Attentional and Neuropsychological Difficulties Experienced with Epilepsy

This webinar will focus on a review of the common cognitive and attentional difficulties faced by individuals with epilepsy. Information will be provided about how epilepsy can impact the brain and behavior. Additional focus will be given to a review of the role of neuropsychological assessment in guiding academic and behavioral treatments.

Hilary Murphy Ph.D. is a licensed clinical psychologist and formally trained pediatric neuropsychologist with a specialization in the neuropsychological assessment of neurodevelopmental and neuro-medical disorders. Dr. Murphy has extensive experience evaluating children, adolescents, and young adults. Her training in school psychology provides her with expertise in collaborating and consulting with educators and other professionals. She adopts a multi-faceted approach to neuropsychological assessment, which takes an individual’s culture, social-emotional functioning, cognitive profile, and academic performance, into account to develop a holistic understanding of each patient’s unique presentation.

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1:48 Tonight, we’re welcoming doctor Hilary Murphy. Doctor Murphy is active with NJCTS, and has done numerous in-services for us as well as twoother Webinars. on ADHD. Doctor Murphy is a licensed clinical psychologist and formally trained in pediatric neuropsychologist with a specialization and neuropsychological assessment of neurodevelopmental and neuro medical disorders. 2:19 Doctor Murphy has extensive experience evaluating children, adolescents, and young adults. 2:25 Her training and school psychology provides or with expertise in collaborating and consulting with educators and other professionals to adopt a multi-faceted approach to neuropsychology assessment, will take, which takes an individual’s culture, social, emotional functioning, cognitive profile, and academic performance, into account, to develop a holistic understanding of each patient’s unique presentation. 2:55 Welcome, doctor Murphy, we look forward to your presentations. 3:03 Thank you so much. I’m so excited to be here again to be able to present on this topic. one of the things that always excited me when I was studying a student, and as I entered into my field, was understanding the needs of a lot of the different patients that I was, that I had the privilege of working with. And one of my greatest areas of interest was in working with individuals with epilepsy. You know, this is a really broad topic, I really want to be able to give everyone who has joined here today. A general knowledge of some of the topics that we want to talk about. And certainly, we won’t be able to go into as much depth as I would like for every individual, kind of part of this kind of discussion. But I really want to start to at least expand the discussion of some of the cognitive issues that individuals with epilepsy can experience. 3:49 Now, one of the things that I always like to start with is outlining some of the objectives that I have. Certainly, one of the biggest questions that I typically get whenever I meet with a client is, What is A neuropsychologist, what do you do? We’re obviously going to talk a lot about some of the attentional difficulties that individuals with epilepsy can experience focusing a lot on attention and executive dysfunction. I also want to tie in some of the stressors that individuals with epilepsy can experience and how these kinds of psychosocial stressors can then impact aspects of cognitive functioning. And we’re going to talk a little bit about how the findings from a neuropsychological evaluation can be used to help to guide things like treatment and appropriate interventions now. 4:34 one of the other things that I like to talk about, too, because certainly, I’m presenting this through the tourettes kind of center is, is there some relationship between something like epilepsy and tic disorders such as Tourette’s syndrome? Well, the answer is yes. one of the things that we know about some of the research that has been coming out recently is that there is a higher risk for individuals who have tic disorders like Tourette’s, to also potentially developed epilepsy and seizures. In addition, certain seizure presentations, specifically what we call … 5:10 seizures, which are these kind of brief movements. They usually look like. Jerking movements can often be mistaken for ticks and vice versa. Sometimes, these complex or subtle motor ticks can be mistaken for epilepsy. 5:25 And, in addition, you know, one of the things that we always want to talk about is it certainly in terms of the cognitive profiles, we know that individuals with epilepsy and tic disorders are also far more likely to experience things like attentional weaknesses and anxiety. So, certainly, there’s a lot of overlap whenever we’re talking about something like a neurological or neurocognitive disorder. And so, I think it’s always good to remember that while these are really distinct experiences, there can be a lot of overlap. Once we get to kind of the cognitive functioning piece, and we’ll talk a little bit about why that is later on as we get into that area. Now, like I mentioned before, oftentimes I get the question whenever somebody comes in. one of my first things to start with as they say, have you ever heard of somebody like me? Do you know kind of what you’ve been referred for, what we’re going to be doing today And oftentimes they get the responsive. 6:18 I’m not sure, Sometimes people will say, I know I’m supposed to be answering questions, some people say, Do, I know we’re going to be doing a series of tests, so one of the best things to kind of understand at a neuropsychologist as that essentially it’s our job to understand brain behavior relationships. 6:33 What that means is that we study all areas of cognitive functioning. 6:39 Cognitive function is a really broad term. It encompasses a lot of different domains. So, you know, one of the things that we do is we want to take a presenting concern. So if someone’s coming in saying, I’m having attentional weaknesses, I want to better understand what I can do about it. We look at their medical history. We look at reports from their parents if they’re adults. And oftentimes, I’m talking to their spouses, or significant others. We get teacher reports, cultural and linguistic factors. We combine that with things like behavior, as well as how an individual performs on the tests that we give. 7:16 And, essentially, what we do is, then, we provide a lot of recommendations about how we can support someone to be a successful student, to be a successful adult, to achieve the goals that they’ve set out for themselves. Now, like I mentioned before, when we talk about cognitive functioning, that’s a really broad umbrella term. And it includes things like general IQ, language, skills, visual spatial and non-verbal abilities, aspects of fine motor functioning, attention, and executive control, are going to be talking about, today, We look at aspects of memory. How does an individual learn. We can look at areas of academic functioning and tie that in together with how someone is doing socially, emotionally, in terms of their behavior regulation, and essentially then try to design a treatment plan. Collaborating with schools, collaborating with parents or other providers, such as speech therapists, applied behavior analysis Specialists. Just to make sure that they’re kind of given wraparound care, we try to address all of the areas that could be impacting. 8:16 So on now, one of the first things I think is important to talk about is what is epilepsy. 8:22 You know, oftentimes when I explore this topic with clients when they come in, we have kind of a general working knowledge. And it’s usually informed by what we’ve seen on TV in terms of what seizures look like. Certainly there is a really wide variety of what seizures can look like in different individuals. So when we think about epilepsy, this is essentially a disorder that’s characterized by seizures and when I use the term seizures, it means that there is abnormal, electrical activity in the brain. 8:54 And because of the abnormal electrical activity, there’s changes in behavior. For some people, like I mentioned before, it can look like jerking, motions people’s muscles, contents up. For other people, it can actually be far more subtle than that. You can see what are called absence seizures, where essentially an individual can be looking straightforward, are kind of involved in something. They may stop what they’re doing. Or, I love this phrase because I think everybody kind of knows what I’m talking about when I use it. 9:23 They look as though they’re zoning out and just for brief periods of time. And then they seem to snap back, they come back. Now, again, when we think about understanding why it’s important to know how something like epilepsy can interfere with attention and why it’s important to think about screening for epilepsy when we are considering. If a child does have kind of inattentive issues or problems with maintaining focus, it’s because we know that these kinds of absence seizures, oftentimes, just look like a child being distracted. That’s exactly what it looks like And because they are so brief and they can be so frequent. It’s not unusual for many of these kids to initially be referred for an assessment Because people worry that they may have ADHD, because that’s exactly what it looks like. 10:13 So certainly one of the things that we know is that it’s not always kind of this what we think of as a big or what we used to call a grand mal seizure where someone kind of stiffens and shakes and all of these things. Seizures can come in a lot of different forms for a lot of different people. 10:31 And one of the things that we know is that, despite what they look like, there’s always going to be an impact on how a person thinks and how a person behaves. And that’s why, working not just with a neurologist and other medical professionals, having someone like a neuropsychologist is very, very important to help you to understand a child’s needs, especially as they get a bit older. Now, when we think about prevalence, again, one of the things it’s important to remember is that epilepsy is quite common in terms of neurological terms. 11:00 And one of the most important things that I think is very, kind of, uh, confidence building for us, is the fact that many individuals are able to control their seizures with medications. But the thing to remember is that when we use these, use, these anti epileptic drugs, or …. That’s how they’re typically referred to. 11:21 That’s probably how I’m going to refer to them as we move through this talk that that is something that’s very important for seizure control and medical functioning. But like any medication, there are often side effects that come along with it. So like I mentioned before, we know that somebody’s functioning, when they have epilepsy, in terms of their attention, it’s going to be impacted. But one of the side effects of some of these medications, and there’s a wide variety of them that are available, can also be that it slows people down, and it can impact their attention also. 11:53 So in a lot of ways, sometimes we see this kind of two pronged kind of issue coming in and interfering with a child’s functioning overall. And what we know is that even when we achieve the seizure control, we can still see some of the cognitive difficulties that are just associated with having something like epilepsy. So it’s important to remember oftentimes and understandably so. one of the biggest focuses, once a child is diagnosed with epilepsy, which typically happens after two or more unprovoked seizure episodes. 12:27 They want to focus on medically stabilizing the child we want to get a medication that works. We want to make sure that the seizure stop and that is absolutely common sense. 12:37 But then, after that, there’s a lot of other things that can happen. Because now you may have a child who is then coping with a chronic medical condition. And this is where some of those kind of stressors that we’re going to talk about a little bit later on really also start to play a part in a child’s functioning overall. 12:54 Now, when we think about how the brain works, one of my favorite kind of ways to explain it is to think about it as an orchestra. I’m going to talk to you about specific areas of the brain that can be impacted when we have attentional weaknesses, when we have certain kinds of seizures. 13:10 But the thing to remember is that whenever we’re performing complex actions, focusing on something, taking notes in class, trying to write a paper, trying to follow through on a conversation. We are using multiple areas of our brain all at once. It’s why a lot of times, when, when people will talk about the fact that we only use 10% of our brains, I assure you that is not true. We are using a lot more of our brains, you know, to, to be able to function in daily life. 13:39 one of the things to remember is that when there’s one area of the brain that’s impacted, everything else is also going to be thrown A bit off. Kilter. That’s quite important when we think of something like epilepsy because there’s two different kinds. 13:55 Generally, there’s focal epilepsy, Meaning that just one part of the brain is where the seizures are coming from And there is another kind called generalized. Meaning that it starts in one place. But then what happens is that other areas of the brain are involved. So, when we think about generalized, it means it’s not just one area. Lots of other areas are starting to get involved to, whenever there’s any injury to the brain. 14:20 Everything is thrown off in the same way that if you take out one section of the orchestra, the, the orchestra will play the song but it’s not going to sound right. There’s going to be something wrong or missing and that’s the same thing that happens for anyone who has any kind of neurological or neuropsychological issue. They’re going to be able to perform tasks, but not as efficiently, not as effectively, or potentially not as easily, as individuals who don’t have that kind of disorder. 14:51 Now, when we think about some of the co-occurring conditions, meaning that this is something that we often see in someone who also has epilepsy. There are several different cognitive issues that are very frequently implicated, or that we frequently see, obviously, ADHD and executive dysfunction is one of them. We’re going to be talking about that in a moment, But also things like mood issues. Autism is quite common, learning disabilities, and intellectual disability, so there’s all of these, you know, really complex behaviors that can be impacted when someone has this ongoing medical condition. Now, let’s talk a little bit about what we mean when we say something like ADHD, or attention and executive functioning. Most of our kind of attentional functions and what we think of as executive control and I’ll define both of those in a minute. They live in the area of the brain called the pre-frontal cortex or the frontal lobe. That’s that red area in the diagram there. 15:45 It’s the foremost part of the brain and what a lot of people think is they assume that because something like attention and executive functioning isn’t fully developed until we’re close to kind of young adulthood, anywhere from our teen years to kind of twenties or so kind of college age. It means that we’re kind of going along, This part of our brain almost isn’t online and then we wake up on our 18th birthday, and boom, there it is. 16:13 Now, one of the reasons that this part of the brain is so important, particularly for adolescence and young adulthood is, is that one of its greatest kind of demands, one of the biggest skills that has its self regulation. So we’re able to stop ourselves from acting on impulse. We’re able to follow through on goals. We’re able to kind of resist short-term distractions to follow through on something that we know we have to do. 16:37 And one of the things that we know is that it’s not that it just turns on on our 18th birthday. It is slowly developing over time. What’s quite interesting is that we actually start to see some of the building blocks for attention and executive functioning starting as early as infancy. If you’ve ever seen a baby laying in a crib, looking up at something like immobile or a toy and they start kicking their legs and focusing their eyes? Well, that is the building block that will eventually become their attention span. And what’s also very interesting, is that when we think about executive functioning skills, we actually see that there are kind of these windows of, like, big periods of growth. Think of them as, like growth spurts for your brain. 17:19 That happened. The first one is actually in preschool, and if you think about it, a child being able to follow along with classroom demands, kind of stop themselves from budding into conversations, being able to wait their turn as they play games. All of these skills are the ones that are starting to come online, being able to express themselves when they’re upset or frustrated. The next big kind of jump in terms of development actually happens towards the end of elementary school, and then middle school, and then the brain is kind of fully functioning, once we get kind of into late adolescence and early adulthood. Now you might say to me, Well, why is that so important for this kind of a presentation? What’s important, because if a child has a disorder or something like epilepsy, that presents early in their childhood. And certainly, there are certain epilepsy syndromes that can present as early as infancy and follow someone, or occur kind of in the middle of early childhood elementary school. 18:14 What we know then is that it’s going to disrupt the brain’s ability to kind of build this structure here in particular. So, again, when we think about the orchestra kind of analogy, it’s interfering with that one section of being able to kind of fully participate with the rest of the orchestra. 18:34 Now, oftentimes, when we think about attention, we have a really narrow view about what that means, attention is really fascinating, there’s a lot of different pieces to it. Now, when we think about kind of attention as a neuropsychologist, I think about the fact that we’re not just paying attention, as I like to say in a vacuum, meaning that as you’re listening to me right now. I’m going to bet that you’re ignoring some of the things that are going on in your background. Perhaps the rest of your family, moving around in your house, things going on outside your window. The desire for you to maybe sit and scroll through Instagram as you listen to this webinar. Now, one of the biggest features of attention, and one of the things that we know, is, kind of the distinguishing factor between someone who has really good attention, and someone who, perhaps, the struggling, a little bit more, is the fact that someone isn’t just able to focus. 19:27 They can resist any distractions. They can ignore other things in their environment that aren’t as important. So, if we take the example of a classroom, A child who has a very good kind of grasp on attention, can focus on the teacher talking, and doesn’t notice as much someone behind them as clicking their pen or something’s going on outside in the hallway. They can focus on that, because they know that it’s what’s important. For a child who struggles with that, essentially their brain can’t really focus on, what’s important, that it can’t distinguish what it is that they’re supposed to be paying attention to. 20:02 So if everything is equally important, then we’re listening to the person with the pen, and then we’re listening to the teacher, and then there’s something that’s going on outside. Oh, and then I think to myself, I don’t remember if I packed my lunch today, that’s going to be something really important in the next thing. Oh, I wonder what I’m going to have for dinner when I get home tonight. You can see how all of these distractions all of these sites, if they’re given the same importance, they’re going to get into somebody’s way. Now one of the other things that we know is that it’s not just paying attention. It’s also being able to kind of divide our attention, the best example I have for something like this that’s a very practical thing, is being able to take notes when we’re in class. 20:39 So, one of the things that I always like to clarify is that people think that something like multitasking exists. People can’t really multitask. 20:48 When we think of something like multitasking, you do 1 of 2 things, either A, you do two things kind of switch from one to another. So, in the example of taking notes, you look up at the teacher briefly, In your mind, you kinda paraphrase what she’s saying and you start to write it down so that you have brief reminders of what you have to say. Or the other part that people often think as multitasking is you do something. That’s so kind of overland for you, you don’t have to think about it. 21:16 Think about like walking and chewing gum. You don’t have to pay as much attention to either of those tasks. They’re kind of automatic for you. But if I said to you, I want you to walk and also solve a really challenging calculus problem, well, you might not be able to kind of keep walking and do that at the same time. Now, the reason I bring that up is, again, oftentimes when I work with especially kind of adolescents and teenagers with attentional issues that they’ll say to me, well, I’d like to do multiple things at once, I like to have music in the background or a TV playing, Or I’d like to have my phone here Because I’ll go on my phone, and then I go back to my work. And usually, what I’ll say is that I feel like those are all distractions. Those are things that are kind of time sucks. And, again, we’ll talk a little bit more about that, when we discuss briefly, some of the potential treatments that we can use, or interventions that can be helpful. 22:05 Now, when I refer to something like executive functioning, one of the things that’s really important here, that I always have to outline is that there is no one clear agreed upon definition for what we think executive functioning is. 22:20 Now, the way that I have always thought about it, the way that oftentimes, people who work in kind of development. Think about it, is this really broad term. It is, it’s an, it’s an umbrella term that has all of these different skills that are required for goal directed behavior. 22:37 Everything we need to set a realistic goal, and follow through on the steps that we need to do to achieve that goal. 22:46 Now, one of the things that is also really important to point out here is that as the child gets older, the importance of these skills increases substantially as we age. The reason for that is that obviously, as children get older, we expect them to take on a lot more responsibility for regulating themselves, for managing their workload academically, and for also navigating aspects of their social functioning. So one of the things that’s also important to kind of tie in, in terms of executive functioning, is, that it’s not just goal directed activity, it’s also our ability to function independently. So when I talk about executive functioning, it includes things like behavior. And emotional regulation includes our ability to inhibit impulses includes our working memory, which in, which oftentimes is tied to our attention span, our ability to manage time, start tasks. How flexible we can be kind of mentally. And our ability to plan. 23:49 So whenever I’m working with somebody who struggles with aspects of executive functioning, it’s not surprising for me to see it kind of bleeding into or getting in their way particularly academically now. Again, I’ve worked primarily with elementary, middle, school, and high school aged individuals. So really one of the biggest things that I think about whenever I’m talking about something like executive control is how it then applies to academics. 24:15 And one of the things that we know from research is that the importance of executive functioning has actually been found to have this really unique relationship to academic achievement. Even above and beyond some of the features of ADHD or attention deficit hyperactivity disorder. Now, the reason that these two skills go together, attention, regulation, and executive functioning is, partially because they live in similar parts of the brain. They both are really involved in this pre-frontal cortex or frontal lobe, but also, these, again, are these kind of higher level skills that are developed over time. Now, whenever I think about academic functioning, again, there’s two aspects of this. 25:02 A executive functioning skills are what allows a child to plan long term assignments, like a book report, to break things down, to know how long it will take them realistically to complete things, to be able to get started, to avoid procrastination, and to actually monitor the quality of their work and their behavior, so that they meet the goal that they set for themselves. 25:26 But, also, it’s important to highlight the fact that, as academics become more challenging, writing, reading, and mathematics all start to increasingly draw on executive functioning skills. Even above and beyond, just managing demands and deadlines. It’s thinking through things. 25:46 So, you know, one of the things that I always kind of outline to parents is the example of writing. Written expression is probably one of the most, if not the most Executive Lee demanding skills that we have. Whether we realize it or not, in order to be good writers, we have to be able to brainstorm topics. We have to be able to plan out how long it will take to produce written work. We have to break the task down into separate kind of activities. So, selecting a topic, doing research highlighting areas to discuss, then producing a draft, editing that draft, editing again. 26:24 And, also, we know that in terms of being able to regulate ourselves, this is a task that is long, is tedious. You know, one of the things that I always go back to is good writers write once great writers write many times. And for a child who struggles to regulate themselves and perhaps, get started on things and also regulate their frustration, this is going to be torturous. And oftentimes, I see these two things going hand in hand. Other examples are things like reading comprehension, where we have to remember what we know from the previous chapter. 26:58 We have to make these ongoing predictions about what we’re reading. As we read through the texts, we have to stay focused or in mathematics, where we have to do these multi-step tasks and equations. And whenever we have a multi-step process, we know that we are more likely to make mistakes because of all of these different steps and all of the cognitive skills we need to be able to attend to something like this. So, it’s not surprising that even in children who are very, very capable, either intellectually or academically, we can see that they’ve kind of fail to meet the mark. They don’t perform up to their potential. Because of all of these underlying weaknesses. 27:36 Now, when we think about what attention deficit hyperactivity disorder looks like an individuals with epilepsy, it’s important to get a little bit of history years ago Because it was always acknowledged that there would be attentional weaknesses in someone who has epilepsy. You actually could not diagnose ADHD in a child who has already provided with the diagnosis of epilepsy. 28:00 Now, over time and with a lot more research, what we’ve understood is is that for some individuals, the attentional weaknesses that they demonstrate go so far above and beyond what we would think of just for epilepsy alone that they warrant two diagnoses. So, oftentimes, when we’re working with individuals, they can have kind of this, this discussion of, is this enough of a difficulty, doesn’t have enough of an impairment on this person’s life to warrant an additional diagnosis, or is it kind of within expectations for what we might expect for someone who already has epilepsy. And there’s a lot of discussions, oftentimes, with clinicians about what’s the use of giving this additional diagnosis. Now, personally, I think for many people, it can be very validating. And oftentimes, too, because many people are not aware of what epilepsy can look like in terms of how we function and how we, you know, are able to Performance School or perform, in terms of our jobs. I think having that additional label is really useful because it gives us a quick and dirty understanding of, oh, I understand that if you have ADHD, you’re going to be distractable. You might make mistakes. You’re going to have all of these things. 29:14 Now we know that, like I mentioned before, it is highly, highly common for someone who has epilepsy to also be at a much higher risk of developing ADHD. And we also don’t see any significant differences in terms of boys and girls on whether or not they have ADHD and epilepsy. But like I mentioned before, we always have to consider, could this also be a side effect of the medication that a child is on. So there’s many different levels that we have to analyze in order to determine if this isn’t an appropriate diagnosis. 29:42 I always like to highlight two that whenever we, as neuropsychologists, are called on to make a diagnosis of ADHD, I oftentimes will get a question from parents of know, I feel like every child I meet has ADHD. I feel like a lot of people have this. Is this a real diagnosis? 29:59 And what I usually like to explain is is that for many people, we all experience times we’re not as focused was we would like. We’re not as organized as we would like. We, you know, put things off. 30:10 But, many times, these little difficulties, this idiosyncracies don’t have a significant impairment on our ability to be successful, students or successful adults. 30:24 But, for other individuals, it does. So, whenever we’re called on to make this diagnosis, that is a huge part of the equation. I’ve seen many people that come in for 1 or 2 days of testing with me, and they don’t do as well on some of the attentional measures, as perhaps I would expect. 30:43 But when I talk to them, when I review all of that information that I outlined before, their medical history, their educational history with their teacher, say with their parents, say what they say, I’ll find out the fact that, really, there’s no evidence that it’s getting in their way, could be a little bit of a weakness but it’s not something that’s functionally impairing. And that’s very, very important for us. Because sometimes I have people who come in and they assume that, well, the minute that I walk into the office, you’re just gonna think that I have ADHD. And really, I argue no, oftentimes I kind of have a clean slate, I’m not tied to any one diagnosis. I’m gonna give you kind of what the data supports and what is going to be most helpful for you as you move through life to understand how you function as the other. People also know what you need to be successful. Now, when we think about what the attentional profiles in individuals with epilepsy look like, they are a little bit different from just people who have ADHD, attention deficit hyperactivity disorder alone. Now, when we think about ADHD, a lot of times there’s questions about, well, what how does ADD fit into this? How does just, you know, what? what do these terms mean? 31:50 What we used to call ADD or Attention Deficit Disorder, is now under the umbrella of this larger diagnosis of ADHD or attention deficit hyperactivity disorder. I personally do like to think of it almost like a spectrum. 32:06 At one end, we have people who are very, very distractible. There are people, who have a lot of those executive functioning issues. Oftentimes, they’re described to me as people who move a little bit slower than their peers Their daydream me. They’re lost in their own thoughts there easily, internally, distracted At the other end of the spectrum. We have kids who are jumping out of their seat there, always calling out. They really struggled to regulate their frustration. They’re loud. They’re active there, you know, kind of the boisterous part of the room, They’re the kind of stereotypical ADHD presentation and then we have the middle where it’s a mix of the two of kind of those two extremes. What we used to think of as ADD is more of this inattentive presentation, the first one I talked about. 32:57 We also have this primarily hyperactive or impulsive presentation, and then we have the far more common one, which is the combined. When we think about ADHD alone, that kinda middle diagnosis is the one that’s most commonly provided, because it essentially says that we have evidence of distractibility, impulsive Behavior and restlessness. 33:18 Now, when we think about what this looks like an individuals with epilepsy, it’s a bit different because they are far more likely to just look inattentive. They are someone who really struggles, to regulate their focus for long periods of time. They can struggle on kind of persistence on tasks. They’re more likely to get lost in their own thoughts. And, again, if we think about some of the seizure presentations that I talked about before, that’s not surprising, because there are some seizures that look like attentional issues. And also we know that this is something that is kind of unique to individuals with epilepsy. Now, the other thing that’s very important is that for many individuals, these attentional weaknesses are often seen or they’re reported before seizures emerge. So, there is some suggestion that there are some change in how someone is functioning before seizures or even present in that person’s life. There’s something that’s different about how their brain is working. 34:10 Now, I talked about the fact that there are a lot of psychosocial stressors that can come along with being someone or being an individual who has a chronic medical condition. For a lot of kids, there can be the sense of guilt. There can be this idea that, you know, people don’t have as high of expectations of me, or there can be a fear that they may have a seizure in public. And, again, like I mentioned, seizures can look very different for a lot of people. For some people, it’s very subtle. And for others, it’s very, very obvious and for a lot of kids, especially adolescents, it can be quite embarrassing and freight. 34:52 one of the things that we know is that unfortunately, for a lot of kids, what can happen is that they can be reluctant over time to remain consistent with their medication because there can be effects of their medication on their ability to consistently pay attention. They can feel slow, or sluggish or lethargic. For some people, it can cause some kind of irritability or mood changes. And so, again, there’s all of these other things that can come into play, and also the fact that there can be a family burden for a lot of individuals. Certainly, having a child with a chronic medical condition can be a stressor, both emotionally, financially, and oftentimes kids do sort of take on this role and their families feeling like they’re the one that’s sick. They’re the one that is the, quote, unquote, problem, And, again, when we think about how well parents and family members and other caregivers react to a child with epilepsy, that can be quite important. 35:52 Now, the reason that I talk about aspects of stressors in the context of this kind of talk is the fact that one of the thing now, that we know is that the presence of any level of distress, whether it’s anxiety, depression, or just general tention, it’s going to have a negative impact on our attentional resources. 36:12 The best way to think about this is the fact that, for us, our brain has a limited amount of attention. it can give, at any given time. Think of it like a bank account. You have so many attention dollars that, you know, any point in your day. 36:27 If all of your attention dollars are spent on thinking about how upset you are, how frustrated you are, something that went wrong in terms of, you know, your relationship with somebody else, or if you’ve ever had a day where you’re just really preoccupied with something that you need to take care of, or a fight that you have with a loved one. You can probably relate to the fact that when you’re at work or wherever you were in that they you weren’t your best self, you weren’t fully present because you’re so consumed with this you’re attentional dollars are being spent on this stressful event. 36:58 Well, if you combine that with the fact that somebody with epilepsy and ADHD or just either one of those issues alone, already is kind of at a deficit in terms of their attentional dollars. You can see why the addition of any stressor is going to make it even harder for them to consistently perform up to their potential. It’s also important because we know that there is a really high prevalence rate of mood disorders within the epilepsy population, and that for some individuals, they’re seasonal presentation can include mood symptoms. There are some people were the way that their seizure comes on. So, if we talk about, you know, the … period … meaning seizure, they can get frustrated, angry, aggressive, or very, very depressed. We call that kind of echo, anger, or …, or depression, or there’s also Excel anxiety. So couple that with the fact that then you can have just this ongoing stressor. I don’t want to have a seizure and somebody else sees it. 38:01 Am I going to be, OK? Do I have to take medicine for the rest of my life? Why did this happen to me, or mom and dad, OK? They’re really worried about me. I want to be more independent. Can I drive, can I go out on my own? All of these really basic things that we think about in terms of independence. That may be challenging for a child who has this chronic medical condition. 38:23 Now, when we think about the fact that there are certain risk factors for having a mood disorder, again, it’s all of these complicating issues. We know that for some people, it’s having a brain injury. For a lot of children, when we kinda think about how kind of seizures come on or why they experience epilepsy, one of the causes can be a head injury. It can be acquired epilepsy as opposed to someone who has more of a congenital disorder where it was something that was present at birth. Or, for some people were not sure. We’re not sure why they have them. We know that there is this genetic link, But it’s not, you know, direct 1 to 1. So, that’s a really complicated disorder that can come about in a lot of different ways. They can depend on the severity of the syndrome. 39:06 Certainly, we can have syndromes that really don’t have a significant or severe impact on daily life, all the way up to someone who is very disabled because of this condition, as well as the presence of these stressors, the family dynamics, as well as what kind of medications that they’re on. 39:24 So, this sort of brings me to one of the last pieces before we take a little bit of time to answer any questions that may come up. And it’s the question was, how do we help, then? We know that these children are at risk for having a lot of these issues. So what can we do in terms of being caregivers, in terms of being teachers or school personnel, in terms of being mental health professionals or other related therapists, occupational speech, or kind of physical therapists? The answer is kind of multi-faceted. 39:56 As parents and family members, one of the most important things is to be educated, to be aware of what this is to be an open communication with your child’s care team, as well as their school. And with your child, it’s important that we involve children in aspects of their care in a developmentally appropriate way. one of the things to remember is that oftentimes, children who have chronic medical conditions, they feel like they don’t have a lot of agency, they feel that they don’t have a lot of control over what happens to them, And that is a really realistic reaction, because in all honesty, they don’t, if they have to be on medication, that’s oftentimes a decision that’s made without them. If they have to see certain professionals, to make sure that they’re OK, whether it’s a therapist, or a school, kind of specialized teacher, or a certain kind of doctor, all of these decisions are made without them. 40:49 So, whenever we involve them in a way of talking about why we have to do some of these things, how we want to handle some of these kind of concerns. I think that can be very, very empowering for children. And as they get older, making sure that the rest of their treatment team, whether it’s clinical, whether it’s medical, whether it’s school based, that they slowly involve the child in this process, as well. 41:12 As teachers, oftentimes, it’s understanding that children who have something like epilepsy and ADHD, they are going to require specialized care. And that, really, one size, does not fit all. 41:25 Certainly, you know, we know that there can be a lot of cognitive issues in individuals with epilepsy, but one of the risk factors for having this negative kind of outcome is, if we have lowered expectations for these child, many individuals who have epilepsy and ADHD are functioning within normal limits. If not above what we would expect, cognitively, their reasoning skills are well developed. They are capable of success, but whenever we have the presence of this kind of medical condition, we oftentimes want to understandably enough kind of take some demands off. And that’s not always something that’s helpful. We want children to feel like we’re meeting them where they are. 42:05 We understand that certain things can be challenging, but also that we have appropriate or high expectations of them, so that they do learn how to strive, in terms of the, you know, finding their best whenever that may be. In addition, making sure that you have open an ongoing communication with the family, like I mentioned. Oftentimes, when we see some of these behaviors, especially in ADHD, it’s not unusual for these kids to be mislabeled as the kids who are the class clown. They’re always disruptive. They’re trying to get out of it. Now, certainly one of the things that we know about attention is that this is highly tied to motivation. If you are not interested in a task, it is going to be far more challenging for you to consistently pay attention to that and follow through. In the example I like to give is the fact that if you put me in a classroom talking about psychology or epilepsy or one of these things that are very, very interested in conspiracy theories, I’m going to be able to pay attention probably for hours at a time. 43:06 But if you put me in a calculus class, which is something that I am not interested in and also not good at, it’s going to be much harder for me despite the fact that I can regulate myself a little bit better. That’s also a misconception about ADHD. Parents sometimes say to me, well, they can have attentional issues, because if I give them Legos or a video game or something that they love to do, they can do that for hours. 43:29 But in reality, one of the ways that I think about 82 really is a primary deficit, and our ability to stick with things that perhaps are not as intrinsically interesting or kind of engaging for us. 43:43 one of the biggest skills is adults that we develop, is the ability to understand that we have to kind of do the short-term work, to have the long term gain, You know, being able to push through a class that we don’t really like, but knowing that that’s going to help us. You know, when we get to college. Or to kind of get the grade that we need. Or using it as a stepping stone. 44:03 For something else, You know, making sure that we don’t just excel in things that we really, you know, are more interested in, that we are also trying our best in everything else that we do. 44:16 In terms of being involved in aspects of mental health, one of the things that I think is very important, and I think it extends not just to mental health, but to anytime that we are involved in treatment with a child. 44:28 one of the things that I think can be quite challenging is the idea that we consider this, what do I like says is toxic positivity. 44:38 Know, one of the best examples that I have of this, was when I was training as a postdoc, I was actually in a rehab hospital, meaning that I was working with children who were kind of recovering from things like traumatic brain injuries or brain surgery. Or any of these things were oftentimes, they were given this really intensive care in terms of speech therapy, psychological, cognitive therapy, physical and occupational therapy in order to help them regain skills. 45:10 And when I was participating in one of these therapy sessions, whether speech or OT, with one of the clients that I worked with, I made the mistake of saying, you know, it’s all going to be OK or some one of those, like, just general platitudes. 45:26 And the trial turned to me and said, no, it’s not. 45:32 I had an injury And now I have to relearn how to walk and to do things that I never thought about before. 45:40 And so one of the things that we have to remember is that in our effort, to be positive and not feel uncomfortable when working with these really serious concerns, These really kind of chronic conditions. Is that, yes, we want to say everything’s gonna be OK. But sometimes it’s OK to not be OK, and it’s OK to give children that space to say, This is hard for me. I don’t like having to take medicine. Or in the case of certain epilepsy syndromes, kids may be on this extremely strict diet where then we have to explain to the family why they can’t have things like you birthday cake or cupcakes, even just one time, because, unfortunately, that raises the risk of something like a breakthrough seizure. So, if you ever read about a ketogenic diet for certain epilepsy syndromes, it’s something that is really important for medical functioning. 46:28 But has the secondary effect on our social skills, especially for young kids. How can you go to a birthday party and not be able to have some of the treats and goodies that are there? And how do we explain that to a child who’s still very young, you know? And again, it’s sort of a simplistic example, but I think it’s important to remember that we can’t just focus on one area, so whenever we have a medical concern, it can’t just be about how our body is functioning. Our body is connected to our brain. Our brain controls how we think, how we feel, and how we act. All of these things are inter-connected. We can just focus on one piece with the expense of anything else. 47:08 So I hope that these are kind of helpful guidelines, or a helpful discussion of this very interesting topic in terms of treatments. You know, they can range quite while, or I should say, vary quite a bit when we think about some of the things that we recommend for children, because epilepsy can take so many forums. And because ADHD and these attention deficits can come in many different kinds of shapes, Sizes, and flavors. We know that oftentimes, we can range from having something like a Section 504 Plan, where a child is accommodated to function in a mainstream or general education classroom, to having a really strict and robust IEP or individualized education program, where essentially, there is a binding legal document. That outlines not just how a child can be accommodated in the school, but it changes how they’re taught, if they’re given, you know. 48:03 Pull out services or speech therapy or occupational therapy or placement in a self contained classroom or a specific kind of classroom that supports language development or supports kind of adaptive skills. There’s a lot of different things that we can recommend academically. There’s exploring the idea of outside therapies, like I’ve mentioned before of OT, speech therapy, physical therapy, working with a behavioral therapists to manage aspects of our emotional functioning, and all of these things can really be discussed, working with the school, working with an outside clinician like a neuropsychologist. I think that that can be a discussion in and of itself. 48:44 So, I know that we’re getting down to about 10 minutes left in our time together today. So, I’d like to take a moment and perhaps explore some of the questions that have come up, so that I make sure that we have time to answer some of these, and then obviously also, I’ll be able to address some of them the blog. 49:03 And before we get to that final part, I really want you guys to consider checking out some of the additional resources that are provided through the tourettes kind of association. 49:14 may say think being, being able to access some of these webinars, being able to hear some of these speakers, talk about areas of expertise, can really open up a lot of different avenues. I know, like I mentioned before, often have people don’t know that somebody like, like me exists until they’re referred to see me. There’s a lot of different professions and a lot of different supports and services, and also many different topics related to not just tourettes, but other aspects of cognitive and behavioral functioning that can be so helpful for families, for children themselves, to understand what’s going on. So, I really encourage you to check that out. 49:50 So, with that being said, let’s open it up to some questions and kind of go from there. 50:00 OK, or you gave us a lot of information? 50:06 Um, so I’ll start with our first question that came in, Ken. 50:14 He does provoke T S, and I believe, that’s anti angela anti epileptic drugs. 50:22 That is a very, very, very good question. 50:25 Now, I’m going to say that I can give a little bit of an answer on this, but it’s something because I do not prescribe. Medication would be an excellent question for a treating physician or medical doctors or someone like an neurologists psychiatrists. 50:43 I am not aware of side effects that can provoke something like TF. However, I also recognize that ADD medications, there are many different types out there, and that side effects sometimes can be rare. So I would redirect that, to be something, perhaps, address to a particular neurologist, someone who has expertise in managing and prescribing medications, because they would be someone that is the most Kind of knowledgeable about a subject like that. 51:17 Fair enough. 51:18 Fair enough, As you were talking about school related stuff. 51:30 Somebody commented that they’re an added diagnosis other than epilepsy is necessary, because educators don’t truly understand that there can be modifications needed for epilepsy. 51:47 I would absolutely agree with that. 51:49 I think being able to provide the most comprehensive picture is the way that I have always approached evaluations. Some people really like to be you know, kind of succinct and give the, you know, 1 or 2 diagnoses. And it’s not to say that that’s wrong in any way, shape, or form. 52:04 But, as someone who was originally trained as a school psychologist, I believe that providing as many appropriate diagnoses and the most complete picture of where a person is not just medically and physically, but cognitively and emotionally is very, very important. So, I would absolutely agree with that. Oftentimes, when I’m working with families, you know, one of the things that can come up is kind of what is the most appropriate classification for my child. And, certainly, that varies from child to child. But, a lot of times, if I have more than one presenting concerns to something like a medical diagnosis, such as epilepsy and perhaps attentional weaknesses or ADHD and maybe a learning disability, all of these things, you know, do kind of co occur together. 52:48 I’ll talk about the fact that classifying it appropriately as being multiply disabled or having multiple disabilities can be very, very helpful to frightening term and I don’t really like it, but it reflects the fact that there’s more than one thing that’s going on and it allows kind of this opening up of services. So I think that that comment is very, very spot on, and I fully agree with that it’s why also having someone who’s not just a neurologist, but also a neuropsychologist can be helpful in providing those clear diagnoses. 53:19 You may or may not be able to answer this: If brain activity is considered stable with a med, is the person safe for having seizures? 53:31 That is a very complicated question. It’s a very good one for a neurologist, but I will give you a very bare bones answer. Oftentimes, when we think about safe from having seizures, that can be a really challenging question. Particularly in kids. Because one of the things that we know is that as people get older, their brain and body changes, so their tolerance for something like a medication can also change. So for some people, we see that they can be stable, or kind of what we call seizure free on medication for a long period of time, Meaning that the medication is working. Now, some people misinterpret that as meaning that well, then I don’t need the medicine anymore. And really we know that that can be a tricky thing. 54:11 Some people do over time, come off of medication, But that is a really individualized thing. There is no kind of one size fits all for something like that. Because it depends on what kind of epilepsy It is. How severe it is, and how kind of a person is functioning on their medication. What that really means, if you are seizure free on medication, you are not experiencing known seizures. Or you are having E J’s are kind of brain electrical studies that are saying that you’re not having a seizure in that time, it means that your medication is working. That’s the most accurate way of thinking about it, And it’s not to be scary, It’s just to also take it seriously. And it’s a good thing to discuss with your physician about, you know, what does this mean for me in long term? Because that really varies from person to person. So, I hope that’s helpful. 55:01 Uh, you talked about how, if there was a class on. 55:11 On something that you like, your attention as much better than, say, count the classes about calculus. 55:20 How care, What are some tools we can give children to learn how to better focus on the classes that they consider boring. 55:32 That is a phenomenal question. one of the things that I usually like, and one of my first, kind of go to techniques for something like that, is building in a reward. So whenever, I think about the fact that I, let’s say, let’s use that example of having the study for a class like calculus, which is a challenging for me. And also, not that interesting to me. 55:52 Oftentimes, when I have a class like that, or when I’m working with a student that may struggle with aspects of attention and focus, when something’s not as interesting, I’ll say, plan something that motivates you something you want to do. Get this studying done. This test down, this assignment done first. 56:13 And then reward yourself because then what you’re doing is you’re tying in something that is motivating is exciting to something that’s not, you know, as fun or interesting. In psychology. We call it the … principle or kind of grandma’s rule, meaning that before you have dessert motivating, you have to eat your vegetables. So for calculus. So that’s something that can be really helpful and depending on how old the child is and how taxing the task is, we can design behavior plans, so that someone can earn rewards. Whether it’s small things over time, or whether it’s being able to engage in a preferred task, like using a tablet, or kind of going online or using social media. 56:55 Most kids get a little bit older, we can talk about Earning larger rewards. You know, oftentimes, I’ll talk about the fact that we don’t work for free. I love what I do, But I also love to have kind of the freedom and the ability to use money to spend on things that I really do enjoy spending time with my family, are going out or doing anything like that. So, making sure that we tie in the fact that there is some reward overall and make it meaningful for that child. I think that’s one of the first techniques that can be helpful. In addition, making sure that the child is involved, as much as we can, as developmentally appropriate, as, as we can make it, in, kind of developing what is important. What’s getting in your way. You know, oftentimes, one of the other techniques are one of the other potential services that can be very helpful for people who stuck, who struggle with ADHD. Your executive dysfunction, is working with an executive skills coach. 57:47 They’re actually trained professionals who develop an individualized plan for someone who struggles with things like getting things started, or kind of staying consistent on a task. And one of the things that can be helpful is, is that you’re working with someone who knows all of these techniques, and they can troubleshoot with you. And oftentimes, for kids, we work, not just with the child, but also with the adults in their life. To make sure that they are being motivated appropriately. And they’re being essentially, they’re staying consistent with the plan that we developed. So there’s a lot of different ways, but one of the best things to do, is to tie it to something that is very motivating for you. 58:29 You talked about, quickly about 504 plans, and then you said something about IEPs being a really buying legally binding document. 58:40 I just wanted to make a comment than a 504 as a binding document, as well, you know, so don’t don’t think that one is better than the other. 58:52 It’s, it’s, it’s are different, but when the 504 is a binding document as well Absolutely. 59:03 Is essentially, one, allows you to stay within a general education or a mainstream classroom with accommodations, like sitting at the front of the room Or being able to access the school nurse to, You know, kind of have a safety plan or making sure that we have an FM system, or some of these other things, Whereas an IEP really has these changes, and how we teach kids. So I’m glad that you clarified that. Thank you, Kelly. You’re absolutely right. 59:28 Do all seeds or true to all seizures have warning signs? That’s a really good question, and the answer is not necessarily. So oftentimes when we think about warning signs, we think of something almost like an aura. Sometimes before somebody experiences a seizure, they’ll describe things like feeling weird, feeling a little bit of deja vu, feeling what we call epigastric rising. It’s a fancy way of saying kind of like a rising in their trust. 59:55 Where some of these other just unusual for now, and I’m not dissimilar to what people will describe when they have migraines. They’ll have these kind of visual changes that kind of tell them OK, and migraine is coming on. Some people can have those. But some people don’t. So for example, with Amazon’s epilepsy, people oftentimes have very little, if any idea, that they’re experiencing episodes, because there are so brief. There so frequent. And they’re just not aware of the fact that there’s any obvious changes in their behavior. It’s why oftentimes it can be overlooked for a period of time, or it can be mistaken for something else like distractibility and ADHD, So it’s something that can happen in certain kind of seizure presentations but not always. And that’s, again, kind of a really good example of how epilepsy is, you know, a broad term that encompasses a lot of different things and a lot of different presentations. 1:00:52 So you were talking about things that can be distracting. 1:01:00 In there, you said, listening to music or music in the background that kids like to have music in the background. 1:01:08 Personally, I like to have music in the background. sometimes. 1:01:12 Other times, I have to turn it off you’re It’s not. Is there a be all and end all? Should they never have their music? or Another question? I would say that there’s no be all end all. Oftentimes, whenever I’m talking with people who are coming in and describing a lot of these attentional difficulties, we really want to take stock of what do you think could be getting in your way? So, in the example of someone saying to me, Well, I like to listen to music, I’ll talk about the fact, or do you ever find yourself being distracted by, Do you ever get up kind of dance along with it? Do you ever find yourself listening to the music a little bit more than writing the paper that you were supposed to be working on, or getting distracted and kind of turning around saying, oh, this song makes me think of this, or who, I don’t like the song. And then you spend 10 or 15 minutes choosing what kinda playlist you want to play. So there’s a lot of questions, because you’re absolutely right, there’s some people who can say something like classical music, can be very, very helpful to them. 1:02:15 Are listening to songs like their specific playlist that they’ve heard over, and over again, that they associate with studying, So there’s not necessarily this one thing, but oftentimes that I’ll say to people, is that you really can only fully focus on one thing at a time. So, if you’re focusing on the music, you’re not focusing on your work, the music should be background, meaning that it’s kind of already there, and because we know that, in order to fully pay attention, we have to ignore as much as we can. We want to make sure that that kind of background noise isn’t making it more challenging to focus. I’m glad you asked that, because certainly attention, there’s no one size fits all. It really is a lot more diverse than we usually give it credit for. 1:02:59 Because Mom was always playing the radio from the time she woke up, I was just, Is it OK to work in front of a television? 1:03:10 I’m the same either. 1:03:13 Same way. 1:03:15 Uh, well, that seems to be the majority of our questions for this evening, and I appreciate your time, doctor Murphy. So, I think we’ll end the webinar at this point. 1:03:32 So, thank you for everyone for joining our webinar and attentional neuropsychological difficulties Experienced with epilepsy. There is an exit survey, which we need everyone attending to fill out. The webinar blog is now open and available for the next seven days on … Website, for any additional questions that were not covered in tonight’s presentation, That website is … dot org. Also, an archived recording of tonight’s webinar will be posted to our website. Our next presentation, Collaborative Problem Solving, will be presented by doctor Jeremy Lichtman and is scheduled for June 30th, 2022. 1:04:17 This ends tonight’s webinar. Thank you, doctor Murphy for your presentation. And thank you, everyone, for attending. 1:04:23 Goodnight. 1:04:25 Thank you. Goodnight.


  1. ReneeC says:

    If brain activity is considered stable with med is the person safe from having seizures?

    • Hilary Murphy Ph.D. says:

      This is a great question! I should say that this is a question that is best directed to a physician as they are best able to discuss the nuances of medication. However, in working with colleagues, they often describe patients who are seizure free on medication as having appropriately managed seizures. Essentially, that the medications an individual is taking are working.

  2. Laura R says:

    Can AED provoke Tourette syndrome?

    • Hilary Murphy Ph.D. says:

      Since I don’t prescribe medications, this is something that a neurologist or other physician would be well suited to answer. However, I did receive some feedback from colleagues about infrequently seeing tics manifest after starting certain medications. However, in these anecdotal experiences, these side effects resolved. I encourage anyone concerned about this issue to consult with their doctor.

  3. JillSmith says:

    What tools can we use to help get our child through a class that they find boring?

    • Hilary Murphy Ph.D. says:

      Oftentimes, I recommend parents rely on a concept in psychology called “Grandma’s Rule” or the Premack Principle. Essentially, this involves coupling a desired behavior or reward with something less interesting (e.g., like having to eat your vegetables before having dessert). This coupling provides a natural reinforcer for something that isn’t as fun. For example, when a child sits down to do homework, I often recommend they start with the subject they enjoy the least so that they avoid putting it off or procrastinating. Using positive reinforcement, like earning rewards, can also be an effective method. For some children, it can be important to find ways to practice practical academic skills in more engaging ways. I like using the example of working with a child to cook or bake while following a recipe. This can be done under adult supervision and can facilitate practical reading (e.g., reading the recipe aloud to the parent) and math (e.g., working with measurements, time, and fractions) in a non-threatening way.

  4. LMontgomery says:

    You spoke of 504s and IEP’s but you said that IEP’s are a legal binding document. Does that make an IEP better than a 504? or are they both binding documents?

    • Hilary Murphy Ph.D. says:

      Certainly, both a Section 504 Plan and an Individualized. Education Plan (IEP) are binding legal documents. However, the difference between these two programs depends on the needs of the student. In a section 504 plan, a student is provided with accommodations to function optimally in a general education classroom. These supports typically include preferential seating, extended time, and in some instances related services such as occupational therapy. These supports allow a student to access a general education curriculum but does not change how instructions provided. In contrast, an IEP involves modifications to how a student is taught in order to provide the most appropriate education. This may include dyslexia specific reading instruction, placement in a specialized classroom, and other supports addressing conditions which may interfere with the child’s learning. Both plans have strengths and weaknesses and a decision about which is most appropriate depends on the unique needs of the student.