Behavioral, Cognitive, and Social Aspects of Childhood Epilepsy

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Chapter 62 Behavioral, Cognitive, and Social Aspects of Childhood Epilepsy

Wendy G. Mitchell, Michèle Van Hirtum-Das, Jay Desai, Quyen N. Luc

Children and adolescents with epilepsy and adults with childhood-onset epilepsy often are reported to have social maladjustment, including poor educational attainment, lower than expected occupational status, poorer perceived health and fitness, more frequently reported behavior problems, lower rates of marriage as adults, and higher rates of social isolation at all ages [Camfield et al., 1993; Clement and Wallace, 1990; Hoare, 1984; Jalava and Sillanpaa, 1997; Rutter et al., 1970; Sillanpaa, 1990]. These poor outcomes have multiple causes. In any particular patient, one or more causes of poor functioning may be identified and, at times, remedied. In general, neither epilepsy nor the seizures themselves are the most important cause of cognitive or behavioral disability. The underlying causes of cognitive and behavioral dysfunction may be subtle or obvious, but generally are complex and multifactorial. In some instances, underlying neurologic structural lesions cause both epilepsy and other disabilities, including cognitive dysfunction. In others, such as benign focal epilepsy of childhood, learning and behavioral disorders are more difficult to explain, and the relationship with epilepsy is almost certainly not causal.

Cognitive and Behavioral Disorders

Cognitive Disabilities in Children with Epilepsy

Although not all children with epilepsy have cognitive impairment, epilepsy is more frequent in cognitively handicapped children than in the general population [Britten et al., 1986; Forsgren et al., 1990; Sillanpaa, 1992]. Various population-based prospective and cohort studies of mentally retarded children have documented the prevalence of epilepsy to be 15–35 percent. Children with severe mental retardation and cerebral palsy have the highest rates of epilepsy. Table 62-1 contains information from selected population-based or cohort studies that estimate the prevalence of epilepsy in mentally retarded populations. Caution must be used in interpreting this information, since definition of both epilepsy and mental retardation varies. Several studies divide mentally retarded groups into mild (intelligence quotient [IQ] of 50–70) and moderate to severe mental retardation (IQ under 50). Epilepsy is substantially more prevalent in severely retarded cohorts. Prevalence of epilepsy is highest in cohorts of mentally retarded children with associated cerebral palsy [Curatolo et al., 1995; Sussova et al., 1990]. Even excluding children with major structural brain disease causing epilepsy and associated disabilities, mental retardation is more common in children with epilepsy than in children without epilepsy, with or without other chronic illnesses. Table 62-2 lists selected studies of the prevalence of mental retardation in cohorts of children with epilepsy or in populations surveyed for both mental retardation and epilepsy. Again, definition of both epilepsy and mental retardation is not uniform.

Table 62-1 Rates of Epilepsy in Cognitively Impaired Children and Adolescents: Population and Cohort Studies

Table 62-2 Frequency of Cognitively Impaired in Children with Epilepsy: Population and Cohort Studies

Cognitive Function in Benign Childhood Epilepsy Syndromes

Many studies have noted subtle cognitive dysfunction in children with epilepsy syndromes known to have a good prognosis, easily attainable seizure control, and no structural brain disease, such as childhood absence epilepsy and benign focal epilepsy of childhood [D’Allessandro et al., 1990; Dieterich et al., 1985; Olsson and Campenhausen, 1993; Piccirilli et al., 1994; Singhi et al., 1992]. The cognitive dysfunction detected in children with childhood absence epilepsies includes deficits in visual sustained attention and execution of visual-motor tasks [Levav et al., 2002], verbal memory and word fluency [Henkin et al., 2005], and nonverbal memory and delayed recall [Pavone et al., 2001]. Children with benign childhood epilepsy with centrotemporal spikes have been documented as having difficulties in memory and phonologic processing skills [Northcott et al., 2005]. Furthermore, this condition has been shown to be strongly comorbid with reading disability and speech sound disorder (development of motor control of speech). These deficits are thought to be independently inherited traits rather than a consequence of the epilepsy itself, with increased odds amongst relatives of the proband [Clarke et al., 2007]. Benign childhood epilepsy with occipital paroxysms has been found to be associated with selective dysfunction in perceptive-visual attentional ability, verbal and visual-spatial memory abilities, visual perception, visual-motor integration, some language tasks, reading, writing abilities, and arithmetic abilities [Germano et al., 2005].

Cognitive Dysfunction Due to Interictal Epileptiform Discharges

Conflicting evidence exists regarding the role of interictal epileptiform discharges in cognitive function, as distinct from ictal effects and from the long-term stable interictal effects caused by the clinical syndrome or the underlying etiology [Aldenkamp et al., 2004]. Studies using sophisticated computerized cognitive test batteries time-locked to electroencephalography (EEG) discharges have noted transient cognitive impairment with slowing of reaction times and decreased perceptual accuracy during epileptiform discharges [Aldenkamp et al., 1996; Binnie, 2003, 1993; Shewmon and Erwin, 1989]. At least one study has shown low incidence of such impairment and questioned its clinical significance [Fonseca et al., 2007]. Refinement of methodology has suggested that a larger proportion of presumed transient cognitive impairment can be attributed to subtle seizures, while interictal epileptic activity has a smaller effect upon cognitive functioning [Aldenkamp et al., 2004]. Finally, the effects of such transient cognitive impairment on more stable tasks, such as reading or intelligence, have not been studied and are unknown.

Learning Disabilities and Academic Underachievement

Learning disability is diagnosed when one or more areas of learning are significantly below expectations, and not explained by overall cognitive level, sensory abnormalities, or lack of opportunity or teaching (see Chapters 43 and 45). Learning disabilities are reported to be more frequent in children with epilepsy. Studies have shown that children with epilepsy are at higher risk for repeating a year in school and over half require special education services. Although the frequency of special education placement was significantly higher in the children with remote symptomatic epilepsy and epileptic encephalopathies, in one study 48.9 percent of those considered neurologically normal received some form of special educational services [Berg et al., 2005].

Educational underachievement in reading, writing, and math has been reported in a variety of settings, comparing children with epilepsy both with their normal peers and with children with other chronic illnesses, such as asthma [Bagley, 1970; Fastenau et al., 2004; Holdsworth and Whitmore, 1974; Mitchell et al., 1991; Seidenberg et al., 1986; Selassie et al., 2008; Stores, 1981; Stores and Hart, 1976; Sturniolo and Galletti, 1994; McNelis et al., 2007]. It is unclear whether the relationship is a direct one, in which the epilepsy, seizures, or medications themselves cause learning disability, or an indirect one, in which an underlying neurologic condition causes both seizures and abnormalities in perception, memory, and visual-motor skills. Educational underachievement may be excessive in subjects drawn from inner-city teaching hospitals because of social factors entirely unrelated to medical conditions [Mitchell et al., 1991]. Parental expectations for a child with epilepsy are often lowered, at times inappropriately [Chavez, 1985; Hartlage and Green, 1972; Hoare and Kerley, 1991; Long and Moore, 1979]. Even after the effects of sociocultural variability have been accounted for, at least some children with epilepsy manifest learning disabilities. In one study comparing children with newly diagnosed epilepsy to children with recently diagnosed moderate asthma, academic underachievement was significantly more common in children with epilepsy, particularly boys with severe epilepsy [Austin et al., 1998]. Earlier seizure onset, generalized nonabsence seizures, and comorbid attention-deficit hyperactivity disorder (ADHD) appear to be risk factors for learning disability amongst children with epilepsy. However, a diagnosis of epilepsy, even when seizures are less severe and controlled, should provide sufficient cause to screen children for learning disability and to monitor academic performance continuously [Fastenau et al., 2008].

Detailed neurocognitive batteries in children with epilepsy demonstrate higher than expected rates of dyslexia, visuospatial difficulties, nonverbal learning difficulties, attention/executive/construction difficulties, verbal memory and learning problems, language difficulties, and slowed processing speeds [Mitchell et al., 1992; Fastenau et al., 2009]. With psychometric testing, almost half of the children with epilepsy met criteria for a learning disability [Seidenberg et al., 1986; Fastenau et al., 2008]. Some of these findings may be related to subtle or overt underlying structural lesions causing both the epilepsy and the learning disability, but not all can be readily explained. Numerous studies attempting to identify demographic, neurological, and seizure-related risk factors for academic underachievment have shown inconsistent results. Inadequate seizure control, early age of onset, longer duration of disorder, and polytherapy have not universally been shown to be associated with academic underachievement. Additionally, in children with normal IQ, no significant relationship between epilepsy type/syndrome and educational problems has been found [Mitchell et al., 1991; Oostrom et al., 2005; McNelis et al., 2007].

Attention Deficit, Impulsivity, and Overactivity

Attention, impulsivity, and activity level can be measured in various ways, ranging from parent and teacher questionnaires to psychometric testing to computerized continuous performance tasks. Regardless of methods used, most studies of children and adults with epilepsy demonstrate an excess incidence of inattention, impulsivity, and slowed reaction time [Kinney et al., 1990; Mitchell et al., 1992; Stores, 1978]. These findings should not imply that clinical ADHD is extremely common in children with epilepsy, although the prevalence is probably somewhat higher than in the general population. As with overall cognitive function in children with epilepsy, simple cause and effect relationships are uncommon. Underlying neurologic conditions may cause both ADHD and epilepsy [Kinney et al., 1990]. Antiepileptic medications may affect attention and impulsivity, both positively and negatively, at least in some persons [Mitchell et al., 1993; Riva and Devoti, 1996]. Measured effects on attention are small, and may not be clinically significant. In rare instances, frequent seizures may affect attention, and seizure control may eliminate an apparent attention deficit. There is some evidence that frequent epileptiform discharges may disrupt attention, which may improve with antiepileptic treatment [Gordon et al., 1996].

Autism and Autistic Spectrum Disorders

Autistic spectrum disorders are associated with an increased incidence of epilepsy, but evidence that one causes the other is lacking [Carlton Ford et al., 1995; Cavazzuti and Nalin, 1990; Olsson et al., 1988; Steffenburg et al., 1996; Wong, 1993]. A number of syndromes are associated with a high incidence of both autistic behavior and seizures (e.g., Angelman’s syndrome, tuberous sclerosis), but the coincidence of seizures and behavioral disorder is due to the underlying condition. A possible rare exception is the child in whom autistic behavior develops along with language regression, accompanied by an epileptiform EEG (continuous spike-and-wave pattern during sleep) [Hirsch et al., 1990; Kyllerman et al., 1996; Perez et al., 1993; Roulet et al., 1991]. This condition has been considered to be a variant of Landau–Kleffner syndrome. Behavior and language may improve with treatment with antiepileptics (rarely), corticosteroids, or corticotropin, or after subpial transection of epileptogenic cortex [Hirsch et al., 1990].

Psychiatric Disorders in Childhood Epilepsy

Little evidence exists to support the notion that severe psychiatric disorders are more common in children with epilepsy. Although major psychiatric illnesses, such as schizophrenia, obsessive-compulsive disorder, or affective disorders, may coexist with childhood epilepsy, the prevalence is not higher than in the general population. Treatment of coexisting severe psychiatric disorder and epilepsy may be complex. Some antiepileptics (carbamazepine, valproic acid) are reported to be beneficial in treatment of certain psychiatric disorders, most notably bipolar affective disorder [Fenn et al., 1996]. In general, however, treatment of epilepsy does not relieve symptoms of major psychiatric illness. Occasionally, “paradoxical normalization,” or “forced normalization,” is reported in children who experience a decrease in psychiatric symptoms when seizures are uncontrolled, with worsening of symptoms when seizures are in good control [Amir and Gross-Tsur, 1994].

Depressive disorders and mood disturbances have been reported more frequently in adolescents and adults with epilepsy than in healthy peers. Prevalence of depression in children and adolescents with epilepsy is significantly higher than in the general pediatric population [Dunn et al., 1999; Ettinger et al., 1998]. Moreover, depressive disorders are often underdiagnosed and undertreated in patients with pediatric epilepsy [Plioplys, 2003]. A number of studies have clearly highlighted that suicidal ideation and attempts are more likely to be seen in children and adolescents with epilepsy than in the general pediatric population [Baker, 2006; Oguz et al., 2002; Thome-Souza et al., 2007]. In addition to depression, anxiety disorders are frequent comorbidities in childhood epilepsies [Ekinci et al., 2009]. The etiology of depressive symptoms may be complex; social stigma, lack of employment opportunities, and lack of social contacts may contribute to depression. Self-reported quality of life is lower in adolescents with epilepsy than in adolescents with asthma. Although this difference was more striking for young persons with active epilepsy, quality of life measures were low, even when seizures were fully controlled or inactive [Austin et al., 1996].

Behavioral Problems, Conduct Disorders, and Delinquency

Behavioral disturbances in children and adolescents with epilepsy may be due to family factors and parental anxiety about epilepsy, rather than a primary result of epilepsy or of the underlying neurologic disorder [Austin et al., 1992; Carlton Ford et al., 1995; Gortmaker et al., 1990; Hoare and Kerley, 1991; Lothman and Pianta, 1993; Mitchell et al., 1994; Pianta and Lothman, 1994]. Self-esteem is reported to be lower and behavioral problems are more frequent in children and adolescents with epilepsy than in peers with or without chronic illnesses such as asthma or diabetes [Apter et al., 1991; Austin, 1989; Hoare and Mann, 1994; Matthews et al., 1982; Westbrook et al., 1991]. When children with epilepsy are assessed at the time of first seizure diagnosis, behavior problems are frequently reported by parents and teachers, particularly in children who had previously unrecognized seizures [Austin et al., 2001, 2002]. Children with epilepsy have higher rates of oppositional-defiant disorder [Dunn et al., 2009; Jones et al., 2007] and conduct disorder [Davies et al., 2003; Dunn et al., 2009] compared to the general population.

Adolescents and young adults with childhood-onset epilepsy have slightly higher than expected rates of delinquency in some studies [Camfield et al., 1993]. It is uncertain whether this propensity is due to underlying brain disease with poor impulse control, stigma, lack of opportunity, or other sociocultural factors. A population-based study in Finland, however, failed to find a relationship between delinquency and epilepsy in males up to age 22 years, although delinquency was associated with a history of central nervous system trauma [Rantakallio et al., 1992].

Cognitive and Behavioral Outcome of Specific Epilepsy Syndromes

Infantile Spasms

Certain pediatric epilepsy syndromes have been associated with significant, sometimes devastating, cognitive or behavioral declines. Perhaps the best studied of the catastrophic childhood epilepsies is infantile spasms. Mental retardation has been reported in up to 80 percent of children with infantile spasms and is described as severe in more than half of the cases [Jambaqué, 1994]. Although many patients exhibit global arrest of development, specific cognitive deficits, such as speech difficulties and impaired visuospatial abilities, have been noted in others [Besag, 2004]. Thirteen percent of those with cryptogenic infantile spasms were reported to exhibit persistent autistic features. In children with infantile spasms due to tuberous sclerosis, rate of autism is higher (58 percent) [Bolton et al., 2002; Hunt and Dennis, 1987; Riikonen and Amnell, 1981]. Effective early treatment of both cryptogenic and symptomatic spasms may improve cognition and behavior [Caplan et al., 2002; Jambaqué et al., 2000; Kivity et al., 2004]. Other prognostic factors for a better cognitive outcome include sustained seizure control with the first medication [Partikian and Mitchell, 2009], age at onset equal to or greater than 4 months, and absence of atypical spasms and partial seizures [Riikonen, 2009].

Epileptic Encephalopathies of Infancy

Many of the epileptic encephalopathies with neonatal or infantile onset are associated with frequent seizures that are notoriously refractory to treatment with both conventional and newer antiepileptic medication. Included in this group are severe myoclonic epilepsy of infancy (Dravet’s syndrome), early infantile epileptic encephalopathy (Ohtahara’s syndrome), neonatal myoclonic encephalopathy (or early infantile myoclonic encephalopathy), and migrating partial seizures of infancy. Delayed development usually is seen by the second year, and interpersonal relationships rarely progress past a level expected for that of a 2-year-old [Besag, 2004]. Behavior in the affected child typically is hyperactive with autistic features. It is difficult to attribute the abnormalities in cognition and behavior fully to the frequent seizures and paroxysmal findings on EEG, when an undiagnosed metabolic or genetic etiology may play a causative or contributory role. In children with tuberous sclerosis or Sturge–Weber syndrome, early control of seizures is associated with a more favorable neurodevelopmental and behavioral outcome [Jambaqué et al., 2000; Kramer et al., 2000].

Lennox–Gastaut Syndrome

Lennox–Gastaut syndrome frequently has been associated with autistic features and cognitive deficits, although published literature specific to this topic is sparse [Besag, 2004]. Long-term follow-up evaluation of these patients commonly reveals slowness of intellectual ability and motor speed, apathy (possibly better described as an inability to engage with the environment secondary to frequent epileptiform discharges), and perseverative behavior [Kieffer-Renaux et al., 2001].

Electrical Status Epilepticus in Sleep and Landau–Kleffner Syndrome

Electrical status epilepticus in sleep is an EEG pattern detected in some cases of pediatric epilepsy that often is associated with specific cognitive and language dysfunction. It frequently is encountered in those syndromes described as continuous spikes and waves (during slow-wave sleep and Landau–Kleffner syndrome). With continuous spike-and-wave activity in sleep, a typical decrease in the IQ or developmental quotient is noted by most investigators [Boel and Casaer, 1989; Roulet-Perez et al., 1993]. Of interest, some 40–60 percent of children with continuous spike-wave sleep exhibit an expressive aphasia, which is in contrast with children with Landau–Kleffner syndrome, who tend to present with a verbal or auditory agnosia [Galanopoulou et al., 2000]. In patients with Landau–Kleffner syndrome, language may recover spontaneously, partially improve with therapy, or unfortunately remain permanently affected despite improvement of the EEG abnormality [Besag, 2004].

Benign Focal Epilepsies of Childhood

Of specific note is the syndrome termed benign childhood epilepsy with centrotemporal spikes (benign rolandic epilepsy). Although this disorder was once thought of as a universally benign syndrome, increasing evidence suggests that a subpopulation of children may present with recent impairment of overall cognitive functioning, or difficulties with visual perception, concentration, and short-term memory [Weglage et al., 1997].

Family, Community, and Cultural Perceptions of Epilepsy

Social acceptance and inclusion of children and adolescents with epilepsy are far from complete, even when seizures are infrequent or fully controlled. In some cultural settings, it is not generally disclosed to friends or extended family that a child has epilepsy [Ju et al., 1990]. Some children are not sent to school if seizures are uncontrolled. Despite laws guaranteeing disabled and medically impaired children full access to education, some schools discourage attendance by children with active seizure disorders. All of these prejudices may further impair social and academic function in children with epilepsy. Fear of stigmatization may contribute to the high frequency of nondisclosure of epilepsy among adolescents [MacLeod and Austin, 2003]. It has been suggested that society’s understanding of epilepsy, as reflected through literature, has changed over time, and the ancient belief that seizures were a supernatural force has given way to the present understanding that epilepsy represents a medical condition [Jones, 2000]. However, a survey of a newer medium, movies released between 1937 and 2003 from four continents, found portrayal of all of the ancient beliefs about epilepsy, including demonic or divine possession, genius, lunacy, delinquency, and general “otherness” [Baxendale, 2003].

Social Adjustment of Adults with Childhood-Onset Epilepsy

Population-based studies from several countries document that social functioning is impaired in adults who had childhood-onset epilepsy, compared with their healthy peers [Farmer et al., 1992; Sillanpaa, 1990]. Marriage is less frequent, employment is less frequent and at less skilled occupations, and social isolation is more frequent. Differences are more striking when adults have on-going seizures, but are present even when complete remission or control has been obtained. Even when studies were restricted to adults with childhood-onset absence epilepsy, a disorder thought to be benign and likely to remit, social functioning continued to be impaired in comparison with that in nonepileptic peers [Dieterich et al., 1985]. Other studies of outcome in adults with childhood-onset epilepsy find substantial maladaptation as well, particularly in social and vocational function. Social functioning is generally much more impaired in the subgroup of adults with on-going seizures than in those who attain complete remission. A population-based study of adults in Nova Scotia, evaluated 25 years after a diagnosis of juvenile myoclonic epilepsy, documented a high frequency of social isolation, unemployment and social impulsiveness, with 74 percent having at least one major unfavorable social outcome [Camfield and Camfield, 2009].

In long-term follow-up (30 years) of a population-based cohort of children with epilepsy in Finland, about 60 percent of subjects were independent in activities of daily living, and 57 percent were employed, most in manual labor or semiskilled positions [Sillanpaa and Helenius, 1993]. Several studies are notable for including only adults with childhood-onset absence [Olsson and Campenhausen, 1993] or mixed generalized seizures (absence plus generalized tonic-clonic) [Dieterich et al., 1985]. Young adults with persisting absence seizures since childhood or adolescence, originally identified during a population-based study of absence epilepsy, were compared with a Swedish reference sample of young adults, assessing the impact of epilepsy on schooling, occupation, leisure-time activities, friends, daily routines, and housing. Although the overall employment rate did not differ from that in the reference subjects, persons with epilepsy were more likely to be employed in an unskilled job or in an occupation below that expected for educational level. Social isolation was reported in 34.5 percent, compared with 7.9 percent of the reference group. A high percentage of subjects (74 percent) reported that epilepsy had affected at least one area of their social functioning [Olsson and Campenhausen, 1993]. In a Finnish study of adults who had uncomplicated childhood-onset epilepsy, quality of life of adults with epilepsy in remission on medication was lower, and rates of unemployment were higher, than in comparison subjects or in adults whose epilepsy was in remission after withdrawal of medication [Sillanpaa et al., 2004].

Effects Of Antiepileptic Drugs on Behavior, Attention, and Mood

General Effects of Antiepileptic Drugs

Cognitive, psychiatric, and behavioral abnormalities in children with epilepsy often are attributed to antiepileptic medications. Most of these effects are unsupported by data from well-controlled, randomized, prospective clinical research. It is clear, however, that idiosyncratic adverse behavioral and cognitive responses can occur with any antiepileptic drug (see Chapter 59). In addressing issues of abnormal cognition and behavior in the management of pediatric epilepsy, several factors need to be recognized. Epilepsy occurring in the developing brain is likely to be substantially different from that in an adult in both its qualities and response to treatment. In addition, the most refractory epilepsies are likely to begin in childhood. The management of severe childhood epilepsy may prove challenging in that the choice of antiepileptic medication depends on the type of syndrome in which the seizures occur, as well as the cognitive and behavioral abnormalities that may occur with these syndromes. Finally, treating a combination of several seizure types in one patient may be difficult, because some anticonvulsants that are effective in treating one type of seizure may be ineffective or even exacerbate another seizure type.

In well-designed, controlled studies, evidence of long-term adverse cognitive effects of antiepileptic medications is generally slight or difficult to document objectively. A few studies have randomized subjects at the onset of seizures to receive one of several antiepileptic drugs [Aikia et al., 2006; Fritz et al., 2005; Forsythe et al., 1991; Mitchell and Chavez, 1987]. Most studies, however, examine patients assigned nonrandomly to receive various antiepileptic drugs when medication is started, changed, or withdrawn [Aldenkamp et al., 1993; Aman et al., 1994; Chen et al., 1996; Mitchell et al., 1993; Sabers et al., 1995; Stores et al., 1992]. The only double-blind, placebo-controlled, long-term studies of the behavioral effects of monotherapy with antiepileptic drugs are limited to studies of phenobarbital for febrile seizures in infants and toddlers [Farwell et al., 1990; Camfield et al., 1979]. There are many observational studies addressing cognitive and behavioral side effects, often comparing newer antiepileptic agents with older ones. These are typically limited to small patient cohorts and short-term follow-up. Comparative, blinded trials of anticonvulsant monotherapy in pediatrics are extremely limited. One exception is a recently completed comparative trial of monotherapy for childhood absence epilepsy compared ethosuximide, lamotrigine and valproic acid [Glauser et al., 2010]. While efficacy was similar for ethosuximide and valproic acid, negative behavioral effects were more frequent with valproate, particularly affecting attention.