**8. Children with epilepsy**

Children constitute the main domain of people with epilepsy; this subpopulation faces many challenges. These challenges begin with the different etiologies of epilepsy in Sudan and Africa, of these etiologies central nervous system infectious agents (malaria, onchocerciasis), and perinatal insults constitute the main causes of epilepsy. Such causes could explain why the majority of people with epilepsy are in Africa. In addition, these causes along with other factors contribute to the poor outcome of epilepsy in the developing world.

Children with epilepsy have comorbidities including autism, intellectual disability that could be caused by perinatal insults and cerebral palsy; they are also more vulnerable to physical and sexual abuse. Studies from Sudan demonstrated that 10% of children with epilepsy have associated attention deficit hyperactivity disorder (ADHD) [25], one third had learning disabilities, and 10% had motor disabilities [26], theses comorbidities represent the difficulty in the management of these children, as a multidisciplinary approach is required in management, which is usually unavailable in Sudan and the developing world.

Since the 1950s, children with neurological disorders were seen in adult neurology clinics, as pediatric neurology training program in Sudan has recently been initiated, with a few pediatric neurologists available.

Currently there is one pediatric neurology tertiary center and four specialized child neurology clinics in Sudan, 3 of them are located in the capital, these 4 clinics serve the whole of Sudan, as well as referred patients from neighboring countries including: Chad, Eretria, and South Sudan where facilities for neurological investigations are limited. The shortage of pediatric neurologists and pediatric neurology centers and their location mainly in the capital, along with the high cost of transportation to the center, long waiting lists till evaluation by a specialist, further complicate the management of children with epilepsy [8].

#### **8.1 Epilepsy in schools**

It is important to review epilepsy status in school settings where children spend most of their time. Schools in Sudan rarely have dedicated clinics to accommodate children's health needs, and while school teachers should act as caregivers, most of them are usually ill-informed or lacking appropriate knowledge about epilepsy, and none of them have had any sort of training to help in case of a seizure, so a considerable proportion does not know what to do when a child develops a seizure [27, 28].

Many teachers fall as victims of the communities' misconceptions and could even play a passive role in the stigma, contributing to the child's anxiety. Many had no idea about possible causes of epilepsy and guessed that parents would not sign up their children with epilepsy to school due to suspected mental sub-normality, stigma, or fear of unattended falls or attacks. On the other hand, figures demonstrated a significant amount of children ditch school altogether because of the illness. Other students do not mind having a classmate with epilepsy at school but they share their teachers' beliefs and misconceptions, and would sometimes, as a result, engage in bullying and discriminatory behaviors against them. The condition is barely touched in school curriculums and students do not undergo any sort of training to help them act properly around their peers who have epilepsy.

## **9. Women with epilepsy**

Globally, 50% of women and girls with epilepsy are in the reproductive age range [29]. Epilepsy in the developing countries has a slight male predominance; this is likely due to underreporting of epilepsy in women due to negative attitudes and stigma facing them, that include difficulties in getting married, increased divorce rates, having children or even being abandoned by their families because of their illness, and harder chances of being employed. This underreporting of epilepsy in women leads to deficits in health care seeking behavior, hence contributing to the epilepsy treatment gap in women.

Apart from the aforementioned social difficulties, women with epilepsy are challenged with many issues that include the effect of epilepsy and AEDs on their sexual function, contraception, pregnancy, fetal abnormalities, childbirth, and breastfeeding [30–33].

Due to the shortage of neurologists in Sudan, the majority of women with epilepsy are managed and counseled by non-specialized doctors. A study conducted in Sudan to assess doctors' knowledge of women issues and epilepsy using standardized knowledge of women issues and epilepsy (KOWIE II) questionnaire concluded that the majority of Sudanese doctors' knowledge was unsatisfactory. They were unaware of sexual dysfunction among women with epilepsy, that women with epilepsy should continue taking their AEDs when they are pregnant, and that women can safely breastfeed while taking AEDs [34].

#### **10. Conclusion**

Sudan has been a victim of war, poverty, substandard infrastructure, and a failing healthcare system. These factors along with epilepsy stigma, misconceptions and false believes represent major challenges in epilepsy management in Sudan.

#### **11. Recommendations**

All these challenges must be approached systematically to ensure the best management for patients with epilepsy. Such approaches include the need for a mass movement against epilepsy headed by individuals experienced in the field, and fundamental governmental partnership and aid to provide organizational efforts and funding for instituting and decentralizing neurology facilities outside Khartoum, and ensuring the availability and affordability of investigations and medications especially the new generation AEDs. Epidemiologic studies are needed *Challenges Related to Epilepsy Management in Sudan, an Example of Low-Middle Income… DOI: http://dx.doi.org/10.5772/intechopen.93907*

to outline the treatment gap of epilepsy and guide nationwide strategies and efforts to increase the awareness of communities about epilepsy are needed especially in the rural areas to fight disease stigma, Special groups need further attention such as making efforts for prevention of infections leading to epilepsy in children, the involvement of other healthcare providers such as social workers, speech and language therapists, nutritionists, and special teachers in the management of children with epilepsy can never be overemphasized. Lastly, telemedicine should be implemented in the management of epilepsy in Sudan.

### **Authors' contribution**

**Ismat Babiker** wrote the following sections: children with epilepsy, women with epilepsy, co-wrote AEDs in Sudan, and contributed in chapter editing.

**Awab Saad** wrote Sudan: background and population, healthcare system in Sudan, Neurology in Sudan, co-wrote epilepsy misconceptions in Sudan, and contributed in chapter editing.

**Basil Ibrahim** wrote stigma, health related stigma, manifestation of stigma in high vs. low-income countries, stigma in low-income countries and in Sudan, and contributed in chapter editing.

**Mohamed Abdelsadig** wrote the collapse of the healthcare system in Sudan, epilepsy in schools, scarce personnel and trained physicians, co-wrote AEDs in Sudan, epilepsy misconceptions in Sudan, and contributed in chapter editing.

#### **Conflict of interest**

The authors declare no conflict of interest.

#### **Author details**

Ismat Babiker\*, Awab Saad, Basil Ibrahim and Mohamed Abdelsadig University of Medical Sciences and Technology, Khartoum, Sudan

\*Address all correspondence to: ismatbabiker94@gmail.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
