Childhood epilepsy is linked to significantly poorer exam grades and long term educational attainment, with the lowest levels of academic prowess among those whose neurological disorder started when they were very young, finds a large, long term Danish study, published online in the Journal of Neurology Neurosurgery & Psychiatry.
While it's not clear if the condition directly impairs brain function to the extent that it compromises educational achievement, the mechanisms are likely to be multifactorial and cumulative, warranting proactive assessment and support for those affected, suggests a linked editorial commentary.
Up to 1% of children in high income countries have epilepsy, which may be accompanied by neurodevelopmental disorders, such as autism spectrum disorder, attention deficit/hyperactivity disorder (ADHD), cerebral palsy, and intellectual disability, note the researchers. These children may also find it difficult to focus and concentrate, they add.
Despite the fact that epilepsy is among the most common neurological disorders of childhood, only a few large scale studies on long term educational outcomes have been published.
To build on the evidence base, the researchers measured educational achievement among Danes whose epilepsy was diagnosed in childhood, tracking their academic prowess from adolescence up to the age of 35, and focusing in particular on the potential influence of epilepsy subtypes and co-existing psychiatric issues.
They included all 1,195,138 children (just over 51% of them boys) born in Denmark between 1 January 1987 and 31 December 2005, whose educational attainment was tracked up to the end of 2023.
They retrieved relevant information on diagnoses on epilepsy and other psychiatric and neurological conditions before the age of 15 and academic performance from primary school onwards from national registry data linked to personal identity card number.
Of the total, 11,758 (1%) were diagnosed with epilepsy at an average age of 7. Information on final exam grades for first level schooling (up to the ages of 15-17) was available for 1,092,980 children (91.5%; epilepsy just under 0.7%) for maths and for 1,083, 374 children (91%; epilepsy 0.7%) for languages.
Children with epilepsy tended to have had more complications of pregnancy, such as low birthweight, Apgar score (basic newborn health check), and gestational age at birth; as well as younger parents with lower levels of education and income.
Of these children, 1400 (12%) didn't complete their first level schooling compared with 45,451 (4%) of the 1,183,380 children without epilepsy.
After adjusting for potentially influential factors, epilepsy was associated with a 3-fold higher likelihood of not completing first level schooling by the age of 17.
And there were gender differences: among girls these odds were nearly 4 times greater; in boys these were 2.5 times greater, despite the fact that early onset and/or complicated epilepsy was more common in boys than in girls.
Children with complicated epilepsy or whose condition had started in very early childhood had 4 times greater odds of not completing first level schooling than those with uncomplicated epilepsy.
Similarly, those with coexisting psychiatric conditions, intellectual disability, or autism spectrum disorder were significantly less likely to complete this level of education.
Final exam grades in maths and languages were also lower among children with epilepsy than they were among children without the condition, a legacy that continued across the spectrum of educational attainment.
For example, among 30 year olds, just over a third (37%) of those with childhood epilepsy hadn't extended their education beyond first level schooling This compares with 15% of those without the condition.
And among 35 year olds, around 1 in 10 (nearly 9.5%) of the epilepsy group had gone on to the highest level of education compared with 1 in 5 (19.5%) of the comparison group.
Children with early onset or complicated epilepsy were especially likely to be educationally disadvantaged as were those with generalised rather than focal epilepsy (affecting one particular area of the brain), particularly for higher education.
Worryingly, the risk of death was substantially higher among those with epilepsy; 6% of those with childhood epilepsy died before the age of 35 compared with less than 1% of those without the condition.
This is an observational study, and as such, no firm conclusions can be drawn about cause and effect, added to which the researchers highlight various limitations to their findings, chief among which is the lack of information on seizure frequency and control, and the use of antiseizure medication—factors that may influence academic performance.
Nevertheless they conclude: "Our findings underscore the need for assessment of academic capacity as well as targeted intervention, integrating educational and psychosocial support to optimise the educational potential for young people with childhood-onset epilepsy."
In a linked editorial commentary, Dr Sallie Baxendale of UCL Queen Square Institute of Neurology in London, emphasises that the study doesn't prove that childhood epilepsy impairs cognitive development.
"Rather, it demonstrates that children with epilepsy follow different educational trajectories. This distinction matters," she says.
"Educational achievement is not a direct measure of brain function. It is a proxy measure, an outcome dependent to some extent on cognitive ability, but also shaped by school attendance, teacher and family expectations, psychiatric comorbidity, stigma and social exclusion, treatment burden, and the practical disruptions associated with managing a chronic neurological condition," she writes.
She concludes: "The most useful implication of this study is not determinism but intervention: better recognition of educational risk; proactive school liaison; monitoring of attendance; psychological support; anti- stigma work; and timely neuropsychological assessment.
"The findings should prompt us to ask not only what epilepsy may do to the developing brain, but also what living with epilepsy does to a child's opportunities to learn."
