Abstract
Ekinci O, Okuyaz Ç, Erdoğan S, Gunes S, Ekinci N, Kalınlı M, Teke H, Direk MÇ. J Child Neurol 2017;32(14):1083–1091.
PURPOSE: We aimed to (1) compare quality of life (QOL) among children with epilepsy, epilepsy and attention-deficit hyperactivity disorder (ADHD), and primary ADHD and (2) compare ADHD symptom dimensions and subtypes between children with epilepsy-ADHD and primary ADHD. METHODS: A total of 140 children; 53 with epilepsy, 35 with epilepsy-ADHD, and 52 with primary ADHD were included. KINDL-R (quality of life measure), Turgay DSM-IV Disruptive Behavior Disorders Rating Scale (T-DSM-IV-S), and Conners’ Parent Rating Scale (CPRS) were completed. Neurology clinic charts were reviewed for epilepsy-related variables. RESULTS: Children with epilepsy-ADHD had the lowest (poorest) KINDL-R total scores. Epilepsy-ADHD group had more inattentiveness symptoms, whereas primary ADHD group had more hyperactivity/impulsivity symptoms. The frequencies of ADHD combined and inattentiveness subtypes were 60% and 40% in children with epilepsy-ADHD and 80.7% and 19.3% in children with primary ADHD, respectively (P = .034). CONCLUSION: ADHD in epilepsy is associated with a significantly poor quality of life and predominantly inattentiveness symptoms.
Commentary
Maximizing quality of life is undeniably the ultimate goal for medical care. Even though clinicians are intrigued by elegant physiologic or pathologic processes, for patients, interventions matter only when they have a meaningful effect on quality of life. Attention deficit hyperactivity disorder (ADHD) has long been viewed as having a tremendous negative effect on quality of life. After all, being unable to adequately sustain attention not only has ripple effects in terms of function with school or work but also with social development and family interactions. Successful treatment of ADHD may make a marked difference in a child's performance in a variety of settings and improve quality of life as a result.
Quality of life has also long been an important outcome measure in epilepsy, and recent measures for pediatric quality of life are becoming better utilized in clinical practice. Adolescent self-reports and parent reports provide valuable information that can help validate treatment efforts even beyond disease-specific measures (1).
Ekinci and colleagues attempt to address quality of life in pediatric epilepsy and to ascertain the impact that an ADHD diagnosis may have. The effort is very straightforward in its method. The cross-sectional sample was from a tertiary care center in Turkey. Disciplined exclusions for intelligence quotient, comorbid conditions, and referral bias are well accomplished. and the comparison groups are well defined. Three groups are defined: epilepsy alone, ADHD alone, and ADHD with epilepsy. It is hard to know intuitively whether ADHD or epilepsy may have a more negative effect on quality of life, so in that sense, the study is important and is a valuable contribution.
Ultimately, the study showed that the additive effects of epilepsy and ADHD are worse for quality of life than either condition alone. This is not particularly surprising, the finding that quality of life was worse for ADHD alone than for epilepsy alone may be unexpected. Having ADHD appears to be more of a burden than having epilepsy.
Although more subjects in the combined epilepsy and ADHD group had predominantly inattentive symptoms than subjects in the ADHD only group, that difference did not change the overall results. While the precise differences surely would vary with a larger sample size and with additional epilepsy-specific characteristics taken into account, but the main point of this article is not about the quantitative aspects.
Those details are important to researchers and statisticians and may be of academic interest. Study designers and methodologists may discuss how best to measure ADHD and its subtypes and could consider medication effects and treatment outcomes, all of which are interesting. But what will be most meaningful is the simple fact that ADHD has devastating effects on quality of life in children with epilepsy. That fact cannot be ignored.
Ekinci and colleagues include some details in the discussion regarding treatment for ADHD. Conventional wisdom among practitioners is to avoid use of stimulant medicines in the context of epilepsy (2). However, the evidence base does not support this practice (3). Treatment responses for stimulant medicine for ADHD are among the most robust in all of pediatric psychiatry (4). The evidence base for ADHD treatment includes more than 200 controlled studies for stimulants (5, 6). The overlap with epilepsy cannot be denied, especially with the prevalence of ADHD approaching 40% in pediatric epilepsy (7).
Based on the existing literature, clinicians appear to spend a lot of energy discussing anticonvulsant treatment strategies for pediatric epilepsy and relatively little effort addressing treatment of ADHD that may also be present. Yet given its effect on quality of life, the treatment of ADHD may be at least as important as the treatment of seizures. In keeping with the prevalence noted earlier, perhaps 40% of the pediatric epilepsy literature should be devoted to ADHD co-occurrence. If quality of life were the primary goal of treatment, then the proportion of the research effort devoted to ADHD treatment would be more that it is today.
While some may fault Ekinci and colleagues for their small sample size or for the limited availability of corroborating diagnostic information for ADHD, the reality is that they have convincingly made one undeniable point: neurologists need to pay attention to ADHD. The preoccupation with seizure counts and thresholds and use of adjunct medicines are of course relevant to any comprehensive treatment strategy, but such myopic efforts may be a massive distraction to what matters the most: improving quality of life.