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Epilepsy and Learning Disabilities

Epilepsy and Learning Disabilities
- Prithika Chary, Chennai.

Epilepsy is a disturbance of the electrical activity of the brain. When disordered cerebral neurons generate abnormal electrical discharges in an intermittent manner, the external manifestations ia as seizures, fits or convulsions. When these fits occur in a chronic, recurrent manner, it is called Epilepsy. Epilepsy occurs in different ways in different people and can be due to different causes. The commonest variety of Epilepsy has no obvious discernable cause, except for a tendancy for the individual to have seizures. Some epilepsies have a genetic basis and can be associated with mental retadation, and other congenital abnormalities. Even without a genetic basis, epilepsy in children can be associated with other disturbances of brain function such as learning disabilities.

Children with epilepsy have several problems related to academic and scholastic performances. Their primary problem is due to the occurrance of the seizure itself, which interupts school attendance, involves frequent visits to the doctor and/or hospital, and if seizures are frequent enough considerable damage to the brain can occur. Secondary problem relates to medication and its side effects, such as impaired cognition, drowsiness, etc. which can interfere with the scholastic performance. Children with epilepsy may also have adjustment problems related to the fear of seizures, stigmatisation and marginalisation by peers and teachers, overprotection by parents leading to diffidence and low motivation and undue dependance on others for help.

Learning disorders have to be distinguished from learning disabilities.

Children may have difficulty with acquiring scholastic skills for a variety of reasons, such as lack of sleep, hunger, social factors such as poverty, ill health, bad family atmosphere, inadequate peer recognition and support, etc. and these are called learning disorders. Learning disabilities imply a specific disturbance in the brain and includes dyslexia, autism, attention deficit disorder, minimal brain dysfunction, developmental speech and language disorders, etc. Probably the first three in order of mention attract the attention of special educators and teaching institutions.

In many instances, children with these conditions may have seizures, be hyperactive or have other behavioral disturbances - the significance of this is that these superadded disorders magnify the primary problem and make training or teaching of these children difficult and frustrating.

Considerable evidence now exists that children with dyslexia inherit via gene markers on chromosome 6 and 15 a weakness in the area of the left hemisphere responsible for linking the perception and production of the sound patterns of speech. In a series of PET (Positron Emission Tomography) scans in well compensated dyslexic adults, during several phonological tasks, dyslexics showed significantly less left hemisphere activation than it did in ability match controls.

Children with learning difficulties may have normal or rarely superior intelligence as in the case of Albert Einstein who was dyslexic. People with severe learning disabilities have intelligence levels of less than 50% of the average, while those with moderate learning disabilities have a level of intelligence between 50% and 70%. Many children with severe learning disabilities have other impairments, including epilepsy (in about 25%). A smaller percentage of people with moderate learning disabilities also have seizures.

The association of epilepsy and learning disability in a particular person is realted often to the occurance of brain damage, though both epilepsy and learning disability can occur without any known cause. Head injury, cerebral palsy, brain infection like meningitis and encephalitis, conditions like tuberous sclerosis can be associated with both seizures and learning disabilities. Parents often ask whether epilepsy can cause learning disabilities. The answer is yes, especially if they share the same cause of brian damage as above. More often than not, epilepsy is associated with learning disorders as outlined above. The types of seizures a person with learning disability can develop are similar to those in the general population.

In general when epilepsy and learning disability are associated, the epilepsy is often more difficult to control. The type of seizure which is often difficult to control is a complex partial seizure, and because of the association of learning disability with epilepsy as mentioned above, it may seem as if patients with these two conditions more often have complex partial seizures.

There is also a gender difference in the incidence of learning disability and epilepsy. Males are slightly more prone to have epilepsy than females. Learning disability, also is twice as common in males as in females. The male differentiated brain is normally less skilled in verbal tasks and more skilled in visuospatial tasks than the female brain. When a disorder occurs in the  brain, the male differentiated brain has more difficulty with visuospatial as language tasks. In addition, function is more compartmentalised in the male brain and more general and bilateral in the female brain, rendering the latter better at coping with disturbances in brain function.

The next question is whether such children with epilepsy and learning disability should go to a special school. This dpends more on the degree of severity of the learning disabilty and not the epilepsy. If the learning disability is moderate or severe, a special school is indicated.

Epilepsy can make learning disabilities worse in a number of ways:-

1. As the child grows the difference in scholastic skills may become more obvious when compared with peers.

2. The lifestyle of children with epilepsy may be restrictive and frustrating, and hence the child achieves or aspires to achieve little education. Epilepsy and treatment may impare cognition and worsen the learning disability. This is particularly a problem with drugs like phenytoin, phenobarbitone and primidone and less with sodium valproate and carbamazepine.

3. Subclinical seizures may be occuring. And EEG can usually identify these, but occasionally these may be very difficult to identify. Very brief of subtle impairments in consciousness can occur which interfere with learning and worsen learning disability.

4. Additional brain damage could have occured, as after status epilepticus, or head injuries associated with recurrent seizures.

5. There may be an underlying progressive disease which worsens both the epilepsy and the learning disability.

  A thorough medical evaluation and investigation can determine which of these are important.

Parents of children with epilepsy are naturally anxious that the child remain seizure free, specially during school hours, more so if the child has a learning disability. There are several avoidable factors which can provoke seizures, and a little care to avoid these can improve seizure control : Lack of sleep, exposure to too much sun, fever, tiredness, emotional stress including over  excitement, missing or inadequate meals. 

An important condition that needs to be discussed for completion is the entity known as minimal brain dysfunction (MBD). In this children may have various combinations of hyperactivity, learning disability and can be associated with motor co-ordiantion problems with or without epilepsy. They may present as hyperactivity alone, learning disability alone or as the mixed type. There is no particular type of learning disability more common in association with MBD or epilepsy, the incidence and prevailence of learning disability being the same as that of the general.

Like with any disability love, patience, perseverance and a realistic and practical approach will go a long way in helping children with learning disability and epilepsy to not only cope but to reintegrate into society.