25 ADHD
Many children with epilepsy have difficulty paying attention, staying on task, or controlling their impulses. For some, this meets the criteria for Attention Deficit Hyperactivity Disorder (ADHD). For others it falls short of a formal diagnosis but still causes real problems at school and at home. Either way, attention difficulties are among the most common and most treatable challenges your child may face alongside epilepsy.
25.1 What Is ADHD?
ADHD is a condition in which a person consistently struggles with paying attention, controlling impulses, or sitting still, or some combination of all three. The symptoms have to be present in more than one setting (for example, both at home and at school), and they have to be significant enough to get in the way of everyday life.
There are three main presentations. The inattentive type involves difficulty focusing, following through on tasks, and staying organized. This presentation is more common in girls and is often missed until the teenage years. The hyperactive-impulsive type involves difficulty sitting still, waiting turns, or thinking before acting. The combined type includes features of both. You do not need to have hyperactivity to have ADHD. A quiet child who simply cannot concentrate may be just as affected as one who cannot stop moving.
25.2 How Common Is ADHD in Children with Epilepsy?
In the general pediatric population, roughly 5 to 7% of children have ADHD. In children with epilepsy, the rates are considerably higher. The largest meta-analyses to date estimate pooled prevalence rates of 22% and 31%, representing a two-and-a-half to five-fold increase compared to children without epilepsy1,2. The most common presentation is the inattentive subtype, accounting for roughly 61% of ADHD cases in this population2,3.
Prevalence varies with epilepsy severity. In children newly diagnosed with epilepsy, roughly 12 to 39% have comorbid ADHD. In children with drug-resistant epilepsy, rates can reach 70%4. Large population-based studies have confirmed that this association holds even after accounting for socioeconomic, perinatal, and family factors5.
The relationship runs in both directions. Children with epilepsy are more likely to develop ADHD, and children with ADHD are more likely to develop epilepsy6. In many children, attention problems appear before the first seizure by months or years. ADHD is not simply a consequence of epilepsy; in many cases it reflects the same underlying brain differences.
Known risk factors for ADHD in children with epilepsy include earlier age at seizure onset, poorly controlled seizures, treatment with multiple antiseizure medications, male sex, intellectual or developmental disabilities, and a family history of seizure disorders or psychiatric illness2,7,8.
Despite the high prevalence, ADHD is significantly underdiagnosed in children with epilepsy. One study found that only 2.6% of affected children had been formally identified by their clinicians3. If you have concerns about your child’s attention, raise them directly with your epilepsy team.
25.3 Which Comes First?
The relationship between epilepsy and ADHD runs in both directions, and waiting for seizures to be fully controlled before addressing attention is rarely the right approach. Studies have found that ADHD symptoms can affect quality of life in children with epilepsy even more than the seizures themselves9. Attention difficulties harm your child’s development, self-esteem, and academic progress independently of seizure control.
25.4 Can Seizure Medications Affect Attention?
Yes. Some antiseizure medications (ASMs) can worsen attention and processing speed, particularly at higher doses. Topiramate (Topamax) is well known for cognitive slowing and word-finding difficulty. Phenobarbital can cause sedation and attention problems, especially in younger children. Benzodiazepines such as clobazam (Onfi) and clonazepam (Klonopin) can cause sedation, particularly when first started. Zonisamide (Zonegran) causes cognitive slowing in some patients10.
If you notice a clear change in your child’s attention or mental sharpness after a new medication is started or a dose is increased, tell your epilepsy team. There may be alternative medications that control seizures equally well with fewer cognitive side effects. Never stop or reduce the dose on your own, as this can cause breakthrough seizures.
A small number of ASMs, including lamotrigine (Lamictal), may have neutral or mildly positive effects on alertness in some patients.
25.5 The ILAE Recommends Routine Screening
The International League Against Epilepsy (ILAE) Pediatric Commission recommends that children with epilepsy be screened for ADHD starting at age 6, or at the time of epilepsy diagnosis, and that screening be repeated annually and after any change in antiseizure medication8. The Strengths and Difficulties Questionnaire (SDQ) Hyperactivity subscale has the highest diagnostic accuracy for ADHD screening in this population, with a sensitivity of 86% and specificity of 98%2.
This means that asking about attention and behaviour should be a routine part of every epilepsy visit, not something that only comes up if a teacher complains.
25.6 How Is ADHD Diagnosed?
There is no single blood test or brain scan for ADHD. Diagnosis is based on a careful history, direct observation, and validated rating scales completed by parents and teachers. A child and adolescent psychiatrist or psychologist typically leads this process.
Neuropsychological testing is particularly valuable for children with epilepsy. It goes beyond confirming ADHD to map out the specific pattern of your child’s strengths and weaknesses across memory, processing speed, language, and executive function. This information directly shapes the support your child receives at school.
Every child with epilepsy benefits from knowing their cognitive profile, not just whether or not they have ADHD. Ask your epilepsy team about a referral.
25.7 Treatment
25.7.1 Behavioural and School-Based Strategies
For younger children, generally under 8 years old, behaviour therapy should always be tried before medication. This involves working with a therapist to help parents apply consistent, structured strategies at home: predictable routines, clear expectations, immediate and specific praise, and planned consequences. These approaches help children with ADHD build self-regulation skills over time.
At school, children with ADHD and epilepsy may qualify for an Individualized Education Plan (IEP) or a 504 plan. Useful accommodations include extended time on tests, preferential seating, frequent check-ins from the teacher, and breaking tasks into smaller steps. The chapter on school support covers this process in more detail.
25.7.2 Medications for ADHD
When behaviour strategies alone are not enough, medication can make a significant difference. The most effective medications for ADHD are stimulants, specifically methylphenidate-based medications (Ritalin, Concerta, Biphentin) and amphetamine-based medications (Adderall, Vyvanse).
Many parents worry that stimulants will worsen seizures. Current evidence is reassuring: methylphenidate is effective and well-tolerated in children with epilepsy, with clinically meaningful improvement in 60 to 75% of patients, and ADHD medications do not appear to increase seizure risk4,8. The concern is greatest in children with very poorly controlled seizures or a recent history of prolonged seizures. In these cases the decision should be made carefully with your epilepsy team and a psychiatrist.
Non-stimulant options, including atomoxetine (Strattera), guanfacine (Intuniv), and clonidine (Kapvay), are available when stimulants are not suitable, though they are generally less effective for core ADHD symptoms.
Medication for ADHD in a child with epilepsy should be managed by a child and adolescent psychiatrist, working closely with your epilepsy team. Never start or stop ADHD medication without guidance from your doctors.