Factors Associated with Academic Achievement in Children with Controlled Epilepsy

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Epilepsy & Behavior 2, 217–223 (2001)doi:10.1006/ebeh.2001.0166, available online at http://www.idealibrary.com on

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Factors Associated with Academic Achievementin Children with Controlled Epilepsy

Jane Williams, Ph.D.,1 Tonya Phillips, M.D.,ay L. Griebel, M.D., Gregory B. Sharp, M.D.,ernadette Lange, M.D., Terence Edgar, M.D.,nd Pippa Simpson, Ph.D.

Department of Pediatrics, University of Arkansas for Medical Sciences, 800 Marshall,Little Rock, Arkansas 72202

Received January 5, 2001; revised February 2, 2001; accepted for publicationFebruary 26, 2001

Children with epilepsy are at risk for academic underachievement. Multiple etiologies for this aca-demic vulnerability have been suggested by past research including lower self-esteem, inattention,memory inefficiency, and lower socioeconomic status. The present study assessed 65 children (meanage 5 10 years, 5 months) with well-controlled epilepsy on the four primary factors, as well asacademic achievement and intelligence. A stepwise regression analysis was employed with academicachievement as the dependent variable and measures of self-esteem, attention, memory, and socio-economic status as independent variables. When intelligence was controlled, attention was the onlyvariable associated with achievement scores. Seizure variables including seizure type and duration ofepilepsy were not associated with differences in academic performance. Findings support the impor-tance of measuring attention skills in children with epilepsy and suggest that reduced auditoryattention skills may be associated with decreased academic performance in these children.© 2001 Academic Press

Key Words: epilepsy; pediatric; achievement; cognitive; psychosocial.

INTRODUCTION

Children with epilepsy are at risk for educationalunderachievement and commonly demonstrate a dis-crepancy between academic performance and intellec-tual ability (1, 2). However, specific subtypes of learn-ing problems in children with epilepsy have not beenfound (3), as underachievement has been reported inall academic areas (4). Children with epilepsy are of-ten retained in school at a higher rate than expectedwhen compared with matched controls (5, 6). In aprospective study in which children with epilepsywere followed into adulthood, findings suggested that

1 To whom correspondence should be addressed. Fax: (501) 320-840. E-mail: [email protected].

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educational problems persisted even in subjects whowere medication and seizure free (7).

This increased academic risk may be related to boththe effects of having a chronic illness and the effects ofa central nervous system (CNS) disorder. However,children with epilepsy have been found to be atgreater academic risk than children with other chronicillnesses, such as diabetes and asthma, as well ascompared with children in the general population (8–10). The findings of greater difficulties for childrenwith epilepsy compared with other chronic illnessgroups would suggest unique effects of seizure disor-ders on academic performance.

Questions remain about the underlying mecha-nisms and factors associated with academic vulnera-bility among children with epilepsy. Multiple factors,other than the impact of seizures and medications,

218 Williams et al.

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may influence academic performance including cog-nitive functions, environmental variables, personalityand motivation of the child, family adjustment, andsocial variables (2).

Four specific factors that have been suggested inprevious research to impact academic performance inchildren with epilepsy include self-esteem, attention,memory, and socioeconomic status.

Children with epilepsy more consistently demon-strate lower self-esteem than children with otherchronic illnesses such as diabetes (11), and self-con-cept of school functioning has been found to have astronger relationship with adaptive functioning inchildren with epilepsy than in children with othermedical conditions (12). For children with epilepsy,lower self-esteem has been associated with decreasedacademic performance (13). Children who demon-strate both decreases in school self-concept and high-severity epilepsy have been found to be at most riskfor educational problems over time (12). Lower self-esteem may result from the significant stigma thatcontinues to be attached to epilepsy as both childrenwith epilepsy and controls have been found to at-tribute more shame and guilt to incompetence due toepilepsy than to incompetence due to other illnesses(14).

Attention and memory difficulties have specificallybeen associated with school performance in childrenwith epilepsy (1). In a study examining satisfactoryversus unsatisfactory academic performance, verbalmemory and attention skills were found to be weakerin children with epilepsy demonstrating unsatisfac-tory academic progress, while visual–spatial abilities,problem-solving skills, nonverbal memory, and motorskills were intact (15). Lateralized memory dysfunc-tion, typically found in adults with temporal lobeepilepsy, has not been consistently reported in chil-dren (4), and memory difficulties are noted for chil-dren with an extratemporal seizure focus (16). Bothmemory and attentional difficulties have been foundregardless of seizure type, suggesting a diffuse neuro-cognitive process.

Family factors have been reported to significantlypredict problems in academic achievement for chil-dren with epilepsy. In a study by Mitchell et al. (17),low socioeconomic status and cultural variables werethe major determinants of underachievement. Recentdiagnosis versus longstanding diagnosis and treat-ment did not distinguish between children who were
underachieving.
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In addition to these factors, demographic and sei-zure variables have been examined in relation to aca-demic achievement in children with epilepsy. Al-though findings have been inconsistent, seizure vari-ables (e.g., seizure type, age of onset, duration,laterality of seizure focus) have not been strongly as-sociated with academic performance with the possibleexception of seizure severity (4). In a recent study ofacademic performance on standardized achievementtests, no epilepsy variables were found to have signif-icant relations with academic achievement in childrenwith epilepsy (6). Demographically, male gender hasbeen found in some studies to be a greater risk factorfor underachievement (8) although this finding hasalso been inconsistent.

A multietiological approach has been recommendedin research studies concerning the impact of epilepsyon psychosocial functioning (18). The present studyemployed a multietiological approach to: (1) assessacademic achievement in children with epilepsy; (2)examine the relationship between academic achieve-ment and self-esteem, attention, memory, and socio-economic status; and (3) determine the effects of sei-zure type, gender, and duration of epilepsy on cogni-tive and academic variables.

METHODS

Subjects

Children (n 5 65) diagnosed with epilepsy wererecruited on a consecutive basis through the outpa-tient neurology clinics at a large children’s hospital.Criteria for study inclusion were: age 8 to 13 years,anticonvulsant (AED) treatment for at least 6 months,AED monotherapy with no concomitant medicationsthat could have CNS effects, and seizures generallywell controlled (i.e., no more than four seizures in thepast 6 months). Children who had been treated forattention deficit hyperactivity disorder, had a historyof a severe head injury, or had been diagnosed withmental retardation or learning disabilities were ex-cluded from the study.

The mean age of children in the study was 10 years,5 months (SD 5 20 months). There were 37 females(57%) and 28 males (43%). Ethnicity was generallyreflective of the area served by the hospital, with 51Caucasian children (78%), 12 African- American chil-dren (18%), one Native American child (2%), and oneHispanic child (2%).

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219Achievement in Children with Epilepsy

Forty-four children were diagnosed with complexpartial seizures, and 21 were diagnosed with general-ized seizures. Of the children with complex partialseizures, 23 had experienced secondary generaliza-tion. One child had experienced status epilepticus. Allof the children had abnormal EEGs with the exceptionof one child with a normal EEG but a clinical seizuredescription that included tonic–clonic movements.Median time from diagnosis was 25 months (range 56–129 months). Of the total sample, 53 had a normalMRI or CT, one child had an abnormal MRI, and 11had not had neuroimaging. The majority of childrenwere treated with carbamazepine (n 5 28) or valproicacid (n 5 19). Other AEDs included phenobarbital(n 5 2), gabapentin (n 5 5), phenytoin (n 5 3),lamotrigine (n 5 3), and ethosuximide (n 5 5).

Procedure

The study was approved by the Institutional Re-view Board. Written consent was obtained from par-ents and written assent was obtained from each childin the study. Only one child who met eligibility for thestudy criteria refused to participate. Testing of thechildren was accomplished at the time of their clinicvisit and lasted approximately 11

2 hours.AED serum levels (Table 1) were obtained for 38 of

he children on the day of testing, while 11 childrenad levels drawn within 2 weeks of the assessment.he 5 children on gabapentin did not have blood

evels drawn, but none had experienced any furthereizures. Of the remaining children, 9 had levelsrawn within 6 months of the assessment, and 2 chil-ren, who had a longstanding history of therapeuticerum levels based on medical record review, haderum levels drawn more than 6 months before thessessment. Fifty-four of the children had serum levels

TABLE 1

Serum Levels of AEDs

AEDNumber of

subjectsExpected range

(mg/liter)

Serum level

Mean Range

arbamazepine 28 4–12 6.2 0.8–12alproic acid 19 50–100 76.6 25.3–107.7henobarbital 2 10–20 10.9 10.6–11.1abapentin 5 Not establishedhenytoin 3 10–20 10.7 8–12.9amotrigine 3 4–18 7.2 2.5–12.3thosuximide 5 45–100 52.6 12.3–69.2

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ithin the therapeutic range, and 6 children had AEDevels below the therapeutic range.

The majority of children (n 5 48) had not had aeizure within the last 6 months, 2 children had hadne seizure, 6 children had had two seizures, 8 chil-ren had had three seizures, and one child had had

our seizures. Parent and school report as well aseview of the medical record determined seizure oc-urrence.

easures

Parents were given a questionnaire concerning de-ographic information. Socioeconomic status (SES)as based on parental reporting of educational and

ccupational levels which resulted in a composite in-ex score (19).Children were tested individually by a psychologi-

al examiner or psychologist with a test battery thatncluded measures of intelligence, attention, verbal

emory, self-esteem, and academic achievement.Each child was given the verbal section of the Kauf-an Brief Intelligence Test (K-BIT) (20) as a screeningeasure of verbal intelligence. This test assesses the

hild’s word knowledge and verbal concept forma-ion.

Attention was assessed with the Number Letteremory subtest from the Wide Range Assessment ofemory and Learning (WRAML) (21). The Number

etter subtest requires the child to immediately recallombinations of numbers and letters of increasingength, and has been found to differentiate betweenhildren with attention deficits and normal controls22).

Verbal memory was assessed with the Californiaerbal Learning Test—Child Version (CVLT-C) (23)nd Story Memory from the WRAML. The CVLT-Cnvolves a 15-item word list that is repeated over fiverials and measures new learning. The total recallcore for the CVLT-C is based on the five learningrials. Story Memory requires the child to recall infor-

ation from meaningful stories.Self-esteem was measured with the Self-Esteem In-

ex (SEI) (24), an 80-item paper-and-pencil self-reportnventory. The child uses a Likert-type scale to rate herr his perceptions of personal traits and characteris-ics. During the study, if the child had any difficultyeading or understanding terms, the examiner readhe items or defined words as requested by the child.he SEI provides an overall quotient as well as fourubscales including Familial Acceptance Scale, Aca-

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demic Competence Scale, Peer Popularity Scale, andPersonal Security Scale. In previous research, bothglobal self-concept and self-concept of academic abil-ity have been found to correlate positively with aca-demic achievement although self-concept of academicability has been found to be more strongly related toacademic achievement (25).

Academic achievement was evaluated with theWoodcock–Johnson Tests of Achievement—Revised(WJ-R) (26). Children were administered the Letter–Word Identification, Dictation, and Applied Problemssubtests, which measure reading recognition, spelling,grammar, and math conceptual skills. These subtestsare combined into an Early Development Skills Clus-ter Score.

Statistical Analysis

Descriptive statistics were used to examine aca-demic achievement, cognition, attention, memory,SES, and self-esteem.

A stepwise regression analysis was employed todetermine the relationship between achievement andthe four primary factors (self-esteem, attention, mem-ory, and SES) while controlling for verbal IQ. Corre-lations and partial correlations controlling for verbalIQ were examined to limit the number of terms re-

TABLE 2

Means (SD) of Variables Measured in Children with Epilepsy(n 5 65)

Variable

Mean (SD)

Sample Expected

erbal IQ (SD) 95.6 (12.5) 100 (615)ocioeconomic Status 37.5 (11.4) Range 5 0–66

Skills Development 96.9 (11.7) 100 (615)Letter/WordIdentification 100.5 (13.4) 100 (615)Dictation 91.6 (9.7) 100 (615)Applied Problems 102.8 (13.6) 100 (615)

AttentionNumber/Letter Memory 7.7 (2.5) 10 (63)

MemoryCVLT-C Total Recall 53.5 (8.6) 50 (610)Story Memory 8.8 (2.8) 10 (63)

Self-esteemOverall Quotient 106.9 (15.5) 100 (615)Familial Acceptance 11.5 (2.6) 10 (63)Academic Competence 12.4 (4.3) 10 (63)Peer Popularity 11.2 (3.0) 10 (63)Personal Security 9.4 (3.4) 10 (63)


quired in the regression analysis. Due to the extremelyhigh correlation between verbal IQ and achievement,significance level for entry into the regression analysiswas set at 0.15 to control for possible type II errors, theprobability of accepting no significance falsely. Be-cause this was a high level of significance, results werevalidated by running several 90% randomly selectedsamples through the same stepwise regression.

Epilepsy and demographic variables including du-ration, seizure type, gender, and type of AED wereexamined with the use of t tests.

RESULTS

Means and standard deviations for the variablesmeasured are found in Table 2. Verbal IQ, academicskill development, verbal memory skills, and self-es-teem were within the average range. Mean SES wasreflective of skilled craftsmen, clerical workers, andsalespersons. The only lower than expected meanscore was on Number Letter Memory, which waswithin the low average range. Performance on thistask suggested decreased auditory attention.

The following variables were entered into the step-wise regression analysis: verbal IQ, CVLT-C Total Re-call, Story Memory, Number Letter Memory, SEIComposite Score, SES, and interaction terms with ver-bal IQ. The SEI Composite Score was chosen as themeasure of self-esteem as it was more highly corre-lated with skill development (r 5 . 0.33) than theAcademic Competence score (r 5 . 0.25). The SkillDevelopment Composite Score was employed as thedependent measure. Results indicated that verbal IQand attention were significantly associated with aca-demic achievement for these children (Table 3). Ran-domly selected 90% subsamples resulted in P valuesfrom 0.04 to 0.14 for entry of Number Letter Memory.When the total sample was included, significance forentry was 0.14.

TABLE 3

Results from Stepwise Regression Analysis Concerning VariablesAssociated with Early Achievement Skills

Predictor

Early Skills Development

R2 t P

Verbal IQ 0.62 8.64 0.000Attention (Number letter) 0.64 1.49 0.142


T tests were performed on verbal IQ, CVLT-C TotalRecall, Story Memory, Number Letter Memory, Self-Esteem Composite, Skills Development, and SESbased on duration of epilepsy, gender (female vsmale), seizure type (complex partial vs generalized),and type of AED (carbamazepine vs valproic acid).Duration of epilepsy was composed of two groupsinvolving children who had been treated for epilepsyfor less than 24 months (n 5 32) and children whohad been treated for more than 24 months (n 5 33).Comparisons for possible medication effects werebased on children taking carbamazepine (n 5 28) orvalproic acid (n 5 19) as the majority of subjects weretreated with one of these anticonvulsants. There wereno significant differences in IQ, SES, academic skills,verbal memory, self-esteem, or attention based on du-ration of epilepsy, gender, seizure type, or type ofAED. Results of comparison of variables based onAED type are found in Table 4.

DISCUSSION

Results suggested that children with epilepsy in thepresent study, who generally had well controlled, id-iopathic or cryptogenic epilepsy and therapeutic AEDlevels, performed within expectations for their mea-sured abilities on standardized academic achievementtests. This finding is supported by a recent study inwhich children with inactive or low-severity epilepsydemonstrated achievement that was comparable tonational norms (27).

There was no evidence of lower global or academicself-esteem in these children, which is in contrast tothe outcome reported by Hoare and Mann (11). How-ever, in their study, 25% of the children with epilepsy

TABLE 4

Comparison of Group Performances Based on AED Type

VariableCarbamazepine

(n 5 28)Valproic acid

(n 5 19)

Verbal IQ (mean) 94.6 95.6Socioeconomic Status (mean) 34.5 38.5Skills Development (mean) 96.5 96.1Number/Letter Memory

(mean) 7.6 7.8CVLT-C Total Recall (mean) 53.5 54.6Story Memory (mean) 8.5 9.7Self-Esteem Quotient (mean) 107.6 106.6

had more than one seizure per month and 15% hadintractable seizures. It has been suggested that as sei-zure frequency increases, children with epilepsy maybe more vulnerable to problems with affect and self-esteem (28). Severity of epilepsy may account for dif-ferences in findings concerning self-esteem. Presentfindings are supported by a recent study (29) thatfound no differences between children with well con-trolled epilepsy and age-matched healthy children ona self-report measure of well-being (i.e., self-esteem,alertness, mood, elation, stability, and vitality).

Memory skills were within the average range forlearning new verbal information and recall of complexprose. Auditory attention skills were lower than ex-pected based on performance on Number Letter Mem-ory, which is highly sensitive to inattention. Thesefindings are in agreement with an earlier study thatdemonstrated intact memory skills, but subtle difficul-ties with attention in children with epilepsy who hadno diagnosed learning or behavioral disorders (30).

As in previous studies, we did not find differencesin achievement based on duration of epilepsy, type ofAED, or seizure type. It has been suggested that dis-tinguishing between epilepsy syndromes and seizuretypes may assist in determining the impact of epilepsyon achievement. In one study, children with second-ary generalization whose seizure disorder was associ-ated with a diffuse or multifocal acquired brain insultperformed more poorly in achievement and schooladaptation than children with other epilepsy syn-dromes (28). The underlying etiology may be morerelated to decreased achievement than specific seizuretype.

The most critical finding in this study was the rela-tionship between achievement and auditory attention.While past research has consistently demonstrated adisruption of attention skills in children with epilepsywith either normal intellectual functioning or loweredIQ (31), the present study demonstrates a link betweenauditory attention skills and academic performance inthese children. Even though verbal intelligence ac-counted for the greatest amount of variance in aca-demic skills, auditory attention made a unique contri-bution to academic achievement. Attention skills weremore predictive of academic performance than self-esteem, memory, SES, or epilepsy variables.

The association between attention and achievementmay be a key to understanding decreased academicperformance in children with epilepsy (32). A moregeneralized pattern of inattention, regardless of sei-zure type, may reduce the ability to attend to auditory


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information within the environment, resulting in de-creased achievement. This hypothesis would explainthe absence of specific learning disability subtypesand would lend support to growing evidence for acommon underlying neurological abnormality as theprimary contributor to specific cognitive difficulties inchildren with epilepsy (33). As suggested by Stores(34), the disruption of either subcortical or corticalmechanisms may result in reduced attention skills.

The present study did not include children withsymptomatic epilepsy, intractable seizure disorders,learning disabilities, and/or attention deficit hyperac-tivity disorder which limits generalization of findingsto these groups. Examination of these factors in rela-tion to attention and academic achievement would beimportant. Determination of whether attention skillsdecrease with more severe epilepsy and comorbidconditions and are significantly associated with un-derachievement would strengthen present findingsand lead to possible academic interventions. In addi-tion, a prospective investigation of the relationshipbetween these variables and self-esteem would in-crease our understanding concerning direction of cau-sality. Continued use of a multietiological model isstrongly recommended.

ACKNOWLEDGMENTS

Appreciation is expressed to G. T. Spence and Susan Jeter, Psy-chological Examiners, for assistance in patient assessment and toAmy Hendon, Research Assistant, for assistance in data collection.

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