A new study from Denmark shows that childhood epilepsy is associated with poor school performance. Epilepsy is a common neurological disorder among children, affecting nearly 1%. Epilepsy results in epileptic seizures, but teachers and classmates may not necessarily know that a child has epilepsy if the seizures are well managed. The study shows, however, that even children with uncomplicated epilepsy perform significantly worse in Danish and mathematics than other children. The reason for this finding is unclear, but the findings emphasise that schools need to increase awareness about and support for children with epilepsy.
Epilepsy is a common neurological disorder among children, and it has long been known that children with severe epilepsy often have learning difficulties and typically therefore also problems at school. However, most children receive such good drug treatment that they avoid epileptic seizures, with almost no symptoms – but not quite, according to a new study.
“Our study shows that even children with uncomplicated epilepsy have significantly lower academic performance than their peers. Several factors probably contribute to this finding, but the results suggest a widespread need for educational support of children with epilepsy in school, even when they have no other comorbidities and even when the epilepsy appear well managed and the seizures are under control,” explains co-author Julie Werenberg Dreier, Senior Researcher, National Centre for Register-based Research, Aarhus University, Denmark.
Largest study of its kind
The study shows that epilepsy can have profound social and educational consequences. However, previous studies have been limited in scope and often focused on small samples or children treated in one hospital department.
“These studies, which have usually been based on small samples, have not clearly shown how epilepsy generally affects children’s school performance. When the samples are small, it becomes challenging to examine whether there are any sex or age differences and to evaluate the influence of different types of epilepsy medication and possible comorbidities. In addition, previous studies have not always been representative of children with epilepsy in general, since they often include mainly children with more severe types of epilepsy. One of the big unanswered questions has been whether school performance is also affected among children with uncomplicated epilepsy,” says Julie Werenberg Dreier.
The researchers used Denmark’s extensive population and health registries to identify children with epilepsy – including uncomplicated epilepsy – and to examine how they perform academically compared with their peers.
“The study is the largest of its kind, including 4,659 children with epilepsy and a reference cohort of 46,590 sex- and age-matched children without epilepsy attending public primary and lower-secondary schools in Denmark. We compared more than 15,000 national test results in Danish and mathematics for the children with epilepsy with more than 150,000 results from the reference cohort,” explains Julie Werenberg Dreier.
Familial and genetic underpinnings less important
The study shows that children with epilepsy had considerably poorer academic performance than those without epilepsy. Children with complicated epilepsy (such as with underlying cerebral palsy, brain tumour or traumatic brain injury), those using antiseizure medication, those with recurrent prescriptions for rescue medication and those with psychiatric comorbidity had the greatest reductions in performance. However, the poorer performance was observed across all epilepsy subgroups, including among children with uncomplicated epilepsy.
“Children with epilepsy scored on average 48.2 points versus 56.7 points for the reference cohort on a scale from 1 to 100 – that is 8.5 points lower. Even after adjusting for parental education and income, the difference was 7 points,” explains Julie Werenberg Dreier.
Although the difference was greater for specific subgroups, such as children with epilepsy and intellectual disability or attention-deficit/hyperactivity disorder, the adjusted difference for the 3,534 children with uncomplicated epilepsy was 6 points.
“Interestingly, children with epilepsy also scored lower than their siblings without epilepsy, which suggests that the poorer academic performance of children with epilepsy attending public schools cannot be immediately attributed to familial or genetic underpinnings,” notes Julie Werenberg Dreier.
Another indication that genetic underpinnings are less important for the school performance of children in this study, was that academic performance declined mainly around the time when epilepsy was diagnosed and that it did not normalise again later.
“If this primarily resulted from genetic underpinnings, we would expect them to already be doing worse before developing epilepsy. Other factors are therefore probably more important in this group of children,” says Julie Werenberg Dreier.
May affect ability to concentrate
Some of the obvious potential causes for children with epilepsy having poorer test results could include seizure activity, side-effects of epilepsy medication and social consequences, including absence from school.
“Our study was based on data from administrative registries, and we therefore had limited clinical information about the specific type of epilepsy, seizure frequency and how well they tolerate any drug treatment. However, academic performance was poorer for children with repeated prescriptions for rescue medication, which is probably correlated with seizure activity, but another potential cause may be absence from school,” explains Julie Werenberg Dreier.
A previous study showed that almost half of children with epilepsy miss more than 15 school days per year.
“Previous studies of children with diabetes in Denmark investigated academic performance and absence from school. Similar to children with epilepsy, they have a chronic condition that requires examination and regular check-ups, but their school performance is not worse despite being absent from school more often. This may suggest that the lower school performance seen in children with epilepsy could be related to the condition itself – perhaps because this is a brain disorder – which is different from other chronic conditions,” explains Julie Werenberg Dreier.
Nevertheless, the researchers will examine whether absence from school is one explanation.
“If this is the case, then extra teaching hours might potentially compensate for any absence. We will also investigate the children’s well-being. For example, if they worry a lot about having seizures, this may affect their ability to concentrate and thus ultimately their learning,” adds Julie Werenberg Dreier.
Losing control of the body
According to Julie Werenberg Dreier, regardless of the causes, we should recognise and be aware that children with epilepsy, including those with uncomplicated epilepsy, may need support at school.
“Parents and teachers might think that if the seizures are under control, then everything is fine. But our findings suggest that even if the seizures are well-managed, there could be other ways epilepsy can affect school performance, such as the child experiencing increased fatigue,” says Julie Werenberg Dreier.
Overall, the study therefore shows considerable need to be aware of the academic challenges that children with epilepsy can face at school. Sometimes epilepsy is so invisible that the school does not know that a child has epilepsy.
“Epilepsy can be associated with stigma, so many children with epilepsy may not want to share with their classmates or teachers that they have epilepsy. Because many children with epilepsy may never have had a seizure at school, then the school will only know if they are informed by the family” explains Julie Werenberg Dreier.
Very important for future progress
The researchers emphasise that parents should be aware of the epilepsy even if the seizures are under control.
“In that case, people might want to forget everything about the epilepsy and say that there is nothing more to worry about, but the family can play an important role by paying extra attention to possible changes in their children’s acedemic performance, especially in the first years after diagnosis, if there are any changes in their medication, or if mental health problems arise,” says Julie Werenberg Dreier.
Julie Werenberg Dreier therefore hopes that the study may help both parents and schools realise that epilepsy is a condition that should be taken seriously.
“It is important to address the academic challenges if they arise and to be aware of whether support at school is needed, because we know that their performance at younger ages plays an important role for their further educational development and success,” she adds.
Co-author Jakob Christensen, Consultant and Clinical Professor at Aarhus University Hospital, has participated in preparing the Danish Health Authority’s recommendations for cross-sectoral courses for people with epilepsy:
“The family should support the child’s education and focus on epilepsy to ensure the child receives appropriate support. Doctors and nurses should also focus on coordinating efforts and sharing knowledge across sectors – and complying with the recommendations of the Danish Health Authority about coherence between the healthcare system and municipal services for children with epilepsy. More systematic assessment of learning is important if underlying problems are suspected, such as through neuropsychological testing,” concludes Jakob Christensen.