A STUDY OF BEHAVIOURAL PROBLEMS IN CHILDREN WITH HISTORY OF FEBRILE CONVULSION
Dissertation submitted to
THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY In partial fulfilment for the requirement for the degree of
DOCTOR OF MEDICINE (BRANCH – XVIII) PSYCHIATRY
Register No.: 201728202
DEPARTMENT OF PSYCHIATRY
TIRUNELVELI MEDICAL COLLEGE AND HOSPITAL TIRUNELVELI – 627011
MAY-2020
CERTIFICATE BY THE GUIDE
This is to certify that this dissertation titled “A STUDY OF BEHAVIOURAL PROBLEMS IN CHILDREN WITH HISTORY OF FEBRILE CONVULSION”
submitted byDR.M.DINESH BABU to the Tamilnadu Dr.M.G.R Medical university, Chennai, in partial fulfilment of the requirement for the award of the Degree of Doctor of Medicine Branch–XVIII Psychiatry during the academic period of 2017-2020is an original bonafide research work carried out by him under my direct supervision and guidance. I forward this to the Tamil Nadu Dr.M.G.R. Medical University, Chennai, Tamil Nadu, India.
Date:
Place: Tirunelveli
Dr. A.GODSON M.D., Assistant Professor, Department of Psychiatry, Tirunelveli Medical College,
Tirunelveli.
CERTIFICATE BY THE HEAD OF THE DEPARTMENT
This is to certify that the dissertation entitled “A STUDY OF BEHAVIOURAL PROBLEMS IN CHILDREN WITH HISTORY OF FEBRILE CONVULSION”
is a bonafide and genuine research work carried out by Dr.M.DINESH BABU under the guidance and supervision of Dr.A.GODSONM.D., Assistant professor, Department of Psychiatry, Tirunelveli Medical College, Tirunelveli in the Department of Psychiatry, Tirunelveli Medical college, Tirunelveli, in partial fulfilment of the requirements for the degree of M.D in Psychiatry.
Date:
Place: Tirunelveli
Dr.G.RAMANUJAM M.D., Professor and HOD of Psychiatry,
Department of Psychiatry, Tirunelveli medical college,
Tirunelveli.
CERTIFICATE BY THE DEAN
I hereby certify that the dissertation entitled“A STUDY OF BEHAVIOURAL PROBLEMS IN CHILDREN WITH HISTORY OF FEBRILE CONVULSION”
is a bonafide and genuine research work carried out by Dr.M.DINESH BABU under the guidance and supervision of Dr.A.GODSON M.D., Assistant professor, Department of Psychiatry, Tirunelveli Medical College, Tirunelveli in the Department of Psychiatry, Tirunelveli Medical college, Tirunelveli, during his postgraduate degree course period from 2017-2020 in partial fulfilment of the requirements for the degree of M.D in Psychiatry. This work has not formed the basis for previous award of any degree.
Date :
Place : TIRUNELVELI
Prof.Dr. S. M.KANNAN,M.S., MCh.,(Uro) The DEAN
Tirunelveli Medical College, Tirunelveli - 627011.
DECLARATION BY THE CANDIDATE
I, Dr.M.DINESH BABU., solemnly declare that this dissertation titled “A STUDY OF BEHAVIOURAL PROBLEMS IN CHILDREN WITH HISTORY OF FEBRILE CONVULSION” is a bonafide and genuine research work done by me under the guidance and supervision of Dr.A.GODSON M.D., Assistant professor, Department of Psychiatry, Tirunelveli medical college, Tirunelveli.
The dissertation is submitted to the Tamil Nadu Dr.M.G.R. Medical University, Chennai-32 in partial fulfilment of the University requirements for the award of the degree of Doctor of Medicine in Psychiatry.
The Tamil Nadu Dr. M.G.R. Medical university, Chennai shall have the rights to preserve, use and disseminate this dissertation in print or electronic format for academic/research purpose.
Place : Tirunelveli Date :
Dr.M.DINESH BABU,M.B.B.S., Register No.: 201728202
Post Graduate Student, Department of Psychiatry, Tirunelveli Medical College,
Tirunelveli - 627011
ACKNOWLEDGEMENT
I owe my thanks to our DEAN, Prof.Dr. S.M.KANNAN.M.S., MCh., Tirunelveli Medical College, Tirunelveli for permitting me to utilize the facilities and clinical materials for conducting this study.
I am extremely grateful to the Professor& HOD of Psychiatry, Dr.G.RAMANUJAM M.D., Tirunelveli Medical College, Tirunelveli, for his constant encouragement and guidance throughout the study and for his periodic reviews.
I am indebted to Dr.A.GODSON M.D., Assistant Professor of Psychiatry, for his support, guidance and help without which it would have been difficult to carry out this study.
I am extremely thankful to my professors Dr. M.B.ABDUL RAHUMAN M.D.,, and Dr.S.JEEVACREEDOM VICTORY D.P.M.,for helping me with their time and advice during the study.
I wish to thank the paramedical and non-medical staff of the Department of Psychiatry for their cooperation in this study.
I thank all the patients who consented to participate in this study without which this study would not have been possible.
I wish to acknowledge my parents, friends and family members for their everlasting encouragement.
Above all I thank the Lord Almighty for his kindness and benevolence.
CERTIFICATE - II
This is to certify that this dissertation work titled “A STUDY OF BEHAVIOURAL PROBLEMS IN CHILDREN WITH HISTORY OF FEBRILE CONVULSION” of the candidate DR.M.DINESH BABU, with registration Number 201728202 for the award of M.D. Degree in the branch of PSYCHIATRY (XVIII). I personally verified the urkund.com website for the purpose of plagiarism check. I found that the uploaded thesis file contains from introduction to conclusion page and result shows 1 PERCENTAGEof plagiarism in the dissertation.
Date:
Place: Tirunelveli
Dr.A.GODSON M.D., Assistant Professor, Department of Psychiatry, Tirunelveli Medical College,
Tirunelveli.
TABLE OF CONTENTS
S.No TOPIC PAGE
No.
1. INTRODUCTION 1
2. REVIEW OF LITERATURE 6
3. AIM AND OBJECTIVES 25
4. MATERIALS AND METHODS 26
5. STATISTICAL ANALYSIS AND RESULTS 32
6. DISCUSSION 67
7. CONCLUSION 74
8. STRENGTH OF THE STUDY 75
9. LIMITATIONS 76
10. FUTURE DIRECTIONS 77
11. BIBLIOGRAPHY 12. APPENDIX
SEMI-STRUCTURED PROFORMA RATING SCALES
CONSENT FORM MASTER CHART
INTRODUCTION
Febrile convulsion is the most common seizure disorder in childhood, with an estimated prevalence of 2-4%, affecting children before age 5 years (1). Although the natural history of Febrile Convulsions is well understood, the cognitive and behaviour outcomes have long been a subject of controversy [2]. Such controversy is the result of differences in case selection, neuropsychological measures, and the duration of follow- up[1,2].
Hallmark feature of febrile convulsion is that, they almost always will not present after the age of 6years [3]. At younger age, the disturbance in developmental functions might be present due to seizure episodes, which tend to disappear at later years[4]. The outcome of the behavioural functions, after the child is completely seizure free, is studied in our research. The self limiting nature of this illness adds a better result in assessing the outcome of behavioural profile than with any other chronic illness or seizure types.
JUSTIFICATION OF STUDY Behaviour
Behaviour is a very ‘broad’ term to define, which include not only overt acts but also many internal events such as thinking, learning, emotions, etc.
Behaviour is defined as the internally coordinated responses (actions or
external stimulus, excluding responses more easily understood as developmental changes[5]. Or it can be simply stated as ‘anything a person does that can be observed’[6].
Neurobiology of behaviour
When moving into, what constitutes a behaviour, Again it can be influenced by multiple unrelated factors like sex difference, food habits, medical condition, substance use, social factors like a countries political policies, environmental factors, personal life, etc [7].
The neurobiology of the behaviour is not just simply the motor events executed through spinal cord and peripheral tissues, but also the content or the scenario in which the behaviour occurs, planned and coordinated by other regions of the brain, thus making it a complex act. A systematic decoding of any behaviour involves answering an age old question of phylogeny[7].
Evolutionary behaviour
Millions of years ago why do we evolve to acquire this behaviour? What survival advantage or an environmental adaptability that a human had among other species to acquire this behaviour? This was answered by various scientists like Darwin, through theories like natural selection, kin selection, reciprocal altruism, etc[6,7].
Behavioural genetics
This brings us to next hierarchy that how ‘genes’ inherited these evolutionary behaviours. Genes has deterministic power on all human behaviour. All sorts of behaviours have a genetic component, a genetic basis and a genetic cause. Genes are strings of DNA containing information.
Molecular genetics reveals life’s information flow from DNA to RNA and through various proteins coded by them, shaping our behaviour. This theoretical structure is more explanatory and predictive. Knowing the DNA sequence, its promoter and regulatory genes and its alteration by mutation, gene therapy, environmental influence, etc, will have a drastic changes and adaptations in behaviour. By virtue, behaviours are adapted gradually through small incremental changes from variability and adaptation to the environment[8].
Psychosocial aspect of behaviour
This tells us the other factor influencing the behaviour ‘the environment’.
Same gene functions differently in different environment. Our internal milieu like blood flow, hormone level changes based on how sensitive are we to those
The explanation of behaviour can be concluded by the holistic effects starting from neuron, neuronal circuitry, neurotransmitter, environmental stimulus, childhood developmental schema, including ontogeny, genetics and phylogeny (i.e. evolutionary behaviour)[7].
Thus the state of the neurons and its supportive structures play a pivotal role in final common pathway to produce behaviour. Hence we can expect behavioural abnormalities in persons having a defective or vulnerable state of the neural architecture.
Seizure disorders mostly result due to vulnerable neuronal architecture like fragile neuronal cell wall, channels, myelin sheath etc. These abnormal excitation or firing of neurons in these disorders may be precipitated by various stressors like toxins, abnormal proteins, infection, temperature etc[9].
Hence it is natural to suspect all types of seizure disorders to develop behavioural abnormalities. Febrile convulsions are not manifested beyond certain age by unknown mechanism most probably neuronal and glial
maturation [10]. Thus it is judicious to study the long term behavioural outcome in children with history of febrile convulsion.
REVIEW OF LITERATURE
FEBRILE CONVULSIONS
Febrile seizures are the most common form of childhood seizures [11]
Kurland LT et al.
Annegers JF et al. identified few variant of febrile seizure based on their mode of presentation and termed a new entity called complex febrile seizure . These are based on their properties like prolonged duration, recurrence focal onset ect., While most of the remaining variant are considered simple[12-13].
Blakley SA et al. [16] works focused on finding various risk factors in development of febrile convulsions, their tendencies to develop into future episodes. These includes duration of fever, age of onset of the condition at less than 18 months of age, height of temperature ( if peak temperature is higher, the probability of future episode is low), family history of febrile seizure. The family history of other seizure disorders also holds a relative risk.
There are multiple risk factors and their studies like Berg AT et al. also helped in identifying independent variables[14-17]. These consists of various factors like age, sex, socioeconomic status, ethnicity and neurodevelopmental abnormality. Complex febrile seizure is also not a risk factor for developing recurrent episodes of febrile seizure.
In an epidemiological and prevalence study by Shinnar S et al. the peak incidence was found to be about 18 months of age and the age group in which the illness presents are within 6 months and 5 years. And it is highly unlikely to see the manifestation of febile seizures above 7 years of age[17].
Morbidity and mortality rates are very minimal in case of febrile convulsions Shinnar Set al[15].
And no association with brain damages are found in any of the above studies[14-17].
Only a small set of population among the febrile convulsion group tend to develop future episode Blakley SA et al and they are also easily manageable.
Recent studies found role of anticonvulsant in preventing complex febrile
The entire pattern of treatment protocols has been changed based on these findings[16].
Hallmark of febrile convulsions is that, it is triggered by a stressor of high temperature and doesn’t occur beyond age of 6 years.
DEFINITION AND CLASSIFICATION
A febrile convulsion was defined as an event in infancy or childhood, usually occurring between six months and six years of age, associated with fever but without evidence of intracranial infection or a defined cause [18].
This definition was developed at a 1980 consensus conference at the National Institute of Health. Measurement of fever was not mandatory. Seizures in the first four weeks of life were not included. Convulsions that occurred during fevers after vaccination were included. Studies revealed that neuro- developmental and behavioural problems are common among children who develop febrile convulsion before the age of 6years.
The International League Against Epilepsy defines a febrile seizure as “a seizure in association with a febrile illness in the absence of a [central nervous system] infection or acute electrolyte imbalance in children older than 1 month of age without prior afebrile seizures”. The temperature associated with the
febrile illness must be greater than 38.4°C, although the temperature may not be evident until after the seizure[18].
Convulsions occurring due to a primary infection associated with pyrexia will not be included as febrile convulsion.
Some earlier studies proposed lower age limit of 1 month or 3 months of age Hauser WA et al[46] and it also does clearly define the upper age limit [11-
14].
FACTORS IN FEBRILE SEIZURES
The Pathology Of Fever
Fever is the triggering agent in epileptifom excitation of neurons in febrile seizure patients. Earlier studies like Bonadio W et al[29]. considered steep rise in temperature might be responsible for this trigger rather than the degree of the temperature. This finding was also in relation with several animal studies.
HYPERTHERMIA[47-48]
Hyperthermia acts by increasing the body temperature above the set point. In response to this the hypothalamus alters the internal milieu to decrease body temperature. Whereas in case of fever, the hypothalamus itself tries to increase the body temperature to a new set point. As these two conditions acts by
This mechanism also reveals that sudden increase in temperature is not a risk factor to precipitate a febrile convulsion episode.
HEREDITY
Familial predisposition is an important and common risk factor in epilepsy as well as in Febrile Seizures Rimoin DL et al [34]. The incidence-rates in first degree relatives were around 17% to 31%, for febrile seizures. A ratio of 1:5 when a sibling is affected and increases in ratio of 1:3 when both parents have suffered from febrile convulsions was the risk of acquiring the illness Annegers JF et al[35].
A monozygotic twins study showed concordance of 80% for Febrile Seizures cases. In a recent twin pairs study, Tsuboi and Endo [34] recognized concordance in 18/26 (69%) monozygotic twins compared with 4/20 (20%) in dizygotic.
We conclude that the genetic make up plays important role in the development of Febrile Seizures. The exact mechanism by which genes are linked to febrile seizures is still unknown. Congenital disorders with Febrile Seizures have recently been described, but all are still sporadic in number. Despite intensive research on the topic, the very relation between a positive family history and complex Febrile Seizures remains inconclusive.
Austin J et al.[49] have done a case control study using same scale as ours between children with previously unprovoked seizures and their healthy siblings. Even though heritability factor would influence the study they found that rates of behavioural problems are higher in seizure vulnerable patients.
Total behavioural are higher with special emphasis to internalizing as well as attention and somatic problems. This report also emphasis that epilepsies are pervasive problems and can go hand on with behavioural problem.
McDermott S et al. [50] in their very large population based study analysed outcome of the behavioural problems in childhood epilepsies along a non-CNS related physical problem with that of the general population. In their result they established relation of behavioural problems with both the physical problems, major cardiac problems in their case. And it was found that childhood seizures had higher tendency (4.7 times more likely) than other physical problem (around 3 fold) and with healthy children.
Behavioural problems
Various spectrum of behavioural outcome are assessed using behavioural questionnaire in almost all studies. The questionnaire should be able to record the child’s competencies and problems as reported by the parents are care givers.
EPIDEMIOLOGY
Emotional/behavioral problems in childhood are often usefully divided into
Internalizing disorders (symptoms of depression, anxiety, and social withdrawal) and
Externalizing problems (disruptive behaviors, including hyperactivity and conduct problems)[52].
CHILDHOOD ANXIETY
Anxiety sensitivity is a temperamental or trait-like factor under genetic influence that is considered a risk factor for anxiety in general. It is characterized by a tendency to interpret physiological symptoms as a sign that something harmful will result. Such factors, while not specific to anxiety, may predispose children in certain environments to become symptomatically more anxious and impaired. Similarly, an attention bias toward threatening cues and a tendency to interpret ambiguous situations as threatening are associated with children with current anxiety disorder. Although such relationships cannot be considered causal, it is possible that such attentional biases coupled with environmental variables such as parenting influences (e.g., hearing information from a parent about the potential dangers of a situation) may ultimately shape anxiety-related beliefs and behaviours [52]. Anxiety sensitivity has been related
specifically to panic in adolescents and otherwise has been linked to anxiety in general.
Clinical features includes
1. Excessive worry (apprehensive expectation), occurring more days than not for at least6 months, about a number of events or activities (such as work or school performance).
2. Child finds it difficult to control the worry.
3. Restlessness or feeling keyed up or on edge 4. Being easily fatigued
5. Difficulty concentrating or mind going blank 6. Irritability
7. Muscle tension
8. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
DEPRESSED OR IRRITABLE MOOD
Most common form of presentation of childhood depression is irritable mood
[52]. The various symptoms includes
Depressed mood
Decreased pleasure or interest
Weight loss or gain
Insomnia or hypersomnia
Psychomotor retardation or agitation
Fatigue or loss of energy
Inappropriate guilt
Feeling worthless
Decreased concentration and attention
Self harm
the variation duration and severity of these symptoms are used as specifies in diagnosis and management
The child found to be enjoying little, rather be alone, won’t talk much, will be secretive, shy, timid, lacks energy, sad and withdrawn.
SOMATIC COMPLAINTS
These are included under internalizing problems. Thus exhibiting it in various physical forms [52]. The child may present with few these complaints like
Sleep disturbance
Head ache
Body ache
Feels dizzy
Overtired
Constipation
Nausea
Vomiting
Stomachache
Eye problem
Skin problems, etc.
SOCIAL PROBLEMS
Various behavioural problems may presented with difficulty in social adaptation like
• Being dependent,
• Lonely,
• Doesn’t get along with others,
• Being jealous,
• Others out to bully him or get in trouble with him.
• The child will be accident prone,
• Gets teased often,
• Not liked by other peers,
• Clumsy.
They usually prefer younger kids and may have speech problem.
This might also leads to underachievement [53]. The child may become shy and withdrawn due to fear of failure and will develop poor self confidence. It is usually related to lack of involvement in family, peer pressure, learning problem, emotional problem, etc
THOUGHT PROBLEMS
This type of syndrome has different manifestations like [57]
• Recurrent thoughts in mind,
• Harming self,
• Hears things even when no source was around,
• Sees strange things,
• Twitching,
• Skin picking,
• Exposing sex parts in public,
• Preoccupied more about sex parts
• Repeats acts,
• Sleeps less,
• Hides or stores things,
• Odd behavior,
• Bizarre ideas, trouble in sleeping like sleep walking ,
• Sleep talking, etc.
ATTENTION PROBLEMS
Attentional difficulties also have been found to be closely associated with educational problems in children with seizure disorders [56]. The literature currently contains no study that directly evaluates on a population basis neurocognitive attention in school-age children with a history of febrile convulsions. They may show features of
Can’t concentrate
Can’t sit still, where required
Acts young
Fails to finish task
Confused
Daydreams
Impulsive
Poor schoolwork
Stares / inattentive
RULE BREAKING BEHAVIOUR
These come under externalizing problems [59]. Its various manifestations are
• Rule breaking,
• Bad company,
• Lacking guilt,
• Substance abuse like alcohol, tobacco, etc.
• They often prefer older kids company,
• Has tendency for lying,
• Cheating,
• Stealing at home or even outside home,
• Swearing,
• Vandalism,
• Truanting,
• Running away
• Fire setting,
• Thinking of sex too much,
• Using drug,
• Involving in sex, etc.
AGGRESSIVE BEHAVIOUR
Aggressive and rule breaking behavior are externalizing problems with features of conduct problems like[60]
• Arguing,
• Being mean to others,
• Demanding attention,
• Destroying own things,
• Destroying others things,
• Disobedient at home,
• Disobedient at school,
• Gets in fight,
• Attacks people,
• Screams a lot,
• Stubborn, sullen,
• Mood changes,
• Sulky,
• Suspicious,
• Teases a lot,
• Temper,
• Threatens others,
• Loud, etc.
OTHER BEHAVIOURAL PROBLEMS
The other behavioural problems that are not mentioned earlier are[52]
Bed wetting
Bragging
Cruel to animals
Eating problems
Nail biting
Thumb sucking
Over eating
Wishing to be opposite sex, etc.
These behaviours are recently updated in our rating scale. This contributes scores to a overall behavioral profile both in clinical and normal range.
Schoenfeld et al.[53]explored the respective relations of age at seizure onset, time of active seizures, and frequency of seizures and secondarily generalized seizures in the past year with behavior problems in children with complex partial seizures. They found that frequency of complex partial seizures in the past year was the strongest predictor of behavior problems. This study can also function as determining risk factors and independent factors that develop future behavioural problem in complex partial seizure children.
Austin et al. [54] found that adolescents with active epilepsy had more behavior problems than did youth whose seizures had resolved or youth with asthma.
Lendt et al. [55] found a reduction in behavior problems in a group of children after successful surgery for epilepsy compared with children with persistent focal seizures.
A few studies, however, did not show an association between behavior problems and more frequent seizures. For example, in a prospective study of children, Mitchell et al. [56]did not find more frequent or severe seizures to be associated with behavior problems.
Kariuki SM ET AL.[40] found earlier episodes of seizure’s associations with behavioural disturbances. This is a large group cohort study with follow-up up to 16 years of age. No form of behavioural or emotional problems has been linked with any type of febrile convulsion in this national birth cohort study. It also found that foetal risk indicators and social disadvantages at birth has association with emotional and behavioural disturbance at 7, 11 and 16 years of age.
Guha P et al. [41] studied prevalence of behavioural disturbance in an Indian population in a prospective study in association with nephrotic syndrome and cortico steroid management, which shows a higher prevalence in behavioural and emotional problems. This Indian study found association of various behavioural and emotional problems like hyperkinesis, obsessive compulsive neurosis, conduct disorder, etc., Relapse and low socioeconomic status are other factors associating with behavioural disturbances.
Golding J et al.[41] had done huge population based study on the long term outcomes in behavioural and intellectual problem in febrile convulsion children and found that febrile convulsion children performed as well as general population. Thus establishing no significance of behavioural or intellectual disturbances in febrile convulsion children in long run.
Chang YC et al [42] in his study also assessed attention and neurocognitive function along with behavioural outcome and established that no abnormality in behavioural or scholastic as well as attention function in febrile convulsion children. Moreover a better control of attention and distractibility was found in cases than the control group
Visser AM et al. [4] also studied executive function along with behavioural outcome in preschool children and found no significant disturbance or relation in their function in febrile convulsion children. He also found a risk of delayed language development in recurrent febrile seizures.
Wallace SJ et al. [45]in his study of long term psychological outlook also found no significant dysfunction in febrile convulsion children.
AIM & OBJECTIVES
AIM OF STUDY
To determine behavioural outcome and find any correlation of behavioural abnormalities with febrile convulsion.
OBJECTIVES
To assess the behavioral outcome in children with history of febrile convulsions.
To assess the behavioural outcome in control group.
To find out correlation between behavioural abnormalities and febrile convulsions.
MATERIALS AND METHODOLOGY
SETTING
The study was conducted in department of Psychiatry at Govt. Tirunelveli Medical College, Tirunelveli, a tertiary care centre for Tamilnadu. The necessary prior permission for the conduct of the study was obtained from institute Ethical Committee, Tirunelveli Medical College, Tirunelveli.
STUDY POPULATION
Children aged 8-12years attending paediatric and psychiatric OPD at Tirunelveli Medical College
STUDY DESIGN
case control study
INCLUSION CRITERIA:
• Case – Age group : 8-12yrs
-Children attending pediatric and psychiatric opd with at least one episode of febrile convulsion with onset before the age of 5 years
• Control – Age group: 8-12yrs
-Children without convulsion attending pediatric and psychiatric OPD for minor physical illness
EXCLUSION CRITERIA:
- Children with severe medical co-morbidity
- Children with past history of other neurodevelopmental disorders before onset of febrile convulsion or other defined cause.
- Children's parents or guardians who are not willing for study
OPERATIONAL DESIGN
The sample selected in study were patients in Tirunelveli medical college hospital. Patients who had febrile convulsions are considered cases. And in control group are patients without febrile convulsions. The study wasconducted over a duration of one year. The entire study was explained in simplified manner to the patients. Patients were re-interviewed using semi-structured profoma. Their behavioral outcome was assessed using CBCL(childhood behavior checklist) . The data was collected for cases and controls.
STATISTICAL METHODS:
Data entry was done in MS-Excel.
Qualitative data is given in frequencies with their percentages Quantitative data is given in mean and standard deviations
The statistical analysis is done using statistical package for social sciences (SPSS)
TOOLS USED
Semi-structured profoma
CBCL(childhood behaviour checklist)
DESCRIPTION ABOUT THE TOOLS USED
SEMISTRUCTURED PROFOMA:
o This contains the sociodemographic profile of the child and its parents like Name, age, sex, religion, academic performance, socioeconomic status and family structure.
o Its second part contains questions to find the child has any history of febrile illness.
TheChild Behavior Checklist (CBCL)
This is a component of the Achenbach System of Empirically Based Assessment (ASEBA). The ASEBA is used to detect behavioural and emotional problems in children and adolescents. The CBCL is completed by parents. The other two components are the Teacher’s Report Form (TRF) (completed by teachers), and the Youth Self-Report (YSR) (completed by the child or adolescent himself or herself). The 2001 revision of the CBCL, the CBCL/6-18 (used with children 6 to 18), is made up of eight syndrome scales:
• Anxious/Depressed
• Depressed / Withdrawn
• Somatic complaints
• Social problems
• Thought problems
• Attention problems
• Rule-breaking behaviour
• Aggressive behaviour.
These groups into two higher order factors—internalizing and externalizing.
The time frame for item responses is the past six months.
The 2001 revision also added six DSM-oriented scales consistent with DSM diagnostic categories:
• Affective problems
• Anxiety problems
• Somatic problems
• ADHD
• Oppositional defiant problems
• Conduct problems.
The CBCL (and the YSR) are also scored on (optional) competence scales for activities, social relations, school and total competence. In 2001, options for multicultural norms were added allowing scale scores to be displayed in relation to different sets of cultural/societal norms. Scales were also added for obsessive compulsive disorder (OCD) and posttraumatic stress disorder (PTSD).
The CBCL consists of 113 questions, scored on a three-point Likert scale (0=absent, 1= occurs sometimes, 2=occurs often).
Their results denote whether the child’s level of behaviour function falls within clinical range for children of same gender and age.
RESULTS
STUDY POPULATION
Pic 1: Case & Controls
Among 120 sample evaluated 63 of them fulfil the criteria of febrile convulsion and remaining satisfy the requirement of control group. Equal number of samples is available in cases and control
0 10 20 30 40 50 60 70
Case Control
63
57
Cases & Controls
AGE DISTRIBUTION
Pic 2: AGE COMPARISON
Of 120 children studied 63 of them had history of febrile convulsions, 57 of them were control group. The age group selected for study is 8-12 years. The mean age of the study population is 10.0 with a standard deviation of 1.4
The mean age of the cases are 10.1 with standard deviation of 1.4 The mean age of the control group is 9.9 with standard deviation of 1.3
10.1 9.9
0 2 4 6 8 10 12 14
Cases Controls
(in years)
Table 1. Age Distribution of the study population
Groups
Age
(in years) p-value
Mean SD
Cases (n=63) 10.1 1.4
0.54
Controls (n=57) 9.9 1.3
Total 10.0 1.4
Independent t-test used;
p-value <0.05 is significant
Theage distribution of the study population is shown in the table 1.
Both cases and control were comparable with the age group.
Independent t- test is used for statistical analysis
GENDER DISTRIBUTION
Pic 3: Gender distribution
Statistically significant number females seen in cases
This significance denotes association of female gender with febrile convulsions
0 10 20 30 40 50 60 70 80 90
Cases Controls
55.6
84.2
44.4
15.8
Gender distribution
Males Females
Table 2. Gender Distribution between the groups
Sex
Groups
χ2 p-value
Cases (n=63)
Controls (n=57)
n % n %
Male
(n=83) 35 55.6 48 84.2
11.5 0.001 Female
(n=37) 28 44.4 9 15.8
Pearson Chi-square used;
p-value <0.05 is significant
It is obvious that female cases were more than control (44.4% vs. 15.8%) and is statistically significant (p-0.001)
RELIGION COMPARISON
Pic4: Distribution of religion amongst groups
In our study Hindus are dominating in both case and control population (68.3%
and 78.9%), followed by Christian (22.2% and 12.3%), and Muslim (9.5% and 8.8%).
0 10 20 30 40 50 60 70 80
Hindu Muslim Christian
68.3
9.5
22.2 78.9
8.8 12.3
Distribution of religion amongst groups
Cases Controls
Table 3. Religion comparison between the groups
Religion
Groups
χ2 p-value
Cases (n=63)
Controls (n=57)
n % n %
Hindu
(n= 88) 43 68.3 45 78.9
2.17 0.33
Muslim
(n=11) 6 9.5 5 8.8
Christian
(n=21) 14 22.2 7 12.3
Fisher’s exact test used;
p-value <0.05 is significant
There is no statistically significant correlation between case and control in the comparison of religion. ‘p’ value is 0.33 i.e >0.05. This was done by Fisher’s exact test method.
ACADEMICS PERFORMANCE
Pic5: Relationship pf academics with groups
Febrile Convulsion children are good performers than control group
0 10 20 30 40 50 60 70 80 90
Not going to
school Poor Average Good
1.6
9.5
60.3
28.6
0 5.3
82.4
12.3
Cases Controls
Table 4. Academics comparison between the groups
Academics
Groups
χ2 p-value
Cases (n=63)
Controls (n=57)
n % n %
Not going
to school 1 1.6 0 0.0
7.37 0.03
Poor 6 9.5 3 5.3
Average 38 60.3 47 82.4
Good 18 28.6 7 12.3
Fisher’s exact test used;
p-value <0.05 is significant
Therole of academics within the study population was shown in table 4.
Those who are good in studies are seen more in febrile convulsion group, which is in contradiction to the expectation. And moreover this difference was found to be statistically significant (p value = 0.3)
SOCIO-ECONOMIC STATUS
Pic 6:Relationship of SES with the groups
Most of the study population are seen in upper middle class and lower middle class both in case and control. But there was no statistically significant difference in the socio-economic status of the cases and the control group
0 20 40 60 80 100 120
Upper Middle Lower Middle Upper Middle Lower Middle 6.4
46 46
1.6 7
38.6 54.4
0
Cases Controls
Table 5. Socio-Economic Status comparison between the groups
SES
Groups
χ2 p-value
Cases (n=63)
Controls (n=57)
n % n %
Upper Middle (n=8)
4 6.4 4 7.0
1.7 0.69
Lower Middle (n=51)
29 46.0 22 38.6
Upper Lower (n=60)
29 46.0 31 54.4
Lower
(n=1) 1 1.6 0 0.0
Fisher's exact test used;
p-value <0.05 is significant
FAMILY DYNAMICS
Pic 7: Relationship of family structure with the groups
Nuclear family dominates in both the case and control in our study. Even then comparable values are found in all type of family structure in controls as well as cases
0 50 100 150 200
Joint Nuclear Single Parent Guardian
9.5
85.7 3.2
1.6
8.8
91.2 0
0
Relationship of family structure with the groups
Cases Controls
Table 6. Family structure comparison between the groups
Family Structure
Groups
χ2 p-value
Cases (n=63)
Controls (n=57)
no % no %
Joint
(n=11) 6 9.5 5 8.8
2.4 0.63
Nuclear
(n=106) 54 85.7 52 91.2
Single Parent (n=2)
2 3.2 0 0.0
Guardian
(n=1) 1 1.6 0 0.0
Fisher’s exact test used;
p-value <0.05 is significant
There was no significant difference in the family structures of the cases and the control group.
ANXIETY SYNDROME
Pic No 8: Anxiety/Depression profile comparison
More cases are seen in clinical range of anxiety than controls though they are not statistically significant
0 50 100 150 200
Normal Range Borderline Clinical
85.7 4.8
9.5
87.7 10.5
1.8
Cases Controls
Table 8. Comparison of Anxiety/Depression between the groups
Anxiety/Depression
Groups
χ2 p-
value Cases
(n=63)
Controls (n=57)
No % No %
Normal Range
(n= 104) 54 85.7 50 87.7
4.2 0.09
Borderline
(n=9) 3 4.8 6 10.5
Clinical
(n=7) 6 9.5 1 1.8
Fisher's exact test used;
p-value <0.05 is significant
P value of 0.09, which is statistically insignificant was obtained when comparing anxiety syndrome with febrile convulsion children. In our study higher prevalence of clinical range of anxiety and depression (9.5%) were noted in cases than control (1.8%). This difference is statistically insignificant (p>0.05).
DEPRESSION DISORDERS
Pic No 9: Withdrawn/Depression profile
Depression syndrome almost have equal prevalence in normal range (90.5% vs 84.2%) as well as in clinical range (1.6% vs 1.8%). Even though cases has lesser clinical range of children, they are not statistically significant.
0 50 100 150 200
Normal Range Borderline Clinical
90.5 7.9
1.6
84.2 14
1.8
Withdrawn/Depression profile
Cases Controls
Table 9. Comparison of feeling Withdrawn/Depression between the groups
Withdrawn/Depressed
Groups
χ2 p-
value Cases
(n=63)
Controls (n=57)
No % No %
Normal Range
(n= 105) 57 90.5 48 84.2
1.4 0.68
Borderline
(n=13) 5 7.9 8 14.0
Clinical
(n=2) 1 1.6 1 1.8
Fisher’s exact test used;
p-value <0.05 is significant
No relation was established between depression syndrome and febrile seizures in our study. P value of 0.68 which is statistically insignificant was obtained using Fisher’s exact test
SOMATIC PROBLEMS
Pic No 10 Profile of somatic complaints
No statistically significant relation was established for somatic problems in febrile convulsions
0 20 40 60 80 100 120 140 160 180
Normal Range Borderline Clinical 92.1
4.7 3.2
86
14 0
Cases Controls
10. Comparison of somatic complaints between the groups
Somatic complaints
Groups
χ2 p-value
Cases (n=63)
Controls (n=57)
No % No %
Normal Range (n= 107)
58 92.1 49 86.0
4.2 0.08
Borderline
(n=11) 3 4.7 8 14.0
Clinical
(n=2) 2 3.2 0 0.0
Fisher’s exact test used;
p-value <0.05 is significant
While most of the control group lies in border line range (14.0%) when compared to cases which is 4.7%. p value was 0.08 which was statistically insignificant. But among the cases 3.2% was found to have clinical range of somatic symptoms.
SOCIALPROBLEMS
Pic No 11 Profile of social problems between the groups
Febrile convulsion children tend to develop clinical range of social problems than control group
0 20 40 60 80 100 120 140 160 180 200
Normal Range Borderline Clinical
95.2
1.6 3.2
87.7
12.3 0
Cases Controls
Table 11. Comparison of social problems between the groups
Social problems
Groups
χ2 p-value
Cases (n=63)
Controls (n=57)
No % No %
Normal Range (n= 110)
60 95.2 50 87.7
6.6 0.01
Borderline
(n=8) 1 1.6 7 12.3
Clinical
(n=2) 2 3.2 0 0.0
Fisher's exact test used;
p-value <0.05 is significant
Prevalence of 3.2% social problems was found in febrile convulsion children, where control groups none of them was found to have a clinically significant social problem. But they are present in large no in border line range (12.3%) when compared to cases 1.6%. p value was 0.01 which was statistically significant
THOUGHT DISORDERS
Pic No 12 Profile of thought problems between the groups
Febrile convulsion children are found to develop thought problems more likely and well in clinical range.
0 10 20 30 40 50 60 70 80 90 100
Normal Range Borderline Clinical
90.4
4.8 4.8
84.2
15.8
0
Cases Controls
Table 12. Comparison of thought problems between the groups
Thought problems
Groups
χ2 p-value
Cases (n=63)
Controls (n=57)
No % No %
Normal Range (n= 105)
57 90.4 48 84.2
5.9 0.02
Borderline
(n=12) 3 4.8 9 15.8
Clinical
(n=3) 3 4.8 0 0.0
Fisher’s exact test used;
p-value <0.05 is significant
In this study, Febrile convulsion children was found to have association in developing thought problems when compared to control group. p value was 0.02 which was found to be statistically significant.4.8% of cases are falling in clinical range whereas none of them fall into clinical range in control group. But control group children dominate in border line range of problem (15.8%) when
ATTENTION PROBLEMS
Pic No 13 Comparison of Attention Problems
Comparable values are found in cases as well as controls regarding attention function/problem
0 10 20 30 40 50 60 70 80 90
Normal Range Borderline Clinical
85.7
3.2
11.1 84.2
10.5 5.3
Cases Controls
Table 13. Comparison of attention problems between the groups
Attention problems
Groups
χ2 p-value
Cases (n=63)
Controls (n=57)
No % No %
Normal Range (n= 102)
54 85.7 48 84.2
3.5 0.17
Borderline
(n=8) 2 3.2 6 10.5
Clinical
(n=10) 7 11.1 3 5.3
Fisher’s exact test used;
p-value <0.05 is significant
Febrile convulsion children develop more attention problem (11.1%) than control (5.3%). Yet there was no much variation existing between cases and control group since p value was 0.17 which was statistically insignificant. More over the control are present more in border line range (10.5%) than cases (3.5%).
RULE BREAKING BEHAVIOUR
Pic No 14 Comparison of Rule breaking behaviour
No obvious difference found in following graph between the two groups
0 10 20 30 40 50 60 70 80 90 100
Normal Range Borderline Clinical
93.7
4.8 1.5
89.4
8.8 1.8
Cases Controls
Table 14. Comparison of rule-breaking behaviour between the groups
Rule- breaking behavior
Groups
χ2 p-value
Cases (n=63)
Controls (n=57)
No % No %
Normal Range (n= 110)
59 93.7 51 89.4
1.03 0.73
Borderline
(n=8) 3 4.8 5 8.8
Clinical
(n=2) 1 1.5 1 1.8
Fisher's exact test used;
p-value <0.05 is significant
Prevalent of rule breaking behaviour has almost similar values in normal as well as clinical range in both groups. We can see controls are more in border line range (8.8%) than case (4.8%). But p value of 0.73 was statistically insignificant.
AGGRESSIVE BEHAVIOUR
Pic No 15 Comparison of Aggressive behavior(%)
Comparable clinical level of aggressive disorders noted. Controls more presenting in clinical and borderline range
0 10 20 30 40 50 60 70 80 90 100
Normal Range Borderline Clinical
93.7
4.8 1.5
86
12.3
1.7
Cases Controls
Table 15. Comparison of aggressive behaviour between the groups
Aggressive behavior
Groups
χ2 p-value
Cases (n=63)
Controls (n=57)
No % No %
Normal Range (n= 108)
59 93.7 49 86.0
2.4 0.29
Borderline
(n=10) 3 4.8 7 12.3
Clinical
(n=2) 1 1.5 1 1.7
Fisher's exact test used;
p-value <0.05 is significant
Regarding aggressive behaviour of the study population there was no much significant relationship exist between cases and controls. p value was 0.29 which is statistically insignificant. We can also see control group more in border line range.
INTERNALIZING SYNDROMES
Pic No 16 Internalizing profile (%)
Febrile convulsion children more presenting in clinical range of internalising problems. And this value is statistically significant.
0 10 20 30 40 50 60 70 80 90
Normal Range Borderline Clinical
81
6.3 12.7
84.2
14
1.8
Cases Controls
Table 16. Comparison of internalizing profile between the groups
Internalizing profile
Groups
χ2 p-value Cases
(n=63)
Controls (n=57)
No % No %
Normal Range (n= 99)
51 81.0 48 84.2
6.5 0.03
Borderline
(n=12) 4 6.3 8 14.0
Clinical
(n=9) 8 12.7 1 1.8
Fisher's exact test used;
p-value <0.05 is significant
There was significant association in internalizing behavioural problems among the children with the history of febrile convulsions when compared to control group Prevalence of 12.7 % internalizing profile present in cases when compared to control group where only one percent present. Though control group have higher presentation in border line range (14% vs 6.3%) as p value
EXTERNALIZING SYNDROMES
Pic No 17 Externalizing profile (%)
Relationship can’t be established between externalising problems and febrile convulsion as the finding are similar in two groups
0 10 20 30 40 50 60 70 80 90 100
Normal Range Borderline Clinical
93.7
4.8 1.5
89.5
8.8 1.7
Cases Controls
Table 17. Comparison of externalizing profile between the groups
Externalizing profile
Groups
χ2 p-value Cases
(n=63)
Controls (n=57)
No % No %
Normal Range (n= 110)
59 93.7 51 89.5
1.04 0.73
Borderline
(n=8) 3 4.8 5 8.8
Clinical
(n=2) 1 1.5 1 1.7
Fisher’s exact test used;
p-value <0.05 is significant
Higher presentation of control group in border line range (8.8% vs 4.8%) and in clinical range (1.7% vs 1.5%) were found. But p value was 0.73 which is statistically insignificant which implies there was no significant correlation existing between cases and control in externalizing behavioural problems.
BEHAVIOURAL ABNORMALITY
Pic No 18 Total CBCL score (%)
In this study, control group falls to majority of normal range around 84.2% when compared to cases 68.3%. In cases nearly one third falls into Borderline and clinical range when compared to control group where only one sixth exists.
Since p value was 0.13, there was no statistically significant value when comparing the total child behavioural checklist score between cases and control group.
0 10 20 30 40 50 60 70 80 90
Normal Range Borderline Clinical
68.3
20.6
11.1 84.2
10.5 5.3
Cases Controls
Table 18. Comparison of total CBCL score between the groups
Total CBCL score
Groups
χ2 p-value
Cases (n=63)
Controls (n=57)
No % No %
Normal Range (n= 91)
43 68.3 48 84.2
4.04 0.13
Borderline
(n=19) 13 20.6 6 10.5
Clinical
(n=10) 7 11.1 3 5.3
Fisher’s exact test used;
p-value <0.05 is significant
This table18. shows overall behavioural functions and problems between the groups
Febrile convulsion children develop more behavioural problem in border line (20.6% vs 10.5%) and clinical range (11.1% vs 5.10%). Even then no significant correlation exist as p(0.13) is more than 0.05
DISCUSSION
The study was conducted in Department of Psychiatry, Tirunelveli Medical College. Ethical committee approval for conducting the study was obtained from Institutional ethical committee.
The cases were chosen from children attending psychiatry and paediatric OPD and their sibling’s whose parents or caregivers willing to participate in our study.
In our study a total number of 120 children participated. Among them 63 of them had prior history of febrile convulsion and the remaining 57 of them fall in control group. This is a considerable number which favours in decreasing in error of the result. An equal number of cases and control are present in our study sample. This also leads to a more reliable result when comparing the groups. A similar population was seen in study conducted by Wallace et al. [57]
where same and equal number of population are present in case and control groups.
Both cases as well as controls are comparable with the same age group, with the cases belonging to mean of 10.1 ∓1.4 years and the controls to a mean of 9.9 ∓ 1.3 years. Age matching groups of cases and controls helps in ease of statistical analysis and reliable results. A study by YC Chang et al. [58] had closely related age groups. Thus not affecting the validity of the outcome of their study and also presenting with results similar to our study.
Female are more (44.4% vs. 15.8%) in cases group when compared to its counterpart. While no such relations were established in sex difference in previous studies both in first febrile seizure as well as recurrent febrile seizures as in Berg AT et al.[60] andKnudsen FU et al. [61]respectively.
The relationship of religion in our study shows no significant propensity to develop febrile convulsion. These matching the previous results that ethnicity has no role or a risk factor developing recurrent febrile convulsion like in Shinnar S et al. [62] Hindu’s followed by Christians’, Muslims and other religions are the order from most to least are presented in cases as well as in control group.
In expectations to the contrary, febrile convulsion group children performed well in academics. Most of the seizure disorders usually present with some form of disturbances in intellectual functioning or even a severe mental retardation. These finding were replicated by Verity CM. et al. [63] states that there are no long term effects of febrile convulsions on intellectual functioning.
But few hospital based studies presence of mental retardation
Febrile convulsion has no relationship with socio-economic status in our study. This also in accordance with various studies like Neville BG et al.[64]
stating that socioeconomic status is independent from other risk factor for febrile convulsions.
Wassmer E et al. [65]study shows no differences with any family groups in relation to febrile convulsions. This is a case control study where parents were given information regarding the medical condition. This finding is again seen in our study. Other confounding factors other than family structure like housing, general health knowledge were not found to be in association with development of febrile convulsion
In present study around five fold children with febrile convulsion tend to develop clinically significant anxiety symptoms than the control group, yet this doesn’t have any statistically significant association. Similar results were obtained invisser AM et al.[66]
Almost similar percent , 1.6% and 1.8% in children with or without febrile seizure are seen having depressive disorders. Which suggests depression is in no way related to febrile seizures. This was supported by Lux AL [67], he mentioned that the illness of febrile convulsion per se don’t produce depression, rather its treatment with benzodiazepines might have effects on causing depression.
A febrile convulsion child doesn’t have sensitivity to develop somatic problems in their long term life. These results are found in almost all studies comparing behavioural problems with febrile convulsion like visser AM et al.
[68] Even though few febrile seizure children in our study group had somatic complaints, the value is statistically insignificant.
