Epilepsy is a prevalent condition characterized by variations in its clinical presentation, etiology, and amenability to treatment. Through history, neuropsychologists have played a significant role in performing research studies on changes in language, memory, and executive functioning in patients with epilepsy, including those undergoing surgical treatment for medically refractory seizures. These studies provided a foundation for establishing neuropsychologists as critical members of interdisciplinary clinical teams specializing in evaluation and treatment of epilepsy. This article describes a number of elements of specialized neuropsychological practice that have evolved over the years within a tertiary care epilepsy center. Through diagnostic interview and objective testing, the neuropsychologist is able to provide a more complete and objective understanding of a patient's cognitive and behavioral functioning than what is obtained by other clinicians through brief office visits. While assessment of cognition, mood, and behavior is the most commonly provided service to patients with epilepsy from all age groups, there are many instances when neuropsychologists in surgical settings are called to perform more specialized procedures, including the intracarotid amytal (Wada) procedure, electrocortical stimulation mapping of language eloquent brain regions, and functional brain imaging procedures. While working as a neuropsychologist on an interdisciplinary epilepsy care team requires specialized knowledge and clinical training, it is extremely satisfying due to the diversity of the patient population and the particular challenges resulting from the often unique manner that cognition and behavior can be affected in patients with epilepsy across the lifespan.
Objective: Word finding or “naming” difficulty is a symptom of multiple neurological disorders; therefore, naming assessment is an integral component of neuropsychological evaluation. Prior work has found weaker second-language naming in healthy proficient bilingual youth than monolingual youth, and similar findings have been shown in adults with epilepsy. Considering the potential influences of both early onset epilepsy and bilingualism on brain development, we compared naming in English second language (ESL) and monolingual youth with epilepsy. To assess the impact of bilingualism independent of the known effects of seizure laterality (i.e., poor naming in those with left, dominant-hemisphere seizures), we excluded patients with left language dominance and unilateral seizures. We hypothesized that like other groups, naming would be weaker in ESL than in monolingual youth with epilepsy. Participants and Methods: Participants included 84 children with seizures that could not be lateralized clinically (n=36), bilateral seizures (n=20), centrotemporal spikes (n=3), and those with unilateral seizures and atypical language dominance (n=25), ages 6-15 years old: 66 monolingual, English (mean age: 10.87 ± 2.70 years) and 18 ESL (mean age: 10.78 ± 2.88 years). Those with FSIQ < 70 and vocabulary SS < 6 were excluded to ensure English proficiency. Independent samples t-tests, multivariate ANOVA, and chi-square tests compared groups on demographic factors and test performance. All measures (FSIQ, WISC/WASI Vocabulary, letter and category fluency, Children’s Auditory (AN) and Visual Naming (VN) Tests) were administered in English. Results: Monolingual and ESL groups did not differ in: age, sex, SES, seizure type (i.e., non-lateralized, bilateral, centrotemporal spikes, or atypical language dominance), epilepsy onset age, or number of AEDs. Comparisons also showed no differences in FSIQ, vocabulary, letter fluency, or category fluency (all ps > 0.05). By contrast, auditory and visual naming performances were weaker among ESL patients than monolingual patients: AN accuracy, F(1,81) = 10.89, p = 0.001; AN tip-of-the-tongues (TOTs), F(1,81) = 6.35, p = 0.014; AN Summary Scores (SS), F(1,81) = 6.17, p = 0.015; VN accuracy, F(1,81) = 4.66, p = 0.034; VN SS, F(1,81) = 4.87, p = 0.030, with the exception of VN TOTs, which approached significance, F(1,81) = 3.55, p = 0.063. Conclusions: Consistent with findings in bilingual healthy youth and ESL adults with epilepsy, naming in ESL youth with epilepsy was weaker than in monolingual children. The groups did not differ on other aspects of language. Thus, unlike other expressive verbal functions, naming is adversely affected in the second language of bilingual people with epilepsy across the age span. These results suggest that poor naming in ESL patients cannot be used to infer a naming deficit, and/or left (dominant) temporal lobe dysfunction.
Objective: Executive dysfunction is common in children with epilepsy.Despite earlier studies demonstrating that the Behavior Rating Inventory of Executive Function (BRIEF) is a clinically useful instrument for detecting executive deficits in a school-age epilepsy population, little is available for younger children.The purpose of this study is to evaluate the sensitivity of the preschool age version of this instrument (BRIEF-P) in young children with epilepsy and to examine its inter-rater reliability.Method: The parents of 22 clinically referred children with epilepsy (Age: M ¼ 4.05, SD¼.95, Range ¼ 2 -5; IQ: M ¼ 83.31, SD¼ 25.65, Range: ¼ ,40-129) completed the BRIEF-P as part of a more comprehensive neuropsychological evaluation.For a smaller subset (n ¼ 12), teachers also submitted BRIEF-P forms.Using a cutoff t-score of ≥65 as the threshold for impairment, sensitivity of the BRIEF-P variables was established.Intra-class correlation coefficients (ICCs) assessed inter-rater reliability (IRR) of the parent and teacher forms.Results: At the parent scale level, emergent metacognition (EMI) (Parent ¼ 59%, Teacher ¼ 42%) and global executive composite (GEC) (Parent ¼ 41%, Teacher ¼ 42%) were frequently elevated.The most commonly elevated subscales were inhibition (Parent ¼ 36%, Teacher ¼ 60%), working memory (Parent ¼ 63%, Teacher ¼ 75%) and planning/organization (Parent ¼ 41%, Teacher ¼ 33%).With the exception of the emotional control subscale on the BRIEF-P, all other indices demonstrated moderate to excellent IRR, ranging from an ICC of .532 to .918.Conclusion: This study provides preliminary support for the BRIEF-P in preschool aged children with epilepsy; both the parent-report form and teacher-report form show sensitivity to executive dysfunction in these children.Furthermore, the BRIEF-P appears to have strong inter-rater reliability.
Objective: Despite numerous studies on IQ in childhood epilepsy, no published data are available for the Wechsler Intelligence Scale for Children -Fifth Edition (WISC-V) in pediatric epilepsy.The current study examines the sensitivity of WISC-V index and subtest scores in detecting cognitive problems in children with epilepsy and explores the relationship among WISC-V scores and epilepsy severity variables.Method: 80 clinically-referred children and adolescents with epilepsy were administered the WISC-V as part of a comprehensive neuropsychological assessment.Scores were compared to controls matched for age, gender, race/ethnicity, and parent education obtained from the standardization sample.T-tests compared WISC-V indices and subtests for patients and controls and Chi-Square analyses compared the rate of Low scores (i.e., ≤2 standard deviations below means) in patients versus controls.Correlational analyses assessed the relations between epilepsy severity factors (e.g., age of onset, duration of epilepsy, number of epilepsy medications, seizure frequency) and WISC-V variables.Results: All WISC-V composites and subtests were significantly lower in patients versus controls (p < .001).With the exception of Figure Weights (p = .70),the rate of Low index and subtest scores was greater in patients than controls (p < .01).Among epilepsy severity variables, age of seizure onset and number of epilepsy medications were adversely related to WISC-V performance, whereas seizure frequency had the weakest relationship.Conclusions: The WISC-V is sensitive to epilepsy-related cognitive problems in clinically referred children with epilepsy, though Figure Weights may be of lesser sensitivity.Early age of epilepsy onset and polypharmacy appear to be related to greater cognitive burden.
Objective: To relate neuropsychological performance to measures of cerebral injury in persons with MS selected for cognitive impairment. Methods: Participants were 37 individuals with relapsing–remitting (59.5%) and secondary progressive (40.5%) MS. They were tested at baseline as part of a clinical trial to enhance cognition with an acetylcholinesterase inhibitor. Eligibility criteria included at least mild cognitive impairment on a verbal learning and memory task. A modified Brief Repeatable Battery of Neuropsychological Tests formed the core of the behavioral protocol. Neuroimaging measures were central (ventricular) cerebral atrophy, lesion volume, and ratios of N -acetyl aspartate (NAA) to both creatine and choline. Results: A clear, consistent relation was found between cognitive and MR measures. Among neuroimaging measures, central atrophy displayed the highest correlations with cognition, accounting for approximately half the variance in overall cognitive performance. NAA ratios in right hemisphere sites displayed larger correlations than those on the left. Multiple regression models combining the MR measures accounted for well over half the variance in overall cognitive performance. The Symbol Digit Modalities Test was the neuropsychological task most strongly associated with the neuroimaging variables. Conclusions: If a strong and stable association can be firmly established between cognitive and MR variables in appropriate subsets of MS patients, it might aid in the investigation of interventions to enhance cognition and modify the course of the disease.
Effort assessment is of particular importance in pediatric epilepsy where neuropsychological findings may influence treatment decisions, especially if surgical interventions are being considered. The present investigation examines the Test of Memory Malingering (TOMM) in 60 children and adolescents with epilepsy. The overall pass rate for the sample was 90%. TOMM scores were unrelated to age, though there was a significant correlation between TOMM Trial 2 scores and intelligence estimates. Overall, the TOMM appears to be a valid measure of effort in young epilepsy patients, though caution should be used when interpreting scores for those with very low IQ, especially if behavioral problems are also evident. Caution should also be exercised in interpreting scores in children with ongoing interictal epileptiform activity that may disrupt attention.
Executive function deficits are common in children and adolescents with epilepsy. Though the Wisconsin Card Sorting Task (WCST) is often considered the "gold standard" for executive function assessment, its sensitivity—particularly in the case of the 64-card version (WCST-64)—is insufficiently established in pediatric samples, including children and adolescents with epilepsy. The present investigation assesses the sensitivity of the WCST-64 in children and adolescents with epilepsy in comparison to another measure: the Tower of London – Drexel Version (TOL-DX). A total of 88 consecutively referred children and adolescents with epilepsy were administered both the WCST-64 and TOL-DX as part of a comprehensive neuropsychological evaluation. The sensitivity of WCST-64 and TOL-DX variables were established and relations with epilepsy severity measures and other executive function measures were assessed. Of the WCST-64 variables, Perseverative Responses is the most sensitive, but detected executive function impairment in only 19% of this clinically referred sample; in contrast, the TOL-DX Rule Violations detected executive function impairment in half of the sample. Further, TOL-DX performances are more strongly related to epilepsy severity variables and other executive function measures in comparison to the WCST-64. Despite its popularity amongst clinicians, the WCST-64 is not as sensitive to executive dysfunction in comparison to other measures of comparable administration time, such as the TOL-DX.
