Great Ormond Street Hospital & University College
London Institute of Child Health,
London,, UK
Educational Functioning and Academic
Attainment in Children with Focal Epilepsy
Sue Harrison
Department of Neuropsychology
Great Ormond Street Hospital & University College London Institute
of Child Health
Background
• Population based studies have suggested
~30% of children with epilepsy have cognitive impairment
Berg, 2005; Camfield & Camfield, 2003; Sillanpaa 2009
~50-60% require educational support & special needs help
Berg et al. 2008
• People with epilepsy rate school difficulties as their greatest concern
Fisher, 2000
• Awareness of the additional burdens of epilepsy now well developed
-cognitive and learning problems may be more problematic than the seizures
th
themselves
l
Cross, 2002; ILAE, 2003
Epilepsy: Educational attainment and long term outcomes
p py
g
Controls
Adults with uncomplicated childhood onset epilepsy
childhood onset epilepsy
N=99
All N=99
Sz & medication free N=66
No post 16 education
No post 16 education
23%
47%
46%
No vocational training
51%
66%
42%
Unmarried/no partner
Unmarried/no partner
10%
35%
19%
No children
16%
50%
28%
No driving licence
No driving licence
11%
39%
14%
Unemployed
8%
31%
13%
T bl d t d f
Table adapted from Sillanpaa et al, 1998
Sill
t l 1998
• History of educational/learning problems is a significant predictor of poor long term social outcomes term
social outcomes (Camfield et al, 1993; Berg et al, 2008)
(Camfield et al 1993; Berg et al 2008)
• Childhood and education ‐ a vulnerable time, but also a “window of opportunity”
in which to intervene.
Epilepsy: Continuum of severity
Epilepsy: Continuum of severity
•
Adapted from Rejis et al, 2006 & ILAE, 2010
Symptomatic/
cryptogenic ~30%
Idiopathic ~ 70%
d
h
Generalised idiopathic epilepsies
~90 % IQ normal ~10% mild impairment
Focal eg benign occipital epilepsy
Normal or mild IQ impairment & mild heterogenous
cognitive problems
Focal eg TLE with hippocampal sclerosis
~40 % IQ normal ~60% IQ< 70
Some focal deficits
Increasing severity
Generalised eg West syndrome, Lennox Gastaut syndrome
> 75% impaired IQ, often 2,3,4, sds
below mean with regression
Epilepsy: Educational attainments Study
Subjects
Test
Findings
Rutter
R
tt et al. t l
1970
63 idiopathic 63
idi
thi
epilepsy, Isle Of Wight, UK
R di
Reading
II year reading age delay 3 times di
d l 3 ti
more common than in normal
population.
Seidenberg et al, 1986
122 epilepsy outpatients, USA
Reading, Spelling, Maths
Poor Spelling (33%), Reading (22%), Arithmetic (28%) for IQ.
Mitchell & Chavez, 1991
78 CWE, California
Reading, Spelling
Poor Reading (16%) Spelling (24%) General Knowledge (50%) for IQ.
Oostrom et al, 2003
51 CWE from developmental study, Holland
y,
Reading, Spelling, Maths
CWE 6 points below IQ matched controls for reading, spelling and arithmetic.
McNelis et al, 2005
106 with recent onset epilepsy, USA
Reading,
Spelling
12.5% of the group 1 sd below the test normative mean. FFastenau
t
et al, t l
2008
175 epilepsy 175
il
outpatients,USA
Reading, R
di
P
Poor Reading (9%), Writing R di (9%) W iti
Writing, Maths (28%), Maths (20%) for IQ level.
Educational attainments‐key findings from previous studies
previous studies
•
Children with epilepsy have higher risk of educational underachievement than children without seizures and compared with children with other chronic disorders.
•
Reading most commonly reported impaired attainment, but when numeracy and writing examined, these are more impaired.
writing examined, these are more impaired.
•
Methodological issues and heterogeneous groups mean that more research is needed to clarify the situation
needed to clarify the situation.
Aims of study
Aims of study
• D
Determine
i the
h effects
ff
off childhood
hildh d onset ffocall epilepsy
il
on educational
d
i
l
performance and academic skills
• Identify
Id tif which
hi h epilepsy
il
related
l t d ffactors
t
iinfluence
fl
educational
d
ti
l attainments
tt i
t
Methods
Retrospective case note review of 390 children aged 5 to 16 years who completed tests of academic attainments at GOSH between 1999 and 2010.
•
Demographic information: age, gender, handedness
•
Wechsler attainment tests (WORD & WIAT‐II)
– Single word reading
– Reading comprehension Reading comprehension
– Single word spelling
– Numerical operations
•
FSIQ, CMS verbal and visual memory
•
Clinical epilepsy variables including age of onset, duration and frequency of l
l l
bl
l d
f
d
df
f
seizures, lesion side, location and pathology
Sample: Demographics
• N= 390
• Mean no of seizures per month: 171 (sd 359)
• Mean age at onset of epilepsy: 3.77 years (sd 3.32)
• Mean age at assessment: 10.6 years (sd 4.10)
Mean age at assessment: 10 6 years (sd 4 10)
Gender
female
51%
%
male
49%
Pathology
Not known
14%
Dev tumour
21%
Hemi malformation
8%
Seizure Frequency
Other
13%
Location of abnormality
Mesial Mesial
Focal
Focal temporal malformation
sclerosis
17%
Hypoxia/ 16%
ischaemia
11%
Parieto‐
occipital
11%
Frontal Frontal
19%
Multilobar
28%
Temporal Temporal
42%
monthly
19%
weekly
18%
daily
63%
Intellectual function and memory
Intellectual function and memory
Incidence of impairment in academic attainments
c de ce o
pa e t acade c atta
e ts
Distribution of academic functions in the sample Academic attainments in epilepsy predicted from IQ
Actual
100
*
95
*
Predicted
*
S
Standard Score
s
90
85
80
75
70
65
60
55
50
Word reading
Spelling
Numerical operations
Reading comprehension
•Scores for all academic attainments are lower than predicted by FSIQ.
Which academic attainments are most impaired?
• All attainments are
r=.29
around 1 to 1.5 sds
below mean.
• Word reading and
spelling are the least
impaired.
• Reading
comprehension is
the most impaired.
MANOVA analysis
Significant effects?
Significant effects when covary with FSIQ?
with FSIQ?
Gender
No
No
Handedness
No
No
Side of lesion
No
No
Location of lesion
(F {4,260}=4.13) **multilobar
No longer significant
Pathology of lesion
(F {5,260}=5.93)*hypoxia‐
ischaemia, *hemi‐malformation No longer significant
Congenital/acquired No
No
• No significant effects for epilepsy related variables once FSIQ
controlled for.
Correlations
**FSIQ
No significant effects for
seizure frequency or
number of medications.
*Age at assessment
Once FSIQ controlled for no
significant effects for age at
onset of seizures.
Educational attainments and age
g
Older children show
greater delay in
educational attainments.
Consistent with Seidenberg et al,
1986; Mitchell et al, 1991
N=390
Multiple regression
B (Std error)
Beta
p
Constant
33.65 (3.69)
Full Scale IQ
0.73 (0.04)
0.76
p<.001
Age at assessment
‐0.80 (0.22)
(
)
‐0.135
p<.001
NB Adjusted
Adj t d R2=0.60,
0 60 F(2
F(2,282)=215.43,
282) 215 43 p<.001
001
“the predictive power of epilepsy related variables for educational outcomes is
limited” Fastenau et al, 2008
Impact of IQ and memory
Impact of IQ and memory
MANOVA F (3, 260)=15.14, p<.001
*
Word reading
Spelling
Numerical ops
Reading
comp
•Intellectual
te ectua impairment
pa e t assoc
associated
ated with
t educat
educational
o a impairment.
pa e t
•For children with normal IQ, impaired memory forecasts deficits in
reading comprehension.
Summary & Implications
Summary & Implications
•Up to half of all children with focal epilepsy had significantly impaired
levels of academic attainment.
•Reading comprehension was significantly lower than all other academic
p
with this area.
attainments. Memoryy deficits forecasted problems
• Young people of secondary age lagged behind chronological age by 4
years, whilst those of primary school age were 1 year behind.
• Level
L
l off iintellectual
t ll t l ffunctioning
ti i and
d age att assessmentt were significant
i ifi
t
predictors of academic outcome.
•These findings call for
-early and regular educational screening
-evaluation of intellectual and memory status when planning
educational support
-educational interventions to develop reading comprehension