Comorbidities
Although a major goal in the treatment of epilepsy is stopping the seizures, it is not the only treatment goal. Patients with epilepsy are a risk for a number of comorbidities. Comorbidity refers to the cooccurrence of two supposedly separate conditions that occur together more than by chance. For example, depression occurs more frequently in patients with epilepsy than in the normal population, so that epilepsy and depression are comorbidities. Comorbidities are not necessarily causal. For example, because epilepsy and depression are comorbidities does not mean that epilepsy caused the depression or depression caused the epilepsy. Rather, it is possible that both conditions have a common biologic substrate or that another independent variable triggers one of the comorbidities. For example, epilepsy often leads to drug therapy, which could cause depression independent of the epilepsy. Although some overlap occurs, children and adults are considered separately.
I. CHILDREN
Children with epilepsy are far more likely to have a psychiatric disorder than are children without epilepsy or with other chronic disorders. In a large British survey, it was found that rates of psychiatric disorder in children with epilepsy was 37% compared with 11% in diabetes and 9% in control children. Emotional disorders, conduct disorders, attention disorder/hyperactive disorder (ADHD), anxiety, and autism-spectrum disorder are overrepresented in children with epilepsy. Emotional, behavioral, and relationship difficulties are common in children with epilepsy and constitute a significant burden to the children and their families, indicating the need for effective mental health services for these children.
A. Attention Deficit/Hyperactivity Disorder
1. Definitions
Children with epilepsy are at substantial risk for ADHD. Clinical studies suggest a prevalence of 30% to 40%, several fold higher than that of the normal population. Children with epilepsy and ADHD differ from children with ADHD who do not have epilepsy by having a higher incidence of the inattentive form of the disorder. In addition, in the general population, ADHD is more common in boys than in girls, whereas in children with epilepsy, an equal female/male ratio is found.
2. Treatment
Educational and psychological evaluations are helpful in identifying ADHD and distinguishing the condition from depression and learning disabilities. Psychoeducational interventions can be quite useful. Children with ADHD typically work better if they are taught in a quiet and structured environment. A
personal aide can help redirect the child’s attention. A consistent educational program at home as well as in school is important, and the parents should be engaged in the education plan. Antiepileptic drugs, such as barbiturates and benzodiazepines that may exacerbate the ADHD, should be avoided.
personal aide can help redirect the child’s attention. A consistent educational program at home as well as in school is important, and the parents should be engaged in the education plan. Antiepileptic drugs, such as barbiturates and benzodiazepines that may exacerbate the ADHD, should be avoided.
Although stimulant medications have been a mainstay in the treatment of ADHD in children with epilepsy, concerns exist that these drugs could lower the seizure threshold. Seizures associated with stimulant medications are unusual, and drugs such as dexedrine, methylphenidate, and atomoxetine can be quite useful. Bupropion, an atypical antidepressant, should be avoided because it can lower the seizure threshold.
B. Depression
1. Definitions
A higher-than-expected incidence of depression is found in children with epilepsy. In a study of adolescents with epilepsy, 23% had symptoms of depression. It has been found that adolescents’ attitudes, attributions, and satisfaction with family relationships are related to depression and should be assessed in the clinical setting. Children with epilepsy are at risk for suicide.
Children may not have the vocabulary to talk about such feelings and so may express their feelings through behavior. Younger individuals with depression are more likely to show phobias, separation anxiety disorder, somatic complaints, and behavior problems, such as anger and aggression. The adolescent may demonstrate academic decline, disruptive behavior, loss of interest in activities, and problems with friends. Sometimes one can also see aggressive behavior, irritability, and suicidal ideation. The parent may say that the child hates himself or herself and everything else.
2. Treatment
All children with suspected depression should have a psychological evaluation with testing. Once diagnosed, patients may benefit from counseling. Antiepileptic drugs that could be contributing to the problem should be discontinued and substituted with drugs that might improve mood. For example, eliminating barbiturates and benzodiazepines and substituting lamotrigine, carbamazepine, or valproate, when appropriate for the child’s seizure disorder, can be very useful.
Selective serotonin reuptake inhibitors (SSRIs) have improved the outlook for the medication treatment of child and adolescent depression. The side effects are not as annoying as those of the older medications. These medications are somewhat less toxic in overdose. Fluoxetine has been shown to be effective in depression and does not increase the risk of suicide.
C. Cognition
1. Definitions
Apart from control of the seizures, one of the most important factors in determining how well a child with epilepsy progresses toward independence is cognition. Mental retardation is higher in children with epilepsy than in the normal population. The
majority of the mental retardation in children with epilepsy is a result of the insult leading to the epilepsy. For example, children with hypoxic-ischemic insults, head trauma, or genetic causes of their epilepsy are retarded because of these insults. Most children with epilepsy have stable intelligence. In the small percentage of children that have a progressive decline in intelligence over time, the seizures are usually intractable.
majority of the mental retardation in children with epilepsy is a result of the insult leading to the epilepsy. For example, children with hypoxic-ischemic insults, head trauma, or genetic causes of their epilepsy are retarded because of these insults. Most children with epilepsy have stable intelligence. In the small percentage of children that have a progressive decline in intelligence over time, the seizures are usually intractable.
2. Treatment
Recognizing that the child is retarded is critical. Inappropriate placement in a grade in which he or she is incapable of succeeding can result in considerable anxiety, frustration, and may result in a conduct disorder. All children with epilepsy who are not progressing in school should have psychological testing. Once identified, the child can be placed in the correct educational program. Antiepileptic drugs that could impair attention or learning, such as barbiturates or benzodiazepines, should be avoided.
D. Learning Disabilities
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