Northeast Regional Epilepsy Group

1. Northeast Regional Epilepsy Group Do children with epilepsy have cognitive problems? How to ensure success in school

2. Robert W. Trobliger Director Clinical Neuropsychology NEREG

3. Among adults with epilepsy, complaints of: • slowed mental processes • problems with attention • problems with memory are common

4. Children with epilepsy often present with problems with cognitive functioning involving: • Attention • Executive functioning • Memory • Language

5. Children with epilepsy obtained lower scores than controls across measures of cognition and higher scores on measures of behavioral issues. http://pediatrics.aappublications.org/content/112/6/1338.short 2003

6. Problems with cognitive functioning are related to and can cause other problems

7. language difficulties learning difficulties and poor academic performance behavioral problems poor socio-professional prognosis http://www.seizure-journal.com/article/S1059-1311%2806%2900036-7/fulltext

8. Despite similar intelligence and educational background, significantly more patients with epilepsy (51%) than control subjects (27%) required special educational services. http://pediatrics.aappublications.org/content/112/6/1338.short

9. Factors behind cognitive difficulties among children with epilepsy

10. Epilepsy is a symptom rather than the cause of brain dysfunction.

11. There are structural changes that precede seizure onset

12. Some studies show that in newly diagnosed and untreated patients with epilepsy, cognitive problems are already present in more than 50% of patients http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1797884/

13. Epilepsy can cause changes within the brain • which can further affect cognitive functioning

14. An ongoing epileptogenic process can irreversibly damage the brain, especially the maturing brain, even if seizures are controlled

15. and can cause persistent changes in cognitive functioning and global intellectual deficits

16. Need for monitoring and treatment

17. factors which can impact • changes in cognitive functioning: • seizure type • age of onset • severity and frequency of seizures

18. anatomical location and etiology • and side effects of antiepileptic drugs. • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3362729/

19. In addition to seizures, there are associated disorders • which can impact functioning

20. Attention Deficit Hyperactivity Disorder • (ADHD)

21. ADHD subtypes • ADHD – Combined Presentation • ADHD – Predominantly Inattentive Presentation • ADHD – Predominantly Hyperactive-Impulsive Presentation • Other Specified ADHD • Other Nonspecified ADHD

22. DSM-5 Criteria • People with ADHD show a persistent pattern of inattention • and/or hyperactivity-impulsivity that interferes with functioning or development: http://www.cdc.gov/ncbddd/adhd/diagnosis.html

23. Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:

24. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities. • Often has trouble holding attention on tasks or play activities. • Often does not seem to listen when spoken to directly. • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked). • Often has trouble organizing tasks and activities. • Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework). • Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). • Is often easily distracted • Is often forgetful in daily activities.

25. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person's developmental level:

26. Often fidgets with or taps hands or feet, or squirms in seat. Often leaves seat in situations when remaining seated is expected. Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless). Often unable to play or take part in leisure activities quietly. Is often "on the go" acting as if "driven by a motor". Often talks excessively. Often blurts out an answer before a question has been completed. Often has trouble waiting his/her turn. Often interrupts or intrudes on others (e.g., butts into conversations or games)

27. In addition, the following conditions must be met: • Several inattentive or hyperactive-impulsive symptoms were present before age 12 years. • Several symptoms are present in two or more setting, (e.g., at home, school or work; with friends or relatives; in other activities). • There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning. • The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

28. Prevalence in the general population • 11% of US school aged children received a diagnosis of ADHD • by a health care provider by 2011 • as reported by parents • http://www.cdc.gov/ncbddd/adhd/features/key-findings-adhd72013.html

29. 6.4 million children including • 1/5 high school boys • 1/11 high school girls

30. among children with epilepsy • between 12 and 17% • between 20 and 40% • Dunn DW, Kronenberger WG. 2005.  • Kaufmann R, Goldberg-Stern H, Shuper A. 2009.  • http://www.ncbi.nlm.nih.gov/pubmed/21310

31. higher occurrence of ADHD – inattentive type • seizure/epilepsy variables do not seem to be important correlates

32. Regarding attention, there may be problems managing both internal and external stimuli.

33. Problems with attention – internal

34. Internal distractions – thought processes

35. Which can include concentrating on managing their own behavior, which can cause problems actually focusing on lessons

36. 2015 study demonstrated that children with ADHD allowed to move functioned better on working memory tasks • Authors suggested that the results likely would generalize to the classroom, allowing children to likely spend less time trying to control themselves • http://link.springer.com/article/10.1007%2Fs10802-015-0011-1

37. In Classroom: • opportunities to move while working • standing up while working • sewing pedal for tapping • squeeze balls while listening/reading

38. Fidget spinners?

39. Problems with attention – external

40. Problems managing distractibility – sights and sounds

41. Preferential seating in the classroom

42. Separate location for tests/quizzes

43. Extra time for tests/quizzes

44. Quiet place to work at home

45. managing distractions • tv, radio, internet, phones

46. other people can be a distraction

47. other work on a table/desk can be a distraction • (or anxiety producing)

48. Problems with Executive Functioning

49. starting tasks • organizing/prioritizing tasks • planning/breaking down tasks • catching/correcting mistakes (self monitoring) • finishing tasks

50. Memory Problems