Behavioral disturbances after initiation of valproate in a young child: Alternate explanations possible?

Siddharth Sarkar; Prarthana Saraswathi; Anu Rita Jayaraman; Siva T Ilango; Priya Sivashankar

CASE REPORT

Year : 2015 | Volume : 1 | Issue : 1 | Page : 60-62

Behavioral disturbances after initiation of valproate in a young child: Alternate explanations possible?

Siddharth Sarkar, Prarthana Saraswathi, Anu Rita Jayaraman, Siva T Ilango, Priya Sivashankar
Department of Psychiatry, Sree Balaji Medical College and Hospital, Chromepet, Chennai, Tamil Nadu, India

Date of Submission	11-Jul-2015
Date of Acceptance	09-Sep-2015
Date of Web Publication	9-Nov-2015

Correspondence Address:
Siddharth Sarkar
Department of Psychiatry, Sree Balaji Medical College and Hospital, 7, Works Road, Chromepet, Chennai - 600 044, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

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Abstract

Valproate is one of the commonly used medications for the treatment of seizures. Though this medication is used frequently in the treatment of behavioral abnormalities and aggressive behaviors, rarely it has been associated to cause irritability and other behavioral problems. Access of parents to unsubstantiated easily accessible medical literature in the internet may predispose them to ascribe behavioral problems to medications. We present a case of a 3½-year-old child who was recently started on valproate after seizures and had presented with behavioral problems in the form of irritability, tantrums, and outbursts mainly in the family context after initiation of valproate. We discuss alternate possible explanations for such behavioral problems.

Keywords: Children, irritability, seizures, valproate

How to cite this article:
Sarkar S, Saraswathi P, Jayaraman AR, Ilango ST, Sivashankar P. Behavioral disturbances after initiation of valproate in a young child: Alternate explanations possible?. J Curr Res Sci Med 2015;1:60-2

How to cite this URL:
Sarkar S, Saraswathi P, Jayaraman AR, Ilango ST, Sivashankar P. Behavioral disturbances after initiation of valproate in a young child: Alternate explanations possible?. J Curr Res Sci Med [serial online] 2015 [cited 2021 Feb 25];1:60-2. Available from: https://www.jcrsmed.org/text.asp?2015/1/1/60/168915

Introduction

Valproate is a commonly used medication for the treatment of seizures, especially in the pediatric age group.^[1] Behavioral problems have been described among children receiving valproate,^[2] though less frequently than with other antiepileptic medications such as phenytoin and levetiracetam.^[3],[4] Growing access to unsubstantiated medical literature in the internet has also fuelled parental anxiety about the potential side effects of medications. We describe a case of behavioral abnormalities reported in a child after initiation of valproate for the treatment of seizures.

Case Report

A 3½-year-old boy was brought to our department with history of behavioral disturbances which were noted to be prominent after initiation of valproate to control seizures. The child was born out of planned pregnancy after nonconsanguineous marriage and had an uneventful antenatal period. The child was born at term with elective caesarean section due to oligohydramnios. He had cried immediately after birth though neonatal jaundice required phototherapy for 2 days and the child was discharged thereafter. The child had shown milestones appropriate to age according to the parents.

At 6 months of age, the child had a seizure episode associated with a fever, with tonic movements of upper and lower limbs and uprolling of eyes. He had three further similar episodes of seizures precipitated by a fever over the course of 3 years. The parents had shown to a pediatrician who suggested clobazam to be given during the periods of fever. At 3½ years of age, another seizure occurred, this time not precipitated by fever. The child also showed jerky movements during the night time while asleep, especially before and immediately after morning awakenings. There were no absence seizures or atonic attacks. An electroencephalogram was done, which showed an abnormal record and was suggestive of myoclonic seizures. Hence, the child was started on syrup valproate 400 mg/day (25 mg/kg/day), about 2 weeks prior to consultation at our center.

After initiation of valproate, the mother noted that the child had become more irritable than before. The parents reported that he would throw tantrums more often as compared to before, especially when his demands were not adhered to. The parents report that the child was more aggressive toward them, but not other children, doctors or other relatives. They also reported that the child would be more fatigued, and would not sit for studying with the mother for the same duration as before. His sleep and appetite was otherwise normal, and there was no history of any disorientation, nausea, recurrent crying spells, or expressed anxiety. Further exploration revealed that the mother, who was a homemaker, has been especially considerate toward the child after the occurrence of the recent seizure episode. She has been pampering the child more often than before and has been getting things of his liking. The father also has been more considerate to their only child, and attempts to spend more time with him and avoids getting angry at the child's mischief. There was no history suggestive of psychiatric illness in the family though there was history of seizures in the father during episodes of fever and occurrence of seizure disorder in father's paternal uncle and his son.

The present consultation was initiated by the mother who had read about possible behavioral disturbances with valproate on the internet. She could not recollect which sites she referred to for the information, but reports that this made her concerned to discuss the potential issues with the medications with a psychiatrist. On clinical observation in the outpatient, the child was co-operative, alert, playful, and did not demonstrate any hyperactivity or irritability. He seemed to have the good attention span and completed tasks appropriate to his age. As prominent behavioral symptoms could not be demonstrated, the parents were reassured, given advice about negative reinforcement for minimal behavioral problems, and were asked to follow-up as required.

Discussion

The present case study puts forth a situation wherein overanxious parents may seek help from the medical professionals after reading about a medical condition, or potential adverse events of treatment options. In the present case, the behavioral problems in the form of tantrums, obstinacy and irritability was confined mainly during the interaction with the parents. Such irritability was not reported or observed elsewhere. One of the possible causes of such tantrums and circumscribed irritability could have been parental laxity or pampering after the occurrence of seizures. Parent-child interaction is a complex dynamic entity influenced by a variety of contextual characteristics.^[5] This needs to be taken into consideration while addressing issues, which primarily affect interpersonal relationship between just the parent and the child.

Valproate has been associated with behavioral disturbances in children and adults.^[6],[7] One report describes irrelevant talk, singing and dancing, and talking to self as a result of the initiation of valproate in a 12 years old.^[2] However, valproate as a medication has also been utilized to reduce behavioral disturbances in children presenting with aggression and irritability who do not suffer from seizures. It is also used for the treatment of pediatric bipolar disorder and conduct disorder, which are both associated with irritability, tantrums, and otherwise aggressive behavior.^[8],[9] Epilepsy or the seizure disorder itself may be associated with the occurrence of behavioral problems in children.^[10] In the present case, it seems that behavioral disturbances observed after initiation of valproate may be ascribed to other factors also including the dynamics of parenting.

The present case suggests that in-depth exploration of behavioral problems is required when parents bring children with behavioral problems and having additional medical problems. The parents may resort to the internet to get support as well get information about medical conditions though sometimes the authenticity of the information may be doubtful.^[11],[12] Explaining the line of exploration and the management decisions may help in better management of these children and provide support to the parents in distress.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Guerrini R. Valproate as a mainstay of therapy for pediatric epilepsy. Paediatr Drugs 2006;8:113-29.
2.	Nagalakshmi NC, Ramesh M, Parthasarathi G, Harugeri A, Christy MS, Keshava BS. Valproic acid-induced abnormal behavior. Indian J Psychiatry 2010;52:71-3. [PUBMED]
3.	Schmitz B. Effects of antiepileptic drugs on mood and behavior. Epilepsia 2006;47 Suppl 2:28-33.
4.	Feng XF, Chen YX, Liu L, Xiao N. Retention rates of levetiraceram in Chinese children and adolescents with epilepsy. Eur J Paediatr Neurol 2015;19:143-8.
5.	Kuczynski L. Handbook of Dynamics in Parent-child Relations. Thousand Oaks: Sage Publications; 2002.
6.	Alvarez N, Hazlett J, Courcelle R. Behavioral changes produced by valproic acid. Clin Electroencephalogr 1982;13:50-3. [PUBMED]
7.	Sobhan T, Munoz C, Ryan W. Agitation as a paradoxical effect of divalproex sodium: A case report. J Neuropsychiatry Clin Neurosci 2001;13:528-30. [PUBMED]
8.	Steiner H, Petersen ML, Saxena K, Ford S, Matthews Z. Divalproex sodium for the treatment of conduct disorder: A randomized controlled clinical trial. J Clin Psychiatry 2003;64:1183-91.
9.	Díaz-Caneja CM, Moreno C, Llorente C, Espliego A, Arango C, Moreno D. Practitioner review: Long-term pharmacological treatment of pediatric bipolar disorder. J Child Psychol Psychiatry 2014;55:959-80.
10.	Besag FM. Behavioral aspects of pediatric epilepsy syndromes. Epilepsy Behav 2004;5 Suppl 1:S3-13.
11.	Bernhardt JM, Felter EM. Online pediatric information seeking among mothers of young children: Results from a qualitative study using focus groups. J Med Internet Res 2004;6:e7.
12.	Plantin L, Daneback K. Parenthood, information and support on the internet. A literature review of research on parents and professionals online. BMC Fam Pract 2009;10:34.