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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 2  |  Page : 213-216

An observational study on behavioral problems among the children with epilepsy


1 Department of Pediatrcs, Kakatiya Medical College, Warangal, Telangana, India
2 Department of Microbiology, GSL Medical College, Rajahmundry, Andhra Pradesh, India

Date of Submission26-Jun-2022
Date of Acceptance16-Sep-2022
Date of Web Publication23-Dec-2022

Correspondence Address:
Prof. P Anil Kumar
Department of Pediatrcs, Kakatiya Medical College, Warangal, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_147_22

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  Abstract 


Background and Aim: Psychological and biochemical factors are responsible for the behavioral problems in children with epilepsy. A study was conducted to find the prevalence of behavioral problems in children with epilepsy and also to identify the relation among socioeconomic status, age of onset of seizure, and frequency of seizure attacks with the prevalence of behavioral problems. Materials and Methods: It was a prospective observational study conducted in the Department of Pediatrics, Kakatiya Medical College, Warangal. Convenient sampling was considered; the study was conducted for 2 years. Children aged 1–12 years, admitted with epilepsy to pediatric intensive care unit and pediatric wards, were included in this study. Those were having intellectual problems, cerebral palsy, developmental delay, and metabolic and neurodegenerative disorder were excluded from the study. Sociodemographic information was collected from the parents in a standard pro forma. Diagnostic and Statistical Manual of Mental Disorders-oriented scales for different ages were used for the assessment of behavior by translating into regional language. Chi-square test was used; P < 0.05 was considered statistically significant. Results: A total of 112 children were included; male: female ratio was 1.39; 41 (36.6%) children had behavioral problems; age-wise, there was significant difference; gender-wise, there was no significant difference. Attention-deficit/hyperactivity problems were identified to be the predominant. Statistically, there was no significant difference between behavioral problems either with mother education or with parent's socioeconomic status, respectively. When brain imaging was done, normal studies were revealed in 32% of children with behavior problem. Conclusion: Each and every child with epilepsy aged <5 years and frequency of seizure attack >1 time/year needs thorough screening for behavioral problems irrespective of gender and family characteristics.

Keywords: Behavioral problems, children, epilepsy


How to cite this article:
Sudhakar B, Jyothi VU, Sowmya V G, Kumar P A, Bhookya SK, Surender K, Chandra T J. An observational study on behavioral problems among the children with epilepsy. Arch Med Health Sci 2022;10:213-6

How to cite this URL:
Sudhakar B, Jyothi VU, Sowmya V G, Kumar P A, Bhookya SK, Surender K, Chandra T J. An observational study on behavioral problems among the children with epilepsy. Arch Med Health Sci [serial online] 2022 [cited 2023 Jan 31];10:213-6. Available from: https://www.amhsjournal.org/text.asp?2022/10/2/213/364951




  Introduction Top


Childhood epilepsy is an important concern to psychiatrists due to the frequency of associated behavioral problems. Worldwide, epilepsy in children is the most common neurological disorder.[1] As per the WHO 2019 annual report, 80% of children with epilepsy live in low- and middle-income countries, around 12 million in India.[2] It is responsible for 0.5% of worldwide disease load.[3]

Several psychological and biochemical factors are responsible for the behavioral problems in children with epilepsy.[4] Child behavior checklist is a popular tool used for the detection of behavioral problems in epilepsy.[5],[6] With these, the study was conducted to find the prevalence of behavioral problems in children with epilepsy and also to identify the relation among socioeconomic status of child, age of onset of seizure, and frequency of seizure attacks with the prevalence of behavioral problems.


  Materials and Methods Top


It was a prospective observational study conducted in the Department of Pediatrics, Kakatiya Medical College, Warangal. The study was conducted for 2 years from November 2019 to October 2021. Study protocol was approved by the institutional ethics committee. Informed written consent was taken from either of the parents after explaining in detail about the methods and procedures involved in the study in their own language.

Children aged 1–12 years, admitted with epilepsy to pediatric intensive care unit and pediatric wards, were included in this research. Those were having intellectual problems, cerebral palsy, developmental delay, and metabolic and neurodegenerative disorder were excluded from the study. Data were collected from the parent by an interview method; parameters such as age of the child, educational status of mother, socioeconomic status of the child, age of onset of seizure, frequency of seizure attacks, and neuroimaging of those children were collected in a standard pro forma. However, there is no constant time period of parent interview from the episode of the seizure. Convenient sampling was considered in this research. All those satisfied the inclusion criteria during the study were included.

In this research, Diagnostic and Statistical Manual of Mental Disorders-oriented scales[7] for different ages were used for assessment of behavior of the children. Each item was rated on 3-point scale; 0 = None, 1 = Sometimes, and 2 = Always. These scales were translated into regional language of the patient under the guidance of a psychiatrist, and the information was filled. Modified Kuppuswamy scale[8] was used for the assessment of socioeconomic status.

Statistical analysis

Data were entered into Microsoft Excel (Windows 7; version 2007), and analyses were done using the Statistical Package for the Social Sciences (SPSS) for Windows software (version 22.0; SPSS Inc., Chicago, IL, USA). Descriptive statistics such as frequencies and percentages were calculated for categorical variables were determined. The association between variables was analyzed using Chi-square test. P <0.05 was considered statistically significant.


  Results Top


A total of 146 children were included, but 34 were not considered due to various reasons. The data were analyzed with 112 children; male: female ratio was 1:39. As per the information received from the parents, 41 (36.6%) children had behavioral problems; age-wise, there was significant difference [Table 1]; gender-wise, there was no significant difference (P = 0.203). Attention-deficit/hyperactivity problems were identified to be the predominant [Table 2].
Table 1: Age-wise correlation of behavioral problems in the study children

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Table 2: Prevalence of different behavior problems among the study children

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Statistically, there was no significant difference between behavioral problems either with mother education (P = 0.232) or with parent's socioeconomic status (P = 0.384), respectively. When brain imaging was done, normal studies were revealed in 32% of children with behavior problem, and it was 68% those without the problem; the difference was statistically not significant (P = 0.125). Statistically, there was significant difference between behavior problems with frequency of seizures (P = 0.04) and type of seizures [Table 3].
Table 3: Distribution of behavior problems among the children with generalized and focal seizures

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  Discussion Top


Children with epilepsy are at a greater risk of psychiatric and behavioral problems. These behavioral disorders in epilepsy are multifactorial, involving both neurologic and psychosocial factors. According to Freilinger et al.,[9] children with seizures have 4.7 times higher risk of behavioral problems. As per an Indonesian study,[10] it was found that 60% of children with epilepsy were diagnosed with psychiatric and behavioral problems, and 33% of them had a history of receiving mental health services. As per these reports, diagnosis and management of behavioral problems should be the primary consideration in clinical services and should be integrated with an appropriate educational support.

Contrast to the available reports, in this research, 36.6% (41) of children with epilepsy had behavioral problem; Datta et al. reported that 53.8% of behavioral disorders occurred in children with epilepsy.[11] Neurocysticercosis was found to be the secondary cause for behavior problems.[3],[12] As per El Tantawi's and Hamdey's[13] report, age of onset, type of seizure, antiepileptic drugs (AEDs), and duration of epilepsy are the influencing factors of childhood epilepsy with behavioral problems. Similarly, in this report also, more behavior problems were diagnosed in those children where the onset of seizures were <5 years; the difference was statistically significant (P = 0.0471). With the type of seizure also, statistically, there was significant difference with the behavior problems. Abnormal brain imaging was seen in 46% of the children with behavioral problems, and normal brain imaging was seen in 32% with behavioral problem; statistically, there was no significant difference. Morningstar et al. also reported a higher rate of abnormal imaging among the children with behavior problems.[14]

Studies also reported that behavior disorders seen in the children with epilepsy and hyperactivity disorders are the most common.[15] Lagunju et al.[16] reported that out of 84 children with epilepsy, behavioral disorders, conduct problems, emotional disorders, and hyperactivity disorders were 46.4%, 27.3%, 11.9%, and 20.2%, respectively. The prevalence of attention-deficit and hyperactivity problems was reported to be 23.3%,[17] whereas it was 25% in this research. Several studies had observed that the occurrence of epilepsy at young age is associated with more severe problems in attention, concentration, and memory.[18] This could be damage to the frontal lobe connectivity by paroxysmal interictal discharges, interruption of the normal maturational processes by seizures, and the delay of white matter volume increase during development.[19]

In this research, attention-deficit/hyperactivity problems were the leading, followed by oppositional defiant problems and depression problems [Table 2]; attention-deficit/hyperactivity problems were reported to be the leading behavior problems in the literature.[20] Similar to Kariuki et al.'s report, in this research also, statistically, there was no significant difference between the mother's education and behavior problems.[20] Similar to Kariuki et al.'s[20] report, in this study also, there was no significant difference, respectively, between the parent's socioeconomic status and frequency of seizure episode with behavior problems.

Pianta and Lothman found that parenting and family characteristics are the important predictors of behavioral problems in epilepsy.[21] Findings of this study showed that family factors alone cannot be used to explain behavioral problems in children with epilepsy. These findings are consistent with Kariuki et al.'s[20] study. Although this was not part of the assessed parameters in this study, it is important to point toward other researchers who demonstrated that lack of epilepsy awareness and inappropriate knowledge of the parents lead to excessive care of the child, which in turn results in disability of the child even in performing their personal activities, gradually leading to loss of function of the child.[22] Therefore, it is important to prevent parental overprotection by correctly managing parental knowledge.

For most of the currently used AEDs, behavioral side effects are minimal or infrequent; hyperactivity, confusion, loss of coordination, and behavioral issues are common side effects with phenobarbitone. AEDs may have positive effects on behavior.[23] Divalproex sodium (Depakote) and carbamazepine (Tegretol) are helpful in some patients with bipolar disorder, and emerging data suggest that other AEDs such as gabapentin and lamotrigine may be beneficial. Perampanel causes anger, behavioral issues, and mood fluctuations. Fariba and Gokarakonda[24] reported that impulsivity and aggression were decreased in 14 patients with autism taking divalproex sodium as a psychotropic medication. In this study, it was found that duration of usage of sodium valproate alone as monotherapy has no positive correlation with the prevalence of behavioral problems. Hence, sodium valproate is safer to use in children with epilepsy and behavioral problems.

Strength of the study

Inclusion of children with different ages, different socioeconomic statuses, and different etiological causes of epilepsy are the strengths of this research.

Limitations of the research

The impact of multiple seizure types and polytherapy on the prevalence of behavioral problems could not be assessed due to small sample size and limited availability of patients on polytherapy, respectively; this is the limitation of this research.


  Conclusion Top


Each and every children with epilepsy aged 1–12 years and frequency of seizure attack >1 time/year needs thorough screening for behavioral problems irrespective of gender and family characteristics.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Singhi P, Gupta A. Epilepsy in children-important facets. Indian J Pediatr 2021;88:991-2.  Back to cited text no. 1
    
2.
WHO Factsheet 20 June, 2019. Available from: https://www.who.int/news-room/fact-sheets/detail/epilepsy. [Last accessed on 2022 May 28].  Back to cited text no. 2
    
3.
Garg D. Specific considerations for epilepsy in India. Curr Med Issues 2020;18:105-10.  Back to cited text no. 3
  [Full text]  
4.
El Tantawi NT, Hamdey I. Behavioral problems in children with epilepsy: A case-control study. Alex J Pediatr 2019;32:41-5.  Back to cited text no. 4
    
5.
Allison Bender H, Auciello D, Morrison CE, MacAllister WS, Zaroff CM. Comparing the convergent validity and clinical utility of the behavior assessment system for children-parent rating scales and child behavior checklist in children with epilepsy. Epilepsy Behav 2008;13:237-42.  Back to cited text no. 5
    
6.
Gleissner U, Fritz NE, Von Lehe M, Sassen R, Elger CE, Helmstaedter C. The validity of the child behavior checklist for children with epilepsy. Epilepsy Behav 2008;12:276-80.  Back to cited text no. 6
    
7.
Achenbach TM, Rescorla LA. Manual for ASEBA School Age Forms and Profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth and Families; 2001.  Back to cited text no. 7
    
8.
Patil SV, Mahajan SA, Doke PP, Gothankar JS. Coherence between existing system of defining urban poor with Kuppuswamy and Hashim's system; which is more relevant? Indian J Community Med 2021;46:489-93.  Back to cited text no. 8
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9.
Freilinger M, Reisel B, Reiter E, Zelenko M, Hauser E, Seidl R. Behavioral and emotional problems in children with epilepsy. J Child Neurol 2006;21:939-45.  Back to cited text no. 9
    
10.
Novriska D, Sutomo R, Setyati A. Behavioral problems in children with epilepsy. Paediatr Indones 2014;54:324.  Back to cited text no. 10
    
11.
Datta SS, Premkumar TS, Chandy S, Kumar S, Kirubakaran C, Gnanamuthu C, et al. Behaviour problems in children and adolescents with seizure disorder: Associations and risk factors. Seizure 2005;14:190-7.  Back to cited text no. 11
    
12.
Verma A, Chopra B, Kaushik JS, Gathwala G. Cognitive and behavioral profile of treatment – Naïve children aged 6–14 years with neurocysticercosis from North India. Ann Indian Acad Neurol 2018;21:300-3.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
El Tantawi N, Hamdey I. Behavioral problems in children with epilepsy: A case-control study. Alex J Pediatr 2019;32:41.  Back to cited text no. 13
    
14.
Morningstar M, Hung A, Mattson WI, Gedela S, Ostendorf AP, Nelson EE. Internalizing symptoms in intractable pediatric epilepsy: Structural and functional brain correlates. Epilepsy Behav 2020;103:106845.  Back to cited text no. 14
    
15.
Fine A, Wirrell EC. Seizures in children. Pediatr Rev 2020;41:321-47.  Back to cited text no. 15
    
16.
Lagunju IA, Bella-Awusah TT, Takon I, Omigbodun OO. Mental health problems in Nigerian children with epilepsy: Associations and risk factors. Epilepsy Behav 2012;25:214-8.  Back to cited text no. 16
    
17.
Choudhary A, Gulati S, Sagar R, Sankhyan N, Sripada K. Childhood epilepsy and ADHD comorbidity in an Indian tertiary medical center outpatient population. Sci Rep 2018;8:2670.  Back to cited text no. 17
    
18.
Oliveira EP, Neri ML, Capelatto LL, Guimarães CA, Guerreiro MM. Rolandic epilepsy and dyslexia. Arq Neuropsiquiatr 2014;72:826-31.  Back to cited text no. 18
    
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Samanta D. Epilepsy in Angelman syndrome: A scoping review. Brain Dev 2021;43:32-44.  Back to cited text no. 19
    
20.
Kariuki SM, Abubakar A, Holding PA, Mung'ala-Odera V, Chengo E, Kihara M, et al. Behavioral problems in children with epilepsy in rural Kenya. Epilepsy Behav 2012;23:41-6.  Back to cited text no. 20
    
21.
Pianta RC, Lothman DJ. Predicting behavior problems in children with epilepsy: Child factors, disease factors, family stress, and child-mother interaction. Child Dev 1994;65:1415-28.  Back to cited text no. 21
    
22.
Kinkar A, Alqarni D, Alghamdi A, Wali S, Alghamdi N, Saloom S, et al. Parental knowledge, attitudes, and behaviors toward their epileptic children at King Abdulaziz University Hospital: Cross-sectional study. Interact J Med Res 2020;9:e12697.  Back to cited text no. 22
    
23.
Ketter TA, Post RM, Theodore WH. Positive and negative psychiatric effects of antiepileptic drugs in patients with seizure disorders. Neurology 1999;53:S53-67.  Back to cited text no. 23
    
24.
Fariba KA, Gokarakonda SB. Impulse control disorders. In: Stat Pearls. Treasure Island (FL): Stat Pearls Publishing; 2022. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562279/. [Last accessed on 2022 May 08].  Back to cited text no. 24
    



 
 
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