Daniel Miles, MD


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Pediatric Epilepsy: Cognitive Problems, Medication Effects and Autism

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Daniel Miles, MD

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