Health Status and Quality of Life in Epileptic Children and Adolescents

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1 Original Article Health Status and Quality of Life in Epileptic Children and Adolescents Mona S. Mohammad 1, Samia Abd El-Razzak Hemeida 2, Amany M. Rabah 3 Departments of Community Medicine 1, Neurology 3, Cairo University; Community Research National Research Center 2 ; Egypt ABSTRACT Background: Epilepsy and its treatment have a direct bearing on major aspects of life style. Demographic, social and economic factors affect health status among epileptic children and adolescents. Objective: evaluation of some aspects of health status among epileptic children and adolescents mainly through quality of life scoring. Methods: 150 epileptics with idiopathic epilepsy and 100 age and sex matched controls were included. Social level scoring, IQ, identification of HRQoL score, clinical examination and laboratory tests for drug intoxication level and measuring the serum level of AEDs were done. Results: The mean scores of all domains of QoL were significantly lower in patients compared to controls (p < 0.01). Females, non educated subjects, patients living in rural areas (except in social support), very low social level, patients with generalized fits and polytherapy receiving patients had lower mean QoL scores as compared to their counterpart (p<0.05). Patients on polytherapy had higher toxicity score relative to monotherapy group (p<0.05). Significant correlation was found between QoL domains and IQ score and toxicity scores. Age is correlated with toxicity scores, school behaviour and health perception. Seizure frequency is negatively correlated with QOL domains. Conclusion: Epileptic patients had lower mean scores of all domains of quality of life specially those with frequent fits, those on polytherapy and in patients with generalized fits. (Egypt J Neurol Psychiat Neurosurg. 2010; 47(1): 83-92) Key Words: Epilepsy- quality of life health assessment antiepileptic drug side effects. INTRODUCTION Epilepsy is a chronic disabling neurological disease characterized by recurrent seizures and uncertainty in seizure frequency, severity and prognosis. Onset of the disease occurs primarily during childhood and adolescents 1. In the 1990 WHO analysis of worldwide burden of disease, epilepsy ranks among the top three causes of neurological disabilities particularly among the young. Epilepsy in adolescents magnifies the problem of adolescence as it is a disease with chronic disability and the penalties for seizures at this time are far more severe than in childhood 2. Epilepsy and its treatment have a direct bearing on major aspects of life style such as education and employment prospects, relationships, self-consciousness and many other aspects 3. During the 1990s, the interest in systematic assessment of the health status of patients with epilepsy, by using standardized questionnaires, has increased. Several new disease-specific instruments have been developed to assess the impact of epilepsy in people lives. These instruments include the health related quality of life questionnaires, socioeconomic data and medication toxicity 4. Correspondence to Amany M. Rabah, Department of neurology, Cairo University, Egypt. Tel: amanyrabah@hotmail.com Adolescents have a special instrument that has been developed for assessment of the quality of life as a special interest. Other assessments for health status of epileptic patients include a direct examination focusing on signs and symptoms of neurotoxicity and systemic toxicity effects of anti-epileptic drugs by using modified VA Neurotoxicity Scale and modified VA Systemic Toxicity Rating Scale. Other factors that can affect the health status of an epileptic patient include the socio-economic status and social variables 5-7. Assessments of serum drug levels are useful for documenting the level corresponding to the maximum tolerated dosage of AEDs, assessing medication status and patient compliance when a break through seizure has occurred. It is also used for sorting out the probable cause of non-specific medication side effects when patients are taking multiple medications, ensuring an appropriate medication level in patients who are unable to report adverse effects (as young children and cognitively impaired individuals) 8. The quality of care for people with epilepsy may be improved because information gleaned from the questionnaire could lead to increased detection of patients' problems with daily functioning and wellbeing; guide therapeutic management and lead to improvement in patients' HRQoL and satisfaction with care 9. Egypt J Neurol Psychiat Neurosurg. Jan 2010 Vol 47 Issue 1 83

2 The aim of this study is to assess some aspects of health status among epileptic adolescent and children with special reference to quality of life and manifestations of drug toxicity. SUBJECTS AND METHODS This case control study was conducted on 150 epileptic children and adolescents and 100 normal controls matched for age, sex and social level to the patients group. Patient group: Their age ranged from 8-20 years with a mean of 15.99±2.91 y. They included 80 (53.3%) males and 70 (46.7%) females. All patients had idiopathic epilepsy for more than one year whether on anti-epileptic drugs (AEDs) or not. Patients were classified according to the International Classification of Epileptic Seizures 10. Exclusion Criteria: Excluded from the study, symptomatic epilepsy, patients with systemic disease that may affect the health status and the quality of life (diabetes mellitus, liver or kidney disease), physically handicapped children, patients with neurologic disorders other than epilepsy or any psychiatric illness, mental retardation (IQ<70), change of AEDs in the past four months, patients on medication with CNC effect as antidepressants and hypnotics. Control group: Their ages ranged from 8-20 years with a mean of 15.37±2.97 years. They included 53 (53%) males and 47 (47%) females. Methods: I. Complete clinical and neurological assessment based on the Convulsive Disorder Clinic Sheet of Department of Neurology, Cairo University. II. Social score sheet: used to ascertain the socioeconomic status (patients & controls). It consists of six questions determining simple parameters for social classifications for health research. Scoring of the sheet: Each item has scores with minimum and maximum values. The total score of the sheet equals the algebraic summation of the score of the six questions. According to the total score, subjects were divided into four groups with different social levels: high social class with score ranging from 50 to 57; middle social class with score between 40-50; low social class with score between score and very low social class with score below III. Intelligent quotient (IQ): Two tests derived from Wechsler Intelligence Scale for Children (WISC III) (12) were used. The IQ for all our subjects was above 70. IV. Health-related quality of life inventory of epilepsy (HRQOL): QOLwas assessed by the health related quality of life inventory of epilepsy developed in 1999 (QOLIE-AD-48). The inventory consisted of nine subscales (domains) contains 48 items. These subscales are: 1. Epilepsy impact (assessed in twelve items); 2. Memory and concentration (assessed in ten items); 3. Attitudes toward epilepsy (assessed in four items); 4. Physical functioning (assessed in five items); 5. Stigma (assessed in six items); 6. Social support (assessed in four items); 7. School behavior (assessed in four items); 8. Health perception (assessed in three items); 9. Anxiety (assessed in three additional items). Analysis of the sheet: Initially, items were allocated to domains on conceptual grounds. A total of 48 QOL items were included. In addition, a single open-ended question asked subjects to comment on the questionnaire and note topics that were not covered. The questionnaire was divided into two sections as (1) generic (physical, mental, emotional), and (2) epilepsy specific (the effects of epilepsy and antiepileptic medication). Section 1 topics included overall health perceptions, physical activities, impact of physical or emotional problems, mood, concentration, memory, cognitive skills, and social support from family and friends. Section 2 topics included impact of epilepsy and antiepileptic drugs on activities, fears about seizures, perceived severity of seizures, adverse mental and physical effects of medication, and role limitations, including driving. Items from the stigma scale and CATIS were included in this section 13. Scoring instructions of the HRQOLIE-AD-48: 1. The preceded numeric values of items point scores is converted, with higher converted scores always reflecting better quality of life. For example, items with a four-point response are coded as 0, 33.3, 66.7, 100; items with a fivepoint response are coded as 0, 25, 50, 75, and The mean value of the items in each subscale is calculated. Adjust the dominator to include only items answered. 3. To calculate the total score, we multiplied the mean by the relative weight for the subscale. 4. The weighted values for all subscales to determine the total (summary) score is added. 5. T-scores can be determined for each subscale and the total (summary) score to represent linear transformations with a mean of 50 and standard 84 Egypt J Neurol Psychiat Neurosurg. Jan 2010 Vol 47 Issue 1

3 deviation of 10 for the cohort evaluated. Higher T-scores reflect a more favorable quality of life. V. Antiepileptic drug toxicity scales: The manifestations of AED toxicity were assessed by using a modification of the Neurotoxicity Rating Scale and a modification of the Systemic Toxicity Rating Scale (5, 14). All toxicity is scored relative to normal for this patient at pre-entry. Both rating score is the sum of the items from 1 to 8 and total score is calculated. Individual item scores can range from 0 to 50 points on both scales. VI. Serum drug level: done for 80 patients on AEDs. Evaluation of the result was considered within, above, or below therapeutic serum level according to Chadwick, (15). VII. Electroencephalography (EEG): done using Nihon Kohden 14-channel EEG machine. Electrodes were arranged according to the 10/20 International System, using mono and bi-polar montages. According to Elwan et al. (16) the recorded EEG findings were described as normal or abnormal; the abnormalities were described as epileptogenic activities or dysrhythmias. The epileptogenic activities were either, focal, focal with secondary generalization, and generalized discharges. Dysrhythmias were either, generalized or focal; and its form was either delta or theta activities. Epileptiform activity was considered lateralized if more than (80%) of the discharges originated from one side (17). VIII. Magnetic Resonance Imaging (MRI) of the brain: Non-enhanced MRI of the brain was performed at MRI unit of the Radiology Department of Kasr El-Aini Hospital using General Electric Medical System Signal 1.0 Tesla to exclude secondary epilepsy. Statistical Analysis: Descriptive statistics was presented as Mean±SD, number and percentage (frequency distributions). Unpaired student t-test (two sided) and Non-parametric testing were used for comparing two groups. Significance level of 0.05 and 0.01 was used throughout all statistical tests within this study RESULTS 1) The socio-demographic results: The sociodemographic data of patients and controls are shown in Table (1). The educational level was significantly lower in patients ((p=0.049) and the family history of epilepsy was significantly higher in patients (p=0.000) 2) IQ results: IQ of patients ranged from with a mean of 82.82±6.42 while in controls it ranged from with a mean of 91.61±5.97, the difference was highly significant (P<0.01). 3) Clinical characters of seizures: * Type of seizures: Eighty-two (54.7%) patients had secondary generalized seizures, 41 (27.3%) had primary generalized seizures and 27 (18.0%) had focal seizures. * Frequency of seizures: Those with daily seizures were 23 patients (15.3%), 40 (26.7%) had weekly seizures, 48 (32.0%) had monthly seizures and 39 (26.0%). didn't have seizures in the past year. * Relation to sleep: 27 (18.0%) patients had their seizures occurring strictly during sleep. * Anti epileptic drugs (AEDs) treatment: Eighty-two (54.7%) patients were on monotherapy while 45 (30%) were receiving polytherapy. Twenty-three patients (15.3%) were non compliant on treatment. 4) Quality of life inventory results: The comparison between patients and controls in the QOL domains and total score is shown in Table (2). Patients had significantly lower scores in memory/concentration, physical functioning, school behaviour, social support and total score of QOL (P<0.05). 5) Scores of toxicity scales: The systemic toxicity score ranged from 0 50 with a mean of 2.94 ± 7.17 while the neurotoxicity score ranged from 0-28 with a mean of 2.33 ± On the other hand, the total score for both scales ranged from 0-51 with a mean of 5.27 ± According to the frequency of toxic manifestations, 41 patients (27.33%) had systemic toxicity and 23 (15.33%) had neurotoxicity while 47 (31.33%) had both systemic and neurotoxicity. 6) Serum level of AEDs: patients with subtherapeutic serum level were 31 (38.8%), 35 (43.8%) had therapeutic level, whereas patients with toxic serum level were 14 (17.4%). 7) Clinical comparisons: Comparison between males and females: A. Educational level and IQ: no significant difference was found between males and females as regards the level of education and IQ (p > 0.05). B. Quality of life inventory: the comparison is shown in Table (3). Females had significantly lower scores in epilepsy impact, stigma, attitude towards epilepsy anxiety and total score of QOL in comparison to males (P<0.05). Comparison between educated and noneducated patients: in the QOL domains and total score is shown in Table (3). Non-educated had significantly lower scores in social support and total QOL score in comparison to educated (p<0.05). Egypt J Neurol Psychiat Neurosurg. Jan 2010 Vol 47 Issue 1 85

4 Comparison of QOL scores according to residency: The comparison between patients living in urban, slum and rural areas in the QOL domains is shown in Table (4). Patients living in rural areas had significantly lower score in stigma and school behaviour while they had significant higher scores in social support (p<0.05). Comparison between patients according to social level: Comparison between patients with different social level (according to social score) in the QOL domains is shown in Table (5). Comparison between patients with different types of epilepsy: The comparison between patients with focal, generalized and 2ry generalized fits in the QOL domains is shown in Table (6). Patients with generalized type of epilepsy had significantly lower scores of all QOL domains except social support in comparison to other types (p<0.05). Comparison between patients according to number of AEDs: The comparison between patients on polytherapy, monotherapy and noncompliant patients in the QOL domains and the toxicity scores is shown in Table (7). Patients on polytherapy had significantly lower health perception score and significantly higher mean values of toxicity scores (p<0.05). 8) Clinical correlations: Age correlation: a significant positive correlation was found between age and school behaviour and a significant negative correlation with health perception and toxicity scores (p<0.05). IQ correlation: There were a significant positive correlation between QOL domains and the total score with the IQ score except in stigma which has a negative correlation with the IQ score i.e. the higher the IQ the more feeling of stigma (p<0.05). Toxicity scores correlation: As regards the QOL domains, a significant negative correlation was found between epilepsy impact, memory, concentration, physical functioning, school behaviour, health perception, anxiety and total QOL score with the systemic and neurotoxicity scores (p<0.05). Seizure frequency: a statistically significant negative correlation was found between seizure frequency and the scores of QOL domains and the total QOL score (P<0.01). Table 1. Frequencies of some socio-demographic variables among patients and controls. Variable patients (n=150) Control (n=100) P value No. (%) No. (%) Residence Slum Urban Rural Social level Very low social Low social Middle social High social Education Primary education Prep. Second Education Diploma High education Total (for educated) Not educated 70 (46.7%) 56 (37.3%) 24 (16.0%) 26 (17.3%) 94 (62.7%) 25 (16.7%) 5 (3.3%) 40 (26.7%) 20 (13.3%) 48 (32.0%) 12 (8.0%) 120 (80.0%) 30 (20.0%) 49 (49.0%) 37 (37.0%) 14 (14.0%) 18 (18.0%) 48 (48.0%) 26 (26.0%) 8 (8.0%) 39 (39.0%) 13 (13.0%) 26 (26.0%) 9 (9.0%) 90 (90.0%) 10 (10.0%) * Consanguinity Positive Negative Family history of epilepsy Positive Negative 51 (34.0%) 99 (66.0%) 69 (46.0%) 81 (54.0%) 27 (27.0%) 73 (73.0%) 24 (24.0%) 76 (76.0%) ** 86 Egypt J Neurol Psychiat Neurosurg. Jan 2010 Vol 47 Issue 1

5 Table 2. Comparison between patients (n=150) and controls (n=100) according to the scores of quality of life domains and total quality of life score. Item Patients (n = 150) Control (n = 100) Sig. Mean ± SD Mean ± SD Health perception ± ± Memory/concentration ± ± ** Physical functioning ± ± ** School behavior 85.7 ± ± * Social support ± ± ** Epilepsy impact ± Stigma ± Attitude towards epilepsy ± Anxiety 75.5 ± TOTAL ± ± ** Every domain and total score has minimum of 0 and maximum of 100 (higher scores indicates better QOL) No. of subjects in school behavior were 120 for patients and 90 for controls. * Statistically significant difference (p<0.05) ** Statistically highly significant difference (p<0.01) Table 3. Comparison between (males and females) and (educated and non-educated) patients as regards scores of QOL domains and total QOL score. Quality of life domain Males (n=80) Females (n=70) P educated Non educated P-value Epilepsy impact 75.4± ± * 73.1± ± Memory/concentration 72.4± ± ± ± Physical functioning 86.1± ± ± ± Stigma 69.5± ± * 63.8± ± Social support 84.5± ± ± ± * School behavior 88.8± ± Health perception 66.8± ± ± ± Attitude towards epilepsy 57.5± ± ** 53.8± ± Anxiety 80.1± ± * 75.0± ± Total quality of life score 74.3± ± * 73.2± ± * Table 4. Comparison between patients lived in urban, rural and slum areas in QOL scores. Quality of life domain Urban Slum Rural P-value (n=56) (n=70) (n=24) Epilepsy impact 72.7 ± ± ± Memory/concentration 74.3 ± ± ± Physical functioning 86.1 ± ± ± Stigma 65.4 ± ± ± * Social support 83.1 ± ± ± * School behavior 91.9 ± ± ± ** Health perception 67.3 ± ± ± Attitude towards epilepsy 56.8 ± ± ± Anxiety 80.2 ± ± ± Total score 74.0 ± ± ± Egypt J Neurol Psychiat Neurosurg. Jan 2010 Vol 47 Issue 1 87

6 Table 5. Comparison between patients with different social scores as regards QOL scores. Quality of life domain High social Middle social Low social Very low social P-value (n=5) (n=25) (n=94) (n=26) Epilepsy impact 75.4 ± ± ± ± * Memory/concentration 62 ± ± ± ± Physical functioning 79 ± ± ± ± ** Stigma 66 ± ± ± ± * Social support 71.2 ± ± ± ± School behavior 91.3 ± ± ± ± Health perception 71.3 ± ± ± ± ** Attitude towards epilepsy 46.2 ± ± ± ± Anxiety 91.7 ± ± ± ± * Total score 74.7 ± ± ± ± * Table 6. Comparison between patients with different types of epilepsy in the QOL domains and total quality of life score. Quality of life domain Focal (n=27) Generalized (n=41) 2ry generalized (n=82) P-value Epilepsy impact 84.7 ± ± ± ** Memory/concentration 81.1 ± ± ± ** Physical functioning 92.6 ± ± ± ** Stigma 83.7 ± ± ± ** Social support 86.8 ± ± ± School behavior 91.5 ± ± ± * Health perception 71.6 ± ± ± * Attitude towards epilepsy 64.6 ± ± ± * Anxiety 89.5 ± ± ± ** Total score 82.3 ± ± ± ** Table 7. Comparison between patients according to number of AEDs in QOL score and in toxicity scores. Quality of life domain Non compliant (n=23) Monotherapy (n=82) Polytherapy (n=45) P-value Epilepsy impact 76.7 ± ± ± Memory/concentration 69.1 ± ± ± Physical functioning 87.2 ± ± ± Stigma 68.1 ± ± ± Social support 79.6 ± ± ± School behavior 88.3 ± ± ± Health perception 53.4 ± ± ± ** Attitude towards epilepsy 49.4 ± ± ± Anxiety 82.6 ± ± ± Total score 71.9 ± ± ± Toxicity scores Systemic toxicity ± ± * Neurotoxicity ± ± ** Both toxicities ± ± ** 88 Egypt J Neurol Psychiat Neurosurg. Jan 2010 Vol 47 Issue 1

7 DISCUSSION Epilepsy is a major neurologic disorder seen in childhood and adolescents with extensive impact on patients' physical, psychological and social functioning 18. The majority of our patients and controls were living in slum areas (46.7% and 49% respectively) and most of them were from low social level. This may be because the social level is affected by the residence. In agreement to this 19, said that epilepsy and its sequelae were more prevalent in patients with low social levels. Non educated subjects were significantly higher among our epileptic patients as compared to controls (p<0.05). 20,21 stated that up to (30%) of the investigated children with epilepsy face problems in school, and many of them were referred to special education because of their learning disabilities. It was postulated that epilepsy has a marked negative impact on education at any stage of life regardless of their handicaps and this may be related to cognitive limitations, behavioral problems or educational underachievemen 22. In the present study, the patients IQ was significantly lower than in controls. Similarly, Dodrill 23 and Browne & Holmes 24, Abdel-sayed et al. 25, found that though the intelligence of epileptics who are not overtly brain-damaged even those with controlled seizures lies in the average range, yet their IQ scores tend to be slightly lower than controls. On the contrary, Hannah and Brodie 26, showed that the IQ of epileptics with no brain damage lies in the average range or even higher, and the majority of them attend ordinary schools. The contradictory conclusions of literatures could be affected by sampling of patients, and other methodological issues. Anti-epileptic drugs may be the cause of the impaired cognition, as most children and their parents complained of impaired cognitive functions associated with AED treatment 27. Diminished quality of life is a common feature of epilepsy. The present work showed that patients had significantly lower scores in all domains of QOL (except health perception) in comparison to controls. This is in agreement with several previous studies On the contrary, Zhu et al. 32 revealed insignificant differences between epileptics and controls. Family support, age selection and cultural and religious beliefs are proposed to explain these cross-cultural differences. Also in developing world a combination of economic priorities and culturally mediated perceptions of epilepsy as a nonmedical and feared stigma may further disadvantage people with epilepsy in this respect. Females in the current study had significantly lower mean scores in of QOL compared to males (p<0.05). Djibuti and Shakarishvili 33, stated that female sex was the factor that significantly predicted a lower anxiety score among epileptics and correlated strongly with low QOL scores. The differences found may be due to either the characteristics of epilepsy or the social background of the epileptic patients. In the contrary, Amer 34 showed no sex difference in aspects of QOL in a study conducted over 55 adult Egyptian epileptic patients. The educated group of our patients had significantly better total score of QoL and social support and worse scores in stigma and anxiety. In agreement to this result, Amer 34 found that educated subjects had higher score in QOL aspects. Poor QOL may affect epileptic patients to leave education especially when there is not enough social support. Epileptics are prevented from participating in education owing to the stigma attached to epilepsy and so it affects the educational status and not the reverse. 35 Patients living in rural areas had significant lower scores in school behaviour and stigma with significantly higher score for social support in our work. These results could be explained by the fact that rural areas have good social relations and expanded families that made them to have better social support but more feeling of stigma. However, they had lower income, bad medical care that made the other variables worse among them. This finding also confirmed in previous studies 36,37. Devinsky et al. 38, by using QoLIE-AD-48 showed that lower socioeconomic status were more likely to report poor overall QoL and stated that overcrowding, lack of good education, unhealthy environment may be the cause of such results and the higher social levels had better chance of medical care. The same results was detected in our study as patients with low social level had significantly lower scores of epilepsy impact, physical functioning, stigma, health perception, anxiety and total score of QOL in comparison to high social level patients (p<0.05). Also, a significantly lower scores of QOL domains was found in our patients with generalized seizures in comparison to patients with focal and 2ry generalized seizures (p<0.05). In agreement to the present results Cramer et al. 39, and Gus et al. 40 found that patients with generalized fits had the least score of QOL. As regards AEDs and their effects on QOL, Hoare 41 showed that patients under polytherapy had poorer scores and the more the number of AEDs the more the side effects the more will be the effect on QOL score. The same was found in the current work as patients on polytherapy had significantly lower health perception score in comparison to patients on monotherapy. Also, toxicity scores were significantly higher in patients on polytherapy versus those on monotherapy (p<0.05). Almost all AEDs affect cognitive functions especially with chronic use, polytherapy and when associated with high serum levels 42,31. Mauri-Llerda et al. 30, showed that impaired memory and concentration were common in epileptics owed to AEDs that can cause negative effects on QOL score, especially the benzodiazepines and barbiturates. Egypt J Neurol Psychiat Neurosurg. Jan 2010 Vol 47 Issue 1 89

8 Age was significantly positively correlated with behavior (p=0.03) and negatively with health perception and toxicity scores (p<0.05) but not with total score of QOL. This goes with Amer 34 ; Engelberts et al. 43 and Miller et al. 42, who stated that early age is significantly associated with more deficits in school behavior and age was not predictive of diminished overall health related QOL. On the other hand, Baker et al. 44, found that younger people were more likely to report feeling stigmatized by their condition. Older people were more anxious and depressed than those diagnosed earlier and their overall perception of QOL was more likely to be negative. This controversy may be explained by the differences in sociodemographic, social, academic leveling and characters of fits and the wider range of age. As regards AED toxicity, the pharmacokinetic differences may play a part in the age-related differences in the incidence of adverse effects. Young age is considered a risk factor 45. IQ is negatively correlated with stigma and positively correlated with other QOL domains. In agreement, Amer 34 stated that epilepsy affects intelligence in early age and is significantly associated with deficits in physical functioning and school behavior. A significant negative correlation was found between toxicity scores and some domains of QOL (P<0.05). In agreement, Devinsky et al. 38, stated that cognitive functions were affected significantly with toxic adverse effects of AEDs especially with poly therapy. A significant negative correlation was found between seizure frequency and scores of QOL (p<0.05). Similar results was found in previous studies that epilepsy has the greatest impact among children who had uncontrolled seizures and seizure frequency was strongly associated with bad quality of life 28,41,46. They concluded that seizure-frequency reduction needed to improve HRQoL among medically treated individuals. In conclusion, while seizures are the most common physical symptom of epilepsy, treatment must include far more than medical intervention for seizure control. Virtually all aspects of life are affected by the disorder including personal relationships, employment and perception of self and overall quality of life. REFERENCES 1. Shneker BF, Fountain NB. Epilepsy. Dis Mon Jul; 49(7): Colin DM, Christina B, Kim MI, Mie I, Fat DM, Shibuya K et al.: Global Burden of Disease in 2002: data sources, methods and results. Global Programme on Evidence for Health Policy Discussion. WHO. Paper No. 54; 2003 Dec [updated 2004 Feb; cited 2009 Mar]. Available from: paper54.pdf. 3. Smith JP. Healthy bodies and thick wallets: the dual relation between health and economic status. J Econ Perspect. Spring. 1999; 13 (2): Devinsky O., Vickrey B.G., Cramer J., Perrine K., Hermann B., Meador K. and Hays R.D.: Development of the quality of life in epilepsy inventory. Epilepsia Nov; 36 (11): Cramer J.A., Smith D.B., Mattson R.H., Delgado Escueta A.V. and Collins J.F.: A method of quantification for the evaluation of antiepileptic drug therapy. Neurology. 1983; 33 Suppl 1: Cramer JA, Westbrook LE, Devinsky O, Perrine K, Glassman MB, Camfield C. Development of the Quality of Life in Epilepsy Inventory for Adolescents the QOLIE-AD-48. Epilepsia. 1999; 40(8): Stavem K, Loge JH, Kaasa S. Health status of people with epilepsy compared with a general reference population. Epilepsia Jan; 41 (1): Walters RJ, Hutchings AD, Smith DF, Smith PE: Inappropriate requests for serum anti-epileptic drug levels in hospital practice. QJM Jun; 97 (6): Gilliam FG. Epilepsy - success in clinical practice: translating trials to practice. Eur J Neurol Nov; 12 Suppl 4: Commission on Classification and Terminology of the International League Against Epilepsy: Proposal for revised classification of epilepsies and epileptic syndromes. Epilepsia. 1989; 30 (4): Fahmy SI, El-Sherbini AF. Determining simple parameters for social classifications for health research. Bulletin of the High Institute of Public Health, 1983; 13(5): Wechsler D. Wechsler intelligence scale for children. 3 rd edition. The Psychological Corporation, San Antonio; Austin JK, Huberty TJ. Development of the Child Attitude Toward Illness Scale. J Ped Psychiatry; 1993; 18: , 14. Cramer JA. A clinimetric approach to assessing quality of life in epilepsy. Epilepsia. 1993; 34 Suppl 4: S Chadwick D. Seizures, epilepsy, and other episodic disorders. In: Walton J, editor. Brain s Diseases of the Nervous System. 10 th Edition., Vol. II. New York: Oxford University Press Inc; p Elwan O, Taher Y, Barrada H.. Electroencephalographic changes in chronic cerebrovascular occlusive disorders. Clin Electroencephalogr. 1974; 5: Risinger MW, Gumnit RJ. Intracranial electrophysiologic studies. Neuroimaging Clin N Am Nov; 5 (4): Beghi E, Frigeni B, Beghi M, De Compadri P, Garattini L. A review of the costs of managing 90 Egypt J Neurol Psychiat Neurosurg. Jan 2010 Vol 47 Issue 1

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10 الملخص العربى الحالة الصحية ونوعية الحياة لمرضى الصرع من األطفال والمراهقين Egypt J Neurol Psychiat Neurosurg. Jan 2010 Vol 47 Issue 1