Elsevier

Epilepsy & Behavior

Volume 42, January 2015, Pages 22-28
Epilepsy & Behavior

Parent-rated emotional–behavioral and executive functioning in childhood epilepsy

https://doi.org/10.1016/j.yebeh.2014.11.006Get rights and content

Highlights

  • The sample displayed elevated symptoms of emotional-behavioral and executive functioning based on parent rating scales.

  • Only a small proportion of those with clinically significant symptoms had a history of psychological or counseling services.

  • Select demographic and epilepsy-related variables were associated with emotional-behavioral and executive functioning.

Abstract

The present study examined clinical and demographic risk factors associated with parent-rated emotional–behavioral and executive functioning in children and adolescents with epilepsy. The medical records of 152 children and adolescents with epilepsy referred for neuropsychological evaluation were reviewed. Results indicated that the sample displayed significantly elevated symptoms across the emotional–behavioral and executive domains assessed. Executive functioning and behavioral symptoms had the highest rates of clinically elevated scores, with lowest rates of elevated scores in internalizing and externalizing emotional problems. Only 34% of those participants with clinically significant emotional–behavioral or executive functioning difficulties had a history of psychological or counseling services, highlighting the underserved mental health needs of this population. In regard to clinical factors, the majority of seizure-related variables were not associated with emotional–behavioral or executive functioning. However, the frequency of seizures (i.e., seizure status) was associated with behavioral regulation aspects of executive functioning, and the age at evaluation was associated with externalizing problems and behavioral symptoms. Family psychiatric history (with the exception of ADHD) was associated with all domains of executive and emotional–behavioral functioning. In summary, emotional–behavioral and executive functioning difficulties frequently co-occur with seizures in childhood epilepsy, with both seizure-related and demographic factors contributing to the presentation of such neurobehavioral comorbidities. The present findings provide treatment providers of childhood epilepsy with important information to assist in better identifying children and adolescents who may be at risk for neurobehavioral comorbidities and may benefit from intervention.

Introduction

Childhood epilepsy is often associated with psychiatric disorders such as attention deficit hyperactivity disorder (ADHD), depressive disorders, and anxiety disorders [1]. Based on diagnostic interviews in clinically referred samples, studies have identified comorbidity rates of 26–40% for ADHD, 27–36% for anxiety disorders, 13–23% for depressive disorders, and 13% for oppositional defiant disorder [2], [3], [4]. Within a community sample of children and adolescents with epilepsy [5], the comorbidity rate was 21% for ADHD, 13% for depressive disorders, 5% for anxiety disorders, and 5% for oppositional defiant disorder/conduct disorder (ODD/CD). Initial research hypothesized that such neurobehavioral comorbidities of epilepsy were primarily due to consequences of stigmatization, life obstacles, and other psychosocial stressors. However, the more recent theory in the field is that the shared underlying neurobiologic pathogenic mechanisms responsible for the manifestations of seizures play a large role in neurobehavioral comorbidities [6], [7], [8], [9]. Neurobehavioral comorbidities appear to be the rule rather than the exception in epilepsy, with challenges frequently identified in emotional, cognitive, and social functioning [7], [10]. Given the identified shared genetic pathways with other neurodevelopmental disorders as well as the frequency of these neurobehavioral comorbidities, epilepsy has more recently been classified as a neurodevelopmental disorder, as have autism spectrum disorders, intellectual disability, and schizophrenia [6], [11].

Neuropsychological evaluation can be an effective clinical tool in the delineation of difficulties in emotional–behavioral and executive functioning, two neuropsychological domains frequently involved in a range of psychiatric conditions [12], [13], [14]. One method of assessing emotional–behavioral and executive functioning is parent-rating forms, which have proven effective in the assessment of childhood conditions such as ADHD, depressive disorders, and anxiety disorders [12]. Because of their clinical effectiveness, as well as brevity and cost-efficiency, rating forms have been frequently used in children with epilepsy to identify psychiatric comorbidities [15]. While a complete review of studies using rating forms in childhood epilepsy is beyond the scope of this article, Rodenburg and colleagues [16] conducted a meta-analysis on the use of rating forms (parent, teacher, and self) to assess emotional–behavioral functioning in childhood epilepsy. Results indicated medium to large effect sizes across symptoms of psychopathology, most notably in attention problems, thought problems, and social problems.

A few studies to date have used the Behavior Assessment System for Children—Second Edition—Parent Report Scales (BASC-2-PRS) [17] to assess emotional–behavioral functioning in childhood epilepsy [15], [18], [19], [20]. While each research group uniquely studied emotional–behavioral functioning in their respective samples, the studies generally identified elevated symptoms across the domains of internalizing problems, externalizing problems, and behavioral symptoms. For example, within a mixed clinical sample, Clary and colleagues [20] identified the most frequently occurring clinical elevations in the subdomains of atypicality (45%), withdrawal (37%), and depressive symptoms (29%). In another study, Bender and colleagues [15] identified clinical elevations in the domains of externalizing problems in 7%, behavioral symptoms in 10%, and internalizing symptoms in 19% of their mixed clinical sample. Within a sample of childhood absence epilepsy, Vega and colleagues [18] identified clinical elevations in the subdomains of anxiety (11%) and depression (24%). Additionally, at least three studies have used the Behavioral Rating Inventory of Executive Function (BRIEF) [21] parent-report form to assess the everyday or behavioral components of executive functioning in a mixed clinical sample of children with epilepsy, in a sample of children with intractable epilepsy, and in a group with idiopathic epilepsy (generalized and location-related) [22], [23], [24]. Broadly, these studies identified significantly elevated symptoms in their samples with epilepsy across BRIEF domains and subdomains, reflecting significant executive functioning difficulties in the everyday behaviors of these children and adolescents.

The majority of research studies have not found epilepsy-related variables to be significantly associated with emotional–behavioral functioning in children and adolescents with epilepsy [1], [4], [25], [26], [27], [28]. However, while the sum of the research is inconclusive, a few studies have identified some specific relationships between epilepsy variables and select outcomes. For example, younger age at seizure onset and longer duration of epilepsy have been associated with the presence of anxiety disorders as well as anxiety and depressive symptoms [4], [19], [27]. Seizure frequency/severity and medication status (polytherapy versus monotherapy) have been associated with the presence of internalizing disorders as well as anxiety and depressive symptoms [5], [27], [29]. Further, temporal lobe seizure foci have been associated with increased behavioral problems and diagnosis of depression [2], localization-related seizures have been associated with tic disorders and depressive disorders, generalized seizures have been associated with conduct disorder, and childhood absence epilepsy has been associated with anxiety disorders [3], [4]. Associations have also been examined between epilepsy-related variables and executive functioning using both performance-based and parent-report measures [23]. MacAllister and colleagues identified significant associations between epilepsy-related variables (seizure frequency, number of antiepileptic drugs [AEDs], and age at epilepsy onset) and performance-based executive functions (impulsivity and total time of problem solving). In contrast, they found no associations between epilepsy-related variables and parent-rated executive functioning (i.e., BRIEF) [23]. In sum, more information is needed regarding the variables or factors that are responsible for such neurobehavioral comorbidities [4] in order to provide clinicians with appropriate information on how to accurately identify and treat those patients who are at increased risk for such comorbidities.

This study aimed to provide clarity to prior inconsistent research findings by examining clinical and demographic risk factors associated with parent-rated emotional–behavioral and executive functioning in children and adolescents with epilepsy within a large clinically referred mixed sample. The present study sought to examine the potential influence of demographic, family history, and epilepsy-related variables on emotional–behavioral functioning (internalizing and externalizing problems and behavioral symptoms) and executive functioning (metacognition and behavior regulation) as measured by parent-rating scales. While the BASC-2 and BRIEF have previously been studied in childhood epilepsy, the current study simultaneously assessed the factors associated with both scales within a large mixed clinical sample to provide a more cohesive understanding of emotional–behavioral and executive functioning in childhood epilepsy.

Section snippets

Participants

Institutional Review Board approval was obtained through the Johns Hopkins University School of Medicine. Three hundred forty-one children, adolescents, and young adults with epilepsy consecutively referred for neuropsychological evaluation at the Kennedy Krieger Institute (KKI) between 2009 and 2014 were considered for inclusion in the present study. Participants were generally referred for neuropsychological evaluation to characterize cognitive functioning and guide treatment planning.

The

Results

All domain scores on the BASC-2 and BRIEF were significantly higher in the group with epilepsy than published normative data, including BRIEF GEC (p < .001), BRIEF MCI (p < .001), BRIEF BRI (p < .001), BASC-2 Externalizing Problems (p < .01), BASC-2 Internalizing Problems (p < .001), and BASC-2 BSI (p < .001). Percentages of participants scoring in the clinical range extended from 8.9% (BASC-2 Externalizing Problems) to 46.9% (BRIEF MCI). Almost a quarter of the sample had at least one clinical elevation

Discussion

Given prior inconsistent research findings, the present study examined clinical and demographic risk factors associated with parent-rated emotional–behavioral and executive functioning in children and adolescents with epilepsy. This is the first study to our knowledge that has examined and successfully identified such risk factors for emotional–behavioral and executive functioning dysfunction within a large outpatient sample of patients with childhood epilepsy. The following can summarize the

Conclusions

In conclusion, childhood epilepsy is often characterized by emotional–behavioral and executive functioning difficulties, yet the mental health needs of these young people continue to go underserved. The present study identified seizure-related and demographic variables associated with parent ratings of emotional–behavioral and executive functioning, specifically seizure status, age at evaluation, and family psychiatric history. Assessing these variables in the clinical treatment of childhood

Conflict of interest

We wish to confirm that there are no known conflicts of interest associated with this publication.

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