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Keywords:

  • First seizures;
  • Children;
  • Self-esteem;
  • Symp-toms of depression;
  • Family environment;
  • Parenting

Summary

  1. Top of page
  2. Summary
  3. Purpose and Hypotheses
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. References
  10. Supporting Information

Purpose: To test over time the relationships of neuropsychological functioning to mental health in children following a first recognized seizure and, of primary importance, to determine if the strength of these relationships differs based on risk and protective factors.

Methods: In a larger prospective study, 135 children with a first seizure (ages 8–14 years) and 73 healthy sibling controls completed neuropsychological testing at baseline and 36 months. Structured telephone interviews were used to obtain data from children on mental health and family environment; major caregiving parents provided data on demographic and family variables. Data analyses included correlation coefficients and linear regression models.

Results: Children with seizures showed an overall trend for improvement in mental health. More children with seizures than siblings had declines in processing speed. Declines in neuropsychological functioning were correlated with worse mental health. With regard to risk and protective factors, higher parent education protected against decline in self-esteem related to decline in processing speed. Better family functioning and greater parental support protected against decline in self-esteem related to decrease in verbal memory and learning. Older child age protected against increase in depressive symptoms related to decline in processing speed.

Discussion: Seizure onset had a negative impact on mental health in children with declines in cognitive functioning except for older children and those with more family resources. Children should be assessed for declines in processing speed and, if found, those subgroups of children with less educated or more anxious parents and those in less supportive families should be targeted for interventions.

Children with chronic epilepsy have poorer self-concept and more symptoms of depression than children with other chronic illnesses such as asthma (Austin, 1996; Zashikhina & Hagglof, 2007; Chiou & Hsieh, 2008) or diabetes (Hoare & Mann, 1994). Low self-esteem is linked to poorer psychosocial adjustment and lower life fulfillment (Collings, 1990, 1995). Symptoms of depression are also common in chronic epilepsy, with children and adolescents having an estimated prevalence of 23–26% (Ettinger et al., 1998; Dunn & Austin, 1999) and adults having prevalence rates up to 80%; in adults, rates are consistently four to five times higher than for the general population (Miller et al., 2008).

Low cognitive functioning has been associated with more mental health problems in the general population (Nigg et al., 1999) as well as in children with chronic epilepsy (Hermann, 1982; Papero et al., 1992; Schoenfeld et al., 1999; Buelow et al., 2003; Caplan et al., 2004). One rationale for this association is that children with cognitive deficits have difficulty at school, which contributes to a more negative self-image (Wolman & Basco, 1994). Prior studies have been limited by using broad indices of cognitive functioning (e.g., IQ), which are less sensitive to brain dysfunction than are specific neuropsychological tests (Dodrill, 2004). Other limitations include small samples and cross-sectional designs (Hermann, 1982; Papero et al., 1992; Schoenfeld et al., 1999; Buelow et al., 2003; Caplan et al., 2004). Although prior studies explored the association between cognitive functioning and mental health problems in children with chronic seizures using only a cross-sectional design, it is important to explore this relationship longitudinally in children with new-onset seizures because both cognitive deficits (Oostrom et al., 2003b; Hermann et al., 2006; Fastenau et al., 2009) and mental health problems (Austin et al., 2001) have recently been found in these children. Our first goal was to explore the relationships of neuropsychological functioning with self-esteem and symptoms of depression and to determine if changes in neuropsychological functioning over time were associated with changes in self-esteem and depression in children with new-onset seizures. We hypothesized that declines in neuropsychological functioning would be associated with worsening self-esteem and symptoms of depression.

Our second goal was to explore if selected risk and protective factors would moderate (strengthen or weaken) the association between cognitive functioning and mental health. We explored family factors because studies show that children with either chronic or new-onset epilepsy who live in more positive family environments (i.e., high family mastery) have fewer mental health problems and those whose parents have more negative responses related to the epilepsy (e.g., high anxiety) have more mental health problems (Austin et al., 2004; Oostrom et al., 2005; Rodenburg et al., 2005; Austin & Caplan, 2007). Therefore, we hypothesized that factors in the child’s environment could serve as either risk or protective factors and moderate (change) the strength of the association between cognitive functioning and mental health functioning (see Fig. 1). Specifically, we proposed that the association would be weaker when the environment had high levels of protective factors (e.g., positive family environment) and stronger when the environment had high levels of risk factors (e.g., high parent anxiety, hostility, and depression). Understanding risk and protective factors will provide a foundation for developing family interventions to help reduce or prevent mental health problems in children with seizures and neuropsychological deficits.

image

Figure 1.   Theoretical model depicting demographic and family variables as moderating associations between changes in neuropsychological functioning and changes in mental health.

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Purpose and Hypotheses

  1. Top of page
  2. Summary
  3. Purpose and Hypotheses
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. References
  10. Supporting Information

As part of a larger, 36-month longitudinal study of children with a first-recognized seizure (FRS), we explored: (1) changes in neuropsychological functioning relative to a sibling sample; (2) associations (cross-sectional and change over time) between neuropsychological functioning and self-esteem and symptoms of depression, respectively; and (3) if the strength of the associations of neuropsychological functioning to self-esteem and symptoms of depression differed for subgroups with differing levels of risk and protective factors. We hypothesized that protective factors would be high caregiver education, high family mastery, high family functioning, and supportive parenting responses. Conversely, we hypothesized that negative parent affect (high anxiety, high hostility, and high depression) would be risk factors. Finally, we explored child age at onset as either a risk factor or protective factor.

Method

  1. Top of page
  2. Summary
  3. Purpose and Hypotheses
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. References
  10. Supporting Information

Participants

As part of a larger study, children 6 through 14 years of age who had had a FRS within the preceding 3 months were recruited at two academic medical centers in Indianapolis and Cincinnati. In Indiana, children were also recruited through private practices and fliers to school nurses. Exclusion criteria for the larger study were a provoked seizure (e.g., infection, trauma), a chronic health condition or impairment that limited activities of daily living, or an estimated IQ <55. Institutional review boards approved the study. Parents gave written consent and children assent. The sample for the current study was restricted to children who were 8 years old or older at baseline and who had complete data for both baseline and 36 months. This was the youngest age at which self-report data on mental health were obtained in the larger study because self-report measures are considered to be reliable at this age. Of the 349 children in the larger study, 109 were younger than 8 years, 95 were missing neuropsychological testing data, and 10 were missing self-esteem or depression data. The final sample of 135 did not differ according to race, sex, or caregiver education (p > 0.05) from those in the same age range without complete data. The mean age for those with complete data was higher (mean 10.8) than for those without (mean 10.0, p = 0.0037).

Data source and collection procedures

Data were collected using computer-assisted telephone interviewing (CATI), a commonly used data collection method for telephone interviewing (Morency, 2008). The CATI method utilizes computer software so instrument items appear on the interviewer’s computer screen. The interviewer reads the items to the respondents and enters their responses into the computer. Our research team has extensive experience with this method, and data collected has been found to be reliable and valid in past studies. Major caregiving parents provided data on demographic, seizure, family, and parenting variables and children provided data on mental health and family variables. Data from medical records and parent report of seizures were collected at every data-collection point. Seizure type and epileptic syndrome were classified by board-certified child neurologists (authors TJdG and DWD) using International League Against Epilepsy (ILEA) criteria (CCT-ILAE, 1981, 1989) and all available data at 36 months.

Measurement

Demographic variables

Child age was calculated at the date of first recognized seizure. Caregiver education was measured using the highest number of years of school completed (beginning with grade 1) by the major caregiving parent.

Neuropsychological functioning

Children were individually tested using a battery of well-standardized neuropsychological tests within 6 months [mean 2.7, standard deviation (SD) 2.0] of their FRS (baseline) and 36 months after FRS (mean 38.0, SD 2.7). Test scores were converted to age-corrected standardized scores. Factor analysis of the test battery yielded four factors: Language, Processing Speed, Executive/Attention/Construction, and Verbal Memory and Learning (see Table S1). See Byars et al. (2007) for a report on the factor analysis of the neuropsychological testing battery.

Child mental health

Self-esteem.  Self-esteem was measured using a 14-item scale taken from the Child Health Questionnaire CHQ-CF-87 (Landgraf et al., 1996), which captures the child’s satisfaction with multiple aspects of the self (e.g., school, athletic ability, friendships, appearance). Children respond to items on 5-point scales as to how good or bad they feel about each aspect during the past 4 weeks, from (very good) to (very badly). A total score is calculated with a possible range of 0–100 and lower scores indicating poorer self-esteem. Internal consistency reliabilities were .91 and .89 for baseline and 36 months, respectively.

Symptoms of depression.  Symptoms of depression were measured using the Child Depression Inventory (CDI) (Kovacs, 1985), a 27-item self-report instrument. Children respond to items on 3-point scales, with higher scores reflecting more symptoms of depression. Scores are summed for a total score, which was used in analyses. A total score greater than 12 suggests risk of clinical depression. The scale has shown good psychometric properties in children with epilepsy (Dunn et al., 1999). Internal consistency reliabilities were 0.88 and 0.81 at baseline and 36 months, respectively.

Family variables

We investigated family environment, parenting response, and parent affect at 36 months because we wanted a measurement of parental perceptions and family environment occurring after the initial response to seizures when the family had had time to adjust to having a child with seizures. We selected the 36-month data collection because we believed that parent perceptions related to seizures and the family environment would be stable at that time. Total or mean scores at 36 months were used in analyses. Internal consistency reliabilities for 36 months for all family variables appear in Table S2.

Family environment.  Family mastery and family functioning were measured. Mastery, which reflects how well the family unit is working together to solve problems and to support each other, was measured using a subscale of the Family Inventory Resources for Management (McCubbin & Thompson, 1991). On this scale parents respond to items on 4-point scales ranging from 0 (not at all) to 3 (very well), with a higher score reflecting greater mastery.

To measure family functioning, the Family APGAR (Smilkstein, 1978) was completed by parents and the Revised Family APGAR (Austin & Huberty, 1989) was completed by children. Both scales have five items that measure family members’ satisfaction with characteristics of the family: adaptation, partnership, growth, affection, and resolve. Respondents select how often they are satisfied with aspects of the family on 5-point scales of 1 (never) to 5 (always).

Parenting response.  Parent responses to their child’s seizures were measured using subscales (Child Support, Family Life/Leisure, Child Autonomy, and Child Discipline) on the Parent Response to Child Illness scale (Austin et al., 2008). These subscales reflect parent–child interactions and family leisure activities in the context of seizures. Parents rate level of agreement to items on 5-point scales of 1 (strongly disagree) to 5 (strongly agree).

Parent affect.  Parental affect was measured with the brief version of the Multiple Affect Adjective Checklist (MAACL) (Zuckerman & Lubin, 1965). Using a Yes/No answer format, parents responded as to whether they had experienced each of 46 emotions within the previous 2 weeks. Lower scores reflect lower levels of each emotion. The MAACL has three subscales: anxiety, depression, and hostility.

Statistical methods

Change in neuropsychological functioning compared to siblings

For each neuropsychological factor score, the percentage of children and siblings who had mean changes from baseline to 36 months that were ±1 SD (based on the sibling data) or more than the mean sibling change was calculated. Generalized linear mixed models that adjusted for the correlation between child and sibling were used to test whether the percentages of children who decreased or increased by ≥1 SD were different from the siblings.

Relationship between neuropsychological functioning and mental health

Correlations were calculated to investigate cross-sectional associations at baseline and at 36 months. In addition, correlations were calculated to measure associations of changes in neuropsychological variables from baseline to 36 months to changes in self-esteem and depression scores from baseline to 36 months.

Tests of moderating effects of risk and protective factors

Variable A is said to moderate the relationship between a risk factor B and an outcome C if A is uncorrelated with B, A precedes B, and the strength of the relationship between B and C depends on the level of A. If high levels of A strengthen the detrimental effect of B on C, then A is a moderating risk factor. If high levels of A weaken the detrimental effect of B on C, then A is a moderating protective factor. Linear regression models were used to investigate the moderating effects of each demographic or family variable on the relationships between change in each of the four neuropsychological functioning measures and the two child outcomes of change in self-esteem and depressive symptom scores from baseline to 36 months (changes calculated as 36-month scores – baseline scores), adjusting for baseline outcomes. Changes from baseline to 36-month neuropsychological score and demographic or family variable were included as explanatory variables, with the interaction term between change in neuropsychological score and demographic or family variable included to investigate its risk or protective effect. Demographic variables (child age and caregiver education), family environment (mastery and functioning), parent response (child autonomy, family life/leisure, child support, and child discipline), and parent affect (anxiety, depression, and hostility) were tested as moderating risk factors or protective factors. All variables were standardized prior to modeling as recommended by Fraizer et al., 2004. In addition, changes in neuropsychological factors were not strongly correlated with any of the risk or protective factors being tested (magnitudes of all correlations were 0.35 or lower).

The Hochberg step-up Bonferroni adjustment for multiple comparisons was used to adjust for multiple tests performed within each mental health outcome and risk/protective factor variable combination (four tests—one for each neuropsychological variable—within each combination). If there was a significant interaction effect, we tested the standardized betas (which can be thought of as adjusted correlation coefficients) for significance at three levels of the moderator: the 10th (low), 50th (middle), and 90th (high) percentiles, again using the Hochberg step-up Bonferroni adjustment to account for multiple testing.

Results

  1. Top of page
  2. Summary
  3. Purpose and Hypotheses
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. References
  10. Supporting Information

Sample description

The mean age of the children was 11 years at baseline and 14 years at 36 months. The mean estimated IQ, which was measured by the Kaufman Brief Intelligence Test (K-BIT, Kaufman & Kaufman, 1990), was in the average range. Years of caregiver education ranged from 9–20, with a mean of 13.9 (SD 2.3) years. More than 90% had one seizure type, approximately 50% had idiopathic epileptic syndromes, and only 10% had symptomatic epileptic syndromes (Table 1). During the 36 months, 32 (24%) had no further seizures, 103 (76%) had at least one recurrent seizure, and 11 (8%) reported seizures at every data collection. Most of the children (n = 104, 77%) were treated with an antiepileptic drug (AED) for some period during the 36 months. At 36 months 56% were receiving an AED and of these, 96% were on monotherapy.

Table 1.   Sample characteristics
 N = 135
  1. SD, standard deviation.

Age at testing in years [mean (SD)]11.0 (2.0)
IQ [mean (SD)]103.3 (16.0)
Sex (% Female)51.1
Race (% Caucasian/non-Hispanic)86.7
Age at first recognized seizure in years [mean (SD)]10.8 (2.0)
Multiple seizure types (%)9.6
Primary seizure type (%)
 Generalized nonabsence31.1
 Generalized absence13.3
 Simple partial6.7
 Complex partial12.6
 Partial with secondary generalization35.6
 Undetermined0.7
Primary epileptic syndrome (%)
 Generalized idiopathic absence11.9
 Generalized idiopathic tonic–clonic22.2
 Generalized symptomatic/cryptogenic2.2
 Localization-related idiopathic17.0
 Localization-related cryptogenic33.3
 Localization-related symptomatic7.4
 Undetermined6.0
Recurrent seizure during 36 months (% Yes)76
Treatment with medication during 36 months (% Yes)77

Improved mental health was found for the entire sample over the 3 years. Although not statistically significant, mean scores on self-esteem increased from 84.4 (SD 15.5) at baseline to 86.7 (SD 12.5) at 36 months. The reduction in depressive symptoms from 7.7 (SD 7.1) to 5.5 (SD 5.0) was statistically significant (p = 0.0005). At baseline, 27 of 135 children (20.0%) and at 36 months, 20 of 135 (14.8%) scored at or above a clinical cut-off of 12 on the CDI (Kovacs, 1992). At 36 months, mean scores for family environment were in the neutral range (Table S2). Parent response scores ranged from neutral to moderately high. Parent affect scores for anxiety, depression, and hostility were low.

Change in neuropsychological functioning

For neuropsychological change, children with seizures were compared to their siblings rather than using national norms alone because siblings were retested at the same time points as the children with seizures, thereby controlling for practice effects in a precise manner that is not captured in national normative studies (in which retest intervals are typically 2–4 weeks and are typically based on only a small subsample that is too small to allow for age corrections). In addition, siblings control for family, home, and school-system variables that cannot be controlled using national norms. Compared to their siblings, children with seizures showed more decline in processing speed between baseline and 36 months; 23% of children declined at least 1 SD compared to only 8% of the siblings (p = 0.01). See Table 2. There were no other significant differences between children and siblings. Although compared to their siblings neuropsychological functioning varied <1 SD for the many of the children with seizures, it is important to note that 58 (42.9%) of children with seizures had a decline of ≥1 SD in at least one area of cognitive functioning.

Table 2.   Changes in neuropsychological functioning from baseline to 36 months for 135 children and 73 siblings relative to the mean sibling change and SD of change
 Decrease ≥1 SDChange <1 SDIncrease ≥1 SD
ChildSiblingChildSiblingChildSibling
  1. SD, standard deviation.

  2. aChild percent significantly different from sibling percent (p < 0.01).

Language16 (12%)14 (19%)105 (78%)48 (66%)14 (10%)11 (15%)
Processing speed31 (23%)a6 (8%)94 (70%)64 (88%)10 (7%)3 (4%)
Executive/attention/construction10 (7%)2 (3%)94 (70%)51 (70%)31 (23%)20 (27%)
Verbal memory & learning15 (11%)8 (11%)100 (74%)54 (74%)20 (15%)11 (15%)

Relationships between neuropsychological functioning and mental health

The magnitudes of the correlations of neuropsychological factors with self-esteem and symptoms of depression for the entire sample were low but most were statistically significant at baseline (r = 0.13 to 0.20 for self-esteem and r = −0.16 to −0.26 for depression) and 36 months (r = 0.14 to 20 for self-esteem and r = −0.24 to −0.28 for depression). Correlations between changes in neuropsychological factors and changes in self-esteem and symptoms of depression showed a similar profile (see Table 3). Positive correlations with self-esteem indicate that improvements in neuropsychological functioning were associated with improvements in self-esteem. Negative correlations with symptoms of depression indicate that improvements in neuropsychological functioning were associated with reduction in symptoms of depression.

Table 3.   Correlations between changes in neuropsychological functioning and changes in child self-esteem and symptoms of depression from baseline to 36 months
Change in neuropsychological factorsChange in self-esteemChange in symptoms of depression
  1. *p < 0.10; **p < 0.05; ***p < 0.01.

Language0.22***−0.19**
Processing speed0.15*−0.12
Attention/executive/construction0.22***−0.22**
Verbal memory and learning0.22***−0.19**

Tests of moderating effects of risk and protective factors on self-esteem

A major goal was to test selected demographic and family variables as risk or protective factors for relationships between changes in neuropsychological functioning and changes in mental health variables. Models that had an adjusted interaction at p < 0.10 level (trend) are reported in Table 4. After adjustment, three moderating variables were significant at the 0.05 level for self-esteem (caregiver education, family functioning, and child support) and one for symptoms of depression (child age). Significant results and trends are described in subsequent text.

Table 4.   Moderating effects for self-esteem with adjusted p < 0.10
Moderating variableNeuropsychological variablep-valueStandardized betas and p-values by level of risk/protective factor
UnadjustedAdjustedLowMediumHigh
Caregiver educationProcessing speed0.0070.0260.39 (p = 0.0003)0.24 (p = 0.0004)0.02 (p = 0.8401)
Family functioning (Child)Verbal memory and learning0.0050.0190.44 (p = 0.0002)0.27 (p = 0.0002)0.11 (p = 0.1338)
Child supportVerbal memory and learning0.0120.0490.57 (p = 0.0002)0.28 (p = 0.0002)0.07 (p = 0.4228)
Child supportLanguage0.0300.0910.52 (p = 0.0046)0.23 (p = 0.0015)0.02 (p = 0.8393)
Parent anxietyProcessing speed0.0190.0770.06 (p = 0.4920)0.11 (p = 0.2320)0.38 (p = 0.0003)
Caregiver education

A protective effect was found for caregiver education (p = 0.03). For high caregiver education (college education), there was no relationship between change in processing speed and change in self-esteem. However, for both less than high school and up to 1 year post–high school, there was a positive association between change in processing speed and change in self-esteem, with decline in processing speed associated with decline in self-esteem. This relationship was stronger for lower levels of education (β = 0.39, p < 0.001 for less than high school, β = 0.24, p < 0.001 for high school + 1 year).

Family environment

Child report of family functioning was a protective factor for the relationship of change in verbal memory and learning with change in self-esteem (p = 0.02), with no relationships at high levels of family functioning and positive relationships at low and medium levels of family functioning (β = 0.44, p < 0.001 and β = 0.27, p < 0.001 for low and medium levels, respectively). In other words, decline in verbal memory was associated with decline in self-esteem in families with low and medium levels of child report of family functioning.

Parenting response

Child support was a protective factor in the relationship of change in verbal memory and learning with change in self-esteem (p = 0.05). No relationship was found in families with high levels of parental emotional support to the child; however, in families with low emotional support to the child, decline in verbal memory and learning was associated with decline in self-esteem (β = 0.57, p < 0.001 for low levels of support, β = 0.28, p < 0.001 for medium levels). See Fig. 2. There also was a trend for child support to serve as a protective factor in the relationship between language changes and changes in self-esteem (p = 0.09), with similar values for the standardized betas.

image

Figure 2.   Changes in child self-esteem by changes in verbal memory and learning for three levels of parental support at 36 months.

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Parent affect

There was a trend for parental anxiety to serve as a risk factor in the relationship between change in processing speed and change in self-esteem (p = 0.08), with no relationships found for low or medium levels of parent anxiety. To put it another way, decline in processing speed was associated with a decrease in self-esteem only in the children whose caregiving parents had high levels of anxiety.

Tests of moderation effects of risk and protective factors on symptoms of depression

In general, the patterns were similar to the self-esteem models (signs of standardized betas differ because high scores indicate worse symptoms of depression). Models with an adjusted interaction at p < 0.10 are presented in Table 5. After adjustment, only child age was significant at the p < 0.05 level. Significant results and trends are described in subsequent text.

Table 5.   Moderating effects for symptoms of depression with adjusted p < 0.10
Moderating variableNeuropsychological variableUnadjustedAdjustedStandardized betas and p-values by level of risk/protective factor
ppLowMediumHigh
Child ageProcessing speed0.0120.047−0.45 (p = 0.0002)−0.22 (p = 0.0002)0.00 (p = 0.9959)
Family masteryExecutive/attention/construction0.0210.086−0.29 (p = 0.0060)−0.09 (p = 0.3082)−0.03 (p = 0.7307)
Family life/leisureExecutive/attention/construction0.0250.080−0.31 (p = 0.0081)−0.11 (p = 0.1424)−0.00 (p = 0.9547)
Family life/leisureVerbal memory and learning0.0270.080−0.31 (p = 0.0006)−0.13 (p = 0.0776)−0.04 (p = 0.6658)
Parent anxietyProcessing speed0.0230.090−0.09 (p = 0.2918)−0.14 (p = 0.0938)−0.39 (p = 0.0003)
Child age

In older children there was no relationship between decline in processing speed and an increase in symptoms of depression. For younger children and middle age group of children, a decline in processing speed was associated with an increase in symptoms of depression (β = −0.45, p < 0.001 for younger, β = −0.22, p < 0.001 for middle age). In other words, older age served as a protective factor in the relationship.

Family environment

There was a trend for family mastery to serve as a protective factor for the relationship between executive/attention/construction and symptoms of depression (p = 0.09). There was no relationship for children with medium or high levels of family functioning but there was a negative relationship for children with a low level of family mastery.

Parenting response

In addition, there were trends for family life/leisure to serve as a protective factor relative to relationships of decreases in executive/attention/construction and verbal memory and learning to increases in symptoms of depression (p = 0.08 in each case). In both cases no relationships were found in families with medium or high levels of family life/leisure; however, in families with low levels, declines in these areas of neuropsychological functioning were associated with increases in symptoms of depression.

Parent affect

There was a trend for parental anxiety to be a risk factor for the relationship between processing speed and depression symptoms (p = 0.09). Similar to the finding for self-esteem, decline in processing speed was associated with an increase in symptoms of depression, but only for children whose primary caregivers reported high levels of anxiety.

Discussion

  1. Top of page
  2. Summary
  3. Purpose and Hypotheses
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. References
  10. Supporting Information

Three major findings emerged. First, children with a FRS showed variability in both mental health and neuropsychological functioning over the first 3 years. Second, neuropsychological functioning was associated with self-esteem and symptoms of depression at each time point and with change over time. Third, the magnitude of associations between neuropsychological factors and, respectively, self-esteem and symptoms of depression depended on whether children had certain risk or protective factors.

Change in mental health and neuropsychological functioning over time

In general, findings were encouraging. Although mental health scores varied, there was an overall trend for children to show improvement in self-esteem and depression symptoms over time. This lack of persistence in mental health problems early in the course of pediatric epilepsy has been previously described (Oostrom et al., 2003a). Moreover, this improvement indicates that in children who are otherwise developing normally and are age 8 years or older, the onset of seizures does not have a generally negative impact on mental health over the first 3 years.

Findings were also generally positive with regard to change in neuropsychological functioning. The majority of children with seizures showed the same amount of improvement as their siblings in three of the four neuropsychological functioning domains. Compared to their siblings, however, children with seizures showed greater decline in processing speed. A number of studies have found children with uncomplicated epilepsy to have more impaired processing speed than controls (Boelen et al., 2005; Hermann et al., 2006; Berg et al., 2008). Declines in processing speed might be due, at least in part, to AED use. Berg et al. (2008) found no relationship between processing speed deficits and AED use 8–9 years following onset. However, a preliminary longitudinal analysis from the present cohort did show a relationship (Fastenau et al., 2007). In that study, children who were medicated for the 3 years showed a decline in processing speed. Siblings and children who were never medicated had similar scores at baseline and 36 months and both improved over time. Those who were medicated part of the time scored below siblings at baseline but showed the same trajectory as siblings and never-medicated children, and children who were never medicated did not differ from siblings at baseline or at 3 years.

Processing speed declines also might be the earliest emerging in a pattern of deficit associated with epilepsy. Processing speed tasks have been shown to be among the most sensitive to brain dysfunction (Larrabee et al., 2008). Alternatively, processing speed might represent a common vulnerability in differing patterns of deficit associated with a variety of seizure types, localizations, and syndromes. These patterns might be obscured in a large and varied sample such as this one.

Relationship between neuropsychological functioning and mental health

As anticipated, lower cognitive function was associated with worse self-esteem and symptoms of depression, and declines in cognitive functioning were associated with worsening self-esteem and symptoms of depression. The magnitude of the correlations was low and below the correlation of 0.30 found between global cognitive functioning and mental health problems in the cross-sectional study by Schoenfeld et al. (1999). One reason for the low association is that neuropsychological functioning, self-esteem, and symptoms of depression were measured by different methods (i.e., independently administered tests of cognition tests versus self-report of subjective feelings about self). Moreover, we had hypothesized that children with declines in neuropsychological functioning would be aware of them, which would negatively affect self-perceptions. However, if children were not aware of their cognitive change, their self-perceptions would not change. Another possibility is that worsening mental health could lead to poorer cognitive functioning (e.g., changes in processing speed may be symptoms of depression). Finally, the modest magnitude of these correlations is consistent with our hypothesized moderating role of risk and protective factors, which is discussed further in subsequent text.

Moderating effects of risk and protective factors

The major aim was to test the moderating effects of relevant risk and protective factors on the relationship between neuropsychological functioning and mental health. In general, we found that the subgroup of children with cognitive decline who were in more positive family environments (i.e., higher caregiver education, better family functioning, and more emotional support from parents) were better able to maintain self-esteem in the context of cognitive decline.

The finding that higher caregiver education served as a protective factor for self-esteem in the context of decline in processing speed suggests that parents with more education may be better able to help their children maintain their feelings of self-esteem when experiencing psychomotor slowing. Lower parent education has previously been linked to poorer mental health in children with epilepsy (Carlton-Ford et al., 1995). The protective effects of higher levels of family functioning and greater parental emotional support suggest that children who are satisfied with family interactions are better able to maintain their self-esteem when they experience reductions in memory and learning. These findings are consistent with prior studies showing that positive family interactions are related to better mental health in children with epilepsy (Austin & Caplan, 2007).

Our hypothesis that high parent anxiety would be a risk factor for cognitive decline was supported only at the trend level for both self-esteem and symptoms of depression. A decline in processing speed had stronger negative effects on both self-esteem and symptoms of depression in the child when the caregiving parent was highly anxious. Anxious caregivers may express more critical comments or be less able to provide positive emotional support to children, both of which have been associated with poorer self-esteem in children with epilepsy (Hodes et al., 1999). Another explanation is that anxious parents inadvertently model ineffective coping behaviors for their children (Drake & Kearney, 2008). Therefore, a child who had decreasing neuropsychological functioning in the context of a highly anxious parent would be more likely to show reductions in self-esteem and increases in symptoms of depression.

Although the finding that younger age was a risk factor for symptoms of depression in children with decreasing processing speed was not predicted, there are at least two possible explanations for why older age at seizure onset would be a protective factor. Older children would have had more time to solidify their sense of self prior to seizure onset and might, therefore, be less vulnerable to reacting adversely to any subsequent neuropsychological changes. Also, older age can be viewed as a personal resource that would help children to deal with both seizure onset and declining cognitive functioning. Older children might have more life experiences and possibly more confidence in their ability to cope with declines.

Limitations

Although to our knowledge this was the first study to examine the effect of risk and protective factors on the relationship between cognitive functioning and mental health, only a small percentage of tests carried out for moderation reached statistical significance. We found some empirical support for 7 of the 12 variables (two demographic and five family variables) that we tested as moderators; however, only three remained significant after adjusting for multiple tests. This study was limited because children with more severe seizure conditions, who might have been more likely to have changes in neuropsychological functioning, were excluded. In addition, although we proposed that changes in neuropsychological functioning led to changes in mental health, we could not identify directions of cause and effect. Finally, there is the possibility that both neuropsychological functioning and mental health were changing in relation to a variable that was not investigated in this study.

Conclusions and clinical implications

We found some empirical support for our hypotheses that risk and protective factors influence the relationships between cognitive functioning and mental health, even in this sample of children who had relatively subtle changes in cognitive functioning. Our study showed that a subgroup of children with seizures had more decline in processing speed than their siblings during the first 3 years after seizure onset. Clinically, children with new-onset seizures should be assessed for processing speed declines and, when found, younger children, those with less educated or more anxious parents, and those in less supportive families should be assumed to be most at risk for worsening mental health and should be targeted for services. Clinically, this study highlights the importance of assessing parenting and the family environment when treating children with epilepsy in the clinical setting. Findings suggest that interventions for subgroups of children at risk for mental health problems should focus on parental emotional support of the child and reducing parent anxiety. Interventions should target parents’ learning skills related to identifying and addressing their children’s needs for emotional support. Finally, parents with high anxiety should be assessed to identify areas of concern and worry as well as their needs for information and support so interventions can be tailored to address these areas (Austin et al., 2002).

Acknowledgments

  1. Top of page
  2. Summary
  3. Purpose and Hypotheses
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. References
  10. Supporting Information

This research was supported by the NIH/National Institute of Neurological Disorders and Stroke (NS22416, J. K. Austin, PI). The authors acknowledge Angela McNelis and Janet Kain for coordinating data collection, Beverly Musick for coordinating data management, Carolanne Benson and Paul Buelow for technical and administrative support, and Phyllis Dexter for editorial support.

Disclosure

  1. Top of page
  2. Summary
  3. Purpose and Hypotheses
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. References
  10. Supporting Information

None of the authors has any conflicts of interest. We confirm that we have read the Journal’s position on issues involved in ethical publication, and affirm that this report is consistent with those guidelines.

References

  1. Top of page
  2. Summary
  3. Purpose and Hypotheses
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. References
  10. Supporting Information
  • Austin J, Huberty T. (1989) Revision of the Family APGAR for use by 8-year-olds. Fam Syst Med 7:323327.
  • Austin J. (1996) A model of family adaptation to new-onset childhood epilepsy. J Neurosci Nurs 28:8292.
  • Austin J, Harezlak J, Dunn DW, Huster GW, Rose DF, Ambrosius WT. (2001) Behavior problems in children before first recognized seizures. Pediatrics 107:115122.
  • Austin J, McNelis A, Shore C, Dunn D, Musick B. (2002) A feasibility study of a family seizure management program: be Seizure Smart. J Neurosci Nur 34:3037.
  • Austin J, Dunn D, Johnson C, Perkins S. (2004) Behavioral issues involving children and adolescents with epilepsy and the impact of their families: recent research data. Epilepsy Behav 5(suppl 3):S33S41.
  • Austin J, Caplan R. (2007) Behavioral and psychiatric comorbidities in pediatric epilepsy: Toward and integrative model. Epilepsia 48:16311651.
  • Austin J, Shore C, Dunn D, Johnson C, Buelow J, Perkins S. (2008) Development of the parent response to child illness (PRCI) scale. Epilepsy Behav 13:662669.
  • Berg A, Langfitt J, Testa F, Levy S, DiMario F, Westerveld M, Kulas J. (2008) Residual cognitive effects of uncomplicated idiopathic and cryptogenic epilepsy. Epilepsy Behav 13:614619.
  • Boelen S, Nieuwenhuis S, Steenbeek L, Veldwijk H, van de Ven-Verest M, Tan I, Aldenkamp A. (2005) Effect of epilepsy on psychomotor function in children with uncomplicated epilepsy. Dev Med Child Neurol 47:546550.
  • Buelow J, Austin J, Perkins S, Shen J, Dunn D, Fastenau P. (2003) Behavior and mental health problems in children with epilepsy and low IQ. Dev Med Child Neurol 45:683692.
  • Byars AW, deGrauw TJ, Johnson CS, Fastenau PS, Perkins SM, Egelhoff JC, Kalnin A, Dunn DW, Austin JK. (2007) The association of MRI findings and neuropsychological functioning after the first recognized seizure. Epilepsia 48:10671074.
  • Caplan R, Siddarth P, Gurbani S, Oh D, Sankar R, Shields WD. (2004) Psychopathology and pediatric complex partial seizures: seizure -related, cognitive, and linguistic variables. Epilepsia 45:12731286.
  • Carlton-Ford S, Miller R, Brown M, Nealeigh N, Jennings P. (1995) Epilepsy and children’s social and psychological adjustment. J Health Soc Behav 36:285301.
  • CCT-ILAE. (1981) Proposal for revised clinical and electroencephalographic classification of epileptic seizures. From the Commission on Classification and Terminology of the International League Against Epilepsy. Epilepsia 22:489501.
  • CCT-ILAE. (1989) Proposal for revised classification of epilepsies and epileptic syndromes. Commission on Classification and Terminology of the International League Against Epilepsy. Epilepsia 30:389399.
  • Chiou H, Hsieh L. (2008) Comparative study of children’s self-concepts and parenting stress between families of children with epilepsy and asthma. J Nurs Res 16:6573.
  • Collings J. (1990) Epilepsy and well-being. Soc Sci Med 31:165170.
  • Collings J. (1995) The impact of epilepsy on self-perceptions. J Epilepsy 8:164171.
  • Dodrill C. (2004) Neuropsychological effects of seizures. Epilepsy Behav 5:S21S25.
  • Drake KL, Kearney CA. (2008) Child Anxiety Sensitivity and Family Environment as mediators of the relationship between parent psychopatholgy, parent anxiety sensitivity, and child anxiety. J Psychopathol Behav Assess 30:7986.
  • Dunn D, Austin J. (1999) Behavioral issues in pediatric epilepsy. Neurology 53:S96S100.
  • Dunn D, Austin J, Huster G. (1999) Symptoms of depression in adolescents with epilepsy. J Am Acad Child Adol Psychiatry 38:11321138.
  • Ettinger A, Weisbrot D, Nolan E, Gadow K, Vitale S, Andriola M, Lenn N, Novak G, Hermann B. (1998) Symptoms of depression and anxiety in pediatric epilepsy patients. Epilepsia 39:595599.
  • Fastenau PS, Johnson CS, Byars AW, Dunn DW, Austin JK. (2007) A 3-year prospective study of neuropsychological changes in children following the first recognized seizure: relationship to neurological and psychosocial variables. J Int Neuropsychol Soc, 13:126.
  • Fastenau P, Johnson C, Perkins S, Byars A, DeGrauw T, Austin J, Dunn D. (2009) Neuropsychological status at seizure onset in children: risk factors for early cognitive deficits. Neurology 73:526534.
  • Fraizer PA, Tix AP, Barron KE. (2004) Testing Moderator and Mediator Effects in Counseling Psychology. J Counsel Psychol 51:115134.
  • Hermann B. (1982) Neuropsychological functioning and psychopathology in children with epilepsy. Epilepsia 23:545554.
  • Hermann B, Jones J, Sheth R, Dow C, Koehn M, Seidenberg M. (2006) Children with new-onset epilepsy: neuropsychological status and brain structure. Brain 129:26092619.
  • Hoare P, Mann H. (1994) Self-esteem and behavioural adjustment in children with epilepsy and children with diabetes. J Psychosom Res 38:859869.
  • Hodes M, Garralda ME, Rose G, Schwartz R. (1999) Maternal expressed emotion and adjustment in children with epilepsy. J Child Psychol Psychiatr 40:10831093.
  • Kaufman AS, Kaufman NL. (1990) Kaufman Brief Intelligence Test (K-BIT). American Guidance Service, Circle Pines, MN.
  • Kovacs M. (1985) The Children’s Depression Inventory (CDI). Psychopharmacology Bull 21:995998.
  • Kovacs M. (1992) Children’s Depression Inventory (CDI) Manual. Multi-Health Systems, Inc, North Tonawanda, NY.
  • Landgraf JM, Abetz L, Ware JE Jr. (1996) The CHQ user’s manual. The Health Institute, New England Medical Center, Boston, MA.
  • Larrabee GJ, Millis SR, Meyers JE. (2008) Sensitivity to brain dysfunction of the Halstead-Reitan vs an ability-focused neuropsychological battery. Clin Neuropsychol, 22:813825.
  • McCubbin H, Thompson A. (1991) Family assessment inventories for research and practice. Family Stress Coping and Health Project. University of Wisconsin-Madison, Madison, WI.
  • Miller J, Kustra R, Vuong A, Hammer A, Messenheimer J. (2008) Depressive symptoms in epilepsy. Drugs 2008: 14931509.
  • Morency C. (2008) Enhancing the travel survey process and data using the CATI system. Transportation Planning and Technology 31:229248.
  • Nigg JT, Quamma JP, Greenberg MT, Kusche CA. (1999) A two-year longitudinal study of neuropsychological and cognitive performance in relation to behavioral problems and competencies in elementary school children. J Abnorm Child Psychol 27:5163.
  • Oostrom K, Smeets-Schouten A, Kruitwagen CLJJ, Peters ACB, Jennekens-Schinkel A. (2003a) Behavioral problems in children with newly diagnosed idiopathic or cryptogenic epilepsy attending normal schools are in majority not persistent. Epilepsia 44:97106.
  • Oostrom K, Smeets-Schouten A, Kruitwagen CLJJ, Peters ACB, Jennekens-Schinkel A. (2003b) Not only a matter of epilepsy: early problems of cognition and behavior in children with “epilepsy only”– A prospective, longitudinal, controlled study starting at diagnosis. Pediatrics 112:13381344.
  • Oostrom K, van Teeseling H, Smeets-Schouten A, Peters A, Jennekens-Schinkel A; Childhood DSoEi. (2005) Three to four years after diagnosis: cognition and behaviour in children with ‘epilepsy only.’ A prospective, controlled study. Brain 128:15461555.
  • Papero P, Howe G, Reiss D. (1992) Neuropsychological function and psychosocial deficit in adolescents with chronic neurological impairment. J Dev Phys Disabil 4:317340.
  • Rodenburg R, Meijer AM, Dekovic M, Aldenkamp AP. (2005) Family factors and psychopathology in children with epilepsy: a literature review. Epilepsy Behav 6:488503.
  • Schoenfeld J, Seidenberg M, Woodard A, Hecox K, Inglese C, Mack K, Hermann B. (1999) Neuropsychological and behavioral status of children with complex partial seizures. Dev Med Child Neurol 41:724731.
  • Smilkstein G. (1978) The Family APGAR: a proposal for a family function test and its use by physicians. J Fam Pract 6:12311239.
  • Wolman C, Basco DE. (1994) Factors influencing self-esteem and self-consciousness in adolescents with spina bifida. J Adolesc Health 157:543548.
  • Zashikhina A, Hagglof B. (2007) Mental health in adolescents with chronic physical illness versus controls in Northern Russia. Acta Paediatr 96:890896.
  • Zuckerman M, Lubin B. (1965) Manual for the Multiple Affect Adjective Checklist. eDits, San Diego, CA.

Supporting Information

  1. Top of page
  2. Summary
  3. Purpose and Hypotheses
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgments
  8. Disclosure
  9. References
  10. Supporting Information

Table S1. Descriptive statistics for neuropsychological factors at baseline and 36 months.

Table S2. Descriptive statistics for family variables at 36 months.

FilenameFormatSizeDescription
EPI_2575_sm_TableS1.doc40KSupporting info item
EPI_2575_sm_TableS2.pdf45KSupporting info item

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