Attention-Decit Hyperactivity Disorder in Children with Benign Epilepsy and Their Siblings

Odeya Bennett-Back, MD, Amit Keren, MD, and Nathanel Zelnik, MD

This prospective study explores the prevalence and characteristics of attention-decit hyperactivity disorder in children with benign epilepsy, compared with its prevalence in their siblings. Among 40 patients with benign epilepsy, 28 (70%) were diagnosed with attention-decit hyperactivity disorder: 19 with the inattentive type, one with the hyperactive type, and eight with the combined type. In the control group of 12 siblings, only two (16.7%) were diagnosed with attentiondecit hyperactivity disorder (P < 0.03). A trend toward an increased risk for attentional difculties was evident in children whose seizures were more resistant and required more than one antiepileptic drug for seizure control. Children with more epileptiform features in their electroencephalograms were also more subject to signs of attention decit hyperactivity disorder. Larger scale studies are required to validate our ndings. 2011 Elsevier Inc. All rights reserved. Bennett-Back O, Keren A, Zelnik N. Attention-decit hyperactivity disorder in children with benign epilepsy and their siblings. Pediatr Neurol 2011;44:187-192. appears to be the inattentive form [1,2,6,7]. Studies during the last decade indicate that attention-decit hyperactivity disorder is also frequent in children with benign epilepsy [1,2,8]. Because these two conditions are quite common, both would be expected to occur concurrently in a substantial number of children. This circumstantial relationship is more likely not just random, and both conditions may have a common underlying causative etiology, regardless of the severity and frequency of seizures. Such possible mechanisms include hereditary factors with a common propensity to both conditions that may alter the levels of various brain neurotransmitters or may affect brain plasticity, neurogenesis, and apoptosis [1,9-11]. We hypothesized that, in addition to possible underlying factors that predispose the brain to epileptogenesis and attention difculties, the epileptic activity itself (which in many cases may be primarily subclinical) leads to attention difculties. Hence even in children with benign epilepsy, a high prevalence of attention-decit hyperactivity disorder is expected, and its frequency is beyond that anticipated for the childs specic familial background. In the present study, to eliminate the probability that basic familial, environmental, and hereditary factors contribute to the occurrence of attention-decit hyperactivity disorder, the prevalence and characteristics of attention-decit hyperactivity disorder in children with epilepsy were compared with the prevalence and characteristics of attentiondecit hyperactivity disorder in their nonepileptic siblings rather than the general population. The effects of interictal epileptic activity and the number of antiepileptic drugs required were additional factors explored in correlation with behavioral problems and seizure severity.

Introduction The prevalence of attention-decit hyperactivity disorder in school-age children with epilepsy is high, in the range of 31-40% [1-3], and increases to 59% in those who require special education [4]. This prevalence is signicantly higher than the 6-12% reported worldwide in the general population [5]. Unlike cases in the general population, the most prevalent subtype in school-age children with epilepsy

From the Child Neurology and Development Center, Department of Pediatrics, Carmel Medical Center and Rappaport Faculty of Medicine, Technion, Haifa, Israel.

Communications should be addressed to: Dr. Zelnik; Department of Pediatrics, Carmel Medical Center; 7 Michal Street; Haifa 34362, Israel. E-mail: zelnik@netvision.net.il Received May 24, 2010; accepted October 4, 2010.

2011 Elsevier Inc. All rights reserved. doi:10.1016/j.pediatrneurol.2010.10.003  0887-8994/$ - see front matter

Bennett-Back et al: ADHD and Epilepsy 187

Patients and Methods Patients

We included children 6-17 years of age from the outpatient Neuropediatric Clinic of Carmel Medical Center. All manifested benign idiopathic or cryptogenic epilepsy (i.e., a history of two or more unprovoked seizures) that began at least 6 months before our assessment. All demonstrated normal intelligence, without additional neurologic handicaps or other chronic health problems. Exclusion criteria comprised a diagnosis of attentiondecit hyperactivity disorder before the onset of epilepsy, subnormal cognitive abilities, or a history of low birth weight (<1.5 kg), intrauterine morbidity, perinatal asphyxia, signicant head trauma, brain lesions, or other risk factors for neurologic dysfunction that could contribute to the development of attention-decit hyperactivity disorder. Epileptic syndromes were dened according to the classication of the International League Against Epilepsy [12]. The control group consisted of siblings of patients in the same age range (6-17 years) who were willing to participate.

were collected from the clinical history and from neuropsychologic tests and rating scales performed outside the frame of this research for clinical purposes. The prevalence of attention-decit hyperactivity disorder among epileptic children was estimated using a 95% condence interval (calculated using the condence interval for proportion). The comparison of the rate for attention-decit hyperactivity disorder between the study and control groups was performed using the McNemar test for comparing proportions in paired samples. In cases where statistical analysis would be meaningless (for the small subgroups of epilepsy compared with the control group), we omitted it and considered the data as more exploratory and less conclusive. This study was approved by the Ethics Committee of our hospital, and informed consent was obtained from the parents of all participants.

Results The Study Group: Children With Epilepsy Of the 202 patients with epilepsy retrieved from our clinics database, only 40 (25 boys and 15 girls) met the clinical inclusion criteria (age range, 7-17 years; mean, 11.5 3.28 years S.D.). The main reasons for disqualication included preschool age (n = 43), complicated epilepsy (n = 67), lesional epilepsy or underlying neurologic problems (n = 18), and ndings of attention-decit hyperactivity disorder that occurred before the onset of seizures (n = 24). The distribution of epilepsy syndromes and subtypes is reported in Table 1. Thirty patients (75%) achieved full seizure control (Group 1); eight patients (20%) were fairly-tomoderately controlled (Group 2); two patients (both with primary generalized epilepsy) were not controlled, and manifested at least one major seizure every 3 months or multiple short absences, despite adequate therapy (Group 3). Thirtyseven patients (92.5%) received antiepileptic therapy (24 received monotherapy, and 13 received two drugs), and three patients did not receive antiepileptic drugs. The rst-line drugs administered as monotherapy included valproate (14 patients), carbamazepine (nine patients), and lamotrigine (one patient). Add-on drugs included topiramate (eight patients), phenytoin (one patient), clobazam (one patient), or combinations of two rst-line drugs (three patients).
Table 1. Distribution of epileptic syndromes and subtypes of studied children Epilepsy Subtype or Syndrome Generalized seizures Primary generalized epilepsy Idiopathic absence epilepsy Cryptogenic generalized seizures Juvenile myoclonic epilepsy Partial seizures Complex partial seizures Benign partial epilepsy of childhood with centrotemporal spikes Cryptogenic focal seizures (with or without secondary generalization) Nonclassied seizures Total Number of Patients 21 (52.5%) 8 (20%) 8 (20%) 3 (7.5%) 2 (5%) 16 (40%) 6 (15%) 5 (12.5%) 5 (12.5%) 3 (7.5%) 40

Data Collection
CLINICAL PARAMETERS OF EPILEPSY Several parameters were evaluated. Patients health records were retrospectively reviewed during the clinical course of their epilepsy, along with the numbers and types of antiepileptic drugs used. Routine electroencephalogram recordings were reviewed for all patients. The study group was divided into three subgroups, based on the clinical course and response to medical treatment. Group 1 included patients who were seizure-free for more than 1 year on antiepileptic drugs at the time of the study. Group 2 included children with a fair response to medical treatment, and only 2-3 seizures during the year before the study. Group 3 included patients who manifested four or more seizures within the year before the study. Some patients in this group exhibited brief absence seizures on a weekly basis. Patients whose seizures were more frequent or complicated were not dened as manifesting benign epilepsy and were excluded. Waking and sleeping electroencephalogram records were obtained from before the initiation of antiepileptic treatment and periodically during medical follow-up. Characteristics of interictal epileptiform activity were subdivided into three groups: Group 1, patients whose electroencephalograms did not reveal any denite epileptic activity; Group 2, patients whose interictal electroencephalograms revealed mild epileptiform activity, dened as less than ve spikes or short spike-wave complexes (lasting 1 second or less) per minute; Group 3, patients whose electroencephalograms demonstrated more than six spikes or spikewave complexes per minute. Some patients in Group 3 manifested abundant spike activity or longer segments of spike-wave activity (lasting more than 1 second). The participants in our study required one or two antiepileptic drugs. A few patients with a benign clinical course elected to withdraw from antiepileptic drug therapy. ASSESSMENT OF ATTENTION-DEFICIT HYPERACTIVITY DISORDER The diagnosis of attention-decit hyperactivity disorder was based on the Diagnostic and Statistical Manual of Mental Disorders-IV criteria for attention-decit hyperactivity disorder [13], and clinical evaluation was performed by a pediatric neurologist using the patients clinical history, interviews with the parents, and observations and examinations during clinic visits. The behavioral prole was assessed according to attentiondecit hyperactivity disorder criteria, with the assistance of questionnaires designed by Conners [14]. Only patients whose signs met the attentiondecit hyperactivity disorder criteria of the Diagnostic and Statistical Manual of Mental Disorders-IV and whose rating score was at least 1.5 standard deviations from the mean on one of the attention components were diagnosed with attention-decit hyperactivity disorder. In addition, the Test of Variables of Attention [15], a common and commercially available computerized continuous performance test, was performed. Comorbidities of attention-decit hyperactivity disorder, such as learning disabilities, anxiety, depression, and oppositional or conduct disorders,

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Table 2. Prevalence of ADHD and its subtypes in children with epilepsy, compared with their siblings without epilepsy* Attention Decit Hyperactivity Disorder Hyperactive and Combined 4 3 2 9 (32.2% of ADHD) 1

Epilepsy Data Generalized seizures(n = 21) Partial seizures(n = 16) Nonclassied epilepsy (n = 3) All types of epilepsy(n = 40) Siblings(n = 12) * P < 0.03.

Inattentive 11 7 1 19 (67.8% of ADHD) 1

All Types 15 10 3 28 (70%) 2 (16.7%)

Non-ADHD 6 6 0 12 (30%) 10 (83.3%)

Abbreviation: ADHD = Attention-decit hyperactivity disorder

Control Group The control group consisted of 12 subjects (10 boys and two girls). These children were siblings of the study patients, and they came from 10 families (nine families with one sibling, and one family with three siblings). Their age range was similar to that of the study group, i.e., 8-17 years (mean, 12.7 3.62 years S.D.). All developed normally, attended regular schools, and had no history of underlying neurologic conditions or a history of prenatal or perinatal problems. Characteristics of Attention-Decit Hyperactivity Disorder in the Epilepsy and Control Groups Among the 40 children in the study group, 28 (70%) manifested attention-decit hyperactivity disorder. In contrast, in the control group (n = 12), only two siblings (16.7%) manifested attention-decit hyperactivity disorder (P < 0.03). The subtypes of attention-decit hyperactivity disorder and its prevalence in patients with generalized

and partial seizures are described in greater detail in Table 2. Analyzing the frequencies of attention-decit hyperactivity disorder in 10 families containing patients with epilepsy and matching siblings, we revealed that in ve families (50%), attention-decit hyperactivity disorder was evident only in children with epilepsy. In three families (30%), neither children with epilepsy nor their siblings manifested attention-decit hyperactivity disorder, and only in one family (containing one patient with epilepsy and three siblings) did one of the three siblings manifest attention-decit hyperactivity disorder, whereas all the other 10 families containing patients with epilepsy and matching siblings (including the child with epilepsy) did not (P < 0.02). No signicant difference was evident in the susceptibility of patients with generalized epilepsy (71.4%) and patients with partial seizures (62.5%) to develop attention-decit hyperactivity disorder. Yet all eight patients with absence epilepsy manifested attention-decit hyperactivity disorder. The association between seizure control with number of antiepileptic drugs used and the presence of attention-

Table 3. Percentages of ADHD among children with epilepsy: Correlation with course of the disease, electroencephalogram interictal epileptiform activity, and number of antiepileptic drugs required for optimal seizure control Clinical Course of Epilepsy Group 1: Seizure-free for >1 year Group 2: Two or three seizures in 1 year Group 1: Four or more seizures in 1 year Electroencephalogram Epileptiform Activity Group 1: Normal or nonspecic record Group 2: Less than ve interictal spikes or spike-wave complexes per minute Group 3: More than six interictal spikes or spike-wave complexes per minute Number of AEDs Required for Optimal Seizure Control Group 1: Requires one AED or less Group 2: Requires two AEDs Abbreviations: ADHD = Attention-decit hyperactivity disorder AEDs = Antiepileptic drugs Patients With ADHD 20 (67%) 6 (75%) 2 (100%) 5 (50%) 11 (65) 12 (92%) Patients Without ADHD 10 (33%) 2 (25%) 0 5 (50%) 6 (35%) 1 (8%)

18 (67%) 10 (77%)

9 (33%) 3 (23%)

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decit hyperactivity disorder is reported in Table 3. In general, it indicates that in children with seizures that are difcult to control and require multiple antiepileptic drugs, a higher propensity to exhibit signs of attention-decit hyperactivity disorder occurs. Table 3 also demonstrates the association between electroencephalographic features and the presence of attention-decit hyperactivity disorder. It clearly exhibits a trend toward an increased presence of attention-decit hyperactivity disorder in children with frequent interictal epileptiform activity. In regard to comorbidities of attention-decit hyperactivity disorder, signicant differences were not evident in the prevalence of anxiety between the epilepsy group and the control group (5% vs 8.3%, respectively), whereas behavioral (oppositional and negative behavior) problems were slightly more common in the control group (16.7%, vs 7.5% in the epilepsy group). However, learning disabilities other than attention-decit hyperactivity disorder were more common in the epilepsy group (42.5%, vs 25% in the control group; P < 0.05). Discussion Our study reveals that children with epilepsy manifested a higher prevalence of attention-decit hyperactivity disorder than their siblings without epilepsy (70% vs 16.7%, respectively). Unlike children with attention-decit hyperactivity disorder in the general population, and as reported in previous studies on attention-decit hyperactivity disorder in children with epilepsy [1,2,6,7], the inattentive type in the present study proved to be the predominant form. One crucial question regarding attention-decit hyperactivity disorder in children with epilepsy concerns whether this condition differs from attention-decit hyperactivity disorder in the general population. As a rule, attention-decit hyperactivity disorder is a descriptive diagnosis, and therefore a variety of conditions may be present under the umbrella of this diagnosis. Because attentiondecit hyperactivity disorder is a clinical syndrome rather than a disease entity, conceptualizing it as a secondary sign that occurs in many patients with epilepsy would not be unreasonable [16]. Some experts suggest that in many children with epilepsy, manifestations of attention-decit hyperactivity disorder, occasionally associated with abnormal electroencephalogram results, may predate the occurrence of epileptic seizures [1,7]. The abnormal development of the cortical system, with atypical sensory-motor activation in patients with attention-decit hyperactivity disorder and increased levels of glutamate in their basal ganglia, may explain the predisposition of these patients to epileptic seizures [17,18]. Even children with attention-decit hyperactivity disorder without epilepsy exhibit an increased incidence of abnormal electroencephalogram results, in a range varying from 6.1-30.1% in children with attention-decit hyperactivity disorder vs only 3.5% in the general population [19,20]. Evidence is also accumulating that interictal

epileptic discharges or subclinical epileptic activity may lead to impairments in cognition and attention [21,22]. Although the small number of patients does not allow us to offer more conclusive results, our data suggest that children with benign epilepsy are at higher risk for attentional problems, beyond the expected probability in their families. The association of benign epileptic syndromes, such as childhood absence epilepsy or benign epilepsy of childhood with centrotemporal spikes (which are often subclinical, but share abundant interictal electroencephalogram abnormalities), and attention-decit hyperactivity disorder was previously reported [23-25]. In the present study, in most cases of absence epilepsy or benign epilepsy of childhood with centrotemporal spikes, a relationship was evident between the amount of subclinical epileptiform discharges in the electroencephalogram and the increase in the rate of occurrence for attention-decit hyperactivity disorder. To date, antiepileptic drug treatment for subclinical epileptiform activity is recommended only in cases with cognitive regression in patients with continuous spike-wave activity during sleep [26,27], and the drugs of choice for attentional signs in epilepsy are methylphenidate and its derivatives [8,9,28,29]. Other reasons may exist for the association of epilepsy and attention-decit hyperactivity disorder. The association of epilepsy and attention-decit hyperactivity disorder depends not only on drug interactions or the secondary psychosocial impacts of the disease, but also on the type and localization of epileptogenic foci. Attentional difculties are slightly more common in patients with generalized epilepsy [2,9]. In our study, the available data supported this observation only for absence epilepsy. However, we cannot exclude the possibility that the relatively small number of eligible participants precluded us from reaching more conclusive gures. Previous studies demonstrated that in addition to attentional difculties, children with absence epilepsy exhibited difculties with behavior, verbal learning and memory, word uency, and controlled ne motor responses [23-25]. In regard to children with nonlesional partial epilepsy, attention-decit hyperactivity disorder was particularly common in patients with benign epilepsy of childhood with centrotemporal spikes and frontal lobe epilepsy. The high prevalence of attentional problems in patients with frontal lobe epilepsy was explained by research data indicating that frontal and prefrontal lobe dysfunction is a major cause of difculties in sustaining inhibition control and executive functions in patients with attention-decit hyperactivity disorder [30]. The occurrence of attention-decit hyperactivity disorder in patients with benign epilepsy of childhood with centrotemporal spikes was explained by their increased susceptibility to distraction and by the abundance of their rolandic spikes, which are particularly dominant during sleep [31,32]. Although dened as benign seizures, some children more than others in our study presented with clinical pictures that were more complicated and less responsive to

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medical treatment. The more complicated the course of the disease, the higher the risk of attention-decit hyperactivity disorder, a nding that is compatible with the fact that intractable and frequent seizures are known to alter cognition and attention [6]. In this respect, in addition to the presence of more prolonged, frequent, and complicated seizures, disease intractability also means an increased use of polytherapy, with an increased rate of drug interactions as well as secondary psychosocial impact that may further aggravate the manifestations of attention-decit hyperactivity disorder [28]. Limitations of the Study The main drawback of this study involved the limited number of patients who met the entry criteria, and the even smaller number of siblings who were appropriate for the control group. Nevertheless, some of our observations are supported by previous studies, and this study was strengthened by its prospective sibling design with a careful selection of patients and emphasis on patients who developed signs of attention-decit hyperactivity disorder after the onset of seizures. The selection of siblings with similar genetic and environmental backgrounds for the control group allowed us to focus our analysis on epilepsy per se. Such a methodological design supports our view that in many patients with epilepsy, the disease itself and its clinical and subclinical epileptic activity are strong determinants for the occurrence of attention-decit hyperactivity disorder, compared with preliminary propensity or other hereditary and environmental factors. We do not have a clear explanation for the higher than expected number of children with attention-decit hyperactivity disorder. Perhaps the number was somewhat skewed by the inclinations of families with attention-decit hyperactivity disorder to participate in the study. Conclusions The present study suggests that attention-decit hyperactivity disorder is quite common in children with benign epilepsy. A trend toward an increased risk for attentional difculties was evident in children whose disease course was slightly more complicated, whose electroencephalogram revealed more epileptic discharges, and who required more than one antiepileptic drug for seizure control. Despite the small cohort in this study, these ndings raise the possibility that these forms of epilepsy are less benign than previously thought. Future studies of larger scale groups are required to validate our ndings.
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