in caMS were included. Data on design, sample characteristics, measures of fatigue, clinical, psychological, and social variables, and key findings were extracted. Twelve studies were narratively synthesized.

RESULTS

Clinical factors appeared largely unrelated to fatigue, whereas associations between fatigue and tests of neurocognitive functioning, and fatigue and diagnosable psychiatric disorders, were mixed. However, fatigue and depressed mood consistently correlated. A small number of studies indicated associations between fatigue and reduced quality of life and school performance.

INTERPRETATION

A sufficient explanatory model of fatigue in caMS is lacking as studies in this area are few and diverse. Future research should endeavour to identify potentially modifiable clinical and psychosocial factors that are associated with fatigue in caMS so that interventions targeting such factors may be developed.

Neuropsychological correlates of multiple sclerosis across the lifespan

Multiple sclerosis can adversely affect cognitive functioning whether the disease has an adult or pediatric onset. The research thus far suggests that pediatric MS shares many features with adult MS but is also unique in several respects. One particular characteristic of pediatric MS is that, while physical disability develops more slowly as compared with adult patients, the impact of cognitive deficits in children may be more substantial as they are in a period of life during which they acquire many skills that are needed to transition into independently functioning adults. Our review takes a lifespan approach to MS, comparing and contrasting the neuropsychology (i.e., cognitive, psychological, and psychosocial factors) of these two populations. Understanding how MS manifests across the lifespan has important implications for tailoring assessment and treatment for individuals with MS as they transition from childhood to adulthood, and later life.

Navigating life and loss in pediatric multiple sclerosis

Multiple sclerosis (MS) is a chronic disease of the central nervous system that can cause unpredictable disability. Over the past 10 to 15 years, practitioners and researchers have come to recognize that children and adolescents are at risk for this disease. Drawing on the experiences of pediatric MS patients and their parents, I designed this study to explicate the process of adjustment to the disease. Using Charmaz's constructivist grounded theory methodology, I developed a preliminary theory that captures the experience of grief in the adjustment process of young people with MS. The core of the theoretical model focuses on two separate, yet overlapping processes: recurring loss and carrying on. Significant turning points influenced the oscillation between these two processes, highlighting the interconnection of intrapersonal and interpersonal dynamics in adjustment to the disease. Results reinforce and extend current grief literature and provide an alternative perspective on adjustment to pediatric chronic illness.