Epilepsy&

Epilepsy & Behavior 4 (2003) 729–732

Behavior

www.elsevier.com/locate/yebeh

Anxiety in children with epilepsy

Jane Williams,* Chris Steel, Gregory B. Sharp, Emily DelosReyes, Tonya Phillips,Stephen Bates, Bernadette Lange, and May L. Griebel

Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA

Received 9 June 2003; revised 20 August 2003; accepted 20 August 2003

Abstract

Although the prevalence is unknown, affective disorders are more common in children with epilepsy than in healthy controls. The

purpose of the present study was to examine the occurrence of anxiety in children and adolescents with epilepsy and to determine

factors associated with elevation of these symptoms. Children and adolescents ðn ¼ 101Þ between the ages of 6 and 16 years were

given the Revised Children�s Manifest Anxiety Scale (RCMAS). Mild to moderate symptoms of anxiety were reported by 23% of the

patients. Based on regression analysis, factors significantly associated with increased anxiety included the presence of comorbid

learning or behavioral difficulties, ethnicity, and polytherapy. Results suggest the need to monitor children and adolescents with

epilepsy for affective symptoms in order to provide appropriate interventions.

� 2003 Elsevier Inc. All rights reserved.

Keywords: Epilepsy; Anxiety; Childhood

1. Introduction

As a group, children with epilepsy experience moreemotional problems compared with healthy controls [1].

The two most common affective disorders occurring in

this population are depression and anxiety, although

their prevalence in children is unknown. The unpre-

dictability of seizures, the fear of death, parental reac-

tions of distress and fear, the stigma associated with

epilepsy, and misinformation about the disorder may

predispose children and adolescents to anxiety andnegative affective responses [2].

In a study by Ettinger et al. [3], 16% of 44 children

and adolescents with epilepsy between the ages of 7 and

18 years had elevated symptoms of anxiety on the Re-

vised Children�s Manifest Anxiety Scale. Using a T score

of 60 or above, the percentage was similar to that of a

normal population. Factors including gender, age,

monotherapy versus polytherapy, and convulsive versusnonconvulsive seizures did not result in differences in

* Corresponding author. Present address: Wake Forest University

Medical Sciences, NWAHEC, One Medical Center Boulevard, Win-

ston-Salem, NC 27157-1060, USA.

E-mail address: janewill@wfubmc.edu (J. Williams).

1525-5050/$ - see front matter � 2003 Elsevier Inc. All rights reserved.

doi:10.1016/j.yebeh.2003.08.032

symptoms of anxiety. They did not find significant cor-

relations between anxiety scores and epilepsy duration,

age of seizure onset, or number of recent seizures.Margalit and Heiman [4] used the State–Trait

Anxiety Inventory to examine anxiety in children with

epilepsy, children with learning disabilities, and heal-

thy controls between the ages of 8 and 14 years.

Children with epilepsy were found to report signifi-

cantly higher levels of trait anxiety than normal con-

trols although they did not differ from children with

learning disabilities.In a study by Alwash et al. [5], children and adoles-

cents with epilepsy (48.5%) were found to have a sig-

nificantly higher tendency to develop symptoms of

anxiety when compared with healthy controls (16.8%)

based on DSM-IV criteria. Anxiety symptoms were

more likely to be present when seizures were un-

controlled.

Oguz et al. [6] used the State–Trait Anxiety Inventoryto compare children and adolescents with epilepsy and

healthy controls. Increased anxiety was found for the

children with epilepsy, especially after puberty. Al-

though the younger and older children with epilepsy did

not differ in elevation of symptoms, younger children

(9–11 years) had elevated levels of trait anxiety while

730 J. Williams et al. / Epilepsy & Behavior 4 (2003) 729–732

older children (12–18 years) had elevated levels of bothtrait and state anxiety when compared with healthy

controls. Increased anxiety was associated with in-

creased seizure frequency and polytherapy for younger

and older children. Epilepsy duration was associated

with increased anxiety only for the older group. No

effect in symptom elevation was noted for seizure

type, age at seizure onset, or electroencephalographic

findings.The number of studies that have examined anxiety in

children with epilepsy is small and the prevalence re-

mains unknown. Although severity of epilepsy has been

associated with increased anxiety, other disease-related

factors do not appear to be predictive of anxiety in these

children. The goals of the present study are to increase

knowledge concerning the occurrence of anxiety in a

broad sample of children and adolescents with epilepsyand to determine other factors that may be predictive of

its presence. Unique to this study is the examination of

comorbid conditions commonly found in children with

epilepsy, socioeconomic status, and ethnicity. Identifi-

cation of risk factors may assist health care providers in

determining which children require more monitoring

and intervention for affective symptoms.

2. Methods

2.1. Subjects

Subjects were children and adolescents ðn ¼ 101Þbetween the ages of 6 and 16 years (mean ¼ 11.29

years, SD ¼ 2:4) who had been diagnosed and treatedfor epilepsy for at least 1 year. The mean time since

diagnosis was 4.8 years (range¼ 1–15 years). There

were 48 females and 53 males. Ethnicity included

Caucasian ðn ¼ 76Þ, African American ðn ¼ 23Þ, and

other ðn ¼ 2Þ. Mean socioeconomic status (SES) was

within the middle range (mean¼ 34.7, range¼ 13–61)

based on educational and occupational levels of the

parents [7].Children were consecutively recruited at the time of

their visit to outpatient neurology clinics at a university-

affiliated children�s hospital. Children who had severe

cognitive disabilities or were nonverbal were excluded

from the study. Seizure type included 62 children with

complex partial seizures, 13 with generalized tonic–

clonic seizures, 25 with absence seizures, and 1 with

mixed seizures. Of the 66 children who had brain MRI,79% had normal scans and 21% had abnormal scans.

Eighty-three of the children were on one antiepileptic

drug (AED), 15 were on 2 AEDs, and 3 were on 3

AEDs. Based on parent report, 80% of the children were

perceived to have good control of their seizures (i.e.,

none to few seizures), 10% were perceived to have

moderate control (i.e., no more than two to three

seizures a month), and 10% were perceived to haveuncontrolled seizures (i.e., daily or weekly seizures).

Concerning comorbid conditions, 51 of the children had

no other diagnosis besides epilepsy, 32 had learning or

language disabilities, and 18 had been diagnosed with

attention deficit hyperactivity disorder (ADHD). Diag-

noses of comorbidities were made prior to the study by

professionals within the school setting for learning or

language disabilities and by other health care providersfor ADHD.

2.2. Procedure

The study was approved by the Human Research

Advisory Committee. Written consent for participation

was obtained from the parent, and assent was obtained

from the child. None of the children refused participa-tion. At the time of the office visit, demographic and

seizure severity information was collected as were data

concerning comorbid learning or behavioral disorders.

Each child was administered the Revised Children�sManifest Anxiety Scale (RCMAS) [8]. For younger

children or children who had reading disabilities, the

RCMAS was read to the child by the research assistant.

2.3. Instrument

RCMAS is a 37-item questionnaire that assesses

anxiety in children and adolescents between 6 and 19

years of age. RCMAS is a self-report questionnaire in

which the child responds in a yes/no format to state-

ments involving physiological symptoms, social con-

cerns, and worry. Results are reported in a total anxietyscore (mean ¼ 50� 10) as well as scores from three

subscales including Physiological Anxiety, Worry/

Oversensitivity, and Social Concerns/Concentration. In

addition, there is a subscale (i.e., Lie scale) that serves as

a validity index. All subscales have a mean of 10� 3.

Higher scores on the total index and three subscales

indicate increased anxiety. Higher scores on the Lie scale

indicate an inaccurate self-report.

2.4. Statistics

Descriptive statistics and frequencies were used to

examine overall results from the RCMAS and to de-

termine the number of children and adolescents who

scored within the clinical range. T tests were used to

examine differences in anxiety and gender, presence ofcomorbid conditions, ethnicity, and number of AEDs.

A stepwise regression analysis was performed with the

dependent variable consisting of the total mean score on

the RCMAS and predictor variables consisting of co-

morbid conditions, gender, age of child, ethnicity, SES,

number of AEDs, MRI findings, seizure type, seizure

control, and years since diagnosis. Three categories were

Table 4

Differences in anxiety based on presence of comorbid conditions,

ethnicity, and number of AEDs

RCMAS

total score

t P

Presence of comorbid conditions

No other comorbid conditions

ðn ¼ 51Þ44.6 4.33 <0.001

Mild to moderate learning/behavior 54.3

J. Williams et al. / Epilepsy & Behavior 4 (2003) 729–732 731

established with respect to presence of comorbid dis-abilities including: children with no other diagnosed

conditions, children diagnosed with mild learning and/or

behavioral problems, and children with moderate

learning and behavioral problems who required signifi-

cant interventions within the school setting. A discrimi-

nant analysis was employed to determine the accuracy of

group prediction based on regression results.

problems (n ¼ 50)

Ethnicitya

African-American (n ¼ 23) 44.9 2.62 <0.012

Caucasian (n ¼ 76) 51.1

Number of AEDs

Monotherapy (n ¼ 83) 48.1 2.62 <0.046

P2 AEDs (n ¼ 18) 56.2

aOnly two subjects were in the ‘‘Other’’ category and were not

included in the analysis for ethnicity.

3. Results

The mean total T score on the RCMAS was within

the normal range as were the scores for the other sub-

scales (Table 1). Frequency distribution indicated that

23 children (23%) had scores higher than 1 SD above the

mean (Table 2).Results from the regression analysis suggested that

presence of comorbid conditions, ethnicity, and number

of medications were significant predictors of higher

levels of anxiety (Table 3). Caucasian children and ad-

olescents with mild to moderate learning/behavior dis-

orders who were on polytherapy were more likely to

experience greater symptoms of anxiety (Table 4). Dis-

criminant analysis suggested that when these threevariables were included, the correct classification was

67%, with 65% of low-anxiety subjects correctly classi-

fied and 69% of high-anxiety subjects correctly classified.

Table 3

Results from stepwise regression analysis concerning variables asso-

ciated with anxiety in children with epilepsy

Predictor RCMAS total score

R2 t P

Comorbid conditions 0.13 3.5 0.001

Ethnicity 0.18 )2.8 0.006

Number of AEDs 0.23 2.4 0.016

Table 1

Scores from the RCMAS for children (n ¼ 101) with treated epilepsy

RCMAS scale Mean score (SD)

Total T score (range 25–87) 49.5 (12.2)

Physiological anxiety 9.6 (3.4)

Worry/oversensitivity 9.1 (3.2)

Social concerns/concentration 9.7 (3.2)

Lie scale 10.7 (3.1)

Table 2

Number of children with symptoms below and above the clinical range

for anxiety

RCMAS total scorea Number of children

T score< 60 78 (77%)

T score 60–69 18 (18%)

T score P70 5 (5%)

aKey: <60¼Normal range; 60–69¼mild to moderate anxiety

symptoms; P70¼moderate to severe anxiety symptoms.

Differences were not found based on gender (mal-

e¼ 50.2, female¼ 48.8) or seizure type (complex

partial¼ 49.7, primary generalized¼ 45.5, absence¼51.1, mixed¼ 52.0).

4. Discussion

Study results suggest that the majority (77%) of

children and adolescents with treated epilepsy had

anxiety scores within the normal range. However, 18%

had mild to moderate symptoms, while 5% had mod-

erate to severe symptoms of anxiety. Occurrence of

anxiety symptoms exceeded the rate in the normative

population and was higher than reported by Ettinger

et al. [3] when measured with the Revised Children�sManifest Anxiety Scale. The presence of more severe

epilepsy and the inclusion of children with comorbid

conditions in our study may account for this difference.

Consistent with findings in the majority of studies,

differences on the basis of gender, age, epilepsy duration,

or seizure type were not found. However, in the present

study, number of medications (monotherapy versus

polytherapy) was a significant predictor of anxiety. Thisis consistent with Oguz et al. [6], who found that poly-

therapy and seizure frequency were associated with in-

creased anxiety, and with Alwash et al. [5], who found

that uncontrolled seizures were associated with a sig-

nificantly higher risk of anxiety. It would appear that

epilepsy severity, especially as measured by polytherapy,

may be associated with higher levels of anxiety in these

children and adolescents. It is also possible that poly-therapy may directly increase symptoms of anxiety.

Unique to this study was the exploration of the as-

sociation between anxiety and comorbid learning/be-

havior problems. In children without epilepsy, the risk

for anxiety is increased when either learning disabilities

or ADHD are present. As children with epilepsy are at

732 J. Williams et al. / Epilepsy & Behavior 4 (2003) 729–732

increased risk for learning and/or behavior problems [9],it was not surprising to find a significant association

between anxiety and comorbid learning/behavior prob-

lems in these children.

In addition to severity of epilepsy and the presence of

comorbid conditions, ethnicity was associated with in-

creased anxiety. Caucasian children with epilepsy who

had co-morbid learning disabilities or ADHD were at

increased risk for anxiety. The reasons for the associa-tion between ethnicity and anxiety could not be

determined.

Results from the present study would suggest the

importance of monitoring affective symptoms in chil-

dren and adolescents with epilepsy. It would appear that

children with associated learning or behavior disorders

who are prescribed multiple AEDs may be at particular

risk for adjustment difficulties. Provision of informa-tion, referral to support groups involving other children

and adolescents with epilepsy, school interventions,

medication evaluation, and/or individual therapy may

be beneficial and should be formally studied.

References

[1] Dunn D. Neuropsychiatric aspects of epilepsy in children. Epilepsy

Behav 2003;4:101–6.

[2] Aldenkamp AP, Mulder OG. Psychosocial consequences of

epilepsy. In: Goreczny A, Hersen M, editors. Handbook of

pediatric and adolescent health psychology. Boston: Allyn &

Bacon; 1999. p. 105–44.

[3] Ettinger AB, Weisbrot DM, Nolan EE, et al. Symptoms of

depression and anxiety in pediatric epilepsy patients. Epilepsia

1998;39:595–9.

[4] Margalit M, Heiman T. Anxiety and self-dissatisfaction in epileptic

children. Int J Soc Psychiatry 1983;29:220–4.

[5] Alwash RH, Hussein MJ, Matloub FF. Symptoms of anxiety and

depression among adolescents with seizures in Irbid, Northern

Jordan. Seizure 2000;9:412–6.

[6] Oguz A, Kurul S, Dirik E. Relationship of epilepsy-related factors

to anxiety and depression scores in epileptic children. J Child

Neurol 2002;17:37–40.

[7] Hollingshead AB. Four factor index of social status. New Haven,

CT: Author; 1975.

[8] Reynolds CR, Richmond BO. Revised children�s manifest anxiety

scale. Los Angeles: Western Psychological Services; 1985.

[9] Williams J. Learning and behavior in children with epilepsy.

Epilepsy Behav 2003;4:107–11.