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Management of ADHD in Youth With Comorbid Epilepsy


Key Summary Points

  • It is important to be vigilant clinically to recognize the presence of epilepsy in patients with attention deficit hyperactivity disorder (ADHD), and vice versa.

  • The longer the duration of seizures or subclinical epileptiform discharges, higher the likelihood of finding ADHD or its symptoms.

  • In cases with subclinical seizures and ADHD, identification of the underlying epilepsy and type will guide treatment. In some cases, appropriate use of antiepileptic drugs may significantly reduce ADHD symptoms, thus eliminating the need for being on multiple medications.

  • The quality of sleep along with seizure control is greatly predictive of cognitive and behavioral outcomes. Thus, correcting sleep is a big part of improving the quality of life and prognosis.

  • In the majority of cases, cautious stimulant usage is safe and appropriate for ADHD comorbid with epilepsy.

Disclosure Statement

Dr Mishra has no relevant financial disclosures. Dr Salpekar receives research funding from Lundbeck for an investigator-initiated clinical trial.

Introduction

Epilepsy is a common illness in children and adolescents. Although epilepsy is often considered a neurologic condition, psychiatric comorbidities are associated with epilepsy well beyond the prevalence in the general pediatric population. Of all psychiatric comorbid conditions, management dilemmas are perhaps most prominent in the association of attention deficit hyperactivity disorder (ADHD) and pediatric epilepsy. Children with epilepsy as many as 40% or more will also have ADHD. However, clinicians are often stymied in terms of treating these comorbidities because of long-standing fears of altering the seizure threshold with stimulants or other available medication treatments. Unfortunately, the evidence base guiding the use of stimulants in the context of epilepsy is underdeveloped, and, in many ways, insufficient to dispel long-standing conventional wisdom, discouraging the use of stimulants in persons with epilepsy. As a result, many clinicians undertreat ADHD in this population, leading to additional morbidity. This chapter will review pertinent details of this comorbidity and offer reasoned approaches to treating ADHD in the context of epilepsy. In doing so, clinicians may be better able to provide comprehensive care in this population and improve quality of life.

Attention Deficit Hyperactivity Disorder

ADHD is the most common pediatric psychiatric illness. It affects about 5%–6% of the pediatric population. Children with ADHD are first recognized because of multiple social impairments such as frequent conflicts with peers, poor frustration tolerance, and physically being unable to remain seated in a classroom setting. Academic impairments such as poor learning and low grades are common. These symptoms tend to be the most apparent in school-age children and appear twice as often in boys. However, the gender differences are less in older children and the prevalence may be equal in both genders by adulthood.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition , ADHD is diagnosed when the youth presents with symptoms of inattention and with/without hyperactivity and impulsivity, in two or more settings, causing significant problems in social, school, or work functions. The illness presents in multiple different permutations and combinations, but the interrater reliability of the diagnostic criteria for ADHD far surpasses the level obtained in diagnosing most other psychiatric illnesses. Specific diagnostic criteria are outlined in Box 5.1 .

BOX 5.1
DSM-5 Criteria for Attention Deficit Hyperactivity Disorder (ADHD)
From American Psychiatric Association, DSM-5 Task Force. Diagnostic and Statistical Manual of Mental Disorders: DSM-5 . 5th ed. Washington, D.C.: American Psychiatric Association; 2013. vol. xliv, 947 p., with permission.

People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development:

  • 1.

    Inattention: six or more symptoms of inattention for children up to age 16 years, or five or more symptoms for adolescents 17 years and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:

    • Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.

    • Often has trouble holding attention on tasks or play activities.

    • Often does not seem to listen when spoken to directly.

    • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).

    • Often has trouble organizing tasks and activities.

    • Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period (such as schoolwork or homework).

    • Often loses things necessary for tasks and activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

    • Is often easily distracted.

    • Is often forgetful in daily activities.

  • 2.

    Hyperactivity and impulsivity: six or more symptoms of hyperactivity-impulsivity for children up to age 16 years, or five or more symptoms for adolescents 17 years and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:

    • Often fidgets with or taps hands or feet, or squirms in seat.

    • Often leaves seat in situations when remaining seated is expected.

    • Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).

    • Often unable to play or take part in leisure activities quietly.

    • Is often “on the go” acting as if “driven by a motor.”

    • Often talks excessively.

    • Often blurts out an answer before a question has been completed.

    • Often has trouble waiting for his/her turn.

    • Often interrupts or intrudes on others (e.g., butts into conversations or games).

  • In addition, the following conditions must be met:

    • Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.

    • Several symptoms are present in two or more setting (e.g., at home, school or work; with friends or relatives; in other activities).

    • There is clear evidence that the symptoms interfere with or reduce the quality of social, school, or work functioning.

    • The symptoms do not happen only during schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).

  • Based on the types of symptoms, three kinds (presentations) of ADHD can occur:

    • Combined presentation : if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months.

    • Predominantly inattentive presentation : if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past 6 months.

    • Predominantly hyperactive-impulsive presentation : if enough symptoms of hyperactivity-impulsivity, but not inattention, were present for the past 6 months.

The diagnosis of ADHD requires the onset of at least six inattention symptoms and six hyperactive-impulsive symptoms by the age of 12 years. Inattention impairments include an inability to attend to detail, making careless mistakes in schoolwork, having trouble sustaining attention, not listening when spoken to directly, not following through on instructions, being disorganized, losing important things, getting easily distracted, and being forgetful. The hyperactive-impulsive impairments include fidgeting/tapping hands or feet, squirming or restless physical movement, running around class, routinely getting out of their seat, climbing furniture, and appearing to be always “on the go.” Children with ADHD may also talk excessively, have difficulty waiting for their turn, and interrupt or intrude on others’ conversations or activities. The core impairments in ADHD often lead to additional problems with executive functions such as working memory, self-regulation, internalization of speech, and processing of information. ADHD leads to impairments in areas other than only academics and behavior. High impulsivity, hyperactivity, and inattention also result in children needing repeated reminders to stay on task and to behave both at home and school. These children also frequently find it hard to establish friendships with their peer group because of inability to engage in the back and forth of conversation that children who can focus are able to do. Self-esteem is also affected because of these children struggling for social acceptance and academic success as compared with peers who can focus well and follow directions better, thus integrating into the mainstream of their peer groups.

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