Learning and behaviour

Overview

A subset of individuals with epilepsy will experience some degree of cognitive impairment1, the causes of which are complex and multi-determined2.

While research indicates a higher incidence of intellectual, academic, and behavioural difficulties in children with epilepsy, it is important not to assume all children with epilepsy will have learning difficulties, but to be aware of early signs to enable prompt intervention in order to help each child maximise their potential.

An educational or detailed neuropsychological assessment can help identify a slowing or a regression in the developmental, academic, or social abilities of a child or adolescent. Alternatively, it may help reassure a parent that the child is on-track.

The following sections provide information on some of the signs of learning and behaviour difficulty relating to epilepsy, the assessment of learning and behaviour, and how to make a referral for assessment.

Aetiology

The aetiology of increased risk for neuropsychological compromise in children with epilepsy is complex and multi-factorial, with research identifying the following contributing factors3:

  • The underlying pathology/syndromal diagnosis giving rise to seizures
  • Epileptic electro-neurophysiological dysfunction (particularly frequency, severity, and intractability of seizures)
  • Medical complications (e.g. multiple or prolonged episodes of status epilepticus, falls resulting in head injury etc.)
  • Anti-epileptic medications (i.e. a complex relationship with cognition)
  • Other factors (e.g. psychosocial variables, age of onset, neurodevelopmental and aging effects)
    • 1. Seidenberg, M. & Pulsipher, D.T. (2007). Cognitive Progression in Epilepsy. Neuropsychol Re, 17:445-454.
    • 2. Schoenberg et al. (2011). Epilepsy and Seizures. In Schoenberg & Scott (Eds.), The Little Black Book of Neuropsychology, New York: Springer.
    • 3. Schoenberg et al. (2011). Epilepsy and Seizures. In Schoenberg & Scott (Eds.). The Little Black Book of Neuropsychology, NY: Springer.

    Signs and symptoms

    Signs of possible learning or behaviour difficulty
    The following difficulties are sometimes reported by families or  schools, which may indicate early cognitive or behavioural problems warranting further detailed investigation:

    • Slowed ability to reach developmental milestones compared to siblings/peers
    • Development of or escalation of behaviour problems
    • Increasing difficulty with school work or homework (e.g. a drop in performance compared to previously)
    • Reports from school of poor concentration, not listening, not following instructions, not finishing work, interrupting others, difficulty working independently
    • Increasing frustration in the classroom
    • Getting into trouble with the teacher
    • Increasing dislike of school or school avoidance
    • Reports of difficult behaviour from the school, but good behaviour at home (and vice versa)
    • Moody, emotional outbursts after school
    • Conflict in the home setting

    Typically, neuropsychological compromise is greatest in patients with epileptic encephalopathies (e.g. West’s Syndrome, Lennox-Gastaut Syndrome, Dravet’s syndrome etc.) who commonly exhibit mental retardation, autistic features, and behavioural problems.1 Cognitive compromise may also be pronounced in symptomatic epilepsies (i.e. related to a known structural abnormality).2
     
    Research has also documented neuropsychological deficits ranging from subtle to more pronounced, in the so called ‘benign’ generalized idiopathic epilepsies (e.g. Childhood Absence Epilepsy, Juvenile Myoclonic Epilepsy) and in ‘Benign' Rolandic Epilepsy3,4,5.
     

    Attention and ADHD

    Attentional compromise is often documented in children with epilepsy - with ADHD reportedly affecting three to five times more children with epilepsy compared to children without.6 This is especially the case with absence epilepsy.
     
    Attentional compromise can affect learning, memory functioning, academic performance, and psychosocial functioning. Consequently, early identification of attention difficulties is important to allow early intervention and improve long-term outcomes for children with epilepsy.

    • 1. Schoenberg et al. (2011). Epilepsy and Seizures. In Schoenberg & Scott (Eds.). The Little Black Book of Neuropsychology, NY: Springer.
    • 2. Schoenberg et al. (2011). Epilepsy and Seizures. In Schoenberg & Scott (Eds.). The Little Black Book of Neuropsychology, NY: Springer.
    • 3. Schoenberg et al. (2011). Epilepsy and Seizures. In Schoenberg & Scott (Eds.). The Little Black Book of Neuropsychology, NY: Springer.
    • 4. Besag, F.M.C. (2006). Cognitive and Behavioural Outcomes of Epileptic Syndromes: Implications for Education and Clinical Practice. Epilepsia, 47(2): 119-125.
    • 5. MacAllister, W.S. & Schaffer, S.G. Neuropsychological Deficits in Childhood Epilepsy Syndromes. Neuropsychol Review, 17:427-444.
    • 6. Plioplys, Dunn, & Caplan (2007). 10-year Research Update Review: psychiatric Problems in Children With Epilepsy. J. Am. Acad. Child Adolesc. Psychiatry, 46(11):1389-1402.

    Assessment guidelines

    According to The NICE Guideline; The Epilepsies (released  October 2004 and updated January 2012), neuropsychological assessment should be considered in children, young people, and adults in whom it is important to evaluate learning disabilities and cognitive dysfunction, particularly in regard to language and memory.

    More specifically, the NICE Guideline suggests referral for a neuropsychological assessment is indicated, when:

    • A child, young person or adult with epilepsy is having educational or occupational difficulties
    • An MRI has identified abnormalities in cognitively important brain regions
    • A child, young person, or adult complains of memory or other cognitive deficits and/or cognitive decline.

    Neuropsychological assessments

    Assessments focus on the relationship between the brain, cognitive functions (thinking skills), and behaviour.

    The assessments involve the use of sensitive and specialised tests to assess a range of behavioural, cognitive and academic abilities, typically including:

    • overall intellectual ability (IQ)
    • processing speed
    • attention (immediate, sustained, divided)
    • higher-order executive skills (e.g. planning, problem solving, multi-tasking)
    • learning and memory
    • expressive and receptive language function
    • visual-spatial, visuoperceptual, and visuoconstructional skills
    • sensory-perceptual skills (e.g. dyspraxia)
    • academic performance
    • behaviour
    • emotional/psychiatric functioning
    • impulse control

      Assessment referrals

      The major Children’s Hospitals in NSW and the ACT can provide neuropsychological assessment via referral. Waiting lists may be significant, however patient lists are often triaged based on urgency.

      The following Public Hospitals offer neuropsychological assessment of children and adolescents:

      • Sydney Children’s Hospital, Randwick
      • The Children’s Hospital Westmead
      • John Hunter Hospital (Newcastle)
      • Canberra Hospital

      In addition, Neuropsychologists in private practice can also conduct detailed neuropsychological assessments. The Australian Psychological Society (APS) provides a searchable database of providersand as does the Australian Health Practitioner Regulatory Authority (AHPRA) .
       
      Information to include

      In your referral, it is useful to provide the following information to enable the neuropsychologist to tailor test selection according to patient need:

      • Presenting complaint / reason for referral (e.g. concerns about behaviour, academic performance, attention/concentration, or memory etc.)
      • Diagnoses (e.g. epilepsy syndrome/pathology, other medical conditions)
      • Brain imaging and/or EEG results, where available
      • Current medications (e.g. AED’s)
      • History of previous surgery
      • History of previous head injury (e.g. falls, trauma etc.)
      • History of comorbid diagnoses (e.g. ADHD, depression, autism etc.)

      General Educational Assessments

      General educational assessments (for children over 6 years of age) can also be conducted, often within the school setting. These are useful for documenting academic ability and may also assess overall intellectual ability and individual cognitive domains.

      However, full neuropsychological assessment is preferable where children are suspected of having memory, processing speed, attention, and/or executive compromise (e.g. difficulty with planning and organising, problem solving, carrying out multi-stepped tasks, persevering, and sustaining attention etc.), as it involves detailed assessment of these frontally mediated higher-order abilities.

      Assessment outcomes

      Results provide detailed information for parents and schools. Analysis of the cognitive profile can pinpoint areas of difficulty and also determine areas of cognitive strength.

      This information can then be used to:

      • advise parents and teachers of tailored management and compensatory strategies to assist the child
      • develop education plans to support the child
      • aid referral to appropriate support services (e.g. counselling, speech therapy, occupational therapy etc.)

      Based on the results of the assessment, the neuropsychologist can also:

      • Advocate for the child’s needs at school
      • Visit schools and/or talk with school staff
      • Assist schools in applying for support funding (e.g. Teacher’s Aide)
      • Advise about and help request Special Provisions for exams (e.g. HSC)
      • Help parents access support services as needed (e.g. tutoring, behaviour management, speech and language pathology, occupational therapy)