Educational Assessment in Pediatric Epilepsy

Thomas B. King, M.Ed.Debbie Ramer, M. Ed.Educational ConsultantsDivision of Child Neurology

Why Assess?

Incidence of Epilepsy

2,000,000 people in the United States have some form of epilepsy30 %, or about 300,000 are under the age of 186/1000, or approximately 0.5 % to 1% of children in the US are diagnosed with epilepsyLarge numbers of children may have undetected or untreated epilepsy.

(Epilepsy Foundation of America)

Incidence

Most common CNS disorder affecting childrenAbout 5% to 10% of children will have a

seizure within the first 20 years of life

Educational Implications

Most children with epilepsy test within the Average IQ range and will remain in regular education classes. (Epilepsy Foundation of America)

The majority of children with epilepsy will attend their neighborhood schools.

However, some children with epilepsy will experience academic and/or behavior problems.

Hidden Epilepsy you don’t have to have a seizure

BECTS to LKS spectrumabout 8% of children with Rolandic

Discharges have epilepsymost will have cognitive dysfunctionIQ may not be affectedprocessing disorders cause learning

disabilities and behavior disordersEpilepsia. 2006 Nov;47 Suppl 2:67-70

Factors that effect school performance

Type of epilepsy

Level of control

Any related medical condition

Age of onset is a factor

Problems that children with epilepsy may face in school

Learning Disabilities are a common, but frequently overlooked co-morbid condition.

(Pellock, 1999)Almost 1/3 of children with epilepsy are also identified as ADHD (Kanner, 2001)Grade retention and special education identification is more common in children with epilepsy. (Bailet & Turk, 2000)There is a higher rate of psychiatric disorders in children with epilepsy (Kanner, 2001)

Problems that children with epilepsy may face in school

Poor seizure control is associated with decreased reading achievement.

(Bailet & Turk, 2000)

Nocturnal seizures are believed to have a detrimental effect on language, memory, and alertness. (Aldenkamp, 1999)

Reasons that children with epilepsy have these problems

Underlying etiology – what is causing the seizure may also interfere with one or more of the child’s psychological processes. Medicines for seizures may affect a child’s ability to learn (side effects). Unrecognized seizure activity in the brain may interfere with attention. Absence from school may affect academic performance

Reasons that children with epilepsy may face these problems

Behavior problems can result from the seizure activity itself, medication, the child’s own anxiety, or parental overprotection. Behavior problems are twice that of other

chronic disorders not involving the CNS and four times that of healthy children

Questions a physician can ask to determine if there are problems at

school

How is the child’s attention span? Have any teachers ever mentioned attention as a concern? Is the child able to complete assignments and homework within a reasonable amount of time?Can the child follow verbal and written instructions?

Questions a physician can ask to determine if there are problems at

school (cont.)

Is the child able to retain information short-term and over time?What were the child’s grades on the last report card?How many days of school has the child missed this year?Has the school referred the child for any remedial classes or for any testing?

Questions a physician can ask to determine if there are problems at

school (cont.)

Has the child ever repeated a grade?Does the child have an IEP or 504 plan at school?Is there inconsistency in the child’s performance from day to day?How is the child’s handwriting and written performance?

Why do we need to assess children with epilepsy?

Needs of children vary greatly.Long-term risk of learning problems requires monitoring of educational progress, neurocognitive screening, and possibly comprehensive educational evaluation. Testing conducted by a specialist knowledgeable about epilepsy can determine whether the child’s difficulty at school is due to a specific learning disability.

School’s Role

The school must have a plan that outlines the appropriate response to a seizure

The teacher can contribute to a child’s social and psychological development by reassuring other students and including the child with epilepsy as fully as possible in regular classroom activities.

Role of the educational consultant

Provide education for the school about the child’s seizure type, seizure first aid, and educational implications of the child’s condition. Facilitate communication between the child’s school, family, and the doctor. Determine if learning problems exist and recommend appropriate educational interventions.

Role of the educational consultant (cont.)

Guide the family and school in obtaining appropriate school services for the child.

Provide workshops and programs to educate school personnel and classmates about epilepsy and educational implications.

Why do we need to assess these children?

Once identified for special education, appropriate educational services and instructional techniques can be sought.

Early identification can lead to strategies for compensation and lead to a more successful school experience.

What needs to be assessed?

Overall Cognitive or Intellectual Ability

Processing Abilities

Academic Achievement

Overall Intellectual Ability Verbal Abilities vs. Performance Abilities

or What you know and how you show what you know

Weschler Intelligence Test (WISC-III)

Woodcock Johnson III (W-J III)

WISC-IV Indices

Verbal ComprehensionPerceptual ReasoningWorking MemoryProcessing Speed

WISC-R Subtest Profiles

Children with epilepsy, as a group, tended to do less well on the following WISC-R subtests (Aldenkamp et al., 1990)VocabularyCodingInformationDigit Span

WISC-R Subtest Profiles (Rodin et al., 1986)

VocabularyCodingInformationPicture Arrangement

WISC-R Subtest Profiles (Dodrill, 1986)

ArithmeticCodingInformationDigit Span

W-J III Broad Cognitive Areas

Verbal Ability

Thinking Ability

Cognitive Efficiency

W-J III Cattell-Horn-Carroll Factors

Comprehension-KnowledgeLong-Term RetrievalVisual-Spatial ThinkingAuditory ProcessingFluid ReasoningProcessing SpeedShort-Term Memory

W-J III Additional Clinical Test Clusters

Phonemic AwarenessWorking MemoryBroad AttentionCognitive FluencyDelayed RecallKnowledge

Processing Abilities Factors of Cognitive Function

Auditory ProcessingVisual ProcessingVisual-Motor IntegrationProcessing SpeedMemoryLanguage FunctionsAttention and Concentration

Auditory Processing (Important in Temporal Lobe Epilepsy)

Auditory Analysis

Auditory Synthesis

Auditory Memory

Tests used to assess auditory processing

(You might see the term CAP in your chart)

SCAN (given by an audiologist)Filtered WordsAuditory Figure GroundCompeting Words

W-J IIISound BlendingIncomplete WordsSound AwarenessAuditory Attention

Phonological Processing (Auditory Processing’s “Evil Twin”

Phonological Awareness

Phonological Memory

Rapid Naming

Tests to Assess Phonological Processing

(Standard Audiometric Evaluations are not enough)

Comprehensive Test of Phonological Processing (CTOPP)

Phonemic AwarenessPhonemic MemoryRapid Naming

Test of Phonological Awareness (TOPA)Lindamood Auditory Conceptualization Test

Processing Speed (Is the child efficient with processing?)

Clerical Speed

Rapid Naming

Tests to Measure Processing Speed (There is no one test, but tests within batteries should

be monitored)

WISC-IVProcessing Speed Index (Coding-Symbol Search)

W-J IIIVisual MatchingDecision SpeedPair Cancellation

CTOPPRapid Naming Index

Processing Abilities Visual-Motor Integration

Visual Perception

Motor Coordination

Integration

Tests to Assess VMI (Simple handwriting assessment can

also help)

Developmental Test of Visual-Motor IntegrationVisual PerceptionMotor CoordinationIntegration

Bender Gestalt

Memory (What you don’t process deeply, you

don’t remember)

Visual Memory

Verbal Memory

Tests to Assess Memory (Memory should always be assessed in the

smallest possible slice)

Test of Memory and Learning (TOML)Wide Range Assessment of Memory and Learning (WRAML)WISC-III

Freedom from Distractibility

W-J IIILong-Term RetrievalShort-Term MemoryWorking Memory

Language (Where many processes intersect)

Oral LanguageReceptive VocabularyExpressive Vocabulary

Written Language

Reading Comprehension

Tests to Assess Language (Language is a part of most Verbal

Ability assessments)

WISC-IVVerbal Comprehension

W-J IIIOral Language Comprehension-KnowledgeVerbal Ability

Tests to Assess Language (cont.)

Peabody Picture Vocabulary Test (PPVT-III)

Expressive One-Word Picture Vocabulary Test

Receptive One-Word Picture Vocabulary Test

Oral and Written Language Scales (OWLS)

Academic Performance Areas to be Assessed

ReadingDecodingComprehensionFluency

WritingBasic SkillsExpressionFluencySpelling (encoding)

Academic Performance Additional Areas to be Assessed

MathBasic Concepts of MathMath OperationsMath Applications

LanguageListening ComprehensionVocabulary (expressive and receptive)Oral Language Performance

Weschler Achievement (WIAT)

Basic Reading (Reading Words in Isolation)Reading ComprehensionMath Reasoning (Problem Solving)Numerical OperationsSpellingListening ComprehensionWritten Expression

W-J III Areas of Achievement Assessed

Reading Broad Reading (Including reading fluency)Basic Reading Skills (Including word attack)Reading Comprehension

MathBroad Math (including math fluency)Math Calculation SkillsMath Reasoning

W-J III Academic Areas

Written LanguageBroad Written Language (including writing fluency)Basic Writing SkillsWritten Expression

Oral Language Oral Language SkillsListening Comprehension SkillsOral Expression

Spelling

Testing Younger Children Examples of Achievement Tests

Test of Early Reading Ability (TERA-2)

Test of Early Written Language (TEWL-2)

Test of Early Math Ability (TEMA)

Other Achievement Tests of Note There are a great many achievement tests

on the market

Kauffman Test of Educational Achievement (K-TEA)Peabody Individual Achievement Tests (PIAT)KeyMath - Revised (KeyMath-R/NU)Woodcock Reading Mastery Tests - Revised/NU (WRMT-R/NU)Test of Written Language (TOWL-3)

Post- AssessmentNow What?

Staffings

Staffings are offered to all families after an educational evaluation is conductedStaffings allow the parents, educational consultant, and doctors to discuss all the test results, address questions and concerns, and develop a comprehensive treatment plan. An educational treatment plan is suggested.

Common Learning Problems

Learning DisabilitiesMental RetardationDevelopmental DelaysSlow LearnerGeneric Learning Problem (sometimes the result of motivation, interest, etc.)

Some children with epilepsy and learning difficulties will qualify for special

education services in public schools.

(But not all kids)

Special Education

Local School Division Guidelines(Must comply with IDEA 1997 & State Regulations)

State Regulations(Must comply with IDEA 1997)

Federal RegulationsIDEA 1997

Special Education Services

Disability Categories in VirginiaAutismDeaf-BlindnessDevelopmental Delay (ages 5 - 8)Emotional DisturbanceHearing Impairment/DeafLearning DisabilitiesMental Retardation

Multiple DisabilitiesOrthopedic ImpairmentOther Health ImpairmentSevere DisabilitiesSpeech/Language ImpairmentTraumatic Brain InjuryVisual Impairment

Most children with epilepsy and learning problems qualify for special education services under one of the following categories:

Learning Disability (LD)Mental Retardation (MR)Other Health Impairment (OHI)Developmental DelaySpeech-Language Impairment

Specific Learning Disability

“Specific learning disability” means a disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, that may manifest itself in an imperfect ability to listen, think, speak, read, write, spell or do mathematical calculations. The term includes such conditions as perceptual disabilities, brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia. The term does not include learning problems that are primarily the result of visual, hearing, or motor disabilities; of mental retardation; of emotional disturbance; or of environmental, cultural, or economic disadvantage.

Specific Learning Disability Criteria for Identification

In Virginia, a child may be determined to have a learning disability if:

(1) The child does not achieve commensurate with the child’s age and ability levels in one or more of the areas listed in subdivision 2 … if provided with learning experiences appropriate for the child’s age and ability levels; and

(2) the team finds that the child has a severe discrepancy between achievement and intellectual ability in one or more of the following areas:

Specific Learning Disability (cont.)

Oral Expression;Listening Comprehension;Written Expression;Basic Reading Skill;Reading Comprehension;Mathematical Calculations; orMathematical Reasoning.

Specific Learning Disability (cont.)

(3) The group may not identify a child as having a specific learning disability if the severe discrepancy between ability and achievement is primarily the result of:

(A) a visual, hearing, or motor impairment;(B) mental retardation(C) emotional disturbance; or(D) environmental, cultural, or economic

disadvantage.

Developmental Disability

“Developmental Disability” is defined in IDEA 1997 as a disability affecting a child aged 3 through 9 who is

(I) experiencing developmental delays, as defined by the State and as measured by appropriate diagnostic instruments and procedures, in one or more of the following areas: physical development, cognitive development, communication development, social or emotional development, or adaptive development; and

(II) who, by reason thereof, needs special education and related services. Virginia regulations do not specify any further criteria, so the local school divisions are left to define the term “developmental delays” for eligibility purposes.

Mental Retardation

The term “Mental Retardation” is not defined in IDEA 1997.

The Virginia state regulations define “Mental Retardation” as significantly subaverage general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period that adversely affects a child’s educational performance.

Virginia regulations do not set forth any specific criteria for defining or determining what is considered “subaverage.”

Mental Retardation (cont.)

The American Association on Mental Retardation (AAMR) defines “subaverage general intellectual functioning” as scores more than two standard deviations below the mean on a standardized test of intelligence.

Most schools use the following scores to further define the level of mental retardation:

(A) IQ = 50-55 to approx. 70 = Mild MR/ EMR(B) IQ = 25 to 50 -55 = Moderate MR/ TMR(C) IQ = Below 25 = Severe & Profound MR

Mental Retardation (cont.)

Many children with IQ’s that fall within the 70 - 80 range are considered “Slow Learners”. Such students, in general, are not found eligible for special education services under the category of mental retardation or learning disabilities, even if they are struggling in school.

Other Health Impairment (OHI)

In Virginia, “Other Health Impairment” is defined as having limited strength, vitality or alertness, including a heightened alertness to environmental stimuli, that results in limited alertness with respect to the educational environment, that (a) is due to chronic or acute health problems such as heart condition, tuberculosis, rheumatic fever, nephritis, arthritis, asthma, sickle cell anemia, hemophilia, epilepsy, lead poisoning, leukemia, attention deficit disorder or attention deficit hyperactivity disorder, and diabetes, and (b) adversely affects a child’s educational performance.

Other Health Impairment (OHI) (cont.)

Virginia regulations do not set forth any further criteria for eligibility under OHI.

IDEA 1997 does not define the term “Other Health Impairment”

Educational Treatment Options: The continuum of special

education services

Regular Education Curriculum -- with or without accommodations and modifications

Regular Education Curriculum - in co-taught classes (Both a regular and special education teacher)

Resource class - part of the day (<50%) is spent in a separate classroom with a special education teacher receiving instruction that is supposed to be individualized to the student’s needs.

Educational Treatment Options: The continuum of Special

Education Services

Self-Contained class -- more than 50% of the day is spent in a separate class with a special education teacher receiving instruction that is supposed to be individualized to meet the child’s needs. Special SchoolsHome-based InstructionInstruction in hospitals and institutions

Educational Treatment Options: The Continuum of Special

Education Services

Placement decisions are made by the IEP team, which parents are members of, after goals and objectives have been written to address the child’s needs.

Children must be served in the “least restrictive environment” possible.

Clinical versus School Realities

Unfortunately, some of the children we see in the clinic who are having school/ learning problems and appear to need special help in school, will not qualify for special education services for a variety of reasons.

Clinical versus School realities

These reasons include:(A) the child does not meet the specific

criteria for eligibility under one of the 14 disability categories, which is further complicated by

(B) differences between school system definitions of eligibility criteria for certain disability categories;

Clinical versus School Realities

(C) multiple interpretations of test results; and

(D) the ambiguity of the language in many of the definitions of the disability categories.

Clinical versus School Realities

Schools are only required to provide an “appropriate” education, not an “optimal”education.

It is important to note that schools are also limited, in many cases, by financial and personnel resources.

Clinical versus School Realities

As such, even if a child is found eligible for special education services, he/she may not receive the “best” educational treatment of program.

Clinical versus School Realities

The good news is, not all children with epilepsy will need special education services in the schools in order to be successful.