As with most neurologic populations, attention and executive function deficits are quite common in childhood epilepsy. As such, a comprehensive neuropsychological evaluation must include assessment of these skills, especially considering the fact that attentional and executive function deficits often lead to considerable academic underachievement. In epilepsy, attentional impairment is secondary to several factors, including the underlying brain pathology, which causes both the cognitive deficits and seizures, as well as the seizures themselves (causing preictal, ictal, and postictal symptomology). Moreover, interictal EEG phenomena often results in disrupted attention as many antiepileptic medication side effects. It should also be noted that certain seizure types (e.g., absence seizures) have, as their primary manifestation, a behavioral arrest which may be behaviorally indistinguishable from inattention. It should not be surprising that, given the above, attention deficit/hyperactivity disorder (ADHD) is quite common in children with epilepsy.

For example, in a study of 175 children and adolescents with various seizure types, 42 % of adolescents and 58 % of children were in the “at-risk” range for attention problems on the Child Behavior Checklist (CBCL), and 25 % adolescents and 37 % of children fell in the “clinical” range. Categorical classifications on the Child and Adolescent Symptom Inventories indicated that 11.4 % had possible ADHD-combined subtype, 44 % had possible ADHD-inattentive subtype, and 2.3 % had ADHD-hyperactive subtype. The inattentive subtype of ADHD was more common in children with epilepsy; in children with developmental ADHD, the combined subtype (with features of both inattention and hyperactivity) is far more common. Further, girls with epilepsy may be more likely to show attention problems. Epilepsy-related variables (e.g., seizure type, location of onset) were not significant predictors of ADHD symptoms (Dunn, Austin, Harezlak, & Ambrosius, 2003).

Hermann et al. (2007) evaluated the rate, subtype, and clinical correlates of ADHD in children with idiopathic epilepsy recruited from neurology clinics in the Midwestern United States. Results were similar to prior findings, indicating that ADHD is more common in children with epilepsy than controls (31.5 % versus 6.4 %). Again, the inattentive subtype was more common (52.1 %) than hyperactive (13.1 %), combined subtypes (13.1 %), or ADHD—not otherwise specified (17.4 %). Notably, the symptoms of ADHD predated onset of epilepsy in 82 % of cases, and those with ADHD and epilepsy showed poorer performance across most neuropsychological tasks, with motor/psychomotor speed and executive functioning (e.g., response inhibition, mental flexibility, working memory, etc.) often being affected. Epilepsy variables, such as specific syndrome, medications, age of onset, and duration of epilepsy, did not predict ADHD diagnosis. Given the high likelihood of ADHD in children with epilepsy, a competent neuropsychological evaluation should heed the guidelines set forth by the American Academy of Pediatrics to appropriately diagnose ADHD. These guidelines suggest that the clinician must assess the formal DSM-IV criteria through evidence obtained from both parents and teachers, including information regarding the age of onset, duration of symptoms, and degree of functional impairment (American Academy of Pediatrics, 2000).

“Executive functions,” mediated by a network of neuroanatomical circuits involving the prefrontal cortex and its connections (Miller & Cummings, 2007; Stuss & Knight, 2002), refer to higher-order cognitive functions such as planning, inhibition, set shifting, self-monitoring, organization, working memory, and initiating and sustaining motor and mental activity. Assessment of executive dysfunction in children with epilepsy is important both because of the high rate of such problems in clinical samples and the fact that executive deficits predict poorer quality of life in children. In particular, the constellation of executive dysfunction, low adaptive level, high medication load, and a history of drug-resistant epilepsy contributes significantly to the risk of poor quality of life in children with epilepsy (Sherman, Slick, & Eyrl, 2006). Executive dysfunction is associated with earlier age of epilepsy onset and higher seizure frequency (Hoie, Mykletun, Waaler, Skeidsvoll, & Sommerfelt, 2006), as well as with school performance problems (Hoie et al., 2006). Further, long-term functional difficulties associated with executive dysfunction include behavioral disturbance, social difficulties, and reduced educational and occupational attainment (Baron, 2004; Lezak, 2004).

Executive problems are seen in a number of childhood epilepsies, including frontal lobe epilepsy, temporal lobe epilepsy (see above), idiopathic absence epilepsy (Vuilleumier, Assal, Blanke, & Jallon, 2000), childhood absence epilepsy (Caplan, Siddarth, Stahl, Lanphier, Vona, Gurbani, et al., 2008), and benign rolandic epilepsy (Nicolai, Aldenkamp, Arends, Weber, & Vles, 2006). Children with mild epilepsy (i.e., recent onset, well controlled with medication, normal IQ) tend to have poorer executive functioning than healthy children (Parrish et al., 2007). At the more severe end of the epilepsy spectrum, 40–50 % of children seen in tertiary settings present with clinically significant problems with executive functioning (Rzezak et al., 2007; Slick, Lautzenhiser, Sherman, & Eyrl, 2006). Accurately synthesizing the literature on executive dysfunction in epilepsy requires remaining aware of ascertainment biases, which influence the rate of cognitive deficits in epilepsy; as indicated above, children from tertiary centers often have the highest rates of cognitive and behavioral problems, and those from community settings, the lowest. On the other hand, only recently in the pediatric epilepsy literature have executive functions been systematically assessed. Consequently, some earlier studies on neuropsychological functioning in children with epilepsy may not have reported executive deficits simply because these were not assessed.

There are a number of well-known paradigms that have been used in children with epilepsy and in other clinical groups to assess executive functions. The most well known is the Wisconsin Card Sorting Test (WCST; Kongs, Thompson, Iverson, & Heaton, 2000), a test that measures conceptual reasoning and ability to shift mental set. In one pediatric study involving tertiary-center temporal lobe patients, the WCST had the highest sensitivity among executive functioning tests (77 %; including 50 % for Trail Making B and 26–40 % for fluency tasks; Rzezak et al., 2009). The highest executive dysfunction detection was when the WCST was used in combination with at least one other executive functioning test (94 %).

Although continuous performance tests (CPTs), such as the Test of Variables of Attention (Greenberg, 1988), Conners’ Continuous Performance Test II (Conners, 2004), and the Integrated Visual and Auditory Continuous Performance Test (Sandford & Turner, 1995), are typically considered sustained attention paradigms, all also involve an inhibition component that requires the child to resist impulsive responding over time. Because these tasks also measure reaction time, continuous performance tasks allow for the measurement of multiple neuropsychological domains. These tasks are also generally well validated in terms of sensitivity and validity in clinical groups (Riccio & Reynolds, 2001; Riccio, Reynolds, & Lowe, 2001). In our experience, CPTs are especially sensitive to subtler forms of inattention, impulsivity, and executive dysfunction, likely because they are not administered through direct one-to-one interaction. Instead, the child works independently on a computer and must maintain a goal-directed, focused stance in order to perform well. CPTs are also typically longer than many executive functioning tasks, which may mitigate the novelty effect that sometimes masks executive difficulties.

Fluency tasks are also a classic method for detecting initiation, effortful search, and organization problems evident in the verbal and visual modality. Word fluency tasks require the child to spontaneously provide lists of specific words (starting with a certain letter) or of specific exemplars (from a given category such as animals), within a given timeframe. The analogous nonverbal tasks are design fluency tests, which require generation of novel designs under time constraints. Both the word fluency and design fluency have been relatively well studied in adults with epilepsy (e.g., Martin et al., 2000; Suchy, Sands, & Chelune, 2003). Fluency tasks are part of the standard battery in most epilepsy centers assessing children, though its sensitivity to laterality in children remains to be empirically determined. In one study, approximately 26–40 % of children with temporal lobe epilepsy from a tertiary care center had impaired scores on categorical fluency tasks (Rzezak et al., 2009).

The Rey Complex Figure Test (Rey, 1941), although primarily considered a visual memory test, includes a copy trial that can provide information on organization skills in the visual modality, in addition to visual spatial ability, discussed below. Usually, the comparison to performance on a simpler visual design copying task, such as the Beery-Buktenica visuomotor integration test (VMI; Beery & Beery, 2006), can inform as to whether deficits are primarily organizational or reflect a more fundamental problem with visuospatial or visuomotor skills. Other tasks sensitive to age-dependent expression of executive deficits include the Stroop, Trail Making Test, Tower of London, Contingency Naming Test, and Twenty Questions Test (Jacobs, Harvey, & Anderson, 2007; Rzezak et al., 2007, 2009; Strauss, Sherman, & Spreen, 2006). Many of these basic paradigms have been used as inspiration for executive functioning tests in comprehensive batteries such as the Delis-Kaplan Executive Function System (DKEFS; Delis, Kaplan, & Kramer, 2001) and NEPSY-II (Korkman, Kirk, & Kemp, 2007; for review, see Brooks, Sherman, & Strauss, 2009) and have also been used to assess executive functioning in children with epilepsy (Bender, Marks, Brown, Zaroff et al. 2007; Parrish et al., 2007).

It is well established that performance-based tests of attention and executive functions are not always sensitive to dysfunction by virtue of being administered in a structured, quiet, one-on-one testing environment that reduces the need for self-initiated organization and problem-solving (Strauss et al., 2006). Therefore, specialized questionnaires completed by family members and teachers to assess attention and executive functioning in daily life are useful. To assess attention (with consideration of formal diagnostic criteria for ADHD), indices such as the SNAP-IV (Swanson, Schuck, Mann, et al., 2001), Conners’ Scales (Conners, 2001), or other similar DSM-IV-oriented scales are useful, though more general rating scales that assess attention in addition to other psychological factors are also frequently employed (e.g., CBCL; Achenbach, 1991); Behavior Assessment System for Children-2 (BASC-2; Reynolds & Kamphaus, 2004) and these latter scales have utility in pediatric epilepsy (Bender, Auciello, Morrison, MacAllister, & Zaroff, 2008). Considering executive functions per se, the Behavior Rating Inventory of Executive Function (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000) is increasingly used in the neuropsychological assessment of children with epilepsy. The BRIEF shows sensitivity to executive deficits in children with severe epilepsy (Slick et al., 2006), as well as in children with recent-onset epilepsy with good seizure control (Parrish et al., 2007). A version also exists for preschoolers (BRIEF-P; Gioia, Espy, & Isquith, 2003), which is particularly welcome because reliable performance-based measures of executive functioning designed for this age group for clinical use are lacking.

Ideally, the detection of attention and executive deficits is the first step toward treatment. To date, there have been no studies aimed at improving executive deficits per se in children with epilepsy, but there are a few studies demonstrating successful pharmacological treatment of ADHD in children with epilepsy, some finding improvements in quality of life after treatment (e.g., Yoo et al., 2009). There are also guidelines for treating physicians on how to balance AED treatment with pharmacological treatment of ADHD symptoms (Parisi et al., 2010). When assessing children with epilepsy, the neuropsychologist should include recommendations on treatments aimed explicitly at improving executive dysfunction such as referral for consideration of stimulant medication and behavioral interventions. In addition, many parent and teacher resources aimed at children with primary ADHD (e.g., Barkley, 2000) are useful for children with epilepsy.

Memory deficits are common in children with epilepsy. Further, it has been shown that memory is more disrupted in children with complex partial seizures than other seizure types because these seizures tend to arise from temporal and frontotemporal zones, areas associated with memory and learning. However, generalized epilepsy syndromes such as CAE and BRE may also be associated with memory problems, including poorer memory for nonverbal information in comparison to verbal information (Pavone et al., 2001; Pinton et al., 2006). Notably, a 2001 study did not show differences in memory performance across seizure types (Williams et al., 2001). Given the high base rate of memory problems in epilepsy and the importance of memory in the acquisition of knowledge, a thorough assessment of memory skills is crucial. Hermann, Seidenberg, & Bell (2002) demonstrated progressive cognitive decline (including memory and intellectual functioning) in children with temporal lobe epilepsy, with the decline being associated with epilepsy duration. The authors posited that temporal lobe epilepsy affects a negative impact on brain structure, setting into motion a cascade of cognitive deficits related to reduced cognitive reserve and continuing seizures (Hermann, Seidenberg, & Bell, 2002).

The issue of material specificity of memory deficits is an ongoing debate in the empirical literature. Classically, verbal memory deficits have been associated with left-hemisphere dysfunction, whereas memory for visually presented information is suggestive of right-hemisphere pathology. However, the material specificity of memory deficits in childhood epilepsy has been variable across studies. Generally speaking, much of the empirical evidence suggests that children with memory deficits may show more general cognitive impairment, though those with left-sided temporal lobe epilepsy may perform particularly poorly. This should not seem all that surprising given that an early memory deficit will result in difficulties in the acquisition of knowledge, which will lead to lower overall abilities.

The hypothesis that memory in epilepsy exhibits material specificity (i.e., that left-sided seizures are associated with verbal memory problems and right-sided seizures with visual memory problems) has a long history in the epilepsy literature. For example, in a study by Fedio and Mirsky (1969), children with left temporal lobe epilepsy showed poor retention of verbal information, but both immediate and delayed nonverbal memory was intact. Conversely, children with right temporal lobe epilepsy showed the opposite pattern; these children had impaired recall for nonverbal memory items (Fedio & Mirsky, 1969). Similar results were reported by Jambaque et al. (1993) though the left temporal lobe epilepsy group studied here was lower functioning than the right temporal lobe group overall. However, numerous other studies have failed to show such differences in children (e.g., Camfield et al., 1984; Engle & Smith, 2010; Helmstaedter & Elger, 2009), with researchers essentially finding no difference between visual and verbal memory between left and right temporal lobe epilepsy groups. Of note, a recent study of children with temporal lobe epilepsy demonstrated that children with mesial temporal involvement had lower memory skills than those with lateral involvement. In this group, facial recognition tasks differentiated left and right temporal lobe epilepsies, with the latter showing poorer performance, but other memory tasks were not helpful in determining side of epilepsy onset (Gonzalez, Anderson, Wood, Mitchell, & Harvey, 2007). Moreover, a recent study indicated that though lateralization of seizure focus was not associated with verbal versus visual memory deficits, the laterality influenced the correlation between attention- and material-specific memory (Engle & Smith, 2010).

Variable findings across studies may reflect psychometric issues to some extent but also may be due to the fact that children may show less hemispheric specialization than adults. Further, early damage or disruption of maturational processes of the left hemisphere may be associated with functional reorganization, with the right hemisphere subsuming some aspects of linguistic processing, which likely explains why some studies report lower functioning overall in children with left temporal lobe epilepsy (Jambaque et al., 1993). It has also been suggested that the rapid spread of seizures from one temporal lobe results in dysfunction in both hippocampi, regardless of the side of seizure origin, thus muddying the material specificity of results. There are numerous instruments available to assess memory in children, with several older instruments undergoing revisions that have significantly improved their psychometric properties. The CVLT-C has been frequently utilized in the study of neurologic illness in children and has shown sensitivity to memory impairment in children with epilepsy as well (e.g., Williams et al., 2001). As in adult studies, the Rey-Osterrieth Complex Figure has been utilized in the study of visual memory deficits in childhood epilepsy (Schouten, Hendriksen, & Aldenkamp, 2009). Many pediatric neuropsychologists prefer using co-normed batteries of memory tests so that visual and verbal memory can be directly compared. The past decade has seen the revisions of several such batteries, including the Wide Range Assessment of Memory and Learning, Second Edition (WRAML-2; Sheslow & Adams, 2003), and the Test of Memory and Learning, Second Edition (TOMAL-2; Reynolds & Voress, 2007). Prior research has shown the sensitivity of the WRAML (original version) to deficits in childhood epilepsy (Giordani et al., 2006). The NEPSY-II Edition also includes verbal and visual memory tests, including a task of memory for faces, which again may be of particular importance when evaluating memory deficits in the presence of a right-hemisphere onset. Facial memory tasks are also seen in batteries such as the Children’s Memory Scale (Cohen, 1997), the TOMAL-2 (Reynolds & Kamphaus, 2004), and the KABC-2 (Kaufman & Kaufman, 2002), a larger cognitive battery that extends down to the preschool age.

One of the most dramatic examples of language deficits in the context of pediatric epilepsy is the Landau-Kleffner Syndrome, which has, as its primarily manifestation, an auditory agnosia followed by receptive (and later expressive) language regression. However, as indicated above, subtler language deficits can be seen in other epilepsy syndromes. For example, naming and vocabulary deficits are often seen in children with left-sided temporal lobe epilepsy (Jambaque et al., 1993), and earlier onset is often associated with developmental language problems. However, in other children, language problems may arise or remit depending on epilepsy-related factors. For example, a sample of young children with left frontal simple partial seizures was followed longitudinally. Results suggested dissociations between language comprehension and expressive language. Specifically, comprehension gradually improved, reaching average performance by age 7. In contrast, expressive skills remained poorer (Cohen & Le Normand, 1998). Volkl-Kernstock, Bauch-Prater, Ponocny-Seliger, and Feucht (2009) described a sample of children with benign rolandic epilepsy that showed impairments in receptive language, expressive speech, and expressive vocabulary. An important finding in this study was that after remission of the seizure disorder, language deficits were no longer seen in this group.

Caplan, Siddarth, et al. (2009) commented on the paucity of research conducted on children with epilepsy and normal intellectual function. Interestingly, their study, which included 183 children with either generalized or partial seizures, a quarter of the younger children, a third of the intermediate-aged children, and over half of the adolescent group, showed language deficits in comparison to their age-matched peers. Their findings were interpreted to suggest an “age-related rise” in the vulnerability to language deficits. In a 2008 study of 69 children with absence seizures, nearly half showed language deficits despite, on average, normal IQ (Caplan et al., 2008).

It is also important to recognize the fact that language skills, such as phonological awareness, are the underpinnings of competent reading ability, and such skills have been shown to be deficient in many children with epilepsy (Vanasse, Beland, Carmant, & Lassonde, 2005). Language-based learning disabilities are therefore more prevalent in children with epilepsy than in the general population and more prominent in some kinds of epilepsy versus others. For example, reading deficits are more prevalent in children with temporal lobe epilepsy compared to children with idiopathic generalized epilepsy and benign rolandic epilepsy (Chaix et al., 2006).

The assessment of language is therefore an important consideration in the comprehensive evaluation of neurocognitive functioning in pediatric epilepsy. The astute clinician will note apparent receptive and expressive language deficits in casual conversation, and the ability to understand verbal instructions during other neuropsychological tasks may be initial evidence of receptive language deficits, if present. Moreover, clinicians should pay close attention to the quality of verbal utterances during casual discourse, paying special attention to the rate, rhythm/prosody of speech, articulation, and the quality of grammatical and syntactical constructions. Certain subtests often routinely administered during assessment of intellectual functioning provide excellent opportunities to observe the latter; for example, the Vocabulary, Similarities, and Comprehension subtests of the WISC-IV allow observation of verbal expression under semi-structured conditions and may serve as the initial foundational screening of language on which a more comprehensive evaluation may be built. Measures of confrontation naming may prove important, such as the Boston Naming Test (Kaplan, Goodglass, & Weintraub, 1983) and Expressive One Word Vocabulary Test, Third Edition (Brownell, 2000), as well as measures of verbal initiation and fluency reviewed above. Examples of letter fluency and semantic fluency are available in several batteries with developmentally appropriate normative data, such as the DKEFS (Delis et al., 2001) and the NEPSY-II (Korkman et al., 2007).

If a more comprehensive evaluation of language is deemed necessary based on parent and/or teacher concerns or clinician impressions during screening, several comprehensive language batteries are commercially available. The Test of Language Development and Test of Adolescent Language (Newcomer & Hammil, 1988) have shown sensitivity to language deficits in pediatric epilepsy (Caplan, Siddarth, et al., 2009) offering assessment of vocabulary, syntax, and phonology. School systems often have familiarity with the Clinical Evaluation of Language Fundamentals (CELF)—4th Edition (Semel, Wiig, & Secord, 2003), which provides a comprehensive evaluation of receptive and expressive language abilities. Earlier versions of the CELF have been employed in prior studies; for example, in a sample of children with stroke, those with comorbid epilepsy showed greater language deficits on the CELF-Revised (Ballantyne, Spilkin, & Trauner, 2007). The CELF-IV also provides indices of phonological awareness, which is a foundational skill for competent reading. Other measures of phonological awareness include subtests from the NEPSY-II (Korkman et al., 2007) or the Comprehensive Test of Phonological Processing (Wagner, Torgesen, & Rashotte, 1999). The latter may be particularly important when language-based learning disabilities are suspected, which again are more prevalent in individuals with epilepsy than in the general population.

In surveying the extant literature on cognition in pediatric epilepsy, it becomes readily apparent that visual spatial skills have received fairly sparse attention in comparison to other cognitive domains. This may relate to the fact that deficits in domains such as attention or memory are more likely to manifest as problems in the child’s day-to-day life. Nevertheless, research clearly suggests that children with epilepsy may show visuospatial and motor deficits.

Occipital-parietal areas are crucial in the processing of visuospatial information. This said, as indicated above, neuropsychological findings in pediatric occipital lobe epilepsy have been inconsistent with some studies suggesting PIQ deficits (Gulgonen et al., 2000) and others showing poorer VIQ (Germano et al., 2005). Deficits in visuospatial skills have also been demonstrated in other seizure types as well. For example, in a sample of children with benign rolandic epilepsy, deficits were seen in spatial orientation and spatial memory, and deficits were not associated with side of epilepsy focus (Volkl-Kernstock, Willinger, & Feucht, 2006). In a study employing the NEPSY in children with various epilepsy types, some showed deficits on visuospatial processing tasks. Specifically, 15 % of children showed deficits on the Design Copy subtest, a task of graphomotor construction, and 16 % showed impairment on the “Arrows” subtest, a motor-free spatial perception task. Of the subtests within the NEPSY battery, the task most sensitive to impairment was the Visuomotor Precision subtest, a complex task of visual perception, speed, attention, and motor control; 73 % were impaired on this task (Bender, Marks, Brown, Zach, Zaroff et al. 2007). In a study of children with localization-related epilepsy, a temporal onset was associated with poorer copy of the Rey-Osterrieth Complex Figure (Schouten et al., 2009). Numerous studies have demonstrated deficits in fine motor control in children with epilepsy (e.g., Giordani et al., 2006), and it should be noted that certain antiepileptic medications may produce a tremor and motor slowing as a side effect, which may complicate the assessment of visuomotor skills (see Loring, Marino, & Meador, 2007).

Numerous instruments are available for the assessment of visuospatial and visuomotor skills in children. As indicated, studies have shown that the PIQ (and/or perceptual reasoning) subtests of the Wechsler scales have shown sensitivity to such deficits (Gulgonen et al., 2000). The Beery VMI (Beery & Beery, 2006), a graphomotor task, is perhaps one of the most frequently employed tasks by pediatric neuropsychologists to assess these skills. The NEPSY battery includes an analogous task (i.e., Design Copy) that has shown sensitivity to visuospatial dysfunction in childhood epilepsy (Zach, et al., 2007). Similarly, other NEPSY subtests assess visual spatial skills that do not involve a motor component (e.g., Arrows) and have been successfully used in this population (Bender, Marks, Brown, Zach, et al., 2007). It should also be noted that other more “classic” neuropsychological tasks that were initially designed for use in adults, such as the Rey-Osterrieth Complex Figure (Rey, 1941) and Judgment of Line Orientation test (Benton, Varney, & Hamsher, 1978), have pediatric norms available and may be used in children. To assess fine manual dexterity, many pediatric neuropsychologists employ the Purdue Pegboard, which has shown sensitivity to motor skills deficits in childhood epilepsy. The grooved pegboard is another option for such assessment (Mathews & Klove, 1964). It is recommended that the assessment of visual spatial skills in children with epilepsy employs both motor tasks and pure perceptual tasks that will not be adversely affected by poor motor control.

Unfortunately, mood disorders are fairly common in pediatric epilepsies, and for this reason, a comprehensive neuropsychological evaluation should involve assessment of the child’s mental health. A review of depression and anxiety disorders in pediatric epilepsy was recently published (Ekinci, Titus, Rodopman, Berkem, & Trevathan, 2009), and readers are referred there for a more comprehensive discussion, but major findings will be discussed here. In studies of pediatric epilepsy, the prevalence rates of psychological challenges vary quite widely due to methodological issues, including how mood disorders were assessed (e.g., self-report forms, parent-report forms versus clinical interview). In a population-based survey of mental health problems in children with epilepsy completed by Davies, Heyman, and Goodman (2003), over 16 % of children had noteworthy mental health problems. Another study employed a more comprehensive interview of psychiatric problems (e.g., the Kiddie Schedule for Affective Disorders and Schizophrenia [KSADS]) and found that 12 % of children with complex partial seizures had anxiety or depression, and 13 % of those with childhood absence epilepsy had anxiety and/or depression. Importantly, suicidal ideation was also reported in many of these children (Ott et al., 2001).

With respect to factors that predict mental health problems, gender effects have been seen in some studies. For example, one study showed that girls with epilepsy were more often depressed than boys (Dunn, Austin, & Huster, 1999). Some have shown that seizure frequency may be related to mood (Oguz, Kurul, & Dirik, 2002), and others have shown that children with epilepsy and associated intellectual disability may show more severe mood disorders (Buelow et al., 2003; Davies et al., 2003). Psychiatric problems may also be related to antiepileptic medication use. One study, for example, reported a high rate of depression in children treated with phenobarbital in comparison to those treated with carbamazepine (Brent, Crumrine, Varma, Allan, & Allman, 1987); depression subsided when phenobarbital was discontinued (Brent, Crumrine, Varma, Brown, & Allan, 1990). An extremely noteworthy finding is that of children having significant mental health problems; only a third may receive proper treatment for such difficulties (Caplan, Sagun, et al., 2005).

The impact of having a child with epilepsy also places considerable strain on a family. The degree of impact is related to several key factors, including the severity of the epilepsy, how complicated the medical management is, the restrictions placed on child and family as a result of the illness, and the innate coping skills of family members and the resources afforded to them (see Camfield, Breau, & Camfield, 2001). As many as 50 % of mothers of children with epilepsy are at risk for psychiatric difficulties such as clinical depression (Ferro & Speechley, 2009; Wood, Sherman, Hamiwka, Blackman, & Wirrell, 2008). The total impact that epilepsy has on a family has been shown to relate to factors such as cognitive problems, neurologic complications, as well as variables such as age of onset, frequency of seizures, medications, and the frequency of visits to the doctor. Other studies have examined the impact of epilepsy on social competence and peer relations. One study, for example, showed that lower IQ and externalizing behaviors are related to poorer social competence (Caplan, Sagun, et al., 2005).