Ask the Experts Transcript: Mood Disorders in Children with Epilepsy

Featured Expert: David Dunn, M.D.

Dr. David Dunn is a child neurologist and child and adolescent psychiatrist at Indiana University School of Medicine. He went to medical school at Tulane in New Orleans, did neurology and child neurology at Tulane and Columbia University in New York, and psychiatry and child psychiatry at Indiana. At Indiana University he works with Dr. Joan Austin studying the behavioral aspects of epilepsy in children. He also runs the ADHD clinic and is residency training director for child psychiatry and the combined pediatrics, psychiatry, and child psychiatry program.

Thank you all for joining us tonight. Our guest tonight is Dr. David Dunn. He will be happy to answer your questions on mood disorders in children with epilepsy.

Dr. David Dunn: Thank you very much. I am happy to be here today.

"How can you decide if the mood swings are just the teenage thing or the drugs?"

Dunn: That's an excellent question. Making a diagnosis of depression in a child or in a teenager can be difficult. First symptoms differ by the stage the child is going through. Second, many of the symptoms in children and adolescents are different from those we see in adults. Children often present with irritability, refusal to do their work, and just generally obnoxious behavior. Yet this may be the beginning of a depression. Third, symptoms tend to wax and wane in children. Adults may be down and depressed for days at a time but a child or an adolescent may look depressed at home but then seem happy when they are out with friends.

So basically, the things you need to watch for are these symptoms of depression. First, the child or the adolescent may complain of being depressed or they may just be irritable or have a real intolerance for frustration.

Second, there is some loss of interest in activities that used to be pleasurable to the depressed child or adolescent. He or she seems more withdrawn, seems to spend more time alone, and seems to prefer to stay in his or her room. The third sign you might watch for is fatigue. The depressed child often seems chronically tired. Fourth, they may have problems with concentration that can adversely affect school performance. There can be other signs as well. Many depressed children either lose weight or gain excess weight. Some have difficulty sleeping at night. They are tired and sleepy during the daytime. They can seem either excessively restless or may have very slowed movements. The teenagers may have thoughts of being worthless or chronic feelings of guilt. The teenagers are also the ones who begin to have suicidal thoughts. They might talk about feeling that they are better off dead.

These are the basic symptoms of depression. When you begin to see these symptoms, think more of depression and less of just a stage of life. Remember that children and teens will often deny being depressed. Sometimes they just don't understand the emotions, and sometimes they may think it is a sign of weakness. Even if your child says they are not depressed and they have these symptoms, consider the possibility of depression.

"How come some doctors don't seem to recognize the tie between mood and epilepsy?"

Dunn: That's a good question. Because of the pressures of time, physicians are often very focused on the exact problem that their patient comes in with. A physician treating a child with seizures may start by asking about numbers of seizures, changes in seizure type, and the effectiveness and side effects of anti-epileptic drugs. If the child's seizures seem to be under good control, they may forget to ask about school and behavior. This is a time for parents to take over and let the doctor know what their real concerns are. Treating a child with epilepsy has to be a collaborative effort between the neurologist, the parent and the child.

"What are some of the best resources to find a doctor for a child with epilepsy and mood disorders?"

Dunn: A good comprehensive epilepsy center should have a team in place to deal with complicated problems associated with epilepsy. Ideally, there should be a neurologist, nurses, social worker, and a psychiatrist or psychologist on the team. Many medical schools and large medical centers will have comprehensive epilepsy programs. Another option is to contact your local Epilepsy Foundation. If you are not sure where to find the local Foundation you can click the 'Local Info' link at the top of the page.

"Both my daughter and I are epileptic with hers being more severe than mine. In the past couple of months my family and I have noticed a great change in my daughter's interest in learning and focus. Should this be a great concern for us considering that she is entering second grade and the summer is almost up or is this just a phase she could be going through?"

Dunn: That's a complicated question. We just talked about depression and mood disorders, and how to separate those from just a normal stage but what you are describing could be a sign of other problems as well. We know that children with epilepsy may have problems with attention span, and memory. If this a concern, you should contact your school and ask them to do a psycho-educational assessment. They can measure both learning potential and learning achievement. Another question you might want to ask is could her interest and focus problems be associated with her seizures. You should watch for seizures occurring during the night that may be making her tired and sleepy during the day. You should have your neurologist repeat her examination and make sure that she has no side effects from her AED. Kids that are having a decline in learning and attention could also have entirely unrelated problems such as physical illnesses like anemia, mononucleosis or thyroid problems. There can also be behavior problems such as fear of bullying at school that may lead a child to avoid going to school.

"Is a child with epilepsy more likely to have ADHD?"

Dunn: ADHD -- Attention Deficit Hyperactivity Disorder -- seems to be a common problem in children with epilepsy. In the past, we used to worry about confusing absence seizures and ADHD. Generally teachers and parents can tell the two apart by watching to see if the child can immediately respond when touched or when their name is called. ADHD symptoms are seen in approximately 1/4 to 1/3 of children with epilepsy. The kids with epilepsy more often have problems with inattention than problems with hyperactivity. We need to treat this early to prevent failure in school. The stimulant medicines like Ritalin can be used safely in children with epilepsy.

"My son has had simple and complex partial seizures since age 3, undiagnosed until age 9 (previous to that these were staring episodes lasting a few minutes). He always had trouble with irritability and explosiveness -- poor self-calming. The Neuropsychologist did say that his seizures originate in the part of the brain that controls self-calming, and he does seem to be doing better now that he is on meds that work. Are there any good resources for helping to teach self-calming now that his capacity is improving? And how will testosterone fit in as he gets older?"

Dunn: You have asked two questions. The latter question is mostly about puberty. In general, we don't see major changes in behavior associated with puberty. Some things do occur. As an example, the incidence of depression changes from being equal in boys and girls to being more common in girls. In general, you should not expect major changes in behavior.

The first part of the question is about teaching self-calming. This is an excellent goal for parents. It also reminds us that one of the ways of treating mild depression is psychotherapy. The most commonly used form of psychotherapy for depression is cognitive behavioral therapy. This is often done with the help of a psychologist, social worker or other therapist. Sometimes parents can do much of the teaching. With this therapy, the child is taught how his thoughts are affecting mood. He is then shown how to identify and change negative distorted thoughts about himself, his experiences, and his future.

Parents should try to set up a schedule for the depressed adolescent. It is important that the adolescent be encouraged to take part in enjoyable social activities and to avoid isolating himself or herself. Children with depression may stay at home watching TV, playing video games, and sleeping instead of spending time with friends.

Resources that parents might use to help with teaching include a number of good books. There is a text called "Skills Training for Children with Behavior Disorders" by Michael L. Bloomquist. Another book, "Coping Skills Interventions" by Susan Forman, was originally written for therapists but can be used by parents as well. We've also used two excellent books by Thomas W. Phelan, "1-2-3 Magic" and "Surviving your Adolescent." These are two books that are particularly good for helping with discipline problems and other behavior disturbances.

"Dr. Dunn, my 4-year-old daughter has intractable epilepsy and autism. She receives behavior therapy in the home, and while we have seen an improvement in her speech/language/communication skills, we really aren't seeing improvements in behavior. She takes Keppra, which is noted for causing behavior changes, and in her case it is making her a danger to herself and others (she hits others with whatever is handy, with no provocation, and her newest behavior is running away from home -- we've safety proofed our home the best we can, but she sometimes still manages to get outside), although it does control her seizures fairly well. What type of therapy/treatment plan can you recommend?"

Dunn: You've posed a hard problem. How do you distinguish behavior problems due to epilepsy, side effects of medicine, or an underlying behavior problem. Certainly children with autism have a number of difficult behaviors that may require both counseling and medication.

We always have to consider possible side effects of AEDs. Almost all our drugs can cause behavioral problems.

We seem to see more behavior problems in those AEDs that cause sedation. Phenobarbital and primidone (Mysoline) are drugs that can cause ADHD symptoms in about a third of the children receiving these medications. They also cause frequent mood problems. Some of the newer medicines like topiramate (Topamax) or zonisamide (Zonegran) have also caused symptoms of inattention, hyperactivity, and depression.

If these symptoms occur immediately after starting an AED, you have two choices. First choice might be to try lowering the dose or changing to a new AED. This should be done only with your doctor's assistance. A second option may be to treat the behavior problem with medication and continue the AED. You would probably do this if the AED had been very successful in controlling seizures.

For example, if a child has gotten a very good response from an AED but has become depressed, you could try adding one of the serotonin reuptake inhibitors such as sertraline (Zoloft). This medication does not seem to cause seizures. It also has only limited drug interaction with the AEDs. Adding on an antidepressant such as fluoxetine (Prozac) may inhibit the breakdown of an AED. This could cause increased blood levels of the AEDs. It is important to watch blood levels of medications anytime you add a new medication.

"In my early teens, depression seemed to overpower the fact that my anti-convulsants were helping to stop my seizures. They were helping, but not enough, as guys in gym class refused to pick me for their sports teams. I was always the last one left, so got stuck on someone’s team. In my city, the Epilepsy Foundation didn’t exist back then, and the teachers thought I belonged in a school for the mentally retarded! When I attempted suicide to stop it, I got put on an anti-depressant which just made me have MORE seizures!!! My neurologist said it’s like a see-saw with anti-depressants on one side, and anti-convulsants on the other side. If the strength of anti-depressants rises, the strength of anti-convulsants drops! Is there any anti-depressant that doesn’t make my anti-convulsant levels drop?

Dunn: You can combine anti-depressants and AEDs. People do worry about two things happening. First, some of the anti-depressant drugs can lower the seizure threshold and cause you to have more seizures. This is particularly the case with high doses of bupropion (Wellbutrin). It was less of a problem, but can occur with tricyclic anti-depressants and with venlafaxine (Effexor).

Nevertheless, you can use these drugs if you watch the dose and blood levels of medication. The serotonin reuptake inhibitors like fluoxetine (Prozac), sertraline (Zoloft), citralopram (Celexa), and paroxetine (Paxil), are generally very safe for people with epilepsy. They do not seem to lower the seizure threshold.

The second concern about using AEDs together with anti-depressants is the possibilities of drug interactions. Fluoxetine (Prozac), paroxetine (Paxil), and fluvoxamine (Luvox) do inhibit the metabolism of AEDs and may cause a rise in blood levels for the AEDs. This is not as much a problem with citalopram (Celexa) or sertraline (Zoloft). Sometimes it takes a couple of trials, but there should be a possibility of finding the right drug to relieve depression. You should look for a psychiatrist that is comfortable in treating people with epilepsy or is willing to work with your neurologist to find the right combination of medication. In addition, remember that psychotherapy can be quite helpful.

"Are children with epilepsy more susceptible to bipolar disorder?"

Dunn: That's a hard area, because we are beginning to rethink what bipolar disorder in children really is. We used to think that bipolar disorder was rare in people with epilepsy. It probably is, though we may have missed some cases. We should think about bipolar disorder when there is a family history of bipolar disorder or when the child has major problems with sleep.

The child with bipolar disorder will have periods when he or she seems to need very little sleep, is able to stay awake and is not tired during the daytime. We think about bipolar disorder when children develop unusually grandiose ideas. This can be hard to separate from normal childhood fantasies. The 4-year-old that says she will be either president or a fireman is probably normal. But the 16-year-old that is failing in school and says he plans to go to Harvard is getting grandiose.

Another sign of bipolar disorder is early emergence of sexual acting out, more so than that seen in the average child of the same age. We think of bipolar disorder when children have frequent fluctuation in mood, marked irritability, and significant hyperactivity and distractibility. Fortunately, most of the mood stabilizers used to treat bipolar disorder are also AEDs. Divalproex sodium (Depakote), carbamazepine (Tegretol), and lamotrigine (Lamictal) are all used to treat bipolar disorder. It is still a hard disorder to treat, and if you think your child has bipolar disorder, you should plan on seeing a child psychologist or psychiatrist.

Thank you for all of your excellent questions. I am sorry we were not able to get to all of your questions. We will try to have typed answers for many questions available here on the Foundation website within a few days. Please remember that most of these disorders are treatable, but it often requires persistence on the part of parents.

Thank you, Dr. Dunn, for joining us and lending your expertise for this special Epilepsy Foundation Chat Event. And thank you to everyone for participating and making this event such a success. Have a very pleasant evening, and good night.