Nursing free dissertation topic: Epilepsy and How it Occurs in Children
Epilepsy and How it Occurs in Children
Epilepsy is a condition of the brain that is manifested after sudden and recurrent discharge of abnormal quantities of cerebral neurone transmitter substances creating errors in signal transmissions that result in seizures. Seizures occur as a result of the errors in signal transmission after material or significant alterations such as those caused by abnormal paroxysmal neurone discharge levels (Engel, Taylor and Trimble 2008, p2077). Generally, a manifestation of a seizure is accompanied by drastic brain function breakdown which can be on different levels of expression ranging from weird sensations affecting behavior at its best to sudden violent muscular contractions that may cause complete loss of body control or unconsciousness at its worst. As an illustration of heavy loss of brain functionality at such instance of a seizure attack, victims may experience violent body shakes, fall down and severely bit their tongues. Epilepsy is not a brain disease itself but an expression of a symptom of a number of conditions that could range from injury damage to brain tissue, unusual brain development, brain disease and the cause is elusive in many diagnosis cases leaving a huge gap for research in such cases (Scambler 1989, p1).
Causes of epilepsy in children or in adults are as speculative as it can be due to the several predisposing factors and confidence of diagnosis and attribution can be difficult. As highlighted above, epilepsy is not a disease in itself and it can therefore be used to probe cerebral conditions or diseases that may be involved but there is a knowledge gap for certain isolated dead-end cases. According to major literature as Aicardi, Engel and Pedley (2008, p2116) reckon, the several forms of epileptic seizures that can be diagnosed largely depend on the origins or causes, some of which the author highlights including; exposure to chemoconvulsants and toxins, genetic predisposition, congenital malformations, brain tumors, brain infections, acquired metabolic malfunctions and degenerative disorders among many others. In alcoholic adults, it has been reported that chronic alcoholism can trigger eventual degeneration of brain neurones consequently resulting in epilepsy.
Epilepsy in Children
Cognizant of the fact that the above highlighted predisposing factors of epilepsy causation are largely acquired, it may be important to isolate certain cases that can be observed only in children. As an illustration, it may be difficult to expect epileptic expression in children as a result of alcoholism. The mechanism of expression of epileptic conditions in children may therefore be different since the onset is at an earlier stage in life than in life, hence the different set of predisposing factors and the subsequent difference in the type of epilepsy in children. The bulk of literature around epileptic conditions in children is built around the premise that brain development anomalies constitute the biggest threat to children brain conditions such as epilepsy and autistic spectrum of brain conditions. According to Brooks-Kayal (2011, p14), there is a direct link between developmental brain disorders and epilepsy for the obvious reason that the two conditions are as a result of impairment in brain functionality. The author approximates the occurrence of epilepsy in autistic or developmental malfunctioned cases in children at 30 per cent to illustrate the connection that other major brain conditions have with epilepsy.
The similarity in the pathological functioning of these sets of brain conditions offers explanation to their occurrence (Brooks-Kayal 2011, p18). According to the author, it is a widely acceptable premise that the involvement of all these conditions in the disruption of transmission of nervous impulses at the synapses may be the causative threshold that characterizes their manifestation. Usually, as the author observes, the disorders seemingly affect the flexibility of the synaptic physiology manifesting a developmental disruption of the nervous functionality of excitation and inhibition of the synapses. This is a common phenomenon in developmental conditions such as Fragile X Syndrome, Tuberous Sclerosis Complex and Rett’s Sundrome , among many other brain developmental conditions. Such impairments during development result in the neuroligin and neuropilin 2 gene mutations whose expressions cause Autistic Syndrome Disorders, Intellectual Developmental Disabilities and epilepsy. Similarly, the development of epilepsies in a child may cause the development of other intellectual and development conditions due to the impairment of synaptic flexibility involved in epilepsy which act as their triggering factor.
Epileptogenesis or the process of development and expression of epilepsies takes months to years depending on the nature of the precipitating event that eventually causes stabilization of the seizure eliciting mechanisms. The ultimate stage of epileptogenesis is the impact on the respective genes usually in form of post translational modification in the preparation of the condition expression for the condition in the child. Expression occurs after transcriptional changes followed by the degeneration of normal neurones in the brain. Initial stages of expression begin with the generation of new set of abnormal neurones, reorganization of the neurones and gliosis which get established and stronger as the spontaneous seizures continue to occur (Baram et al. 2002, p4592). As illustrated, these changes are somewhat permanent and are difficult to be reversed if the extent of the damage is beyond reparable level. The brain experiences changes in cellular composition as mutated neural cells replace the inflammation and death of normal brain cells that otherwise eventually lose their functionality. As a result, the brain experiences abnormal control of excitatory and inhibitory mechanism of neurotransmitter substances that is manifested by erratic regulation and modulation of synaptic activities. It however is unclear under what conditions epileptic seizures occurring in children manifest remission as the children grow, contrary to expectations of the above irreversible characterization given to epilepsy by Brooks-Kayal (2011) and Baram et al. (2002).
Child Epilepsy Categorization
Following the guidelines of the International League Against Epilepsy (ILAE), it is possible for pediatricians and health professionals to classify epileptic conditions for a better approach in management (Wilmshurst 2004, p429). According to the author, there are several factors that can be applied in the categorization of the conditions which manifest epileptic spectrum of conditions and their severity must be distinguished in order to devise the best intervention to assist the child to live a near-to-normal life. Three major categories of the ILAE categorization criteria give three high impact epilepsy conditions namely the Paroxysmal Events, Focal Epilepsy and Generalized Epilepsy. Under paroxysmal events, there are four sub-categories of epileptic attacks which include firstly the reflex anoxic attacks which are characterized by breathing difficulties intermitted by crying among toddlers to 6 year olds. Secondly, syncope category involves fainting and is experienced by all children groups but is commonest among adolescent girls. Thirdly, benign paroxysmal vertigo experienced by toddlers where frightening episodes that cause paleness appear resulting to silent clinging to caretakers with cases of vomiting also being reported. Fourthly, pseudoseizures are manifested through rolling on the ground but not necessarily as a result of full blown epilepsy. This category may be as a result of psychological diagnoses such as abuse and exclusion (Wilmshurst 2004, p430).
The second category of epileptic categorization is referred to as focal epilepsies that are the commonest occurring from 8 to 12 years onwards. First subcategory is referred to Benign Focal Epilepsy of Childhood (BFEC) whose triggering factor is usually sleep interrupted by facial twitches that capture the child causing inability to respond vocally while the seizure lasts but usually for a short while. This subcategory is usually resolved through remission after adolescence. The second subcategory of focal epilepsies is referred to as Benign Epilepsy with Occipital Paroxysms (BEOP) which is also triggered by sleep usually lasting longer than BFEC, usually differentiated by severe headaches, temporary blindness, nausea and scans illustrate occipital excitation.
The third category involves generalized epilepsies has six subcategories which include Childhood Absence Epilepsy (CAE), Juvenile Myoclonic Epilepsy (JME), Atypical Absences, Tonic Seizures, Myoclonic seizures and Drop Attacks. CAE begins from 4 to 6 year olds with brief automatisms and unresponsiveness that are cleared before onset of adolescence. JME is triggered by light sensitivity upon awakening from sleep resulting in epileptic attack manifesting myoclonus activity from sleep. Atypical absences manifest affected cognition after exposure to a number of certain epilepsy triggering agents with prolonged features. Tonic seizures are strong in manifestation likely to affect autonomic nervous system. Myoclonic seizures are short spasms that affect the entire body that can range from simple impact to severe drops. Drop attacks express full epilepsy syndromes with short lived stiff to slump falls without after-fall drowsiness. A fourth category exists but it is not as important as the above three categories since the manifestations as per the title are ere epilepsy syndromes that mildly affect infants to 2 year old children (Wilmshurst 2004, p431).
Timing of Epileptic Attacks in Children
The attack on a child by seizures usually results in the suspicion of epilepsy, which could not be the case across all occurrences. Seizures can attack children due to exposure to certain conditions that are generally reversible and that cause nervous complications. Some of the commonest mild factors triggering seizures in children include hyperthermia, general body electrolyte imbalance and a number of biochemical imbalances including hypoxia. Epilepsy becomes manifest if more seizures occur after the first one and if the seizures occur on a repetitive fashion (Ackermann and Toorn 2011, p142). There are preconditions that affect the expression of seizures and epilepsy which can be monitored for the management of the attacks.
In order to determine when seizures amount to epileptic attack, a child needs to have medical examination from a medical professional. Generally, a large group of seizures can be managed by a general practitioner since they constitute common disorders that do not require specialized medical care. However, recurrence of seizures requires special diagnosis using specialized procedures such as EEG (Electroencephalographic), GEFS + (Generalized Epilepsy with Febrile Seizures Plus) and SMEI (Severe Myoclonic Epilepsy in Infancy). Other diagnosis techniques such as neuroimaging may be necessitated for higher degrees of accuracy in the detection of the specific condition. Pediatric intervention in the diagnosis is very important since the expression of the child in describing the nature of attack may be compromised by age and other factors. The input of pediatric intervention in dealing with epilepsy and related attacks is usually recommended by the ILAE instead of general practitioners unless it involves the management of general disorders without special complications.
Psychological Issues in Children with Epilepsy
As highlighted above regarding the nexus between brain functionality and epileptic conditions, it implies that children suffering from epilepsy and other brain development conditions are exposed to some form of social and psychological difficulties. Firstly, the diagnosis and treatment of epileptic conditions requires specialized attention from pediatrician or neurologist with similar expertise which may difficult for the family to deliver. The mere treatment from specialized professional and maybe specialized facilities may amount to some level of stigma for the child and the family. Generally, epileptic children are usually compromised in term of their brain development which extends to their learning and intellectual development (Brooks-Kayal 2011, p13). As a result of the complication thereon, there is a high chance that people may perceive them as antisocial and mentally retarded which negatively affects their psychological self-outlook.it is difficult for children to have a normal life among other normal children when epileptic conditions disrupt the life of the child, which makes it a socially disturbing phenomena that affects emotional development.
Psychological conditions are four times more common in epileptic children than in normal children (Lalkhen and Spangenberg 2006, p60). Due to their awareness that they have special needs, their presence of epileptic children among normal people may force them to feel inadequate and embarrassed of their condition. Behavioral displays of fearfulness, dependency and anxiety may trigger negative psychological attitudes among these children, with cases of withdrawal from social limelight likely to be reported. According to Lalkhen and Spangenberg (2006, p60), there is a high possibility of social isolation, low self esteem and future dependence that affects important life decisions made by these children. According to the author, children suffering from epilepsy have a higher tendency to drop out of school due to low self-image as a result o damaged psychological development.
At the family level, children with epilepsy may present a challenge to the members of the family as special attention must be kept on them. Frustration and shock are reported of parents whose children are diagnosed with epilepsy. Parents are also psychologically affected when they experience the attacks on their children and the impact is damaging to the whole family. Taking care of the child as a person with special needs is also psychologically draining for such parents, when compared with the setting of taking care of a normal child. According to Lalkhen and Spangenberg (2006, p61), the roles of the family members are affected due to the fact that the care of the child is a priority for everyone. Parents may neglect their other healthy children due to the psychological impact that the epileptic attacks present to the parents.
Treatment and Management
Drug therapy to cases of child epilepsy is only allowed in confirmed diagnoses of cases with prescription ranging from case to case depending on the manifestation of epileptic attack. Epilepsy has different types of routine treatment regimens which facilitate control of severe seizures and the damages they can cause. Regimens such as phenobarbitone are commonly suded around the world on a daily dosage to confirmed cases of epilepsy (Magasi, Ntsanwisi and Rataemane 2011, p57). Side effects may be experienced in certain regimens on older age groups that on the contrary perform better on younger age categories. Prescription s therefore supposed to be followed as directed by the physician. There are other second-line regimens such as topiramate and vigabatrin among other drugs but their usage is dependent on the response that a patient makes to treatment. Other drugs of choice include biotin, pyridoxal derivatives, and acetazolamide (Wilmshurst 2004, p432). Generally, withdrawal of treatment is regressively prescribed to facilitate coping with the withdrawal shock. Other interventions include ketogenic diets, antenatal gene therapy and surgery.
As mentioned earlier, some forms of epilepsy are complex and may permanently and severely impair the functioning of the brain resulting in psychological complications. To assist the child to cope with the challenge, it is advisable to facilitate psychological support and counseling for the child and the entire family. Medical professionals dealing with the conditions must assist the parents and family members to approach the condition with the appropriate frame of attitude and avoid psychological distress. Assisting the family and the child to come to terms with the condition may facilitate development of the child since trauma and stigma coping will have been facilitated. The child can be assisted to face such challenges with a bold and stronger attitude enabling establishment of a strong foundation in terms of psychological and social development (Lalkhen and Spangenberg 2006, p63).
Epilepsy presents a class of brain disorders that present difficult diagnosis and management challenges that require the input of a pediatrician or neurologist with child care specialization. Manifestation of seizures of different kinds must be distinguished from pathological presentation of epilepsy which has a distinct development process unlike seizures that may be triggered by simple physiological functions breakdown. Diagnosis of epilepsy and the appropriate categorization is important in the determination of the appropriate intervention to be adopted. Psychological trauma associated with brain conditions imply that assistance must be availed to assist children and families to cope with social challenges of the condition. Although epilepsy at childhood may present a permanent disorder, there are several mysterious phenomena observed in the condition such as natural remission and complete disappearance that still intrigue medical pediatric interventions and only future research can shed light to explain such phenomena.
Ackermann, S. & Van Toorn, R. (2011) Managing First-Time Seizures and Epilepsy in Children. CME, vol. 29, no. 4, pp142-148
Aicardi, J., Engel, J. & Pedley, T. (2008) Epilepsy: A Comprehensive Textbook, Vol. 1. Philadelphia, PA: Lippincott Williams & Wilkins
Baram ,T. Z., Bender, R. A., Brewster, A., Chen, Y., Dube, C. & Eghbal-Ahmadi, M. (2002) Developmental Febrile Seizures Modulate Hippocampal Gene Expression of Hyperpolarization-Activated Channels in an Iso-Form- and Cell-Specific Manner. Journal of Neuroscience, vol. 22 pp.4591–4559
Brooks-Kayal, A. (2011) Molecular Mechanism of Cognitive and Behavioral Comorbidities of Epilepsy in Children. Epilepsia, vol.52, no. 1, pp.13-20 Doi:10.1111/j.1528-1167.2010.02906.x
Engel, J., Taylor, D. & Trimble, M. (2008) “Neurology of Behavioral Disorders” in Aicardi, J., Engel, J. & Pedley, T. Epilepsy: A Comprehensive Textbook, Vol. 1. Philadelphia, PA: Lippincott Williams & Wilkins
Lalkhen, N. & Spangenberg, J. J. (2006) Children with Epilepsy and their Families: Psychological Issues. SA Fam Pract, vol. 48, no. 6, pp60-63
Magasi, D., Ntsanwisi, V. & Rataemane, S. (2011) Alternative Psychosis (Forced Normalization) in Epilepsy. SAJS, vol. 17, no. 2, pp.565-59
Scambler, G. (1989) Epilepsy. London, UK: Routledge Publishers
Wilmshurst, J. M. (2004) Approach to Epilepsy in Childhood. Epilepsy, vol. 22, no. 8, p427-433
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