BEHAVIORAL PROBLEMS IN EPILEPTIC CHILDREN – A TERTIARY CARE EXPERIENCE

Dr. Virender Kumar, MBBS, MD, Dr. Uruj Qureshi, MBBS, MD (Community Medicine) and Dr. Geeta Kumari, MBBS. 1. Assistant Professor, Department of Paediatrics, GMC Srinagar. 2. Medical Officer, Health & Medical Education, J&K Govt. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History

Frequency of seizure was defined as per Sabbagh, et al. 28 . All patients were receiving antiepileptic drugs (phenytoin sodium/sodium valproate/carbamazepine/ clobazam) either as monotherapy or in combinations of two or three. Children who were admitted for acutecontrol of seizures were assessed once it was controlledand they were discharged from the hospital. Contolled seizure was defined as cases who were seizure free for atleast 6 months before assessment and those who hadrecurrence of seizures despite antiepileptic medications were considered as uncontrolled seizure. Revised Kuppuswamy scale was 29 was used for the assessment of socio-economic status.
Assessment for behavioral problems was done by a clinical psychologist. The native language of the study population was Kashmiri and the questions were translated from English in Kashmir, Counseling was provided to children and families having clinical range abnormalities, and non-responders were referred to psychiatrist for pharmacotherapy. Statistical analysis Data obtained was entered into Microsoft Excel and was analysed in Statistical Package for Social Sciences (SPSS Ver. 20). Student's 't' test was used to compare the observations of patients with controls. Chi-square test was applied for comparisons of data of proportions. A P value of <0.05 was considered as statistically significant.

Results:-
A total of 70 children with epilepsy and 70 healthy controls in a similar age group were enrolled, and were further sub-divided into two age-groups: 2-5 years (32 epilepsy and 29 controls) and 6-14 years (38 epilepsy and 41 330 controls). Mean and standard deviation of age of onset of disease was 2.4±1.73 years and 4.3±2.32 years in 2-5 and 6-14 years age-group, respectively. We had 41 males in 2-5 years and 51 in 6-14 years age-groups in cases with epilepsy. In 2-5 years age group, 31 (51.7%) received sodium valproate, 10 (16.7%) phenytoin sodium and 19 (31.7%) cases drugs in combinations (levetiracetam, carbamazepine/oxcarbamazepine, clobazam); The corresponding figures in 6-14 years age-group were 45 (56.2%), 10 (12.5%) and 25 (31.3%), respectively. No significant differences in total behavioral problems between children on monotherapy as compared to polytherapy in both younger (10.5% vs17.1 %, P=0.35) as well as older age groups (35% vs41.5%, P=0.41), respectively. A relatively higher percentage of children with below average IQ had total behavioral problems in comparisonto those who had average IQ in both younger (18.6% vs13.6%, P=0.96, relative prevalence (RP) 1.15,confidence interval (CI) 0.25-5.30) as well as older age group (49% vs34%, P=0.15, RP 1.03, CI 0.39-2.75), but the differences were found to be insignificant.Thirty nine (65%) children in 2-5 years group and 44 (55%) in 6-14 years had controlled seizures and the resthad uncontrolled seizures at the time of assessment. Inyounger agegroup, there was no significant difference in the occurrence of behavior problems between childrenwith controlled and uncontrolled seizures (2.5% vs9.5%,P=0.25, RP 0.18, CI 0.48-12.37). However, in the older age group, children with uncontrolled seizures had higher incidence of behavior problems than children with controlled seizures (50% vs18.1%, P=0.003; RP 2.44, CI 0.07-0.50). None of the parents of cases had any history of psychological problems. No significant differences in mean values of different domains were found in children on monotherapy versus polytherapy in both age groups.However, in the 6-14 years age-group, uncontrolled seizures were significantly (P<0.05) associated with internalizing behavioural problems.
Mean values of behavioral scores in patients withepilepsy aged 2-5 years were significantly higher ascompared to control in the CBCL domains of emotional reactivity (P=0.021), withdrawn (P=0.004), attentionproblems (P<0.001), aggressive behavior (P<0.001), externalizing (P<0.001) and total behavior problems (P<0.001). In the 6-14 years age group, all thedomains showed significantly higher scores in patients than controls, except somatic complaints and thought problems. Further, 23.3% children withepilepsy of 2-5 years had externalizing behavior scores, and 21.2% and 45% of 6-14 years had internalizing andexternalizing behavior scores in the clinical range, respectively.

Discussion:-
In the present study, most of the behavior domains inchildren with epilepsy had higher mean scores thancontrols, but below the cut-off levels. Externalizing behavioral problems appeared to affect patients of boththe age-groups, but internalizing behavior such asdepression and anxiety were mostly limited to school-age children.  Impaired attention, anxiety, depression, hyperkinetic, impulsivity, low self-esteem and thought problems aresome of the co-morbidities reported earlier, mostly in mixed age-group of children 11,12,13,15 . In addition,educational underachievement has been also observed inthese children 29 . Behavior problems may not only occur following idiopathic epilepsy but also due to secondary causes like neurocysticercosis 30 . Abnormalexcitability and disrupted synaptic plasticity in the developing brain can result in epilepsy and subsequentlybehavior problems in these patients 31 .
We did not observe any difference in the incidence of behavioral problems in children with below average IQ incomparison to cases with average IQ in both the age groups. It may be possible that effect of IQ was not distinctly seen because of lesser number of cases in thesub-groups. In contrast, Buelow, et al. 32 observed a higher risk of occurrence and mean problem scores incases with low IQ as compared to patients having middleor high IQ groups, and all types of problems were foundin children with low IQ. Similar to our findings, Powell,et al. 33 also observed no significant difference inbehavior between children with epilepsy having decreased seizure-frequency as compared to those withgood seizure-control.
A significant effect of age of onset, frequency of seizures and number of antiepileptic drugs in relation tobehavioral problems have been reported earlier 11,16,28 . We found younger age of onset, and frequency of seizures were significantly associated with behavioralproblems. In addition, duration of disease in both age groups and antiepileptic drugs in older children alsoaffected the internalizing problems. However, no difference in behavioural problems was observed between mono and polytherapy. In contrast, effect ofpolytherapy over behavioural problems was found by Datta, et al. 34 in their patients with epilepsy. It appearsthat multiple factors affect the behavioral domains inchildren with epilepsy. Further, it is likely that the child's psychological perception of the disease situation,especially in older children, could be another contributing factor to the patient's behavior during the course of illness. Thus, use of minimum number of antiepilepticdrugs for seizure-control should be aimed, to minimize the occurrence of behavioral impairment inthese children.
The strength of the present study is the use of astandardized validated measurement tool, applied in twoage-groups of population to observe the different behavioral pattern. However, it has certain limitations as findings are based only on parent-reported observations.We did not observe the effect of parental educational level and teacher-report of school-going children, whichmay limit the generalizability of the results up to someextent. Further, it would be also be pertinent to carry out follow-up assessments to document resolution of problems after discontinuation of treatment.
In conclusion, due attention should be given for recognition of behavioral co-morbidities in children with epilepsy. They need periodic assessment during epilepsytreatment and if abnormalities are detected, may need counseling and also adjustment on behalf of parents.