Diagnosing Epilepsy

PRESENTATION: Children with epilepsy may fall behind.

All is not lost. The condition can be treated

By Dr. Dina Saleh

Epilepsy is a condition in which disturbances to the brain’s normal electrical activity cause recurrent seizures or brief episodes of altered consciousness. A teenager or a child may have different presentations such as strange sensations, emotions, and behavior or sometimes jerks or spasms, and loss of awareness. Having a single seizure as the result of a high fever (called febrile seizure) or head injury does not necessarily mean that a person has epilepsy. Only when a person has had two or more unprovoked seizures, he or she is considered to have epilepsy. Once epilepsy has been diagnosed, parents want to know the long-term outcome, such as whether the seizures will stop after using medications, will the epilepsy be outgrown, and how it will affect the child’s learning, development and cognition.

Cognition is the intellectual process by which one becomes aware of, perceives, or comprehends ideas. It involves all aspects of perception, thinking, reasoning, and remembering. Cognitive function depends on the function of a complex interrelated and distributed neuronal network including several domains such as attention, language, verbal and nonverbal memory, intelligence, executive function and motor domains.

The effects of epilepsy on a child’s cognitive, behavioral, intellectual, and social development are extremely variable and appears to be multi-factorial. The extensive literature on the topic, going back many decades, shows that patients with chronic seizures experience greater rates of cognitive deficits, emotional problems, physical and psychiatric disease, health care utilization, educational and occupational underachievement, failure in fulfilling normal social roles, and reduced quality of life.

However, recent studies have demonstrated that abnormalities in cognition can be apparent at or near the time of epilepsy diagnosis and that academic problems either antedate the first recognized seizure or are recognized soon after diagnosis.
Several major factors may contribute to these learning difficulties and cognitive dysfunction such as seizure-related effects, medication-related effects, psycho-social factors, and developmental disorders.

Seizure-related effects include the cause of epilepsy, at what age seizures began, the seizure type(s), what part of the brain is affected by seizure activity, and how frequently the seizures happen. Different seizure types can have different impacts on a child’s school performance. For example, absence seizures (common type of childhood seizures) which are characterized by a brief loss of consciousness, may prevent a student from hearing and seeing what is happening in his class while he is having seizures. This loss of contact with his surroundings can therefore impede his learning. Children may also fall behind from missing school for doctor’s appointments, tests, or while recovering from a major seizure.

Medication-related effects include the type of medication, the number of medications, and the dosage level of medication a child may be taking. Some commonly prescribed medications have side effects which may include drowsiness, inattention or restlessness, all of which can have an adverse impact on a student’s learning potential.

Psycho social factors including family coping strategies, school and parent expectations, and behavioral or emotional problems can all impact the learning of a student who has epilepsy. More importantly is the stigma that still surrounds epilepsy in some communities, which can lead to stress in a student’s life, resulting in poor school performance and low self-esteem.

Children with epilepsy may also have developmental disorders that can impact their school performance. These disorders may include learning disabilities, attention deficit/hyperactivity disorder (ADHD), developmental delay, mental retardation, and autism.

In many studies, it has been shown that some cognitive deficits were present in the context of grossly intact global intellectual functioning and are often not apparent in a standardized IQ or academic achievement test. Therefore, special comprehensive tests for evaluation of attention, ability to process information and memory are often conducted by a team of experts, which may include psychologists, speech and language therapists, and social workers to identify such subtle deficits.

Now it is evident that all patients with epilepsy even those with new onset are at increased risk for cognitive or behavioral impairment, and the origin for this type of impairment appears to be multi-factorial. Therefore, regardless of the severity of the condition, children with epilepsy need special attention to ensure that there are no subtle learning difficulties.

The sooner a child’s learning disabilities are identified, the sooner school personnel and parents can develop effective strategies that will help the child succeed academically. Open, honest communication between the family and the school about the challenges the student is facing is critical in this development process. Tutoring and counseling may be effective in helping the student succeed with her/his schoolwork, in addition to modifications and accommodations made by their teachers within the classroom setting.

The International League Against Epilepsy (ILAE) which is the world’s preeminent association of physicians and other health professionals working toward a world where no persons’ life is limited by epilepsy has released in 2015 its recommendations about routine screening of cognitive behavior in new onset epilepsy with neuropsychological assessment as well as routine provision of feedback to patients, families, and clinicians about the implications of the assessment results, including specific clinical recommendations of what can be done to improve a patient’s cognitive or psycho-social functioning and alleviate the distress of any difficulties identified.

Dr. Dina Saleh, Consultant Pediatrics Neurology Division, American Center of Psychiatry and Neurology

 

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