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A study on behavioral disorders, academic difficulties, and parental handling patterns in children with epilepsy

1 Department of Psychiatry, BYL & Topiwala Nair Hospital, Mumbai Central, Mumbai, Maharashtra, India
2 Department of Psychiatry, Seth GSMC and KEM Hospital, Mumbai, Maharashtra, India
3 Department of Pediatrics, Seth GSMC and KEM Hospital, Mumbai, Maharashtra, India

Date of Submission18-Nov-2021
Date of Acceptance26-Dec-2021
Date of Web Publication12-Jul-2022

Correspondence Address:
Neena Sawant,
Department of Psychiatry, Seth GSMC and KEM Hospital, Parel, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpn.JPN_210_21



Background: Various psychiatric comorbidities have been reported in children with epilepsy (CWE), but Indian data on the same are lacking. Aim: This study was undertaken with the aim to find the prevalence and type of behavioral problems in CWE, academic difficulties, and parental handling patterns. Materials and Methods: Sixty-five patients of CWE and 65 controls were recruited after ethics approval and parent consent. All children were interviewed and diagnosed for psychopathology as per ICD-10 criteria, along with Strength and Difficulties Questionnaire. Parental handling questionnaire was used to assess the patterns of care or control among parents. Academic difficulties were assessed using open- and closed-ended questions. Results: Behavioral disorders were seen in 44.6% of CWE when compared with 12% of the control group. Hyperkinetic disorders were significant in CWE. Conduct and oppositional defiant disorders were not so prevalent. On Strength and Difficulties Questionnaire, a significant difference was seen on domains of hyperactivity and prosocial behavior in CWE when compared with controls, whereas emotional, conduct, peer problems, and total difficulty scores revealed no significant differences in both the groups. Academic difficulties were more in CWE, although absenteeism was not seen in both the groups. Parents of CWE had significant scores on care and control domains and were more overprotective and rigid in their behaviors when compared with the control group parents. Conclusion: Significant behavioral disorders are seen in CWE, which entails the need to have a multidisciplinary approach for early diagnosis and better control of symptoms. Parental awareness and appropriate parenting need to be emphasized for better prognosis in CWE.

Keywords: Academic difficulties, behavioral problems, children with epilepsy, parental handling patterns

How to cite this URL:
Singh R, Sawant N, Vaswani R. A study on behavioral disorders, academic difficulties, and parental handling patterns in children with epilepsy. J Pediatr Neurosci [Epub ahead of print] [cited 2023 Sep 25]. Available from: https://www.pediatricneurosciences.com/preprintarticle.asp?id=350284

   Introduction Top

Epilepsy is the most prevalent, chronic neurological disorder affecting children and their families with an estimated prevalence of 5.5 cases per 1000 children.[1] The prevalence of associated psychopathology in children with epilepsy (CWE) is 16–77%. Reasons for psychopathology are multifactorial arising from a complex interplay of multiple etiological variables.[2]

The neurological variables include frequent, severe seizures, early age of onset, symptomatic epilepsy, and polytherapy.[3],[4],[5] Various psychiatric comorbidities seen in CWE are depression, anxiety, attention deficit/hyperactivity disorder (ADHD), conduct disorders, oppositional defiant disorder (ODD), for enuresis,[6] sleep disturbances,[7] increased tantrums, tic disorders,[6] and somatic complaints. The increase in behavioral problems can be attributed to chemical and structural changes in the neurocircuit, parental overprotection, low self-esteem, social stigma, and others.

Epilepsy frequently begins in childhood, and children’s awareness of what is happening to them is largely a function of their parents’ explanations and behavior. Children may feel ashamed and apprehensive about their epilepsy; parental overprotection may lead to anger and resentment among children.

There are very few Indian studies which have looked at parental understanding and handling of a chronic illness such as epilepsy. It has been established that children with long-standing epilepsy have behavioral problems at rates almost 5 times higher than general population children and 2½ times higher than children with other chronic medical conditions.[8] In general, CWE display more attention problems and internalizing problems (withdrawal, somatic complaints, anxiety, and depression symptoms) than they do externalizing problems such as acting out and conduct problems.[9]

As there is a dearth of Indian studies in CWE, we undertook the present study to determine the prevalence and type of behavioral disorders in CWE, academic difficulties, and parental handling patterns on the family. We also studied the correlation of behavioral problems with the parental handling patterns in CWE.

   Materials and Methods Top

This was a cross-sectional observational study initiated after Institutional Ethics Committee permission and written informed consent of the parent and assent from the children having epilepsy (patient group) and those without epilepsy (control group) in the Outpatient Department of Pediatrics of a tertiary care hospital after satisfying the inclusion and exclusion criteria. Sample size was 65 in each group with inclusion criteria of children being diagnosed with epilepsy as per ILAE criteria, having epilepsy for more than 6 months for the patient group, and children without epilepsy but having minor ailments such as cough, cold, fever, etc. for the control group. Children in the age group of 5–12 years and those whose parents consented were included in the study. Children having epilepsy due to medical causes such as fever, metabolic changes, meningitis/encephalitis, cerebral palsy or those already diagnosed and/or under treatment for any psychiatric illness such as hyperactivity or behavioral disturbances, autism spectrum disorders, and intellectual disabilities were excluded from the study.

All parents were interviewed with a semi-structured proforma, which enquired about the socio-demographic details of the children, birth and developmental details, neurological details of epilepsy such as age of onset, its duration, type, frequency, etiology, medications, etc. Academic details of learning problems, grade retention, school attendance, irregularity, and dropouts were noted. All children were assessed clinically for the presence of behavioral problems, hyperactivity, and habit disorders as per the structured history-taking proforma, and the children were clinically diagnosed for psychopathology as per ICD-10 diagnostic guidelines and the following scales were applied.

Strength and Difficulties Questionnaire

Strength and Difficulties Questionnaire (SDQ) is a well-standardized behavioral screening questionnaire, designed to assess the behavior, emotions, and relationships in children aged 4–16 years. It is available in Indian languages and its parent’s version was administered. It yields scores on five domains, namely, emotional symptoms, conduct problems, inattention-hyperactivity, peer problems and prosocial behavior, and total impact and total difficulties score. A total difficulty score of 0–13 was normal, 14–16 was considered borderline, and 17–40 was taken as abnormal. The five impact scores were then summed to generate a total impact score ranging from 0 to 10. A score of 0 was taken as normal, 1 as borderline, and ≥2 as abnormal.[10],[11]

Parent Handling Questionnaire

Parent Handling Questionnaire (PHQ) is a 14-item questionnaire measuring two parental handling variables, viz., care consisting of 10 items (1–10) and control consisting of 4 items (11–14) with a 3-point Likert rating. Items are worded in a manner in which higher scores depict lower levels of care as well as control.[12]

   Results Top

The mean age of the CWE was 9.69 ± 2.35 years, whereas the mean age of controls was 9.26 ± 2.35 years with age ranging from 5 to 12 years. There was no significant difference between ages of cases and controls as both were matched. In our study population, CWE included 37 (57%) males and 28 (43%) females, whereas controls had 47 (72%) males and 18 (28%) females. Majority were Hindus with 81.54% (n = 53) in CWE, and 93.85% (n = 61) of the control group staying in nuclear families. The mean duration of epilepsy was 4.52 years with a standard deviation of 1.55. Abnormal EEG was seen in only 50.77% of the cases and magnetic resonance imaging also showed no structural abnormality and was normal in majority of the cases. It showed abnormality in only 24.62% (n = 16) of the cases. Majority of CWE were controlled on one drug (86%), whereas only six patients were refractory and had uncontrolled seizures.

As per ICD-10 criteria, we found behavioral disorders in around 44.62% (n = 29) of the CWE when compared with 12.31% (n = 8) of the normal controls, which was extremely significant. Hyperkinetic disorders were reported as the most common disorder in pre-schoolers and school-aged CWE. Around 34% (n = 22) of the CWE had disturbance of activity and attention, and 3% (n = 2) fulfilled all the criteria of hyperkinetic disorders as well as conduct disorder in CWE when compared with 1.54% (n = 1) of the control group. Around 7.69% (n = 5) were diagnosed with unsocialized conduct disorder [Table 1].
Table 1: Type of behavioral disorders as per the ICD-10 diagnosis

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When we compared both groups on various domains of SDQ with the domain total score, then a significant difference was seen on domains of hyperactivity and peer problems with CWE having a higher mean than normal controls. Prosocial behavior was extremely significant in the control group than CWE. On other domains such as emotional and conduct problems and total difficulty score, no significant differences were seen. Comparison of internalizing and externalizing problems in both the groups showed significant externalizing behaviors in CWE [Table 2].
Table 2: Comparison of SDQ domains in both the groups

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Approximately 41% (n = 27) of CWE had scholastic backwardness when compared with 24% (16) of the controls, with only 4.61% (n = 3) of CWE reporting frequent failures. No group satisfied criteria for absenteeism, and there was more than 75% attendance in school.

When PHQ items were compared, on care items 2, 4, and 5 and on control items 11 and 12, a statistically significant difference was seen between the two groups. The total care score, total control score, and the total PHQ scores were highly significant with CWE having higher mean scores when compared with the controls [Table 3].
Table 3: Comparison of parental handling pattern between the two groups

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   Correlation of Behavioral Problems (SDQ) and Parental Handling Pattern (PHQ) Top

When we studied for correlation between the behavioral problems as per SDQ and parental handling pattern as per PHQ, no statistically significant difference was seen on most of the domains, except for a negative association of conduct problems with low care. There was no association between the total SDQ score and the total PHQ score in our sample [Table 4].
Table 4: Correlation of SDQ with PHQ in children with epilepsy

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   Discussion Top

Nearly 45% of our sample of CWE had ICD-10 diagnosis of behavioral disorders. Similar findings have been found in several epidemiological studies with prevalence rates of psychopathology between 35% and 50% in CWE.[13] Studies have documented a lifelong psychiatric disorder diagnosis in 35% of the PWE[14] and between 20% and 50% in both adults and children.[15],[16],[17],[18] Austin et al.[19] reported that around 41.1% of CWE were at risk for both internalizing and externalizing behavioral problems.

Seizure variables related to behavioral problems include early age of onset, poor seizure control, long duration of epilepsy, high seizure frequency, and multiple seizure types. Poor child and family response to the condition, side effects of antiepileptic medications, and the underlying neurological dysfunction are also identified as causes for behavioral problems.

When CWE were assessed for the types of behavioral problems, we found a significant difference with CWE having more hyperkinetic disorders of activity and attention when compared with the controls. The symptoms most commonly reported among these children were frequently forgetting their things at school, breaking off from tasks, leaving activities unfinished, excessive restlessness, excessive talkativeness, frequent changes from one activity to another, and fidgeting. Thome-Souza et al.,[20] Dunn and Kronenberger,[21] and Besag et al.[22] found a prevalence of ADHD to be 30–40% in CWE, which is much higher than that in general population and goes with our findings. Jones et al.[23] reported that 26.4% of CWE without developmental and other neurological conditions had hyperactivity. Hermann and co-workers[24] reported that 31.5% of clinic-referred CWE had ADHD when compared with 6.4% in cousin controls of the CWE. In a population of children with “severe” epilepsy, Sherman et al.[25] reported a high prevalence with 70% of CWE meeting clinical cut-offs on the ADHD Rating Scale.

The possible causes of hyperkinetic disorders in CWE could be the underlying mechanism causing both conditions, co-occurrence of other psychiatric disorders, associated underlying brain dysfunction, frequent subclinical epileptiform discharges, postictal elevated mood, interictal manic psychosis, and adverse effects of antiepileptics.[13] Conduct disorder was less prevalent in both our groups contrary to those of other researchers.[26] The symptoms which were frequently reported by parents for conduct were lying, stealing, bullying, disobedience, and back answering. Cumulative effects of multiple risks (i.e., susceptibility genes for aggression and violence, heritable risk factors, parental psychopathology, low socio-economic status, adverse life events, poor parenting practices, history of abuse and neglect, poor executive cognitive functioning) can cause conduct problems in young children.

About 11% of the CWE (n = 7) fulfilled the criteria for ODD when compared with 6% (n = 4) of the controls. It was found that the symptoms of ODD were seen to exist as a comorbid condition in hyperkinetic disorders. Commonly reported symptoms in our patients were hostility, being defiant, negativistic, provocative, losing temper, and being disruptive. Prevalence of ODD between 10% and 17%[23] and 11%[12] in generalized seizures has been reported, which is in keeping with our findings. Behavioral problems could be due to the structural damage in the brain resulting in epilepsy, or sometimes the side effects of the antiepileptic medications or the environmental and genetic causes. Children may find it difficult to cope with the illness, and aggression could be a reaction to it.

We did not see significant differences in both the groups on all the domains of SDQ, as reported by some researchers.[27] CWE had significant hyperactivity and peer problems. In contrast, the controls had significant prosocial behaviors. Children who scored abnormally on emotional symptoms had headaches/stomach aches, were worrisome, often unhappy and disheartened, fearful, scared, and nervous in new situations. CWE were more short-tempered, disobedient, had lying, cheating, and stealing behaviors when compared with those without epilepsy. The emotional and conduct domains did not show any significant differences. Our findings were in keeping with Alfstad et al.,[28] who found significant difference on domains of hyperactivity, peer problems, and total impact score. We found significant externalizing behaviors on SDQ in CWE, which is similar to the findings of Mishra et al.[29]

Approximately 41% (n = 27) of CWE had been facing academic problems when compared with 16 (24.62%) children in the control group. Failures were comparatively less in our sample, and school absenteeism (child having less than 75% attendance at school) was not seen in both groups. Several researchers have reported an academic decline in CWE.[27],[30] More than 50% of the parents agreed that their child had to miss the school at some point of time because of epilepsy. The reasons given by parents were seizures just before or a day prior going to school, appointments with doctors, and going for various investigations. Studies have reported that 88% missed at least one school day due to various reasons attributable to epilepsy.[31] Modage et al.[27] in their study reported a significant irregular school attendance in epileptic children when compared with non-epileptics, and they also had a significant number of school drop-outs. We also had children who missed about 20–30 days in school in a year, but there was no long absenteeism more than 75% per semester. This does reflect that children were probably better controlled on medication.

Low care and control were the handling patterns of parents of CWE. They had higher means on care items no. 2, 4, and 5, which were statistically significant. Most of the parents of CWE agreed that they did not praise their child often or spend enough talk time with their child and often failed to make their child feel better when they are upset. On the contrary, parents of the control group were high on caring for their children, which also included being there for the child when their child needed help. They would also make the child feel happy whenever he/she was upset and would often fulfill their demands.

On control items 11 and 12, which were statistically significant, parents of CWE felt that their child could not take care of himself in their absence and that their spouse was more lenient/strict toward the child. They would often console or overprotect the child whenever he/she was reprimanded by the other parent. Some of them would get very angry on the child if he/she did not behave well. This depicts lower child–parent relationship quality, overparenting, and a rigid parental attitude toward the child. This further affects child’s adjustment with peers and environment, his/her behavior, and overall quality of life. Researchers have found that children who perceived their parents as overprotective or restrictive were more depressed and had more behavioral problems.[32] They became overdependent on their family, lacked confidence, were anxious, lacked social skills, and found it difficult to make friends.[33],[34],[35]

A correlation between behavioral problems and parental handling revealed a negative association with conduct problems and parents showing low care. Other behaviors like hyperactivity, emotional symptoms, peer problems, and prosocial behaviors were not associated with increased or decreased care or control in the parents. Studies have shown that scores in CWE depicted high care and high control which may be pathological and may contribute to cause of high externalizing behaviors such as conduct problems or delinquency in these children.[12]

   Conclusions Top

Our study highlights the prevalence of behavioral disorders in CWE and the need to create awareness among physicians, pediatricians, and parents about the same. Early referral and treatment of the comorbid psychiatric disorders would improve the coping, school-related difficulties, overall quality of life of CWE, and also the parental handling behaviors.

Limitations and future directions

There were certain limitations such as selection bias in recruiting cases for the study group as only patients seeking medical help at a tertiary care center were included. We did not consider the confounding factors of type of epilepsy and behavioral side effects of antiepileptics. A larger sample size with longer follow-up period would offer a better picture of the longitudinal outcome of behavioral problems after epilepsy is well controlled. Liaison with the pediatric and neurology departments to create awareness about the psychopathology in children is also essential.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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