A parental questionnaire containing 25 items to distinguish epileptic (absence seizures [AS]) and nonepileptic staring [NES] characteristics in 40 children presenting with staring spells was tested at the Cleveland Clinic, Ohio. Results from 17 children with AS and 23 with NES, diagnosed by neurologic exam, EEG, and video EEG, were compared. Features with high specificity for NES (responsive to touch, uninterrupted play, event recognized by teacher or health professional) occurred more frequently in NES than in AS. Each of these features had moderate sensitivity. Body rocking occurred only in patients with NES, but sensitivity was low. Features with high specificity for AS included limb twitches, upward gaze, and urinary incontinence during staring episode; but sensitivity for these features was low. Problems with learning or attention were reported in 40% of children in both groups. A more frequent positive family history for staring or AS in the AS group was not significant. [1]

COMMENT. A history of staring spells is often elicited during the pediatric neurology evaluation of children presenting with short attention, distractibility, and other symptoms of ADHD. The need for an EEG in patients with ADHD and in those presenting with staring spells requires clinical judgement. The questionnaire employed in the above report assists in the differentiation of nonepileptic staring (NES) events and absence epilepsy, and offers a group of features that may be considered strongly exclusive of a diagnosis of epilepsy. The diagnosis of NES is most likely in children who respond to touch while staring, continue playing, exhibit body rocking, and are initially identified by a teacher, nurse, or psychologist. In a child with these clinical features and a normal interictal EEG, a video recording may be deferred. The occurrence of associated limb twitching, upward eye movements, interrupted play, or urinary incontinence are indicative of absence epilepsy, and EEG documentation of epileptiform discharges, with or without video-recording, is essential.

Epileptic seizures temporally associated with nonepileptic seizures are reported in 4 patients, one child and 3 adults, evaluated at the New York University Medical Center [2]. A 12-year-old girl with medically refractory partial seizures since age 8 years had video-EEG documented epileptic and nonepileptic conversion seizures. Attacks were characterized by auditory hallucinations, vertigo, automatisms, screaming, and impaired consciousness. A simple partial seizure progressed to a complex partial seizure and then evolved into a NES. She had a history of sexual abuse. MRI revealed right frontoparietal dysplasia, an area critical for impulse control and behavioral inhibition. The epileptic seizure may trigger the conversion NES, especially in a patient with right frontal lobe pathology.