Psychotropic medication use in patients with epilepsy: effect on seizure frequency.

Physicians are often reluctant to use psychotropic medications in epilepsy patients with psychiatric disorders because of concern over the potential risk for lowering seizure threshold. This study assesses retrospectively the impact of psychotropic medications on seizure frequency in 57 patients seen consecutively at an epilepsy center. During psychotropic drug therapy, seizure frequency decreased in 33% of patients, was unchanged in 44%, and increased in 23%. Mean seizure frequency was not statistically different between pre-treatment and treatment periods (t = 0.23, df = 56). Simultaneous adjustments in antiepileptic drug regimen could not account for the findings. Results support the position that psychotropic medications, introduced slowly in low to moderate doses, can be safely used in epilepsy patients with comorbid psychiatric pathology during the regular course of clinical care.

Brief report: Adolescents' attitudes toward epilepsy: further validation of the Child Attitude Toward Illness Scale (CATIS).

OBJECTIVE: To examine adolescents' attitudes toward having epilepsy using the Child Attitude Toward Illness Scale (CATIS) and to provide further psychometric validation of the scale in this population. METHODS: Participants were 197 adolescents aged 11 to 17 years who completed the CATIS at two points and two external validation scales. Test-retest and internal consistency reliability and construct validity were computed. Analysis of variance was used to examine differences in attitudes according to gender, age, and epilepsy severity. RESULTS: Girls, older adolescents, and those with more severe epilepsy had more negative attitudes toward having epilepsy than boys, younger adolescents, and those with moderate or mild epilepsy, respectively. Psychometric analyses yielded excellent internal consistency reliability and good test-retest reliability. The CATIS was moderately correlated with self-esteem and mastery, supporting its construct validity. CONCLUSIONS: The CATIS is a useful and psychometrically sound tool to assess adolescents' attitudes toward having chronic illness.

Development of the Quality of Life in Epilepsy Inventory for Adolescents: the QOLIE-AD-48.

PURPOSE: We report the development of an instrument to assess health-related quality of life (HRQOL) in adolescents with epilepsy. METHODS: A sample of 197 English-speaking adolescents (aged 11-17 years) with epilepsy completed a test questionnaire of 88 items. Also included were mastery and self-esteem scales to assess external validity. A parent simultaneously completed an 11-item questionnaire to evaluate the child's HRQOL. Both adolescent and parent questionnaires were repeated in 2-4 weeks. Demographic information and information pertaining to seizures were collected at baseline along with assessment of systemic and neurologic toxicity. RESULTS: The QOLIE-AD-48 contains 48 items in eight subscales: epilepsy impact (12 items), memory/concentration (10), attitudes toward epilepsy (four), physical functioning (five), stigma (six), social support (four), school behavior (four), health perceptions (three), and a total summary score, with higher scores indicating better HRQOL. Internal construct validity was demonstrated in a single-factor solution for the eight dimensions. All correlations were statistically significant at p < 0.05 level. Internal consistency reliability estimated by Cronbach's alpha coefficient was 0.74 for the summary score and ranged from a low of 0.52 (three-item Health Perceptions Scale) to 0.73-0.94 for the other individual scales. Good test-retest reliability was found for the overall measure (0.83). Summary score correlations with the two external validity scales, self-efficacy and self-esteem were 0.65 and 0.54, respectively. Statistically significant differences in summary scores indicating that HRQOL was increasingly better for adolescents as seizure severity decreases (no seizures = 77+/-13, low = 70+/-17, high = 63+/-17) were found among seizure-severity groups. CONCLUSIONS: These data describe the development of a robust instrument to evaluate HRQOL in adolescents with epilepsy. Empiric analyses provide strong evidence that the QOLIE-AD-48 is both a reliable and valid measure for adolescents with epilepsy.

Depressive symptoms in inner-city mothers of young children: who is at risk?

OBJECTIVE: To identify factors associated with depressive symptoms in inner-city mothers of young children. DESIGN: A cross-sectional survey was administered to a convenience sample of English-speaking mothers attending a well-child visit for a child aged 6 months to 3 years in a hospital-based, inner-city, general pediatric clinic. The maternal interview collected data on sociodemographic characteristics, and mothers' health and financial status. Mothers completed the Psychiatric Symptom Index (PSI), a 29-item checklist shown to have very good validity and reliability in a multicultural population. A total score of >/=20 represents high levels of symptoms; scores >/=30 strongly suggest major depression. RESULTS: Two hundred seventy-nine mothers completed the PSI. Mothers ranged in age from 14 to 48 years (mean, 27 years). Seventy-one percent were unmarried; 57% received public assistance. Forty-two percent of mothers were Hispanic, 40% black, 9% white, and 10% mixed or other races. Forty-eight percent were foreign-born. Twenty-four percent reported having a medical condition; 6% had activity limitation because of illness. The mean PSI score was 19; 18% of mothers had a PSI score >/=30 and 39% scored >/=20. PSI scores did not vary by age, race, birthplace, educational level, employment, marital status, or family composition. PSI scores were higher for mothers receiving public assistance (21 vs 17), with self-reports of poor or fair financial status (22 vs 15) and poor health status (52 vs 17). Mothers with activity limitations because of illness had significantly higher PSI scores (34 vs 18). Multiple regression analyses confirmed the independent relationships of these maternal characteristics to high PSI scores. CONCLUSIONS: Depressive symptoms in inner-city mothers of young children are common. In this population of women with many risk factors, traditional sociodemographic risk factors did not successfully identify those who are depressed. However, mothers' self-reports of poor financial status, health status, or activity limitation because of illness were associated with higher levels of depressive symptoms. These findings may assist clinicians in distinguishing which mothers are likely to be depressed when almost all are at high risk.

Nonepileptic seizures after head injury.

PURPOSE: To examine the role of head injury as a risk factor in the development of nonepileptic seizures (NES). Specifically, we will determine the relative frequency of head injury among NES patients referred to our center and will describe several pertinent clinical features and personal characteristics. METHODS: Retrospective record review of patients referred to our center for evaluation of seizures over a 4-year period. All patients with NES were evaluated as in a previously described protocol, which included intensive video EEG monitoring, provocation by suggestion, and psychiatric interview. All NES patients with a history of head injury were extracted for this report. RESULTS: Of 102 patients with NES, nearly one-third (32%) had an antecedent head injury; 52% were male, mean age was 34 years, and 12% had coexisting epilepsy. Multiple psychiatric disorders were not uncommon (79%), and a history of abuse was found in 35%. All but four patients had documented financial gain from their injury. Follow-up at 1 year found poor long-term outcome with lasting disability; despite that, the majority (91%) of head injuries were minor. CONCLUSIONS: Our preliminary findings suggest that prior head injury is associated with the development of NES and may contribute to the pathogenesis of NES in vulnerable patients. Head injury and sexual or physical abuse appear to occur in comparable proportions in patients with NES. This suggests that head injury and abuse may be equally important risk factors in the development of NES.

Comparison of adjustment of school-age children with and without chronic conditions: results from community-based samples.

We assessed whether children in the 1990s who were identified as having chronic conditions by using a new noncategorical technique (the Questionnaire for Identifying Children with Chronic Conditions) were as well adjusted as children without chronic conditions, and whether selection factors or sociodemographic variables accounted for any observed differences. Random-digit-dial telephone surveys were conducted using two separate samples: one consisting of 1275 children in 654 inner-city households and the other of 1388 children in a national sample of 712 households. Children with chronic conditions had poorer parent-reported functioning on the Personal Adjustment and Role Skills Scale total score and three of its six subscales (Hostility, Dependency, and Productivity). Differences in two other subscales (Withdrawal and Anxiety/Depression) were significant only for the inner-city sample. The results were consistent when controlling for other potentially confounding factors. These findings demonstrate that mental health risks continue to occur among contemporary community-based samples of children with chronic health conditions who are identified by using noncategorical techniques. These risks have implications for the care of those children.

Implications for estimates of disability in children: a comparison of definitional components.

OBJECTIVE: To test how prevalence estimates and characteristics of children vary by the way that disability is defined. Specifically, to determine 1) the proportions of children identified as disabled by one particular operationalization of disability based on parental reports of three types of consequences (i.e., functional limitations [FL]), dependence on compensatory mechanisms (CD), and service use or need beyond routine [SU/N]), and 2) whether children identified as disabled by these three types of consequences differ by type of disorder or condition, age, socioeconomic status, or race. METHOD: We analyzed a national dataset representing a random sample of 712 households with 1388 children. The Questionnaire for Identifying Children with Chronic Conditions (QuICCC) was used to identify children with disabling conditions. We divided the QuICCC items into three discrete sets, reflecting three definitional components of disability, and compared the proportions and characteristics of children fitting these components separately and in combination. RESULTS: Using the QuICCC definition of disability, SU/N identified the largest proportion of children (72%), followed by CD (55%) and FLs (49%). Forty-four percent of children were identified by only one component, 36% by two components in any combination, and 20% by all three components. The type of disorder or condition generally did not vary by the three definitional components, although the FL component may be more effective at identifying children with sensory impairments. Children identified by two or more components were more likely to have multiple conditions and had more pervasive disorders than those identified by only one component. The youngest children (0 to 3 years old) may be less likely to be identified as disabled than children of other ages, especially by FLs. FLs also were more likely to identify children from the poorest and least educated families. CONCLUSIONS: Although the specific findings reported here pertain to a single definitional approach (the QuICCC), the data highlight that who will be classified as disabled (and who will not) may be dependent on how disability is defined. The implications of using different definitions and definitional components on both the prevalence and the characteristics of children with disabilities need to be considered before data can be applied responsibly and appropriately.

Relationship of parental psychological distress to consequences of chronic health conditions in children.

OBJECTIVE: To assess whether parents' self-reported psychological distress was related to consequences of chronic health conditions in their children as reflected by three domains: functional limitations, reliance on compensatory mechanisms, and service use above routine care. METHODS: We used telephone survey data on children's health and parents' psychiatric symptoms from an inner-city community sample (n = 380) and a population-based national sample (n =398). RESULTS: In the national sample, parents of children with functional limitations were more distressed than parents whose children experienced other types of condition consequences or none. In the inner-city sample, presence of a health condition was associated with greater parental distress, but there were no significant effects by consequence type. CONCLUSION: Research needs to determine if parents of children with functional limitations represent a high-risk group and to identify the factors associated with their elevated distress.

The Questionnaire for Identifying Children with Chronic Conditions: a measure based on a noncategorical approach.

OBJECTIVE: To report on the development of the Questionnaire for Identifying Children with Chronic Conditions (QuICCC). This new instrument identifies children and adolescents who have chronic health conditions based on the noncategorical conceptual framework outlined in our earlier work. It uses the consequences of conditions as a method for identifying children with chronic health conditions and is completely independent of diagnosis. METHOD: Through a combination of techniques, we developed and piloted items and created 39 brief question sequences that were designed to be administered to a parent or guardian of children < 18 years of age. The prototype was field tested extensively and refined using data from local hospital-based samples representing 318 households and 666 children. The instrument was then administered to two large representative samples (local: 657 households, 1275 children; national: 712 households, 1388 children) to establish validity and reliability. RESULTS: Content, convergent, construct, and criterion validity each have been demonstrated. The QuICCC has good test-retest reliability. Parents find the questions easy to answer. It took 7 to 8 minutes on average to obtain information about all the children in a family. The QuICCC successfully identified children with a wide range of different conditions that are usually considered chronic, and excluded those with acute illnesses and those with conditions but no current consequences. CONCLUSIONS: The Questionnaire for Identifying Children with Chronic Conditions is a practical instrument that can be used for epidemiological purposes. It offers considerable flexibility and has many potential applications in health care delivery research.

Framework for identifying children who have chronic conditions: the case for a new definition.

Efforts to identify children with ongoing health conditions generally rely on lists of diagnoses. However, there has been a growing trend to use a noncategorical, or generic, approach in which such children are identified by the consequences of their condition. Recent legislation and the Supreme Court decision in Sullivan v Zebley adopt this broader concept and mandate that a noncategorical approach be used in determining eligibility for services and benefits. Traditional condition lists are less desirable because (1) every disorder to which children are subject cannot be included, (2) diagnoses may be applied inconsistently by clinicians and across settings, (3) condition labels alone do not convey the extent of morbidity for individuals, (4) there is a bias toward identifying only those children who have access to the medical care system, and (5) there is often a gap between emergence of symptoms or consequences and diagnosis. We developed a noncategorical framework for identifying children with ongoing health conditions that responds to the federal mandate and uses consequences of disorders, rather than diagnostic labels. It can be applied to meet the objectives of services, research, policy, reimbursement, or program eligibility; is consistent across diagnoses; is descriptive of the impact of morbidity; is adaptable to meet specific purposes; and can be modified by imposing different severity levels. Our screening tool will soon be available for practical use.

Applying stigma theory to epilepsy: a test of a conceptual model.

Tested a theoretical model that sought to explain the association of stigma to self-esteem among adolescents with epilepsy. The model depicted hypothesized relationships among several characteristics of epilepsy (seizure type, seizure frequency, and duration of epilepsy), perceived stigma, management of disclosure, and self-esteem. Subjects were 64 adolescents 12 to 20 years old with idiopathic epilepsy. In a hierarchical multiple regression analysis, variables were entered into the equation in the order specified a priori by the model. Results showed that the data supported some hypotheses tested in the model: (a) Seizure type and seizure frequency predicted low self-esteem, and (b) the belief that epilepsy is stigmatizing predicted low self-esteem. However, several relationships of major theoretical significance were not realized. Explanations for why some aspects of stigma theory were not supported by the data are offered.

Properties of visual inputs that initiate horizontal smooth pursuit eye movements in monkeys.

Smooth pursuit eye movements allow primates to fixate and track small, slowly moving objects. Pursuit usually requires visual targets; our aim was to determine the properties of the visual signals transmitted to the pursuit motor system. Rhesus monkeys were rewarded for tracking spots of light that underwent discreet changes in velocity under a variety of visual conditions. We measured the resulting smooth eye acceleration in a 100-msec interval that began with the initiation of pursuit and ended before there had been time for visual feedback. This approach allowed us to vary the parameters of visual stimulation and measure eye movement responses in a way that provides estimates of the properties of signals transmitted by visual pathways. The initiation of pursuit showed different properties early and late in the interval we studied. In the first 20 msec of pursuit, eye acceleration was in the correct direction, but was independent of the initial position of the moving images, the velocity of the stimulus, or the presence or absence of background illumination. Thereafter, the initiation of pursuit depended strongly on all of the above parameters. Eye acceleration was highest when the moving images fell close to the fovea and decreased sharply as eccentricity was increased up to 21 degrees. When the background was diffusely illuminated, eye acceleration showed velocity selectivity; it was highest for a middle range of velocities (30 to 60 degrees/sec) and decreased for higher velocities. When the background was dark, eye acceleration increased as a function of target velocity up to 150 degrees/sec. We conclude that the initiation of pursuit has at least 2 visual components. The two components have different latencies and show quite different relationships to the visual properties of the stimulus, suggesting two cell populations that could provide the visual inputs for pursuit.