Stress and seizure control in children: where to now?

Commentary This is the first study to examine the relationship of both recurrent and acute stressors (noncatastrophic) with seizure frequency in a large sample of 153 children and adolescents with epilepsy and their association with life events. The findings demonstrate that seizure frequency increased in about half the children in this sample and is associated with both types of stressors, that about 25% of children responded to both recurrent and acute stressors, and that both recurrent negative and positive stressors were related to increased seizure frequency. Similar to adults (1–5), children with epilepsy appear to respond to recurrent and acute noncatastrophic stressors with increased seizure frequency. The study's many strengths include its large sample size, the well-defined inclusionary and exclusionary criteria; inclusion of demographic, developmental, and IQ variables in the analyses; the separation between positive and negative stress factors; examination of the role of sleep, medication noncom-pliance, and seizures as stressors; and comparison of the 153 participants and 192 nonparticipants in the study in terms of their age, sex, and epilepsy-related variables. Although the authors provided a good discussion of the study's limitations, they did not consider several additional potential confounding factors. The study included children aged 2 to 16; yet, the article includes no information on how many children were in the different age groups, nor how the distribution of the subjects in this wide range of age groups was related to the study's findings. In addition, they did not indicate if and how the 17.1% of subjects treated with ketogenic diet, vagal nerve stimulator, and adrenocorticotropic hormone (ACTH) might have contributed to the direction of the study's stressor findings. The authors found a significant association between arousal, anger, fear, and nervousness with acute stress, as well as between arguments with stress sensitivity and negative stressors. However, they provide no information on how they defined and differentiated between these behaviors. Furthermore, since these phenomena could be preictal manifestations in children, parents might misinterpret them as stressors that increase seizure frequency. The smaller number of antiepileptic drugs and stressful events in the medical charts of the nonparticipants could imply a selection bias in the participant parents who had children with more difficult to control seizures and stressful life events. Nevertheless, the clinical and research implications of the study's findings are important and underscore the need for well-designed treatment programs and studies. Children without epilepsy who have psychiatric diagnoses and behavior …