Medical Management Considerations
Resources for Families
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Description and Cause
Epilepsy is defined as a neurological disorder manifested by two or more unprovoked seizures. A seizure is a behavioral alteration due to abnormal and excessive electrical brain activity. A person who has multiple seizures due to fever, trauma, infection, etc. is not considered to be epileptic. Epilepsy may be caused by genetic conditions, head injury, stroke, brain tumor, toxic poisoning or severe infections like meningitis and encephalitis. These causes may occur during the prenatal, perinatal or postnatal period. In 70% of cases no etiology can be identified.
1:100 to 1:200 individuals in general population and 1:4 individuals with mental retardation suffer from epilepsy.
The International League Against Epilepsy has proposed a system of classification which includes partial seizures, generalized seizures, unclassified epileptic seizures and status epilepticus.
I. Partial Seizures
Simple Partial (without impairment of consciousness)
Complex Partial (with impairment of consciousness)
II. Generalized Seizures
Typical Childhood Absence (petit mal) Non-Convulsive Seizures
Note: The vast majority of “petit mal” in people with mental retardation is behavioral, but those due to seizure are more likely complex partial seizures rather than absence seizures.
Tonic-clonic (grand mal) Convulsive Seizures
III. Status Epilepticus
Status epilepticus is most commonly caused by anticonvulsant drug withdrawal. It is estimated that 8% of people with generalized seizures experience status epilepticus. (Return to the index for a full document on status epilepticus.)
Status epilepticus is more common at the extremes of life and is associated with high morbidity and mortality
MEDICAL MANAGEMENT CONSIDERATIONS
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Note: These considerations are in addition to the normal medical care provided to an individual without epilepsy.
Management of epilepsy is usually predicated upon the assumption that the least invasive treatment options should be employed first, which generally suggests the following hierarchical approach:
Note: There is some debate over the optimal age range for the last three approaches.
Uncomplicated and well-controlled epilepsy can easily be managed by the primary care physician, particularly when monotherapy is used. However, management of seizures with antiepileptic medication polypharmacy may prove to be challenging to some primary care physicians. When the primary care physician feels that the needs of their patient exceed their own knowledge and experience, referral to a pediatric neurologist is warranted. In addition, referral to a comprehensive epilepsy center is warranted for the evaluation of treatment with vagal nerve stimulation or epilepsy surgery.
I. Management by Age
Infancy (Birth to 1 year)
Adolescence and Adulthood (13 years and over)
Most people with epilepsy are cognitively normal and are able to self-support and thrive in the community without unusual support systems; the following should be considered only when appropriate, such as for persons with mental retardation.
II. Standard Anticonvulsant Medications
III. Management of Specific Influencing Factors
Food and Drink
IV. Psychosocial Considerations
Children with epilepsy and their parents face many psychosocial barriers because of the health implications of epilepsy, the stigma associated with epilepsy, and the unpredictability of the occurrence of seizures. They may experience:
Traditional counseling and psychiatric interventions have been of some help, yet there is a growing need for interventions that are child centered, skill based, and family focused. According to Dr. Mary Ann Lewis, et al., this program should:
The goal of therapy is optimal quality of life, and consideration should be given to the impact of the seizure disorder and of its treatment on peer relationships, schooling, employment, family, and other interrelated dynamics.
Several studies document that children and adolescents with epilepsy are at high risk for psychiatric problems which are often not identified. Educational/psychosocial programs should address mental health symptoms, as well as focusing upon quality of life. A description and critique of psychosocial interventions published in peer-reviewed journals (Wagner and Smith, 2005) is highly recommended for understanding the various methods and outcomes of all of the educational interventions published in the literature.
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Peer-reviewed Journal Articles/Academies
America’s Working Group on Status Epilepticus (1993). Treatment of Convulsive Status Epilepticus Journal of the American Medical Association, 270(7), 854-859.
(1998). Consensus Statements: Medical Management of Epilepsy. Wilder, B.J. (Section Ed.). Neurology, 51 (5 Suppl 4), S39-S43.
Lewis, M.A. et al. (1989). Randomized Trial of a Program to Enhance the Competencies of Children with Epilepsy. Epilepsia, 31(1), 100-109.
Mattson, R.H. (1998). Medical Management of Epilepsy in Adults. Neurology, 51(4), 15-20.
Nadkarni, S., LaJoie, J., Devinsky, O. (2005). Current Treatments of Epilepsy. Neurology, 64(3), 2-11.
Phillips, P. (1997). Current view of advances in epilepsy. Journal of the American Medical Association, 278(11), 883-886.
Scheuer, M.L., Pedley, T.A. (1990). The Evaluation and Treatment of Seizures New England Journal of Medicine, 323(21), 1468-1474.
Wagner, J.L. & Smith, G. (2005). Psychosocial Intervention in Pediatric Epilepsy: A Critique of the Literature. Epilepsy & Behavior, Article in Press, Corrected Proof, 1-11.
Special Interest Groups/Other Publications
American Epilepsy Society. et al. (2003). Living Well with Epilepsy. Report of the 2003 National Conference on Public Health and Epilepsy.
Baxter, P. (2005). Epilepsy and Sleep. Developmental Medicine and Child Neurology, 47(11), 723.
Berg, A.T. (2005). Special Education Needs of Children with Newly Diagnosed Epilepsy. Developmental Medicine and Child Neurology, 47(11), 749-753.
Besag, F.M.C., Nomayo, A., Pool, F. (2005). The Reactions of Parents who think that a Child is Dying in a Seizure In Their Own Words. Epilepsy and Behavior, 7, 517-523.
Capute, A.J. & Accardo, P.J. (1996). Developmental Disabilities in Infancy and Childhood: Vol. 1. Neurodevelopmental Diagnosis and Treatment. Baltimore: Paul H. Brookes.
Capute, A.J. & Accardo, P.J. (1996). Developmental Disabilities in Infancy and Childhood: Vol 2. The Spectrum of Developmental Disabilities. Baltimore: Paul H. Brookes.
Datta, S.S., et al. (2005). Behaviour Problems in Children and Adolescents with Seizure Disorder: Associations and Risk Factors. Seizure, 14, 190-197.
Eastern Los Angeles Regional Center. (1998). Wellness Initiative<
Elliot, I.M., Lach, L., Smith, M.L. (2005). I Just Want to be Normal: A Qualitative Study Exploring how Children and Adolescents View the Impact of Intractable Epilepsy on their Quality of Life. Epilepsy & Behavior. (Article in Press), 1-15.
Gillian, F. (2002). Optimizing Health Outcomes in Active Epilepsy. Neurology, 58, 9-20.
Kelley, R.E. (2000). Status Epilepticus: Diagnosis and Management. Louisiana State University Medical Center. Accessed December 13, 2005.
Mitchell W.G. (1995). Long-Term Prognosis for Children with Epilepsy. Current Problems in Pediatrics, 25(3), 113-120.
National Information Center for Children and Youth with Disabilities. (1998). Epilepsy Fact Sheet. Accessed November 25, 1998.
Ogata, A., Amano, K. (2000). A Psychosocial Approach to Epileptic Patients. Epilepsia, 41(9), 36-38.
Piccioli, M. et al. (2005). Do Video Games Evoke Specific Types of Epileptic Seizures? Epilepsy and Behavior, 7, 524-530.
Reid. S. (2001). MOSES: An Educational Program for Patients with Epilepsy and Their Relatives. Epilepsia, 42(3), 76-80.
Sinclair, D. (1997). Status Epilepticus. University of Alberta Department of Pediatrics. Accessed February 5, 1999.
Smith Consultant Group & McGowan Consultants. (1998). Epilepsy. In M.L. Snyder(Ed.),Health and Wellness Reference Guide (pp. 197-214), TN: Neri Productions.
Strine, T.W. et al. (2005). Psychological Distress, Comorbidities, and Health Behaviors Among U.S. Adults with Seizures: Results from the 2002 National Health Interview Survey. Epilepsia, 47(7), 1133-1139.
Toffler, W.L., Fields, S.A. (1999). In M.R. Dambro (Ed.) Griffith’s 5 Minute Clinical Consult (pp. 978-979). Baltimore, MD: Lippincott Williams & Wilkins.
Tsang-Wai, R. et al. (2005). Outcomes in Pediatric Epilepsy: Seeing Through the Fog. Pediatric Neurology, 33, 244-250.
RESOURCES FOR FAMILIES
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Wakeforest University Baptist Medical Center Epilepsy Information Service
California Department of Developmental Services
California Regional Centers
Epilepsy Foundation of America
Epilepsy Foundation of San Diego County
Exceptional Parent Magazine
March of Dimes Birth Defects Foundation
National Institute of Neurologic Disorders and Stroke
Cornell University Comprehensive Epilepsy Center
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Theodore A. Kastner, M.D., M.S.
Felice Weber Parisi, M.D., M.P.H.
Mary Ann Lewis, Dr.P.H., R.N., F.A.A.N.
Jaime Mejlszenkier, M.D., F.A.A.N.
Terrance D. Wardinsky, M.D.
Larry Yin, M.D., M.S.P.H., F.A.A.P.
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This document does not provide advice regarding medical diagnosis or treatment for any individual case, and any opinions or statements contained in this document are not intended to serve as a standard of medical care. Physicians are encouraged to view the considerations presented in this document in light of evolving scientific information. This document is not intended for use by the layperson. Reproduction of this document may be done with proper credit given to California Department of Developmental Services.