This paper reflects simply the bringing-together of a range of evidence and advice in the assessment and treatment of epilepsy in children. Particular emphasis is given to the nature of the links between the effects of epilepsy, or of the medication used for seizure control, and intellectual or scholastic performance. The conclusion highlights the need for individualised and regular assessments and for the avoidance of assumptions or generalisations.

According to the British Epilepsy Association, it is only recently that the range of educational implications of this disorder has become evident.

Given this, the significance of early identification of epilepsy is underlined; and, in this, the role of the school nurse may be very important in linking the school staff and the family in respect of relevant health issues.

The majority of children with epilepsy attend mainstream school but where problems arise may be outside the school setting i.e. the epilepsy itself may not be critical, but where there are familial or social problems, it may be seen as a major problem.

Further, a child with epilepsy may experience emotional or scholastic difficulties as a result of the anxiety or negative reactions of peers, the failure of the individual to come to terms with this condition, or inappropriate treatment on the part of anyone concerned. For example, the families of an epileptic child may experience feelings similar to those of a sense of loss when epilepsy is diagnosed or the symptoms are observed; and these feelings can, in some extreme cases, be translated into an attitude of indifference or rejection, or may be followed by attempts to challenge the diagnosis and by anger/depression.

Guidance from the B.E.A. also highlights the likely impact upon the siblings of the epileptic child, such as teasing from peers because of the child's condition, or a tendency to fall short of potential achievement out of a belief that it is unfair to emphasise the relative handicap of the sibling by their own high performance.

A review of studies suggests that many epileptic children, albeit a minority of all those affected, will have learning and behaviour problems. Such problems are by no means inevitable or even very likely, but epileptics as a group appear more at risk than normal controls and the prime need is to identify those children in whom the risk is greatest.

There are various factors which appear to be linked with a greater probability of learning and behaviour problems;

1. The severity and frequency of seizures, and the extent of the disruption to the child's routine.

2. The major site of disturbance within the brain.

3. The type of seizure and its duration. Prolonged seizure (non-convulsive status epilepticus) may be linked to confusion and odd behaviour; and brief discharges may still affect learning and memory.

4. The impact of anti epileptic medication.

5. Gender differences. Boys appear more at risk of secondary problems than girls.

1. Family attitudes, such as extreme anxiety, over-controlling or over-permissive, or pessimism.

2. School attitudes... a tendency for challenges or pressures upon the child to be minimised, or to limit access to physical/sporting activities (and to send the child home unnecessarily after a minor seizure).

3. Negative self-image.

It is noted that these factors can operate in combination or interact such that a negative cycle may be set up.

Meanwhile, it is possible that children who are not epileptic may be subject to the impact of such factors as a result of misperception or misdiagnosis. In particular, fainting, sleep disorders, anxiety attacks and breath-holding attacks may be confused with epileptic seizures.

Alternatively certain epileptic attacks of a non-convulsive type may not be diagnosed, but may be seen as day dreaming or misbehaviour.

The implication again highlights the need for early and accurate diagnosis and, thereby, access to appropriate management.

1. Generalised Tonic-Clonic Seizure (Grand Mal).

The best known and most easily recognised form of epilepsy in which the individual becomes unconscious with muscles stiffening and relaxing in convulsive movements, and the condition may continue for several minutes. Following this, there is a period of confusion and a dazed appearance and a need to sleep. Such seizures tend to occur early in the morning.

2. Generalised Absences (Petit Mal)

These involve brief interruptions to consciousness without any convulsive movement and may not be recognised, or, if noticed at all either by the child or the teacher, may be misidentified as day dreaming or inattention.

3. Complex Partial Epilepsy (Temporal Lobe)

In this condition, the seizure involves a period of clouded consciousness during which the child may show repetitive movements, different from normal behaviour, which may be misinterpreted as silliness or attention-seeking. The hallmarks of this type of seizure are the repetitive nature of the movements and the child's confused state as the child returns to full consciousness.

The educational implications include the following:

a) Epilepsy may affect children of any ability level.

b) The immediate impact of the epileptic seizure is upon attention, concentration and memory.

c) Individual "absences" may not be readily noticed, but their cumulative effect may be significant.

d) The impact of medication to control epilepsy may particularly inhibit concentration and memory.

N.B. Seizures, which are largely unpredictable, may be triggered by fatigue or stress; and, in a minority of cases (involving tonic-clonic seizures) by flashing or flickering light. This latter propensity is more common among girls than boys and is observed for the first time around the age of puberty.

Evidence suggests that anti-epileptic drugs have a "narrow" therapeutic ratio, i.e. the benefits and the negative effects are almost on a par.

Negative effects may include

a) A reduction of the ability to distinguish flashing lights, and a tendency instead to see the lights as fused together.

b) Impairment of accuracy of eye movements in, for example, tracking moving objects.

c) Impairment of sustained attention and perceptual motor performance; diminished concentration.

d) Impairment of memory, mental speed, and motor speed.

e) Impairment of problem solving capacity.

It has to be acknowledged that the effects of medication will vary according to the individual children concerned, the frequency or intensity of the drug usage, the particular drug used and the time scale over which the drugs have been given.

Further, it may be very difficult to distinguish between the effects of the drugs, and the effect of the epileptic condition itself.

However there does seem to be consistent evidence that phenobarbitone has a markedly negative impact upon young children in terms of hyperactive, irritable, lethargic, or defiant behaviours.

Recurrent seizures are symptoms of an underlying abnormality in brain functioning. The impact upon intellectual (and social) development may be considered under three headings:

a) The effects on learning of regular seizures

b) The possibility of some insidious mental deterioration

c) The relationship between epilepsy and development

The major issue concerns the (long term) effect upon learning of anti-convulsant drugs contrasted with the anticipated benefit of continuing or increasing dosage in terms of learning as a result of better seizure control.

Early research on reading progress among children with epilepsy suggests an average retardation of one year in the age group 10-11 (with controls in place for overall level of intellectual ability).

Further, newly diagnosed children are predicted to show some deterioration in measured ability, by an average of 10 points, during the first years of treatment... and, as reported earlier, children treated with phenobarbitone scored less well than controls on alternative medication on a range of neuro psychological tests, and on parental reports of staying on task, attitude and perseveration.

Studies at Lingfield Hospital School demonstrate that at least 10% of children with complicated epilepsy decline in terms of IQ measures by more than 20 points during their school careers; and more recent studies suggest that a 20+ point deterioration may be observed in a greater number of complicated epilepsy cases.... around 25%.

In terms of general developmental progress, it is reported that neonatal seizures, indicative of perinatal brain damage or biochemical disturbance, carry a poor prognosis for intellectual development.

However, it must be remembered that, even among children showing severe impairments, the "focus" of the impairment may be specific... e.g. the issue may be in the area of short term memory or consolidation rather than a matter of global problems.

The implication is for careful, ongoing observation and assessment and access for the children to a range of early teaching methodology thus to tap particular strengths and compensate for weaknesses.

To determine whether those children whose epilepsy is not so severe as to necessitate special schooling are prone to specific learning difficulties is difficult, because of the relatively small samples, and possible confounding of a number of variables.

However, there is evidence that a discrepancy belween IQ and RQ is common among epileptic children; and the performance of boys is typically poorer than that of girls. Under achievement to a similar or greater extent is also observed in numeracy.

One has to note that particular forms of epilepsy will be associated with different patterns of skills and disabilities ... with the strong implication for regular review assessments, and the avoidance of decisions based on single assessments. The ability to cope with concepts in mathematics when presented through practical or concrete means may be greater than when there is reliance upon mental processing alone.... suggesting that the impact of epilepsy or medication is more general than specific ; and some findings have suggested that classroom noise rather than silence is linked to improved performance among epileptic children, possibly through some alerting effect.

One needs to recognise, too, that there may be some interaction between educational difficulties and epilepsy. For example, intensive remedial provision can lead to more pressure on the child and to a worsening of the epilepsy... other children respond well. It appears that children with a combination of anxiety/low confidence and immature motor development in early school years are the ones who are most at risk for continuing and increasing disorders at later development stages.

In sum, it is necessary to avoid general assumptions about the type of behaviour, attainments, and psycho social characteristics shown by individuals with epilepsy. there are many different ways in which learning and behaviour may be affected, hence the need for systematic and ongoing assessment. One must also avoid attributing all problems to the effects of epilepsy. Emotional, learning and behavioural problems are commonly multifactorial; and individuals with epilepsy are likely to encounter all or any of the kinds of challenges, disadvantages, etc. that can afflict all individuals. Thus one should not assign all the problems in somebody with epilepsy to the fact that they have this condition.

M.J. Connor May 1996.

[See also: Epilepsy - Nature, Mangement and Memory - June 1994]