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Research article Topical Sections

Assessment of behavioural problems in preschool and school going children with epilepsy

  • Introduction 

    Children with epilepsy are at greater risk of developing psychiatric and behavioural disorders such as attention deficit/hyperactivity disorder (ADHD), conduct disorder, autism spectrum disorder (ASD), as well as affective and aggressive disorders than normal children which may affect the well- being and quality of life of the child.

    Aim and Objectives 

    This study aims at identifying behavioural problems in children with epilepsy enabling early diagnosis and intervention. The objectives were to assess the presence and type of behavioural problems in children with epilepsy.

    Methods 

    A prospective cross-sectional study was conducted on children who were diagnosed as epilepsy in two age groups of 1.5–5 years and 6–18 years recruited by non-probability convenience sampling. Data regarding seizure semiology, clinical features and treatment were obtained. Children underwent IQ assessment, electroencephalogram and brain neuroimaging. Child Behaviour Check List (CBCL) was administered to parents or primary caregivers after obtaining informed consent. Results were analyzed for presence of behavioural problems using SPSS-23.

    Results 

    In the study, out of 50 study subjects, 72% were between 6–18 years. 60% children had generalised seizures, 58% children had epilepsy for <2 years and abnormal EEG was present in 80% children. 6% children had behavioural problems and 4% had borderline presentations. Co-relation of behavioural problems with age was statistically significant with p value 0.027. Behavioural problems identified were aggressiveness and anxiety.

    Conclusion 

    Childhood epilepsy is associated with behavioural problems along with other co-morbidities warranting a search during follow-up visits.

    Take-home message 

    Early identification and treatment of behavioural problems in children with epilepsy by periodic assessment during follow up visits, careful selection of combination of drugs and appropriate dose can improve the overall outcome in children taking antiepileptic drugs (AEDs) for epilepsy.

    Citation: Harshitha Shanmuganathan, Radha Kumar, D.V. Lal, Chaudhary Devanand Gulab, E. Gayathri, Kesavaraj Pallavi Raja. Assessment of behavioural problems in preschool and school going children with epilepsy[J]. AIMS Neuroscience, 2022, 9(2): 277-287. doi: 10.3934/Neuroscience.2022015

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  • Introduction 

    Children with epilepsy are at greater risk of developing psychiatric and behavioural disorders such as attention deficit/hyperactivity disorder (ADHD), conduct disorder, autism spectrum disorder (ASD), as well as affective and aggressive disorders than normal children which may affect the well- being and quality of life of the child.

    Aim and Objectives 

    This study aims at identifying behavioural problems in children with epilepsy enabling early diagnosis and intervention. The objectives were to assess the presence and type of behavioural problems in children with epilepsy.

    Methods 

    A prospective cross-sectional study was conducted on children who were diagnosed as epilepsy in two age groups of 1.5–5 years and 6–18 years recruited by non-probability convenience sampling. Data regarding seizure semiology, clinical features and treatment were obtained. Children underwent IQ assessment, electroencephalogram and brain neuroimaging. Child Behaviour Check List (CBCL) was administered to parents or primary caregivers after obtaining informed consent. Results were analyzed for presence of behavioural problems using SPSS-23.

    Results 

    In the study, out of 50 study subjects, 72% were between 6–18 years. 60% children had generalised seizures, 58% children had epilepsy for <2 years and abnormal EEG was present in 80% children. 6% children had behavioural problems and 4% had borderline presentations. Co-relation of behavioural problems with age was statistically significant with p value 0.027. Behavioural problems identified were aggressiveness and anxiety.

    Conclusion 

    Childhood epilepsy is associated with behavioural problems along with other co-morbidities warranting a search during follow-up visits.

    Take-home message 

    Early identification and treatment of behavioural problems in children with epilepsy by periodic assessment during follow up visits, careful selection of combination of drugs and appropriate dose can improve the overall outcome in children taking antiepileptic drugs (AEDs) for epilepsy.



    In biological systems, the continuous predator-prey model has been successfully investigated and many interesting results have been obtained (cf. [1,2,3,4,5,6,7,8,9] and the references therein). Moreover, based on the continuous predator-prey model, many human factors, such as time delay [10,11,12], impulsive effect [13,14,15,16,17,18,19,20], Markov Switching [21], are considered. The existing researches mainly focus on stability, periodic solution, persistence, extinction and boundedness [22,23,24,25,26,27,28].

    In 2011, the authors [28] considered the system incorporating a modified version of Leslie-Gower functional response as well as that of the Holling-type Ⅲ:

    {˙x(t)=x(a1bxc1y2x2+k1),˙y(t)=y(a2c2yx+k2). (1)

    With the diffusion of the species being also taken into account, the authors [28] studied a reaction-diffusion predator-prey model, and gave the stability of this model.

    In model (1) x represents a prey population, y represents a predator with population, a1 and a2 represent the growth rate of prey x and predator y respectively, constant b represents the strength of competition among individuals of prey x, c1 measures the maximum value of the per capita reduction rate of prey x due to predator y, k1 and k2 represent the extent to which environment provides protection to x and to y respectively, c2 admits a same meaning as c1. All the constants a1,a2,b,c1,c2,k1,k2 are positive parameters.

    However, provided with experimental and numerical researches, it has been obtained that bifurcation is a widespread phenomenon in biological systems, from simple enzyme reactions to complex ecosystems. In general, the bifurcation may put a population at a risk of extinction and thus hinder reproduction, so the bifurcation has always been regarded as a unfavorable phenomenon in biology [29]. This bifurcation phenomenon has attracted the attention of many mathematicians, so the research on bifurcation problem is more and more abundant [30,31,32,33,34,35,36,37,38,39,40].

    Although the continuous predator-prey model has been successfully applied in many ways, its disadvantages are also obvious. It requires that the species studied should have continuous and overlapping generations. In fact, we have noticed that many species do not have these characteristics, such as salmon, which have an annual spawning season and are born at the same time each year. For the population with non-overlapping generation characteristics, the discrete time model is more practical than the continuous model [38], and discrete models can generate richer and more complex dynamic properties than continuous time models [39]. In addition, since many continuous models cannot be solved by symbolic calculation, people usually use difference equations for approximation and then use numerical methods to solve the continuous model.

    In view of the above discussion, the study of discrete system is paid more and more attention by mathematicians. Many latest research works have focused on flip bifurcation for different models, such as, discrete predator-prey model [41,42]; discrete reduced Lorenz system [43]; coupled thermoacoustic systems [44]; mathematical cardiac system [45]; chemostat model [46], etc.

    For the above reasons, we will study from different perspectives in this paper, focusing on the discrete scheme of Eq (1).

    In order to get a discrete form of Eq (1), we first let

    u=ba1x,v=c1a1y,τ=a1t,

    and rewrite u,v,τ as x,y,t, then (1) changes into:

    {˙x(t)=x(1xβ1y2x2+h1),˙y(t)=αy(1β2yx+h2), (2)

    where β1=b2c1a1,h1=b2k1a21,α=a2c1,β2=c2bc1a2,h2=bk2a1.

    Next, we use Euler approximation method, i.e., let

    dxdtxn+1xnt,dydtyn+1ynt,

    where t denotes a time step, xn,yn and xn+1,yn+1 represent consecutive points. Provided with Euler approximation method with the time step t=1, (2) changes into a two-dimensional discrete dynamical system:

    {xn+1=xn+xn(1xnβ1y2nx2n+h1),yn+1=yn+αyn(1β2ynxn+h2). (3)

    For the sake of analysis, we rewrite (3) in the following map form:

    (xy)(x+x(1xβ1y2x2+h1)y+αy(1β2yx+h2)). (4)

    In this paper, we will consider the effect of the coefficients of map (4) on the dynamic behavior of the map (4). Our goal is to show how a flipped bifurcation of map (4) can appear under some certain conditions.

    The remainder of the present paper is organized as follows. In section 2, we discuss the fixed points of map (4) including existence and stability. In section 3, we investigate the flip bifurcation at equilibria E2 and E. It has been proved that map (4) can undergo the flip bifurcation provided with that some values of parameters be given certain. In section 4, we give an example to support the theoretical results of the present paper. As the conclusion, we make a brief discussion in section 5.

    Obviously, E1(1,0) and E2(0,h2β2) are fixed points of map (4). Given the biological significance of the system, we focus on the existence of an interior fixed point E(x,y), where x>0,y>0 and satisfy

    1x=β1(y)2(x)2+h1,x+h2=β2y,

    i.e., x is the positive root of the following cubic equation:

    β22x3+(β1β22)x2+(β22h1+2β1h2)x+β1h22β22h1=0. (5)

    Based on the relationship between the roots and the coefficients of Eq (5), we have

    Lemma 2.1 Assume that β1h22β22h1<0, then Eq (5) has least one positive root, and in particular

    (ⅰ) a unique positive root, if β1β22;

    (ⅱ) three positive roots, if β1<β22.

    The proof of Lemma 2.1 is easy, and so it is omitted.

    In order to study the stability of equilibria, we first give the Jacobian matrix J(E) of map (4) at any a fixed point E(x,y), which can be written as

    J(E)=(22xβ1y2(h1x2)(x2+h1)22β1xyx2+h1αβ2y2(x+h2)21+α2αβ2yx+h2).

    For equilibria E1, we have

    J(E1)=(0001+α).

    The eigenvalues of J(E1) are λ1=0,λ2=1+α with λ2>1 due to the constant α>0, so E1(1,0) is a saddle.

    For equilibria E2, note that

    J(E2)=(2β1h22β22h10αβ21α),

    then the eigenvalues of J(E2) are λ1=2β1h22β22h1,λ2=1α, and so we get

    Lemma 2.2 The fixed point E2(0,h2β2) is

    (ⅰ) a sink if 1<β1h22β22h1<3 and 0<α<2;

    (ⅱ) a source if β1h22β22h1<1 or β1h22β22h1>3 and α>2;

    (ⅲ) a a saddle if 1<β1h22β22h1<3 and α>2, or, β1h22β22h1<1 or β1h22β22h1>3 and 0<α<2;

    (ⅳ) non-hyperbolic if β1h22β22h1=1 or β1h22β22h1=3 or α=2.

    In this section, we will use the relevant results of literature [38,39,40] to study the flip bifurcation at equilibria E2 and E.

    Based on (ⅲ) in Lemma 2.2, it is known that if α=2, the eigenvalues of J(E2) are: λ1=2β1h22β22h1,λ2=1. Define

    Fl={(β1,β2,h1,h2,α):α=2,β1,β2,h1,h2>0}.

    We conclude that a flip bifurcation at E2(0,h2β2) of map (4) can appear if the parameters vary in a small neighborhood of the set Fl.

    To study the flip bifurcation, we take constant α as the bifurcation parameter, and transform E2(0,h2β2) into the origin. Let e=2β1h22β22h1,α1=α2, and

    u(n)=x(n),v(n)=y(n)h2β2,

    then map (4) can be turned into

    (uv)(euu22β1h2β2h1uv+O((|u|+|v|+|α1|)3)2β2uv2β2h2u22β2h2v2+4h2uv+α1β2uα1vα1β2h2u2α1β2h2v2+2α1h2uv+O((|u|+|v|+|α1|)3)). (6)

    Let

    T1=(1+e02β21),

    then by the following invertible transformation:

    (uv)=T1(sw),

    map (6) turns into

    (sw)(es(1+e)s22β1h2β2h1s(2sβ2+w)+O(|s|+|w|+|α1|)3w+F2(s,w,α1)), (7)

    where

    F2=2β2[(1+e)s2+2β1h2β2h1s(2sβ2+w)]2β2h2(1+e)2s22β2h2(2sβ2+w)2+4(1+e)h2s(2sβ2+w)
    +(1+e)α1β2sα1(2sβ2+w)(1+e)2α1β2h2s2α1β2h2(2sβ2+w)2
    +2(1+e)α1h2s(2sβ2+w)+O(|s|+|w|+|α1|)3.

    Provided with the center manifold theorem (Theorem 7 in [40]), it can be obtained that there will exist a center manifold Wc(0,0) for map (7), and the center manifold Wc(0,0) can be approximated as:

    Wc(0,0)={(w,s,α1)R3:s=aw2+bwα1+c(α1)2+O(|w|+|α1|)3}.

    As the center manifold satisfies:

    s=a(w+F2)2+b(w+F2)α1+c(α1)2=e(aw2+bwα1+c(α1)2)(1+e)(aw2+bwα1+c(α1)2)22β1h2β2h1(aw2+bwα1+c(α1)2)(2β2(aw2+bwα1+c(α1)2)+w)+O(|s|+|w|+|α1|)3,

    it can be obtained by comparing the coefficients of the above equality that a=0,b=0,c=0, so the center manifold of map (7) at E2(0,h2β2) is s=0. Then map (7) restricted to the center manifold turns into

    w(n+1)=w(n)α1w(n)2β2h2w2(n)α1β2h2w2(n)+O(|w(n)|+|α1|)3
    f(w,α1).

    Obviously,

    fw(0,0)=1,fww(0,0)=4β2h2,

    so

    (fww(0,0))22+fwww(0,0)30,fwα1(0,0)=10.

    Therefore, Theorem 4.3 in [38] guarantees that map (3) undergoes a flip bifurcation at E2(0,h2β2).

    Note that

    J(E)=(22xβ1(y)2(h1(x)2)((x)2+h1)22β1xy(x)2+h1αβ21α),

    then the characteristic equation of Jacobian matrix J(E) of map (3) at E(x,y) is:

    λ2(1+α0α)λ+(1α)α0ηα=0, (8)

    where

    α0=22xβ1(y)2(h1(x)2)((x)2+h1)2,η=2β1xyβ2((x)2+h1).

    Firstly, we discuss the stability of the fixed point E(x,y). The stability results can be described as the the following Lemma, which can be easily proved by the relations between roots and coefficients of the characteristic Eq (8), so the proof has been omitted.

    Lemma 3.1 The fixed point E(x,y) is

    (ⅰ) a sink if one of the following conditions holds.

    (ⅰ.1) 0<α0+η<1, and α01α0+η<α<2(1+α0)1+α0+η;

    (ⅰ.2) 1<α0+η<0, and α<min{α01α0+η,2(1+α0)1+α0+η};

    (ⅰ.3) α0+η<1, and α01α0+η>α>2(1+α0)1+α0+η;

    (ⅱ) a source if one of the following conditions holds.

    (ⅱ.1) 0<α0+η<1, and α<min{α01α0+η,2(1+α0)1+α0+η};

    (ⅱ.2) 1<α0+η<0, and α01α0+η<α<2(1+α0)1+α0+η;

    (ⅱ.3) α0+η<1, and α>max{α01α0+η,2(1+α0)1+α0+η};

    (ⅲ) a saddle if one of the following conditions holds.

    (ⅲ.1) 1<α0+η<1, and α>2(1+α0)1+α0+η;

    (ⅲ.2) α0+η<1, and α<2(1+α0)1+α0+η;

    (ⅳ) non-hyperbolic if one of the following conditions holds.

    (ⅳ.1) α0+η=1;

    (ⅳ.2) α0+η1; and α=2(1+α0)1+α0+η;

    (ⅳ.3) α0+η0,α=α01α0+η and (1+α0α)2<4((1α)α0ηα).

    Then based on (ⅳ.2) of Lemma 3.1 and α1+α0,3+α0, we get that one of the eigenvalues at E(x,y) is 1 and the other satisfies |λ|1. For α,β1,β2,h1,h2>0, let us define a set:

    Fl={(β1,β2,h1,h2,α):α=2(1+α0)1+α0+η,α0+η1,α1+α0,3+α0}.

    We assert that a flip bifurcation at E(x,y) of map (3) can appear if the parameters vary in a small neighborhood of the set Fl.

    To discuss flip bifurcation at E(x,y) of map (3), we choose constant α as the bifurcation parameter and adopt the central manifold and bifurcation theory [38,39,40].

    Let parameters (α1,β1,β2,h1,h2)Fl, and consider map (3) with (α1,β1,β2,h1,h2), then map (3) can be described as

    {xn+1=xn+xn(1xnβ1y2nx2n+h1),yn+1=yn+α1yn(1β2ynxn+h2). (9)

    Obviously, map (9) has only a unique positive fixed point E(x,y), and the eigenvalues are λ1=1,λ2=2+α0α, where |λ2|1.

    Note that (α1,β1,β2,h1,h2)Fl, then α1=2(1+α0)1+α0+η. Let |α| small enough, and consider the following perturbation of map (9) described by

    {xn+1=xn+xn(1xnβ1y2nx2n+h1),yn+1=yn+(α1+α)yn(1β2ynxn+h2), (10)

    with α be a perturbation parameter.

    To transform E(x,y) into the origin, we let u=xx,v=yy, then map (10) changes into

    (uv)(a1u+a2v+a3u2+a4uv+a5v2+a6u3+a7u2v+a8uv2+a9v3+O((|u|+|v|)4)b1u+b2v+b3u2+b4uv+b5v2+c1uα+c2vα+c3u2α+c4uvα+c5v2α+b6u3+b7u2v+b8uv2+b9v3+O((|u|+|v|+|α|)4)), (11)

    where

    a1=22xβ1(y)2f(0)β1x(y)2f(0); a2=2β1xyf(0);

    a3=1β1(y)2f(0)12β1x(y)2f(0); a4=2β1yf(0)2β1xyf(0);

    a5=β1xf(0); a6=12β1(y)2f(0)16β1x(y)2f(0);

    a7=β1xyf(0)2β1yf(0); a8=β1f(0)β1xf(0),a9=0;

    f(0)=1(x)2+h1,f(0)=2x[(x)2+h1]2,f(0)=6(x)22h1[(x)2+h1]3,f(0)=24x(h1(x)2)[(x)2+h1]4.

    b1=α1β2(y)2(x+h2)2; b2=1+α1α1β2yx+h2; b3=α1β2(y)2(x+h2)3; b4=2α1β2y(x+h2)2;

    b5=α1β2x+h2; c1=β2(y)2(x+h2)2; c2=1β2yx+h2; c3=β2(y)2(x+h2)3;

    c4=2β2y(x+h2)2; c5=β2x+h2; b6=α1β2(y)2(x+h2)4; b7=2α1β2y(x+h2)3;

    b8=α1β2(x+h2)2;b9=0.

    Now let's construct an matrix

    T2=(a2a21a1λ2a1).

    It's obvious that the matrix T2 is invertible due to λ21, and then we use the following invertible translation

    (uv)=T2(sw),

    map (11) can be described by

    (sw)(s+f1(s,w,α)λ2w+f2(s,w,α)), (12)

    where

    f1(s,w,α)=(λ2a1)a3a2b3a2(λ2+1)u2+(λ2a1)a4a2b4a2(λ2+1)uv+(λ2a1)a5a2b5a2(λ2+1)v2+(λ2a1)a6a2b6a2(λ2+1)u3+(λ2a1)a7a2b7a2(λ2+1)u2v+(λ21)a8a2b8a2(λ2+1)uv2+(λ2a1)a9a2b9a2(λ2+1)v3a2c1a2(λ2+1)uαa2c2a2(λ2+1)vαa2c3a2(λ2+1)u2αa2c4a2(λ2+1)uvαa2c5a2(λ2+1)v2α+O((|s|+|w|+|α|)4),f2(s,w,α)=(a1+1)a3+a2b3a2(λ2+1)u2+(a1+1)a4+a2b4a2(λ2+1)uv+(a1+1)a5+a2b5a2(λ2+1)v2+(a1+1)a6+a2b6a2(λ2+1)u3+(a1+1)a7+a2b7a2(λ2+1)u2v+(a1+1)a8+a2b8a2(λ2+1)uv2+(a1+1)a9+a2b9a2(λ2+1)v3+a2c1a2(λ2+1)uα+a2c2a2(λ2+1)vα+a2c3a2(λ2+1)u2α+a2c4a2(λ2+1)uvα+a2c5a2(λ2+1)v2α+O((|s|+|w|+|α|)4),

    with

    u=a2(s+w),v=(λ2a1)w(a1+1)s;

    u2=(a2(s+w))2;

    uv=(a2(s+w))((λ2a1)w(a1+1)s);

    v2=((λ2a1)w(a1+1)s)2;

    u3=(a2(s+w))3;

    u2v=(a2(s+w))2((λ2a1)w(a1+1)s);

    uv2=(a2(s+w))((λ2a1)w(a1+1)s)2;

    v3=((λ2a1)w(a1+1)s)3.

    In the following, we will study the center manifold of map (12) at fixed point (0, 0) in a small neighborhood of α=0. The well-known center manifold theorem guarantee that a center manifold Wc(0,0) can exist, and it can be approximated as follows

    Wc(0,0)={(s,w,α)R3:w=d1s2+d2sα+d3(α)2+O((|s|+|α|)3)},

    which satisfies

    w=d1(s+f1(s,w,α))2+d2(s+f1(s,w,α))α+d3(α)2
    =λ2(d1s2+d2sα+d3(α)2)+f2(s,w,α).

    By comparing the coefficients of the above equation, we have

    d1=a2((a1+1)a3+a2b3)1λ22(a1+1)((a1+1)a4+a2b4)1λ22+(a1+1)2((a1+1)a5+a2b5)1λ22,d2=c2(a1+1)a2c1(1+λ2)2,d3=0.

    So, restricted to the center manifold Wc(0,0), map (12) turns into

    ss+e1s2+e2sα+e3s2α+e4s(α)2+e5s3+O((|s|+|α|)4)F2(s,α), (13)

    where

    e1=A1a22A2a2(a1+1)+A3(a1+1)2;

    e2=A8a2+A9(a1+1);

    e3=2A1d2a22+A2a2d2(λ22a11)2A3d2(λ2a1)(a1+1)A8a2d1

    A9(λ2a1)d1A10a22+A11a2(a1+1)A12(a1+1)2;

    e4=A8a2d2A9(λ2a1)d2;

    e5=2A1a22d1+A2a2d1(λ22a11)2A3d1(λ2a1)(a1+1)+A4a32

    A5a22(a1+1)+A6a2(a1+1)2A7(a1+1)3;

    with

    A1=(λ2a1)a3a2b3a2(λ2+1);A2=(λ2a1)a4a2b4a2(λ2+1);A3=(λ2a1)a5a2b5a2(λ2+1);A4=(λ2a1)a6a2b6a2(λ2+1);

    A5=(λ2a1)a7a2b7a2(λ2+1);A6=(λ21)a8a2b8a2(λ2+1);A7=(λ2a1)a9a2b9a2(λ2+1);A8=a2c1a2(λ2+1);

    A9=a2c2a2(λ2+1);A10=a2c3a2(λ2+1);A11=a2c4a2(λ2+1);A12=a2c5a2(λ2+1).

    To study the flip bifurcation of map (13), we define the following two discriminatory quantities

    μ1=(2F2sα+12F2α2F2s2)|(0,0),

    and

    μ2=(163F2s3+(122F2s2)2)|(0,0)

    which can be showed in [38]. Then provided with Theorem 3.1 in [38], the following result can be given as

    Theorem 3.1. Assume that μ1 and μ2 are not zero, then a flip bifurcation can occur at E(x,y) of map (3) if the parameter α varies in a small neighborhood of origin. And that when μ2>0(<0), the period-2 orbit bifurcated from E(x,y) of map (3) is stable (unstable).

    As application, we now give an example to support the theoretical results of this paper by using MATLAB. Let β1=1,β2=0.5,h1=0.05,h2=0.1, then we get from (5) that map (3) has only one positive point E(0.0113,0.2226). And we further have μ1=e2=0.11340,μ2=e5+e21=4.48690, which implies that all conditions of Theorem 3.1 hold, a flip bifurcation comes from E at the bifurcation parameter α=2.2238, so the flip bifurcation is supercritical, i.e., the period-2 orbit is unstable.

    According to Figures 1 and 2, the positive point E(0.0113,0.2226) is stable for 2α2.4 and loses its stability at the bifurcation parameter value α=2.2238. Which implies that map (3) has complex dynamical properties.

    Figure 1.  Flip bifurcation diagram of map (3) in the (α, x) plane for β1=1,β2=0.5,h1=0.05,h2=0.1. The initial value is (0.0213, 0.2326).
    Figure 2.  Flip bifurcation diagram of map (3) in the (α, y) plane for β1=1,β2=0.5,h1=0.05,h2=0.1. The initial value is (0.0213, 0.2326).

    In this paper, a predator-prey model with modified Leslie-Gower and Holling-type Ⅲ schemes is considered from another aspect. The complex behavior of the corresponding discrete time dynamic system is investigated. we have obtained that the fixed point E1 of map (4) is a saddle, and the fixed points E2 and E of map (4) can undergo flip bifurcation. Moreover, Theorem 3.1 tell us that the period-2 orbit bifurcated from E(x,y) of map (3) is stable under some sufficient conditions, which means that the predator and prey can coexist on the stable period-2 orbit. So, compared with previous studies [28] on the continuous predator-prey model, our discrete model shows more irregular and complex dynamic characteristics. The present research can be regarded as the continuation and development of the former studies in [28].

    This work is supported by the National Natural Science Foundation of China (60672085), Natural Foundation of Shandong Province (ZR2016EEB07) and the Reform of Undergraduate Education in Shandong Province Research Projects (2015M139).

    The authors would like to thank the referee for his/her valuable suggestions and comments which led to improvement of the manuscript.

    The authors declare that they have no competing interests.

    YYL carried out the proofs of main results in the manuscript. FXZ and XLZ participated in the design of the study and drafted the manuscripts. All the authors read and approved the final manuscripts.


    Acknowledgments



    The authors acknowledge the immense help received from the scholar whose article are cited and included in references to this manuscript. The authors are also grateful to authors/publishers/editors of all those articles, journals and books from where the literature for this article has been reviewed and discussed.

    Limitations of the Study



    Major limitations of the present study were small sample size; a larger sample could have brought in the effects. A comparison cohort would have been useful in this study design which was another limitation of the study. Larger study on Indian population on multidrug treatment may give more insight into its effect on behaviour. The generalisability of study findings is limited as the study was from a single centre with limited catchment area. Hence adequate caution needs to be exercised while generalizing the findings to population groups with different demographic structure. It was a onetime assessment of children with epilepsy those with borderline scores were not followed up.

    Source of financial support



    Nil.

    Conflict of interest



    None declared.

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