Although children with epilepsy are at increased risk for injury, limitations on activities should be relatively few. When restrictions are excessive, they may lead to significant psychological difficulties with impaired self-esteem.

Childhood is filled with inherent risks, and the child with epilepsy is at only a minimally greater risk than before the seizures began. Making guidelines that can be applied to all children with epilepsy is impossible because seizure type, duration, and frequency all may affect the number of restrictions.

Restrictions may also vary over the course of the disorder. Restrictions should be more stringent during the first 2 to 3 months after onset of the disorder, until the physician and family are in agreement that further seizures are unlikely, and for 2 to 3 months after discontinuing antiepileptic medication. In children with persistent, recurrent seizures, restrictions usually remain the same.

Parents must be particularly careful around water. Children with epilepsy are at higher risk for drowning than are children without epilepsy, whether in a bathtub or during recreational swimming. Recreational swimming should occur only with close supervision and in clear water. Swimming in lakes, rivers, and the ocean is very risky. Young children should never be left alone in the bathtub, even for a few seconds. Older children should be encouraged to use a shower and reminded not to lock the bathroom door when showering. Unsupervised swimming should never occur.

All children should avoid open fires, hot stoves and ovens, and dangerous machinery. Parents must assume that a seizure could occur at any time and should avoid allowing a child to be in a situation where a seizure could be deadly. For example, children should not stand near the edge of platforms of subway or train stations.

Very few restrictions should be placed on recreational activities. Activities in which the child is high off the ground, such as rock or rope climbing, should be discouraged. Although bike riding can be pursued safely by most children, it should be avoided by children with frequent seizures in whom impairment of consciousness occurs. Skating, roller-blading, and skateboarding should be restricted only in children with frequent seizures. Even in children with well-controlled epilepsy, these activities should not occur on busy streets. Skydiving and scuba diving should be prohibited.

The child with epilepsy should be encouraged to participate in organized sports. Although some physicians restrict contact sports in the belief that head trauma can precipitate seizures, no evidence exists that patients with epilepsy are at higher risk for
seizures after minor head injury. Children who have a regular exercise program may actually have fewer seizures and side effects than do children who are sedentary.

Parents of young children are often terrified that the child will have an undetected seizure and die during sleep. Having the child sleep in the same room as the parents may be appropriate for the first few months after diagnosis. The parents should also be instructed to purchase an intercom that can be turned on and placed in the child’s room, so they can be alerted by any crying or an abnormal breathing pattern. Soft or restricting sleeping surfaces should be avoided with infants and young children.

Caregivers other than the parents should be told that the child has epilepsy and be given a description of the seizure, along with first-aid measures. Because seizures can be extremely frightening, baby-sitters should be chosen with care. Local epilepsy support groups often have a list of experienced baby-sitters.

Children who are at risk for prolonged seizures present additional problems when the family travels or visits remote areas in which medical care may not be readily available. Before traveling, parents should inquire about the closest medical facility that can deal with a child with epilepsy. It is recommended that the parents be given instruction in administering rectal diazepam or other rescue medications, in case a prolonged seizure ensues.

Rarely, children have a seizure while watching television, playing an electronic screen game, or using a computer. Most of these children have a photoconvulsive response on electroencephalography. Television, computers, and video games should be restricted only when a consistent relation is seen between watching television or playing video games and seizures. Parents often erroneously blame video-game playing or television watching for a seizure, even when the seizure occurs some time after play. The parents must be informed that if television or the video game is responsible for the seizure, the seizure will occur during the activity.

Children with epilepsy are at significant risk for a variety of problems involving cognition and behavior. The distribution of IQ scores among children with epilepsy is skewed toward lower values, and the number of children requiring special education services varies from 10% to 33%. Behavioral and psychiatric disorders in children with epilepsy are also higher than in the normal population, with surveys demonstrating that the prevalence of psychiatric disease is 2 to 4 times greater among children with epilepsy than in control subjects. Although the cognitive and behavioral abnormalities may often be explained by the etiologic factors responsible for the epilepsy, evidence exists that some children with poorly controlled epilepsy have progressive declines of IQ on serial intelligence tests, and behavioral and psychiatric deterioration over time. Whether this decline is secondary to antiepileptic medications, to progression of the underlying encephalopathy responsible for the seizures, or to the seizures per se is not certain.

A number of factors place the child at increased risk for cognitive impairment: an early age at seizure onset, intractable seizures, and polytherapy. The etiology of the epilepsy is also important. Children with symptomatic epilepsy are at higher risk for cognitive impairment than are children with idiopathic epilepsy.