Maximizing School Functioning and the School-to-work Transition

Michael Seidenberg

David C. Clemmons

Introduction

Epilepsy is a common childhood neurologic disorder, affecting approximately 5 to 10 children in every 1,000. The vast majority of people with epilepsy begin having their seizures during the childhood years, and for many, the seizures persist for an extended period of time.²² Thus, the view of epilepsy as a potentially chronic childhood disorder has important implications for long-term academic, social, and vocational adjustment.³⁸

In this chapter, we discuss issues relevant to maximizing school and vocational adjustment in children and adolescents with epilepsy. A basic theme of this chapter is that a multidisciplinary assessment and intervention approach offers the most effective means to (a) identify children in need of educational or vocational services, (b) determine the nature and extent of services needed, and (c) develop effective intervention programs. The use of a multidisciplinary approach recognizes that multiple factors potentially influence academic and occupational development and requires the involvement of professionals from various disciplines (e.g., medicine, education, psychology, social service) as well as the participation of the family and the child. A major practical challenge for implementation of a multidisciplinary assessment and treatment approach is the establishment of the community linkages that enable the members of the various disciplines to interact effectively.

We begin with a review of the current data concerning the nature and extent of academic difficulties among children with epilepsy. Next, we discuss the factors that have been shown to be associated with academic vulnerability among children with epilepsy and their implications for evaluation and intervention. The final section provides the rationale for school-to-work transition programs along with a description of an integrated and comprehensive vocational intervention and training program.

Finally, although the specific condition of epilepsy is discussed here, the academic and vocations problems of many youth with epilepsy are often similar to those of persons with other neurologic conditions affecting the central nervous system (e.g., traumatic brain injury, stroke, multiple sclerosis, etc.). Thus, impairment of cognitive factors such as attention, memory, “multitasking,” problem solving, and overall cognitive efficiency may be more important determinants of academic and vocational success than is their specific etiology. This is not always immediately apparent to many service providers, including many counselors and vocational advisors without specific training in this area.

School Performance of Children with Epilepsy

One can identify three basic questions in considering the school performance of children with epilepsy: (a) Is there increased risk of learning problems? (b) Why are there learning problems? (c) What can be done to help those children with learning problems?

Increased Risk of Learning Problems

A precise estimate of the incidence of academic difficulties among children with epilepsy is hampered by several important methodologic issues. First, most studies reported in the literature examined children seen at tertiary medical centers or specialized epilepsy centers. These children are unlikely to provide a representative sampling of children with epilepsy (e.g., seizure severity, seizure control), and this introduces a selection bias into the determination of the occurrence of academic dysfunction in this population. Second, many of the early studies did not employ objective and standardized measures of academic functioning and instead relied on teacher or parent ratings. Such ratings are potentially biased and invalid estimates of a child’s functioning.

With these limitations in mind, and even though many children with epilepsy have minimal or no significant learning problems, there is considerable evidence of an increased risk for learning and academic problems in this population.¹^,⁵^,¹⁶^,³²^,³⁴^,⁴⁴ Although initial reports focused on reading skills, subsequent studies have shown that problems are often present in academic areas other than reading as well. Seidenberg et al.³⁶ reported that a substantial percentage of children with epilepsy being treated at a tertiary epilepsy center experienced significant levels of academic underachievement in four academic areas: (a) word recognition, (b) reading comprehension, (c) spelling, and (d) arithmetic.

Reasons for Learning Problems

The factors underlying academic vulnerability in children with epilepsy are multivariate, and one can anticipate the need to consider a variety of factors in attempts to establish a comprehensive evaluation and treatment program.²^,³⁸ Seidenberg³⁵ identified four factors as important potential mechanisms linking epilepsy and academic difficulties: (a) seizure correlates,
(b) neuropsychological correlates, (c) medication effects, and (d) psychosocial correlates. Again, it is emphasized that an intervention that identifies the seizures themselves as the only or as the main focus of attention is likely to fall short of a student’s needs.

Seizure Correlates of Academic Dysfunction

The determination of seizure-related correlates of academic dysfunction would be of potential use for early identification and screening of “at-risk” children. Clinical seizure correlates such as focal left-hemisphere spikes, early age of seizure onset, and seizure control have been implicated in some studies.^23.40 However, the findings have been inconsistent concerning the relationship of these variables to academic functioning.¹⁰^,²⁴ Seidenberg et al.³⁶ found that the combined predictive significance of several clinical seizure characteristics (e.g., seizure type, age of seizure onset, seizure control, number of medications, laterality of electroencephalographic [EEG] abnormality) for academic achievement was moderate (between 6% and 17% of the variance). Thus, although knowledge of various aspects of seizure history and seizure characteristics is critical to the diagnosis and medical management of children with epilepsy, this information may be of more limited value in predicting academic outcome. Of interest for the current chapter, similar findings have been reported for predicting vocational adjustment and independent living of adolescents with epilepsy.¹⁵

Neuropsychological Correlates of Academic Dysfunction

In many instances, the academic difficulties do not reflect a generalized intellectual impairment, but instead are related to specific areas of cognitive deficit(s).⁹ Impairments in attention and concentration have commonly been linked to academic dysfunction.³^,⁴^,⁴⁰^,⁴⁴ Seidenberg et al.³⁷ compared two groups of children with epilepsy—a group making adequate academic progress (AA) and a group making poor academic progress (UA)—on a battery of neuropsychological measures. Findings indicated that the UA group was distinctly impaired on measures of auditory perceptual skills, verbal memory, and attention and concentration relative to the AA group. The importance of these specific cognitive areas for academic functioning has been well documented in studies of learning-disabled children.³¹^,⁴²

Furthermore, similar to what is found in the broader learning disability literature, the nature of the underlying cognitive deficits associated with academic dysfunction is not similar for all children with epilepsy. Rather, there appear to be distinctive subtypes of learning deficits among children with epilepsy. A preliminary classification of “subtypes” of learning-disabled children with epilepsy was recently presented.¹ These workers proposed four distinct groups and possible seizure-related features that characterize them: (a) memory-deficit subtype, characterized by specific impairment in memory and learning (a relationship to temporal lobe dysfunction is suggested for these children); (b) attention-deficit type, characterized by global academic underachievement (this group was represented by a high frequency of children with generalized tonic–clonic seizures); (c) speed-factor type, which showed slower information processing and was found to be correlated with polytherapy and long-term treatment with phenytoin; and (d) problem-solving type, characterized by impairments in higher-order cognitive processes such as verbal reasoning and concept formation.

It is not surprising that cognitive deficits are an important mediating factor for school performance. These findings indicating cognitive subtypes serve to highlight the potential importance of detailed cognitive testing for identification and treatment planning for children at risk for academic dysfunction.

Medication Factors

The American Academy of Pediatrics Committee on Drugs³ has called attention to the important effects that antiepileptic drugs (AEDs) can have on cognition and behavioral functioning of children with epilepsy. Several methodologic issues concerning the potential effects of AED on behavior remain open for study, including specific drug type effects, age at time of testing, and drug serum levels. Several investigators have documented the ill-advised use of polytherapy⁴³ and the adverse effects of phenobarbital on cognitive performance.¹⁷ However, the cost–benefit analysis of seizure control versus side effects or direct negative effects of anticonvulsant medication on behavior is quite complicated. Once again, this issue emphasizes the need for data from multiple people involved in the treatment of the child to develop an effective treatment plan.

Psychosocial Factors

Taylor⁴¹ described the “predicament of epilepsy,” which extends beyond the medical neurologic aspects of the seizures themselves and touches on various parts of the person’s life and interaction with the environment. Several investigators have reported an association between academic dysfunction and social environmental factors such as teacher attitudes, parental attitudes and expectations,²¹^,²⁵ child self-esteem, and perceptions of reasons for school success and failure.²⁶ These environmental and behavioral or temperamental features are critical for the establishment of treatment programs to foster educational and vocational development. Freeman et al.²⁰ described a school-based program for children with epilepsy that included assessment and treatment of psychosocial problems (e.g., counseling, epilepsy education) as a critical component as well as vocational and more traditional academic programming. Findings indicated a decrease in school dropout rate and an increase in the numbers of students who later became employed or entered higher education programs or vocational training programs.

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