I see a highly selected population of patients referred for difficult or refractory seizures. A large part of what we do here is determining which patients do not have epilepsy. In fact, a substantial percentage of patients who are referred to epilepsy centers with seemingly intractable seizures from epilepsy is actually determined to have psychogenic nonepileptic seizures. These do occur in the pediatric population, just as depression and anxiety occur in preadolescents and adolescents. Additionally, there are benign focal epilepsies of childhood, such as benign Rolandic epilepsy in the younger population; these seizures are easily identified by their interictal electroencephalogram patterns and are usually outgrown.

In the community, unlike at an epilepsy center, neurologists see an unselected patient population, and it is common for patients with epilepsy to not have a precise diagnosis (eg, focal epilepsy vs primary generalized epilepsy). In those with focal epilepsy, some of the seizures may be secondarily generalized (focal to bilateral tonic-clonic seizures). We know that approximately 30% of patients with focal epilepsy will have bilateral tonic-clonic seizures, and, like their adult counterparts, some children have secondarily generalized seizures with normal interictal electroencephalogram or relevant findings on magnetic resonance imaging. In these scenarios, for the youngest patients (eg, those younger than driving age) with recent-onset epilepsy, it might be reasonable to take a watch-and-wait approach, waiting to start AED treatment until the occurrence of a subsequent seizure, advising against swimming alone, and advising the patient to take showers instead of baths to prevent drowning. As patients grow older and continue to have seizures, however, it is prudent to treat them with the goal of preventing all focal seizures to avert progression to secondarily generalized seizures. And, if there is the possibility of primary generalized epilepsy, one should account for that. If, for instance, we have a 16-year-old female patient in the community who is driving, and if we cannot exclude the possibility of primary generalized epilepsy, then there is no reason to prescribe a narrow-spectrum agent (eg, phenytoin, carbamazepine, oxcarbazepine, pregabalin). We should instead select a broad-spectrum AED, of which there are second- and third-generation options to choose from. Another important consideration in this age group is that, as children transition from childhood to adolescence, efforts are appropriately directed at fostering independence and encouraging these youths to be more in charge of their epilepsy care. At that point, we only have a few more years to work on this, after which a parent may not have as much of a continuing role (eg, filling the weekly pill container, ensuring that they get their appropriate dose, checking with the pharmacy).