14753588, 2013, 2, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/j.1475-3588.2012.00648.x by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [15/11/2022].

See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Child and Adolescent Mental Health 18, No. 2, 2013, pp. 65–75 doi:10.1111/j.1475-3588.2012.00648.x

Review: Psychopathology in childhood epilepsy

Colin Reilly1, Elizabeth Kent2 & Brian G.R. Neville3,4
1
Research and Psychology Departments, National Centre for Young People with Epilepsy (NCYPE), St Piers Lane, Lingfield,
Surrey, RH7 6PW, UK. E-mail: creilly@ncype.org.uk
2
Psychology Department, NCYPE, Lingfield, UK
3
UCL Institute of Child Health, London, UK
4
NCYPE, Lingfield, UK

Background: Population-based studies of psychopathology are important in childhood epilepsy given that
there is a spectrum of severity with regard to the impact of epilepsy and associated behavioural/psychiatric dif-
ficulties. Method: Population-based studies in childhood epilepsy which have focused on global measures of
psychopathology and rates of specific behavioural and psychiatric disorders were reviewed with respect to
prevalence of disorders and possible correlates of difficulties. Clinic-based studies and meta-analyses were
reviewed where they added to an understanding of the correlates or treatment of psychopathology in child-
hood epilepsy. The systematic review methodology was based on a search of PubMed from January 1980 to
June 2011. Results: Children with epilepsy are at significantly higher risk for a range of behavioural and psychi-
atric disorders including attention deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD),
depressive and anxiety disorders. Available evidence suggests that these difficulties are under-recognised and
there have been few studies focussing on interventions to treat these behavioural and psychiatric issues in
childhood epilepsy. Conclusion: Population-based studies suggest high rates of psychopathology in childhood
epilepsy. As a result children with epilepsy need close monitoring with regard to the presence of behavioural
difficulties. There is a need for studies on how such difficulties can be best managed so that affected children
and their families can maximise their quality of life.

Key Practitioner Message:

● Population-based studies suggest that approximately 30% of children with ‘uncomplicated epilepsy’ and
50% of children with ‘complicated epilepsy’ will meet diagnostic criteria for a behavioural or psychiatric dis-
order
● There are significant associations between childhood epilepsy and attention deficit/hyperactivity disorder
(ADHD), depressive disorders, and anxiety disorders. It is not clear how many children with epilepsy meet the
diagnostic criteria for autism spectrum disorder (ASD), but the risk is higher than in the normal paediatric
population. ASD is associated with significant intellectual disability in childhood epilepsy
● The assessment of psychopathology in children with epilepsy can present challenges to child and adolescent
mental health professionals. A consideration of the effects of seizures and antiepileptic medications as well
as informants may be important in diagnostic and treatment decisions
● Collaboration between paediatric neurologists and child and adolescent mental health professionals in the
assessment and management of children with epilepsy is an essential part of a comprehensive assessment
and subsequent development of an intervention programme
● It appears that behavioural and psychiatric disorders are under recognised and undertreated in childhood
epilepsy. Population-based intervention studies to address the behavioural/psychiatric problems often asso-
ciated with childhood epilepsy are lacking

Keywords: Childhood epilepsy; psychopathology; depression, anxiety, ASD; ADHD; population-based studies

der in childhood (Silanpää & Schmidt, 2006), with prev-

Introduction
Epilepsy may be characterised by recurrent (two or
more) epileptic seizures unprovoked by any immediate
cause (Commission on Classification & Terminology of
the International League against Epilepsy, 1981). How-
ever, epilepsy exists within a wide spectrum of other cog-
nitive, behavioural and psychiatric disorders (Jensen,
2011). It is the most common serious neurological disor-
alence estimates of 0.5–1% of all children from birth to
16 years (Camfield, Camfield, Gordon, Wirrell & Dooley,
1996). Epileptic seizures can be classified into ‘general-
ised’ or ‘focal’. ‘Generalised’ epileptic seizures originate
at some point within, and rapidly engage, bilaterally dis-
tributed networks involving both cerebral hemispheres
(Berg et al., 2010). Generalised seizures include tonic-
clonic, absence, myclonic, clonic, tonic, and atonic (Berg

© 2012 The Authors. Child and Adolescent Mental Health. © 2012 Association for Child and Adolescent Mental Health.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA
 14753588, 2013, 2, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/j.1475-3588.2012.00648.x by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [15/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
66 Colin Reilly, Elizabeth Kent, and Brian G.R. Neville Child Adolesc Ment Health 2013; 18(2): 65–75

et al., 2010). ‘Focal’ indicates that the seizures begin pri-
marily within networks limited to one cerebral hemi-
sphere (Berg et al., 2010). Previously terms like ‘simple
partial’, ‘complex partial’ and ‘partial seizures secondar-
ily generalised’ were used as descriptors of focal seizures
(Commission on Classification & Terminology of the
International League against Epilepsy, 1981).
The pioneering study of Rutter, Graham and Yule
(1970) on the Isle of Wight identified that children with
epilepsy were at increased risk for both learning and
behavioural/psychiatric difficulties. In this population-
based study, 18 (28.6%) of 63 children with ‘uncompli-
cated epilepsy’ had a psychiatric disorder compared
with 6.6% of children in the general population.
‘Uncomplicated epilepsy’ referred to seizures that were
not associated with any other brain disease, disorder
or injury. Twenty-two children in the population were
reported to have seizures associated with cerebral
palsy or some other structural brain disorder and the
rate of psychiatric disorder in this group was 58.3%.
Since the study, there have been a number of popula-
tion and clinic-based studies on behavioural/psychiat-
ric problems in children with epilepsy. However, there
have been very few intervention studies to address
these issues in this population and behavioural/psychi-
atric difficulties are under diagnosed and undertreated.
In this systematic review we examine the population-
based studies that have been carried out in order to
understand the nature and prevalence of behavioural
and psychiatric difficulties in childhood epilepsy. We
also review studies which have focussed on treating
these difficulties and make suggestions as to how future
research studies might best address issues of diagnosis
and treatment.
Methodology
For the purposes of the review, psychopathology and
behavioural/psychiatric disorders include attention def-
icit/hyperactivity disorder (ADHD), autism spectrum
disorder (ASD), anxiety disorders and depressive
disorders. The review focuses where possible on popu-
lation-based studies of psychopathology in children
(0–18 years) with epilepsy published in the English
language between January 1980 and June 2011. The
Preferred Reporting Items for Systematic reviews and
Meta Analyses (PRISMA) statement (Moher, Liberati,
Tetzlaff, & Altman, 2009) guided the conduct of the
review. It must be noted that it was not possible to deter-
mine whether or not publication bias affected the evi-
dence for psychopathology in childhood epilepsy and
there is no data or evidence to indicate if such a bias is
prevalent in this area. The search process is illustrated
in Figure 1; further details of the search methodology
are detailed in an online supplementary appendix.
Fourteen population-based studies which examined

Epilepsy and Epilepsy and Epilepsy and Epilepsy and Epilepsy and
Psychopathology
Ddd Autism* (89) ADHD* (16) Depression (229) Anxiety (80)
(97)

Exclusion
criteria
applied

Reviews–all Reviews: Reviews–all Reviews–all Reviews–all

individuals with Autism in Epilepsy (1)
epilepsy (24) Epilepsy in Autism (4)
Epilepsy and Autism (22)
Reviews focussing
on children (4) Clinic based studies:
Autism in epilepsy (4)
Clinic based studies Epilepsy in Autism (17)
(14) Epilepsy and Autism (7)
individuals with individuals with individuals with
epilepsy (3) epilepsy (48) epilepsy (13)
Clinic based (7) Reviews focussing Reviews focussing
studies on children (4) on children (2)
Population based Clinic based (11) Clinic based (10)
studies (1) studies of children studies

Population based Population based studies Treatment studies Population based Population based
studies (1) Autism in epilepsy (1) (0) studies of children studies in children
Epilepsy in Autism (1) (1) (0)
Epilepsy and ASD (0)
Treatment studies Treatment studies
Treatment studies (2) (0)
Autism in epilepsy (1)
Epilepsy in Autism (0)
Epilepsy and Autism (3)

Additional search
Population based
Population based studies on
studies (10)
Psychopathology (14)

*most studies included adults and children

Figure 1. Search process for epilepsy and psychopathology; number of studies in parentheses – see also supplementary online appendix
for detailed description of systematic methodology

© 2012 The Authors. Child and Adolescent Mental Health © 2012 Association for Child and Adolescent Mental Health.

doi:10.1111/j.1475-3588.2012.00648.x
psychopathology were identified. Identified clinic-based
studies and reviews of prevalence, manifestation, corre-
lates and treatment of psychopathology in childhood epi-
lepsy are referred to in the review in the absence of
population based data.
Population-based studies of psychopathology
in childhood epilepsy
Population-based studies in epilepsy are preferred since
those from specialised centres are likely to be biased in
terms of severity and not representative (Hermann &
Whitman, 1992). Measures of psychopathology in
population-based studies may include behavioural
checklists, diagnostic interviews or both. It has been
argued that measurement of rates of psychopathology in
childhood epilepsy via behavioural checklists may be
compromised in that some items may tap into seizure
characteristics as opposed to actual behavioural or psy-
chiatric conditions (Wright, 2009). However, Gleissner
et al. (2008) found that on the Child Behavior Checklist
(CBCL; Achenbach, 1991) the number of ambiguous
items is small and suggest that is it a valid measure of
psychopathology in children with epilepsy. Diagnostic
interviews may be more accurate than checklists as they
are usually carried out by trained professionals with the
parent/caregiver and/or child and may allow probing
regarding the possible contribution of seizure character-
istics to symptoms of psychopathology.
Table 1 shows rates of psychopathology in the popula-
tion-based studies of children with epilepsy carried out
since 1980, and Table 2 shows rates in the two popula-
tion studies which have focussed on psychopathology in
children with epilepsy who have intellectual disability
(ID). The two studies in the United Kingdom and United
States which have used DSM-IV criteria, suggest that
between one third and one half of all children with epi-
lepsy will meet criteria for a psychiatric or behavioural
disorder (Davies, Heyman & Goodman, 2003; Hedderick
& Buchhalter, 2003). Population-based studies suggest
that children with epilepsy have significantly higher rate
of behavioural difficulties than children with other
chronic health conditions or children from the general
population (Alfstad et al., 2011; Carlton-Ford, Miller,
Brown, Nealeigh & Jennings, 1995; Davies et al., 2003;
Høie et al., 2006; Lossius, Clench-Aas, Van Roy,
Mowinckel & Gjerstad, 2006; McDermott, Mani & Krish-
naswami, 1995). Young people with epilepsy and ID have
not been reported to have a significantly higher level of
psychopathology than young people with ID without epi-
lepsy (Lewis et al., 2000).
Differences in the rates of behavioural/psychiatric
disorder are likely to be due to the methodologies (i.e.
measures used and informants surveyed) used to deter-
mine prevalence rates of psychopathology, and the criteria
and search methods used to identify those with epilepsy.
Most of the studies in Tables 1 and 2 employed
screening measures to determine rates of psychopathol-
ogy. These studies are informative regarding the number
of children at risk for a psychiatric disorder and making
comparisons with normative or matched controls. How-
ever, they do not indicate the percentage of children who
would be diagnosed with a psychiatric or behavioural
disorder. In this regard the Davies et al. (2003) and Steff-
enburg, Gillberg and Steffenberg (1996) can be seen to
© 2012 The Authors. Child and Adolescent Mental Health © 2012 Association for Child and Adolescent Mental Health.
14753588, 2013, 2, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/j.1475-3588.2012.00648.x by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [15/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Psychopathology in childhood epilepsy 67
be particularly efficacious as in both studies interna-
tional diagnostic criteria or standardised diagnostic
interviews were used. In the majority of studies parents
are the sole informants about symptoms of psychopa-
thology. In three of the studies self-report measures were
employed and in the two studies where parent and self-
report measures were employed parents reported a
higher number of difficulties than their children (Høie
et al., 2006; Turky, Beavis, Thapar & Kerr, 2008). In the
one study that employed teacher report measures teach-
ers reported that significantly more children with epilepsy
scored above cut-offs compared with control children
although the rate of teacher reported difficulties was
lower than parent reported difficulties. (Høie et al., 2006).
In relation to identifying children with epilepsy, most
of the studies relied on parental report (Alfstad et al.,
2011; Carlton-Ford et al., 1995; Davies et al., 2003;
Lewis et al., 2000; McDermott et al., 1995) or self-report
(Lossius et al., 2006). The other studies have involved
liaison with relevant medical professionals or reviews of
medical registers. In terms of types of seizures and epi-
lepsy syndromes most of the studies do not provide this
information, thus treating the children with epilepsy as
largely a homogenous group. The most impressive study
with regard to descriptions of main seizure type and epi-
lepsy syndrome is that of Høie et al. (2006), which used
the International League against Epilepsy (ILAE; Com-
mission on Classification & Terminology of the Interna-
tional League Against Epilepsy, 1989) classification system.
Autism Spectrum Disorder (ASD) in Childhood
Epilepsy and Epilepsy in those with ASD
The focus in children with epilepsy has primarily been
on ‘Autistic Disorder’ or ICD-10 ‘Childhood Autism’
(World Health Organization, 1992) as opposed to Asper-
ger syndrome/high functioning autism and the terms
‘autism spectrum disorder (ASD)’ and ‘autism’ will be
used interchangeably in this review. In population-
based studies Berg, Caplan and Hesdorffer (2011)
reported that 26 of 501 (5%) children with epilepsy had
ASD. Davies et al. (2003) reported 4 of 25 (12%) children
with ‘complicated epilepsy’ had ASD whereas none of the
42 children with ‘uncomplicated epilepsy’ had ASD.
However, in both these studies, specific ASD screening
or diagnostic measures were not employed. Steffenburg
et al. (1996) reported that in a population based sample
of 90 children with epilepsy and ID, 27% of children with
epilepsy and ID had ‘Autistic Disorder’ based on DSM-III-
R (Diagnostic and Statistical Manual of Mental Disorders-
3rd Edition Revised; American Psychiatric Association
(APA), 1987) criteria. A further 11% had an ‘autistic like
condition’, 3% had Asperger syndrome based on Gillberg
and Gillberg (1989), and 3% had ‘autistic traits’.
The reported prevalence rate of epilepsy in those with
ASD has varied significantly depending on the defini-
tions of ASD used (narrow autism vs. broad spectrum),
age of sample, and definition of epilepsy. Estimates of
the prevalence of epilepsy are likely to be lower when
individuals with high functioning autism/Asperger's
syndrome are included as epilepsy in ASD is associated
with ID, particularly IQ < 50 (Amiet et al., 2008). The
prevalence rate of epilepsy in individuals with Asperger
syndrome is much lower (e.g. Cedurland & Gillberg,
2004) than in those who have ASD and ID. Kagan-
 Table 1. Population-based studies of psychopathology in children with epilepsy since 1980
68

Age of Measures of Identification of

Author and year Location Sample source sample Sample size, n psychopathology epilepsy Main findings

Alfstad et al., 2011 Norway Health Profiles for 8–13 years 110 Strengths and Parents asked if their Children with epilepsy had
Children and Difficulties child has or had significantly higher levels of
Youth in Akershus Questionnaire - epilepsy. total difficulties on SDQ
Study parent report (37.8%) compared with
(SDQ-P) controls (17.0%). Children
with epilepsy had significantly
higher scores on all SDQ subscales
except prosocial behaviour and
parents also reported a higher
impact on daily life score.
Berg et al., 2011 US Connecticut Study 5.9 + 9 years1 501 Review of medical Children were 30.3% of children had one or
of Epilepsy records and recruited from more psychiatric disorder (i.e.
interview about offices of paediatric depression, anxiety, bipolar
presence of neurologists in disorder, schizophrenia, ADHD,
conditions Connecticut Oppositional Defiant Disorder)
41.7% reported a
neurodevelopmental spectrum
disorder (i.e. developmental
Colin Reilly, Elizabeth Kent, and Brian G.R. Neville

delay, language problem,

dyslexia, learning disorder, ASD).
Lossius et al., 2006 Norway Health Profiles for 13–16 124 Strengths and Adolescents asked Adolescents with epilepsy had
Children and Youth Difficulties if they have or significantly higher scores on
in Akershus Study Questionnaire – had epilepsy. all SDQ subscales except
Self report (SDQ-S) prosocial behavior and also
reported a greater impact of
their perceived difficulties
on their daily life.
Turky et al., UK General Practices in 4–17 56 (56 parental Strengths and Diagnosis of epilepsy Based on parental responses
2008 Cardiff, Wales. responses; 31 Difficulties and on AEDs within 47.9% met psychiatric
self-report Questionnaire - the last 6 months. caseness and based on self-
responses) parent and self- report 25.8% of the children
report (SDQ-P and aged between 11 and 17 met
SDQ-S) Moods psychiatric caseness.
and feelings
questionnaire (MFQ)

© 2012 The Authors. Child and Adolescent Mental Health © 2012 Association for Child and Adolescent Mental Health.
Child Adolesc Ment Health 2013; 18(2): 65–75

14753588, 2013, 2, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/j.1475-3588.2012.00648.x by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [15/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
 Table 1. (continued)

Age of Measures of Identification of

Author and year Location Sample source sample Sample size, n psychopathology epilepsy Main findings

Høie et al., Norway Hordland County 6–13 117 CBCL Parent, Children identified Parental report – 50% of
2006 population in teacher and from hospital files, Children with Epilepsy
western Norwaty self-report EEG reviews and scored above cut-offs
contact with GP’s. compared with 10% of
ILAE (1989) controls.
classification used for Teacher report – 37% of
syndromes and children with epilepsy
seizure classification. scored above cut-off
doi:10.1111/j.1475-3588.2012.00648.x

compared with 11% of

controls.
Self-report – 12% of children
with epilepsy scored above
cut-off compared with
11% of controls.
Davies et al., UK British Child and 5–15 67 DAWBA and Parents report of 37% of children with
2003 Adolescent DSM-IV criteria epilepsy epilepsy had a DSM-IV
Mental Health disorder
Survey 56% of children with
‘complicated’ epilepsy had a
DSM-IV disorder
26.2% of children with
‘uncomplicated’ epilepsy
had a DSM-IV disorder
10.6% of children with
diabetes and 9.3% of all
other children had a DSM-IV
disorder.
Hedderick US Rochester <16 years 134 Review of medical Cases of epilepsy were 51% of children with
& Buchhalter, Epidemiology of age records with identified using epilepsy had a DSM-IV
20032 Project respect to DSM-IV Rochester epidemiology disorder
criteria project and ILAE 40.37% of children with
Classification systems epilepsy who did not have
were utilised. ID and/or ASD had a DSM-IV
disorder.
McDermott et al., US Data from National 5–17 121 BPI Parents asked if 31.4% of children with

© 2012 The Authors. Child and Adolescent Mental Health © 2012 Association for Child and Adolescent Mental Health.
1995 Health Interview children had seizures, epilepsy had a ‘behavior
Survey convulsions, or problem’ compared with
epilepsy 21.1% of children with
cardiac difficulties and 8.5%
of controls.
Psychopathology in childhood epilepsy
69

14753588, 2013, 2, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/j.1475-3588.2012.00648.x by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [15/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
 Table 1. (continued)
70
Age of Measures of Identification of
Author and year Location Sample source sample Sample size, n psychopathology epilepsy Main findings

Carlton-Ford et al., US Data from National 6–17 118 (32 active Parents asked 23 Parents asked if child Children with a history of
1995 Health Interview epilepsy and 86 questions about ever had epilepsy or epilepsy had higher levels
Survey history of social and repeated convulsions of reported home behavior
epilepsy) psychological or seizures not problems than those without
problems associated with a fever a history of epilepsy. Those
with active epilepsy did not
differ significantly from
those with inactive epilepsy
with regard to reported
home behaviour problems.
Those with a history of
epilepsy were not reported to
have significantly more
school behaviour problems.

CBCL: Child Behavior Checklist (Achenbach, 1991), DAWBA: Development and Well-Being Assessment (Goodman, Ford, Richards, Gatward & Meltzer, 2000); BPI: Behavior Problem Index, DSM-IV:
diagnostic and statistical manual of mental disorders fourth edition - revised (American Psychiatric Association, 2000), SDQ: Strengths and Difficulties Questionnaire (Goodman, 1997), ID: intellec-
tual disability, ASD: autism spectrum disorder.
1
Children originally diagnosed at an average age of 5.9 years and followed up 9 years later.
2
Colin Reilly, Elizabeth Kent, and Brian G.R. Neville

Abstract only available.

Table 2. Population-based studies of psychopathology in children with epilepsy and intellectual disability(ID) since 1980

Author Age of Measures of

and year Location Sample source sample Sample size psychopathology Identification of epilepsy Main findings

Lewis et al., Australia Cohort representative 8–22 392 with ID 115 CWE DBC Parental report of epilepsy. No significant difference
2000; of population of 82% of those with between rates of psychopathology
young people with ID reported epilepsy were children with epilepsy and ID and
on AEDs. children with ID without epilepsy
Steffenburg Sweden 3 age cohorts in 8–16 90 CWE and ID DSM-III-R criteria Epilepsy defined as two or 53% of children with ID and epilepsy
et al., 1996 Gothenburg Sweden more unprovoked had at least one psychiatric diagnosis
seizures and active although 30 (33%) children could
epilepsy defined as having not be classified because
had a seizure in last 5 years. of profound ID.
Children identified via
paediatric and
neuropsychiatric clinic registers

DBC: Developmental Behaviour Checklist (Einfield & Tonge, 1992), DSM-III-R:Diagnostic and Statistical Manual of Mental Disorders Third edition - revised (American Psychiatric Association (APA),
1987).

© 2012 The Authors. Child and Adolescent Mental Health © 2012 Association for Child and Adolescent Mental Health.
Child Adolesc Ment Health 2013; 18(2): 65–75

14753588, 2013, 2, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/j.1475-3588.2012.00648.x by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [15/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

doi:10.1111/j.1475-3588.2012.00648.x
Kushnir, Roberts and Snead (2005) reviewed the
literature and reported that five population-based
studies had been carried out with estimates for seizure
disorders ranging from 22.8% to 38.5%. Danielsson,
Gillberg, Billstedt, Gillberg and Olsson (2005) reported
that 38% of young adults with Autistic Disorder or an
‘autistic like condition’ had epilepsy at some point in
their lives in their population-based cohort. However,
the number of individuals with ASD without ID in
this study is much lower than that based on current
estimates of the IQ distribution in ASD suggesting that
those with ASD in this population were more likely to be
at higher risk for epilepsy due to the presence of ID.
There have been no population-based studies of epilepsy
in children with autism which have included children
with ASD across all levels of cognitive functioning.
There have been reports that children with epilepsy
who also have ASD are likely to be diagnosed at an older
age than children with ASD alone (e.g. Turk et al., 2009),
suggesting a possible difficulty with differential diagno-
sis for young children with epilepsy. It is possible that
seizure behaviours may mimic or overlap with behav-
iours commonly associated with the triad of impair-
ments associated with ASD thus making diagnosis of
ASD or identification of seizures more difficult. An exam-
ple of this overlap would be the unusual repetitive and
stereotyped behaviours common in children with ASD
which can be difficult to distinguish from clinical
seizures (Tuchman & Rapin, 2002). In some epilepsy
syndromes early development may be normal but with
the onset of high levels of epileptic activity and usually
clinical seizures a combination of cognitive and social
regression occurs in which the phenotype satisfies the
criteria for ASD (e.g. West Syndrome/Infantile spasms
with regression at 4–6 months and Landau–Kleffner
syndrome with regression after 2–3 years of age; Deonna
& Roulet, 2006; Neville, 2007). The regression in lan-
guage seen with Landau–Kleffner syndrome is more dra-
matic and the social deficits are less severe than those
associated with autism, although the distinction may be
clinically difficult to make in younger children (Tuch-
man, 2006). In both Landau–Kleffner syndrome and
West Syndrome, symptoms of ASD may reduce as the
child develops or when effective antiepileptic therapy is
given (Deonna & Roulet, 2006). However, in both syn-
dromes significant features of ASD may persist and for
the practical issue of management they have ASD albeit
via a different route to that of developmental autism.
In children with infantile spasms the prevalence of ASD
is a high as 35% depending on the severity of ID (Sae-
mundsen, Ludvigsson & Rafnsson, 2007).The common
denominator for these phenomena seem to be conditions
which have a high rate of subclinical seizures in sleep
which may amount to continuous spike and waves on
EEG during slow wave sleep (ESESS). Although there is
a risk for the development of ASD in children with some
epilepsy syndromes/electroclincial syndromes espe-
cially those with seizures in the first year of life, the
relationship between epilepsy and the regression/stag-
nation reported in some cases of ASD remains unclear
(Spence & Schneider, 2009). It would appear that epi-
lepsy is not a causal factor in the majority of children
with ASD, even in those who undergo a developmental
regression/stagnation typically at 18–24 months. Nev-
ertheless, there are some situations where the role of epi-
© 2012 The Authors. Child and Adolescent Mental Health © 2012 Association for Child and Adolescent Mental Health.
14753588, 2013, 2, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/j.1475-3588.2012.00648.x by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [15/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Psychopathology in childhood epilepsy 71
lepsy may arise with regard to the development of ASD or
display of autistic behaviours (Deonna & Roulet, 2006).
The predominant type of seizure in those with autism
and epilepsy has varied across studies. Danielsson et al.
(2005) reported that partial seizures with or without sec-
ondary generalisation as the main type in their popula-
tion based study but Bolton et al. (2011) reported that
generalised tonic-clonic seizures were the main type in a
clinic-based study. Bolton et al. (2011) comment that
although they found that generalised tonic-clonic were
the most frequent seizure type it is possible that this sei-
zure type represented secondary generalised seizures
arising from an epileptic focus. In children with epilepsy
who also have ASD it is likely that outcome in relation to
ASD will be strongly mediated by level of developmental/
intellectual functioning. Epilepsy in autism has been
reported to be difficult to treat with low remission rates
(Danielsson et al., 2005; Hara, 2007) although Sansa
et al. (2011) suggest that more than half of the individu-
als with autism in their sample were seizure free or had
infrequent seizures. There have been reports of improve-
ments in features of ASD after surgery in some cases of
childhood epilepsy (Neville et al., 1997). However, it
appears that while current pharmacological and surgical
treatments for children with epilepsy may be effective in
treating seizures, they are rarely effective in improving
difficulties with cognitive, language and social function
(Tuchman, Alessandri & Cuccaro, 2010), or ASD diag-
nostic status (Danielsson et al., 2009).
Attention deficit/hyperactivity disorder in
childhood epilepsy
Population-based studies suggest that rates of ADHD in
children with epilepsy are higher than in the general
population. Berg et al. (2011) reported that 21% of 501
children with epilepsy had ADHD. Davies et al. (2003)
reported that 12% of 25 children with ‘complicated’ epi-
lepsy had ADHD compared with 2.1% of children with
diabetes and 2.2% of the rest of the child population.
However, none of the children with ‘uncomplicated epi-
lepsy’ in the population had ADHD. Hesdorffer et al.
(2004) reported on a population based study of children
with newly diagnosed seizures and found that 13.7% of
the children with epilepsy met DSM-IV (Diagnostic and
Statistical Manual of Mental Disorders–Fourth Edition;
American Psychiatric Association, 1994) criteria. Hedd-
erick and Buchhalter (2003) reported that the preva-
lence of ADHD based on DSM-IV criteria was 17% in
children (16 years or less) with epilepsy in the Rochester
epidemiology project.
There have been suggestions that behavioural check-
lists that are intended to identify difficulties with atten-
tion falsely categorise absence seizures as difficulties
with inattention (Wright, 2009; but see Gleissner et al.,
2008). An expert clinical interview should usually sepa-
rate absence seizures with a clear onset that interrupt
an activity from contingent diversion of attention and
non-specific daydreaming. It is important to get informa-
tion from both teachers and parents on the manifesta-
tion of ADHD symptoms as teachers and parents may
differ significantly with regard to identification of at-risk
children (Sherman, Brooks, Akdag, Connolly & Wiebe,
2010). The gold standard in this population will be
expert clinical interview with a consideration of the pos-

72 Colin Reilly, Elizabeth Kent, and Brian G.R. Neville
sible role of seizures and anti-epileptic drugs (AEDs) in
any diagnostic and/or treatment decisions.
The relatively high rate of ADHD, predominantly inat-
tentive subtype, in childhood epilepsy (e.g. Dunn, Austin
& Perkins, 2009; Hermann et al., 2007) indicates that
difficulties with inattentive symptoms are particularly
predominant in children with epilepsy. Noeker and Hav-
erkamp (2003) and Sherman, Slick, Connolly and Eyrl
(2007) suggest that the high rate of these symptoms may
be attributable to seizure characteristics as opposed to
being of a similar aetiology in children with ADHD with-
out epilepsy. ADHD typically affects significantly more
males than females (American Psychiatric Association,
1994), but this male predominance is not as pronounced
in childhood epilepsy in population or clinic-based stud-
ies (Hermann et al., 2007; Hesdorffer et al., 2004). Sig-
nificant ADHD symptoms may be present for many
children before the onset of epilepsy (e.g. Hermann et al.,
2007), and significant difficulties with inattention may
persist beyond remission of seizures (Berg et al., 2007).
A number of clinic-based studies have included
seizure/epilepsy related variables as possible correlates
for ADHD symptoms in children with epilepsy. Seizure
frequency, duration of epilepsy, and number of AED
medications have not been significantly associated with
a diagnosis of ADHD (Hermann et al., 2007; Sherman
et al., 2007). Studies of the relationship between aetiol-
ogy of epilepsy and ADHD symptoms have not yielded
consistent findings with suggestions that epilepsy asso-
ciated with structural/metabolic causes may be associ-
ated with higher levels of some ADHD symptoms (e.g.
Sherman et al., 2007). However, other reports have failed
to find this relationship (Hermann et al., 2007). The lim-
ited evidence that exists suggests that the combination
of epilepsy and ADHD appears to have significant nega-
tive consequences in areas such as executive functioning
(Hermann et al., 2007), and quality of life (Sherman
et al., 2007) compared with children with epilepsy alone.
In relation to brain structure Hermann et al. (2007)
reported that ADHD in epilepsy is associated with signifi-
cantly increased grey matter in distributed regions of the
frontal lobe and significantly smaller brainstem volume.
It is important to treat symptoms of ADHD in child-
hood epilepsy (Boyes, 2010) and there is evidence that
successful treatment is possible. The research that has
been carried out suggests that ADHD symptoms in some
children with epilepsy may improve on methylphenidate
(MPH; Gross-Tsur, Manor, van der Meere, Joseph & Sha-
lev, 1997; Semrud-Clikeman & Wical, 1999), and the use
of MPH may yield a similar response to those with ADHD
without epilepsy (Kaufmann, Goldberg-Stern & Shuper,
2009) although there is a lack of double blind placebo-
controlled trials. Gonzalez-Heydrich et al. (2010) carried
out a study of OROS-MPH (osmotic-release oral system-
methylphenidate) which has extended/sustained release
in 33 children with epilepsy in a double-blind placebo-
controlled crossover design. Although the authors
reported evidence of efficacy of OROS-MPH on symptoms
of ADHD, there was a small increase in seizure risk on
OROS-MPH compared with placebo (Gonzalez-Heydrich
et al. 2010). The authors concluded that this preliminary
study was too small to resolve the safety concerns
regarding OROS-MPH on seizure frequency. Feldman,
Crumrine, Handen, Alvin and Teodori (1989) reported on
10 children with well controlled epilepsy and MPH was
© 2012 The Authors. Child and Adolescent Mental Health © 2012 Association for Child and Adolescent Mental Health.
14753588, 2013, 2, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/j.1475-3588.2012.00648.x by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [15/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Child Adolesc Ment Health 2013; 18(2): 65–75
given in a randomised double-blind medication–placebo
crossover controlled trial. None of the children experi-
enced seizures over a 4-week period.
In a review of studies of the use of MPH in children
with epilepsy, Kaufmann et al. (2009) concluded that
the efficacy of MPH in improving symptoms of ADHD was
similar to reported rates in children with ADHD without
epilepsy. Kaufmann et al. (2009) added that MPH does
not adversely affect the severity or frequency of seizures
in the individuals with epilepsy, provided seizures are
well controlled. There have been no published reports of
non-pharmacological treatment approaches such as
behavioural approaches for ADHD in children with epilepsy.
Depression/anxiety in childhood epilepsy
It is increasingly being reported that children and ado-
lescents with epilepsy are at significant risk for both
depression and anxiety in population-based studies.
Berg et al. (2011) reported that 13% of children with epi-
lepsy had depression, 5% had anxiety disorder, 3% had
obsessive compulsive disorder (OCD) and 1% had bipo-
lar disorder. Davies et al. (2003) reported that 16% of
children with ‘complicated’ epilepsy had an ‘emotional’
disorder and 16.7% of those with ‘uncomplicated’ epi-
lepsy had an emotional disorder, compared with 6.4% of
children with diabetes and 4.2% of children in the gen-
eral population. Hedderick and Buchhalter (2003) found
that 12% of children with epilepsy had DSM-IV ‘Mood
Disorder’ based on a review of the medical records in a
population based sample. In a population based cohort
Hesdorffer, Allen -Hauser, Olafsson, Ludvigsson and
Kjartanson (2005) reported that children (10 years and
older) and adults with incident unprovoked seizures
were 1.7-fold more likely to have a history of major
depression before seizure onset than controls. There
have been no population-based studies of suicidal idea-
tion solely focussing on children although in Hesdorffer
et al.'s (2005) study a history of attempted suicide was
5.1-fold more common in those with unprovoked sei-
zures compared with controls. Children with epilepsy
drawn from clinic based samples had higher rates of sui-
cidal ideation compared with controls in two clinic-based
studies (Caplan et al., 2005; Oğuz, Kurul & Dirik, 2002).
Barry et al. (2008) and Bayenburg, Mitchell, Schmidt,
Elger and Reuber (2005) emphasise that individuals
with epilepsy may not present with classic symptoms of
depression and anxiety in that some symptoms may be
temporally related to the occurrence of seizures. Such
symptoms of depression and anxiety may occur either
before a seizure (preictally), as a clinical expression of
the seizure (ictal), following a seizure (postictally) or
between seizures (interictal). The existence of epilepsy
specific symptoms of depression and anxiety and their
relationship of these proposed symptoms with more
classic symptoms of the two conditions has yet to be
studied in children with epilepsy.
Epilepsy specific features such as seizure type, age of
seizure onset, and duration of epilepsy have not been
found to be significantly related to symptoms of anxiety
or depression in most studies (e.g. Cusher-Weinsten
et al., 2008; Ettinger et al., 1998; Roeder, Roeder, Asano
& Chugani, 2009). A high seizure frequency or poor
seizure control has been associated with increased
scores on depression and anxiety measures in some

doi:10.1111/j.1475-3588.2012.00648.x
(Adewuya & Ola, 2005; Alwash, Hussein & Matloub,
2000; Oğuz et al., 2002) but not all studies (Cusher-
Weinsten et al., 2008; Dunn, Austin & Huster, 1999;
Ettinger et al., 1998; Vega et al., 2011). Children on
more than one AED or polytherapy have been found to
be at increased risk for significant symptoms of anxiety
and depression in a number of studies (Adewuya & Ola,
2005; Cusher-Weinsten et al., 2008; Oğuz et al., 2002;
Roeder et al., 2009). Other possible influences on symp-
toms of depression in children with epilepsy include
child attitude towards epilepsy and child evaluation of
family relationships (Dunn et al., 1999). Rodenburg,
Meijer, Deković and Aldenkamp (2006) found that family
factors especially those related to the quality of the par-
ent-child relationship appeared to be strong predictors
of psychopathology including depression in children
with epilepsy. The influence of ID in childhood epilepsy
on symptoms of depression and anxiety has not been
extensively studied.
Assessing symptoms of depression and anxiety in
individuals with epilepsy can be challenging (Gilliam
et al., 2006). When they are developmentally able to
respond children and adolescents as well as parents and
teachers, should be asked about relevant symptoms, as
parents and teachers may not be aware of mood and
anxiety symptoms the children are experiencing (Barry
et al., 2008; Caplan et al., 2005). Asking about a family
history of mental health difficulties and significant
changes in behaviour, sleep patterns, activity levels,
relationships, emotions, and patterns of social interac-
tion may help identify symptoms in children with epi-
lepsy and ID. The use of expert clinical interview can
help identify core symptoms and evaluate the potential
contribution of seizures and/or AEDs. The evidence
base for pharmacological or psychological interventions
in children with epilepsy is sparse and there have been
no double-blind studies on the psychopharmacological
treatment of mood and anxiety disorders in children or
adolescents with epilepsy (Barry et al., 2008). Serotonin
Reuptake Inhibitors (SSRIs) are likely to be the pharma-
cological treatment of choice in the treatment of depres-
sion and anxiety (Barry et al., 2008; Plioplys, 2003), and
tricyclic antidepressants are not recommended because
of the potential increased seizure risk (Barry et al.,
2008). In the one published study of a psychotherapy-
based intervention for young people with epilepsy Marti-
nović, Simoncović and Djokić (2006) reported that a
short cognitive-behavioural intervention (CBI) was supe-
rior to treatment as usual in terms of follow-up scores on
a measure of depression in adolescents with epilepsy
who were at risk for depression.
Discussion and conclusion
Studies of psychopathology in population-based studies
of children with epilepsy indicate that they are at a
much higher risk for behavioural and psychiatric disor-
ders than children without epilepsy and children with
other chronic medical conditions. This is true for chil-
dren with epilepsy of varying aetiologies/types and
across all levels of intellectual functioning. The
increased risk is for ADHD, ASD, depression and
anxiety. Population-based studies of children with epi-
lepsy have not employed commonly used ASD screening
or diagnostic measures and as a result estimates of the
© 2012 The Authors. Child and Adolescent Mental Health © 2012 Association for Child and Adolescent Mental Health.
14753588, 2013, 2, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/j.1475-3588.2012.00648.x by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [15/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Psychopathology in childhood epilepsy 73
prevalence of ASD in childhood epilepsy are not based
on systematic screening and well validated assessment
procedures. Future population-based studies of psycho-
pathology will benefit from the use of multiple infor-
mants using well-validated diagnostic instruments. The
use of well validated parent, teacher, and self-report
screening measures is likely to identify the majority of at
risk children provided children who screen positive on
any of the informant measures are deemed at-risk. At-
risk children should then be assessed more comprehen-
sively using appropriate diagnostic measures. The gold
standard for final diagnostic decisions will be expert
clinician diagnosis. Population-based studies also need
to use internationally accepted definitions of epilepsy
(e.g. International League against Epilepsy classifica-
tion) when identifying children with epilepsy, seizure
types and epilepsy syndromes. With regard to correlates
of psychopathology in childhood epilepsy, there is a
need for consensus regarding the methods of determin-
ing seizure severity, frequency, duration and family pre-
dictors as these have often been measured differently in
studies. The school environment may also play a role
with regard to correlates of psychopathology in epilepsy
and attempts need to be made to document the poten-
tial contribution of attitudes among teachers and peers
as potential risk or resiliency factors. As a result of out-
lined difficulties with previous research a clear picture
regarding the causes of psychopathology in childhood
epilepsy has not been forthcoming. In relation to the
rate of ASD in childhood epilepsy here is a need for pop-
ulation-based studies to utilise well-validated screening
and diagnostic methods for ASD across all levels of cog-
nitive ability. There is also a need to follow up popula-
tion-based studies of children with epilepsy to gain an
insight into whether rates of psychopathology are sta-
ble. Such studies will allow a determination of whether
the profile of behavioural and psychiatric difficulties
changes in those who continue to have epilepsy and in
those who are remission. Given the high rates of psycho-
pathology in childhood epilepsy screening all children
for such difficulties would seem warranted.
Ott et al. (2003) reported that although 60% of chil-
dren with epilepsy met criteria for one or more DSM-IV
psychiatric diagnoses, nearly two thirds were not in
receipt of any treatment for the conditions. There is thus
still a need to promote an understanding of the associ-
ated behavioural and psychiatric issues prevalent in
childhood epilepsy so that difficulties can be identified
and managed appropriately but also a need to identify
possible barriers to diagnosis and treatment. Interven-
tions to treat behavioural or psychiatric difficulties in
childhood epilepsy are likely to be similar to interven-
tions for children without epilepsy, although studies to
confirm this are lacking. It is not clear how such inter-
ventions will affect symptoms of psychopathology or the
course and outcome of the child's epilepsy. There is still
a need for appropriately designed studies to treat ADHD
and depression and anxiety via psychopharmacology in
childhood epilepsy. There is also a great need for
research on psychological approaches such as individ-
ual or group cognitive behavioural therapy (CBT), parent
training, family therapy and school-based interventions.
Effective approaches to treating and managing epilepsy
and associated psychopathology in children requires an
appreciation of the intricate relationship between epi-

74 Colin Reilly, Elizabeth Kent, and Brian G.R. Neville
lepsy and other associated disorders (Jensen, 2011).
Therefore, close collaboration between paediatric neurol-
ogists and mental health professionals is likely to be vital.
Acknowledgements
The first author is funded by the Esmée Fairbairn Foundation
and the National Centre for Young People with Epilepsy. The
authors have declared that they have no competing or potential
conflicts of interest arising from this publication.
Supporting information
Additional Supporting Information may be found in the online
version of this article:
Appendix S1. Systematic search methodology (Word docu-
ment).
References
Achenbach, T. M. (1991). Manual for the Child Behavior Check-
list/4-18 and 1991 Profile. Burlington, VT, University of Ver-
mont Department of Psychiatry.
Adewuya, A.O., & Ola, B.A. (2005). Prevalence of and risk
factors for anxiety and depressive disorders in Nigerian ado-
lescents with epilepsy. Epilepsy and Behavior, 6, 342–347.
Alfstad, K.A., Clench-Aas, J., Van Roy, B., Mowinckel, P.,
Gjerstad, L., & Lossius, M.I. (2011). Psychiatric symptoms in
Norwegian children with epilepsy: Effects of age and gender.
Epilepsia, 52, 1231–1238.
Alwash, R.E., Hussein, M.J., & Matloub, F.F. (2000). Symptoms
of anxiety and depression among adolescents with seizures in
Irbid, Northern Jordan. Seizure, 9, 412–416.
American Psychiatric Association (APA). (1987). Diagnostic and
statistical manual of mental disorders- (3rd edn – revised).
Washington, DC: Author.
American Psychiatric Association (APA). (1994). Diagnostic and
statistical manual of mental disorders (4th edn). Washington,
DC: Author.
Amiet, C., Gourfinkel-An, I., Bouzamondo, A., Tordjman, S.,
Baulac, M., Lechat, P., et al. (2008). Epilepsy in autism is
associated with intellectual disability and gender: Evidence
from a meta-analysis. Biological Psychiatry, 64, 577–582.
Barry, J.J., Ettinger, A.B., Friel, P., Gilliam, F.G., Harden, C.L.,
Hermann, B., et al. (2008). Consensus statement: The evalu-
ation and treatment of people with epilepsy and affective dis-
orders. Epilepsy and Behavior, 13, 1–29.
Bayenburg, S., Mitchell, A.J., Schmidt, D., Elger, C.E., & Reu-
ber, M. (2005). Anxiety in patients with epilepsy: Systematic
review and suggestions for clinical management. Epilepsy
and Behavior, 7, 161–171.
Berg, A., Berkovic, S.F., Brodie, M.J., Buchhalter, J., Cross,
J.H., van Emde Boas, M., et al. (2010). Revised terminology
and concepts for organization of seizures and epilepsies:
Report of the ILAE Commission on Classification and Termi-
nology, 2005–2009. Epilepsia, 51, 676–685.
Berg, A.T., Caplan, R., & Hesdorffer, D.C. (2011). Psychiatric
and neurodevelopmental disorders in childhood-onset
epilepsy. Epilepsy and Behavior, 20, 550–555.
Berg, A.T., Vickery, B.G., Testa, F.M., Levy, S.R., Shinnar, S., &
DiMario, F. (2007). Behavior and social competency in idio-
pathic and cryptogenic childhood epilepsy. Developmental
Medicine and Child Neurology, 49, 487–492.
Bolton, P.F., Carcani-Rathwell, I., Hutton, J., Goode, S., How-
lin, P., & Rutter, M. (2011). Epilepsy in autism: Features and
correlates. British Journal of Psychiatry, 198, 289–294.
Boyes, C. (2010). Question 2: Should a child with ADHD and
epilepsy be given Ritalin? Archives of Disease in Childhood,
95, 759–761.
Camfield, C.S., Camfield, P.R., Gordon, K., Wirrell, E., & Dooley,
J.M. (1996). Incidence of epilepsy in childhood and adoles-
cence: A population based study in Nova-Scotia from 1977 to
1985. Epilepsia, 37, 19–23.
© 2012 The Authors. Child and Adolescent Mental Health © 2012 Association for Child and Adolescent Mental Health.
14753588, 2013, 2, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/j.1475-3588.2012.00648.x by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [15/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Child Adolesc Ment Health 2013; 18(2): 65–75
Caplan, R., Siddarth, P., Gurbani, S., Hanson, R., Sankar, R., &
Shields, W.D. (2005). Depression and anxiety disorders in
pediatric epilepsy. Epilepsia, 46, 720–730.
Carlton-Ford, S., Miller, R., Brown, M., Nealeigh, N., & Jen-
nings, P. (1995). Epilepsy and children's social and psycho-
logical adjustment. Journal of Health and Social Behavior, 36,
285–301.
Cedurland, M., & Gillberg, C. (2004). One hundred males with
Asperger syndrome: A clinical study of background and asso-
ciated factors. Developmental Medicine and Child Neurology,
46, 652–660.
Commission on Classification and Terminology of the Interna-
tional League against Epilepsy (1981). Proposal for the
revised clinical and electrographic classification of epileptic
seizures. Epilepsia, 22, 489–501.
Commission on Classification and Terminology of the Interna-
tional League Against Epilepsy (1989). Proposal for the
revised classification of epilepsies and epileptic syndromes.
Epilepsia, 30, 389–399.
Cusher-Weinsten, S., Dassoulas, K., Salpekar, J.A., Hender-
son, S.E., Pearl, P., Gaillard, W.D., et al. (2008). Parenting
stress and childhood epilepsy: The impact of depression,
learning, and seizure related factors. Epilepsy and Behavior,
13, 109–114.
Danielsson, S., Gillberg, C., Billstedt, E., Gillberg, C., & Olsson,
I. (2005). Epilepsy in young adults with autism: A prospective
population-based follow-up study of 120 individuals diag-
nosed in childhood. Epilepsia, 46, 918–923.
Danielsson, S., Viggedal, G., Steffenburg, S., Rydenhag, B., Gill-
berg, C., & Olsson, I. (2009). Psychopathology, psychosocial
functioning, and IQ before and after epilepsy surgery in chil-
dren with drug resistant epilepsy. Epilepsy and Behavior, 14,
330–337.
Davies, S., Heyman, I., & Goodman, R. (2003). A population
survey of mental health problems in children with epilepsy.
Developmental Medicine and Child Neurology, 45, 292–295.
Deonna, T., & Roulet, E. (2006). Autistic spectrum disorder:
Evaluating a possible contributing or causal role of epilepsy.
Epilepsia, 47, 79–82.
Dunn, D.W., Austin, J.K., & Huster, G.A. (1999). Symptoms of
depression in adolescents with epilepsy. Journal of the Ameri-
can Academy of Child and Adolescent Psychiatry, 38, 1132–
1138.
Dunn, D., Austin, J.K., & Perkins, S.M. (2009). Prevalence of
psychopathology in childhood epilepsy: Categorical and
dimensional measures. Developmental Medicine and Child
Neurology, 51, 364–372.
Einfield, S.L., & Tonge, B.J. (1992). Manual for the Developmen-
tal Behaviour Checklist. Melbourne: Monash University Cen-
tre for Developmental Psychiatry, Melbourne and School of
Psychiatry, University of New South Wales.
Ettinger, A.B., Weisbrot, D.M., Nolan, E.E., Gadow, K.D., Vitale,
S.A., Andriola, M.R., et al. (1998). Symptoms of depression
and anxiety in pediatric epilepsy patients. Epilepsia, 39, 595–
599.
Feldman, H., Crumrine, P., Handen, B.L., Alvin, R., & Teodori,
J. (1989). Methylphenidate in children with seizures and
attention-deficit disorder. American Journal of Diseases in
Children, 143, 1081–1086.
Gillberg, I.C., & Gillberg, C. (1989). Asperger syndrome – some
epidemiological considerations: A research note. Journal of
Child Psychology and Psychiatry, 30, 631–638.
Gilliam, F.G., Barry, J.J., Hermann, B.P., Meador, K.J., Vahle,
V., & Kanner, A.M. (2006). Rapid detection of major depres-
sion in epilepsy: A multicentre study. The Lancet Neurology,
5, 399–405.
Gleissner, U., Fritz, N.E., Von Lehe, M., Sassen, R., Elger, C.E.,
& Helmstaedter, C. (2008). The validity of the child behaviour
checklist for children with epilepsy. Epilepsy and Behavior,
12, 276–280.
Gonzalez-Heydrich, J., Whitney, J., Waber, D., Forbes, P.,
Hsin, O., Farone, S. V. (2010). Adaptive phase 1 study of
OROS methylphenidate treatment of attention deficit hyper-
activity disorder with epilepsy. Epilepsy & Behavior, 18, 229–
237.

doi:10.1111/j.1475-3588.2012.00648.x
Goodman, R. (1997). The Strengths and Difficulties Question-
naire: A research note. Journal of Child Psychology and Psy-
chiatry, 38, 581–586.
Goodman, R., Ford, T., Richards, H., Gatward, R., & Meltzer, H.
(2000). The Development and Well Being Assessment:
Description and initial validation of an integrated assessment
of child and adolescent psychopathology. Journal of Child
Psychology and Psychiatry, 41, 645–656.
Gross-Tsur, V., Manor, O., van der Meere, J., Joseph, A., & Sha-
lev, R.S. (1997). Epilepsy and attention deficit hyperactivity
disorder: Is methylphenidate safe and effective? Journal of
Pediatrics, 130, 670–674.
Hara, H. (2007). Autism and epilepsy: A retrospective follow-up
study. Brain Development, 29, 486–490.
Hedderick, E., & Buchhalter, J.R. (2003). Comorbidity of child-
hood-onset epilepsy and psychiatric and behavioral disor-
ders: A population-based study. Annals of Neurology, 54
(Suppl. 7), S115.
Hermann, B., Jones, J., Dabbs, K., Allen, C.A., Sheth, R., Fine, J.,
et al. (2007). The frequency, complications and aetiology of
ADHD in new onset paediatric epilepsy. Brain, 130, 3135–3148.
Hermann, B., & Whitman, S. (1992). Psychopathology in epi-
lepsy. The role of psychology in altering paradigms of
research, treatment, and prevention. American Psychologist,
47, 1134–1138.
Hesdorffer, D.C., Allen -Hauser, W.A., Olafsson, E., Ludvigsson,
P., & Kjartanson, O. (2005). Depression and suicide attempt
as risk factors for incident unprovoked seizures. Annals of
Neurology, 59, 35–41.
Hesdorffer, D.C., Ludvigsson, P., Olafsson, E., Gudmundsson,
G., Kjartansson, O., & Hauser, W.A. (2004). ADHD as a risk
factor for incident unprovoked seizures and epilepsy in chil-
dren. Archives in General Psychiatry, 61, 731–736.
Høie, B., Sommerfelt, K., Waaler, P.E., Alsaker, F.D., Skeidsvoll,
H., & Mykletun, A. (2006). Psychosocial problems and seizure
related factors in children with epilepsy. Developmental Medi-
cine and Child Neurology, 48, 213–219.
Jensen, F.E. (2011). Epilepsy as a spectrum disorder: Implica-
tions from novel clinical and basic neuroscience. Epilepsia,
52(Suppl. 1), 1–6.
Kagan-Kushnir, T., Roberts, W., & Snead, C. (2005). Screening
electroencephalograms in autism spectrum disorders: Evidence
based guidelines. Journal of Child Neurology, 20, 197–206.
Kaufmann, R., Goldberg-Stern, H., & Shuper, A. (2009). Atten-
tion-deficit disorders and epilepsy in childhood: Incidence,
causative relations, and treatment possibilities. Journal of
Child Neurology, 24, 727–733.
Lewis, J.N., Tonge, B.J., Mowat, D.R., Einfeld, S.L., Siddons,
H.M., & Rees, V.W. (2000). Epilepsy and associated psycho-
pathology in young people with intellectual disability. Journal
of Paediatrics and Child Health, 36, 172–175.
Lossius, M.I., Clench-Aas, J., Van Roy, B., Mowinckel, P., &
Gjerstad, L. (2006). Psychiatric symptoms in adolescents with
epilepsy in junior high school in Norway: A population survey.
Epilepsy and Behavior, 9, 286–292.
Martinović, Z., Simoncović, P., & Djokić, R. (2006). Preventing
depression in adolescents with epilepsy. Epilepsy and Behav-
ior, 9, 619–624.
McDermott, S., Mani, S., & Krishnaswami, S. (1995). A popula-
tion-based analysis of specific behavior problems associated
with childhood seizures. Journal of Epilepsy, 8, 110–118.
Moher, D., Liberati, A., Tetzalaff, J., & Altman, D.G. (2009). Pre-
ferred reporting items for systematic reviews and meta-ana-
lyses – The PRISMA Statement. British Medical Journal, 339,
332–336.
Neville, B.G. (2007). Epileptic encephalopathy. Annals of Indian
Neurology, 10, 3–6.
Neville, B.G., Harkness, W.F., Cross, J.H., Cass, H.C., Burch,
V.C., Lees, J.A., et al. (1997). Surgical treatment of severe
autistic regression in childhood epilepsy. Pediatric Neurology,
16, 137–140.
Noeker, M., & Haverkamp, F. (2003). Neuropsychological
deficiencies as a mediator between CNS dysfunction and
inattentive behaviour in childhood epilepsy. Developmental
Medicine and Child Neurology, 45, 717–18.
© 2012 The Authors. Child and Adolescent Mental Health © 2012 Association for Child and Adolescent Mental Health.
14753588, 2013, 2, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/j.1475-3588.2012.00648.x by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [15/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Psychopathology in childhood epilepsy 75
Oğuz, A., Kurul, S., & Dirik, E. (2002). Relationship of epilepsy-
related factors to anxiety and depression scores in epileptic
children. Journal of Child Neurology, 17, 37–40.
Ott, D., Siddarth, P., Gurbani, S., Koh, S., Tournay, A.,
Donald-Shields, W., et al. (2003). Behavioral disorders in
pediatric epilepsy: Unmet psychiatric need. Epilepsia, 44,
591–597.
Plioplys, S. (2003). Depression in children and adolescents with
epilepsy. Epilepsy and Behavior, 4, 39–45.
Rodenburg, R., Meijer, A.M., Deković, M., & Aldenkamp, A.P.
(2006). Family predictors of psychopathology in children with
epilepsy. Epilepsia, 47, 601–614.
Roeder, R., Roeder, K., Asano, E., & Chugani, H.T. (2009).
Depression and mental health help-seeking behaviors in a
predominantly African American population of children and
adolescents with epilepsy. Epilepsia, 50, 1943–1952.
Rutter, M., Graham, P., & Yule, W. (1970). A neuropsychiatric
study in childhood. London: S.I.M.P. William Heinmann Med-
ical Books.
Saemundsen, E., Ludvigsson, P., & Rafnsson, V. (2007). Autism
spectrum disorders in children with a history of infantile
spasms: A population based study. Journal of Child Neurol-
ogy, 22, 1102–1107.
Sansa, G., Carlson, C., Doyle, W., Weiner, H.L., Bluvstein, J.,
Barr, W., et al. (2011). Medically refractory epilepsy in aut-
ism. Epilepsia, 52, 1071–1075.
Semrud-Clikeman, M., & Wical, B. (1999). Components of
attention in children with complex partial seizures with and
without ADHD. Epilepsia, 40, 211–215.
Sherman, E.M.S., Brooks, B.L., Akdag, S., Connolly, M.B., &
Wiebe, S. (2010). Parents report more ADHD symptoms than
do teachers in children with epilepsy. Epilepsy and Behav-
iour, 19, 428–435.
Sherman, E.M.S., Slick, D.J., Connolly, M.B., & Eyrl, K.L. (2007).
ADHD, neurological correlates and health-related quality of life
in severe pediatric epilepsy. Epilepsia., 48, 1083–1091.
Silanpää, M., & Schmidt, D. (2006). Natural history of treated
childhood-onset epilepsy: Prospective, long–term population
based study. Brain, 129, 617–624.
Spence, S.J., & Schneider, M.T. (2009). The role of epilepsy and
epileptiform EEGs in autism spectrum disorders. Pediatric
Research, 65, 599–606.
Steffenburg, S., Gillberg, C., & Steffenberg, U. (1996). Psychiat-
ric disorders in children and adolescents with mental retarda-
tion and active epilepsy. Archives of Neurology, 53, 904–912.
Tuchman, R. (2006). Autism and epilepsy: What has regression
got to do with it? Epilepsy Currents, 6, 107–111.
Tuchman, R., Alessandri, M., & Cuccaro, M. (2010). Autism spec-
trum disorders and epilepsy: Moving towards a comprehsnive
approach to treatment. Brain and Development, 32, 719–730.
Tuchman, R., & Rapin, I. (2002). Epilepsy in autism. Lancet
Neurology, 1, 352–358.
Turk, J., Bax, M., Williams, C., Amin, P., Eriksson, M., & Gill-
berg, C. (2009). Autism spectrum disorder in children with
and without epilepsy: Impact on social functioning and com-
munication. Acta Paediatrica, 98, 675–681.
Turky, A., Beavis, J.M., Thapar, A.K., & Kerr, M.P. (2008). Psy-
chopathology in children and adolescents with epilepsy: An
investigation of predictive variables. Epilepsy and Behavior,
12, 136–144.
Vega, C., Guo, J., Kilory, B., Danielson, N., Vestal, M., Berman,
R., et al. (2011). Symptoms of anxiety and depression in
childhood absence epilepsy. Epilepsia, 52, e70–e74.
World Health Organization. (1992). The ICD-10 classification of
mental and behavioural disorders. Clinical Descriptions and
Diagnostic Guidelines. Geneva: WHO.
Wright, I. (2009). The validity of questionnaire-based assess-
ment of psychopathology in children with epilepsy. Develop-
mental Medicine and Neurology, 51, 336–339.
Accepted for publication: 05 December 2011
Published online: 20 February 2012