Neuropsychological group rehabilitation on neurobehavioral comorbidities in children with epilepsy.

Neurobehavioral comorbidities, particularly attention-deficits, are common in children with epilepsy (CWE). Neurobehavioral problems are manifested in school performance, peer relations, and social competence. Although the high prevalence of these comorbid behavioral problems is fully recognized, there remains to be a lack of studies on the interventions targeted for CWE. A manualized neuropsychological group intervention, Rehabilitation of EXecutive Function and ATtention (EXAT) has been developed for school-aged children (aged 6-12 years) with executive function (EF) and attention-deficits. This study aimed to explore the effects of EXAT on parent- and teacher-rated attention and behavior problems in CWE compared with children with the diagnosis of attention-deficit hyperactivity disorder (ADHD) and children with no formal diagnosis but prominent deficits in EF and attention. Forty-two children attending in neuropsychological group rehabilitation EXAT between the years 2006 and 2017 participated in this retrospective registry study. The CWE group consisted of 11 children, the ADHD group with 16 children, and EF/attention group consisted of 15 children with EF attention and/or problems without diagnosis of ADHD. The CWE group did not differ from the other two study groups (ADHD and no formal diagnosis) before the EXAT intervention. This indicates that attention problems in CWE are similar to those with diagnosed ADHD. The results were promising for applying structured multilevel intervention for CWE and neurobehavioral comorbidities. Lack of group differences between the groups participating EXAT suggests similar intervention effects between CWE, ADHD, and those with less severe EF and attention problems. In parent ratings, intervention effects were higher in hyperactivity and oppositional behavior for children with attention problems and without epilepsy. Parents in the CWE group reported no effects except for one subscale related to hyperactivity. However, teachers reported consistently positive intervention effects for both inattention and hyperactivity-impulsivity along with anxiety and emotional lability. The results suggest that neurobehavioral comorbidities in CWE could be targeted in neuropsychological group intervention. In conclusion, CWE seem to benefit from interventions and behavior modification techniques first developed for children with ADHD.

Effects of the EXAT neuropsychological multilevel intervention on behavior problems in children with executive function deficits.

This is a clinical intervention study of children with executive function (EF) deficits. A neuropsychological multimodal group intervention called EXAT (rehabilitation of EXecutive function and ATtention) was developed at the Psychology Clinic of the University of Tampere. Based on the principles of neuropsychological rehabilitation and behavioral modification, EXAT combines child group training, parent training, and teacher consultations. The aims of this study were to investigate behavior problems before and after the intervention in children attending EXAT and in controls, and to compare intervention effects in hyperactive, inattentive, and EF subgroups based on the primary deficit described in the referral. The participants were 86 children (6-12 years) with a mean IQ of 91.4 attending EXAT and 45 controls. The participants' parents and teachers completed the Conners' Rating Scales-Revised. In addition, the Strengths and Difficulties Questionnaire was completed by the parents attending EXAT. The parents reported statistically significant decreases with medium effect sizes for the CPRS-R subscales for impulsivity, hyperactivity, and oppositional behavior. In the controls within the same time interval, there was increase in restless and impulsive behavior, and a decrease in total problems. The teachers reported positive changes after the intervention in ADHD symptoms and anxiousness/shyness, but the effects sizes were small. The intervention effects were larger in the hyperactive subgroup. Positive intervention effects were related to a younger age, lower IQ, and simultaneous learning support. In conclusion, EXAT - a structured multilevel group intervention - has positive effects on children's behavior regulation skills by decreasing impulsivity and restless behavior.

Night awakening in infancy: Developmental stability and longitudinal associations with psychomotor development.

Fragmented sleep is common in infancy. Although night awakening is known to decrease with age, in some infants night awakening is more persistent and continues into older ages. However, the influence of fragmented sleep on development is poorly known. In the present study, the longitudinal relationship between fragmented sleep and psychomotor development (Bayley Scales of Infant and Toddler Development [Bayley-III]; Bayley, 2009) was investigated in infants with (≥3 night awakenings, n = 81) and without fragmented sleep (≤1 night awakening, n = 70) within the CHILD-SLEEP birth cohort at 8 and 24 months of age. Differences in parent-reported (Brief Infant Sleep Questionnaire [BISQ]) sleep parameters were studied at 8, 18, and 24 months of age. Group differences in night awakening were stable across all assessment points. Infants with fragmented sleep slept less in total than infants without fragmented sleep and they did not compensate their nocturnal sleep during daytime. Additionally, infants with fragmented sleep spent more time awake at night than infants without fragmented sleep. However, psychomotor development did not differ between infants with and without fragmented sleep at 8 or 24 months of age. Our findings indicate that early onset fragmented sleep did not have a negative effect on psychomotor development within the first 2 years despite the differences in sleep length among infants with and without fragmented sleep. In the future, more specific domains of cognitive development and various factors affecting sleep fragmentation should be taken into account when studying the developmental effects of night awakening in infancy. (PsycINFO Database Record

Executive and intellectual functioning in school-aged children with specific language impairment.

BACKGROUND: Earlier research and clinical practice show that specific language impairment (SLI) is often associated with nonverbal cognitive deficits and weakened skills in executive functions (EFs). Executive deficits may have a remarkable influence on a child's everyday activities in the home and school environments. However, research information is still limited on EFs in school-aged children with SLI, mostly conducted among English- and Dutch-speaking children. AIMS: To study whether there are differences in EFs between Finnish-speaking children with SLI and typically developing (TD) peers at school age. EFs are compared between the groups with and without controlling for nonverbal intelligence. METHODS & PROCEDURES: Parents and teachers of children with SLI (n = 22) and age- and gender-matched TD peers (n = 22) completed The Behavior Rating Inventory of Executive Functions (BRIEF). The mean age of the children was 8,2 years. BRIEF ratings of parents and teachers were compared between the children with SLI and with TD peers by paired analysis using conditional logistic regression models with and without controlling for nonverbal IQ. Intellectual functioning was assessed with the Wechsler Intelligence Scale for Children. OUTCOMES & RESULTS: Children with SLI had weaker scores in all parent and teacher BRIEF scales compared with TD peers. Statistically significant differences between the groups were found in BRIEF scales Shift, Emotional Control, Initiate, Working Memory, Plan/Organize and Monitor. Differences between the groups were statistically significant also in intellectual functioning. On BRIEF scales some group differences remained statistically significant after controlling for nonverbal IQ. CONCLUSIONS & IMPLICATIONS: This study provides additional evidence that also Finnish-speaking school-aged children with SLI are at risk of having deficits in EFs in daily life. EFs have been proposed to have an impact on developmental outcomes later in life. In clinical practice it is important to pay attention to EFs in school-aged children with SLI when making diagnostic evaluations and planning interventions for them.

Neurological outcome of childhood brain tumor survivors.

We assessed neurological and neurocognitive outcome in childhood brain tumor survivors. Altogether, 75 out of 80 brain tumor survivors diagnosed below 17 years between 1983 and 1997; and treated in Tampere University Hospital, Finland, were invited to participate in this population-based cross-sectional study. Fifty-two (69%) participated [mean age 14.2 (3.8-28.7) years, mean follow-up 7.5 (1.5-15.1) years]. Neurological status was abnormal in 69% cases. All were ambulatory, but only 50% showed normal motor function. Twenty-nine percent showed clumsiness/mild asymmetry and 21% hemiparesis. One suffered from intractable epilepsy. According to structured interview, 87% coped normally in daily living. Median full-scale IQ was 85 (39-110) in 21 6-16 year olds (70%); in 29% IQ was <70. Thirty of the 44 school-aged subjects attended school with normal syllabus and 32% needed special education. Six of the 16 patients over 18 years of age were working. Regarding quality of life, 38% were active without disability, 33% active with mild disability, 21% were partially disabled, but capable of self-care, and 8% had severe disability, being incapable of self-care. Supratentorial/hemispheric tumor location, tumor reoperations, shunt revisions and chemotherapy were associated with neurological, cognitive and social disabilities. In conclusion, of the 52 survivors, neurological status was abnormal in 69%; 71% lived an active life with minor disabilities, 29% had major neurological, cognitive and social disabilities, and 8% of them were incapable of self-care. Predictors of these disabilities included supratentorial/hemispheric tumor location, tumor reoperations, shunt revisions and chemotherapy. Survivors need life-long, tailor-made multiprofessional support and follow-up.

Cognitive impairment in preschool children with epilepsy.

PURPOSE: Studies have shown that underlying pathology and early onset of seizures are both significant factors contributing to cognitive impairment in children with epilepsy. However, there are only few studies focusing on cognitive impairment in preschool children with epilepsy. The purpose of this study was to describe the cognitive performance in a population-based cohort of preschool children with epilepsy. The aims of the study were to determine frequency of cognitive impairment, level of cognitive functions, and epilepsy-related factors correlating with cognitive impairment. METHODS: The study group consisted of a population-based cohort (N = 64) of preschool children (3-6 years 11 months) with active epilepsy. Medical data and results from previous psychological evaluations were reviewed retrospectively from the medical records. A logistic regression model was used for the prediction of cognitive impairment. KEY FINDINGS: Prevalence of epilepsy was 3.2 per 1,000 children. Cognitive function was considered to be within normal or borderline range for 50%, mildly retarded for 22%, and moderately to severely retarded for 28%. Cognitive impairment was related to complicated epilepsy, age at onset of epilepsy, abnormal magnetic resonance imaging (MRI), and additional neurologic problems. Age at the onset of seizures was the only significant predictor of cognitive impairment. SIGNIFICANCE: The results concur with those of earlier studies on cognitive impairment in childhood epilepsy. Age at onset of epilepsy is also an important factor for cognitive impairment on young children with epilepsy. The results suggest that cognitive impairment is evident early in the course of epilepsy.

Neurocognitive functioning of preschool children with uncomplicated epilepsy.

Only few studies are available on the cognitive functioning of preschool children with uncomplicated epilepsy. The aim of this study was to describe the neurocognitive functioning of 3-6-year-old children with uncomplicated epilepsy. A subgroup of children with uncomplicated epilepsy from a population based cohort of preschool children with active epilepsy (N=64) participated in the study. The neurocognitive functioning of these children (N=13) was compared to that of matched healthy controls (N=13). The Wechsler's Primary and Preschool Scale of Intelligence - Revised and the Developmental Neuropsychological Assessment were administered. The intellectual functioning of the children with uncomplicated epilepsy was within normal range, but differed significantly from that of healthy controls, which was contrary to expectations. Statistically significant differences emerged between the study and the control group in Verbal IQ and Full Scale IQ, but no differences were found in Performance IQ. The children with uncomplicated epilepsy also had minor neurocognitive difficulties in verbal short-term memory (p<.01) compared to healthy children. The result suggests that uncomplicated epilepsy in preschool children may interfere with language and verbal short-term memory functions. Further studies with detailed neuropsychological assessments and follow-up time are needed to gain more insight into the developmental course of children with uncomplicated epilepsy. Also, because of the developmental risks reported in this study, psychological screening and detailed neuropsychological assessment are recommended in clinical practice.

Social functioning and psychological well-being of 347 young adults with epilepsy only--population-based, controlled study from Finland.

PURPOSE: To explore social functioning and psychological well-being in a population-based cohort of epilepsy patients compared to matched controls. METHODS: A random sample of patients with epilepsy (N = 347) and a healthy control group (N = 430) matched for age, gender and domicile were identified through National Registry of Social Insurance Institution in Finland. The data were collected by postal questionnaire assessing various factors related to social and psychological well-being and were analyzed by using linear regression analysis to compare the study and control groups. RESULTS: The age at onset of epilepsy was significantly associated with the level of further education and the level of seizure control with the employment status. The patients with epilepsy and lower level of basic education had also significantly lower level of further education, employment, and fewer social relations. Some differences in psychological well-being were also seen in those with matriculation examination when compared to matched controls. CONCLUSIONS: In young adults with well-controlled epilepsy and successful basic education, social functioning is comparable with healthy peers. The importance of all social and educational support during the time of basic education may be crucial to favorable intellectual, functional, and social development later in life. Both professional and informal support is needed in adjunct to conventional treament of epilepsy, which is emphasized.

Language and motor speech skills in children with cerebral palsy.

UNLABELLED: The aim of the study was to investigate associations between the severity of motor limitations, cognitive difficulties, language and motor speech problems in children with cerebral palsy. Also, the predictive power of neonatal cranial ultrasound findings on later outcome was investigated. For this purpose, 36 children (age range 1 year 10 months to 9 years 0 months) with cerebral palsy due to premature birth and white-matter damage (periventricular leukomalacia) participated in the study. Twenty-two children (62%) had an intelligence level above 70. One-half of this group exhibited motor speech problems. Children with an intelligence level below 70 (n=14, 38%) showed problems in motor speech skills as well as in verbal expressive and comprehensive skills. Neonatal cranial ultrasonography findings were moderately associated with the severity of functional motor limitations. LEARNING OUTCOMES: Readers will be able to: (1) describe different hypotheses regarding the relationship between language, speech, intelligence level and severity of cerebral palsy, (2) discuss how intelligence and functional motor limitations impact language and speech performance for children with cerebral palsy and (3) discuss the predictability of the ultrasound methodology.

The effects of valproate exposure in utero on behavior and the need for educational support in school-aged children.

Children exposed to valproate monotherapy in utero were evaluated with respect to neurological functioning, behavior, and additional educational needs, and the results were compared with those for age- and gender-matched controls exposed to carbamazepine and children with no prenatal exposure to antiepileptic drugs. We identified from the community-based pregnancy registry of Kuopio University Hospital area (1989-2000) all first-born and school-aged children exposed to valproate (N=13). Neurological and neuropsychological assessments were made clinically, and behavioral problems were assessed with the Conners' Teacher Rating Scale (CTRS). Eight children (62%) exposed to valproate and two (15%) each in the carbamazepine-exposed and nonexposed groups (P=0.022) required educational support. Minor dysmorphic features were noted in eight children (62%) exposed to valproate and in three children (23%) each in the carbamazepine-exposed and nonexposed groups. On CTRS, children exposed to valproate received higher scores, indicating behavioral problems. In our small but population-based study, all children exposed to valproate had minor, and some of them major, cognitive or neurological problems. This difference is clearly observed when assessing each child individually, but the many confounding factors explaining at least part of this difference are difficult to control and avoid in clinical practice. Larger studies with a prospective design are needed to confirm these findings.

Children exposed to valproate in utero--population based evaluation of risks and confounding factors for long-term neurocognitive development.

PURPOSE: To evaluate neurological and cognitive functioning of school-aged (> or =6 years) children exposed to valproate monotherapy in utero in a population based, evaluator-blinded, controlled study. METHODS: Studied children (N=39, aged 6.6-13.4 years) and their mothers were identified through a population based pregnancy registry. Mothers with carbamazepine monotherapy and mothers with epilepsy but without antiepileptic drug (AED) treatment during pregnancy and their age and gender matched children served as controls. Hospital records were reviewed and neurological examination (Touwens test), intelligent quotients (IQ) of mothers (WAIS), and children (WISC-III) and neuropsychological assessment of children (NEPSY) were performed evaluator-blinded. RESULTS: The prevalence of low intelligence (FIQ<80) was 19% (4/21) and the prevalence of exceptionally low intelligence (FIQ<70) 10% (2/21) in valproate (VPA) monotherapy exposed children. Children exposed to carbamazepine (CBZ) and children of women with epilepsy but without AED exposure during pregnancy had all at least low average intelligence. The mothers using valproate scored significantly lower (p<0.05) in FIQ, VIQ and PIQ tests and had also significantly lower (p=0.035) educational level. Altogether 21% (8/39) of the children had minor neurological dysfunctions. CONCLUSIONS: In a population based setting inheritance and cumulating environmental factors may partly explain the increased prevalence of neurocognitive symptoms in children exposed to valproate in utero although concern about the possible long-term effects of intrauterine valproate exposure does exist.

Children with functional motor limitations: the effects on family strengths.

Sixty children with functional motor limitations (age range from 15 months to 7 years 3 months) and their parents participated in the study. The objective was to explore the relationship of the severity of their restrictions on family strengths. Functional motor abilities of the children were assessed using Autti-Ramo's Scale. Cognitive functions were assessed using the Swedish standardized version of the Griffiths Scales of Mental Development. Family strengths were indexed using the Family Functioning Style Scale. The social-economical status, children's age and caretakers' age were taken into account. Overall, the results indicated that family strengths were rather strong. Only families rearing a child with severe participation limitations (functional motor limitations and cognitive difficulties) showed less strengths concerning family identity and internal coping relative to families with a child with milder participation limitations.

A retrospective neurocognitive study in children with spastic diplegia.

The study presents the results on neonatal cranial ultrasonography (US) and later intelligence (Wechsler Intelligence Scale-Third Edition and Wechsler Preschool and Primary Scale of Intelligence-Revised) and Neuropsychological assessments of 15 children with spastic diplegia. The assessments were undertaken when the children were 5 to 12 years of age. The children's IQ scores were, as a group, at the lower end of the normal distribution. The neuropsychological assessment indicated that deficits in visuomotor and visuospatial processing were characteristic of the children. No association was found between the neonatal cranial US findings and the IQ and neurocognitive scores. However, the cranial US findings strongly predicted functional motor limitations of the children.

Visual agnosia in a child with non-lesional occipito-temporal CSWS.

In this paper we describe a case of severe visual agnosia in a child with an electrophysiological pattern of continuous spike-wave discharges in slow sleep (CSWS) in the occipito-temporal regions. The neuropsychological spectrum related to this phenomenon is discussed. Published paediatric reports associate visual agnosia (i.e. an inability to recognize objects without impairment of visual acuity) mainly with symptomatic occipito-temporal aetiology (e.g. cortical dysplasia, vascular insults) and other neurological symptoms (e.g. autism). We describe a detailed 2 year electrophysiological and neuropsychological follow-up of an 8-year-old boy with sporadic seizures, occipito-temporal CSWS and visual agnosia. The growth and neurological development of the child had been considered as normal, neurological examination did not reveal any focal signs, visual acuity was intact and MRI was normal. First EEG and six consecutive 24 h video EEG recordings during the follow-up of 22 months showed continuous spike-and-wave activity covering over 85% of the non-REM sleep. According to structured neuropsychological tests (Wechsler Intelligence Scale for Children--Third Edition, A Developmental Neuropsychological Assessment (NEPSY), Test of Visual-Perceptual Skills, Corsi block, Hooper Visual Organization Test) the boy had normal verbal intelligence but major deficits in visual perception, especially in object recognition, impaired shape discrimination and detection, and poor copying skills. Attention and executive functions were intact. There were no difficulties in short- or long-term memory. Verbal cues and naming the objects improved visual memory. Tracing the objects with a finger or by moving the head improved object recognition. Currently the boy attends a special school with a rehabilitation plan including neuropsychological and occupational therapies. This case adds a new facet to the spectrum of neuropsychological deficits in children with CSWS. Sleep EEG should be included in the etiological studies of children with specific neuropsychological problems and detailed neuropsychological assessment is needed for diagnostic and rehabilitation purposes.