Continuing professional development
An overview of epilepsy in
children and young people
LDP99 Solomon N, McHale K (2012) An overview of epilepsy in children and
young people. Date of acceptance: March 3 2012. Updated: June 6 2012.
Nina Solomon is an epilepsy
The role of the nurse is vital in the management of childhood epilepsy. Nurses play a key role in supporting the
child and the family and ensuring that important relevant and accurate information is identified, recorded and
reported to the team responsible for the medical management.
This article aims to give readers an overview of
epilepsy and its management in children and young
people. After reading this article and completing the
time out activities you should be able to:
■■ List the different types of seizures and describe their
■■ Describe the relevant information about any seizures
that you observe to aid accurate diagnosis.
■■ Manage seizures effectively and recognise potential
■■ Discuss the different treatment options available for
■■ Evaluate the impact having epilepsy may have on a
child and his or her family.
Epilepsy is a chronic neurological condition that affects
63,400 people in the UK aged 18 and under (Joint
Epilepsy Council (JEC) 2011). It is characterised by
recurrent epileptic seizures originating in the brain.
An epileptic seizure is a transient occurrence of signs
and/or symptoms resulting from abnormal, excessive or
synchronous neuronal activity in the brain (Fisher et al
2005). This activity results in an alteration in motor
activity, sensation, behaviour or consciousness. There
are more than 40 different types of seizure (JEC 2011).
Seizures usually last from a few seconds to a few minutes
and are self-limiting.
Causes of epilepsy
In approximately 60 per cent of cases, the cause of
epilepsy is not known (Epilepsy Research UK 2011).
30 July 2012 | Volume 15 | Number 6
Both at Young Epilepsy National
Services, Lingfield, Surrey
The types of epilepsy fall into three categories: those
with a genetic cause (idiopathic epilepsy); those
where epilepsy is the secondary result of a separate
structural or metabolic condition (symptomatic
epilepsy); and those where the cause is unknown
(cryptogenic epilepsy) (Berg and Scheffer 2011).
Causes of epilepsy include damage to the brain as a
result of injury, deprivation of oxygen at birth, infections
such as encephalitis or meningitis, malformation or
degeneration of the brain and brain tumours. Metabolic
causes include low blood glucose, calcium and drugs
(including alcohol). Genetic conditions such as tuberous
sclerosis may also be a cause.
Now do time out 1.
Aims and intended learning outcomes
Kirsten McHale is lead nurse for
In 2005 the International League Against
Epilepsy and the International Bureau for
Epilepsy defined epilepsy as a brain disorder
‘characterised by an enduring predisposition
to generate epileptic seizures and by the
neurobiologic, cognitive, psychological and
social consequences of this condition’. With
this in mind, explain why you think epilepsy
is more than just a health condition?
Conflict of interest
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Different types of seizures
Classifying which seizure type(s) a child has experienced
is important for the future management and outcome
of the child’s epilepsy. Seizure types fall into two main
categories: generalised seizures and focal (partial)
seizures (Figure 1).
LEARNING DISABILITY PRACTICE
Figure 1 Areas of electrical activity in focal and generalised seizures
Person goes stiff
and falls, no
Temporal lobe epilepsy is shown above,
but electrical activity can also occur in
other lobes, causing:
■■ Frontal lobe epilepsy
■■ Parietal lobe epilepsy
■■ Occipital lobe epilepsy
to the ground
When a focal seizure
progresses into a
it is called a bilateral
Person goes stiff
and falls, and has
Person stares blankly
for a few seconds
Person has short
Areas of electrical activity
(Adapted from Solomon 2010)
Tonic-clonic seizures Tonic-clonic seizures usually start
with a cry and a loss of consciousness, resulting in the
child going stiff and falling to the ground. The ‘tonic’
or stiff phase then leads to a ‘clonic’ or jerking phase.
Finally there may be confusion, often followed by sleep.
The child may be incontinent of urine.
Tonic seizures In tonic seizures the muscles stiffen and,
if standing, the child will fall heavily, usually backwards,
and will often receive injuries to the back of the head.
There is no jerking.
Atonic seizures In atonic seizures the muscle tone is
lost, causing the child to flop and fall heavily to the
ground and, although recovery is swift, the child will
often experience a head or facial injury.
Myoclonic seizures Myoclonic seizures usually occur
shortly after waking or before retiring to bed when the
child is tired. The muscles jerk rather as if the child
has had some sort of electric shock. There is a brief,
and hardly noticeable, loss of consciousness. These
seizures may occur in clusters in which numerous
seizures can occur over a few minutes, or even a
couple of hours.
LEARNING DISABILITY PRACTICE
Absence seizures Absence seizures usually begin in
childhood or adolescence and may occur many times
a day and provoke a brief ‘trance-like’ state. The child
will stare blankly and be unresponsive for usually five to
ten seconds. Recovery is immediate and these episodes
may go unnoticed. The child’s failure to respond when
being spoken to during a seizure often results in the
child being told off for not paying attention.
Focal (partial) seizures Focal refers to the seizure
coming from one area of the brain. Symptoms that occur
during a focal seizure depend on where in the brain
the abnormal burst of electrical activity occurs and the
function for which that area is responsible (Figure 2,
page 32). Consciousness may be impaired and, in
contrast to absence seizures, children may experience a
state of confusion following the seizure.
Now do time out 2.
Generalised seizures In generalised seizures the whole
brain is affected by changed electrical activity and the
child becomes unconscious of their surroundings. The
following are some examples of generalised seizures.
Describe how you think seizures may present
in temporal lobe epilepsy and parietal lobe
epilepsy. Which symptoms might they have
in common, what factors will be significantly
different and which do you think may help
in making an accurate diagnosis? What is
important to remember in interpreting a
witness account of someone having a seizure?
July 2012 | Volume 15 | Number 6 31
Continuing professional development
Figure 2 The functions of the lobes of the brain
Responsible for: emotional behaviour,
personality, planning, problem solving.
Responsible for: sensory information
(touch, temperature, pressure, pain), orientation,
artistic and musical appreciation.
Processes: images from
the eyes, recognises shapes
Processes: language and short-term memory,
distinguishes one smell and sound from another,
visual memory (pictures and faces), verbal memory
(words and names), recognises auditory stimuli.
(Adapted from Solomon 2011)
Temporal lobe epilepsy Temporal lobe epilepsy can
start in children of any age. The child will have a
warning such as epigastric sensations (butterflies in
the stomach), an odd smell or taste, fear or confusion
afterwards. Because the temporal lobes are responsible
for feelings, emotions and memory, children
experiencing this form of epilepsy may experience a
variety of feelings or emotions, including déjà vu and
jamais vu. Children may also experience seizures that,
on occasion, may generalise into tonic-clonic seizures.
Most children will respond well to antiepileptic drugs.
For those who do not respond to medication, treatment
in the form of surgical resection has a good success rate
(Azrimanoglou et al 2002).
Frontal lobe epilepsy Although the symptoms associated
with seizures arising from the frontal lobe will vary in
nature depending on which part of the frontal lobe is
involved (for example, seizures involving the motor
areas of the brain can produce strange movements
that occur on the opposite side of the body from the
abnormality), the seizures usually occur in clusters
with many brief seizures occurring per night that start
and end abruptly. They may also produce weakness in
certain muscles including those used in speech, which
can last from minutes to hours following the seizure.
These seizures usually occur during sleep and can
present in a strange and dramatic manner involving
head turning, thrashing around or cycling movements
of the legs.
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Occipital lobe epilepsy Seizures occurring in the occipital
lobe usually present with sight-related symptoms, such
as rapid eye blinking, seeing patterns, flashing lights or
colours. Seizures can spread from the occipital lobe to
the temporal or frontal lobes of the brain, which changes
the characteristics of the seizure, making it hard to
recognise as occipital lobe epilepsy. These seizures may
also spread, causing generalised tonic-clonic seizures.
Parietal lobe epilepsy Seizures coming from the parietal
area are usually sensory and result in strange sensations
such as tingling or warmness. They often occur down one
side of the body and some people report that their limbs
feel bigger or smaller than usual. There may also be areas
of numbness of the body during the seizure.
For some children certain situations, such as failing to
take medication, or taking alcohol or recreational drugs,
may increase the chance of a seizure occurring. Other
triggers may include illness, fever, tiredness, stress,
excitement or menstruation. Flickering/flashing lights
(photosensitivity) is a trigger in only 3 per cent of children
with epilepsy (JEC 2011). Seizure triggers can occur
in all types of epilepsy, but are more of a feature in
particular epilepsy syndromes.
Managing convulsive seizures
Many people say that when they first witnessed
a child having a tonic-clonic seizure they found it a
LEARNING DISABILITY PRACTICE
Think back to situations where you have
helped a parent make sense of witnessing
seizures in their child. Why was it important
to help them express their full range of
emotions? What followed next? Was this a
process of developing explanations that they
could share with others, and who might they
usefully share this with?
If the child is aware of an impending seizure, they
should be encouraged to sit or lie down to reduce
the risk of injury. The child should be protected from
any danger, such as sharp edges, hot pipes, traffic
and so on. If possible, the child should remain where
they are and any problematic objects should be moved
out of the way instead. Placing something soft
under their head or cradling their head in your hands
will protect it from banging. The child’s dignity and
privacy should be maintained as much as possible by
shielding them from the view of onlookers.
When a seizure is taking place it is important to
note the time the seizure starts and ends. The child’s
movements should not be restrained but, if possible,
any tight clothing around their neck should be
loosened. Nothing should be placed in the child’s
mouth. A seizure cannot be stopped but should simply
be left to run its course. Once any jerking has stopped,
the child should be placed in the recovery position.
Now do time out 4.
Write down a list of the circumstances that
would prompt you to call an ambulance
to a child having a seizure. Describe
what information will need to be given
to the paramedics and how this might
influence the child’s treatment during and
after a seizure.
If the seizure occurs outside a hospital environment,
an ambulance need only be called if the seizure lasts
for five minutes (or for two minutes longer than is
usual for the child), if the child has repetitive seizures
without regaining consciousness in between, or if there
is an injury, breathing problems or recovery is slow
(Reuber et al 2009).
LEARNING DISABILITY PRACTICE
Box 1 Eyewitness information needed for epilepsy diagnosis
Before the event:
■■ Where did the event take place?
■■ What was the child doing immediately before the event?
■■ Did they complain of any symptoms before the event occurring?
■■ Did they have a fever?
■■ Were they sitting, standing or lying down?
■■ Were they awake or asleep?
During the event:
■■ When did it begin?
■■ What happened first?
■■ Was there a fall, if so, did they fall backwards or forwards?
■■ Were they stiff or floppy?
■■ Was there a change in their breathing or colour?
■■ What movements did they make? Were they trembling, making rapid
movements of the arms or legs, or were the limbs jerking rhythmically?
■■ What level of awareness or responsiveness did they have?
■■ Was there tongue biting or other injury?
■■ Was there any urinary incontinence?
■■ How long did the event last?
■■ What did their eyes do?
■■ Did they lose awareness?
After the event:
■■ What level of alertness did the child have?
■■ Were they confused?
■■ Were they sleepy following the event and, if so, for how long?
■■ Was there any weakness following the episode?
The medical team will need to ascertain whether the
event was an epileptic seizure, if it was, what type of
seizure occurred and whether the child has an epilepsy
syndrome identifiable on the basis of age of onset,
seizure type and specific electroencephalogram (EEG)
characteristics and other features (National Institute for
Health and Clinical Excellence (NICE) 2012).
Once these questions have been addressed,
further discussion will allow the doctor to make a
differential diagnosis. If not epilepsy, this could be
a behavioural outburst, faint, tic, movement disorder
and/or night terrors.
Now do time out 5.
Diagnosis of epilepsy
terrifying experience and that they thought the child
was going to die. Perhaps the most difficult thing
for an observer is the fact there is little that they can, or
Now do time out 3.
Using the NICE outline care algorithm
for children and young people (www.nice.
pdf), list the key actions that need to be taken
before a diagnosis of epilepsy should
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Continuing professional development
Comparison of scans
Compare the advantages and disadvantages of
MRI and CT scans. Which scan do you think
is better in aiding the diagnosis of epilepsy?
When, and why, would each type of scanning
Antiepileptic drugs Whether to treat epilepsy with
antiepileptic drugs will depend on a number of
factors, such as the type of seizures that the child has
experienced, how often they occur and, if established,
the epilepsy syndrome. A syndrome is a group of
characteristic signs and symptoms, such as age at onset
of seizures, seizure types, developmental history and
EEG findings which, if they occur together, can suggest
a particular syndrome.
The impact of having seizures will vary dramatically,
depending on the age of the child. For example, a
toddler is less likely to be left unattended than an
older child who may want to climb, swim and ride
a bike. The consequences of an adolescent losing a
driving licence could have a major impact on the young
person’s independence issues and self-esteem.
Although antiepileptic medication will not cure
epilepsy, it is designed to prevent seizures from
occurring. The main aim of treatment is to stop all
seizures while minimising side effects. Nevertheless,
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Box 2 The most common side effects associated
with antiepileptic drugs
■■ Memory, learning and attention problems.
■■ Drowsiness and lethargy.
■■ Dizziness or unsteadiness.
■■ Double vision.
■■ Changes in mood or behaviour.
■■ Increase or decrease in appetite.
15-25 per cent of children with epilepsy will have
medically intractable epilepsy (Terra-Bustamante et al
2005). Where seizures cannot be stopped without side
effects, the aim is to minimise the number of seizures
and any adverse effects of the treatment.
Some medications work better for certain types of
seizures than for others (Garnett et al 2009). Finding
the right medication is sometimes a lengthy and
frustrating process because the first drug to be tried
may not prove to be the best option. There is no test to
identify which drug will be best.
The use of one antiepileptic drug at a time
(monotherapy) is generally recommended, and
adding more antiepileptic drugs (polytherapy) should
only be considered when attempts at monotherapy
have failed to result in freedom from seizures (NICE
2012). Commonly used antiepileptic drugs include:
carbamazepine, sodium valproate, lamotrigine,
phenytoin, oxcarbazepine, ethosuximide, gabapentin,
levetiracetam, tiagabine, topiramate, phenobarbital,
primidone, clonazepam, lacosamide, zonisamide,
vigabatrin, retigabine and acetazolamide.
Side effects Different antiepileptic drugs can have
different side effects, some of which can be unpleasant.
Only a small number of children experience side effects
and these may subside after the initial introduction
of the medication. The most common side effects
include those listed in Box 2.
Now do time out 7.
Eyewitness account of a seizure The diagnosis of
epilepsy almost entirely depends on the clinical history
and the doctor’s interpretation of the events that
have occurred. According to Chadwick (2002), an
accurate eyewitness account of an event is essential
because the results of an initial medical examination
will often be normal.
The results of any further investigations will be
interpreted with reference to the description of the
event. A diagnosis of epilepsy is incorrectly made in
20-31 per cent of cases and up to 40 per cent of
children referred to a tertiary clinic do not have epilepsy
(JEC 2011). An accurate clinical history is therefore
vital and should include the information shown in
Box 1 (page 31).
An initial medical examination will often be
normal and the results of any further investigations
will be interpreted with reference to the description
of the event. Further investigations may include an
EEG (routine, ambulatory and/or videotelemetry) and
neuroimaging (magnetic resonance imaging (MRI)
and/or computerised tomography (CT)). Gaillard et al
(2009) and NICE (2012) provide useful information on
the different scanning methods.
Now do time out 6.
With more than 20 antiepileptic drugs
available, what factors do you think will need
to be taken into account when prescribing
them? Can you envisage any situations when
giving antiepileptic medication may not be
the best option for a child with epilepsy?
Diet The ketogenic diet is a high-fat, low-carbohydrate
and controlled-protein diet, which may be considered
for children whose seizures are not being controlled by
medication (NICE 2012). This diet is not effec ...
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