1. EPI1124004 Case Study 3: A Boy With Staring Spells and Inattentiveness This is not an actual case study. It has been adapted and developed from scientific literature as referenced. © Eisai Inc 2012. All Rights Reserved.

2. EPI1124004 Parents of a 6-year-old boy are notified that their son appears to be daydreaming at school. Gradually, these episodes have increased to about twice/week, and seem to be more like staring spells lasting about 30-40 seconds. Sometimes, after a spell, the boy goes immediately back to what he had been doing before the episode; other times, he seems to be confused for about 5-10 seconds, after which he returns to his previous activity. His teachers think that he has attention deficit disorder. Parents bring this to the attention of their pediatrician. Family history reveals that the paternal grandfather had epilepsy. Given this family history, the pediatrician suspects a seizure disorder and refers the child to a neurologist. Extended EEG monitoring is recommended. During the monitoring, the boy has a staring spell. EEG shows generalized, bilaterally synchronous, 3 Hz spike and wave discharges that emerge abruptly from a normal background and end abruptly without postictal slowing. Case Study 3: A Boy With Staring Spells and Inattentiveness Question

3. EPI1124004 Parents of a 6-year-old boy are notified that their son appears to be daydreaming at school. Gradually, these episodes have increased to about twice/week, and seem to be more like staring spells lasting about 30-40 seconds. Sometimes, after a spell, the boy goes immediately back to what he had been doing before the episode; other times, he seems to be confused for about 5-10 seconds, after which he returns to his previous activity. His teachers think that he has attention deficit disorder. Parents bring this to the attention of their pediatrician. Family history reveals that the paternal grandfather had epilepsy. Given this family history, the pediatrician suspects a seizure disorder and refers the child to a neurologist. Extended EEG monitoring is recommended. During the monitoring, the boy has a staring spell. EEG shows generalized, bilaterally synchronous, 3 Hz spike and wave discharges that emerge abruptly from a normal background and end abruptly without postictal slowing. Case Study 3: A Boy With Staring Spells and Inattentiveness Question: What would your diagnosis be at this point? Answer Data

4. EPI1124004 Parents of a 6-year-old boy are notified that their son appears to be daydreaming at school. Gradually, these episodes have increased to about twice/week, and seem to be more like staring spells lasting about 30-40 seconds. Sometimes, after a spell, the boy goes immediately back to what he had been doing before the episode; other times, he seems to be confused for about 5-10 seconds, after which he returns to his previous activity. His teachers think that he has attention deficit disorder. Parents bring this to the attention of their pediatrician. Family history reveals that the paternal grandfather had epilepsy. Given this family history, the pediatrician suspects a seizure disorder and refers the child to a neurologist. Extended EEG monitoring is recommended. During the monitoring, the boy has a staring spell. EEG shows generalized, bilaterally synchronous, 3 Hz spike and wave discharges that emerge abruptly from a normal background and end abruptly without postictal slowing. Case Study 3: A Boy With Staring Spells and Inattentiveness Answer: The boy is diagnosed with “Absence Seizures” 1 and treatment is initiated. Parents are counseled regarding compliance and advised to be watchful for changes in the frequency of seizures and any associated side effects. Next Data Question

5. EPI1124004 The boy continues on medication until he is 7 yrs old and in the second grade at school. His seizures have been under control and he has been seizure free for 6 months. In school, he excels in mathematics but has difficulty with reading and has a selective attention span. In general, he is very well coordinated, almost like a natural athlete However, his school work has become increasingly difficult and the parents are concerned about his scattered academic ability. Case Study 3: A Boy With Staring Spells and Inattentiveness Question

6. EPI1124004 The boy continues on medication until he is 7 yrs old and in the second grade at school. His seizures have been under control and he has been seizure free for 6 months. In school, he excels in mathematics but has difficulty with reading and has a selective attention span. In general, he is very well coordinated, almost like a natural athlete However, his school work has become increasingly difficult and the parents are concerned about his scattered academic ability. Case Study 3: A Boy With Staring Spells and Inattentiveness Answer Data Question: If he was your patient, what would you recommend now? Would you consider taking him off medication or suggest additional testing?

7. EPI1124004 The boy continues on medication until he is 7 yrs old and in the second grade at school. His seizures have been under control and he has been seizure free for 6 months. In school, he excels in mathematics but has difficulty with reading and has a selective attention span. In general, he is very well coordinated, almost like a natural athlete However, his school work has become increasingly difficult and the parents are concerned about his scattered academic ability. Case Study 3: A Boy With Staring Spells and Inattentiveness Question Next Data Answer: The boy is taken off medication on a trial basis to determine if the medication was the underlying cause of the observed learning difficulties. 1 Additional testing will be considered based on his response to cessation of medication and any changes in his learning abilities.

8. EPI1124004 Within 6 months of discontinuing medication, the seizures return. Although they are less frequent initially, they start to increase. However, there have been no changes in his school performance. Case Study 3: A Boy With Staring Spells and Inattentiveness Question

9. EPI1124004 Within 6 months of discontinuing medication, the seizures return. Although they are less frequent initially, they start to increase. However, there have been no changes in his school performance. Case Study 3: A Boy With Staring Spells and Inattentiveness Data Answer Question: What would your recommendation be at this point?

10. EPI1124004 Within 6 months of discontinuing medication, the seizures return. Although they are less frequent initially, they start to increase. However, there have been no changes in his school performance. Case Study 3: A Boy With Staring Spells and Inattentiveness Question Next Data Answer: The boy is put back on medication on a modified regimen. 1 Parents are advised that the medication itself was unlikely the underlying cause of his academic difficulties. Detailed neurocognitive testing is recommended to identify specific learning problems and define the appropriate course of action.

11. EPI1124004 Seizures are again under good control within 6 months of starting the modified regimen. Detailed psychometric testing reveals that the boy has a full scale IQ of 132, verbal IQ of 135, performance IQ of 123, and math score consistent with his high IQ. His word reading and written expression are lower than predicted based on his IQ. Additional testing reveals that the child has a learning disability in reading and written expression, mild attention hyperactivity disorder, and dysgraphia. Case Study 3: A Boy With Staring Spells and Inattentiveness Question

12. EPI1124004 Seizures are again under good control within 6 months of starting the modified regimen. Detailed psychometric testing reveals that the boy has a full scale IQ of 132, verbal IQ of 135, performance IQ of 123, and math score consistent with his high IQ. His word reading and written expression are lower than predicted based on his IQ. Additional testing reveals that the child has a learning disability in reading and written expression, mild attention hyperactivity disorder, and dysgraphia. Case Study 3: A Boy With Staring Spells and Inattentiveness Data Answer Question: What would you recommend?

13. EPI1124004 Seizures are again under good control within 6 months of starting the modified regimen. Detailed psychometric testing reveals that the boy has a full scale IQ of 132, verbal IQ of 135, performance IQ of 123, and math score consistent with his high IQ. His word reading and written expression are lower than predicted based on his IQ. Additional testing reveals that the child has a learning disability in reading and written expression, mild attention hyperactivity disorder, and dysgraphia. Case Study 3: A Boy With Staring Spells and Inattentiveness Data Question Answer: Parents are advised that an individualized education plan needs to be set up and that behavior modification techniques would be helpful in aiding the development of this child. 2 Teachers in the school are advised of the child’s condition and the request for altered expectations for written work is honored. Strengths are emphasized so that suitable gifted programs could be identified. 1

14. EPI1124004 Note: Case description is modified and adapted from a talk presented by a nurse practitioner on attention problems. This has also been reviewed by a practicing neurologist for clinical accuracy and timelines presented. Case Study 3: A Boy With Staring Spells and Inattentiveness

15. EPI1124004 References Case modified from Sarah Hunt’s presentation obtained from http://www.aesnet.org/02047134-1438-BCFC-31A5C133030A3B32 http://www.aesnet.org/02047134-1438-BCFC-31A5C133030A3B32 http://www.epilepsy.com/info/family_kids_education Case Study 3: A Boy With Staring Spells and Inattentiveness