Conclusion

The differential diagnosis of epilepsy in children—from the very young to the maturing adolescent—may be difficult, but rarely is it impossible. It demands two processes: the art of history taking, and the intellectual process of diagnosis.

The history comes from an intense direct communication between pediatrician or child neurologist and child, caregivers, or witnesses. If the parents were not there at the time of an event, don't forget the school teachers. From whoever it is gleaned, the precise, detailed, consecutive, all-embracing history remains paramount. If in doubt, have someone at home, school, or outdoor activity capture an event on videotape. If that does not succeed, a useful addition to the history-gathering processes is the method of showing video-recordings of different epileptic and nonepileptic events to parents to discover which, if any, resemble their own child's attacks—the "that's it!" phenomenon.

Although the intellectual process of diagnosis normally integrates all the clinical information from history and examination with the laboratory tests, in the case of paroxysmal events, the history often stands alone. The intellectual process is then to pull together the threads of the history and weigh the probability of epileptic phenomena versus the probability of nonepileptic phenomena in the knowledge that, in total, the latter are more common than epileptic seizures and at least as diverse as the epilep tic events that they imitate. Not only that, but it may be more dangerous for the physician and the patient to miss the diagnosis of a syncope from a cardiac conduction defect than to miss a diagnosis of an early epilepsy.

Even when a diagnosis of epilepsy has seemed secure for many years, still be prepared to question not only the type of epilepsy or epileptic syndrome, but whether it is really epilepsy after all. As we have shown, this applies even when the original diagnosis of epilepsy was certain. Beware writing or even thinking "known epileptic" (156). To quote Stephenson (1) "'known epileptic' means nothing of the kind. Either it is not epilepsy, or the epilepsy is insufficiently understood— otherwise, why the consultation?" May the development of your understanding never cease.

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