Childhood Epilepsy: Mental Health

and Behavior
Mental health and behavioral problems are among the many issues that can
affect children with epilepsy. As with other manifestations, epilepsy's
psychological effects are highly variable. While some people with epilepsy
experience few if any mental health issues, others may suffer debilitating
problems of inattention, anxiety, or mood disorders. It is important to
address these issues early and with appropriate forms of intervention to
reduce the consequences they might have on an individual's long-term

quality of life.
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In this section
 Causes of Mental Health and Behavioral Issues
 Types of Mental Health and Behavioral Issues
 Diagnosis and Treatment

Causes of Mental Health and Behavioral Issues
Although many of the mental health and behavioral problems associated with
epilepsy are also seen in people without epilepsy, they occur more frequently in
those who have the disorder. People with epilepsy are as much as five times
more likely to have mental health and behavioral problems, with an incidence of
between 30 to 50 percent, as compared to 8.5 percent in the general
population.

The factors that may give rise to mental health issues in children with epilepsy
are almost as numerous and varied as epilepsy's many causes. In general, these
factors fall into two broad categories: internal and external. Internal factors are a
result of problems in the structure or function of the brain, whereas external
factors are not biologically based and instead result, for example, from the
reactions of others to an individual's epilepsy or from a child's own response to
feelings of anxiety or depression. Often, both internal and external factors play a
role in mental health issues.

Internal Factors
Internal factors are also referred to as biological or intrinsic factors because they
are part of an individual's biological makeup, rather than environmental factors.
Because the brain is responsible for behavior as well as motor control and
perception, it is not surprising that a disruption of normal brain function such as
occurs in epilepsy might also affect behavior. However, knowledge is limited as
to why or how such a disruption may cause mental health or behavioral
changes.

Seizure type appears to play an important role in the extent and type of
behavioral change that results. For example, children who experience
generalized seizures are more prone to problems with inattention and
hyperactivity than are children who have partial seizures. However, some
complex partial seizures may have even more profound consequences. When,
for example, seizures involve the limbic system, a group of structures
responsible for generating and controlling emotional response, they pose a
particularly high risk of behavioral and personality disorders.

To learn more about the relationship between brain anatomy and seizure type,
see the Brain Interactive.

External Factors

Connecting with her peers
has helped Cherinee develop greater confidence and self-esteem.
Mental health and behavioral issues can also result from external factors that
have no direct connection to the underlying mechanisms of epilepsy. For
example, they may arise from environmental conditions, such as the reactions
of other people to an individual's seizures and epilepsy. Epilepsy and seizures
carry a stigma that can be frightening or unsettling to others who do not fully
understand the disorder. Reactions based on ignorance and misperception can
create serious psychological problems for the individual experiencing seizures.

Typically, an individual's own reaction to his or her condition is the initial cause
of a problem—such as when fear and uncertainty give rise to a deeper and more
chronic condition of anxiety, or when low self-esteem results in poor academic
performance. However, such personality issues may be exacerbated by a social
context in which the stigma about epilepsy and the low expectations of an
individual with epilepsy exist.

Self-esteem and self-image in childhood can be critical to success and happiness
throughout life. How seizures and epilepsy affect self-esteem depends on many
factors. The most important factor is the type of response a child receives from
his or her family.

To learn more about the family's effect on a child's mental health and well-being,
see the Family Lifesection.

Side Effects of Anticonvulsant Medications
Another external factor that may influence the behavior of an individual with
epilepsy is the use of certain medications to control seizures. Anticonvulsant
medications aim to inhibit excessive electrical activity in the brain. This curbs
the abnormal surges characteristic of seizures. However, this effect may also
alter behavioral and cognitive function.

Not long ago, so few epilepsy treatments were available that the side effects on
behavior and cognition were considered a small price to pay for the benefits of
seizure control. However, pharmacological treatments have advanced
considerably along with our current understanding of the causes of seizures and
how they spread through the brain. Today, a drug that significantly impairs a
child's ability to learn or behave normally despite providing control of seizures
might be considered just as unsuccessful as a drug that fails to control that
child's seizures. However, depending on how difficult it is to achieve control of a
child's seizures, accepting some cognitive and behavioral side effects may be
necessary even today.
Types of Mental Health and Behavioral Issues
The most common types of mental health issues associated with epilepsy are
depression, attention deficit disorder (with or without hyperactivity), anxiety
disorders, and aggression.

Depression
Depression is the mood disorder most commonly associated with epilepsy.
However, it can often go unrecognized and untreated in people with the
disorder, especially in children. Epilepsy-related depression can occur before,
during, or after seizures, but is most often associated with periods between
seizures.

The symptoms of depression vary widely from one individual to another. Those
most often seen in children with epilepsy are sleep disturbances, fatigue or
listlessness, lack of enthusiasm, and frequent emotional outbursts. Other
behavioral issues, such as anxiety, agitation, frustration, or impulsive behaviors,
often accompany depression.

Although the cause of depression in people with epilepsy is unknown, it is
thought to result from both internal and external factors.

Attention Deficit Disorder
Attention deficit disorder with or without hyperactivity is considered a common
behavioral problem in children with epilepsy. It is estimated that nearly 8
percent of children with epilepsy have problems with attention. In general,
attention deficit/hyperactivity disorder (ADHD) is a neurobehavioral disorder that
causes individuals to be easily distracted, frustrated, fidgety, impulsive, and
forgetful. The disorder makes learning and social interactions difficult, regardless
of an individual's cognitive abilities. While ADHD is a clinical diagnosis made on
the basis of observation and medical history, mental health experts and
scientists agree that there are identifiable characteristics of the disorder.
Measures such as rating scales and reports from teachers and parents can be
helpful in making the diagnosis.

Anxiety Disorders
Anxiety disorders associated with epilepsy may take the form of chronic,
generalized worrying; acute, overwhelming panic attacks; or obsessive-
compulsive tendencies. The disorders often arise in response to the
unpredictability and lack of control associated with seizures. For some people
with epilepsy, anxiety may cause them to overestimate the threat posed by
future seizures, or underestimate their ability to cope. Such thoughts can cause
physical symptoms that accentuate the feeling of a lack of control.

Aggression
Impulse-control problems are common among children with epilepsy. One of the
most common forms of impulsivity is aggression. Although the cause of
aggression in people with epilepsy varies, the unpredictability of seizures and
the individual's lack of control over them may contribute to frustration and
irritability. In addition, children who are more severely affected and lack good
communication skills may act out their frustration with aggressive or even
violent outbursts. In general, aggressive behaviors tend to become less frequent
and decrease in severity as a person grows older. However, aggressive
tendencies may then be replaced by depression and anxiety.

Autism
Autism is a spectrum disorder, or combination of symptoms, characterized by
deficits in verbal and nonverbal communication skills, severe social dysfunction,
and repetitive behaviors. Such behavioral problems are sometimes seen in
children with Lennox-Gastaut syndrome, tuberous sclerosis complex, Angelman
syndrome, and other genetic disorders. Despite decades of research attempting
to link autism to a wide variety of potential causes, there still is no consensus,
and effective medical treatments have yet to be found. However, there are
behavioral and educational interventions that have been developed specifically
for individuals with autism.

Diagnosis and Treatment
Because of the profound consequences of epilepsy-related mental health issues,
specialists emphasize that early identification and intervention are critical to
improving quality of life and overall outcome. Experts recommend that people
diagnosed with epilepsy be evaluated by a psychiatrist, psychologist, or social
worker for mental health and behavioral problems. These professionals can help
to develop a plan for treating and/or managing these problems to minimize their
effects.
Children with epilepsy may also need help and support in finding ways to
address the social aspects of having a seizure disorder, such as how to talk with
peers about epilepsy, and their fear of having seizures. Knowledge is power for
the young person, and offering information as well as emotional support can
help a child to begin to manage his or her illness. Parental guidance and support
is an essential part of this objective. Helping your child to understand what
epilepsy is, how his or her brain works, and what is happening during a seizure
can help that child feel both empowered and confident.

For more information on how to help your child and others in his or her world
understand epilepsy, see the Talking About Epilepsy section.

Providing support and structure is important in
managing behavioral issues in children with epilepsy.
The most effective treatments for the mental health and behavioral issues
commonly associated with epilepsy often involve a combination of medications
and cognitive and behavioral interventions. Talk therapy plays an important role
in these treatments. Anxiety and depression can sometimes be effectively
managed with antianxiety and antidepressant medications, such as a class of
drugs called selective serotonin reuptake inhibitors, or SSRIs. To treat attention
deficits, certain types of stimulant medications have proven effective.

However, it is important to understand that medications can interact if taken in
combination. This is of particular concern for people who take anticonvulsant
medications to control seizures. The addition of a new medication could cause
the anticonvulsant's effectiveness to decrease or could create toxic blood levels.
Medications used to treat certain psychiatric disorders have also been found to
lower seizure threshold in some children. For this reason, it is important to
consult with a psychiatrist and/or primary care physician before beginning a
course of treatment for mental health issues or any other medical problem. It is
also important to inform all specialists of the full list of medications a child may
be taking. This list should include alternative therapies and vitamin
supplements.
Important Points to Remember
 Epilepsy increases a child's risk of developing mental health and
behavioral problems by a factor of five.
 Between 30 and 50 percent of children with epilepsy will develop a
behavioral or mental health problem.
 The types of behavioral problems associated with epilepsy include
attention deficit, hyperactivity, anxiety, depression, aggression, and autism
spectrum disorder.
 Early identification and treatment of behavioral problems provides the
best possible outcome.
 Experts recommend that all people diagnosed with epilepsy be screened
for mental health and behavioral problems.
 The most effective treatments for epilepsy-related behavioral disorders
often involve a combination of medication and cognitive and behavioral
intervention, including talk therapy.
 Medications can interact with each other. Because of this, it is important
to inform your medical provider about all medications and therapies your child is
on.

Relevant Specialists
Neurologist
A neurologist and a pediatric neurologist are physicians who care for people
affected by disorders of the nervous system. An epileptologist is a neurologist or
a pediatric neurologist who specializes in the treatment of epilepsy.

Psychiatrist
A psychiatrist is a medical doctor who specializes in the diagnosis and treatment
of mental and behavioral disorders. A psychiatrist who treats people with
epilepsy is familiar with the cognitive and behavioral issues that are common to
the disorder and knows what treatment options are most effective for these
issues, including medication options.

Psychologist
A psychologist is a licensed professional who specializes in the diagnosis and
treatment of mental and emotional problems, and may be involved in
evaluation, testing, counseling, and/or psychotherapy.
Social Worker
A social worker is a licensed professional who provides support to families and
children with medical or psychological issues.