|Ahead of print
Epilepsy in children: Cognitive development and academic performance
Aayushi N Kacheria, Sujata V Kanhere, Anjalee Goel
Department of Pediatrics, K.J. Somaiya Medical College, Hospital and Research Centre, Mumbai, India
|Date of Submission||26-Apr-2022|
|Date of Decision||22-Jul-2022|
|Date of Acceptance||16-Sep-2022|
|Date of Web Publication||30-Jan-2023|
Sujata V Kanhere,
Department of Pediatrics, K.J. Somaiya Medical College and Hospital, Eastern Express Highway, Sion, Mumbai 400022
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: Majority of epilepsy begins in childhood and may adversely affect cognitive development making children with epilepsy (CWE) vulnerable to educational problems. Paucity of studies from India evaluating the cognitive development and academic performance of school-going CWE emphasizes the need for this study. Aims: The aim of this article is to assess the cognitive development and academic performance of school-going CWE, between 6 and 12 years of age. Settings and Design: This cross-sectional study was carried out in the Pediatric Neurology Clinic in a tertiary level teaching hospital. Materials and Methods: Forty CWE aged 6–12 years, attending regular school, and taking anti-epileptic drugs were assessed for their cognitive development (IQ) using Malin’s Intelligence Scale for Indian Children and their academic performance using the school annual report card. Statistical Analysis: Tests of significance such as χ2, one-way analysis of variance, and Kruskal–Wallis test were used, P < 0.05 taken as statistically significant. Results: The mean IQ of CWE was 85.6. Sixteen children (42.1%) had an IQ of 90 and above, 15 (39.5%) had an IQ of 70–89, and 7 (18.42%) had Intellectual Disability (IQ<70). Eighty-five percent of CWE scored above 50% in their previous academic year. The category with a higher academic performance had a higher mean IQ (P = 0.001). The category with a lower academic performance had a higher mean number of seizures (P = 0.048). Conclusion: The majority of school-going CWE on treatment (81.58%) did not have intellectual disability with average-to-good performance in school. Seizure control affected academic performance positively.
Keywords: Academic performance, cognitive development, epilepsy, IQ
| Introduction|| |
Epilepsy is a common neurological condition. One-sixth of people with epilepsy reside in India., Majority of epilepsy begins in childhood, adversely affecting cognitive development and scholastic performance.,, Many children with epilepsy (CWE) have normal intelligence, but may not do well in school due to frequent seizures., Seventy percent of children with epilepsy can be successfully treated and school performance is not impaired if epilepsy is well controlled.,,, There is a need to evaluate cognitive development and academic performance in CWE in India. Hence, this study was undertaken.
| Materials and Methods|| |
A cross-sectional study was carried out in the Pediatric Neurology Clinic in a tertiary-level teaching hospital. Approval of the Institutional Ethics Committee was taken before starting the study. Sample size was taken as 40 CWE based on the medical records from the last 3 consecutive years corresponding to the study period. Universal sampling was done. All children between 6 and 12 years of age with epilepsy, taking anti-epileptic medication, being followed up at the Pediatric Neurology OPD, and attending regular school, were included in the study. Children with congenital anomalies, other chronic physical conditions, global developmental delay, and other comorbidities such as learning disabilities and attention deficit hyperactivity disorder were excluded from the study.
Parents of children attending Pediatric Neurology OPD in the study period were requested to answer a pretested validated questionnaire after taking written informed consent. History of epilepsy, including type, frequency, seizure history, history of medication, and pertinent perinatal history along with details of school performance, was obtained from the parent. Social factors affecting academic performance were noted.
The child’s Intelligence Quotient (IQ using MISIC—Malin’s Intelligence Scale for Indian Children) [Indian adaptation of WISC (Wechsler Intelligence Scale for Children)] was assessed by a child psychologist. The academic performance was evaluated using the school annual report card of the previous year. The results of the IQ test (MISIC) and the annual school report of the previous year were recorded in the data collection sheet.
Statistical analysis was done using the OpenEpi software (version 3.01). IQ tests were obtained for 38 of the 40 participants. Hence, all analyses involving IQ were restricted to 38 children. The descriptive analysis is presented as mean and standard deviation for numerical data and frequencies and percentages for categorical data. Appropriate statistical tests of significance such as χ2 test, one-way analysis of variance (ANOVA), and Kruskal–Wallis test were used, with P < 0.05 taken as statistically significant.
| Results|| |
This study was conducted in the Pediatric Neurology OPD in a tertiary-level teaching hospital. The study sample consisted of 40 CWE between the age of 6 and 12 years, attending regular school and taking anti-epileptic drugs.
The age distribution of the sample consisted of 9 (22%) children between the ages of 6 and 8 years, 14 (35%) children between the ages of 9 and 10 years, and 17 (43%) children between the ages of 11 and 12 years. Out of the 40 children in the study, 24 (60%) were males and 16 (40%) were females.
The seizure types varied with 77.5% having generalized onset seizures (26, i.e., 65% of the children having generalized tonic clonic seizures; 5, i.e., 12.5%, with absence seizures) and 9 (22.5%) with focal onset impaired awareness seizures. In this study, onset of seizures ranged from birth to 12 years, of which 4 (10%) children had seizures since birth (neonatal period), 16 (40%) had onset of seizures between the age of 1 month to 3 years, 5 (12.5%) had onset of seizures between 4 and 6 years, 8 (20%) had onset of seizures between 7 and 9 years, and 7 (17.5%) children had onset between 10 and 12 years.
In the study, an IQ test could be completed in 38 children, but 2 children could not complete the test due to ill health. Therefore, while analyzing the data for IQ with academic performance, n was considered as 38. The mean IQs were classified into three categories, based on the range. IQ of 90 and above was classified as average and above average, IQ of 70–89 as low average, and IQ of less than 70 as intellectual disability. There were 16 (42.10%) children with IQ of 90 or more, 15 (39.48%) with IQ between 70 and 89, and 7 (18.42%) with IQ less than 70.
[Figure 1] shows the mean IQs in the three categories to be 53.57, 84.33, and 100.89, respectively. In this study, 7 (18.42%) children belonged to the category of intellectual disability with IQ below 70, whereas 31 (81.58%) children had an IQ of 70 or more, with a mean IQ of 88.18. Three children had an IQ above 110 (above average), which were 112, 119, and 125, respectively. The mean IQ of the study population (38 participants) was 85.64, with that for males being 84.47 and for females being 87.64.
|Figure 1: Mean IQ values for the three IQ categories, where IQ is the intelligence quotient|
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Academic performance based on the percentage of marks obtained in the previous academic year was divided into three groups of 50% and below (A), 51–70% (B), and more than 70% (C) [Figure 2]. As per their school reports from the previous year (2017–18), 6 (15%) children scored 50% and below, 17 (42.5%) children scored between 51% and 70%, and 17 (42.5%) children scored above 70%.
Etiology was not a determinant of academic performance in the majority (31) of CWE. Out of the nine children in whom etiology was present, two out of four children with neonatal seizures, the child with birth asphyxia, and two out of three children with neonatal icterus had average or below average academic performance. However, the child with a history of prematurity had the highest IQ and above average academic performance.
As reported by parents, 8 (20%) participants in the study showed worsened academic performance over the last few years, whereas the parents of the other 32 (80%) participants noticed no significant difference [Figure 3]. Although no specific cause was found, some were attributed to low IQs, whereas others to poor seizure control.
|Figure 3: Has the child’s academic performance worsened in the last few years?|
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[Table 1] shows the mean IQ and mean number of seizures in each of the three groups based on academic performance. Using one-way ANOVA and Kruskal–Wallis test, respectively, mean IQs and mean number of seizures in the three categories of academic performance have been further analyzed, as shown in [Table 2A] and [Table 2B].
|Table 1: Summary of academic performance and correlation with seizure number and IQ|
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|Table 2A: Comparison of mean value of IQs in three categories of academic performance|
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|Table 2B: Comparison of mean number of seizures in the three categories of academic performance|
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[Table 2A] shows the comparison of mean value of IQs in the three categories of academic performance, with A = percentage of marks 50% and below, B = percentage of marks between 51% and 70%, and C= percentage of marks above 70%. Using the one-way ANOVA test, F= 10.403 with 2 df, P = 0.001, which shows that there is a statistically significant difference in the mean IQs in the three categories of academic performance. The table shows that the group with a higher percentage of marks had a higher mean IQ.
[Table 2B] shows comparison of mean number of seizures in the three categories of academic performance. The five children who secured 50% marks or less suffered from a higher number of seizures. The mean number of seizures in category A was 30, in category B was 12, and in category C was 4. Using the Kruskal–Wallis Test, the χ2 value is 6.060 with 2 df, P = 0.048, which shows that there is a statistically significant difference in the mean number of seizures in the three categories of academic performance. The table shows that the group with a lower percentage of marks had a higher mean number of seizures.
[Table 3] shows that there was no statistically significant difference in the IQ of the CWE among the categories of the four variables, namely, age of the child, socio-economic status, gender and age of onset of seizures as well as others including the parents’ education and occupation status.
|Table 3: Factors affecting cognitive development (IQ) in children with epilepsy|
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| Discussion|| |
Epilepsy is one of the commonest neurological disorders seen in children. As per WHO estimate, about 50 million people are living with epilepsy globally and approximately 2.4 million people are diagnosed with epilepsy annually. Recent epidemiological studies from India indicate higher rates of epilepsy among males, rural population, and lower socio-economic status.
The gender distribution of the given sample shows that out of the 40 children in the study, 24 (60%) were males and 16 (40%) were females. This is similar to gender distribution in a study on factors influencing the academic performance of schoolchildren with epilepsy, in which out of 50 CWE, 36 were males and 14 were females. Another study found that epilepsy was greatly associated with the male gender when compared with females.
In our study, using modified Kuppuswamy’s classification of socioeconomic status (2018), we found a larger proportion of the study sample belonged to the upper-lower class of socio-economic status. The socio-economic status of a patient may be a deciding factor for perception, attitude, and treatment compliance among adults. A study from Iceland found that there is an association between socio-economic status and epilepsy in adults, but not in children. Our study also did not find any such association.
Our study population consisted of children between 6 and 12 years of age. We found that generalized tonic clonic seizures were the most common seizure types accounting for 65% of all seizures followed by focal onset impaired awareness seizures (22.5%) and absence seizures (12.5%). Ibekwe et al., in a study about academic performance of 50 schoolchildren with epilepsy between 5 and 14 years of age, also found that the most common seizure type was generalized tonic clonic seizure in 58% of children. History of neonatal seizures has been associated with long-term epilepsy. In our study, only 10% of the children had seizures since birth.
Since majority of the epilepsy begins in childhood, it may have a serious impact on learning and development. Despite advances in the field of epilepsy, the effect of epilepsy on cognitive development is still not well understood. In recent times, the cognitive effects of epilepsy are being studied because these effects may hamper the child’s everyday life, such as their learning process, academic performance, and so on. In our study, the academic performance of only eight children (20%) has worsened over the last few years, as described by the mothers. However, 32 (80%) children showed consistent academic performance.
Strauss et al., in their study, stated that there was a linear decline in IQ seen in persons who developed epilepsy. Although cognitive problems are seen in CWE, they are not the norm. In our study, 42.1% of school-going CWE had average and above average cognitive development with a mean IQ of 100.89. These results are contrary to the findings of the Egyptian study in which they found that epilepsy had a negative effect on intellectual functioning. Bourgeois et al. found that the mean IQ for all CWE was 99.7 ± 20.2, which is higher than the mean IQ of our study. In another study, in which 60 CWE and 60 controls were studied, the mean IQ was found to be 77.96 ± 13 and the mean IQ of their control groups was 86.79 ± 8.66. However, in our study, the mean IQ of the study sample was 85.64, which was much higher than the mean IQ of their study sample and similar to their control group.
In our study sample, there was no significant difference, in the mean IQs, by gender. The mean IQ for males is 84.47 and the mean IQ for females is 87.64. However, another study on IQ in CWE found that females (IQ 72.77) had a significantly lower IQ when compared with males (IQ 82.21).
Camfield and Camfield, in their population-based epilepsy cohort study, reported that 20% of children had an IQ less than 70. In our study, 18.42% of the children fell into the category of intellectual disability with IQ less than 70, which is similar to their study. In a study conducted in Egypt evaluating intelligence in CWE, the prevalence of subnormal IQ (IQ <70) was higher at 33.33%. A few other studies also showed a large percentage of children, ranging between 20% and 30% of their study sample with epilepsy, having low cognitive function with an IQ <70.,,
Berg et al. in 2008 found that children whose seizures started below 5 years of age had a significantly lower IQ. Further, in a study by Cormack et al., onset of seizures at a younger age led to a higher chance of cognitive impairment. However, a study on frontal lobe epilepsy, childhood absence epilepsy, and benign epilepsy with centrotemporal spikes found that the type and duration of epilepsy have an impact on intellectual functioning, whereas age of onset did not. Another study, on IQ among CWE, has stated that age of the child or age of onset of epilepsy was not found to be a risk factor for intellectual dysfunction. In our study, although 62.5% of children had onset of seizures before 6 years of age, they did not show significantly lower IQs.
As per school reports from the previous year of all 40 children, we found that 6 (15%) children scored 50% and below marks, 17 (42.5%) scored between 51% and 70%, and 17 (42.5%) scored above 70%. This shows that academic performance of CWE attending school is good with 85% of children scoring above 50% of marks.
According to their academic performance of the previous year, those children (42.5%) with more than 70% marks had a mean IQ of 98.3. In the group with a higher percentage of marks, mean IQ was higher when compared with the other groups (P < 0.001).
A study by Dakwa and Mudyahoto found that seizures had an impact on children’s learning. They observed that even with normal intelligence, CWE do not perform well academically. In our study, children with a lower percentage of marks were found to have a higher mean number of seizures (P = 0.048).
Factors affecting cognitive development such as age of the child, socio-economic status, father’s education, father’s occupation, mother’s education, and mother’s occupation did not have an impact on the IQ of the children in our study.
The mean IQ of school-going CWE in this study was 85.6, where 42.1% had an average or above average IQ with a mean of 100.89 and only 18.4% CWE had intellectual disability. The overall academic performance of school-going CWE was average to good, with 85% of children scoring above 50% of marks. The group with a higher percentage of marks had a higher mean IQ and lower mean number of seizures. Since our study was a single center hospital-based study, further research on a global platform may be undertaken.
The first author carried out this research under the Short Term Studentship (STS) Program of Indian Council of Medical Research (ICMR) and received a research grant of Rs. 10,000. The corresponding author was the guide for this study. The authors acknowledge Dr. Dipak Patil, Associate Professor, Department of Community Medicine, for his help and guidance for statistical analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]