European Scientific Journal January 2014 edition vol.10, No.

3 ISSN: 1857 – 7881 (Print) e - ISSN 1857- 7431

COGNITION AND ACHIEVEMENT IN

CHILDREN WITH SEIZURE DISORDERS

Lydia Barza, PhD

Zayed University, United Arab Emirates

Abstract
School personnel can help to identify, monitor and accommodate
students with seizure disorders. This article describes the general
characteristics of seizure disorders and reviews research on implications for
cognition and achievement among children. Despite methodological
limitations of research in this area, a few trends are observed. Localization of
seizure activity in the brain and age of onset have a major impact on
cognition. A synthesis of major studies show that deficits often involve one
or more of the following: verbal memory, visual memory, reaction time, and
attention. Challenges in reading comprehension are well documented. Poor
school performance, in general, may be due to frequent lapses of awareness.
Recommendations are for school personnel to monitor and document
symptoms at school.

Keywords: Chronic illness, epilepsy, seizure disorders, cognition,

achievement

Introduction
School personnel, including teachers, school counselors, school
nurses and special education needs coordinators (SENCos), play a vital role
in informing educators and parents about chronic illnesses, such as seizure
disorders. Epilepsy, the term used for recurrent seizures, is one of the most
common neurological disorders of childhood. An understanding of the
condition and its impact on cognition and achievement will afford the
practitioner the knowledge to advocate for relevant services and provide
appropriate social and academic support. The purpose of this article is to
describe the prevalence and general characteristics of seizure disorders and
then systematically review research on its implications for cognition and
achievement among children.Finally, guiding principles for practice are
discussed.
Effectively working with students with seizure disorders first
involves a general understanding of the condition, particularly due to

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commonly held misconceptions about individuals with such illnesses(Jacoby,

Snape& Baker, 2005).School performance issues reviewed from the
literature on students with seizure disorders provide some guidance as to
how they may be placed in the least restrictive and most appropriate
schooling environment, especially since some studies show higher rates of
grade retention and placement in special education programs (Bailet & Turk,
2000; Berg et al., 2005).

Prevalence and characteristics of seizure disorders

A seizure is characterized by uncontrollable, excessive electrical
activity in the central nervous system (CNS). It results from sudden electrical
discharge of neurons in the brain (Black & Hynd, 1995). Rutecki explained
that such “abnormal synchronization of cortical neurons results in a change
in perception or behavior”(Rutecki, 1993, p. 275). It is thought that recurrent
seizures are caused by an inherent brain abnormality. Nevertheless, no
evidence is found for an underlying cause in 50-60% of cases. Recurrent
seizures may subject the individual to transient and chronic brain electric and
neurochemical disturbances (Jokeit & Ebner, 1999). Consequences of
abnormal electrical activity in the brain most often include “loss of
consciousness, an altered state of consciousness, cessation of motor activity,
abnormal motor activity, abnormal sensory perceptions, and loss of bladder
and bowel control”(Wiederholt, 1995, p. 211). Symptoms vary depending
on seizure type.
Recurrent seizures in an otherwise healthy individual are a symptom
of epilepsy. Peak ages of onset are the first two years of life and the onset of
puberty (Black & Hynd, 1995).It is hypothesized that hormonal changes
stress the CNS and may precipitate seizures in susceptible individuals
(Wiederholt, 1995).
The incidence of epilepsy is about 1% of the population and 75%
experience onset before age 20. Epilepsy is estimated to affect up to 50
million people globally and 2.5 million people in the United States with
predominance among males. Approximately 145 diseases are associated with
seizures. Seven to ten percent of the population will have a seizure at some
point in their lives (CDC, 2011; WHO, 2001).

Types of Seizures
Seizures are categorized based on three factors: localization in the
brain, loss of consciousness, and type of muscular activity. According to the
International Classification of Epileptic Seizures (see Table 1), a distinction
is made between partial and generalized seizure types. Partial seizures
involve localized discharges in the brain. They begin focally, meaning onset
is from one brain region or one cerebral hemisphere only. Generalized

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seizures involve discharges from both cerebral hemispheres and subcortical

connections and structures (Black & Hynd, 1995). Abnormal electrical
activities begin in both hemispheres at the same time (Wiederholt, 1995).
This distinction is of importance because some research findings on
cognition and achievement are idiosyncratic based on this factor.
A seizure is described as complex if it is associated with a loss of
consciousness. Conversely, a seizure is described as simple if it is not
associated with a loss of consciousness. Muscular activity is characterized as
tonic, clonic, or both. Tonic muscular activity refers to muscle contraction or
tension. For example, the arms and legs may be extended rigidly for several
seconds. Clonic muscle activity involves alternation between contraction and
relaxation.
Tonic-clonic or grand mal types are most easily identified as a
seizure because of their dramatic physical expression. This type of seizure is
characterized by a sudden cry then unconsciousness, body rigidity, muscle
jerking, clenched teeth, and possible suspended breathing. The seizure
commonly lasts for about 2-3 minutes, while the entire seizure and recovery
period may span about 10-20 minutes.
Nevertheless, typical absence or petit mal seizures are the most
common type of seizure in children. They are characterized by losses of
awareness without changes in muscle tone, vacant stare, rapid eyelid
blinking at about 3 per second, and no recollection of the seizure. Typical
absence seizures classically occur between the ages of 3 and 12 (Wiederholt,
1995). Such seizures last for less than 15 seconds per episode and can be
difficult to diagnose because of their subtle physical manifestations. In the
classroom, a seizure episode of this type is often mistaken for inattention,
ignoring, or daydreaming. However, an awareness of the condition combined
with keen observation by social workers and teachers may aid in the
diagnosis and subsequent medical and educational intervention.

Method
This article synthesizes the results of studies on the cognitive
implications of seizure disorders in children. The methods used to collect the
literature for this paper included a comprehensive literature search of
published literature since 1970 and a review and retrieval of references from
relevant articles. The initial search was conducted using the following key
search words: seizures or epilepsy, and cognition, achievement, education.
These key word searches were conducted in several databases including
PsycINFO and MEDLINE. Fifty papers were synthesized in a narrative
format by topic: cognitive implications, academic implications, and
pharmacological implications. Some papers were included in more than one
section. An article met the relevance criteria if it was a primary study or

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review and if it was published after 1970. A paper was excluded if it was a
single subject case study. Fiftystudies passed the relevance test and data
extraction was completed on those papers. Twenty-eight papers examined
cognitive issues, fifteen examined achievement and seven studies described
pharmacological issues. This paper provides a narrative synopsis of the
relevant studies.

Cognitive issues
Several factors combined contribute towards cognitive dysfunction
(Aldenkamp, 1997; Bourgeois, 1998). Studies on temporal lobe epilepsy
suggest that seizures could produce progressive neuronal damage (Jokeit &
Ebner, 1999; Koh, Storey, Santos, Mian& Cole, 1999; Tasch et al., 1999).
Such damage may have an effect on long-term potentiation involved in
learning(Giovagnoli & Avanzini, 1999). Nevertheless, reviews of the
literatureconclude that children show mild, varied, transient cognitive
difficulties during the course of their epilepsy (Dodrill, 2004; Hermann &
Seidenberg, 2007; Vingerhoets, 2006).

Intelligence
Research studies are consistent in reporting that IQ scores of persons
with seizure disorders are average with a tendency towards the lower end of
the average range (Black &Hynd, 1995; Deonna et al., 2000; Liu, Zhang,
Han, Guo& Wang, 2012; Selassie, Viggedal, Olsson, & Jennische, 2008).
Nevertheless, discrepancy analyses may demonstrate significant deficits
despite average IQ.

Localization in the brain

Localization of seizure focus in specific areas of the brain is
sometimes related to the nature of cognitive impairment (Aldenkamp, 1997;
Bulteau et al., 2000; Kwan & Brodie, 2001). Children with generalized
seizures have greater problems in sustaining attention and poorer mental
abilities compared to those with focal seizures (Dodrill, 1992; Nolan et al.,
2003; Witt & Helmstaedter, 2012). Verbal memory deficits are associated
with left temporal foci, while non-verbal, visual memory deficits are
associated with right temporal foci. Furthermore, generalized absence
seizures are associated with less cognitive dysfunction than tonic-clonic
seizures (Dodrill, 1992).
In general, temporal lobe epilepsy is associated with greater memory
deficit (Drane & Meador, 1996; Helmstaedter, 2002; Tuchscherer et al.,
2010).Subclinical discharges have been associated with less accurate reading
in children(Kasteleijn-Nolst Trenité, Bakker, Binnie, Buerman& Van Raaij,

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1988) and impairment in verbal short-term memory (Siebelink, Bakker,

Binnie& Kasteleijn-Nolst Trenité, 1988).
Correlations between seizure type and cognitive profile are, however,
inconsistent (Fastenau et al., 2004; Kwan & Brodie, 2001; McCarthy,
Richman & Yarbrough, 1995). Different pathologies can have differential
effects on cognition even at the same anatomical site (Hermann, Seidenberg,
Schoenfeld, & Davies, 1997). Williams, Sharp, Bates, and Griebel’s (1996)
study of children with complex partial or absence seizures found no
influence of seizure type on achievement test scores or behavioral ratings.
Yet, poorly controlled seizures correlated with lower reading scores,
withdrawn behavior, and attention problems.

Nature of deficits
Specific deficits in reaction time and attention have been documented
(Mitchell, Chavez, Lee & Guzman, 1991; Selassie et al.).Riva, Saletti,
Nichelli and Bulgheroni(2002) found attention difficulties and impulsiveness
in a study of 8 children between the ages of 6 and 13 with frontal epilepsy.
Nevertheless, several studies concur that the nature of deficits
associated with seizure disorders are transitory, overall cognitive deficits.
Significant weaknesses were found in various domains like verbal,
visiospatial and memory abilities. In a study examining 57 children aged 7
to 10 years with complex partial seizures, Schoenfeld et al. (1999)found
significant cognitive impairment suggesting a profile of diffuse, generalized
cognitive dysfunction compared to sibling controls. No single cognitive
profile was identified in a study of 22 children with typical benign partial
epilepsy, although eight of the children had transient low scores on at least
one cognitive domain and four had delayed language development (Deonna
et al., 2000).

Age of onset
Young age of onset of the seizure disorder is associated with more
severe cognitive impairment (Aldenkamp, Gutter& Beun, 1992; Berg, 2011;
Bulteau et al., 2000; Dodrill, 1986, 1992; El Sabbagh, Soria, Escolano,
Bulteau& Dellatolas, 2006; Farwell, Dodrill& Batzel, 1985; Nolan et al.,
2003; Schoenfeld et al., 1999; Zelnik, Sa'adi, Silman-Stolar& Goikhman,
2001). Kwan and Brodie (2001) suggested this may be due to greater seizure
induced damage and adverse antiepileptic drug reactions. Fastenau et
al.(2009) observed that 27% of their 282 child participants between the ages
of 6 and 14 showed neuropsychological deficits at or near onset of their first
seizure, although no achievement difficulties were yet apparent.

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Impact on Achievement
A synthesis of the research reveals several trends in the literature.
Underachievement in reading skills among this populationis consistently
documented (Kasteleijn-Nolst Trenite et al.; Seidenberg et al., 1986; Stores
& Hart, 1976). There are particular deficits in reading comprehension,
spelling, and arithmetic (Black & Hynd, 1995; Cull, 1988; Gourley, 1990;
Jones, Siddarth, Gurbani, Shields& Caplan, 2010; Mitchell, Chavez, Lee&
Guzman, 1991). Studies reported by Mahapatra(1990) and Rutter, Tizard and
Whitmore(1970) both show that children with epilepsy performed
significantly lower than matched controls on reading comprehension tasks.
Impaired performance on arithmetic skills has also been acknowledged
(Bagley, 1970; Bolter, 1986; Green & Hartlage, 1971; Jones et al.).On the
other hand, one study of recent onset children found mean academic
achievement to be in the average range (McNelis, Johnson, Huberty&Austin,
2005), while one review concluded that low academic achievement is
common rather than general underachievement (Reilly & Neville,
2011).Poor school performance, in general, may be due to frequent lapses of
awareness (Wiederholt, 1995). For example, students may miss important
directions or information relayed by the teacher due to loss of consciousness
for even a few seconds at a time as in absence seizures. Some suggest
symptoms may mimic a learning disorder (Beghi, Cornaggia, Frigeni
&Beghi, 2006; Breier et al., 2000). The prevalence of academic problems in
this population is unknown.

Pharmacological issues
Over fifty percent of persons with seizure disorders can completely
control their seizures with medication. Another thirty percent can improve
management with medication. High dosages of medication and
polypharmacyare associated with impaired intellectual functioning (Bulteau
et al., 2000; Drane & Meador, 1996; El Sabbagh et al.; Selassie et al.) and
reducing the number of medications has been linked to cognitive and
behavioral improvement (Brodie, McPhail, Macphee, Larkin & Gray, 1987;
Nolan et al., 2003).Fortunately, the majority of children on antiepileptic
medications do not experience clinically relevant cognitive or behavioral
adverse effects (Bourgeois, 1998). As an exception, a study of ten 6-12 year
old children with benign rolandic epilepsy found that the children were
quicker on a visual-search task and recalled stories better before treatment
with carbamazepine (Seidel & Mitchell, 1999).
As with all medications, there is a need to investigate individual
responses to treatment (Seidel & Mitchell, 1999). Side effects of the most
common medications used to treat children with seizure disorders include but
are not limited to drowsiness, sedation, ataxia (defective muscular

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coordination), nausea, vomiting, weight gain, and hyperactivity (Rutecki,

1993; Wiederholt, 1995). School personnel may aid medical treatment in this
respect through documentation of symptoms.

Limitations of Studies on Seizure Disorders

Methodological limitations of the research in this area have resulted
in inconsistent and contradictory findings (Dodrill, 2004; Kwan & Brodie,
2001; Vermeulen & Aldenkamp, 1995; Vingerhoets, 2006). Hartlage
andHartlage(1997)suggested that most studies on children are conducted in
major medical centers which tend to house the most severe cases and may
account for part of the inconsistency in findings and somewhat exaggerated
intellectual deficits.
Studies clearly struggle to account for all the complexities and
confounding variables associated with seizure disorders such as age of onset,
type and frequency of seizures, treatment doses, gender, age, ethnicity and
localization in the brain(Kwan & Brodie, 2001). Although most studies
include children between the ages of 5 and 13, much developmental
variability existswithin these age groups. The uniformity in the use and
interpretation of neuropsychological tests is also worthy of scrutiny
(Vermeulen & Aldenkamp, 1995). Further, comparison groups ranged and
often seemed to be a matter of recruitment convenience, from sibling
controls (Bailet & Turk, 2000) to subjects with other chronic illnesses
(Williams et al.).

Guiding Principles for School Personnel

Given what is known about seizure disorders and children, several
guiding principles may apply. Factors contributing to the poor academic
performance of children with seizure disorders include deficits in verbal
memory, visual memory, reaction time/motor speed, and inattention.
Shortfalls in reading comprehension and arithmetic skills have been
documented. In some cases, researchers describe a condition that looks
similar to what you would find in a child with a learning disability. Students
who show less transient deficits may warrant accommodations that would
support their strengths.
There is not information in the seizure disorder literature to support
any one model for school professionals to follow. However, the author
suggests several guiding principles for school personnel to better support and
encourage the child with seizure disorders, based on the literature for
working with students with other chronic conditions. Celano and Geller
(1993) provided recommendations for improving the school performance of
children with asthma that may be applicable to any chronic illness with some
modifications. They are (1) to help the child implement self-management

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programs, (2) to monitor adverse effects of medical treatment, (3) to adopt a

multidisciplinary psycho-educational evaluation, and (4) to promote
educational programming that normalize psychosocial functioning.

Self-Management Programs
Self-management programs empower families and can be
implemented in the school setting. Such a program for children with seizure
disorders may include (a) recognizing when the child may have experienced
a seizure (as in the petit mal type) or when one may be imminent (as in other
types which may experience an “aura” sensation just prior to an episode), (b)
taking medications correctly and managing side effects, (c) developing a
contingency plan with school personnel should a seizure occur while at
school, (d) normalizing the child’s activities, and (e) communicating
effectively with school and health care personnel. The regular or special
education teacher’s role is pivotal for empowering the student and aiding
him or her to participate in the development of the contingency plan.

Monitoring and Documenting Symptoms

Characteristics of seizure disorders are often mistaken for other
illnesses, behavioral problems, or inattention and daydreaming. School
personnel may provide valuable information to the family in diagnosing a
student based on their awareness and diligent record of two of the three
factors that categorize seizures: loss of consciousness and type of muscular
activity. Understanding how various types of the disorder manifest can also
make school professionals more confident in sharing documented concerns
with parents and others. Further, SENCosmay act as advocates for a student
whose condition may be misunderstood and inspire fear among peers. For
example, the student may be encouraged to educate the class, share thoughts
and answer peer questions about seizures.
Rather than writing lengthy technical reports, short journal type
entries or symptom logs may serve well as documentation. For example, one
may notice that the student achieved lower scores than expected or is
excessively sleepy and lacks energy. This information may be shared with
the parents since it is an indication that the student may need an adjustment
in medication. Paying special attention to the time of day and intensity of the
sedationis also relevant.

Multidisciplinary Evaluation
As the research reviewed has shown, academic performance for a
child with seizure disorders may be affected by many factors including,
medical, psychological, pharmacological, and social issues. Such a
multifaceted condition requires a comprehensive and multidisciplinary team

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approach in order to adequately ensure that the child will perform to his or
her highest potential. Those who may be involved on such a team include the
classroom teachers, school social worker, neurologist, pediatrician,
psychiatrist or psychologist and parents. Input from all parties will ensure
that the student’s individualized education plan is comprehensive and
achievable. This will make it possible to promote educational programming
in the least restrictive environment.

ImprovingCollaboration among the School, Parents, the Child, and

Health Care Team
Facilitating communication among everyone involved with the child,
and including the child, is no easy task. However, the responsibility to do so
is shared by all. Of course, the SENCo plays a critical role in coordinating
efforts to meet the needs of the student.It is important to identify day to day
behavior, as well as details about developmental milestones.
Edwards (2004)provided a list of questions for teachers to ask parents
in individual interviews about their child. Questioning strategies are used
that show respect for the parent and take into account the fact that an
emotionally charged topic will be discussed. The suggested questions for
parentsshe outlines, originally intended to help teachers better connect with
parents and understand how to help their children with regard to reading,may
be modified for use with parents of children with medical illnesses. For
example, one may ask ‘How would you prefer I handle the situation should
your son experience a seizure in the school?’

Conclusion
This article provided a brief overview of the characteristics of seizure
disorders, cognitive and achievement issues associated with them, and
guiding principles for school personnel to support children with epilepsy.
Future studies may seek to use a standardized set of neuropsychological
tests, control for more variables and choose more appropriate comparison
groups. If sample size is of concern, a multi-site study may be an alternative.
Research that combines both a quantitative and qualitative methodology is
recommended. In addition, research on the most effective means for
servicing children with seizure disorders in schools is lacking in the
literature. School professionals play a key role in helping to identify, monitor
and advocate for any needed accommodations for these students.

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