Psychiatric Disorders and Learning Problems that

Commonly Occur with Pediatric Epilepsy

Supported by HRSA MCHB Cooperative Agreement Number U23MC26252

Learning Objectives• Identify the 3 most common psychiatric disorders in pediatric

epilepsy

• Identify differences in depression for children and adolescents relative to adults

• Identify at least 2 recommended treatments for depression and anxiety

• Identify learning problems common in children with epilepsy

• Identify the importance of working with school personnel to care for children with epilepsy and mental health and/or learning problems

Slide courtesy of Pedrotty, 2014

Prevalence of Mood and Anxiety Disorders in Pediatric Epilepsy• Depression and anxiety occur more commonly in children with

epilepsy- about 20% of children with epilepsy

• Higher rates are probably related to factors in the family

• These children have high rates of suicide

• Mood and anxiety disorders are often underdiagnosed and undertreated

• Early identification is essential to negative impact, especially suicide

Slide adapted from Pedrotty, 2014

Facts About Depression and Epilepsy

• Depression increases the costs of the disorder by 50%

• Critical to screen new cases of epilepsy

• Early identification of depression helps guide medication decisions

• Most neurologists do not routinely screen for depression when diagnosing epilepsy

• Medical professionals need training to screen and treat for depression when caring for children with epilepsy

Slide adapted from Pedrotty, 2014

Assessment: Primary Care Tools

• https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Pages/Primary-Care-Tools.aspx

• GLAD-PC Toolkit:

www.thereachinstitute.org/images/GLAD-PCToolkit_V2_2010.pdf

Slide courtesy of Pedrotty, 2014

Depression and Anxiety Assessment• Depression and anxiety rarely present with the ‘‘classic” symptoms:

- Depression - sadness, insomnia, anhedonia, psychomotor retardation, and decreased appetite

- Anxiety - overt worrying

• Depression in children may present as aggression and/or disruptive behavior

• Anxiety in children may present as irritability and aggressive behavior

• Symptoms of depression associated with epilepsy may be temporally related to occurrence of seizures

Slide adapted from Pedrotty, 2014

Depression – Sample Questions for Children

• To identify irritability:

(1) Do you have a bad temper?

(2) Do you sometimes get mad for no reason?

(3) If a little thing goes wrong, are you bothered by it for a long time?

• To identify depressed mood:

(1) Are you as happy as others around you?

(2) Do you think that you have a bright future?

(3) Have you ever thought that life was not worth living?

Slide adapted from Pedrotty, 2014

Anxiety - Assessment• The occurrence of seizures can make it difficult to identify and

isolate symptoms of anxiety

• The fear of seizures or seizure-related accidents may lead to symptoms similar to agoraphobia (fear of public places where escape may be difficult)

• Fear of having a seizure may be associated with separation anxiety

• Panic attacks may mimic complex partial seizures

• Fear of embarrassment about having a seizure in public may also lead to symptoms similar to social phobia

Slide courtesy of Pedrotty, 2014

Anxiety – Sample Questions for Children

• To identify anxiety:

(1) Are you the type of person who worries?

(2) What do you worry about?

(3) Does your worrying make it hard for you to sit still?

(3) What things scare you?

Slide adapted from Pedrotty, 2014

Barriers to Treatment

• 2/3 of parents reject recommendation for treatment of depression

• Parents see seizures as focus

• Externalizing symptoms (ADHD, aggression, irritability) become focus rather than internalizing symptoms (anxiety and depression)

Slide courtesy of Pedrotty, 2014

Treatment• Few studies on pediatric epilepsy and comorbidity.

• Therapy + Medication works best.

• Recommended therapies:• Cognitive Behavioral Therapy (best studied)

• Interpersonal Therapy

• Supportive Therapy

• Family and Group

• Psychoeducation of child, parent, and family

• Parent and family support very important

• School Support: 504 plan, IEP

Slide courtesy of Pedrotty, 2014

Medication Treatment of Depression and Anxiety in Children with Epilepsy• Selective serotonin reuptake inhibitors (SSRIs) should be the first-

line drugs in the treatment of depression and anxiety in children with epilepsy

• Prior to starting medications, obtain a detailed history to determine if the child’s mood symptoms reflect AED withdrawal, high doses of AED polytherapy or use of AEDs with known behavioural side effects.

• Referral to a child psychiatrist is recommended if the parent(s) or child describes behaviors that are significantly disruptive or self-destructive or involve substance abuse.

Slide courtesy of Pedrotty, 2014

Epilepsy and suicide• Recognize the bidirectional relationship between suicidality and

epilepsy:

• Patients with epilepsy have a greater risk of suicide

• Patients with a history of suicidality have a greater risk of developing epilepsy

• Suicidal ideation can occur as part of an interictal mood/anxiety disorder or as postictal symptomatology

• The presence of postictal suicidal ideation should alert the clinician to the existence of a current or past serious history of depression

Slide courtesy of Pedrotty, 2014

Suicide-Brief Assessment• Current Ideation (frequency, intensity, duration, lethality, access,

and intent)

• Access to weapons

• Impulsivity (ADHD, anger dyscontrol, substance abuse and ETOH)

• Past Attempt

• Psychosis

• Psychiatric disorder and HX

• Support (social isolation or rejection)

• Competency

• Crisis

Slide courtesy of Pedrotty, 2014

Crisis Safety Plan• Review plan, stress, and stability

• Discuss resiliency of patient – ways to manage suicidal thoughts, anxiety, and depression

• Develop plan to manage lethality, including accessibility, method restriction, work with parents on this directly

• Identify risk and protective factors and ways to manage risk factors

• Work with family on crisis safety plan

• Make appointment for outpatient therapy and follow up

• Call therapist/psychiatrist if they have one

• Write out plan with necessary materials

Slide courtesy of Pedrotty, 2014

Crisis Safety Plan - example• Go to ____________ for follow up (set this up at clinic before they leave)

• RTC on ____________

• Numbers to call: National Suicide Prevention Hotline 1-800-273-TALK or AGORA 1-866-HELP-1-NM, Psychiatric Emergency Service (505.272.2920) office, other

• What would it take to not think about hurting oneself?

• Who can s/he can tell if feeling like hurting self?

• How can s/he remain safe?

• Firearm safety and pill safety discussed?

• What is risky behavior and how can it be stopped (ETHO, SA, high risk activities)?

• How can family monitor mood and take to PES or ED if worsens?

• Is there interest in starting a trial of medicine?

• What other possible diagnoses are present?

• Give handout and/or copy of this plan

• Would it be helpful to contact school counselor or other school staff?

• Does person and parent agree with plan?

• Clinic will call to follow up on (24, 48 and 72 hours) how s/he is doing (enter days and number to be reached at here).

Slide courtesy of Pedrotty, 2014

Epilepsy and learning• Greater risk of problems with attention

• Greater risk of problems with learning and memory

• Routinely ask about school performance

• For children having difficulty, encourage the school to complete cognitive testing. For school-aged children, should include IQ and Achievement testing.

• For children who have significant learning problems, encourage family and school to develop 504 Plan (Other Health Impaired) or IEP

• If behavioral symptoms interfere with success at school, encourage family and school to develop a behavior plan based on Functional Behavioral Assessment

• Be aware of cognitive effects of AEDs, especially multi-drug therapy

• Treat ADHD with medication, educational supports, and behavioral supports

Slide courtesy of Pedrotty, 2014

Summary –Mental Health, Learning and Epilepsy

• Simple epilepsy: about 25% of children will have depression and/or anxiety

• Complex epilepsy: about 50% of children will have depression and/or anxiety

• Suicide thinking and behavior is a low frequency behavior but occurs at a higher rate in children with epilepsy

• Talk about and screen for depression, anxiety, and suicide.

• Children with epilepsy are more likely to have problems with learning and attention

Slide courtesy of Pedrotty, 2014

Summary- Mental Health, Learning and Epilepsy• Educate child and parents on managing epilepsy and comorbid conditions

• Encourage supports at school ( IEP, 504 Plan, social skills training, behavior plan)

• Treat within range of expertise and comfort

• Make referrals for help as needed• Child Psychiatry and Child Psychology

• Developmental-Behavioral Pediatrics

• Child and Family Therapists (psychology, social work, counselling)

• Follow up with the family

• Reassess routinely

Slide courtesy of Pedrotty, 2014

Additional Resources

Tools for Primary Care Providers

• https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Pages/Primary-Care-Tools.aspx

• https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Documents/MH_ScreeningChart.pdf

Additional Resources

• AAP Task Force on Mental Health Algorithm Teams 2006-2007• References for Evidence-Based Programs for Young Children• Brief Mental Health Update• Glossary of Mental Health and Substance Abuse Terms• Health Care Financing Resources• Primary Care Referral and Feedback Form• Mental Health Screening and Assessment Tools for Primary Care

Updated 2/12• Symptoms and Signs Suggestive of Mental Health and Substance

Abuse Concerns• Adapted SAD PERSONS

References• Barry JJ, Ettinger AB, Friel P, Gilliam FG, Harden CL, Hermann B, et al. (2008).

Consensus statement: the evaluation and treatment of people with epilepsy and affective disorders. Epilepsy & Behavior;13:1–29.

• Buelow, JM, Johnson CS, Perkins, SM, Austin, JK and Dunn, DW (2013) Creating avenues for parent partnership (CAPP): an interventions for parents of children with epilepsy and learning problems. Epilepsy & Behavior. 27, 64-69

• Jones JE, (2014) Treating anxiety disorders in children and adolescents with epilepsy: What do we know?, Epilepsy Behavior, http://dx.doi.org/10.1016/j.yebeh.2014.06.021

• Lin, JJ, Mula, M & Hermann, B. (2012). Uncovering the neurobehavioral comorbidities of epilepsy over the lifespan. Lancet. 380: 1180-92

• Reilly C, Agnew R, and Neville BGR.(2011) Depression and anxiety in childhood epilepsy: A review. Seizure, 20, 589-597.

• Wagner, JL, Smith, G, Ferguson, P, van Bakergem, K and Hrisko, S. (2011). Feasibility of a pediatric cognitive-behavioral self-management intervention: Coping Openly and Personally with Epilepsy (COPE). Seizure. 20, 462-467

Slide courtesy of Pedrotty, 2014

References• Langenbahn, D.M, Ashman, T., Cantor, J. & Trott, C. (2013). An evidence-based

review of cognitive rehabilitation in Medical Conditions affecting cognitive function. Archives of Physical Medicine and Rehabilitation. 94: 271-86

• Lin, JJ, Mula, M & Hermann, B. (2012). Uncovering the neurobehavioral comorbidities of epilepsy over the lifespan. Lancet. 380: 1180-92

• Chiappedi, M., Beghi, E., Ferrari-Ginevra, O., Ghezzo, A, Maggioni, E. et al (2010) Response to rehabilitation of children and adolescents with epilepsy. Epilepsy & Behavior, 20; 79-82.

• Economou, NT., Dikeo, D., Andrews, N. & Foldvary-Schaefer, N (2013) Use of the sleep apnea scale of the sleep disorders questionnaire (SA-SDQ) in adults with epilepsy.

• Laatsch, Linda (2008). Manual for Developmental Metacognitive Approach for Cognitive Rehabilitation. Presentation at UNM-HSC.

Slide courtesy of Pedrotty, 2014