The Relationship between Nocturnal Discharges and Language Dysfunction in Rolandic Epilepsy: Treat the Child, Not the Adage

Commentary One of the most commonly cited “principles” of childhood epilepsy management is the concept of “treating the child, not the EEG. ” The implied meaning is that treatment decisions should be made with the idea that the benefit of treatment should be greater than the potential adverse effects or that it is the overall quality of life that should be considered, not a diagnostic feature. However, there are some commonly accepted exceptions to this “rule” such as absence seizures as part of the childhood absence epilepsy syndrome, electrical status epilepticus during sleep (ESES), and hypsarhthymia associated with epileptic spasms. The implication is that epileptiform abnormalities (spikes, sharp waves, electrographic seizures) are different than diagnostic features such as age of onset, sex, or etiology and different from a comorbidity such as attentional and behavioral problems. Rather, the implication is that the electrical abnormality is causal to an associated problem. The problems discussed include inducing more seizures (kindling), doing brain damage (excitotoxicity), and inducing a cognitive or behavioral decline or both (epileptic encephalopathy). Impairments of the various domains of language can be considered a specific subset of the epileptic encephalopathies. The evidence that seizures and epileptiform discharges have a negative impact on language function, with an emphasis on rolandic epilepsy (RE), was recently the subject of a comprehensive review (1). It should be noted that the LandauKleffner syndrome (LKS) and ESES are also raised as examples of epilepsy syndromes that have epileptiform discharges while asleep and language/cognitive features as part of the syndrome definition. The most relevant literature can be approached from at least two perspectives. The frequency of interictal, nocturnal epileptiform discharges in children with language impairment who do not have epilepsy has been reported to range from 13 to 94 percent (1), with the large variance likely explained by the specific language impairments, duration of EEG (routine with sleep versus prolonged), and degree of intellectual disability. The frequencies of nocturnal discharges reported are clearly elevated beyond general population numbers when compared with controls performed in some of the studies. Another approach is to consider the occurrence of language impairments in children with RE. This is set against the backdrop of the label “benign” applied to RE that was formerly considered a defining feature implying age-related resolution, few seizures, pharmaco-responsiveness, and lack of neurocognitive comorbidities. It has been clearly demonstrated that children with RE are subject to several types of language impairments, including problems with reading expression and comprehension, spelling, sound/phonologic, and vocabulary (2–7). These recent studies are methodologically sound with appropriate control populations. Reading Performance in Children With Rolandic Epilepsy Correlates With Nocturnal Epileptiform Activity, but Not With Epileptiform Activity While Awake.