Antidepressants Blog

Most children with epilepsy go to a normal school and do well. When your child starts at any new school you should talk to their new teachers, who may have very old-fashioned or mistaken ideas about what someone with epilepsy can or can not safely be allowed to do.
Explain to the school about your child’s epilepsy, and tell his or her teachers what will happen if they have a seizure. Tell the matron what drugs the child is on. Usually schools are understanding and co-operative, and a headteacher will pass on to the teachers in charge of the child whatever information you give them. But just occasionally they fail to do so. If the school is large and you get the feeling that the headteacher is insufficiently concerned, it would probably be worthwhile talking to your child’s class teacher yourself, just to make sure that the information filters down to the right level.
The child’s own friends usually accept the fact that he or she has seizures quite matter of factly. A few children do get teased, but teasing is often not as big a problem as most parents expect it to be. Some children even find that their seizures make them more interesting to their peers.
Your child’s teachers probably see almost as much of them as you do and an observant and co-operative teacher is a valuable asset. They may recognize changes in your child’s behaviour or physical state even before you do. Always ask them to discuss any changes they do notice with you; these changes may be an indication that your child’s medication needs adjusting.

WHAT TO TELL THE TEACHERS
Make it clear to the school that you want your child to take part in the whole range of the school’s activities. There is no reason why they should not play games, for example, or swim; in fact (except in rare cases) there is every reason why they should do these things.
Explain to teachers that there is usually no need to send your child home after an attack unless they have been hurt. It is enough just to allow them to sit quietly for a while to recover, before carrying on with normal school activities.
Get a clear and realistic assessment from your doctor about what your child should be capable of. It is a good idea, too, to ask your doctor to arrange for the child to be tested by a psychologist so that you know what his level of intelligence is and where his skills or difficulties lie. Once a child is labelled an ‘epileptic’ there is a real danger that their teachers may underestimate their academic potential and give them neither stimulation nor encouragement. The child who is expected to do badly almost certainly will do badly.
Keep a positive attitude. Emphasize what the child can do, not what they can not. Help them to develop social skills so that they are a likeable person.
Make sure that the staff are prepared to treat your child as far as possible just like the other children, both in terms of punishment as well as reward. Teachers may be tempted to let them get away with too much because they are afraid that discipline or reprimand might cause a seizure. Such special treatment will not make your child popular with the other children.
Keep the child’s attendance at school as regular as you can. The reason many children with epilepsy do badly is simply because they have missed so much schooling.

TAKING MEDICATION AT SCHOOL
Most children with epilepsy are able to take their medication twice daily, outside school hours. But a few may need a dose during the school day. And very occasionally, staff may have to give emergency treatment with rectal diazepam to a child in status epilepticus.
If your child needs to take a dose of anticonvulsant during school hours, make sure that the school has written details about how and when the medicine is to be taken, whether it should be given by a named teacher (in which case the parent should give written permission) or whether the child is to be responsible for their own medication. Secondary school children (unless they have learning difficulties that would make it impossible) should be responsible for taking their own medication. Younger children should be encouraged to be self-reliant too, but it will depend very much on how responsible the child is generally, and whether the school is prepared to allow them this particular responsibility. If the medicine is to be stored (for example, if the school is to keep rectal diazepam for emergency use) you need to agree with the school who is responsible for giving it (they may need special training) and where it is to be kept for easy access if it is needed. Label all medication with the child’s name and the dose and frequency of its administration.
In the current climate, many teachers are uneasy about giving rectal diazepam to a child. To protect teachers against the possibility that they might be vulnerable to allegations of child abuse in these circumstances, two adults should be present if rectal diazepam has to be given to a child.

CHILDREN WHO DO NOT ACHIEVE
When your child is first diagnosed as having epilepsy, one of your first concerns is likely to be about the effect the epilepsy will have on their intelligence and mental ability.
Some children who have epilepsy do, undoubtedly, fail to achieve what they should be capable of at school. But once again, this is nearly always a by-product of the epilepsy and not a direct result of it. Sometimes children underachieve because they have fallen behind in their school work through frequent absences, more often underachievement is due to the drugs they are on, though probably a major factor is also the attitude of parents and the school towards children with epilepsy. For everyone’s sake, ask for your child to be properly assessed by a neuropsychologist so that you and the school have a realistic idea of what they should be capable of, and in which subjects they are likely to have difficulties. If the school is unable to organize this itself, ask your doctor to arrange it by referring your child to the local mental health services for psychometric (IQ and skill measurement) assessment.
Whether epilepsy does cause mental deterioration has been a matter of debate for over 100 years. Rapid diagnosis and assessment of the epilepsy after the onset of the first seizure, and good control of seizures seem to be the most important factors involved. If there is mental decline, it is likely to be most noticeable in the first years (or perhaps even the first few months) after the onset of epilepsy. This initial phase is followed by a stable phase with little further deterioration.
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1. Does having a single (isolated) fit mean that someone has epilepsy? No. By definition, epilepsy means having recurrent seizures, so a single fit does not mean that that person has epilepsy. About 60% of people with an isolated fit never have another one. On the other hand, for someone who is destined to develop epilepsy, the first fit will be followed by others in due course.
2. I find the words ‘fits’, ‘convulsions’ and ‘seizures’ confusing as they are used interchangeably. Are they all the same? Yes, they all have the same meaning. ‘Seizures’ is the preferred term, but both the others are quite acceptable. Other expressions which are vague and confusing such as ‘turns’ or ‘funny spells’ are of no value.
3. Our four-year-old son has had two convulsions associated with tonsillitis and fever. Does he have epilepsy? Almost surely not. He has almost certainly had two febrile convulsions which very rarely lead to epilepsy. Febrile convulsions are common, occurring in about 4% of children under the age of five years. These convulsions are due to fever, usually associated with a sore throat, tonsillitis or an ear infection. It is quite uncommon that febrile convulsions require treatment with anticonvulsant medication, but it is of value to try and prevent recurrent episodes by cooling the child down when he or she has a fever and giving medication to bring the fever down (paracetamol).
4. A friend of mine with epilepsy talks about the warning that he gets before a fit. My son has epilepsy but he does not seem to get any warning at all. What does this mean? Some people with epilepsy may get a warning, which is called an aura, at the beginning of a fit. This usually affects people with partial (involving part of the brain only) epilepsy before they then develop a generalised fit. The nature of the aura will vary from person to person and will depend on that part of the brain involved. An aura should not be confused with prodromal symptoms which some people may have for hours or even days before having a fit. These symptoms include irritability, headache, feeling ‘generally unwell’, tummy aches and so on.
5. Did my child’s birth lead to his epilepsy? During birth, the child’s head is subjected to quite strong pressures from the outside, so that small areas of bleeding may occur on the surface of the brain. It is also possible for the same thing to occur inside the brain. Occasionally there may be problems at birth so that the child is born very rapidly or with great difficulty and the stresses on the baby’s head and brain are therefore greater than usual. This is called cerebral (brain) birth trauma (injury).
Naturally it is difficult to be certain that events which occurred at birth are related to the development of epilepsy which may occur some years later. However, in some instances there is a strong suspicion that this may be the case.
It is often confusing for parents to be told that their child’s fits are due to something which occurred at birth, as they would have expected the fits to have started at the time of the injury. This is often not the case and the seizures may only begin in childhood or even later in life.
6. Can seizures occur in newborn babies? Seizures in the
neonatal period (the first month of life) are not uncommon, with
most fits occurring on the first and second days of life. Neonatal
fits have not been discussed in this book as they may not lead
to epilepsy and many of the causes of neonatal fits can be
defined and treated. Causes include difficulties during labour or delivery, abnormalities of the brain, bleeding into the brain, meningitis, hypoxia (a lack of oxygen to the brain), hypoglycaemia (low blood sugar) or a low blood calcium or magnesium. As already mentioned, neonatal seizures in themselves do not necessarily predispose to epilepsy but, if there is associated brain damage, epilepsy may develop in later childhood.
7. Do fits have any effect on memory? It is quite common for people with epilepsy to complain of a poor memory. This seems to be most common in persons with temporal lobe epilepsy, but very frequent seizures, long fits and heavy anticonvulsant therapy may also contribute. There is not a great deal that can be done about this sort of memory loss other than to try and get better seizure control if that is possible.
8. How do anticonvulsant drugs work? Despite the existence of these drugs for many years, the answer to this question is uncertain. In general terms, it seems that anticonvulsant drugs increase the seizure threshold (the resistance of the brain to seizures) and this is probably why they are effective. They seem to prevent, or limit, the production of abnormal electrical activity by the brain.
9. Do fits themselves damage the brain? This of course is difficult to answer accurately as it is not possible to do controlled studies in humans to get the answer. It is probably only prolonged grand mal seizures, including prolonged febrile convulsions, which may be harmful. Again it is difficult to say how long a fit has to be before it becomes dangerous. Most doctors would suggest 15-30 minutes. The damage does not occur from the fit itself, but from the lack of oxygen to the brain during the fit. Probably the most commonly damaged part of the brain, especially in children, is the temporal lobe. Most seizures do not seem to do any harm to the brain.
10. Is it possible to do something which will prevent a fit when you can feel it coming on? If you are lucky enough to be able to develop some way of preventing some of your fits you are indeed fortunate. It is very uncommon that this can be done, but very occasionally some sort of self-control measure may be helpful and will either abort or delay the fit. Self-hypnosis may be useful in the very few people who have an aura of such length that they can hypnotise themselves. Overall there is little that can be done to prevent fits in this way.
11. Can epilepsy be caused by stress? The answer to this common question is that epilepsy is probably never caused by stress or a shock. However, stress may make fits worse, or more frequent, in someone with established epilepsy.
12. Can excitement bring on fits? This is certainly possible and it is known that some people may have more fits when they are excited.
13. Is it possible for someone to bring on fits? Yes, it certainly is. There are two common situations in which people induce fits. Firstly, some people may use a known provoking factor such as overbreathing, flickering light and so on, to bring on a fit at a time that suits them. These are real fits. The second group are those who have false fits (pseudoseizures). These fits have many of the outward appearances of being real, but if the EEG is examined during the so-called fit, it is normal. It may be very difficult to diagnose pseudoseizures, as they often occur in people with epilepsy. As a generalisation, most people with epilepsy, once on regular medication, will have an improvement in seizure control or at least will remain static. It is unusual to see a deterioration. The hallmark of pseudoseizures is deteriorating seizure control despite more and more medication. The diagnosis is best made by video-telemetry so that the fit can be seen and an EEG recorded simultaneously. There is almost always an underlying psychological problem to account for pseudoseizures. In essence, patients are using their existing epilepsy to have more fits so that they can achieve a particular purpose, for instance get out of a difficult situation, although they may be doing it subconsciously. Pseudoseizures are not all that common, but present a diagnostic and treatment problem.
14. My 20-year-old son has just been diagnosed as having epilepsy. He enjoys the occasional beer – is that okay?
Alcohol in moderation is unlikely to have any deleterious effect on epilepsy. However, it is important that people with epilepsy realise what alcohol may do:
It may affect the working of the liver in such a way that anticonvulsant drugs, which are broken down in the body by the liver, may be broken down more rapidly. This may make the drugs less effective.
As we all know, alcohol slows one down. So do the barbiturates and the benzodiazepines (Valium-related drugs such as clonazepam, nitrazepam and clobazam), so it is a good idea to avoid these combinations.
Heavy drinking may provoke seizures, especially during the hangover period the next morning.

15. Does climate have any effect on epilepsy? There is no relationship between climate and epilepsy. There is no scientific evidence that a hot climate is hazardous, although some epileptics feel that their fits are worse in extreme heat.
16. How does a doctor know what dosage of an anticonvulsant to use? The dosage has been learnt from experience over the years. In general, young children tend to use up anticonvulsants more rapidly in their body than do adults. For that reason they need larger amounts of anticonvulsant relative to their body weight than adults do. In children, dosage is usually worked out from the child’s weight and may need to be increased as the child grows. Blood level monitoring may also be useful to guide the doctor in finding the right dosage for an individual patient.
17. I have grand mal seizures which are well controlled. I am a trained secretary who is about to do a word processor course. Is there a risk of having fits from working in front of an electronic screen? You are referring to photosensitive epilepsy. As has already been discussed earlier in this book, some people may have a photosensitive tendency. Their fits may be provoked by various light sources including television, flickering lights and so on. There is no evidence that video display units (VDUs) present a photosensitive problem.
18. I have heard it said that people with epilepsy have an ‘epileptic personality’. Is this true? No. This is based on old observations of people with severe epilepsy who used to live in institutions. Epileptics may have some psychological problems -these may be seen in people with epilepsy and brain damage, in some patients with temporal lobe epilepsy and in those who have had multiple setbacks as a result of their epilepsy. Not surprisingly, if someone has been knocked back for job after job, they are likely to become gloomy and withdrawn. This is not a direct association with their epilepsy. In some people, anticonvulsants, especially barbiturates and benzodiazepines, may cause irritability and drowsiness. But the idea of an epileptic personality should no longer be discussed.
19. Phenytoin may produce unsightly gum swelling. Can this be avoided? Gum swelling probably cannot be avoided completely, but it can be minimised by good oral hygiene. Regular dental supervision and brushing of the teeth associated with the use of dental floss goes a long way to keeping this side effect under control. When treatment with phenytoin is stopped, the gum swelling usually settles down over the next year.
20. How often should someone with epilepsy consult their doctor? This is very much a matter of commonsense. If the patient has mild epilepsy and infrequent seizures, then a checkup every six or twelve months may well be sufficient. On the other hand, if seizure control is inadequate or if the patient is taking a drug like phenytoin which, as we discussed before, is handled with difficulty in the body, then it may be necessary to see your doctor more frequently.
21. Every time I visit my doctor for a check-up or for a prescription, I have a blood level test done. My fits are well controlled and I wonder if this is necessary? No, it is not necessary. It is only necessary to check blood levels if there is a problem that will be helped by knowing the level. Obviously, when the fits are poorly controlled, when starting someone on phenytoin or for some other specific reason, there is value in knowing the blood level. Measuring blood levels should not be a substitute for the much more important matter of the doctor discussing your epilepsy with you. Even if the fits are well controlled, an encouraging chat is usually appreciated by the patient.
22. Why is it necessary to take anticonvulsant medication regularly? To obtain adequate seizure control, anticonvulsants need to be taken regularly to ensure a constant blood level of the drug. This in turn provides a constant brain level of the drug, which helps to control the fits. Taking medication sporadically will not allow this to occur.
23. Do anticonvulsants have any long-term effects? The answer to this is difficult as it is necessary to follow up patients for a long time to obtain this information. In addition, it is hard to separate the possible effects of frequent, severe seizures from the effects of medication. It is felt that the long-term use of barbiturates, and possibly phenytoin, for more than 15 to 20 years may be associated with some intellectual dulling.
24. Do anticonvulsants affect behaviour? Phenobarbitone and primidone can cause overactivity in a proportion of children; probably 20-40% of children may be affected. This does not appear to be the case with the other anticonvulsants.
25. Can epilepsy be cured? Epilepsy cannot be ‘cured’ in the usual sense of the term. However, it can be controlled by medication. For a few people a cure may be achieved surgically. On the other hand, for many people, especially children, the seizures will cease and they will be able to come off their medication .
26. I have recently been doing a lot of physical training for a canoe marathon and have had several fits. Before starting training, I had not had a fit for at least six months. Is there a reason for this? Amongst many other effects on the body, really vigorous physical training tends to make the liver metabolise (break down) anticonvulsants more rapidly, thus lowering the blood level. This has been noted with phenytoin and may apply to other drugs. It is worth getting your blood level checked from time to time during your training and perhaps increasing the anticonvulsant dosage if necessary. You will need to remember that when you stop training and lapse back to a more sedentary life, the situation will return to its previous state and it may be necessary to lower the dose to its previous level.
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Epilepsy

The future of a child with epilepsy depends a great deal on the management of the condition during the younger years. The attitude adopted at home and at school is very important. These children need to share the company of other children, go to normal schools and partake in the usual activities. They are normal children with a particular problem which is in fact much less disabling for many of them than, for example, asthma might be.
Some parents and teachers blame any unusual behaviour, such as outbursts of anger or irritability, on the epilepsy. There is usually no connection between the two unless there are clear indications otherwise. However, there is evidence that in some children learning and behaviour problems do arise in connection with their epilepsy. Those with particular types of epilepsy (especially left-sided temporal lobe epilepsy) are more likely to be affected in this way, and boys more so than girls.
What are the school problems? Children with epilepsy are variously said to be absent minded, lethargic, sleepy and lacking in concentration. Some anticonvulsant drugs may have adverse effects on the child’s schoolwork. Difficulties with reading, inattention of various types, dependency and other kinds of disturbed behaviour may occur. An enlightened teacher may take advantage of a seizure in class to explain to the other students about epilepsy. This is useful both for the child with epilepsy and the other students. Many children with epilepsy (about 50%) have some sort of school problem which may stop them achieving their academic potential. The reasons for this are not entirely clear, but may include the following:
The effects of the anticonvulsant drugs. Phenobarbitone and primidone may affect concentration span and attention to some extent. Chronic intoxication with phenytoin may lead to intellectual deterioration. There is little information about the other anticonvulsants.
Perceptual problems. The information on the effects of epilepsy on reading skills is that:
the reading skills of children with generalised epilepsy are similar to those of non-epileptic children.
children, especially boys, with EEG abnormalities or with focal EEG abnormalities on the left side of the brain, read less well than non-epileptic children.
reading skills of boys with epilepsy, of whatever type, are less good than those of epileptic girls.
long-term phenytoin use is associated with lower reading skills than with other anticonvulsants.
In summary, there may be quite definite learning problems in about half of children with epilepsy, boys more so than girls. These need to be recognised and dealt with as well as possible at an educational level.
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Epilepsy

More specific than any of the precipitants so far discussed are the stimuli which result in

so-called reflex epilepsy. Some young people have seizures induced by flashing lights, as in a discotheque, and this can be studied on an EEC In most of us, an obvious wave can be recorded from the back of the head (the occipital region) if a light is flashed in the eyes. With repeated flashes, these waves follow the flash frequency. At a critical frequency in a young person with photosensitive epilepsy, a totally different response of multiple spikes and waves—the photoconvulsive response—occurs, and a seizure may be induced. This of course is a laboratory situation, but seizures may result, in photosensitive children, from flickering light reflected from water, or by the interruption of steady light filtered through trees observed from a moving car.

The most common type of photosensitivity now encountered is television epilepsy. Experiments have shown that it is the normal sweep of the spots that make up the picture from side to side and down the face of the tube that is responsible, and not any malfunction of vertical picture or horizontal line hold. Susceptible children are most at risk when the screen occupies a considerable proportion of the visual field, as will occur if the size of the screen is large, and the child sits close to it, or approaches it to change the programme. The chances of seizures occurring are lessened by sitting far away from the screen. It may also help to reduce contrast between the screen and surroundings by placing the set near a lamp.

It has also been shown that the photoconvulsive response cannot be elicited if only one eye is exposed to the flashing light. It makes sense, therefore, for susceptible children to cover one eye if they approach the set. Remote programme selection by infra-red control is useful for such children. Both colour and monochrome television sets induce seizures, which are invariably generalized, though they may sometimes be of very short duration—just a few myoclonic jerks of arms and trunk muscles. Video games may also precipitate seizures. However, althought text on computer screens is occasionally associated with seizures, the problem is far less, and only occasional seizures have been reported.

Another type of visual reflex epilepsy occurs on looking at patterns such as squares of linoleum tiling. This may be regarded as typical of the highly specific reflex epilepsies occurring in a very few patients in which seizures may be induced by, for example, reading, hearing music (sometimes by only one particular phrase), or by performing mental arithmetic. The perception of such external stimuli must result in a particular pattern of nerve cell activity—this is presumably in part how we recognize tunes and words. One can only imagine that this particular set of activity in susceptible people acts as a specific template which, like a key in a lock, unlooses a seizure.

Non-specific stimuli—such as a loud noise, or a startle, however caused, may induce myoclonic jerks, and occasionally a generalized tonic-clonic seizure. This type of epilepsy is seen as an inherited feature in some strains of mice, and provides a model for the investigation of the physiology of such seizures, and a model for trying out the potential effectiveness of new anti-epileptic drugs.

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