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Introduction
: Epilepsy is one of the most common neurological disorders seen in
pediatric population. Behavioral problems are often encountered in these
children. Identification of these behavioral disorders and its early
intervention will go a long way in improving quality of life of epileptic
children.
Objectives (1) To study the incidence and spectrum of behavioral
disorders in school going epileptic children.
(2) To evaluate their relation with the age of onset, duration and type
of seizures, EEG pattern and therapy.
Design : Prospective observational cohort study.
Setting : Pediatric Neurology Clinic in a tertiary multidisciplinary
hospital.
Material and Methods : 156 school going (4-15 years) children,
78 with epilepsy (study group) and 78 non-epileptic peers (control group)
were evaluated for behavioral disorder over a period of one year. Detailed
history, systemic examination, and psychological evaluation were done.
Results : The incidence of behavioral disorders (BD) was 34.26%
in the study group while in the control group it was 17.95% and this
was statistically significant (p < 0.05). The commonest age group
with BD in epileptics was 4-5 years (54.55%). Common BD was conduct
disorders followed by vegetative disorders and habit disorders in study
group. Spectrum of conduct disorders seen were hyperkinetic behaviour,
defiance, obstinacy, aggression, lying and antisocial behaviour. Amongst
these hyperkinesias (19.23%) was the commonest BD encountered in epileptics
with or without phenobarbitone therapy. We also observed that the incidence
of BD was higher in those epileptics with early onset of seizures, longer
duration of epilepsy, uncontrolled seizures, with GTC seizures and those
with EEG abnormalities, with the last two parameters being statistically
significant.
Conclusion : All epileptic children, especially those with
early onset and longer duration of epilepsy as well as those with intractable
seizures, need to be closely monitored for behavioral problems. A holistic
approach, comprising medical and surgical therapy, psychosocial counseling
of families and placement of the child both in society and school should
form integral part of management of epileptic children. |
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| INTRODUCTION |
Epilepsy
is a common chronic neurological disorder seen in paediatric population.Behavioral
and cognitive problems are encountered in approximately 20-30% of these
children. Other problems encountered in them range from lack of self-respect,
depression and poor attention span to academic failures, family disregard
and social abuse. The causes of these abnormalities are multifactorial
and are related to underlying seizure activity, treatment modality and
psychosocial issues, aetiology, genetics, adverse effects of antiepileptic
drugs and ongoing seizure activity. Identification of these behavioral
disorders and its early intervention will go a long way in improving
the quality of life among epileptic children.
The present study was undertaken to determine the incidence and spectrum
of various behaviour problems in school going children with seizure
disorders. We tried to correlate the influence of different seizure
types, age of onset of seizures, duration and aetiology of seizures,
different anti epileptic drugs (AED) used and compliance of therapy
and EEG pattern with the occurrence of behavioral disorders. |
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| MATERIAL
AND METHODS |
Sample
Details : This was a prospective observational cohort study involving
156 children conducted over a period of one year at a multidisciplinary
tertiary hospital. 78 consecutive school going epileptics (4-15 years)
attending Paediatric neurology clinic and school health clinic formed
the study group while 78 age matched non-epileptic school children formed
the control group. Patients excluded from the study were a) those with
subnormal or mental retardation on IQ testing b) Patients with febrile
seizures, syncope, hysterical seizures or pseudo seizures or seizures
related to acute cerebral insult.
Data collection : Detailed history of all children with special emphasis
on schooling, academic performance, and peer and family relationship
and behaviour problems was obtained and noted on a pre-structured proforma.
All children underwent a thorough clinical examination and a detailed
neurological examination with special attention focused on their performance
in school with regards to academics and behaviour. Besides routine investigations
EEG, IQ/DQ, CT scan and MRI brain, serum antiepileptic drug levels were
conducted wherever necessary. Epileptic patients in the study group
were classified according to the seizure type by International League
against Epilepsy (ILAE) classification, 1981. The common antiepileptic
drugs used for therapy were phenobarbitone, phenytoin, carbamazepine
and sodium valproate.
Statistical analysis : Chi Square Test was used for analysis. |
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| RESULTS |
The
study group comprised 53.85% boys and 46.15% girls with a male to female
ratio of 1.16:1 and maximum children were from 10-12 years of age. A
similar trend was also noticed in the control group. Majority of the
children (80.77%) had generalized seizures with tonic clonic variety
being the commonest and only 19.23% had partial seizures. Simple partial
seizures (60%) out numbered the complex partial variety. Idiopathic
epilepsy was found in 74.36% and 25.64% had secondary epilepsy due to
a structural disorder, systemic disease, post infectious cause, post-trauma
or perinatal insult.
The incidence of behaviour problems in our study group was 34.62% (27
patients) as compared to 17.95% in the control group and this difference
was found to be statistically significant (p < 0.05). Amongst the
27 epileptic children with behaviour problems 20 children had more than
one behavioral problem resulting in a total of 59 behavioral abnormalities.
From the 14 non-epileptic children only 2 had more than one behaviour
problem resulting in 16 behaviour abnormalities. The common behavioral
problems encountered in the study group were conduct disorders (88.13%)
which were the commonest, followed by vegetative disorders (8.47%) and
habit disorders (3.40%). The control group also showed a similar pattern
but the percentage was much less i.e. 75%, 18.75% and 6.25%, respectively
(Table 1). The spectrum of behavioral problems seen in our study group
was hyper kinetic behaviour (19.23%), obstinacy (15.38%), aggression,
enuresis and pica (Table 1). Hyper kinesis (19.23%) was the commonest
behaviour problem seen in epileptics with or without phenobarbitone
therapy.
Behavioral problems in the study group were commonest between 4-6 years
(54.55%) followed by 13-15 years (38.46%) whereas in the control group
there was a near equal distribution in all age groups. We also noted
that the incidence of behaviour problems was higher in those epileptics
with early onset of seizures (< 3 years of age) and those who had
longer duration of epilepsy (more than 3 years) but this difference
was not statistically significant.
On reviewing the seizure type, 22 of the 27 epileptic children with
behaviour problems had generalized seizures and 5 had partial seizures.
The aetiology was idiopathic in majority (21 children) and only 6 had
secondary epilepsy. No exact relationship between seizure type, aetiology
and occurrence of behaviour disorder could be ascertained. EEG abnormalities
were more common in the epileptics with behaviour problems as compared
to epileptics without behavioral problems (p < 0.01). 11 children
(14.10%) from the study group had a poor scholastic performance as against
2 (2.56%) in the control group and this difference was also statistically
significant (p < 0.01). There also was a higher (50%) incidence of
behaviour problems in children with uncontrolled or partially controlledepilepsy
as compared to children with well-controlled epilepsy 31.82%. Table
2 gives the percentage of behaviour problems with various anti-epileptic
drugs. On comparing the different anti epileptic drugs in the monotherapy
group, we observed that behavioral problems were maximum in children
taking phenobarbitone (60%) followed by sodium valproate (50%), carbamazepine
(29.63%) and phenytoin (27.27%). However this difference was not statistically
significant. We did not observe any correlation with compliance and
development of behavior problems |
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| DISCUSSION |
Despite
advances in the management of epilepsy a significant proportion of epileptic
children suffer from neurological, behavioral and psychosocial consequences
of epilepsy.1,2 In our study the incidence of behaviour problem was
34.62% in the epileptic children and this was significantly higher than
in the non-epileptic children 17.95% (p < 0.05). Trimble MR in his
study reported 20-30% of children with behaviour disturbance in epileptics.3
The spectrum of behavioral problems seen in epileptics ranged from conduct
disorders, to vegetative and habit disorders. The probable reason for
this varied spectrum is that epilepsy is a chronic illness, leading
to a lot of anxiety and problems in psychosocial adaptation. Additionally,
repeated visits to hospital, chronic administration of therapy and parental
anxiety further aggravate the problems.
The incidence of behaviour and cognitive problems is affected by a number
of variables, like age of onset of epilepsy, severity and duration of
seizure, seizure type, antiepileptic drugs, psychosocial factors and
development of status epilepticus.2 Earlier the onset of seizures and
longer the duration of seizure it increases the likelihood of development
of behavioral and cognitive problems in later life.2 We observed a higher
incidence of behaviour problems when onset of epilepsy was before 3
years of age and also when the duration of epilepsy was longer than
three years. Bourgeois et al5 and Tamer SK2 observed in their study
that children with early onset and high seizure frequency had higher
risk for development of behaviour disorders.
Though the seizure type and aetiology per se did not predict development
of behaviour disorders we observed in our study that generalized seizures
were the commonest type noted (22 out of 27 i.e. 81.48%) and the aetiology
in majority was idiopathic i.e. 74.36%. 39.53% of children in our study
had an abnormal EEG and some behaviour problem. Tamer SK noted transitory
cognitive impairment in approximately 50% of patients who showed frequent
subclinical interictal discharge on EEG.2
Often it becomes difficult to determine whether behaviour changes or
poor academic performance by a child who has epilepsy is the result
of the medication, the underlying seizure disorder or both. The most
important practical concern of this issue is the fact, that childhood
is the period of learning and there are parental worries about the possible
adverse impact on learning.2 Various studies have shown that Phenobarbitone
is associated with cognitive and behavioral effects in children, including
attention difficulties, paradoxical hyperactivity, decreased short-term
memory skills and conduct disturbances.6,7 While the adverse effects
of Phenytoin include deterioration of intellectual function, progressive
encephalopathy and personality changes.8
Bourgeois BFD in his study noted that patients on antiepileptic medication
had lower scores for concentration, mental processing and alertness.1
He concluded that impaired alertness may be an attention disorder characteristic
of children with epilepsy and possibly unrelated to the drug. Vining
et al and Taner SK in their study compared behavioral effects between
phenobarbitone, sodium valproate and carbamazepine and found that patients
on phenobarbitone had more hyperactivity as was also seen in our study.6
Studies have revealed that academic achievements are also related to
age at onset of seizure, duration of seizure disorder and type of seizure.2
In our study 14.10% epileptic children had poor scholastic performance
as compared to only 2.56% in the non-epileptic group. Tamer SK in his
study also noted 70.2% children with scholastic backwardness 59.4% had
both scholastic and behaviour problems.2
In conclusion, our study revealed a higher incidence of behaviour problem
in epileptic children and this incidence was marginally higher if the
seizures occurred at early age, lasted for longer duration, were uncontrolled,
had associated EEG abnormalities or the patients were on phenobarbitone
therapy. Hence we recommend that epileptic children should be closely
monitored for development of behaviour problem and cognitive impairment
and especially those with the above-mentioned factors. Newer antiepileptic
drugs like lamotrigine, which have least affection on cognition and
behavioral function should be used. A holistic approach comprising medical
and surgical therapy, psychosocial counseling of families and caretakers
and placement of child both in the society and school are advocated
as an integral part of management of epileptic children. |
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| KEY
MESSAGES |
| • |
34.62%
of epileptics had behavioral problems. |
| • |
Cognitive
and behavioral problems are closely related to age of onset, duration
of seizures, type of anti epileptic drugs and control of seizures. |
| • |
EEG
abnormalities were more common in the epileptics with behavior
problems as compared to epileptics without behavioral problems. |
| • |
Regular
follow up with comprehensive evaluation of cognitive potential
and learning ability, to plan appropriate remediation and intervention. |
| • |
Psychosocial
counseling and play therapy should be an integral part of management. |
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| REFERENCES |
| 1 |
Bourgeois
FD. Anti epileptic Drugs, Learning and Behaviour in Childhood
Epilepsy. Epilepsia 1998; 39 (9) : 913-21. |
| 2 |
Tamer
SK. Cognitive and behavioral concerns in Epileptic Children. Indian
Journal of Pediatrics 1999; 66 : 877-86. |
| 3 |
Trimble MR. Antiepileptic drugs, cognitive function, and behavior
in children: evidence from recent studies. Epilepsia 1990; 31
: S30-34. |
| 4 |
Berlin CM, May DG, Notterman DA, Ward RM, Weismann DN. Behavioral
and cognitive effects of anticonvulsant therapy. Pediatrics 1995;
96 (3) : 538-40. |
| 5 |
Bourgeois BFD, Prensky AL, Palkes HS, Talent BK, Busch SG. Intelligence
in epilepsy : A prospective study in children. Ann Neurol 1983;
14 : 438-44. |
| 6 |
Vinning
EPG, Mellits ED, Dorsen MM, et al. Psychological and behavioral
effects of anti-epileptic drugs in children. A double blind comparison
between Phenobarbital and Valproic acid. Pediatrics 1987; 80 :
165-74. |
| 7 |
Devinsky
O. Cognitive and behavioral effects of antiepileptic drugs. Epilepsia
1995; 36 (suppl 2) : S46-65. |
| 8 |
Herranz JL, Armijo JA, Arteaga R. Clinical side effects of Phenobarbital,
Primidone, Phenytoin, Carbamazepine and Valproate during monotherapy
in children. Epilepsia 1998; 29 : 794-804. |
| 9 |
Farewell
JR, Dodrill CB, Betzel LW. Neurophysiological abilities of children
with Epilepsy. Epilepsia 1985; 26 : 385-400. |
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METFORMIN
IS EFFECTIVE IN TREATING POLYCYSTIC OVARY SYNDROME
Metformin induces ovulation in women with polycystic ovary syndrome
and hyperandrogenic anovulation. In a systematic review and meta-analysis.
Lord and his collaborators from Australia analysed data from 13
studies and 543 women. They found that metformin is an effective
treatment for anovulation, but it is associated with a notable
incidence of gastrointestinal disturbance, and its use long term
and in early pregnancy needs further evaluation. The authors say
the evidence supports its use as a first line agent in this group
of patients.
BMJ 2003; 327 : 951 |
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