Key messages
• One study showed that after three months of treatment, teenagers who received group psychotherapy to address anxiety and depression may have had slightly fewer seizures per month than teenagers who did not have therapy.
• We do not know if other non-medicinal treatments and innovative healthcare support helped to reduce the number of seizures or improve children's quality of life because the evidence was limited and very uncertain.
• The studies did not find that any treatments or new ways of delivering care support harmed the people taking part.
What is epilepsy?
Epilepsy is a brain condition that causes seizures. It affects around one in 1000 children under five years old, and around one in 200 children between five and 19 years old. In a seizure, the brain's electrical signals are suddenly disrupted or become too active. Seizures can be harmful to health and reduce people's quality of life.
What is the role of non-medicinal treatments and innovative care delivery in epilepsy?
Most people with epilepsy take daily anti-seizure medication to help control seizures. However, up to four in 10 children with epilepsy don't respond well to medication alone: seizures persist. Additional, non-medicinal treatments and innovative ways of delivering healthcare support may help children and teenagers with epilepsy manage the mental, emotional, and lifestyle effects of the condition.
We divided these treatments and approaches into three categories, based on how they are designed to work:
• psycho-behavioural treatments, which aim to change a person's behaviour;
• mind-body treatments, such as muscle relaxation and yoga;
• service delivery approaches, such as digital healthcare or epilepsy specialist support.
What did we want to find out?
We wanted to discover if these treatments and service delivery approaches for children and teenagers (younger than 18 years) and their families were better than the usual care that people with epilepsy receive at:
• reducing the number of seizures they experience;
• improving their quality of life.
We also wanted to know if these treatments led to any unwanted, harmful events.
What did we do?
We searched for studies exploring (a) non-medicinal treatments given in addition to the usual care that children with epilepsy receive or (b) changes in how healthcare services are delivered. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and size.
What did we find?
We found six studies, involving 468 participants. They were conducted in five different countries: two studies in China, and one study each in India, Jordan, Sweden, and the UK.
• Three studies investigated psycho-behavioural treatments added to usual epilepsy care.
• One study investigated yoga, a mind-body treatment, plus usual care.
• Two studies investigated new ways of delivering healthcare. In one study, a pharmacist delivered a 30-minute, in-person educational session to adult carers. The other study provided six months of follow-up care via a social media app (WeChat) to parents.
Main results
All the treatments and service delivery innovations we analysed in this review appear to be safe: none of the studies reported that they led to any unwanted or harmful events for the children or their carers.
Psycho-behavioural treatments
• Results from one study showed that after three months of treatment, teenagers who received group psychotherapy may have had slightly fewer seizures per month than teenagers who did not have therapy.
• Evidence from two studies did not show there was a difference in seizure frequency between children who received additional treatments and those who did not.
• We do not know if any of the treatments improved children's quality of life because the evidence is very uncertain. One study did not measure this outcome.
Mind-body treatments
• It is unclear if yoga leads to more children being free from seizures after three months.
• The yoga study did not measure children's quality of life.
Service delivery approaches
• We are very uncertain if the pharmacist-led service approach made any difference to seizure frequency.
• We also do not know if it improved children's overall quality of life after two months. Quality of life was assessed by adult carers, not the children themselves.
• The study offering support via the WeChat app only reported on parents' anxiety and depression, not on seizure control or overall quality of life.
What are the limitations of the evidence?
We have little to no confidence in the evidence because there were too few studies to be certain about the outcomes we were interested in, and all the studies were small. They tested different types of treatments/approaches, were carried out in different ways, and measured seizure frequency and quality of life differently. Most of the evidence relates to short-term effects of up to three months.
Future studies should address the limitations of the current evidence.
How current is the evidence?
The evidence is current to August 2023.
Read the full abstract
In the UK, approximately one in 1000 children aged zero to four years have epilepsy, and one in 200 children between the ages of five and 19 have epilepsy. There is a need to focus on models of service delivery and therapies that target cognitive, psychological, and behavioural aspects to improve seizure control and quality of life.
Objectives
To assess the effects of service delivery, behavioural, and self-management interventions on seizure control and health-related quality of life in children with epilepsy.
Search strategy
We used the Cochrane Register of Studies, MEDLINE, and two other databases, together with reference checking and contact with study authors, to identify the studies included in the review. The latest search date was 21 August 2023.
Selection criteria
We included randomised controlled trials (RCTs) or quasi-RCTs of any design (double/single-blinded, unblinded; parallel, cross-over, or cluster). We included behavioural or self-management interventions aimed at improving seizure control in children with epilepsy (average age 18 years or under), and any service delivery interventions targeting children with epilepsy (average age 18 years or under), their parents/carers, or both.
Data collection and analysis
Our primary outcome was seizure control (i.e. change in seizure frequency, seizure freedom). Our secondary outcomes were: seizure severity, overall quality of life and other aspects of quality of life (such as anxiety and depression), medication usage, knowledge, general health, social and psychological function, and adverse events. We classified outcomes as short-term (up to six months) or long-term (over six months). At least two review authors independently screened all papers, extracted data, and assessed the risk of bias. Data analysis was performed by one review author and checked by at least one other review author. We used GRADE to assess the certainty of the evidence for (1) seizure control and (2) participant-reported overall quality of life using validated scales.
Main results
We included six studies with a total of 468 randomised participants: four behavioural studies (subcategorised into psycho-behavioural interventions investigated in three studies involving 205 children; and one mind-body intervention with 20 children) and two service delivery studies, involving 243 adult carers of children with epilepsy. Most studies had a high risk of performance bias, detection bias, or both (for lack of or inadequate blinding of participants, personnel, or outcome assessors). The risk of bias was low or unclear across all other domains. Due to the studies' heterogeneity, we were unable to conduct a meta-analysis for any intervention or outcome. We identified no eligible self-management interventions.
Psycho-behavioural interventions
Compared to usual care, there was a small important effect showing that systemic family therapy may reduce seizure frequency slightly per month at three months (mean difference (MD) in seizure frequency per month −1.98, 95% confidence interval (CI) −3.84 to −0.12; 1 study, 104 participants; low-certainty evidence).
Evidence was lacking for differences in seizure frequency between behavioural interventions and control groups in the other two studies (94 participants; results reported descriptively at 10 weeks, three months, and 12 months).
Compared to usual care, a manual-based psychosocial group intervention may result in little to no difference in quality of life at three months, but the evidence is very uncertain (Paediatric Quality of Life Inventory: MD −1.40, 95% CI −8.21 to 5.41; 1 study, 76 participants; very low-certainty evidence; Glasgow Epilepsy Outcome Scale for Young Persons: MD −0.33, 95% CI −5.68 to 5.02; P = 0.90; 1 study, 76 participants; very low-certainty evidence). The other two psycho-behavioural studies did not assess overall quality of life.
Mind-body interventions
It is uncertain whether a mind-body intervention (yoga) made a difference in the number of participants who were seizure-free at three months (seizure freedom MD 1.62, 95% CI 0.97 to 2.69; 1 study, 20 participants; low-certainty evidence). This study did not measure quality of life.
Service delivery interventions
One service delivery intervention (a clinical pharmacist-led education intervention) assessed seizure control and overall quality of life versus usual care. The evidence is very uncertain whether there were differences in seizure freedom (MD 1.32, 95% CI 0.86 to 2.00; 1 study, 71 participants; very low-certainty evidence) or overall quality of life at two months (MD 10.46, 95% CI 1.82 to 19.10; 1 study, 71 participants; very low-certainty evidence). Quality of life was assessed by adult carers, not the children themselves.
The other service delivery intervention ('WeChat'-based remote follow-up after hospital discharge) did not evaluate seizure control and only measured aspects of quality of life (anxiety and depression, 162 participants), rather than overall quality of life.
No adverse events were reported in any of the six included studies.
Authors' conclusions
We included six studies in this review, each examining a different intervention, reporting on different outcomes, and involving varied populations. All studies had several limitations, including small sample sizes, lack of blinding, and inconsistent outcome measurement across studies.
Overall, the available evidence was of low to very low certainty. Results for long-term (≥ six months) outcomes were very limited for any type of intervention.
High-quality RCTs assessing service delivery, behavioural, and self-management interventions in children and adolescents with epilepsy are needed. Trials should assess short-term (≤ six months) and long-term (> six months) outcomes.
The development of a core outcome set for children with epilepsy would help ensure trials use relevant, meaningful, and consistent outcomes for evaluating intervention effects.
