Epilepsy and Learning Disabilities
Mark Bailey, Ph.D., R.Psych.
ABLE Developmental Clinic, Surrey, BC
Epilepsy is a neurological disorder that is primarily noted for producing seizures, which are the most obvious and often dramatic feature of epilepsy. However, there are a number of other symptoms of neurological dysfunction that can be associated with epilepsy. Since much of the brain’s activity is devoted to cognitive functions, it is not uncommon for persons with epilepsy to also experience some degree of cognitive dysfunction (ranging from the obvious to the very subtle), which may only be detected through a neuropsychological assessment. This helps explain why some children with epilepsy experience marked learning problems. Children with epilepsy may or may not have learning weaknesses that fit the traditional definition of a “specific learning disability”. A learning disability (or disorder) refers to a condition in which a person is reading, writing and/or arithmetic skills are significantly weaker than expected based on their intellectual ability (i.e. their IQ). A learning disability needs to be distinguished from a low intellectual ability (e.g., a mental handicap or borderline intellectual functioning), which is typically associated with difficulties in most academic skill areas.
Persons with epilepsy may have a specific learning disability, either as a direct result of the neurological dysfunction underlying their epilepsy, or through dysfunction unrelated to their epilepsy. However, a number of children with epilepsy appear to have more generalized learning problems that cannot be defined as a specific learning disability. There are several reasons why this may occur and each is associated with distinct remedial recommendations.
The generalized learning problems experienced by a substantial number of children with epilepsy are often described by their parents as due to weak attention and memory. However, because memorizing/learning is dependent on attention, an attention-deficit frequently appears to be their core weakness (although primary memory impairment does occur in some cases). Consequently, some children with epilepsy have similar learning problems to children with attention-deficit/hyperactivity disorder (ADHD), although they may have few other shared characteristics.
It is important to determine exactly what is causing an attention weakness, because there are several possibilities. Many children with epilepsy are taking some form of anti-epileptic drug (AED). Recent research has shown that most AED’s have the potential to interfere with cognitive functioning. The obvious remedial recommendation is to work together with the child’s neurologist to find the optimal AED type and dose, in order to reduce or eliminate negative side effects. However, this may be difficult to accomplish, because the cognitive effects of AED’s are sometimes hard to specify and because the primary treatment consideration is usually to maintain good seizure control.
There is now also a significant amount of research describing the phenomenon of sub clinical epileptiform discharges (SED’s). SED’s are electrical activity occurring in the brain, below the threshold required to produce an observable seizure (i.e. at a sub clinical level). However, numerous studies have now demonstrated how SED’s can interfere with cognitive functioning. Unfortunately, it may not be possible to determine if this is actually occurring, without conducting EEG monitoring, while observing the child engaging in cognitive/academic activities. Furthermore, if SED’s are not occurring frequently, they will be even more difficult to detect (but likely less detrimental)
The nearest alternative to using EEG monitoring is for persons closely involved with the child (i.e. teachers, parents) to observe him or her for subtle interruptions in ongoing information processing, or conscious awareness, to document when and where these occur and the child’s behaviour at the time. This information should be reported to the child’s neurologist, as it might also denote the occurrence of actual absence seizures. It may be possible to control SED’s through alterations in medications. However, if this is not feasible or completely effective, then it will be necessary to continue closely monitoring the child for these events and to alter learning and performance expectations based on his or her moment-to-moment functioning.
Aside from AED’s and SED’s, it is also possible that the neurological damage or brain malformation, underlying a child’s epilepsy will directly involve the brain structures important for attention. In such a case, the child may appear very similar to one with ADHD. It is also possible that such a child could receive a diagnosis of ADHD, in addition to epilepsy. If so, then a psycho stimulant medication (e.g., Ritalin) might be used to assist the child with his or her attention problems.
For children with epilepsy who have a specific learning disability (with or without attention problems), all of the usual learning assistance techniques are appropriate for teaching them. If they have an attention problem as well, then the recommendations listed above should also be considered. Aside from using the appropriate type and dose of medication (or if the seizure disorder remits), there is often no effective means of eliminating attention fluctuations. Therefore, one must work around them as much as possible and a flexible teaching approach is crucial. It is inappropriate to expect them to remember everything taught. They should be provided with information which other children are expected to learn, such as times tables, the alphabet and formulas, to use as reference material. They should also be allowed to use calculators, dictionaries, spell-checks etc., so that their difficulties storing and/or retrieving basic information from memory does not impede their academic progress and their exposure to more complex academic concepts. Use of these methods will assist the child with epilepsy to maximize his or her learning potential and increase his or her chances of having an enjoyable school experience.