daniel miles, md
DESCRIPTION
Pediatric Epilepsy: Cognitive Problems, Medication Effects and AutismTRANSCRIPT
Pediatric Epilepsy
Cognition, Autism, Medication effects
Pediatric EpilepsyCognition
Cognition
Memory Perception Attention Organization Planning Problem solving abilities
Pediatric Epilepsy Cognition
Children with epilepsy have a disproportionate share of problems with learning and behavior
As a group they have an average IQ that is 10 points below normal
There is a 3-fold increase in mental retardation
Even those without mental retardation are at risk of academic underachievement or school failure
Pediatric Epilepsy Cognition
On the bright side
Half of children with epilepsy have normal academic records
Two-thirds are in regular classes
More than 80% are working at grade level
A majority of children with epilepsy develop normally and have normal cognitive abilities
Pediatric Epilepsy Cognition
Perception and attention have been found to be two of the major factors associated with learning difficulties in children with epilepsy
Boys have more problems than girls
It is difficult to determine the cause for academic difficulties in children with epilepsy
Pediatric Epilepsy Cognition
Underlying factors in academic difficulties:
Intrinsic developmental capability
Associated brain disease
Parent-child interactions
Seizures
Medications
Pediatric Epilepsy Cognition
The underlying brain disease , not the seizures, is the most important factor contributing to subnormal intellect in children with epilepsy
Pediatric Epilepsy Cognition
Epileptic syndrome and prognosis for cognitive function
Unfavorable cognitive development West syndrome Lennox-Gastaut syndrome Doose’s syndrome Landau-Kleffner syndrome Rett syndrome
Pediatric Epilepsy Cognition
Epileptic syndrome and prognosis for cognitive function
Favorable cognitive development Febrile seizures Childhood absence epilepsy Benign partial epilepsy of childhood (Rolandic
epilepsy) Juvenile myoclonic epilepsy
Pediatric EpilepsyAutism
Neurodevelopmental disorder affecting primarily social communication but associated with language impairments and repetitive behaviors
Autism spectrum disorders: a broader group of children including those with autism disorder, pervasive developmental disorders not otherwise specified, and those with Asperger’s syndrome
Pediatric EpilepsyAutism
There is no clear evidence that epilepsy causes autism
The contribution of epilepsy and interictal epileptiform discharges to ongoing cognitive deficits in children with autism remains poorly understood and controversial
There is evidence that common shared anatomical and molecular mechanisms may account for both epilepsy and autism
Pediatric EpilepsyAutism
Epilepsy and autism coexist in up to 20% of children with either disorder
Intellectual disability show a very high prevalence in those with both autism and epilepsy
Early onset seizures may be a factor in making infants at higher risk of autism
Pediatric EpilepsyAutism
Epilepsy was noted in 21% of individuals with autism and intellectual disability versus 8% in individuals with autism without intellectual disability.
There is consensus that there is a strong association between epilepsy, autism, intellectual and motor disability in infants with epileptic encephalopathy, the overall effect of both epilepsy and interictal epileptiform activity,
Pediatric EpilepsyAutism
Mechanisms that lead to epilepsy may also affect the development of social cognition
A recent study revealed malformations of cortical development in 12 of 13 autism brains and in only 1 of 14 control brains. Such malformations of cortical development are commonly found in children with epilepsy
Pediatric EpilepsyAutism
Genome wide studies are demonstrating “copy number variants” or CNVs (deletions, duplications, and insertions) that are common to both epilepsy and autism.
Pediatric EpilepsyMedication Effects on Cognition
Cognitive side effects are generally reported to be mild to moderate in magnitude compared with most of the other types of side effects.
Some studies suggest such side effects have a greater impact on function and daily living than previously suspected.
Pediatric EpilepsyMedication Effects on Cognition
Types of cognitive impairment
Depressed capacity of the information-processing system by producing slowing
Decreased the input of working memory
Decreased mental flexibility
Pediatric EpilepsyMedication Effects on Cognition
Many studies done only compare one agent with another that is thought to have a “favorable cognitive profile”
Pediatric EpilepsyMedication Effects on Cognition
Phenobarbital Cognitive impairment including visual motor and
memory tests
Phenytoin (Dilantin) Attention, memory and memory speed
Valproate (Depakote) Impairment of mental speed
Pediatric EpilepsyMedication Effects on Cognition
Carbamazepine (Tegretol) Favorable compared with other “older” AED’s
Lamotrigine (Lamictal) Does not impair cognition May benefit mental performance “Euphoria” secondary to impact of cognitive
productivity
Oxcarbazepine (Trileptal) No impairment/improved cognitive functioning
Pediatric EpilepsyMedication Effects on Cognition
Topiramate Dose related slowing of mental speed and
inattentiveness Word finding difficulty
Felbatol (Felbamate) “Alerting” No formal studies have been done
Gabapentin (Neurontin) Well tolerated cognitively
Pediatric EpilepsyMedication Effects on Cognition
Vigabatrin (Sabril) Few cognitive side effects
Zonisamide (Zonegran) Sedation
Lacosamide (Vimpat) Sleepiness/fatigue
Rufinamide (Banzel) Sleepiness/fatigue