1. Northeast Regional Epilepsy Group
Do children with epilepsy have
cognitive problems?
How to ensure success in school 1

2. Director Clinical Neuropsychology
Robert W. Trobliger
Director Clinical Neuropsychology
NEREG 2

3. Among adults with epilepsy, complaints of:
slowed mental processes
problems with attention
problems with memory
are common

4. Executive functioning Memory Language
Children with epilepsy often present with problems with cognitive functioning involving:
Attention
Executive functioning
Memory
Language 4

5. Children with epilepsy obtained lower scores than controls across measures of cognition and higher scores on measures of behavioral issues.
2003 5

6. Problems with cognitive functioning
are related to
and can cause
other problems

7. language difficulties
learning difficulties and
poor academic performance
behavioral problems
poor socio-professional prognosis 7

8. Despite similar intelligence and educational background, significantly more patients with epilepsy (51%) than control subjects (27%) required special educational services.

9. Factors behind cognitive difficulties among children with epilepsy

10. Epilepsy is a symptom rather than the cause of brain dysfunction.10

11. There are structural changes that precede seizure onset

12. Some studies show that in newly diagnosed and untreated
Some studies show that in newly diagnosed and untreated patients with epilepsy, cognitive problems are already present in more than 50% of patients

13. Epilepsy can cause changes within the brain
which can further affect cognitive functioning 13

14. An ongoing epileptogenic process can irreversibly damage the brain, especially the maturing brain, even if seizures are controlled

15. and can cause persistent changes in cognitive functioning and global intellectual deficits

16. Need for monitoring and treatment

17. factors which can impact changes in cognitive functioning:
seizure type
age of onset
severity and frequency of seizures 17

18. anatomical location and etiology
and side effects of antiepileptic drugs. 18

19. In addition to seizures, there are associated disorders
which can impact functioning

20. Attention Deficit Hyperactivity Disorder (ADHD)20

21. ADHD – Combined Presentation
ADHD subtypes
ADHD – Combined Presentation
ADHD – Predominantly Inattentive Presentation
ADHD – Predominantly Hyperactive-Impulsive Presentation
Other Specified ADHD
Other Nonspecified ADHD 21

22. People with ADHD show a persistent pattern of inattention
DSM-5 Criteria
People with ADHD show a persistent pattern of inattention
and/or hyperactivity-impulsivity that interferes with functioning or development: 22

23. Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level: 23

24. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
Often has trouble holding attention on tasks or play activities.
Often does not seem to listen when spoken to directly.
Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
Often has trouble organizing tasks and activities.
Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
Is often easily distracted
Is often forgetful in daily activities.

25. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person's developmental level: 25

26. Often fidgets with or taps hands or feet, or squirms in seat.
Often leaves seat in situations when remaining seated is expected.
Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
Often unable to play or take part in leisure activities quietly.
Is often "on the go" acting as if "driven by a motor".
Often talks excessively.
Often blurts out an answer before a question has been completed.
Often has trouble waiting his/her turn.
Often interrupts or intrudes on others (e.g., butts into conversations or games)

27. In addition, the following conditions must be met:
Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
Several symptoms are present in two or more setting, (e.g., at home, school or work; with friends or relatives; in other activities).
There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.
The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). 27

28. Prevalence in the general population
11% of US school aged children received a diagnosis of ADHD
by a health care provider by 2011
as reported by parents 28

29. 6.4 million children including 1/5 high school boys
1/11 high school girls 29

30. among children with epilepsy between 12 and 17% between 20 and 40%
Dunn DW, Kronenberger WG  
Kaufmann R, Goldberg-Stern H, Shuper A   30

31. higher occurrence of ADHD – inattentive type
seizure/epilepsy variables do not seem to be important correlates 31

32. Regarding attention, there may be problems managing both internal and external stimuli.

33. Problems with attention – internal33

34. Internal distractions – thought processes

35. Which can include concentrating on managing their own behavior, which can cause problems actually focusing on lessons

36. 2015 study demonstrated that children with ADHD allowed to move functioned better on working memory tasks
Authors suggested that the results likely would generalize to the classroom, allowing children to likely spend less time trying to control themselves 36

37. opportunities to move while working standing up while working
In Classroom:
opportunities to move while working
standing up while working
sewing pedal for tapping
squeeze balls while listening/reading 37

38. Fidget spinners?

39. Problems with attention – external

40. Problems managing distractibility – sights and sounds

41. Preferential seating in the classroom

42. Separate location for tests/quizzes

43. Extra time for tests/quizzes

44. Quiet place to work at home

45. managing distractions tv, radio, internet, phones45

46. other people can be a distraction

47. other work on a table/desk can be a distraction
(or anxiety producing)

48. Problems with Executive Functioning48

49. organizing/prioritizing tasks planning/breaking down tasks
starting tasks
organizing/prioritizing tasks
planning/breaking down tasks
catching/correcting mistakes (self monitoring)
finishing tasks 49

50. Memory Problems 50

51. Problems with Learning
Often Linked to Attention Problems

52. How to address these problems?52

53. WORK HARDER 53

54. WORK HARDER
DO BETTER 54

55. WORK HARDER
DO BETTER
DO MORE

56. perhaps not best approach56

57. programs, accommodations
school services –
programs, accommodations 57

58. IEP – special services plus accommodations
through the Individuals with Disabilities Education Act (IDEA) 58

59. requires school to provide
an individualized education program (IEP)
designed to:
meet a child's unique needs
and set up measurable growth/goals
through accommodations, modifications, therapies, class placements or even different school settings

60. 504 plan – accommodations
civil rights law that ensures that a child with a disability has equal access to an education, through accommodations and modifications. 60

61. What are some accommodations? Highlighted textbooks
Extra set of textbooks for home use
Extended time on tests or assignments
Separate location for tests/quizzes
Peer assistance with note taking
Frequent feedback 61

62. Enlarged print
Positive reinforcements
Behavior intervention plans
Rearranging class schedules
Visual aids
Preferential Seating
Oral tests

63. silent reminders from teachers regarding behaviors
visual reminders including:
schedules on the board
assignments on board (same place, each day) so can be copied easily
recognizing good behavior
immediately pointing out off task behavior 63

64. Diagnoses warranting Services/Accommodations
ADHD

65. Diagnoses warranting Services/Accommodations
Autism

66. Repetitive behaviors
Issues with social communication
Issues with social interaction

67. About 5% of children with epilepsy develop autism as well.

68. Learning Disorders
Reading
Written Expression
Mathematics 68

69. About 25% of patients with epilepsy have a comorbid learning disorder

70. The diagnosis requires persistent difficulties in
reading, writing, arithmetic, or mathematical reasoning skills
during formal years of schooling. 70

71. Symptoms may include:
inaccurate or slow and effortful reading
poor written expression that lacks clarity
difficulties remembering number facts
or inaccurate mathematical reasoning

72. Academic skills must be well below the average range of scores in
culturally and linguistically appropriate tests of reading, writing, or mathematics.

73. The individual’s difficulties must not be better
explained by developmental, neurological, sensory (vision or hearing), or motor disorders and must significantly interfere with academic achievement, occupational performance, or activities of daily living.

74. Differences between expectations and performances based on history
Usually assessed with formal evaluations of IQ and academic achievement

75. When ability levels are lower than expected given overall level of functioning (IQ),
special education classes may be necessary for further development of skills 75

76. Special Education Classes:
Pull out/Push in class
Integrated Classroom
Self-Contained Class

77. How to get those accommodations?
Contact the school regarding setting up a meeting regarding a potential need for special education services

78. Schools typically have professionals available to do evaluations to determine appropriateness of services
However, neuropsychologists can also do these types of evaluations with particular foci on signs of ADHD, autism, executive issues, and learning/memory difficulties

79. Treating neurologists typically refer children with academic issues for a neuropsychological evaluation to aid the process of getting said services

80. Importance of letting treating neurologist know about any concerns about
cognitive functioning
(problems focusing, remembering)
and academic functioning
(problems grasping concepts, grade retention, poor grades)

81. Following referral for neuropsychological evaluation
Actual Evaluation
Feedback with report provided

82. Recommendations:
Changes in environment/
approach at school

83. Recommendations:
Changes in
environment/
approach at home

84. Minimizing potential distractions such astv
radio
internet
phone 84

85. Learning how to study
Avoiding cramming
Spreading out studies over the course of several days
(“overlearning”)

86. Learning how to study
Studying with other people
Quizzing each other
Self-quizzing

87. Executive Skills –
Planning/Organization
Managing Workloads
Learning how to break down a project
Learning how to break down a reading assignment

88. Planning/organization Keeping track of assignments on paper
Executive Functions-
Planning/organization
Keeping track of assignments on paper
Putting homework assignments to complete in folder
Pausing before leaving school to make sure have all needed papers/books
Immediately putting away assignments in folder upon completion 89

89. Executive Functions –
Planning/Organization
Making checklists of assignments and projects
Using a calendar to plan ahead critical points

90. Executive Functions-
Prioritizing/Organization
approach most difficult work first
shifting to other work or taking breaks as necessary

91. Executive Functions
Planning/Organization
brainstorming ideas for writing
making notes/outline
drafts/editing
asking others to review work

92. Students need to be taught these skills93

93. Skills can be taught.

94. Medication?

95. increased by 28% between 2007 and 2011 4.8% in 2007 6.1% in 2011
percentage children ages 4-7 years taking medication for ADHD, as reported by parents
increased by 28% between 2007 and 2011
4.8% in 2007
6.1% in 2011
average increase about 7% per year 96

96. 43% were treated with medication alone
2009 – 2010 national sample of children with special needs, ages 4-17 years
Most children with ADHD (9/10) received either medication or therapy or both
Of those:
43% were treated with medication alone
13% received behavior therapy alone
31% were treated with a combination

97. ADHD medications can lower seizure threshold 98

98. Contacting school regarding potential need for services/accommodations
What can parents do?
Contacting school regarding potential need for services/accommodations
Regular communication with teachers/school staff
regarding concerns and medical issues
Helping children organize/manage assignments
Helping children get started on tasks, moving back/helping as needed
Checking over children’s work 99

99. Summary
Children with Epilepsy
cognitive difficulties

100. Summary
Children with Epilepsy
academic problems

101. Summary
Children with Epilepsy
Neuro-developmental and Behavioral Issues

102. Difficulties can be managed
with
school services/accommodations

103. Difficulties can be managed with
communication with school staff

104. Difficulties can be managed with
strategies at home

105. Difficulties can be managed with
medication
(where appropriate)

106. Difficulties can be managed with therapy

107. Treatment is ongoing and involves many people.

108. Medical staff need to be updated on changes in functioning (cognitive, academic, and behavioral) so that changes in treatment can be made.

109. Regular meetings with school staff can be helpful regarding making changes in programs and charting a child's progress

110. Children need to feel supported and encouraged.

111. Thank you and questions

112. References
Beghi, M., Cornaqqia, C.M., Frigeni, B., and Beqhi, E. (2006). Learning disorders in epilepsy. Epilepsia, 47 (Suppl 2),
Berg, A.T., Plioplys, S., and Tuchman, R. (2011). Risk and correlates of Autism Spectrum Disorder in Children with Epilepsy: A Community-Based Study. Journal of Child Neurology, 26(5),
Centers for Disease Control and Prevention
Dunn DW, Kronenberger WG. Childhood epilepsy, attention problems, and ADHD: Review and practical considerations. Seminars in Pediatric Neurology. 2005;12:222–8.  . 

113. Hermann, B. and Seidenberg, M. (2007). Epilepsy and cognition
Hermann, B. and Seidenberg, M. (2007). Epilepsy and cognition. Epilepsy Currents, 7(1),
Kaufmann R, Goldberg-Stern H, Shuper A. Attention-deficit disorders and epilepsy in childhood: Incidence, causative relations and treatment possibilities. Journal of Child Neurology. 2009;24:727–33
Oostrom, K.J.,  Smeets-Schouten, A., Kruitwagen, C.L., Boudewyn Peters, A.C., & Aagje Jennekens-Schinkel, A. (2003). Not Only a Matter of Epilepsy: Early Problems of Cognition and Behavior in Children With “Epilepsy Only”—A Prospective, Longitudinal, Controlled Study Starting at Diagnosis. Pediatrics, 112 (6),
Reilly, C.J. (2011). Attention deficit hyperactivity disorder (ADHD) in childhood epilepsy. Research in Developmental Disabilities, 32(3),
NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

114. References
Sarver, D.E., Rapport, M.D., Kofler, M.J., Raiker, J.S., and Friedman, L.M. (2015). Hyperactivity in Attention Deficit Hyperactivity Disorder (ADHD): Impairing Deficit or compensatory behavior? Journal of Abnormal Child Psychology, 43 (7),
van Rijckevorsel, K. (2006). Cognitive Problems related to epilepsy syndromes, especially malignant epilepsies. Seizure, 15(4),
You, S.J. (2012). Cognitive function of idiopathic childhood epilepsy. Korean Journal of Pediatrics. Vol. 55 (5),