Attention Problems:

Controversies and
Consequences for the
Child with Epilepsy
David W. Dunn
Indiana University School of
Medicine

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?

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.

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

Attention Deficit Hyperactivity

Disorder
Inattention: trouble concentrating,
distractible, careless errors, forgetful, loses
thins, doesnt listen, incomplete work, poor
organization, procrastinates
Hyperactivity-impulsivity: fidgets, cant stay
seated, runs, noisy, talks excessively,
interrupts, blurts out answers, cant wait,
constantly on the go

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.

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.

Differential Diagnosis: AEDs

Antiepileptic drugs (AEDs) usually dont
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

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 2530% 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.

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

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

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.

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.

Attention Problems:
Controversies and
Consequences for the
Child with Epilepsy
Sarah Hunt, M.S., CRNP,
CNRN
Wellspan Neurology

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

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.

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

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

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

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

Focal Epilepsy: Your Choices

How
No

many of you chose:

intervention
Provide and review attention scales
for parent and teachers
Evaluate medication as etiology
Neurocognitive testing

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

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

Focal Epilepsy: The Result

Seizure free two years on CBZ at modest
levels (6.5-8.5)
EEG normal
Trial off medication
Success in school
Continued IEP for learning differences and
ADHD symptoms

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 10-30 seconds
No convulsions
No other seizure types

History of fall from bike three months earlier with

fractured right arm

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

Generalized Epilepsy:
Childhood Absence: Treatment

Ethosuximide (ETH):
fewer

seizures
excessive drowsiness with increased dose

Valproate (VPA) initiated: (ETH discontinued)

fewer

seizures
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

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

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

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

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

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?

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

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

Generalized Epilepsy:
Childhood Absence: Resolution

Psychometric testing completed

Atamoxetine
IEP

added

in place

Improvement: sz free, improved learning

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?

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