Epilepsy & Behavior 73 (2017) 1–5

Contents lists available at ScienceDirect

Epilepsy & Behavior

journal homepage: www.elsevier.com/locate/yebeh

Impaired responsibility dimension of self-esteem of Brazilian adolescents

with epilepsy
Nathália F. Siqueira ⁎, Fernando L.B.B. Oliveira, Elisabete Abib Pedroso de Souza
Neurology Department, State University of Campinas (Unicamp), Brazil

a r t i c l e i n f o a b s t r a c t

Article history: This study aimed to compare the self-esteem of Brazilian adolescents with epilepsy and Brazilian adolescents
Received 20 January 2017 without this condition and the correlations between self-esteem of these adolescents with depression and
Revised 22 April 2017 anxiety symptoms. Study participants were 101 adolescents of both sexes, aged 10–19 years old, from elementary
Accepted 15 May 2017
and high school education. Fifty patients diagnosed with uncomplicated epilepsy attending the pediatric epilepsy
Available online xxxx
clinic of University Hospital composed the case group. The other fifty-one adolescents without this diagnosis were
Keywords:
attending public schools in Campinas—SP region. The instruments used were: identification card with demo-
Self-esteem graphics and epilepsy data, Multidimensional Self-Esteem Scale, Beck Depression Inventory and Inventory of
Adolescents State-Trait Anxiety - IDATE. A statistically significant result was found in the Responsibility Self-esteem Dimension
Epilepsy favoring the control group. Significant correlations between self-esteem scores and anxiety and depression symp-
Anxiety toms were also found. The development of a chronic disease such as epilepsy leads to a change in the way the in-
Depression dividual perceives himself and the social environment he is inserted, influencing his behavior. The way people
Brazilian with epilepsy experience their seizures is a subjective measure that will control his/her well-being. Childhood
and adolescence form the basis for a healthy emotional development; thus, our results show the importance of
studying how subjective variables relate to the physical aspects of a chronic disease in these life stages.
© 2017 Elsevier Inc. All rights reserved.

1. Introduction A positive self-esteem is a human need, essential to healthy adapta-

Epilepsy represents a serious health problem. It is a neurological
condition associated with significant physical, relational and behavioral
consequences [1]. Studies have shown that epilepsy prevents the devel-
opment of independence and impairs social function, relationships in
pairs, self-esteem, mood and cognition [1–3].
Epilepsy onset in childhood or adolescence can mean losses in dif-
ferent aspects of daily life and to be considered a real risk factor for
emotional and behavioral problems for the following years [4].
Considering adolescence as a phase of changes and questions, the
main difficulties seem to be related to the prognosis of epilepsy, as
there is a desire for independence, desire for acceptance and youth
empowerment. Epilepsy begins to affect different areas in this phase:
studies, social relationships, ability to drive and drink alcohol, sexuality
and leisure constraints, among others [4–6]. In addition, they fear the
seizures occur in public places and fear of consequent social exclusion
[7]. With all these uncertainties, the adolescents have their self-
esteem and self-confidence shaken, they begin to feel different from
other people, which limits their opportunities for personal and profes-
sional growth [8].
⁎ Corresponding author at: Neurology Department, FCM – UNICAMP, PO Box 6111,
13083-970 Campinas, SP, Brazil.
E-mail address: nfsiqueira@gmail.com (N.F. Siqueira).
tion, and significantly associated with personal satisfaction and ideal
functionality [9]. Self-esteem expresses an attitude of approval or disap-
proval, and indicates the extent to which the individual believes himself
to be capable, significant, successful, and worthy. In short, self-esteem is
a personal judgment of worthiness that is expressed in the attitudes the
individual holds toward himself [9].
The self-esteem manifests and develops in the context of social life,
such as family, school and work. The impact of family life on growth
and development of children and building their self-esteem is crucial.
The stability and good levels of self-esteem can be decisive factors for
mental health [10].
Considering the importance of this subject, the aim of this study was
to compare the self-esteem of Brazilian adolescents with epilepsy and
Brazilian adolescents without epilepsy and the relationship of self-
esteem with depression and anxiety symptoms.
2. Methods
2.1. Participants
In 2011–2012, 101 adolescents aged 10 and 19 according to the
WHO criteria [11], in elementary and high school education level,
with ability to answer the questions by himself/herself partici-
pated in the study. Case participants (50 adolescents registered with

http://dx.doi.org/10.1016/j.yebeh.2017.05.009
1525-5050/© 2017 Elsevier Inc. All rights reserved.
2 N.F. Siqueira et al. / Epilepsy & Behavior 73 (2017) 1–5
uncomplicated epilepsy) attending the pediatric epilepsy clinic of
University Hospital (UNICAMP, Campinas, Brazil). Control participants
(51 adolescents without epilepsy diagnosis) were selected from public
schools in Campinas—SP, Brazil. Inclusion criteria for the case group
were: medical diagnosis of epilepsy for more than 2 years — when the
patient had had at least two unprovoked epileptic seizures (criteria
established in service for epilepsy diagnosis) and uncomplicated
epilepsy (defined as epilepsy with no initially associated neurological
impairment — mental retardation or cerebral palsy). Inclusion criterion
for the control group was: no diagnosis of epilepsy. The exclusion
criteria for both groups were: if they had had brain surgery, used a con-
comitant medication with central nervous system effects (except the
anticonvulsant used to treat the epilepsy), or had another progressive
neurological or psychiatric illness. Data on inclusion/exclusion criteria
were obtained from medical records for the case group and from
parents' reports for the control group.
Mean years of age of case group was 14.02 (Standard Deviation
(SD) = 1.99) and of control group was 12.63 (SD = 1.62); this differ-
ence was statistically significant (p b 0.01). The majority of adolescents
of the case group were male (68%), students (96%), and attending ele-
mentary school (72%). Most adolescents of control group were female
(58.82%), students (100%), and attending elementary school (90.19%).
The difference of gender was statistically significant (p = 0.007).
Adjustment was made for age and gender. For specific features of the
case group regarding medical data (collected from medical records),
most adolescents had focal seizures (62%), had frequent seizures
(56%), were on monotherapy (58%), and mean of onset seizure was
6.4 years; with regard to psychological variables (data collected from
patient reports), 84% of adolescents reported perception of seizure
control; and with regard to social aspects, 58% reported occurrence of
seizures in public places.
2.2. Measures
1. Identification card with demographic data (age, sex, education
level, and job) for both groups and, for case group only, epilepsy
data (age of onset, seizure frequency, type of seizure and drug
treatment); for gathering epilepsy data, the researcher used medical
records available at the pediatric epilepsy clinic. Regarding seizure
frequency, two groups were considered: frequent seizure (one or
more seizures in the last year) and seizure-free (seizure-free for at
least 1 year) — criteria established by the clinic. Type of seizure was
classified according to the International League Against Epilepsy
classification of epileptic seizures [12]: focal seizures, generalized
seizures, focal + generalized seizures. Drug treatment was classified
in monotherapy (one type of medication) and polytherapy (two
or more medications). Data on psychological variable were also
collected. Perception of seizure control data was obtained from pa-
tient reports, in which they evaluated whether their seizures were
controlled or not; these data were subjective and may reflect alter-
ations in the intensity and/or frequency of the seizures [13]. Patients
were also questioned if they had occurrence of seizures in public
places (yes/no). Data on psychiatric history of control group were
obtained from parents' reports.
2. Self-Esteem Multidimensional Scale [14]. This inventory is a
Brazilian version of the Self-Esteem Inventory [15] corrected for
validity and reliability by Gobitta [14]. This scale consists of 56 state-
ments about situations that may or may not happen with the person
and personal feelings that may or may not exist. Five Dimensions
are evaluated (Self, Social Group, Family, School and Responsibility)
and a General score is defined. This instrument is not commercialized
but can be accessed directly with the author.
3. Beck Depression Inventory (BDI) [16], validity and reliability have
been tested by Cunha [17]. The BDI includes a 21-item self-report
which was used to measure depression. Each of the items contains
a 4-point severity rating scale. The scoring algorithm defines scores
of 0–9 points which indicates minimum depression; 10–16 points
which indicates low depression; 17–29 points which indicates
moderate depression; and 30–63 points which indicates major de-
pression. The BDI is being used as a standard reference and is one
of the most common self-report scales used to assess depression
[18] including in adolescents [19].
4. State-Trait Anxiety Inventory (STAI) [20] validated in Portuguese
by Biaggio and Natalício [21]. The test is divided into two sections;
Part I presents 20 statements related to how the person feels most
of the time (Trait); Part II presents 20 statements related to how
the person feels at the time of assessment (State). To assess the
level of trait anxiety and/or state, it is necessary to first apply a cor-
rection to the scores obtained on each item: the values of items 1,
6, 7, 10, 13, 16 and 19 of the Trait scale and 1, 2, 5, 8, 10, 11, 15, 16,
19 and 20 of the State scale must be inverted (in a way that 1 be-
comes 4, 2 becomes 3, 3 becomes 2 and 4 becomes 1). STAI is widely
used in monitoring anxiety states [22] and is also an instrument used
to assess anxiety in children and adolescents [20].
2.3. Procedure
Initially the Ethics Committee of Universidade Estadual de Campinas
(UNICAMP) approved the research (number 176/2005). After that,
written informed consent was obtained from all participants and their
companions (the one with legal responsibility over the participant), on
the day of the outpatient consultation, in an interview to explain the
procedures. Participants were assessed individually at the outpatient
clinic of Psychology Applied to Neurology at the University Hospital of
UNICAMP. On this first day, the objective was to create a positive bond
between the professional and participant (interview/presentation
stage). On the second day, one week later, the objective was to apply
the tools of research (the assessment stage). The selection of partici-
pants for the case group obeyed the demand of our neurology outpatient
clinic, according to the criteria for inclusion and exclusion, acceptance of
the participant and responsibility to take the research.
The selection of participant of control group was made according to
the criteria of inclusion and exclusion, acceptance of the participant and
responsibility to take the research. Two public schools in Campinas—SP,
Brazil, both of elementary and high-school levels, were chosen by
lottery. After the headmaster's authorization, the students were taught
about the research and those who had an interest in participating took
the written informed consent home to get their parents signed the
authorization (interview or presentation stage). All the adolescents of
control group were assessed at the individual class of their school,
when the researcher returned to the school to apply the tools of the
research (assessment stage).
2.4. Statistics analysis
Statistical analysis was performed in the Statistical Package for the
Social Science (SPSS) version 18.0 for Windows.
To describe the sample profile according to the study variables,
data was comprised of: categorical variables with values of percent-
age (%), and descriptive statistics (with measurements of position
and dispersion — mean, standard deviation, minimum, maximum
and median) for continuous variables (scores of scales).
To compare numerical variables between two groups we used the
Mann–Whitney test and Analysis of Covariance (ANCOVA) when needed
to adjust for age and sex.
The level of significance for statistical test was 5% (p b 0.05).
3. Results
Data on General self-Esteem and dimensions – Self, Social Group,
Family, School and Responsibility – of Self-Esteem from both groups
are listed in Table 1.
 N.F. Siqueira et al. / Epilepsy & Behavior 73 (2017) 1–5 3

Table 1 Table 3
Results of self-esteem in case group versus control group. General self-esteem in correlation to seizure frequency, AED and seizure type.

Dimensions N Mean SD Min Median Max Value Value n Mean SD Value p⁎

p⁎ p⁎⁎
Seizure frequency
Case group Frequent 28 208.18 29.87
Self 50 64.64 11.06 38.00 68.00 85.00 No frequent 22 218.41 26.28 0.286
Social 50 61.32 10.43 41.00 63.50 79.00 AED
Family 50 50.68 8.60 25.00 52.00 65.00 None 05 209.40 14.80
School 50 18.64 3.46 11.00 19.00 25.00 Monotherapy 29 216.52 28.85
Responsibility 50 17.40 3.57 10.0 17.00 24.00 Polytherapy 16 206.75 31.25 0.520
General 50 212.68 28.53 138.00 218.50 271.00 Seizure type
Control group Partial 31 220.29 25.91
Self 51 66.96 10.39 36.00 68.00 85.00 0.322 0.551 Generalized 16 199.25 30.91
Social 51 63.18 9.90 46.00 63.00 80.00 0.554 0.573 Partial + Generalized 03 205.67 17.03 0.060
Family 51 49.75 11.99 15.00 54.00 65.00 0.835 0.937
SD: standard deviation.
School 51 18.61 3.32 07.00 19.00 24.00 0.932 0.863
⁎ P-value referring to the test of Mann–Whitney to compare variables between groups
Responsibility 51 19.12 3.10 11.00 19.00 25.00 0.016 0.020
(case group vs control group).
General 51 217.61 31.32 122.00 215.00 273.00 0.392 0.546

SD: standard deviation; Min.: minimum; Max.: maximum.

⁎ p-Value referring to the test of Mann–Whitney to compare variables between groups
(case group vs control group).
⁎⁎ p-Value referring to the ANCOVA — covariates: age, sex.
No significant differences were found between case group and the
controls for General Self-Esteem and Self, Social Group, Family and
School Self-Esteem Dimensions.
A statistically significant result was found in the Responsibility Self-
Esteem dimension (p = 0.020) favoring the control group.
Data of correlations of General Self-Esteem and Anxiety and Depres-
sion Symptoms of adolescents with epilepsy are listed in Table 2.
The results showed significant correlations between the self-esteem
scores and the depression and anxiety trait and state scores in case
group.
Data of correlations of General Self-Esteem and seizure frequency,
antiepileptic drugs (AED) and seizure type are listed in Table 3.
No significant differences were found between General Self-Esteem
and epilepsy condition — seizure frequency, AED and seizure type.
4. Discussion
Adolescents with epilepsy were expected to present difficulties
related to this psychological variable. Data from the literature show
that children and adolescents with epilepsy have low self-esteem
[2,3,23,24]. However, our study on Brazilian adolescents with uncom-
plicated epilepsy found no differences between the case and the control
groups regarding General Self-Esteem. We also found no significant
differences for Dimension of Self-Esteem — Self, Social Group, Family
and School.
Our results, corroborate others studies. Baker et al. [25] in 1995, did
not find significant differences in the self-esteem evaluations of adoles-
cents with epilepsy when compared with control subjects. In 1999, Räty
et al. [26] studied the medical psychological and social aspects – Self-
Esteem and Sense of Coherence – of adolescents with uncomplicated
epilepsy and compared the results with a control group and found no
differences between the groups regarding psychosocial factors.
Table 2
Correlations of total self-esteem and anxiety and depression
symptoms of adolescents with epilepsy.
Total self-esteem
Anxiety trait *r = −0.679
(P = 0.000)
Anxiety state −0.590
(P = 0.000)
Depression −0.474
(P = 0.001)
*r = Spearman correlation coefficient; p = value. The correlation
is underlined in bold.
Lee et [27] in 2008, also found similar results to our study where the
self-concept scores of adolescents with epilepsy were compared with
the mean of the population and no significant differences were found.
Siqueira et al. [28] in 2011, in a study carried out in our country and
using the same instrument also did not find significant differences in
the self-esteem evaluation between group of adolescents with epilepsy
and control group which reinforces our findings. In 2012, a review of the
literature by Ferro et al. [29] found in most of them no significant dif-
ferences in self-concept of adolescents with epilepsy compared with
healthy controls.
Concerning the correlations between General Self-Esteem and
illness severity – seizure frequency, antiepileptic drugs and seizure
type – no significant differences were found. Räty et al. [30] found that
illness severity condition was significantly related to the participants'
general self-concept but more research is needed to understand the
causality of the relationship. Chew et al. [31] in a study with adolescents
with epilepsy found that illness severity was negatively associated with
young people's self-esteem and suggest that young people might have
had existing negative views of themselves prior to their illness, and on
this basis conclude that self-esteem does not vary as function of illness
severity.
Literature survey reveals contradictory data regarding the cor-
relation between epilepsy and self-esteem. The use of different
instruments, different methodologies, characteristics of the popu-
lation, form of assessment tests, different countries in which the
research took place, and sub-categories analyzed may be factors
of variability.
However, our results showed significant differences between the
groups when we evaluated specific aspects of self-esteem. A statisti-
cally significant result was found in the Responsibility Self-esteem
Dimension favoring the control group. The development of self-
esteem begins in the family. Coopersmith [9] points out that in the
study of children and adolescents, family experiences are important
sources of self-esteem. The family is the first identity matrix of the
individual, in which he learns to communicate, to relate, to live
and to understand rules, limits, love, power, dependence and auton-
omy. The diagnosis of epilepsy can be of great impact by announcing
to the person and family the presence of something stigmatizing.
Epileptic seizures due to their unpredictability and loss of momen-
tary control expose people to unpleasant situations. The impact of
epilepsy on the family system will depend on some variables, such
as: severity of epilepsy, degree of expectations and sociocultural re-
quirements, family difficulties in dealing with differences, and the
degree of maturity, rigidity and resilience of the caregivers. The
way a family faces a difficult experience will influence how all of
its members adapt. The difference found in the responsibility di-
mension may be a consequence of the parents' negative beliefs
about the autonomy of their children, overprotection, and restric-
tion of adolescents' Independence [23].
4 N.F. Siqueira et al. / Epilepsy & Behavior 73 (2017) 1–5
Literature shows that the onset of the disease during childhood
or adolescence can be considered a real risk factor for emotional and be-
havioral problems for the following years4. People with low self-esteem
are more vulnerable to the development of serious problems, such as
depression, anxiety, phobias, and others. Sowislo and Orth [32] con-
ducted a study with a longitudinal design in which people were follow-
ed up over time and the findings almost all overwhelmingly support the
vulnerability model of self-esteem and depression. To the authors, low
self-esteem is a risk factor for depression, indicating that low self-
esteem causes depression.
Based on these aspects, we sought to evaluate the correlation be-
tween self-esteem and symptoms of depression and anxiety in adoles-
cents with epilepsy. A significant correlation between the self-esteem
scores and depression and anxiety trait and state scores in adolescents
with epilepsy was found, which means that the adolescents who pre-
sented high self-esteem scores presented low anxiety and depression
symptom rates. Adolescence is a period of changes in all aspects of the
individual's life, so it is considered a very important stage in the devel-
opment of self-concept that, as already mentioned, begins in childhood.
Depression and anxiety in children and adolescents can interfere signif-
icantly with daily life, social relations and general well-being, and may
even lead to suicide.
According to Souza e Salgado [13] during the person's life history
with epilepsy he/she can learn from his/her parents, teachers and
colleagues, negative cognitive interpretations and unadapted behav-
ioral responses to stressful situations that can influence the way he/
she deals with the disease. In facing a chronic disease such as epilepsy,
the attribution of negative meaning can lead to negative feelings and
depression reactions [33], as well as anxiety due to the feeling of per-
sonal vulnerability [34] regardless of their origin.
Souza e salgado [13] discuss how the interpretative distortions are
present when an arbitrary inference appears, such as “people don't
accept me because I am epileptic”. This is reinforced by his or her
disqualifying feeling – “I am sick”, “I am not capable”, “I am different
from the others” – together with a learned perception of rejection,
that reinforces his/her low self-esteem and how a vicious circle keeps
negative and maladjusted feelings.
When self-esteem is fully accomplished, it is the experience of
being fit for life and its demands. Self-esteem, in addition to being a
determinant for the psychic-emotional and physical balance, is closely
linked to the level of satisfaction of the most diverse human needs.
The quality of self-esteem has a profound influence on all sectors of
human existence, whether in the family, at work, in dealing with people
in society, in intimate and personal relationships and in any time and
place. Self-esteem is significantly related to the basic individual style
of adapting to environmental demands. The adolescent when self-
evaluating positively can decrease the chances of onset symptoms of
depression and anxiety favoring a better quality of life.
In this perspective, we see how important is the knowledge of the
psychological processes of the individual involved in a chronic illness.
This knowledge enables us to understand how the intrapsychiatric
variables are linked to subjective interpretations and maintain the dys-
functional emotions.
The relationship between subjective variables, disease and socio-
environmental demand is complex. Often, the development of a chronic
disease such as epilepsy, causes a break in the way the individual perceives
himself/herself, perceives his social environment with influences on his/
her behavior. The way the participant perceives his/her crises is a subjec-
tive measure that will control his/her response to good or bad. Thus, our
results show the importance of studying how subjective variables relate
to physical aspects in a chronic disease, especially in childhood and adoles-
cence, as they are the basis of a healthy emotional development.
Disclosure
The authors have no conflicts of interest to declare.
Acknowledgments
The authors thank Cleide A.M. Silva and Helymar Machado for the
statistical analysis. The authors thank Sabrina Marchiori and Jorge
Augusto Siqueira for the written English revisions.
Appreciation is conveyed to the Brazilian studies on quality of life
in epilepsy performed by: Nathália Ferreira Siqueira, Fernando Luiz
Bustamante Oliveira and Elisabete Abib Pedroso de Souza.
References
[1] Souza, EAP (Org). Epilepsia e trabalho: quebra de paradigmas. Yendis Editora: São
Caetano do Sul (SP); 2010 XIX.
[2] Devinsky O, Westbrook L, Cramer J, Glassman M, Perrine K, Camfield C. Risk factors
for poor health-related quality of life in adolescents with epilepsy. Epilepsia 1999;
40(12):1715–20.
[3] Mcewan MJ, Espie CA, Metcalfe J. A systematic review of the contribuition of
qualitative research to the study of quality of life in children and adolescents with
epilepsy. Seizure 2004;13:3–14.
[4] Sbarra DA, Rimm-Kaufman SE, Pianta RC. The behavioral and emotional correlates of
epilepsy in adolescence: a 7-year follow-up study. Epilepsy Behav 2002;3(4):
358–67.
[5] Marin S. The impact of epilepsy on the adolescent. Am J Matern Child Nurs 2005;
30(5):321–6.
[6] Souza EAP, Fernandes PT, Salgado PCB, Doretto F. Mecanismos Psicológicos e
o Estigma da Epilepsia. Rev Eletron J Cientifico Com Ciencia 2002;34:
98–103.
[7] Souza EAP, Guerreiro MM. Impacto do Diagnóstico em Pacientes e Familiares.
Epilepsia Evolução Terapia 2002;5:3–4.
[8] Barbosa FD. Avaliando a qualidade de vida do adolescente com epilepsia. [Master
Dissertation]. Campinas (SP): Universidade Estadual de Campinas; 2003.
[9] Coopersmith S. The antecedents of self-esteem. São Francisco: Freeman; 1967.
[10] Furegato ARF, Silva EC, Campos MC, Cassiano RPT. Depressão e auto-estima
entre acadêmicos de enfermagem. Revista Psiquiatria Clínica 2006;33(5):
239–44.
[11] World Health Organization. Programación para la salud y el desarrollo de los
adolescentes: informe de un grupo de estúdio. Suiza: Saillon; 1995.
[12] Commission on Classification and Terminology of the International League Against
Epilepsy. Proposal for revised clinical and electroencephalographic classification of
epileptic seizures. Epilepsia 1981;22:489–501.
[13] Souza EAP, Salgado PCB. A psychosocial view of anxiety and depression in epilepsy.
Epilepsy Behav 2006;8:232–8.
[14] Gobbita M. Escala Multidimensional de Autoestima (EMAE): construção e validação
com crianças e adolescentes brasileiros. (PhD thesis). Campinas (SP): Pontifícia
Universidade Católica de Campinas; 2003.
[15] Coopersmith S. Coopersmith Self-Esteem Inventory. Palo Alto (CA): Consulting
Psychologists Press; 1989.
[16] Beck AT, Ward CH, Mendelsohn M, Mock J, Erbaugh J. An inventory for measuring
depression. Arch Gen Psychiatry 1961;4:561–71.
[17] Cunha J. Escalas Beck. Casa do Psicólogo: São Paulo; 2001.
[18] Del Porto JA. Aspectos gerais das escalas para avaliação de depressão. In Escalas de
Avaliação para Monitorizarão de Tratamento com Psicofármacos. Centro de Pesquisa
em Psicobiologia Clínica do Departamento de Psicobiologia da Escola Paulistade
Medicina; 1989. p. 93–100.
[19] Benetti DS, Ambrosini PJ, Branchi M, Barnett D, Mets C, Rabinovich H. Relationships
of Beck Depression Inventory factors to depression among adolescents. J Affect
Disord 1997;45:127–34.
[20] Spielberger CD, Gorsuch RL, Lushene RE. Manual for State-Trait Anxiety Inventory.
Palo Alto (CA): Consulting Psychologists Press; 1970.
[21] Biaggio AMB. Natalício. Manual para o Inventário de Ansiedade Traço Estado
(IDATE). Rio de Janeiro: CEPA; 1979.
[22] Fankhauser MP, German ML. Understanding the use of behavior rating scales in
studies evaluating the efficacy of antianxiety and antidepressant drugs. Am J Hosp
Pharm 1987;44:2087–100.
[23] Artigas J. Psychological and social implications of epilepsy in adolescents. Rev Neurol
1999;28:43–9.
[24] Çengel-Kültür SE, Ulay HT, Erdag G. Ways of coping with epilepsy and related factors
in adolescence. Turk J Pediatr 2009;51:238–47.
[25] Baker GA, Spector S, McGrath Y, Soteriou H. Impact of epilepsy in adolescence: a UK
controlled study. Epilepsy Behav 2005;6:556–62.
[26] Räty LK, Wilde Larsson BM, Soderfeldt BA. Health-related quality of life in young: a
comparison between adolescents and young adults with uncomplicated epilepsy
and healthy controls. J Adolesc Health 2003;33:252–8.
[27] Lee A, Hamiwka LD, Sherman SEM, Wirrell EC. Self-concept in adolescents with
epilepsy: biological and social correlates. Pediatr Neurol 2008;38:335–9.
[28] Siqueira NF, Guerreiro MM, Souza EAP. Self-esteem, social support perception and
seizure controllability perception in adolescents with epilepsy. Arq Neuropsiquiatr
2011;69(5):770–4.
[29] Ferro MA, Ferro AL, Boyle MH. A systematic review of self-concept in adolescents
with epilepsy. J Pediatr Psychol 2012;37(9):945–58.
[30] Räty LKA, Söderfeldt BA, Larsson G, Larsson BMW. The relationship between illness
severity, sociodemographic factors, general self-concept, and illness-specific attitude
in Swedish adolescents with epilepsy. Seizure 2004;13:375–82.
 N.F. Siqueira et al. / Epilepsy & Behavior 73 (2017) 1–5 5

[31] Chew J, Haase AM, Carpenter J. Individual and family factors associated with self-
esteem in young people with epilepsy: a multiple mediation analysis. Epilepsy
Behav 2017;66:19–26.
[32] Sowislo JF, Ulrich Orth U. Does low self-esteem predict depression and anxiety?
A meta-analysis of longitudinal studies. Psychol Bull 2013;139(1):213–40.
[33] Gehlert S. Perceptions of control in adults with epilepsy. Epilepsia 1994;35:81–8.
[34] Wells A. Cognitive therapy of anxiety disorders: a practice manual and conceptual
guide. Chichester: Wiley; 1997.