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

2 Co-Director Clinical NeuropsychologyRobert W. Co-Director Clinical Neuropsychology NEREG 2

3 Children with epilepsy obtained lower scores than controls across measures of cognition and behavior. 3

4 -executive functioningChildren with epilepsy often present with problems with cognitive functioning involving: -attention -executive functioning -memory -language. 4

5 Problems with cognitive functioning can cause other problems – notably social and academic difficulties

6 learning difficulties and poor academic performance behavior problems language troubles learning difficulties and poor academic performance behavior problems poor socio-professional prognosis Rijckevorsel (2006) 6

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

8 -executive functioning-attention -executive functioning -memory -language

9 Factors behind cognitive difficulties amongchildren 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 cognitive problems are already present in more than 50% of patientsSome studies show that in newly diagnosed and untreated epileptic patients, cognitive problems are already present in more than 50% of patients

13 Epileptic seizures 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 cognitive changes and global intellectual deficits

16 factors which can impact changes in cognitive functioning include: Regarding seizures factors which can impact changes in cognitive functioning include: seizure type age of onset severity and frequency 16

17 anatomical location and etiology psychosocial problems and side effects of antiepileptic drugs. 17

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

19 Attention Deficit Hyperactivity Disorder(ADHD) 19

20 ADHD – Predominantly Inattentive Type ADHD – Predominantly Hyperactive ADHD subtypes ADHD – Combined Type ADHD – Predominantly Inattentive Type ADHD – Predominantly Hyperactive -Impulsive Type Other Specified ADHD Other Nonspecified ADHD 20

21 DSM-5 Criteria People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development: 21

22 Often has trouble holding attention on tasks or play activities. 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: 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. 22

23 Often fidgets with or taps hands or feet, or squirms in seat. 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: 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) 23

24 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). 24

25 Prevalence in the general population11% of US school aged children received a diagnosis of ADHD by a health care provider by 2011 as reported by parents 25

26 6.4 million children including1/5 high school boys 1/11 high school girls 26

27 among children with epilepsy between 12 and 17% prevalence of ADHD 27

28 higher occurrence of ADHD – inattentive type seizure/epilepsy variables do not seem to be important correlates 28

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

30 Problems with attention – internal30

31 Internal distractions – thought processes

32 Which can include concentrating onmanaging their own behavior, which can cause problems actually focusing on lessons

33 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 33

34 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 34

35 Problems with attention – external

36 Problems managing distractibility – sights and sounds

37 managing distractions tv, radio, internet, phones37

38 other people can be a distraction

39 Preferential seating in the classroom

40 Separate location for tests/quizzes

41 Quiet place to work at home

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

43 Problems with Executive Functioning43

44 - organizing/prioritizing tasks - planning/breaking down tasks starting tasks - organizing/prioritizing tasks - planning/breaking down tasks - catching/correcting mistakes (self monitoring) - finishing tasks 44

45 Memory Problems 45

46 Problems with Learning Often Linked to Attention Problems

47 How to address these problems?47

48 WORK HARDER 48

49 WORK HARDER DO BETTER 49

50 WORK HARDER DO BETTER DO MORE

51 perhaps not best approach51

52 programs, accommodationsschool services – programs, accommodations 52

53 IEP – special services plus accommodations through the Individuals with Disabilities Education Act (IDEA) 53

54 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

55 504 plan – accommodations civil rights law that ensures that a child with a disability has equal access to an education, through accommodations and modifications. 55

56 What are some accommodations? Highlighted textbooks Extended time on tests or assignments Separate location for tests/quizzes Peer assistance with note taking Frequent feedback Extra set of textbooks for home use 56

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

58 silent reminders from teachers regarding behaviorsVisual 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 58

59 Diagnoses warranting Services/AccommodationsADHD

60 Learning Disorders -Reading -Written Expression -Mathematics 60

61 The diagnosis requires persistent difficulties in reading, writing, arithmetic, or mathematical reasoning skills during formal years of schooling. 61

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

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

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

65 Differences between expectations and performances based on historyUsually assessed with formal evaluations of IQ and achievement

66 When ability levels are lower than expected given overall level of functioning (IQ),special education classes may be necessary for further development of skills 66

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

68 However, neuropsychologists can also do these types of evaluationsSchools typically have professionals available to do evaluations to determine appropriateness of services However, neuropsychologists can also do these types of evaluations

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

70 cognitive functioning (problems focusing, remembering) 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)

71 Changes in environment/approach at school

72 Changes in environment/ approach at home

73 Minimizing potential distractions such astv radio internet phone 73

74 Managing Internal Distractions-Paying attention to internal cues - Knowing when to take a break -Learning how long a good break is

75 Spreading out studies over the course of several daysLearning how to study Avoiding cramming Spreading out studies over the course of several days (“overlearning”)

76 Studying with other peopleLearning how to study Studying with other people Quizzing each other Self-quizzing

77 Planning/Organization Managing Workloads Executive Skills – Planning/Organization Managing Workloads learning how to break down a project learning how to break down a reading assignment

78 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 putting away assignments in folder upon completion - immediately 78

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

80 Prioritizing/Organization approach most difficult work firstExecutive Functions- Prioritizing/Organization approach most difficult work first shifting to other work or taking breaks as necessary

81 Planning/Organization brainstorming ideas for writingExecutive Functions Planning/Organization brainstorming ideas for writing making notes/outline drafts/editing

82 students need to be taught these skills82

83 skills can be taught

84 medication?

85 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 85

86 ADHD medications can lower seizure threshold 86

87 Contacting school regarding potential need for services/accommodationsWhat 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 87

88 Seizures are associated with:Summary Seizures are associated with: Cognitive problems

89 Seizures are associated with:Summary Seizures are associated with: Academic problems

90 Seizures are associated with:Summary Seizures are associated with: Behavioral problems

91 problems can be managed with - school services/accommodations

92 problems can be managed with-communication with school staff

93 problems can be managed with-efforts at home regarding strategies

94 problems can be managed with-medication (where appropriate)

95 Treatment is ongoing and involves many people

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

97 Regular meetings with school staff can be helpful regarding making changes in programs

98 Children need to feel supported and encouraged

99 Thank you and questions