Determinants of IQ profile in children with idiopathic generalized epilepsy

Mathematics Skills in Epilepsy: A Systematic Review and Meta-Analysis

Mathematics incorporates a broad range of skills, which includes basic early numeracy skills, such as subitizing and basic counting to more advanced secondary skills including mathematics calculation and reasoning. The aim of this review was to undertake a detailed investigation of the severity and pattern of early numeracy and secondary mathematics skills in people with epilepsy. Searches were guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Twenty adult studies and 67 child studies were included in this review. Overall, meta-analyses revealed significant moderate impairments across all mathematics outcomes in both adults (g= -0.676), and children (g= -0.593) with epilepsy. Deficits were also observed for specific mathematics outcomes. For adults, impairments were found for mathematics reasoning (g= -0.736). However, two studies found that mathematics calculation was not significantly impaired, and an insufficient number of studies examined early numeracy skills in adults. In children with epilepsy, significant impairments were observed for each mathematics outcome: early numeracy (g= -0.383), calculation (g= -0.762), and reasoning (g= -0.572). The gravity of impairments also differed according to the site of seizure focus for children and adults, suggesting that mathematics outcomes were differentially vulnerable to the location of seizure focus.

Neurocognitive profile in patients with idiopathic generalized epilepsies: Differences between patients, their biological siblings, and healthy controls

BACKGROUND

Idiopathic generalized epilepsy (IGE) is one of the most common epilepsies and is believed to have a strong genetic origin. Patients with IGE present largely heterogeneous neurocognitive profiles and might show some neurocognitive impairments. Furthermore, IGE siblings may demonstrate worse results in neuropsychological tests as well. In our study, we aimed to map the neurocognitive profile both in patients with IGE and the siblings. We also sought to establish a neurocognitive profile for each IGE syndrome.

METHODS

The research sample included 110 subjects (IGE n = 46, biological siblings BS n = 16, and healthy controls n = 48) examined. Subjects were neuropsychologically examined in domains of intelligence, attention, memory, executive, and motor functions. The data obtained from the examination were statistically processed to determine whether and how IGE patients (including distinct syndromes) and the siblings differed neurocognitively from healthy controls (adjusted z-scores by age, education, and gender, and composite z-scores of cognitive domains). Data on anti-seizure medication, including defined daily doses, were obtained and included in the analysis.

RESULTS

IGE patients and their biological siblings performed significantly worse in most of the neuropsychological tests than healthy controls. The neurocognitive profile of composite z-scores showed that IGE and biological siblings had equally significantly impaired performance in executive functions. IGE group also demonstrated impaired composite attention and motor function scores. The profile of individual IGE syndromes showed that JAE, JME, and EGTCS had significantly worse performance in composite execution score and motor function score. JAE presented significantly worse performance in intelligence and attention. JME exhibited significantly worse composite score in the attention domain. Anti-seizure medication, depression, and quality of life were unrelated to cognitive performance in IGE group. The level of depression significantly predicted the overall value of quality of life in patients with IGE, while cognitive domains, sociodemographic, and clinical factors were unrelated.

CONCLUSION

Our study highlights the importance to consider the neurocognitive profile of IGE patients that can lead to difficulties in their education, acceptance, and management of coping strategies. Cognitive difficulties of IGE siblings could support a hypothesis that these impairments emerge from heritable traits.

Neurobehavioural comorbidities of epilepsy: towards a network-based precision taxonomy

Cognitive and behavioural comorbidities are prevalent in childhood and adult epilepsies and impose a substantial human and economic burden. Over the past century, the classic approach to understanding the aetiology and course of these comorbidities has been through the prism of the medical taxonomy of epilepsy, including its causes, course, characteristics and syndromes. Although this 'lesion model' has long served as the organizing paradigm for the field, substantial challenges to this model have accumulated from diverse sources, including neuroimaging, neuropathology, neuropsychology and network science. Advances in patient stratification and phenotyping point towards a new taxonomy for the cognitive and behavioural comorbidities of epilepsy, which reflects the heterogeneity of their clinical presentation and raises the possibility of a precision medicine approach. As we discuss in this Review, these advances are informing the development of a revised aetiological paradigm that incorporates sophisticated neurobiological measures, genomics, comorbid disease, diversity and adversity, and resilience factors. We describe modifiable risk factors that could guide early identification, treatment and, ultimately, prevention of cognitive and broader neurobehavioural comorbidities in epilepsy and propose a road map to guide future research.

Intelligence quotient (IQ) among children with epilepsy: National epidemiological study - Sudan

BACKGROUND

Many studies of selected groups of children with epilepsy have demonstrated an association between epilepsy and cognitive deficits. The aim of this study was to assess the intellectual skills of children with epilepsy and to investigate the influence of gender, age at seizure onset, type of epilepsy, antiepileptic drug used, and control of epilepsy on their intellectual function.

METHODS

This is a descriptive prospective study in which one hundred and eighty-seven patients at school age (6-14 years) were recruited. Epilepsy was classified using the International League Against Epilepsy (ILAE) Commission on Classification and Terminology 2005-2009 report. An intelligence quotient (IQ) test was conducted to all patients using Stanford-Binet Fifth Edition (SB5)/Arabic version.

RESULTS

Eighty-eight (47.1%) patients had an average score on Full Scale IQ (FSIQ), 44 (23.5%) had low average, whereas 18 (9.6%) had borderline impaired or delayed score. In the nonverbal IQ (NVIQ) score, the majority 84 (44.9%) had average score. The performance of the patients in the nonverbal score is better than in the verbal score, which was found to be statistically significant (P-value = 0.01). The FSIQ score was negatively affected by younger age at onset of epilepsy, polytherapy, and uncontrolled seizures.

CONCLUSIONS

Most of children with epilepsy had an average FSIQ; uncontrolled seizure had worse effect on overall FSIQ and memory. Interventions to support children with epilepsy should focus on epilepsy management and school psychosocial domains.

Paradigm Shifts in the Neuropsychology of Epilepsy

This article reviews the major paradigm shifts that have occurred in the area of the application of clinical and experimental neuropsychology to epilepsy and epilepsy surgery since the founding of the International Neuropsychological Society. The five paradigm shifts discussed include: 1) The neurobiology of cognitive disorders in epilepsy - expanding the landscape of syndrome-specific neuropsychological impairment; 2) pathways to comorbidities: bidirectional relationships and their clinical implications; 3) discovering quality of life: The concept, its quantification and applicability; 4) outcomes of epilepsy surgery: challenging conventional wisdom; and 5) Iatrogenic effects of treatment: cognitive and behavioral effects of antiepilepsy drugs. For each area we characterize the status of knowledge, the key developments that have occurred, and how they have altered our understanding of the epilepsies and their management. We conclude with a brief overview of where we believe the field will be headed in the next decade which includes changes in assessment paradigms, moving from characterization of comorbidities to interventions; increasing development of new measures, terminology and classification; increasing interest in neurodegenerative proteins; transitioning from clinical seizure features to modifiable risk factors; and neurobehavioral phenotypes. Overall, enormous progress has been made over the lifespan of the INS with promise of ongoing improvements in understanding of the cognitive and behavioral complications of the epilepsies and their treatment. (JINS, 2017, 23, 791-805).

Control groups in paediatric epilepsy research: do first-degree cousins show familial effects?

To determine whether first-degree cousins of children with idiopathic focal and genetic generalized epilepsies show any association across measures of cognition, behaviour, and brain structure. The presence/absence of associations addresses the question of whether and to what extent first-degree cousins may serve as unbiased controls in research addressing the cognitive, psychiatric, and neuroimaging features of paediatric epilepsies. Participants were children (aged 8-18) with epilepsy who had at least one first-degree cousin control enrolled in the study (n=37) and all enrolled cousin controls (n=100). Participants underwent neuropsychological assessment and brain imaging (cortical, subcortical, and cerebellar volumes), and parents completed the Child Behaviour Checklist (CBCL). Data (based on 42 outcome measures) from cousin controls were regressed on the corresponding epilepsy cognitive, behavioural, and imaging measures in a linear mixed model and case/control correlations were examined. Of the 42 uncorrected correlations involving cognitive, behavioural, and neuroimaging measures, only two were significant (p<0.05). The median correlation was 0.06. A test for whether the distribution of p values deviated from the null distribution under no association was not significant (p>0.25). Similar results held for the cognition/behaviour and brain imaging measures separately. Given the lack of association between cases and first-degree cousin performances on measures of cognition, behaviour, and neuroimaging, the results suggest a non-significant genetic influence on control group performance. First-degree cousins appear to be unbiased controls for cognitive, behavioural, and neuroimaging research in paediatric epilepsy.

Convulsive status epilepticus and health-related quality of life in children with epilepsy

OBJECTIVES

The objective of this study was to examine the association between convulsive status epilepticus (CSE) and health-related quality of life (HRQL) during a 24-month follow-up in a multisite incident cohort of children with epilepsy.

METHODS

Data were collected in the Health-Related Quality of Life Study in Children with Epilepsy Study from 374 families of children with newly diagnosed epilepsy. The Quality of Life in Childhood Epilepsy (QOLCE) Questionnaire was used to evaluate parent-reported child HRQL. Hierarchical linear regression was used to examine the relationship between CSE and HRQL at 24 months postepilepsy. A total of 359 families completed the 24-month assessment.

RESULTS

Twenty-two children (6.1%) had experienced CSE during the follow-up. Children with and without CSE were similar, except a larger proportion of children with CSE had partial seizures (p < 0.001). Controlling for clinical, demographic, and family characteristics, CSE was significantly associated with poorer HRQL (β = -4.65, p = 0.031). The final model explained 47% of the variance in QOLCE scores.

CONCLUSIONS

The findings suggested that not only do children with CSE have significantly poorer HRQL compared with their non-CSE counterparts, but that this factor is independent of the effects of demographic and clinical features known to affect HRQL.

Cognitive functioning in idiopathic generalised epilepsies: a systematic review and meta-analysis

Cognitive function in idiopathic generalised epilepsies (IGE) is of increasing research attention. Current research seeks to understand phenotypic traits associated with this most common group of inherited epilepsies and evaluate educational and occupational trajectories. A specific deficit in executive function in a subgroup of IGE, juvenile myoclonic epilepsy (JME) has been a particular focus of recent research. This systematic review provides a quantitative synthesis of cognitive function outcomes in 26 peer-reviewed, case-control studies published since 1989. Univariate random-effects meta-analyses were conducted on seven cognitive factor-domains and separately on executive function. Patients with IGE demonstrated significantly lower scores on tests across all cognitive factor-domains except visual-spatial abilities. Effect sizes ranged from 0.42 to 0.88 pooled standard deviation units. The average reduction of scores on tests of executive function in IGE compared to controls was 0.72 standard deviation units. Contrary to current thinking, there was no specific deficit in executive function in JME samples, nor in other IGE syndromes. Of more concern, people with IGE are at risk of pervasive cognitive impairment.

Intelligence quotient is associated with epilepsy in children with intellectual disability in India

Background:

Epilepsy is a disorder that is commonly found in people with intellectual disability (ID). The prevalence of epilepsy increases with the severity of ID. The objective of this study was to determine if there is an association between intelligence quotient (IQ) and epilepsy in children with ID.

Materials and Methods:

A total of 262 children, aged 3-18 years, with ID were identified as part of a community-based rehabilitation project. These children were examined for epilepsy and diagnosed by a psychiatrist and physicians based on results of electroencephalogram tests. A Spearman's correlation (ρ) was used to determine if there was an association between IQ scores and the occurrence of epilepsy. X² statistics used to examine the relationship of epilepsy with gender, socioeconomic status, population type, severity of ID, family history of mental illness, mental retardation, epilepsy, and coexisting disorder.

Results:

Spearman's rho –0.605 demonstrates inverse association of IQ with epilepsy. X² demonstrates statistically significant association (P < 0.05) with gender, severity of ID, cerebral palsy, behavior problems, and family history of mental illness, mental retardation, and epilepsy.

Conclusions:

Lower IQ score in children with ID has association with occurrence of epilepsy. Epilepsy is also found highly associated with male gender and lower age.

Intellectual functioning in children with epilepsy: frontal lobe epilepsy, childhood absence epilepsy and benign epilepsy with centro-temporal spikes

PURPOSE

The purpose of our study is to describe intellectual functioning in three common childhood epilepsy syndromes - frontal lobe epilepsy (FLE), childhood absence epilepsy (CAE) and benign epilepsy with centro-temporal spikes (BECTS). And also to determine the influence of epilepsy related variables, type of epilepsy, age at epilepsy onset, duration and frequency of epilepsy, and treatment on the scores.

METHODS

Intellectual functioning was examined in a group of 90 children with epilepsy (30 FLE, 30 CAE, 30 BECTS), aged 6-15 years, and compared with a control group (30). All subjects obtained a Full Scale IQ ≥ 70 and they were receiving no more than two antiepileptic medications. Participants completed the Wechsler Intelligence Scale for Children - Third Edition. The impact of epilepsy related variables (type of epilepsy, age at epilepsy onset, duration of epilepsy, seizure frequency and anti-epileptic drugs) on intellectual functioning was examined.

RESULTS

Children with FLE scored significantly worse than controls on WISC-III Verbal IQ, Full Scale IQ and Processing Speed Index. There was a trend for children with FLE to have lower intelligence scores than CAE and BECTS groups. Linear regression analysis showed no effect for age at onset, frequency of seizures and treatment. Type of epilepsy and duration of epilepsy were the best indicators of intellectual functioning.

CONCLUSION

It is crucial that children with FLE and those with a longer active duration of epilepsy are closely monitored to allow the early identification and evaluation of cognitive problems, in order to establish adequate and timely school intervention plans.

Preliminary feasibility, acceptability, and efficacy of an innovative adherence intervention for children with newly diagnosed epilepsy

OBJECTIVE

To report acceptability, feasibility, and preliminary efficacy from a randomized controlled trial of a family-tailored adherence intervention (AI) targeting nonadherence to antiepileptic drugs in pediatric new-onset epilepsy.

METHOD

30 children with new-onset epilepsy (7.2 ± 3.1 years old, 47% male) and their caregivers participated. At baseline, participants were given adherence electronic monitors. After a 1-month run-in period, participants with good adherence (≥90%) were monitored. Participants with adherence <90% were randomized to the AI or Treatment-As-Usual (TAU) group. The AI group received four adherence promotion intervention sessions over >2 months. Follow-up adherence data were collected.

RESULTS

8 families were randomized (AI, n = 4; TAU, n = 4). Families perceived AI to be feasible and acceptable. Preliminary results demonstrated that the AI group had improved adherence from baseline to post-test.

CONCLUSIONS

A family-tailored AI appears promising and needs to be tested with a larger pediatric epilepsy sample.

Verbal Memory and IQ in Children who Undergo Focal Resection for Intractable Epilepsy:A Clinical Review

Previous studies have indicated an increased likelihood of intellectual and memory impairments in children with epilepsy. It has been argued that early surgical intervention in children with intractable seizures might be advantageous to their development. We conducted a retrospective review of pre- and postoperative IQ and verbal memory scores in 16 paediatric patients who underwent temporal (N = 10) or extra-temporal (N = 6) focal surgery for epilepsy. Patients with an extratemporal seizure focus performed significantly worse than patients with a temporal lobe seizure focus on Full Scale IQ and Verbal IQ before surgery. Postoperatively a statistically significant decline in verbal memory, but not in any of the IQ indices was noticed in the extratemporal group. Individual outcome analyses revealed a significant decline in verbal memory in 22% of temporal lobectomy and 60% of extratemporal cases. Our review suggests that verbal memory but not IQ is vulnerable to postoperative decline in children who undergo focal extratemporal surgery for intractable epilepsy. The findings raise the possibility that extratemporal regions play a role in anterograde memory in children. Given the small number of subjects in this study, further investigations into the cognitive effects of paediatric surgical intervention are recommended.

Review article: Convulsive and non-convulsive status epilepticus: an emergency medicine perspective

Status epilepticus (SE) is divided into convulsive and non-convulsive types; both are associated with significant morbidity and mortality. Although convulsive SE is easily recognized, non-convulsive SE remains an elusive diagnosis as physical signs are varied and subtle. Successful management depends on a comprehensive approach that involves diagnostic testing and pharmacological interventions while ensuring cerebral oxygenation and perfusion at all times. There are a limited number of well-designed studies to support the development of evidence-based recommendations for the management of SE, especially for the management of non-convulsive status. Benzodiazepines, specifically lorazepam, continue to be the most commonly recommended first-line therapy; best treatment for refractory status cases depends on resources available and must be tailored to the individual institution. In order to facilitate care, it is recommended that each institution develop a management protocol for these patients.

Impact of antiepileptic drugs on cognition, behavior, and motor skills in children with new-onset, idiopathic epilepsy

OBJECTIVE

As treatment options for epilepsy have increased, there has been a commensurate increase in interest in the side effect profiles of these drugs.

METHODS

In this study, children between the ages of 6 and 17 with a diagnosis of new-onset, idiopathic epilepsy were evaluated at baseline (n=57) and 6 (n=45) and 12 (n=31) months after initiation of antiepileptic drug therapy.

RESULTS

There was improvement in the cognitive functioning of children after 12 months of treatment. A transient drop in performance of children with generalized seizures (10 of 11 of whom had absence seizures) at 6 months may have been due to persistent seizures, the drugs used to treat them (predominantly ethosuximide), or both. Worsening of reaction time and reaction time variability in the focal seizure group, the only scores showing persistent deterioration over 12 months, may be attributable to the medications used for this group, the most common of which was carbamazepine.

CONCLUSIONS

There were few adverse effects of antiepileptic drug treatment in the group followed over 12 months. Carbamazepine may have been responsible for persistent impairment of reaction time and reaction time variability.

Outcome of convulsive status epilepticus: a review

The outcome of CSE in childhood depends mainly upon the cause but length of seizure may also be important

Performance of Children with Epilepsy and Normal Age-Matched Controls on the WISC-III

Research findings regarding the effects of childhood epilepsy on general intelligence have produced variable results. The aim of this study was to investigate the effects of epilepsy, age of seizure onset, and Antiepileptic Drugs (AED) on intellectual ability as assessed by the Wechsler Intelligence Scale for Children, 3rd Edition (WISC-III; Wechsler, 1991). This study included children with epilepsy assessed with the WISC-III who achieved either a Full Scale, Verbal Scale, or Performance Scale IQ score >or= 70. A clinical sample of children diagnosed with epilepsy (n = 32) were age- and gender-matched with subjects from the normative standardization sample for the WISC-III, yielding a total sample of 64 subjects. Comparison using a MANOVA revealed significant differences across WISC-III Index standard scores (p = 0.0005) and subtest scaled scores (p = 0.0013), with control participants performing better than epileptic participants. Secondary analyses were also conducted considering monotherapy (n = 14) versus polytherapy (n = 11), and age of seizure onset (<6 years, n = 12; 6 > years, n = 15). MANOVA comparisons revealed no significant differences between groups across WISC-III Index standard scores.

Outcome of paediatric convulsive status epilepticus: a systematic review

We did a systematic review on the outcome of paediatric convulsive status epilepticus (CSE) and investigated the role of biological and non-biological variables in reported outcomes. The methodological quality of the 63 studies that met our inclusion criteria was assessed. Study design, type of study, and length of follow-up influenced the outcome. The studies with highest methodological quality are associated with better outcome: short-term mortality between 2.7% and 5.2% and morbidity other than epilepsy less than 15%. The incidence of subsequent epilepsy is not increased after cryptogenic CSE. Causal factor is the main determinant of outcome and the effect of age or duration is difficult to separate from the underlying cause. The risk of sequelae in unprovoked and febrile CSE is low. There is some evidence that CSE, especially febrile CSE, might cause hippocampal injury, although its role in the development of mesial temporal sclerosis is unknown.

Neuropsychological outcome following focal cortical removal for intractable epilepsy in children

In children, surgery for epilepsy has been recognized as a viable treatment option since publication of S. Davidson and M.A. Falconer's outcome study in 1975 [Lancet North Am Ed 5:1260-3], which demonstrated that medical outcome of children who underwent anterior temporal lobectomy paralleled that of adults. Pediatric surgical programs and the literature on medical outcome have grown considerably since that time, with surgery being offered to children with temporal but also extratemporal epilepsy foci. Comparatively little work has been conducted in the area of neuropsychological outcome. This article outlines differences in adult and pediatric outcome studies, reviews the literature on the intellectual and memory outcome in children, and discusses shortcomings of the pediatric outcome research conducted to date.

Intelligence in childhood epilepsy syndromes

Intellectual deficits play a significant role in the psychosocial comorbidity of children with epilepsy. Early educational intervention is critical.

OBJECTIVE

This study aims to determine the intellectual ability of children with common childhood epilepsy syndromes-generalised idiopathic epilepsy (GIE), generalised symptomatic epilepsy (GSE), temporal lobe epilepsy (TLE), frontal lobe epilepsy (FLE), central epilepsy (CE) and non-localised partial epilepsy (PE).

METHODS

A prospective consecutive series of 169 children were recruited. Epilepsy syndrome was identified by clinical data, seizure semiology, interictal and ictal EEG in each child, using International League Against Epilepsy criteria. Each child had neuropsychology assessment using age-normed and validated instruments. After adjusting for important epilepsy variables, 95% confidence intervals were generated for mean full-scale intelligence quotient (FSIQ) using ANCOVA.

RESULTS

Significant differences between epilepsy syndrome groups were found for age of onset (P<0.001), duration of active epilepsy (P=0.027), seizure frequency (P=0.037) and polytherapy (P=0.024). Analysing FSIQ, children with GIE, CE and TLE performed best, and did not differ statistically. Children with GSE had a statistically lower FSIQ than other syndrome groups except PE. FLE functioned significantly better than GSE, but did not differ statistically from other groups.

CONCLUSIONS

In childhood epilepsy, delineation of the syndrome has important implications when considering intellectual potential. This information is invaluable in planning educational interventions and supporting the family.

The effects of refractory epilepsy on intellectual functioning in children and adults. A longitudinal study

The aim of this study was to compare the long-term consequences of refractory epileptic seizures for intellectual functioning in pediatric and adult patients, taking the severity of the epilepsy into consideration. Thirty-four patients, 17 children (mean age 10.2 years) and 17 adults (mean age 24.4 years) were tested twice with the age-appropriate version of Wechsler's Intelligence Scales. The mean test-retest interval in the two groups was 3.5 and 6.0 years, respectively. There were no statistically significant differences between the groups with respect to severity of the epilepsy at Test 1, as indicated by retrospective assessments of seizure severity, interictal EEG pathology, and number of antiepileptic drugs received per patient. Assessments of changes in these variables during the test-retest interval did not indicate different courses of the disease in the two groups. Despite these similarities, a statistically significant difference was found between the children and the adults regarding changes in intellectual functioning. In the children, there was a decline in mean intelligence quotient (IQ) scores during the test-retest interval, while the IQ scores increased in the adult group. It is concluded that recurrent seizures may represent a considerable risk for intellectual decline in children, while intellectual functioning seem to be less vulnerable in adults with early onset of epilepsy.

Risk factors for poor health-related quality of life in adolescents with epilepsy

PURPOSE

To examine potential risk factors for poor health-related quality of life (HRQOL) among adolescents with epilepsy by using the newly developed QOLIE-AD-48. Risk factors were derived from sociodemographic, social, academic, and epilepsy- and health-related domains.

METHODS

The QOLIE-AD-48 was administered to 197 English-speaking adolescents (age 11-17 years from >20 sites in the United States and in Canada). The self-report instrument yields an overall HRQOL score and eight subscale scores. Other data were obtained from family interviews, physician reports, and health records. Multiple regression analyses were conducted to study risk factors for impairment of HRQOL.

RESULTS

Older adolescents (age 14-17 years), those with more severe epilepsy and more symptoms of neurotoxicity, and those living in households with lower socioeconomic status were more likely to report poor overall HRQOL. Risk factors in the eight HRQOL domains were found as follows: (a) Epilepsy Impact: older age in adolescence, more severe epilepsy and neurotoxicity, more hospitalizations during the past year, and fewer hours of extracurricular activities; (b) Memory and Concentration: longer duration of epilepsy, special education classes, and history of repeating a grade in school; (c) Attitude Toward Illness: older age, female gender, and more severe epilepsy and neurotoxicity; (d) Social Support: younger age, male gender, and fewer hospitalizations in the last year; (e) Stigma: lower socioeconomic status and special-education classes; and (f) Health Perceptions: older age, female gender, and lower socioeconomic status. None of the factors examined was significantly associated with HRQOL in (g) Physical Functioning or (h) School Behavior subscales.

CONCLUSIONS

We identified several risk factors for poor HRQOL outcomes in adolescents with epilepsy. Age, increased seizure severity, and neurotoxicity were most consistently associated with poor HRQOL across domains. Older adolescents, independent of epilepsy severity, reported worse overall HRQOL than did their younger counterparts. Older adolescents also were more likely to perceive a greater negative impact on life and general health, and had more negative attitudes toward epilepsy. Adolescent boys and girls may show different sensitivities to various quality-of-life domains.

Cognitive and behavioural concerns in epileptic children

Cognitive performance in an epileptic child has been a difficult issue to predict in day-to-day clinical practice. Several observations made in early and later part of this century do not provide uniform and convincing answer to this issue. Recent trends in research however, have identified certain variables that are shown to be associated with cognitive decline in epileptic children. Together with associated behavioural problems, the resultant school difficulty is the essence of this concern for the parents. The variables related to cognitive deterioration as identified by several studies include underlying brain pathology (symptomatic epilepsy), early age of onset of seizure, severity and intractability of seizure, repeated head trauma, an episode of status epilepticus, presence of interictal subclinical EEG discharge, adverse psychosocial factor and antiepileptic drug (AED). Association of these variables in a given case cannot only predict adverse cognition outcome but also a preventive management package can be planned aiming at avoiding or minimizing these high risk variables.

Antiepileptic drugs, learning, and behavior in childhood epilepsy

Cognitive and behavioral impairments are found more often among epileptic children than among their peers. The cause of these impairments is multifactorial. Identifying the relative contribution of antiepileptic drugs (AEDs) to these problems has been the object of a large number of clinical investigations. This area of research has been characterized by an unusually high number of methodological challenges and pitfalls. Accordingly, results have often been inconsistent and contradictory, except for the more obvious observations that can be derived from clinical experience. Overall, the effects of AEDs on cognition and behavior in children have been overrated in the past. More recent research has benefited from the methodological lessons of previous studies and it suggests that the majority of children taking AEDs do not experience clinically relevant cognitive of behavioral adverse effects from these medications. In addition, some of the newer AEDs may indeed have a better cognitive profile. Nevertheless, clinical experience must be used to identify the subgroup of children who remain at risk for significant and clinically relevant cognitive and behavioral adverse effects of AEDs.

Neuropsychological patterns in pediatric epilepsy

Results from comprehensive neuropsychological assessments of children diagnosed with epilepsy have rarely been reported. Previous research has generally focused on the measurement of overall intellectual ability and achievement skills. In the present study, neuropsychological evaluations including memory, attention, language, achievement, fine motor, executive function, visual motor integration, and behavior were completed on children (n = 79) diagnosed with epilepsy. Neurocognitive skills were within expectations for measured intelligence with the exception of verbal and visual attention skills, which were significantly below expectations based on measured ability. Behaviorally, children were rated by their parents as demonstrating clinically elevated attentional problems. Differences in cognitive and behavioral function were not found according to seizure type. Findings suggested a more diffuse effect of childhood epilepsy reflected in a pattern of decreased attention skills.

Medical and social factors associated with cognitive outcome in individuals with myelomeningocele

The interrelationship between biological and social risk factors and cognitive outcome in individuals with myelomeningocele was examined. The Kaufman Brief Intelligence Test (K-BIT) was administered to 65 children and young adults, age range 4 to 29 during a recent clinic visit. Unshunted individuals had scores in the average range and individuals with uncomplicated hydrocephalus in the low-average range. Although the level of lesion was found to be most strongly associated with total K-BIT score, examination of subscores indicated that socioeconomic status was the factor most strongly associated with Vocabulary score. The importance of both social and biological factors in predicting cognitive outcome in this population is useful in planning intervention strategies.

Predicting cognitive impairment in epilepsy: findings from the Bozeman epilepsy consortium

We examined the contribution of age of seizure onset, seizure duration, seizure laterality, seizure location, gender, handedness, and cerebral speech representation to cognitive attainment in 1,141 patients with medically refractory seizures. The combined influence of the predictor variables was modest. Age of seizure onset was the best single indicator of Full Scale IQ (partial r = .23) and General Memory (partial r = .20). Laterality and location of dysfunction, and cerebral speech dominance were also relevant and independent indicators of aspects of cognition. Except for age of onset of seizures (early onset was associated with poorer cognitive attainment), however, the magnitude of the effects was limited.

Cognitive and behavioral effects of antiepileptic drugs

All antiepileptic drugs (AEDs) have the potential for adverse effects on cognition and behavior. Most of the major AEDs, administered in therapeutic doses, cause little or no cognitive or behavioral impairment in group studies. However, individual variability is considerable, and some patients do not tolerate low serum levels, whereas others tolerate high levels without subjective or objective effects. In the past, carbamazepine (CBZ) and valproate (VPA) have been reported to have the fewest adverse cognitive and behavioral effects in children and adults. However, several recent, well-controlled studies have not found significant differences between the effects of phenytoin (PHT) and those of CBZ or VPA. Greater adverse effects have been found for phenobarbital (PB). However, we must use environmentally relevant measures of cognitive and behavioral functioning to measure effects on daily functioning. Future studies must define cognitive and behavioral toxicity in subpopulations (e.g., post-traumatic epilepsy, mental retardation, depression) and with the new AEDs.