Background High definition transcranial direct current stimulation (HD-tDCS) has been administered over single brain regions for small numbers of sessions. Safety, feasibility and tolerability of HD-tDCS over multiple brain regions, multiple daily stimulations and long periods are not established. Objective We studied safety, feasibility and tolerability of daily HD-tDCS over 2–4 brain regions for 20 sessions in healthy adults. Methods Five healthy adults underwent physical and neurological examination, electrocardiogram (EKG), electroencephalogram (EEG) and cognitive screening (ImpACT) before, during and after HD-tDCS. Four networks (left/right temporoparietal and frontal) were stimulated in sequence (20 min each) using HD-tDCS in 20 daily sessions. Sessions 1–10 included sequential stimulation of both temporoparietal networks, sessions 11–15 stimulations of 4 networks and sessions 16–20 two daily stimulation cycles of 4 networks/cycle (1.5 mA/network). Side effects, ImpACT scores and EEG power spectrum were compared before and after HD-tDCS. Results All subjects completed the trial. Adverse events were tingling, transient redness at the stimulation site, perception of continuing stimulation after end of session and one self-resolving headache. EEG power spectrum showed decreased delta power in frontal areas several days after HD-tDCS. While at the group level ImpACT scores did not differ before and after stimulations, we found a trend for correlation between decreased EEG delta power and individual improvements in ImpACT scores after HD-tDCS. Conclusion Prolonged, repeat daily stimulation of multiple brain regions using HD-tDCS is feasible and safe in healthy adults. Preliminary EEG results suggest that HD-tDCS may induce long lasting changes in excitability in the brain.

Purpose In order to develop a theoretical framework for person-centered care models for children with epilepsy and their parents, we conducted a qualitative study to explore and understand parents’ needs, values, and preferences to ultimately reduce barriers that may be impeding parents from accessing and obtaining help for the child’s co-occurring problems. Methods A qualitative grounded theory study design was utilized to understand parents’ perspectives. The participants were 22 parents of children with epilepsy who ranged in age from 31-53 years. Interviews were conducted using open ended semi-structured questions to facilitate conversation. Transcripts were analyzed using grounded theory guidelines. Results In order to understand the different perspectives parents had about their child, we devised a theory composed of three zones (Zones 1, 2, 3) that can be used to conceptualize parents’ viewpoints. Zone location was based on parents’ perspectives of their child’s comorbidities in the context of epilepsy. These zones were developed to help identify distinctions between parents’ perspectives and to provide a framework within which to understand parents’ readiness to access and implement interventions to address the child’s struggles. These zones of understanding describe parents’ perspectives of their child’s struggles at a particular point in time. This is the perspective from which parents address their child’s needs. This theoretical perspective provides a structure in which to discuss parents’ perspectives on conceptualizing or comprehending the child’s struggles in the context of epilepsy. The zones are based on how the parents a) describe their concerns about the child’s struggles, b) their understanding of the struggles, and c) the parent’s view of the child’s future. Conclusions Clinicians working with individuals and families with epilepsy are aware that epilepsy is a complex and unpredictable disorder. The zones help clinicians conceptualize and build a framework within which to understand how parents view their child’s struggles, which influences the parents’ ability to understand and act on clinician feedback and recommendations. Zones allow for increased understanding of the parent at a particular time and provide a structure within which a clinician can provide guidance and feedback to meet parents’ needs, values and preferences. This theory allows clinicians to meet the parents where they are and address their needs in a way that benefits the parents, family and child.

Summary Objective Birth weight is an important indicator of prenatal environment and subtle variations of birth weight within the normal range have been associated with differential risk for cognitive and behavioral problems. Therefore, we aimed to determine if there are differences in birth weight between full term children with uncomplicated new/recent-onset epilepsies and typically-developing healthy controls. We further examined the relationships between birth weight and childhood/adolescent cognition, behavior, and academic achievement. Methods 108 children with new/recent-onset epilepsy and 70 healthy controls underwent neuropsychological assessment. All participants were born full-term (>37 weeks) without birth complications. Parents were interviewed regarding their child's gestation, birth and neurodevelopmental history. Results Birth weight of children with epilepsy was significantly lower than healthy controls (p=0.023). Whereas birth weight (covaried with age, sex, handedness, and mother's education) was significantly associated with cognition in controls in multiple domains (intelligence, language, aspects of academic achievement), this relationship was absent in children with epilepsy. Birth weight was not associated with clinical epilepsy variables (age of onset, epilepsy syndrome) and was not predictive of a variety of other academic or psychiatric comorbidities of epilepsy. Significance Although the origin of lower birth weight in children with epilepsy is unknown, these findings raise the possibility that abnormal prenatal environment may impact childhood-onset epilepsy. Furthermore, the positive relationship between birth weight and cognition evident in healthy controls was disrupted in children with epilepsy. However, birth weight was not related to academic and psychiatric comorbidities of childhood epilepsy.

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BACKGROUND: The purpose of this project was to examine the usefulness of neuropsychological screening in a multidisciplinary clinic for neuro-oncology populations and determine whether a brief evaluation can adequately screen children for cognitive dysfunction or psychiatric comorbidities. METHODS: Thirty-one children or young adults with a history of CNS tumor had neuropsychological screening as part of their multidisciplinary clinic visit. This screening evaluation consisted of clinical interview, neuropsychological testing, and the completion of emotional/behavioral checklists. Our neuropsychological test battery included the Kaufman Brief Intelligence Test-Second Edition (KBIT-2) and the NIH Toolbox Fluid Cognition Composite, which consists of 6 subtests - flanker task, working memory, processing speed, oral reading, card sort, and memory. RESULTS: Over a 15-month period 31 children, adolescents, and young adults with CNS tumors were seen in our neuropsychology screening clinic. Females made up 39% of the sample. The average age was 12.7 years (range=5–24 years). The average time to complete neuropsychological testing was 60.3 minutes. Thirty-six percent did not have any new neuropsychological diagnoses, 42% had one new diagnosis, 19% had two new diagnoses, and 3% had three new diagnoses. The most common new diagnoses were mild or major neurocognitive disorder (mild=29%, major=6%), anxiety (32%), ADHD (10%), and mood disorder (13%). Neurocognitive test scores were mostly in the average range (Verbal-IQ=97.7; Nonverbal-IQ=95.3; Total IQ=96.2; Flanker T-Score=46.1; Working Memory T-Score=44.0; Card Sort T-Score=43.7; Picture Memory T-Score=48.5). Processing speed and fluid cognition composite scores for the group were in the low-average range (Processing Speed T-Score=42.7; Fluid Cognition Composite T-Score=41.4). Behavioral health recommendations were needed for 71% of this sample. Educational recommendations were needed for 58%. CONCLUSIONS: Brief neuropsychological screening completed as part of multidisciplinary clinics for pediatric neuro-oncology patients was efficient and useful in identifying neuropsychological diagnoses in children and assisted with informing necessary behavioral health and academic interventions.

Objective To outline the usefulness of neuropsychological evaluation in identifying functional neurological disorder. Functional neurological disorder accounts for an estimated 16% of neurology referrals and is a “crisis of neurology” (Edwards & Bhatia, 2012). Adolescents with a history of neurologic compromise, including autoimmune disorders, are at increased risk for comorbid functional neurological disorder (Reuber, Mitchell, Howlett, Crimlisk, & Grünewald, 2005). Method 16-year-old female with a history of Hoshimoto’s encephalopathy referred by her neurologist. Following diagnosis and treatment, she developed a constellation of symptoms, including wide set gait, nystagmus, incontinence, and dystonic episodes. She also reported lapses in memory that lasted a few minutes at a time. During these episodes, she forgot who her mother was and forgot details about her home, which resulted in panic. Results Two neuropsychological evaluations were completed over two years. Psychometric intelligence declined by two standard deviations compared to previous testing one year before. Her performance on memory tasks declined dramatically as well. Despite these declines, there was no decline in activities of daily living. She failed embedded and stand-alone performance validity measures (RDS = 4; TOMM = 29, 30, 28). These findings were described to her neurologist and psychiatrist and we discussed the importance of identifying functional symptoms in the context of her medical history. Conclusions Our evaluation identified significant discrepancies between neuropsychological performance and daily cognitive functioning. The memory lapses she described were inconsistent with any known etiology or illness. Neuropsychological evaluation identified symptoms of a functional nature and assisted in appropriate treatment planning.

Objective To characterize the presence and nature of discrete behavioral phenotypes and their correlates in a cohort of youth with new and recent onset focal and generalized epilepsies (YWE). Methods The parents of 297 YWE (age 8–18; n = 183) and typically developing participants (n = 107), completed the Child Behavior Checklist. The 8 behavior problem scales were subjected to hierarchical clustering analytics to identify behavioral subgroups. Factors examined included: demographics, neuropsychological data, history of academic problems, epilepsy characteristics, parental IQ and education, cortical thickness, daily executive functioning, and number of lifetime-to-date DSM-IV diagnoses. Results Hierarchical clustering identified three behavioral phenotypes which included: no behavioral complications (Cluster 1, 67% of YWE), internalizing problems (Cluster 2, 11% of YWE), and combined internalizing and externalizing problems (Cluster 3, 22% of YWE). These behavioral phenotypes were characterized by orderly differences in the factors analyzed. Cluster 1 was most similar to controls across most metrics while Cluster 3 was the most abnormal. Epilepsy syndrome was not a predictor of cluster membership. Conclusion YWE fall into 3 distinct behavioral phenotypes associated with a variety of co-occurring features and comorbidities. This approach identifies important phenotypes of behavior problem presentations and their accompanying factors that serve to advance clinical and theoretical understanding of the behavioral complications of children with epilepsy and the complex conditions with which they co-occur.