ECONOMÍA JUJEÑA, RELACIÓN DE LOS DATOS ENTRE 1991 Y 2001

primarily on seizure control.

Study Methodology

We analyzed data from the Knowledge Program©

database, an initiative of Cleveland Clinic’s Neurological Institute, to assess patient outcomes for a variety of neurologic conditions.

Data were obtained for patients 0 to 18 years old with a diagnosis of any form of epilepsy seen during a 2.5-year period (January 2009 through June 2011) in Cleveland Clinic’s pediatric epilepsy outpatient service (N = 1,531). We analyzed scores from the ICNDS, the Liverpool Seizure Severity Scale, and patient-reported hours of activity and number of friends using mixed-model regression methods. The individual ICNDS subscales for a single visit were examined for significant differences with respect to individual patient QOL ratings while controlling for patient age and sex.

Pairwise comparisons of the least-squares mean differences between QOL ratings were made using the Tukey-Kramer adjustment for comparison of multiple means. To compare differences between individual ICNDS subscales within a QOL rating, a Bland-Altman

P E D I A T R I C P S Y C H I A T R Y

include psychiatric comorbidities faced by pediatric patients with epilepsy, biomarkers in child psychiatry, and suicide prevention in children and adolescents. She can be reached at 216.444.7459 or [email protected].

Ms. O’Connor is a fourth-year medical student.

SUGGESTED READING

Kauffmann R, Golberb-Stern H, Shuper A. Attention-deficit disorders and epilepsy in childhood: incidence, causative relations and treatment possibilities. J Child Neurol. 2009;24:727-733. Reilly C. Attention deficit hyperactivity disorder (ADHD) in childhood

epilepsy. Res Dev Disabil. 2011;32:883-893.

Sherman EMS, Brooks BL, Akdag S, Connolly MB, Wiebe S. Parents

TAKE-HOME POINTS

• Psychiatric diagnoses in patients with epilepsy are poorly addressed: 60 percent of children with epilepsy fit DSM-IV criteria for a psychiatric diagnosis, yet less than 33 percent of them receive psychiatric services.

• A Cleveland Clinic study of more than 1,500 pediatric outpatients diagnosed with epilepsy over a 2.5-year period examined the relation between QOL and inattentiveness, ability to think and remember, neurological and physical limitations, and epilepsy.

• The study found that the greater the impact of each domain on the child’s social relationships, school perfor- mance and self-esteem, the worse the reported QOL.

Key Study Findings

Inattention, neurological/physical limitations, ability to think and epilepsy were each significantly associated with reduced QOL ratings for children with epilepsy (adjusted P < .05).

Bland-Altman analysis of the differences in ICNDS subscores for attentiveness, other neurologi- cal limitations and ability to think compared with the ICNDS score for epilepsy indicated a significant bias between the ICNDS scores for attentiveness and other neurological limitations when contrasted with the ICNDS score for epilepsy.

Seizure severity and seizure frequency were associated with reduced QOL (P < .005), whereas higher numbers of friends (P < .0005) and hours of activity (P < .005) were positively associated with QOL.

Figure 1. ICNDS cognition and epilepsy subscale scores vs. QOL ratings. A negative trend was observed between QOL and both inattentiveness and epilepsy subscores. The median scores for inattentiveness and epilepsy within each QOL rating are roughly equivalent. Statistical significance cannot be calculated because of the variance in the data.

ICNDS Inattentive Score Changes, First Visit to Second Visit Median; Box: 25%-75%; Whisker: Non-Outlier Range

Inattent_1 Raw Data Outliers Extremes Inattent_2 Raw Data Outliers Extremes

First Visit Quality-of-Life Rating

1 2 3 4 5 6 35 30 25 20 15 10 5 0 -5 IC N D S I nat te nt iv e S co re

The neurologist’s role in treating the concussed patient goes much deeper than simply ordering neurological testing. At Cleveland Clinic, we take a holistic approach that includes not only diagnosis and treatment but also education, prevention and treatment of underlying issues related to persistent headache that may come to the fore following an acute injury. Best Practices in Education, Communication

Our experience in treating pediatric patients with sports-related concussion has yielded some best practices in education and communication that are essential to effective management:

• Emphasize patient/parent education: Patients and parents/

guardians should receive educational literature about concussion and return to play. While face-to-face education certainly is important, often patients and parents are so anxious during a medical appointment that they are unable

to remember important details afterward. Having materials in hand will reinforce key messages.

The American Academy of Pediatrics has helpful informa- tion available on its healthychildren.org website, and the American Academy of Neurology’s Sports Concussion Toolkit at aan.com/concussion is an excellent resource. • Provide confident reassurance: Once neurological testing

is done and tests appear normal, it is important to reassure parents: “Mrs. Jones, this might seem frightening right now, but your child will get better. He is showing zero neurological symptoms. He isn’t having seizures and hasn’t lost any vision, he isn’t weak on one side, and his neurological exam and CT scan are normal.”

Parents want to know that nothing scary is going on from a neurological standpoint. It’s important that the information be conveyed as authoritatively and definitively as possible.

• Address any underlying stress, whether previously present or caused by the incident: In addition to parents’ concerns,

often there are hidden stresses affecting the patient that need to be addressed. For example, a 17-year-old football player may have hidden fears of another concussion and may no longer want to play, but he may be afraid to tell his teammates because he is a star player. We frequently refer to adolescent psychologists in situations such as this. Avoiding a Second Injury

Numerous studies have found that a pediatric patient who experiences a concussion is statistically more likely to have a second one. The pediatric neurologist plays a pivotal role in educating parents and patients about the importance of prevention, especially if symptoms from the first concussion have not yet resolved.

Much debate surrounds the idea of cognitive rest. We

Best Practices: Managing Sports-Related Concussion