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William MacAllister, PhD

William MacAllister, PhD



Pay Attention to This: Attention and Working Memory Challenges in Kids with Epilepsy

Pay Attention to This: Attention and Working Memory Challenges in Kids with Epilepsy



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    William MacAllister, PhD William MacAllister, PhD Presentation Transcript

    • Pay Attention to This: Attention and Working Memory in Pediatric Epilepsy
      William S. MacAllister, Ph.D.
      Pediatric Neuropsychologist
    • To be discussed…
      Brief History of ADHD
      Review of the Diagnostic Criteria
      Associated Features / Comorbid Conditions
      Attention Problems in Epilepsy
      Treatment Considerations
    • History
      First descriptions of ADHD may have appeared 2500 years ago
      Hippocrates described a patient who had quickened responses to sensory experiences, but also less tenaciousness because the soul moves on quickly to the next impression
      Condition was attributed to an overbalance of fire over water
    • History Continued…
      George Frederick Still (1902)
      Defined chief characteristics in 43 kids
      “defects in moral control”
      “abnormal incapacity for sustained attention, restlessness, fidgetiness, violent outbursts, destructiveness, non-compliance”
      Demonstrate little “inhibitory volition”
    • Encephalitis outbreak of 1917
      Called attention to the fact that these children showed similar deficits and allowed scientists of the day to draw parallels between these groups
      Gave rise to the concept of “minimal brain dysfunction”
    • DSM-IV Dx Criteria - Part 1
    • Inattentive Subtype
    • Diagnostic Criteria Part 2
    • ADHD is one of the most common psychiatric conditions of childhood
      Considered one of the best-researched disorders in medicine and the overall data on its validity are far more compelling than for many medical conditions (Goldman et al, 1998)
      In clinic samples, boys are 6-10x more likely to be referred for the d/o and 3-4x more likely to be dx
      May reflect biases - girls less likely to be disruptive
    • Several recent epidemiological studies of ADHD have been conducted
      Rowland et al, 2002; Harel & Brown, 2002; Barbaresi et al, 2002; CDC, 2005
      Prevalence across these studies fairly consistent, with estimates between 6 and 10%
      Estimated to affect 4.4 million children in U.S.
      Interestingly, many identified a “treatment gap”
    • CDC Study
      For example, the CDC study indicated that 7.8% of children met criteria at some point in their lifetime
      But only 4.3% were treated with medications (only 55% of those with ADHD were treated pharmacologically)
    • In kids…
      Higher rates of ER admissions (Leibson et al 2001)
      More burns, TBI, fractures
      Driving accidents more common in adolescence
      More driving offenses (speeding, reckless driving -> suspended licenses)
      Higher rates of STD’s (4x higher; Fischer, 93)
      Higher teen pregnancy rates
    • Associated Disorders
      Tic D/O’s
      Developmental Coordination Disorders
    • Learning Disabilities
      LD’s are comorbid in over 20% of cases
      Reading disorders (16-39%)
      Spelling problems (24-27%)
      Math disorders (13-33%)
    • DCD
      Approximately 6% of population with higher rates in ADHD
      Clumsiness, dysgraphia, articulation deficits
      Likely due to underlying neural substrates involving cortical-basal ganglia circuitry (see Delong 2002)
    • Milich et al, 2002; Coghill et al 2005 believe that ADHD-C and ADHD-I are actually “distinct disorders”
    • Cognition in Epilepsy
      Well established that inattention and hyperactivity are behavioral symptoms common in childhood onset epilepsy (Dunn & Austin, 1999)
      Such symptoms may, in large part, account for the degree of academic underachievement in these children
    • Prevalence of ADHD in epilepsy varies widely across samples studied and measures employed
      Epidemiological studies
      Rutter et al. (1970): Hyperactivity seen in 4/34 children with epilepsy (Isle of Wight Study: UK)
      McDermott et al (1995): Hyperactivity seen is 28% of children with epilepsy, versus 13% in cardiac patients, and 5% in control children
      Carlton-Ford et al (1995): Impulsivity seen in 39% of children with current OR past seizures, versus 11% in controls
    • Teacher Report
      Holdsworth and Whitmore (1974) – Teachers report inattention in 42% of children with seizures
      Sturniolo and Galletti (1994): Inattention or hyperactivity in 58% of children with seizures
      No standardized measures or diagnostic procedures
    • Dunn et al 2003 study
      Studied relations of ADHD Symptoms and:
      Seizure type
      Study examined 175 children
      (85 boys, 90 girls)
      Mean age = 11y 10m
      Recruited from private practices and University Hospital samples
    • Measures
      CBCL (Achenbach)
      Dimensional instrument of symptoms
      CSI-4 / ASI-4 (Gadow and Sprafkin)
      Categorical and Dimensional
      Based on DSM-4 criteria
    • Sample characteristics
    • CBCL Results
      42% of Adolescents and 58% of children were in the “at-risk” range for attention problems
      25% adolescents and 37% of children were in the “clinical” range
    • Dunn Studies
    • ADHD by seizure type
    • ADHD Prevalence by Focus
    • Interesting findings of this study:
      In contrast to ADHD in non-epilepsy patients:
      Inattentive subtype ADHD was more common than Combined
      Girls were more likely to have ADHD than boys
    • Hermann et al (2007)
      Studied 75 children and adolescents with new onset epilepsy (ages 8 – 18) and 62 Controls
      KSADS Interview, Neuropsych
      ADHD was present in 31% of patients and only 6% of controls
      Inattentive subtype predominated, with symptoms of ADHD appearing before seizures
      Children with ADHD and epilepsy had higher rates of school interventions/services
      Neuropsych evaluation revealed prominent executive dysfunction
      ADHD was not associated with epilepsy characteristics or demographic variables
    • Executive Dysfunction
      Slick et al 2006
      BRIEF as primary measure
      80 children and adolescents with intractable epilepsy
    • Slick article
    • Treatment (Pharmacological)
      Methylphenidate (e.g., Ritalin; MPH) is commonly believed to lower seizure threshold
      PDR suggests that methylephenidate is contraindicated in children with epilepsy
      However, no controlled studies have proved this hypothesis
      Only isolated case studies seem to support MPH as analeptic
    • Safety
      Several publications indicate that MPH is safe in children with controlled epilepsy
      (Feldman et al, 1989) – 10 children with ADHD and Epilepsy – MPH effectively treated ADHD Symptoms and no seizures were seen during the 10 weeks of follow-up.
      All had abnormal EEG’s that were unchanged during the study
    • Gross-Tsur et al (1997)
      30 Children with epilepsy and ADHD
      (25 were seizure free on AED’s, 5 with occasional seizures)
      Those that were seizure free prior to MPH remained so after MPH
      Those with ongoing seizures did not show an increase in seizure frequency
    • Gucuyener et al (2003)
      Followed two groups for one year
      one with ADHD and epilepsy, one with ADHD and EEG abnormalities (but no clinical seizures)
      MPH improved ADHD symptoms in both groups
      The epilepsy group experienced no change in seizure frequency AND EEG’s improved
      No patients in the abnormal EEG group experienced seizures
    • Summary of MPH studies
      Most agree that MPH is not contraindicated in children with ADHD
      No compelling evidence that MPH will
      increase risk of seizures in children with ADHD
      will cause seizures in those with ADHD and abnormal EEG
      or will increase seizure frequency in children with ADHD and epilepsy
    • Treatment with Amphetamines (e.g., Adderall, Dexedrine, Vyvanse)
      Effects of these agents in children with ADHD and Epilepsy has NOT been systematically studied
      Torres et al (2008) in their review of the evidence noted that:
      “Amphetamines might be proconvulsant, especially when abused; however there is some evidence that amphetamines may have an anticonvulsant effect in select patients.”
      “Case series for ADHD plus Epilepsy have reported disappointing response rates to amphetamine”
    • Atomoxetine (Strattera)
      No well-controlled trials of Atomoxetine in patients with ADHD and epilepsy
      Summarizing the results of available data “the rate of the positive response to atomoxetine was disappointing” (Torres et al, 2008)
      However, it was noted that almost all of the patients placed on Strattera had already had unsuccessful trials of stimulants
    • Summary of Medication studies suggest that MPH may be the best supported treatment in children with epilepsy and comorbid ADHD
    • Summary Points
      Rate of ADHD in children with epilepsy is several times higher than in general population (5 times higher?)
      Inattentive subtype more common
      Girls more affected than boys
      May be primary reason for school underachievement
      All seizure types at risk
      MPH may be treatment of choice
    • What is an Executive Function?
      Key elements:
      Anticipation and deployment of attention
      Impulse control/self-regulatory processes
      Working memory
      Mental flexibility
      Problem solving
    • What does executive dysfunction look like?
      Inability to focus or maintain attention
      Impulse control deficits
      Poor working memory
      Difficulties self-monitoring
      Inability to plan
      Poor reasoning
    • Neuroanatomy
      PFC (particularly dorsolateral PFC) are the last brain regions to myelinate
      PFC play a critical role in executive fx
      Region does not act in isolation
      Part of broader functional system
      Highly interconnected with other regions
      Damage to PFC is sufficient, but not necessary for executive dysfunction
      e.g., subcortical structures (basal ganglia) as well as the cerebellum are also crucial
    • Yeah… but what is workingmemory?
      Working Memory: A limited capacity memory system that provides temporary storage to manipulate complex cognitive tasks…
    • BaddeleyModel of Working
      Baddeley Model deals mainly with working memory
      Working memory – “a limited capacity system allowing the temporary storage and manipulation of information necessary for such complex tasks as comprehension, learning, and reasoning” (Baddeley, 2000)
      Holding information ‘On-line’ while operating on it.
    • Why is working memory important?
      Working memory deficits have the potential to adversely affect children in academic pursuits
    • School
      Note taking in class requires a tremendous amount of working memory
      Children must dual task as they listen to what the teacher is saying, while concurrently writing down what they have just said
      i.e., the ‘lag’ between the teacher’s real time speech and the child’s handwriting necessitates working memory for them to keep up with the demands of the classroom
    • Academic Achievement
      Several studies have linked executive function deficits (and particularly working memory deficits) to objective performance on academic tasks, even in children who do nothave primary learning disabilities…
    • Mathematics
    • Reading Comprehension
    • So now what?
      Can anything be done about this?
    • Adhd study
    • Stroke study
    • Holmes study
    • Klingberg ADHD Study
    • Interested?
      Call me! Let’s chat!
      Or Megan Marsh, Ph.D.
      OR just see me after this talk…