David W. Dunn Indiana University School of Medicine Attention Problems: Controversies and Consequences for the Child with Epilepsy David W. Dunn Indiana University School of Medicine

Questions Do children with epilepsy have trouble with attention? Do children with epilepsy have more ADHD? How do we recognize these children? How do we help these children?

Academic Problems Brain damage or disease can cause both epilepsy and mental handicap. Children with epilepsy and normal intelligence have more learning problems than siblings or children with other chronic illnesses. Impaired attention leads to learning problems.

Attention in Children with Epilepsy Children with epilepsy have impaired sustained attention on psychological testing About 30-40% of children with epilepsy have symptoms of ADHD

Attention Deficit Hyperactivity Disorder Inattention: trouble concentrating, distractible, careless errors, forgetful, loses thins, doesn’t listen, incomplete work, poor organization, procrastinates Hyperactivity-impulsivity: fidgets, can’t stay seated, runs, noisy, talks excessively, interrupts, blurts out answers, can’t wait, constantly on the go

Recognition: Ask Quality care of the child with epilepsy requires more than reducing seizure frequency. Monitor school performance. Ask about behavior at home and school. Ask about relationships with friends and family.

Differential Diagnosis: Seizures Absence seizures or ADHD, inattentive type: Jane Williams found that “does not complete homework” and “does not remain on task” characterized ADHD not absences seizures Nocturnal seizures: Disrupted sleep leads to restlessness, inattention, distractibility. Watch for daytime sleepiness.

Differential Diagnosis: AEDs Antiepileptic drugs (AEDs) usually don’t cause trouble, but alertness improves with AED discontinuation. Phenobarbital, clonazepam, and topiramate more commonly cause symptoms of ADHD. Each AED can cause cognitive problems in the individual susceptible child

Differential Diagnosis: other disorders Learning disability: Approximately one-third of children with epilepsy have academic underachievement due to LD. Depression: Symptoms of depression occur in 25-30% of adolescents with epilepsy. Trouble with concentration and school failure are major symptoms. Anxiety: Seen in 23% of children with epilepsy. Symptoms include distractibility and restlessness.

Evaluation Reassess seizure control and medications. ADHD questionnaires for parent and teacher. Psychoeducational testing.

Management: Behavioral Parent Training: education about ADHD, training in interventions to reduce impulsivity and improve self-control School intervention: structure, immediate feedback, daily report cards

Management: Medication Stimulants: Methylphenidate (Ritalin) and the amphetamines have been used in children with epilepsy and are safe and effective Atomoxetine may be effective and safe, but there is no data yet. Tricyclic antidepressants and bupropion may lower the seizure threshold.

Summary Children with epilepsy have more problems with attention, particularly sustained attention. Approximately 1 in 3 children with epilepsy have symptoms of ADHD. Stimulant medications are both safe and effective.

Sarah Hunt, M.S., CRNP, CNRN Wellspan Neurology Attention Problems: Controversies and Consequences for the Child with Epilepsy Sarah Hunt, M.S., CRNP, CNRN Wellspan Neurology

Clinical Correlation Case studies: Focal epilepsy, learning disability and inattentiveness Primary generalized epilepsy with difficult to control seizures, and inattentiveness

Guidelines for the clinical portion This portion contains two case presentations At times during the case discussion, each participant will be asked to respond with a choice for treatment The case presentations will follow consecutively with minimal time lag to allow the moderator time to tally responses.

Focal Epilepsy Seven year old, right handed boy New onset GTC seizure during sleep Brief, 2 minutes Recurrence within two hours of initial event Initial EEG with bilateral central temporal spikes with focal slowing Subsequent EEG one month later with left parietal occipital sharp waves Treatment: CBZ (Carbamazepine or Tegretol™) Normal MRI

Focal Epilepsy: The rest of the story In retrospect Probable focal seizures occurring during sleep for several years Second grade Excels at mathematics Difficulty with reading Selective attention Well coordinated: “natural athlete”

Focal Epilepsy: The rest of the story: options? Second grade: 7 months after diagnosis Tolerating medication (CBZ) well School work increasing in difficulty Continues to excel in math and science Parents concerned at scattered academic ability

Focal Epilepsy: time to choose Options for participants: If he were your patient, would you recommend: No intervention, he is seizure free Provide and review attention scales for parent and teachers at school Evaluate medication as etiology Neurocognitive testing

Focal Epilepsy: Your Choices How many of you chose: No intervention Provide and review attention scales for parent and teachers Evaluate medication as etiology Neurocognitive testing

Focal Epilepsy: The outcome Psychometric testing Full scale IQ 132 Verbal IQ 135 Performance IQ 123 Math score consistent with high IQ Word reading and written expression lower than predicted based on IQ Summary Learning disability in reading and written expression Mild attention hyperactivity disorder Dysgraphia

Focal Epilepsy: Intervention IEP Keyboard Altered expectations for writing Behavior modification techniques Modifying the environment Psychostimulant medication: refused by family despite reassurance Emphasize strengths including suitable gifted programs

Focal Epilepsy: The Result Seizure free two years on CBZ at modest levels (6.5-8.5) EEG normal Trial off medication Success in school Continued IEP for learning differences and ADHD symptoms

Generalized Epilepsy: Childhood Absence 7 year old right handed girl New onset staring episodes, arrest of activity, unresponsive to voice or touch 6 or more times daily at home in addition to school Duration 10-30 seconds No convulsions No other seizure types History of fall from bike three months earlier with fractured right arm

Generalized Epilepsy: Childhood Absence EEG: generalized 3 Hz spike wave activity with and without hyperventilation Family Hx: maternal and paternal relatives Normal neurological examination “Doing well in school” PMH: frequent headaches without change in mood or cognition

Generalized Epilepsy: Childhood Absence: Treatment Ethosuximide (ETH): fewer seizures excessive drowsiness with increased dose Valproate (VPA) initiated: (ETH discontinued) some side effects: increased appetite level 96 repeat EEG: OIRDA (occipital intermittent rhythmic delta activity which can be seen in primary generalized epilepsy) dose increased slightly: seizure free

Generalized Epilepsy: Childhood Absence: Treatment (cont) Problems: tremor hair loss (takes a MVI with zinc & selenium) difficulty staying on task struggling in math intermittent episodes of spaciness and lethargy trough VPA level high therapeutic Mom frustrated

Generalized Epilepsy: Childhood Absence: Options If this were your patient, would you: Remain supportive but make no changes. (She is seizure free.) Change medication Lower the dose Obtain psychometric testing Suggest a trial of a psychostimulant

Generalized Epilepsy: Childhood Absence: Your choices How many of you chose to: Make no changes. She is seizure free. Change AEDs Lower the dose Obtain psychometric testing Suggest a trial of a psychostimulant

Generalized Epilepsy: Childhood Absence: Quality of Life AED change again Transition to LTG (lamotrigine) More her “normal self” Seizure free for one year School performance 4th grade Inattentive School performance marginal

Generalized Epilepsy: Childhood Absence: More Options Would you: Ask parents and teachers to complete attention checklists? Repeat the EEG? Refer for psychometric testing? Suggest mother request an IEP based on diagnosis?

Generalized Epilepsy: Childhood Absence: Seizures recur The seizures: Brief staring episode with a missed dose Staring with hyperventilation EEG abnormal: 3Hz sw discharge without clinical change LTG optimized Learning and social issues Has private tutoring No school accommodations Mom reluctant to pursue testing

Generalized Epilepsy: Childhood Absence: Seizures Recur Multiple AED changes: LTG and LEV (Levitiracetam) LTG and Zon (Zonisamide) VPA and LTG The problems: Clinical change in SZ, not in EEG More difficulty at school and at home Inattentive, impulsive, declining grades

Generalized Epilepsy: Childhood Absence: Resolution Psychometric testing completed Atamoxetine added IEP in place Improvement: sz free, improved learning

Generalized Epilepsy: Childhood Absence: Your Choices How many of you chose to: Ask parents and teachers to complete attention checklists? Repeat the EEG? Refer for psychometric testing? Suggest mother request an IEP based on diagnosis?

Summary Increased risk of attention problems and learning disability in children with epilepsy Not all situations are ideal Multiple options exist Stimulant drugs are safe and effective