Understanding Epilepsy and Seizure Disorders in Children

by
Rina Goldberg, M.D., Aviva Bojko, M.D., Orrin Devinsky, M.D.
The Institute of Neurology at Saint Barnabas

Seizures are common in children but can often present diagnostic and therapeutic challenges. Many seizures cause subtle symptoms or problems that are attributed to other causes. For example, sudden abdominal pain or episodes of fear, unusual repetitive movements in sleep, brief staring spells or regression of developmental milestones may result from minor seizure activity. Similarly, not every event that involves jerking, staring or impairment of consciousness is a seizure. Many kinds of behavior can look like seizures.

Daydreaming, breath-holding spells, fainting, panic attacks and movement disorders such as tics can be confused with seizures. It may take time and some tests to sort out which episodes are seizures.

Seizures Defined

A seizure is a brief, excessive surge of electrical activity in the brain that changes how a person feels, senses things or behaves. Seizures in childhood have varied causes, including fever, head injury, infections or disorders of brain development. They can also occur for no apparent reason. A person who has two or more seizures without a reversible cause has epilepsy. 

Seizures may be primary generalized or partial. Primary generalized seizures begin with a widespread electrical discharge involving both sides of the brain. Partial seizures begin with an abnormal electrical discharge restricted to one area of the brain. 

A generalized tonic clonic seizure, or grand mal seizure, is a generalized seizure that is common to many seizure disorders. In this type of seizure the child loses consciousness and stiffens. Rhythmic jerking of the arms and legs follows, which may last several minutes. Drooling, biting of the tongue and loss of urine may occur. After the seizure, the child may be tired and confused for hours, and often sleeps.

Partial seizures may be either sensory, motor or autonomic (occurring involuntarily), depending on the part of the nervous system affected. Partial seizures are simple if the person remains awake and alert, and complex if consciousness is affected. 

Seizure Disorders in Children

Seizures may occur at any age, from the neonate to the elderly. There are several common seizure disorders in children. 

• Febrile seizures – Children aged six months to six years may have generalized tonic clonic seizures with a high fever. Febrile seizures are common, occurring in 2-5 percent of children, and tend to run in families. Most children with febrile seizures do not have seizures after the age of six and have normal development. 
• Childhood Absence seizures – These seizures are staring spells that begin in children between 4 and 12 years of age. More than 75 percent of children will stop having seizures by age 18. The children typically have normal development. Some children with this syndrome may also have generalized tonic-clonic seizures.
• Benign rolandic epilepsy – This is a common seizure disorder that occurs in children 2 to 13 years of age and often runs in families. The most common seizure is a partial seizure with the patient awake that causes tingling or twitching of the face and tongue, with drooling and difficulty speaking. Generalized tonic clonic seizures may also occur during sleep. The seizures are generally easily controlled with a low dose of medication. In most children, the seizures spontaneously stop after age 15. 
• Juvenile myoclonic epilepsy – Seizures consist of a sudden jerk and may be triggered by flickering lights, such as video games, TV or light shining through trees. Generalized tonic clonic seizures and staring spells may also occur. Seizures usually begin shortly before or after puberty. The disorder is usually lifelong, but the seizures are easy to control with medicine. The intellectual functions of persons with JME are normal and the syndrome often runs in families.

Single, brief seizures do not cause brain damage. Although some seizures lasting longer than 20 to 60 minutes may injure the brain, there is no evidence that shorter seizures cause permanent injury to the brain. In some people there may be a cumulative, negative effect of many seizures on brain function.

Diagnosis of Epilepsy

A detailed history of a child’s seizure-like episodes is the most helpful tool for making a diagnosis of epilepsy. The physician will want to know how the episode began and what happened. He or she may ask the following questions:

• Did the spell begin suddenly, shortly after standing or after an argument?
• Was consciousness lost or impaired?
• Were there involuntary movements, staring, eye movements, blinking or loss of bladder control?
• Afterwards, did the child go to sleep or act confused?
• How long did the episode last?

If the episodes occur frequently, the family should make a video recording of an episode for the physician to view. All of this information will help the physician to determine if the episode was a seizure, and if so, what type.

The medical evaluation for epilepsy includes a careful, detailed history and neurological examination. Electroencephalograph (EEG) is the most specific test for diagnosing epilepsy because it records the electrical activity of the brain. It is a safe and painless procedure is which electrodes are applied to the patient’s scalp. The wires measure electrical activity; they do not deliver electrical current to the scalp. A routine EEG usually runs for 20 minutes and may be done in a neurologist’s office or in a hospital.

A more prolonged EEG can be done when the diagnosis is not clear or if a patient is continuing to have frequent seizures despite treatment. Video/EEG monitoring is used to record brainwaves and behavior simultaneously. This helps the physician to determine if behavioral events are seizures, and if so, what type. This may in turn help to determine appropriate medical treatment. 

MRI of the brain looks at the structure of the brain. It is especially important in patients with partial seizures to look at the areas of the brain where seizures may originate. In a person with seizures the MRI may be normal, or show areas of scar tissue, abnormal brain development, small tumors or abnormal blood vessels. Young children may need 
to be sedated in order to hold still for the MRI test.

Treatment Options

Repeated or prolonged seizures may be treated with daily medication. Some types of partial seizure can be treated with brain surgery to remove the area of the brain where the seizures originate. Seizures that do not respond to medication may sometimes respond to a nerve stimulator implanted in the chest that is the size of a pacemaker and connects to 
a nerve in the neck. A specialized diet called the ketogenic diet, which is high fat and low carbohydrate, may also be used in children with seizures that are difficult to control.

Most childhood forms of epilepsy are outgrown by adulthood. For many forms of epilepsy, when the child has been free of seizures for two to four years medication often can be slowly withdrawn and then discontinued under a physician’s supervision.

Epilepsy is perfectly compatible with a normal, happy and full life. The person’s quality of life may be affected by the frequency and severity of seizures, the effects of medication and associated disorders. Living successfully with epilepsy requires a positive outlook, a supportive environment and good medical care. 

(Excerpted from Epilepsy Patient and Family Guide, by Orrin Devinsky, M.D.)

To reach the Institute of Neurology at Saint Barnabas, please call
(973) 322-6600.

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