Seizure safety – brief overview

CDBC/BCAAN Education Bite, Originally emailed June 6, 2025

About seizures

Focal seizures occur when there is seizure activity in a specific part of the brain. Focal seizures can look many different ways including chewing movements, or random-seeming behaviour such as picking at clothes, walking aimlessly, or mumbling. The person may feel sensations, emotions, or involuntary jerking of certain parts of the body. In some focal seizures, the person may be unaware (focal dyscognitive seizures, previously called complex partial seizures). 

Generalized seizures occur due to widespread seizure activity throughout both hemispheres. Absence seizures are a type of generalized seizure that involve a period of unconsciousness with a blank stare and sometimes chewing movements, blinking, or tugging at clothing. During an absence seizure, a person will not remember what happened, and will typically resume right after where they left off. Tonic-clonic seizures (previously called “grand mal”) involve stiffening which causes a fall to the floor and rhythmic jerking/twitching. After this type of seizure, there is typically fatigue and confusion. Myoclonic seizures involve abrupt muscle jerks and consciousness is not impaired. There are also atonic (drop) seizures, tonic seizures, and clonic seizures.

 How to support someone during a seizure

Watch this 4-minute video on seizure first aid from Epilepsy Toronto.

If you have a patient with epilepsy, start by asking about what to look out for (what do their seizures look like, how long they last) and what kind of support you can provide during and after a seizure. Ask what kind of recovery time they need following a seizure. With some seizures, a person might typically feel “back to themselves” right away and ready to continue with what they were doing. For others, they will need a rest and time to recover.

During a seizure, remain calm and stay with the person. You may need to call for help unless the seizure plan does not require it. For example, for a person with absence seizures, they will pass quickly and the person should return to baseline.

During a seizure, ensure the person is safe by moving away objects that could harm them. Do not try to stop their activity or restrain them. Do not put anything in their mouth. For a generalized tonic-clonic seizure, help the person to the floor. Place something soft under their head to help prevent injury. After the seizure is over, turn them on their side in the recovery position in case they vomit (this prevents choking). Be calm and reassuring “You just had a seizure, you are OK.”

Time the seizure from the onset. If this is the person’s first seizure, or if the seizure is greater than 5 minutes, or if multiple seizures occur without coming back to baseline that lasts more than 5 minutes, they will likely need immediate medical assistance. Parents may have and administer special medication to stop the seizure.

Ensure you know how to activate the emergency protocol for your setting. At BC Children’s Hospital, Code Blue can be called only in coverage areas (ACB, BCCH, BCWH, HM, SHY, TACC). A code blue is for a medical emergency, for example, if a seizure does not stop after 5 minutes. If available, press the “Code Blue – Pediatric” button, or call the emergency line at x7111▸ State “Code Blue, [Pediatric/Adult], and [exact location – department/area, building, floor, room number]”

If the emergency occurs outside these areas including another building, or the parking lot/sidewalk, call 911 and also call campus security at 899. Tell security the location and that you have called 911.

CDBC’s FASD Handbook (2021)

Complex Developmental Behavioural Conditions Network Handbook for the Diagnosis of Fetal Alcohol Spectrum Disorder

The goal of this handbook is to provide an over-arching framework for FASD assessments within CDBC, and to address common questions which arise during assessments. This handbook is intended as a reference for clinicians conducting CDBC network assessments. In particular, it provides in depth description of the physicians’ and psychologists’ roles to ensure consistency across the province. The CDBC network uses the 2016 Canadian Guidelines and the Appendix for the diagnosis of FASD.

 

 

Attention-deficit/hyperactivity (ADHD) in the news

CDBC/BCAAN Education Bite, Originally emailed May 9, 2025

An April 2025 New York Times article has been making news: Have We Been Thinking About A.D.H.D. All Wrong?  This article highlights fluctuations in ADHD symptoms, the continuous (not dichotomous) nature of ADHD, and mixed evidence for the long-term benefit of medication for ADHD. Clinicians may want to review this article since it’s making the rounds and you may get questions about it.

From the article – “The failure to find a clear biomarker doesn’t mean that there is no biological basis for A.D.H.D.; most scientists I spoke to agreed that the condition is produced by some combination of biological and environmental forces, though there is little consensus about the relative importance of each. But it does have certain implications for the field, including for the question of medication. If we’re no longer confident that A.D.H.D. has a purely biological basis, does it make sense that our go-to treatment is still rooted in biology?”

The Testing Psychologist podcast discussed this article and gave some specific suggestions for clinicians. It’s worth a listen. Reading the NYT article brought me to a recent update to the  Multimodal Treatment of ADHD (MTA) study which I’ll highlight here.

 Characteristics and Predictors of Fluctuating Attention-Deficit/Hyperactivity Disorder in the Multimodal Treatment of ADHD (MTA) Study (Sibley, et al., 2024)

This study provides detailed comparison of the MTA’s fluctuating ADHD subgroup to the stable ADHD and remission subgroups. This study included 83% of the original sample who had at least one follow up over 18 years old. Unfortunately, this is not an open-access article. I’ve highlighted a few key points here:

In this MTA long-term follow-up study, fluctuating ADHD occurred in 63.8% of the sample, characterized by alternating periods of remission and recurrence. “The high prevalence and moderate severity of fluctuating ADHD indicates that it may be the standard clinical course of ADHD—not a rare variant. Stable persistence appears to be a less common variant of ADHD (10.8% of sample) characterized by early and lasting risk for comorbid mood problems, elevated substance use, stable impairments, and low medication utilization relative to severity. The recovery (9.1%) and stable partial remission subgroups (15.6%) may be rare variants marked by milder ADHD and protective factors such as low parental psychopathology or elevated comorbid anxiety”

 “Among fluctuators, periods of remission (particularly full remission) were associated with higher environmental demands, particularly at younger ages [young adult]…Though fluctuations in demands and remission appear to coincide (particularly at younger ages), it remains unclear whether remission promotes entry into more demanding environments or greater demands facilitate symptom/impairment management…Clinicians should emphasize that ADHD often fluctuates over time and patient monitoring of symptoms is imperative to trigger as-needed return to care.”

 

References

 Sibley, M. H., Kennedy, T. M., Swanson, J. M., Arnold, L. E., Jensen, P. S., Hechtman, L. T., Molina, B. S. G., Howard, A., Greenhill, L., Chronis-Tuscano, A., Mitchell, J. T., Newcorn, J. H., Rohde, L. A., & Hinshaw, S. P. (2024). Characteristics and predictors of fluctuating attention-Deficit/Hyperactivity disorder in the multimodal treatment of ADHD (MTA) study. The Journal of Clinical Psychiatry, 85(4)https://doi.org/10.4088/JCP.24m15395

Respectful and ethical work with interpreters

PHSA has a Language Policy that outlines the appropriate use of language services to reduce or eliminate language barriers to optimize the delivery of safe and equitable care. A few key and interesting points from this document:
  1. Staff are to make “all reasonable efforts” to obtain the services of a Qualified Interpreter.
  2. For Indigenous languages, an Indigenous Patient Liaison or Elder may assist with consent in lieu of a Qualified Interpreter.
  3. The need for interpreter, language required, and any refusal of interpreter must be documented in the patient record, in addition to any other language resources used (e.g., family members).
  4. “Interpretation” refers to the spoken/sign format and “translation” refers to the written format. For documents of two pages or less, the document can be “sight translated” by a Qualified Interpreter. PLS has a paid service available to translate written documents.
  5. Machine translation should only be used for non-medical conversation due to the risk of breach of confidentiality or miscommunication, where no other resources are available.
Practical tips
  1. Most of the time, sitting in a triangle is the best format to be able to communicate via interpreter, but the interpreter may have specific suggestions in your particular setting. With an ASL interpreter, the interpreter will typically stand next to you so that the patient can look back and forth between you and the interpreter easily. There are also lighting considerations with ASL interpretation.
  2. Speak directly to the patient or family member, facing them and not the interpreter. Use words like “you” and “you’re” and avoid saying things like “ask the patient.”
  3. Speak at your normal pace and volume. Speak using 1-2 sentences at a time but avoid breaking up a thought. Avoid asking more than one question at a time.
  4. Clarify unique vocabulary. Avoid jargon, slang, idioms, and acronyms. Be thoughtful with the use of humor – what you may intend as humor may not be the same in the patient’s first language.
  5. Keep in mind that sometimes there is not a direct equivalent term in another language. The interpreter may request an explanation or require more time to convey an unfamiliar concept.
Provincial Language Services has educational Resources and Education. Some highlights:
  1. Making Sense of Language: The Communication Conundrum (video with focus on intercultural communication)

Dyslexia Intervention

CDBC/BCAAN Educational bite: Originally emailed March 13, 2024

Targeted reading interventions improve word reading and spelling: A recent meta-analysis of 53 reading interventions targeting foundational skills for children at risk or with dyslexia show a significant, positive effect on norm-referenced reading outcomes. Dosage (higher=slightly larger effect sizes) and outcome domain (spelling and word reading were more impacted than reading comprehension) were important moderators (Hall et al., 2023). “Mean effects of interventions delivered earlier (in Grades K-2) were not statistically significantly larger than effects of interventions delivered later (in Grades 3–5). Descriptively speaking, though, studies with students in Grades 3–5 were associated with smaller effects (g = 0.16) than studies with students in Grades K-2 (g = 0.36).”

Phonological awareness can be directly taught through instruction: As suggested in the National Panel on Reading (2020), phonological and phonemic awareness instruction are important components of preventing and treating dyslexia. This intervention continues to be well supported as being able to be trained through intervention (Rehfeld et al., 2022). Phonological awareness training must be paired with high quality targeted reading intervention.

Music training may play a role in helping those with dyslexia: A prospective study published in PLoS One (Flaugnacco et al., 2015) suggested that music training can improve phonological awareness and reading in children with dyslexia, presumably due to an underlying poor temporal perception which is improved through training.

Treatments without research support

Neurofeedback: There is not sufficient research to support EEG neurofeedback as an intervention for reading (Othman et al., 2020).

Vision therapy: According to a joint statement which included the American Academy of Pediatrics, section on Ophthalmology “Convergence insufficiency and poor accommodation, both of which are uncommon in children, can interfere with the physical act of reading but not with decoding. Thus, treatment of these disorders can make reading more comfortable and may allow reading for longer periods of time but does not directly improve decoding or comprehension.” Overall, while vision therapy can help individuals with convergence insufficiency, it is not accepted as an appropriate treatment to improve reading, either directly or indirectly (initially published in 2009, and re-affirmed in 2014).

References

American Academy of Pediatrics, Section on Ophthalmology, Council on Children with Disabilities, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, & American Association of Certified Orthoptists (2009). Joint statement–Learning disabilities, dyslexia, and vision. Pediatrics, 124(2), 837–844. https://doi.org/10.1542/peds.2009-1445

Flaugnacco, E., Lopez, L., Terribili, C., Montico, M., Zoia, S., & Schön, D. (2015). Music Training Increases Phonological Awareness and Reading Skills in Developmental Dyslexia: A Randomized Control Trial. PloS one, 10(9), e0138715. https://doi.org/10.1371/journal.pone.0138715

Hall, C., Dahl‐Leonard, K., Cho, E., Solari, E. J., Capin, P., Conner, C. L., Henry, A. R., Cook, L., Hayes, L., Vargas, I., Richmond, C. L., & Kehoe, K. F. (2023). Forty years of reading intervention research for elementary students with or at risk for dyslexia: A systematic review and Meta‐Analysis. Reading Research Quarterly, 58(2), 285-312. https://doi.org/10.1002/rrq.477

Othman, E. S., Faye, I., Sundaram Muthuvalu, M., & Naufal Mohamad Saad, M. (2020). EEG neurofeedback for dyslexia treatment: Limitations and future directions. Journal of Physics. Conference Series, 1497(1), 12028. https://doi.org/10.1088/1742-6596/1497/1/012028

National Reading Panel (U.S.) & National Institute of Child Health and Human Development (U.S.). (2000). Report of the National Reading Panel: Teaching children to read : an evidence-based assessment of the scientific research literature on reading and its implications for reading instruction, https://www.nichd.nih.gov/sites/default/files/publications/pubs/nrp/Documents/report.pdf

Vimont, C. (2017). Vision Training Not Proven to Make Vision Sharper, American Academy of Ophthalmology, https://www.aao.org/eye-health/tips-prevention/vision-training-not-proven-to-make-vision-sharper

Intellectual developmental disorder (IDD) – terminology

CDBC/BCAAN Educational bite: Originally emailed July 18, 2024

Global developmental delay (GDD) is a provisional diagnosis in the DSM that should be used for infants and children 4 years of age and younger where children are not meeting expected developmental milestones in several areas of intellectual functioning. At this age, it is difficult for many children to participate in formal assessment. Test scores are less stable compared to scores for older children (please see the bonus educational bite below, and the previous Bite). Even if a diagnosis of intellectual developmental disorder can be established under age 5, it can be challenging to establish a level of disability. GDD can be diagnosed by a physician or psychologist. When given by an evaluating psychologist, a diagnosis of GDD can be used to apply for services through Children and Youth with Support Needs (CYSN), although a re-evaluation will be necessary to ensure continuity of services when the child is older. Of note, GDD is equivalent to the International Classification of Diseases’ (ICD) diagnosis “unspecified IDD.”

While there is typically good reason to wait to confirm a diagnosis of intellectual developmental disorder (IDD), a diagnosis can be made under age 5, typically when there is robust evidence for disability, and there is also a medical/genetic condition known to be highly co-morbid with IDD.

When the evaluating psychologist identifies an intellectual developmental disorder in a child 5 or older, but cannot reliably assess the degree of the impairment (mild, moderate, severe, profound), unspecified intellectual developmental disorder is the appropriate DSM diagnosis. Of note, with unspecified IDD, the diagnosis of IDD is made with full confidence, it is the degree of the disorder which is unclear. While the DSM notes that this category requires re-assessment “after a period of time,” if the diagnosis is made firmly for good reason, it should be accepted by CYSN and Community Living BC (CLBC). The psychologist’s report should clearly state the reason for the “unspecified” diagnosis. The unspecified category is rarely used, as the degree of the disorder should be diagnosed based on adaptive functioning. Unspecified IDD and GDD are mutually exclusive categories (GDD for under 5, unspecified IDD for 5 and older), and the DSM’s “unspecified IDD” aligns with the ICD’s “other IDD.”

Bonus Research Bite: Early developmental assessment (using the Bayley) and the prediction of later IQ scores

  • When comparing the Bayley-III score at age 2 to the WPPSI score at age 4, only 81% of preterm children retained the same developmental classification (Bode et al., 2014).
  • In preterm children, “Bayley-III cognitive and language scores correlate with later IQ, but may fail to predict delay or misclassify children who are not delayed at school age” (Lowe et al., 2023).
  • The Bayley-III at age 3 strongly correlated with WISC-IV FSIQ at age 6 in very low birthweight children. This study suggested that those with Bayley scores 85-95 did not all end up in the average range on the WISC (some were lower scoring on the WISC; Nishijima et al., 2022).
  • In typically developing children, the Bayley-III Cognitive scores were correlated with WISC-IV Full-Scale IQ (r = .41), and accounted for 24% of the total Full-Scale IQ variation. This study concluded that the Bayley was an insufficient predictor of later IQ (Månsson, et al., 2019).

References

Bode, M. M., DʼEugenio, D. B., Mettelman, B. B., & Gross, S. J. (2014). Predictive validity of the Bayley, Third Edition at 2 years for intelligence quotient at 4 years in preterm infants. Journal of developmental and behavioral pediatrics : JDBP, 35(9), 570–575. https://doi.org/10.1097/DBP.0000000000000110

Lowe, J., Bann, C. M., Dempsey, A. G., Fuller, J., Taylor, H. G., Gustafson, K. E., Watson, V. E., Vohr, B. R., Das, A., Shankaran, S., Yolton, K., Ball, M. B., Hintz, S. R., & Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (2023). Do Bayley-III Composite Scores at 18-22 Months Corrected Age Predict Full-Scale IQ at 6-7 Years in Children Born Extremely Preterm?. The Journal of pediatrics, 263, 113700. https://doi.org/10.1016/j.jpeds.2023.113700

Månsson, J., Stjernqvist, K., Serenius, F., Ådén, U., & Källén, K. (2019). Agreement Between Bayley-III Measurements and WISC-IV Measurements in Typically Developing Children. Journal of Psychoeducational Assessment, 37(5), 603-616. https://doi.org/10.1177/0734282918781431

Nishijima, M., Yoshida, T., Matsumura, K., Inomata, S., Nagaoka, M., Tamura, K., Kawasaki, Y., & Makimoto, M. (2022). Correlation between the Bayley-III at 3 years and the Wechsler Intelligence Scale for Children, Fourth Edition, at 6 years. Pediatrics international : official journal of the Japan Pediatric Society, 64(1), e14872. https://doi.org/10.1111/ped.14872