1. 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

2. 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?

3. 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.

4. 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

5. 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

6. 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.

7. 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.

8. 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

9. 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.

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

11. 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

12. 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.

13. 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.

14. 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

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

16. 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.

17. 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

18. 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”

19. 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

20. 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

21. 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

22. 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

23. 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

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

25. 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 seconds
No convulsions
No other seizure types
History of fall from bike three months earlier with fractured right arm

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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?

33. 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

34. 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

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

36. 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?

37. 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