Pay Attention to This: Attention and Working Memory in Pediatric Epilepsy<br />William S. MacAllister, Ph.D.<br />Pediatri...
To be discussed…<br />Brief History of ADHD<br />Review of the Diagnostic Criteria<br />Associated Features / Comorbid Con...
History<br />First descriptions of ADHD may have appeared 2500 years ago<br />Hippocrates described a patient who had quic...
History Continued…<br />George Frederick Still (1902)<br />Defined chief characteristics in 43 kids<br />“defects in moral...
Encephalitis outbreak of 1917<br />Called attention to the fact that these children showed similar deficits and allowed sc...
DSM-IV Dx Criteria - Part 1<br />
Inattentive Subtype<br />
Diagnostic Criteria Part 2<br />
ADHD is one of the most common psychiatric conditions of childhood<br />Considered one of the best-researched disorders in...
Several recent epidemiological studies of ADHD have been conducted<br />Rowland et al, 2002; Harel & Brown, 2002; Barbares...
CDC Study<br />For example, the CDC study indicated that 7.8% of children met criteria at some point in their lifetime<br ...
In kids…<br />Higher rates of ER admissions (Leibson et al 2001)<br />More burns, TBI, fractures<br />Driving accidents mo...
Associated Disorders<br />LD’s<br />ODD<br />Tic D/O’s<br />Developmental Coordination Disorders<br />
Learning Disabilities<br />LD’s are comorbid in over 20% of cases<br />Reading disorders (16-39%)<br />Spelling problems (...
DCD<br />Approximately 6% of population with higher rates in ADHD<br />Clumsiness, dysgraphia, articulation deficits<br />...
Milich et al, 2002; Coghill et al 2005 believe that ADHD-C and ADHD-I are actually “distinct disorders”<br />
Cognition in Epilepsy<br />Well established that inattention and hyperactivity are behavioral symptoms common in childhood...
Prevalence of ADHD in epilepsy varies widely across samples studied and measures employed<br />Epidemiological studies<br ...
Teacher Report<br />Holdsworth and Whitmore (1974) – Teachers report inattention in 42% of children with seizures<br />Stu...
Dunn et al 2003 study<br />	Studied relations of ADHD Symptoms and: <br />Seizure type<br />Localization<br />Study examin...
Measures<br />CBCL (Achenbach)<br />Dimensional instrument of symptoms<br />CSI-4 / ASI-4 (Gadow and Sprafkin)<br />Catego...
Sample characteristics<br />
CBCL Results<br />42% of Adolescents and 58% of children were in the “at-risk” range for attention problems<br />25% adole...
Dunn Studies<br />
ADHD by seizure type<br />
ADHD Prevalence by Focus<br />
Interesting findings of this study:<br />In contrast to ADHD in non-epilepsy patients:<br />Inattentive subtype ADHD was m...
Hermann et al (2007)<br />Studied 75 children and adolescents with new onset epilepsy (ages 8 – 18) and 62 Controls<br />K...
Executive Dysfunction<br />Slick et al 2006<br />BRIEF as primary measure<br />80 children and adolescents with intractabl...
Slick article<br />
Treatment (Pharmacological)<br />Methylphenidate (e.g., Ritalin; MPH) is commonly believed to lower seizure threshold<br /...
Safety<br />Several publications indicate that MPH is safe in children with controlled epilepsy<br />(Feldman et al, 1989)...
Gross-Tsur et al (1997) <br />30 Children with epilepsy and ADHD <br />(25 were seizure free on AED’s, 5 with occasional s...
Gucuyener et al (2003)<br />Followed two groups for one year<br />one with ADHD and epilepsy, one with ADHD and EEG abnorm...
Summary of MPH studies<br />Most agree that MPH is not contraindicated in children with ADHD<br />No compelling evidence t...
Treatment with Amphetamines (e.g., Adderall, Dexedrine, Vyvanse)<br />Effects of these agents in children with ADHD and Ep...
Atomoxetine (Strattera) <br />No well-controlled trials of Atomoxetine in patients with ADHD and epilepsy<br />Summarizing...
Summary of Medication studies suggest that MPH may be the best supported treatment in children with epilepsy and comorbid ...
Summary Points<br />Rate of ADHD in children with epilepsy is several times higher than in general population (5 times hig...
What is an Executive Function?<br />Key elements:<br />Anticipation and deployment of attention<br />Impulse control/self-...
What does executive dysfunction look like?<br />Inability to focus or maintain attention<br />Impulse control deficits<br ...
Neuroanatomy<br />PFC (particularly dorsolateral PFC) are the last brain regions to myelinate<br />PFC play a critical rol...
Yeah… but what is workingmemory? <br />Working Memory: A limited capacity memory system that provides temporary storage to...
BaddeleyModel of Working <br />Baddeley Model deals mainly with working memory <br />Working memory – “a limited capacity ...
Why is working memory important? <br />Working memory deficits have the potential to adversely affect children in academic...
School<br />Note taking in class requires a tremendous amount of working memory<br />Children must dual task as they liste...
Academic Achievement<br />Several studies have linked executive function deficits (and particularly working memory deficit...
Mathematics<br />
Reading Comprehension<br />
So now what? <br />Can anything be done about this? <br />
Adhd study<br />
Stroke study<br />
        Holmes study<br />
Klingberg ADHD Study<br />
Interested?<br />Call me! Let’s chat!<br />646-558-0852<br />Or Megan Marsh, Ph.D.<br />212-263-8304<br />OR just see me a...
Upcoming SlideShare
Loading in …5
×

William MacAllister, PhD

1,379 views
1,274 views

Published on

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

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,379
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
17
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

William MacAllister, PhD

  1. 1. Pay Attention to This: Attention and Working Memory in Pediatric Epilepsy<br />William S. MacAllister, Ph.D.<br />Pediatric Neuropsychologist<br />
  2. 2. To be discussed…<br />Brief History of ADHD<br />Review of the Diagnostic Criteria<br />Associated Features / Comorbid Conditions<br />Attention Problems in Epilepsy<br />Treatment Considerations<br />
  3. 3. History<br />First descriptions of ADHD may have appeared 2500 years ago<br />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<br />Condition was attributed to an overbalance of fire over water<br />
  4. 4. History Continued…<br />George Frederick Still (1902)<br />Defined chief characteristics in 43 kids<br />“defects in moral control”<br />“abnormal incapacity for sustained attention, restlessness, fidgetiness, violent outbursts, destructiveness, non-compliance”<br />Demonstrate little “inhibitory volition”<br />
  5. 5. Encephalitis outbreak of 1917<br />Called attention to the fact that these children showed similar deficits and allowed scientists of the day to draw parallels between these groups<br />Gave rise to the concept of “minimal brain dysfunction” <br />
  6. 6. DSM-IV Dx Criteria - Part 1<br />
  7. 7. Inattentive Subtype<br />
  8. 8. Diagnostic Criteria Part 2<br />
  9. 9. ADHD is one of the most common psychiatric conditions of childhood<br />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)<br />In clinic samples, boys are 6-10x more likely to be referred for the d/o and 3-4x more likely to be dx<br />May reflect biases - girls less likely to be disruptive<br />
  10. 10. Several recent epidemiological studies of ADHD have been conducted<br />Rowland et al, 2002; Harel & Brown, 2002; Barbaresi et al, 2002; CDC, 2005<br />Prevalence across these studies fairly consistent, with estimates between 6 and 10%<br />Estimated to affect 4.4 million children in U.S.<br />Interestingly, many identified a “treatment gap”<br />
  11. 11. CDC Study<br />For example, the CDC study indicated that 7.8% of children met criteria at some point in their lifetime<br /> But only 4.3% were treated with medications (only 55% of those with ADHD were treated pharmacologically)<br />
  12. 12. In kids…<br />Higher rates of ER admissions (Leibson et al 2001)<br />More burns, TBI, fractures<br />Driving accidents more common in adolescence<br />More driving offenses (speeding, reckless driving -> suspended licenses)<br />Higher rates of STD’s (4x higher; Fischer, 93)<br />Higher teen pregnancy rates<br />
  13. 13. Associated Disorders<br />LD’s<br />ODD<br />Tic D/O’s<br />Developmental Coordination Disorders<br />
  14. 14. Learning Disabilities<br />LD’s are comorbid in over 20% of cases<br />Reading disorders (16-39%)<br />Spelling problems (24-27%)<br />Math disorders (13-33%)<br />
  15. 15. DCD<br />Approximately 6% of population with higher rates in ADHD<br />Clumsiness, dysgraphia, articulation deficits<br />Likely due to underlying neural substrates involving cortical-basal ganglia circuitry (see Delong 2002)<br />
  16. 16. Milich et al, 2002; Coghill et al 2005 believe that ADHD-C and ADHD-I are actually “distinct disorders”<br />
  17. 17.
  18. 18.
  19. 19. Cognition in Epilepsy<br />Well established that inattention and hyperactivity are behavioral symptoms common in childhood onset epilepsy (Dunn & Austin, 1999)<br />Such symptoms may, in large part, account for the degree of academic underachievement in these children<br />
  20. 20. Prevalence of ADHD in epilepsy varies widely across samples studied and measures employed<br />Epidemiological studies<br /> Rutter et al. (1970): Hyperactivity seen in 4/34 children with epilepsy (Isle of Wight Study: UK)<br /> McDermott et al (1995): Hyperactivity seen is 28% of children with epilepsy, versus 13% in cardiac patients, and 5% in control children<br /> Carlton-Ford et al (1995): Impulsivity seen in 39% of children with current OR past seizures, versus 11% in controls<br />
  21. 21. Teacher Report<br />Holdsworth and Whitmore (1974) – Teachers report inattention in 42% of children with seizures<br />Sturniolo and Galletti (1994): Inattention or hyperactivity in 58% of children with seizures<br />No standardized measures or diagnostic procedures<br />
  22. 22. Dunn et al 2003 study<br /> Studied relations of ADHD Symptoms and: <br />Seizure type<br />Localization<br />Study examined 175 children <br />(85 boys, 90 girls)<br />Mean age = 11y 10m<br />Recruited from private practices and University Hospital samples<br />
  23. 23. Measures<br />CBCL (Achenbach)<br />Dimensional instrument of symptoms<br />CSI-4 / ASI-4 (Gadow and Sprafkin)<br />Categorical and Dimensional <br />Based on DSM-4 criteria<br />
  24. 24. Sample characteristics<br />
  25. 25. CBCL Results<br />42% of Adolescents and 58% of children were in the “at-risk” range for attention problems<br />25% adolescents and 37% of children were in the “clinical” range<br />
  26. 26. Dunn Studies<br />
  27. 27. ADHD by seizure type<br />
  28. 28. ADHD Prevalence by Focus<br />
  29. 29. Interesting findings of this study:<br />In contrast to ADHD in non-epilepsy patients:<br />Inattentive subtype ADHD was more common than Combined<br />Girls were more likely to have ADHD than boys<br />
  30. 30. Hermann et al (2007)<br />Studied 75 children and adolescents with new onset epilepsy (ages 8 – 18) and 62 Controls<br />KSADS Interview, Neuropsych<br />ADHD was present in 31% of patients and only 6% of controls<br />Inattentive subtype predominated, with symptoms of ADHD appearing before seizures<br />Children with ADHD and epilepsy had higher rates of school interventions/services<br />Neuropsych evaluation revealed prominent executive dysfunction<br />ADHD was not associated with epilepsy characteristics or demographic variables<br />
  31. 31. Executive Dysfunction<br />Slick et al 2006<br />BRIEF as primary measure<br />80 children and adolescents with intractable epilepsy<br />
  32. 32. Slick article<br />
  33. 33. Treatment (Pharmacological)<br />Methylphenidate (e.g., Ritalin; MPH) is commonly believed to lower seizure threshold<br />PDR suggests that methylephenidate is contraindicated in children with epilepsy<br />However, no controlled studies have proved this hypothesis<br />Only isolated case studies seem to support MPH as analeptic<br />
  34. 34. Safety<br />Several publications indicate that MPH is safe in children with controlled epilepsy<br />(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.<br />All had abnormal EEG’s that were unchanged during the study<br />
  35. 35. Gross-Tsur et al (1997) <br />30 Children with epilepsy and ADHD <br />(25 were seizure free on AED’s, 5 with occasional seizures)<br />Those that were seizure free prior to MPH remained so after MPH<br />Those with ongoing seizures did not show an increase in seizure frequency<br />
  36. 36. Gucuyener et al (2003)<br />Followed two groups for one year<br />one with ADHD and epilepsy, one with ADHD and EEG abnormalities (but no clinical seizures)<br />MPH improved ADHD symptoms in both groups<br />The epilepsy group experienced no change in seizure frequency AND EEG’s improved<br />No patients in the abnormal EEG group experienced seizures<br />
  37. 37. Summary of MPH studies<br />Most agree that MPH is not contraindicated in children with ADHD<br />No compelling evidence that MPH will <br />increase risk of seizures in children with ADHD<br />will cause seizures in those with ADHD and abnormal EEG<br />or will increase seizure frequency in children with ADHD and epilepsy<br />
  38. 38. Treatment with Amphetamines (e.g., Adderall, Dexedrine, Vyvanse)<br />Effects of these agents in children with ADHD and Epilepsy has NOT been systematically studied<br />Torres et al (2008) in their review of the evidence noted that:<br />“Amphetamines might be proconvulsant, especially when abused; however there is some evidence that amphetamines may have an anticonvulsant effect in select patients.”<br />“Case series for ADHD plus Epilepsy have reported disappointing response rates to amphetamine”<br />
  39. 39. Atomoxetine (Strattera) <br />No well-controlled trials of Atomoxetine in patients with ADHD and epilepsy<br />Summarizing the results of available data “the rate of the positive response to atomoxetine was disappointing” (Torres et al, 2008)<br />However, it was noted that almost all of the patients placed on Strattera had already had unsuccessful trials of stimulants<br />
  40. 40. Summary of Medication studies suggest that MPH may be the best supported treatment in children with epilepsy and comorbid ADHD<br />
  41. 41. Summary Points<br />Rate of ADHD in children with epilepsy is several times higher than in general population (5 times higher?)<br />Inattentive subtype more common<br />Girls more affected than boys<br />May be primary reason for school underachievement<br />All seizure types at risk<br />MPH may be treatment of choice<br />
  42. 42. What is an Executive Function?<br />Key elements:<br />Anticipation and deployment of attention<br />Impulse control/self-regulatory processes<br />Initiation<br />Working memory<br />Mental flexibility<br />Planning/organization<br />Problem solving<br />
  43. 43. What does executive dysfunction look like?<br />Inability to focus or maintain attention<br />Impulse control deficits<br />Poor working memory<br />Difficulties self-monitoring<br />Inability to plan<br />Disorganization<br />Poor reasoning<br />Perseveration<br />
  44. 44. Neuroanatomy<br />PFC (particularly dorsolateral PFC) are the last brain regions to myelinate<br />PFC play a critical role in executive fx<br />Region does not act in isolation<br />Part of broader functional system<br />Highly interconnected with other regions<br />Damage to PFC is sufficient, but not necessary for executive dysfunction<br />e.g., subcortical structures (basal ganglia) as well as the cerebellum are also crucial<br />
  45. 45. Yeah… but what is workingmemory? <br />Working Memory: A limited capacity memory system that provides temporary storage to manipulate complex cognitive tasks… <br />
  46. 46. BaddeleyModel of Working <br />Baddeley Model deals mainly with working memory <br />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)<br />Holding information ‘On-line’ while operating on it. <br />
  47. 47. Why is working memory important? <br />Working memory deficits have the potential to adversely affect children in academic pursuits<br />
  48. 48. School<br />Note taking in class requires a tremendous amount of working memory<br />Children must dual task as they listen to what the teacher is saying, while concurrently writing down what they have just said<br />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<br />
  49. 49. Academic Achievement<br />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… <br />
  50. 50. Mathematics<br />
  51. 51. Reading Comprehension<br />
  52. 52. So now what? <br />Can anything be done about this? <br />
  53. 53. Adhd study<br />
  54. 54. Stroke study<br />
  55. 55. Holmes study<br />
  56. 56. Klingberg ADHD Study<br />
  57. 57.
  58. 58.
  59. 59. Interested?<br />Call me! Let’s chat!<br />646-558-0852<br />Or Megan Marsh, Ph.D.<br />212-263-8304<br />OR just see me after this talk… <br />

×