Journal of Health Research and Reviews (in Developing Countries)

REVIEW ARTICLE
Year
: 2019  |  Volume : 6  |  Issue : 2  |  Page : 37--41

The role of school in the management of children with epilepsy


Aminu Taura Abdullahi1, Umar Abdullahi Taura2, Zubaida Ladan Farouk3,  
1 Department of Psychiatry, Aminu Kano Teaching Hospital, Bayero University Kano, Kano, Nigeria
2 Department of Special Education, Bayero University Kano, Kano, Nigeria
3 Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University Kano, Kano, Nigeria

Correspondence Address:
Dr. Zubaida Ladan Farouk
Department of Paediatrics, Bayero University Kano/Aminu Kano Teaching Hospital, Hospital Road Kano, Kano
Nigeria

Abstract

Worldwide, epilepsy affects about 0.7% of children of school age. It is associated with educational difficulties in addition to psychological, social, and other comorbidities. It is important for children with medical conditions such as epilepsy to receive education. The trend is to provide this at mainstream schools. However, there is poor perception and lack of support for children with epilepsy from schoolteachers and the school environment, especially in low and middle-income countries. Teachers, healthcare providers, and policymakers need to have a good understanding of the various issues involved in providing education to these children. We therefore carry out a review of the literature with the aim of highlighting the keys issues pertaining to the education of children with epilepsy. We conclude that the school environment has a role in the management of children with epilepsy from the diagnosis, psychosocial support, and control of stigma to seizure treatment. In particular, there is a need for teachers to be involved in the management of these children in the school environment. Specifically, the involvement of teachers in the provision of rescue medication and safety measures needs to be emphasized.



How to cite this article:
Abdullahi AT, Taura UA, Farouk ZL. The role of school in the management of children with epilepsy.J Health Res Rev 2019;6:37-41


How to cite this URL:
Abdullahi AT, Taura UA, Farouk ZL. The role of school in the management of children with epilepsy. J Health Res Rev [serial online] 2019 [cited 2019 Oct 20 ];6:37-41
Available from: http://www.jhrr.org/text.asp?2019/6/2/37/263247


Full Text

 Introduction



Epilepsy is a chronic neurological condition characterized by recurrent unprovoked or reflex seizures.[1] It is one of the most common neurological conditions, affecting about 70 million people worldwide.[2] It affects about 0.7% of children of school age, making it highly likely that any particular school would have a child with epilepsy at one time or other.[3] Epilepsy often occurs as a syndrome associated with comorbidities in the cognitive, neurological, and neuropsychiatric domains. These associated morbidities are often as important as the seizures in their impact on the quality of life of patients.[4] The educational challenges of epilepsy therefore can be seen from the points of view of diagnosis, treatment, and rehabilitation in respect of the seizure-related, cognitive, neuropsychiatric, psychosocial, and neurological problems of children with epilepsy. Epilepsy has been found worldwide to be associated not only with educational difficulties but also with psychological and social problems.[5]

The trend all over the world is the children with health problems and disabilities are to be educated in mainstream schools. There is therefore the need to tease out the issues that relate to these children such that schools and healthcare providers are better able to cater for their specific needs. We therefore undertook this review with the aim of highlighting the various challenges of providing school education to children with epilepsy.

 Methodology



A narrative review of the literature was done using databases that included PubMed, Google Scholar, and Hinari. Search terms used were “epilepsy” AND “school,” “epilepsy” AND “education,” “seizure” AND “school.” A manual search was used to supplement the database search.

 Current Status of Knowledge: the School and Epilepsy Diagnosis



A significant proportion of school age children with epilepsy exhibit educational difficulties even before their first seizure, which could suggest that an opportunity for early diagnosis had been missed.[6] Children spend much of their waking hours in school, and this makes the school relevant in identifying the behavioral and academic changes that might be related to epileptic seizures. Unexpected decline in school performance in association with lapses in concentration might be the first sign of undiagnosed epilepsy. There is of course the concern that children who daydream excessively in class might risk being wrongly diagnosed as having absences. However, some[7] seizure-related phenomena are so subtle that they might first manifest as changes in behavior or academic performance in the school setting.[8]

One of the biggest problems that arise with the children with special needs particularly those with neurological conditions like epilepsy is the transition to school. This is true all over the world but a bigger challenge in developing countries where even healthy children sometimes failed to be enrolled in school.[9] In Nigeria, net school enrollment is only about 63%, with huge regional and rural versus urban differences. In the northwest of Nigeria, enrollment is only about 43%.[9]

Educationists in Nigeria as in the rest of sub-Saharan Africa are therefore having to overcome the problem of the huge number of out-of-school healthy children. Family factors relating to parental wealth, education, father's job as well as family size, birth order of the child, gender of the child combine with district level factors to determine whether a child is enrolled in school or not. District level factors relating to rural domicile, distances to school, pupil to teacher ratio, an agrarian economy that required child labor are important in keeping children out of school.[10]

To what extent do factors that keep healthy children out of school in developing countries like Nigeria impact on the school attendance of children with epilepsy? Does the diagnosis of epilepsy in a child pose additional hindrance to school attendance? These are important questions, which unfortunately we lack the data to answer. The Nigerian National Policy on Education advocates what it called inclusive education, meaning that children with health problems and disabilities are as much as possible encouraged to attend mainstream schools.[9] It is an open question as to whether the policy is working or not.

 Identification of Comorbid Conditions



Epilepsy is of course more than just seizures. This may be truer in children than any other age group in view of the enormous cognitive demands that schooling places on them coupled with the many comorbid conditions that often occur in epilepsy. These comorbidities may be as disabling as the seizures themselves in terms of their impact on learning. The association of childhood epilepsy with neuropsychiatric and behavioral comorbidities is well documented, occurring in between a quarter to about two-thirds of children with epilepsy.[3],[11],[12] The etiology of these comorbid conditions vary, ranging from the seizure activity, the underlying brain damage, psychosocial impact of the epilepsy, and antiepileptic drugs' side effects down to the epileptogenic process. They have in common the fact that they all have direct relevance to the school environment and learning.[13] Behavioral comorbidities of epilepsy vary from episodic behavioral disturbances as part of seizure prodromes to more pervasive disturbances that occur in attention-deficit hyperactivity disorder (ADHD). ADHD, which has been documented to occur at a rate of up to fifteen times the general population rate in children with epilepsy, is of particular importance in this regard.[14] The specific association of epilepsy with the inattentive type of ADHD further highlights the importance of the school in diagnosis as this form of ADHD may only manifest in the learning environment.[15] Teachers therefore have an important role in alerting to the earliest manifestation of these comorbidities. All these factors may lead to poor school performance, demotivation, and subsequent withdrawal of children from school.

 First Aid and Emergency Seizure Management



Epileptic seizures are unpredictable events, and considering the amount of time children with epilepsy spend in school, the likelihood of seizures occurring in the school is high. Majority of children with epilepsy attend mainstream schools. It is therefore important for all schools, both mainstream and special to have an epilepsy policy detailing actions to take when a child has a seizure.[16] The policy should address issues of safety of the seizing child, how to reassure other children as well as administration of rescue medications in the event of prolonged seizures. Rescue medications such as buccal midazolam or rectal diazepam in children with prolonged seizures could prevent progression to status epilepticus.[17] The specific issue of rescue medication should be an integral part of the individual care plan for all children at particular risk of going into status epilepticus such as those with the Lennox-Gastaut syndrome.

 Participation and General Safety



School policy on epilepsy must include the specific issue of ensuring the safety of children with epilepsy as they participate in school activities such as sports. It is important to the quality of life of children with epilepsy that they do not suffer undue restrictions on account of their illness. However, any seizure that involves impaired awareness or significant loss of motor control could place a child in danger particularly in situ ations involving water or heights.[17] Activities such as swimming must be supervised while most other sporting activities not involving heights should be encouraged. As some seizure types pose more risks than others, this issue too should be part of the individual care plan. For instance, tonic seizures have been reported to of particular risk for drowning.[18]

 Medication Management



Teachers generally, including in developed countries such as the United Kingdom do not consider it their responsibility to administer medications to children in their schools.[19] This applies to both routine and emergency medications. Furthermore, in low middle-income countries (LMIC), teachers have poor knowledge of what to do when a child have epileptic fit, some may resort to practices that are unhelpful or even detrimental.[20],[21],[22],[23],[24] It is important however that the school is involved in the medical management of children with epilepsy as some children would require to be administered their medications in school. Educators particularly in LMIC like Nigeria need to be informed about basic information on epilepsy, life-saving skills as well as general information on first aid to a child having a seizure. Educators need to be made aware that frequent, uncontrolled seizures can disrupt learning, irrespective of cause of the epilepsy and level of intelligence so that they could be motivated to contribute to seizure control efforts.[20],[21],[22],[23],[24],[25] In addition, schools could help to monitor and raise the alarm on antiepileptic drug side effects such as excessive drowsiness or visual problems from diplopia with the sodium channel blockers as these might be more easily observed in the school environment.[13] Through liaison between teachers, parents, and prescribers, it should be possible to incorporate the administration of routine medications into a child's care plan as well as get teachers to be more involved in the medical management of children with epilepsy. The school nurse has a special role in facilitating this liaison.

 Amelioration of Learning Problems



Children with epilepsy have worse social outcomes than their peers with other chronic illnesses even if they are of normal intelligence and their seizures are well controlled.[20],[26] The main underlying reason for this is the common association of childhood epilepsy with learning difficulties, irrespective of intellectual ability. For example, Rutter's Isle of Wight study revealed reading retardation of 2 years or more in children with epilepsy even if they were of normal or above average intelligence.[11] In addition, up to a quarter of children with epilepsy are of subnormal cognitive functioning.[22],[27] There are several factors responsible for these associations, which might all contribute to the child withdrawing from school. In Nigeria, in particular, these include psychosocial, family factors, poor attitude to illness, and stigma.[23] In addition, there is reported unwillingness among teachers in Nigeria to have children with epilepsy in the school environment. This is partially as a result of the wrong perception of epilepsy to be infectious, to teachers not knowing what to do when a child has a seizure, as well as stigma.[20] Epilepsy in any given child might be due to a structural or metabolic brain disease, and such brain disease could provide the substrate for both the epilepsy and learning difficulties. The epileptic process might lead to temporary or statedependent learning difficulty or as in the context of epileptic encephalopathy, permanent learning disability.[13] Seizures, especially those associated with impaired awareness can disrupt learning. Also, epileptiform discharges even in the absence of subclinical seizures may equally disrupt learning.[28] Even focal seizures with preserved awareness might manifest specific cognitive deficits related to the focal cerebral disturbance underlying the seizures. Antiepileptic drugs are commonly associated with cognitive side effects such as impaired concentration and psychomotor speed with adverse consequences on learning.[29] Children with epilepsy also often absent themselves from school, sometimes for reasons unrelated to their seizures, perhaps reflecting parental low expectations and overprotection.[30] Children suffer from the social burden of epilepsy-related stigma, which might manifest in the school environment in the form of negative attitude of teachers or teasing and bullying by fellow pupils.[31] In developed countries like the UK, the combination of statutory instruments against discrimination as well as the efforts of epilepsy charities such as Epilepsy Action and Young Epilepsy have helped schools and teachers to learn more about epilepsy and to feel more confident about supporting pupils with epilepsy. In LMIC like Nigeria, the combination of psychosocial factors and comorbidities of epilepsy are keeping up to half of children with epilepsy out of school.[12] The school psychologist has a special role in the assessment and development of an accommodation plan for behavioral and cognitive problems that have relevance to the school environment. The school psychologist might be particularly relevant in teasing out “state-dependent learning difficulty” due to poor seizure control or antiepileptic drug side effect from more permanent cognitive impairments and designing remediation measures such as “errorless learning” for children with memory problems.[13],[32] Addressing such problems is of high relevance to the quality of life of children with epilepsy.[30]

 Special Education Provision



Up to a quarter of children with epilepsy have an intelligence quotient (IQ) of 70 or less, which would make it likely for them to need special education intervention on this basis alone.[33] In addition, a significant number of children with normal IQ find themselves requiring special education provision partly due to behavioral and psychiatric comorbidities and partly due to global impairments in processing speed.[34] The school has a role in the early identification of the child with intellectual impairment who might need special education placement as this has important implications for learning outcomes and quality of life in general. Leaving children with special education needs to struggle in mainstream schools would have the effect of eroding their confidence and might precipitate behavioral problems.[21] In developed countries like the UK, statutory instruments exist for the formal declaration of this need in the form of statement of education needs. In Nigeria, special educational services are mainly available for children with gross and visible impairing conditions. These include the visually impaired, hearing impaired, and to a certain extent, the mentally retarded.[17] As such there seems to be no any provision for children with epilepsy within the educational setting in Nigeria.

 Psychosocial Issues



Children with epilepsy suffer from a number of disadvantages relating to stigma and misinformation about the condition. This might manifest as rejection, teasing, or bullying by peers, diminished expectation from teachers and parents, or overprotection and excessive restrictions.[33],[34] The consequences of this could be loss of confidence and self-esteem or behavioral problems in the child with epilepsy. These factors could contribute significantly to the child not attending school. Schools should have a policy that foster inclusion and avoid unnecessary restrictions, such that all children come to be accepted as part of the school community. There is need for public awareness and education with the objective of eradicating the stigma attached to epilepsy and getting the community and primary health care workers actively involved in the management of affected person.

 Conclusions



All schools should have an arrangement in place to provide support for children with epilepsy. It would not be feasible to make the arrangement generic regarding the role schools should play in the management of children with epilepsy as needs vary widely from case to case. However, schools should have in place an epilepsy policy that focuses on issues such as seizure management, safety, learning and behavioral problems, and mitigation of the psychosocial impact of epilepsy. An individualized care plan developed in collaboration between the school, the parents, and health services coupled with regular communication between them would help to ameliorate the physical, intellectual, and psychosocial difficulties that children with epilepsy often encounter. Research is needed particularly in LMIC countries on the educational challenges facing the child with epilepsy.

There is a need for public awareness and education with the objective of eradicating the stigma attached to epilepsy and getting the community and primary healthcare workers actively involved in the management of affected person.

 Conclusion



This review seeks to highlight the challenges for the school systems particularly in LMIC of providing education to children with epilepsy in mainstream schools

We elaborated on the roles teachers might play in identifying children with epilepsy, supporting their medical and educational needs, providing safe environments and providing psychosocial support to these children

The review also discussed the special role that school might play in the global effort toward the eradication of stigma associated with epilepsy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Fisher RS, van Emde Boas W, Blume W, Elger C, Genton P, Lee P, et al. Epileptic seizures and epilepsy: Definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE). Epilepsia 2005;46:470-2.
2Ngugi AK, Bottomley C, Kleinschmidt I, Sander JW, Newton CR. Estimation of the burden of active and life-time epilepsy: A meta-analytic approach. Epilepsia 2010;51:883-90.
3Sillanpää M. Epilepsy in children: Prevalence, disability, and handicap. Epilepsia 1992;33:444-9.
4Olubunmi A. Epilepsy in Nigeria – A review of etiology, epidemiology and management. Benin J Postgrad Med 2006;8:8-12.
5Swiderska N, Gondwe J, Joseph J, Gibbs J. The prevalence and management of epilepsy in secondary school pupils with and without special educational needs. Child Care Health Dev 2011;37:96-102.
6Berg AT, Smith SN, Frobish D, Levy SR, Testa FM, Beckerman B, et al. Special education needs of children with newly diagnosed epilepsy. Dev Med Child Neurol 2005;47:749-53.
7Huisman J, Smits J. Effects of household-and district-level factors on primary school enrollment in 30 developing countries. World Dev 2009;37:179-93.
8Aldenkamp A, van Bronswijk K, Braken M, Diepman LA, Verwey LE, van den Wittenboer G. A clinical comparative study evaluating the effect of epilepsy versus ADHD on timed cognitive tasks in children. Child Neuropsychol 2000;6:209-17.
9Antoninis M. Tackling the Largest Global Education Challenge? Secular and Religious Education in Northern Nigeria. World Development. 2014;59:82-92.
10Dudgeon MR. Global midwifery and local traditional birth attendants at the millennium. Midwifery Today Int Midwife 2000:17-20.
11Burton K, Rogathe J, Whittaker RG, Mankad K, Hunter E, Burton MJ, et al. Co-morbidity of epilepsy in Tanzanian children: A community-based case-control study. Seizure 2012;21:169-74.
12Besag FM. Childhood epilepsy in relation to mental handicap and behavioural disorders. J Child Psychol Psychiatry 2002;43:103-31.
13Dunn DW, Austin JK, Harezlak J, Ambrosius WT. ADHD and epilepsy in childhood. Dev Med Child Neurol 2003;45:50-4.
14Hesdorffer DC, Ludvigsson P, Olafsson E, Gudmundsson G, Kjartansson O, Hauser WA. ADHD as a risk factor for incident unprovoked seizures and epilepsy in children. Arch Gen Psychiatry 2004;61:731-6.
15Reilly C, Ballantine R. Epilepsy in school-aged children: More than just seizures? Support Learn 2011;26:144-51.
16Spitz MC. Injuries and death as a consequence of seizures in people with epilepsy. Epilepsia 1998;39:904-7.
17Besag FM. Lesson of the week: Tonic seizures are a particular risk factor for drowning in people with epilepsy. BMJ 2001;322:975-6.
18Bannon MJ, Ross EM. Administration of medicines in school: Who is responsible? BMJ 1998;316:1591-3.
19Ojinnaka NC. Teachers' perception of epilepsy in Nigeria: A community-based study. Seizure 2002;11:386-91.
20Alikor EA, Essien AA. Childhood epilepsy: Knowledge and attitude of primary school teachers in Port Harcourt, Nigeria. Niger J Med 2005;14:299-303.
21Sanya EO, Salami TA, Goodman OO, Buhari OI, Araoye MO. Perception and attitude to epilepsy among teachers in primary, secondary and tertiary educational institutions in middle belt Nigeria. Trop Doct 2005;35:153-6.
22Mustapha AF, Odu OO, Akande O. Knowledge, attitudes and perceptions of epilepsy among secondary school teachers in Osogbo South-West Nigeria: A community based study. Niger J Clin Pract 2013;16:12-8.
23Adewuya AO, Oseni SB, Okeniyi JA. School performance of Nigerian adolescents with epilepsy. Epilepsia 2006;47:415-20.
24Berg AT. Epilepsy, cognition, and behavior: The clinical picture. Epilepsia 2011;52 Suppl 1:7-12.
25Camfield CS, Camfield PR. Long-term social outcomes for children with epilepsy. Epilepsia 2007;48 Suppl 9:3-5.
26Berg AT, Langfitt JT, Testa FM, Levy SR, DiMario F, Westerveld M, et al. Global cognitive function in children with epilepsy: A community-based study. Epilepsia 2008;49:608-14.
27Aldenkamp AP, Arends J, Overweg-Plandsoen TC, van Bronswijk KC, Schyns-Soeterboek A, Linden I, et al. Acute cognitive effects of nonconvulsive difficult-to-detect epileptic seizures and epileptiform electroencephalographic discharges. J Child Neurol 2001;16:119-23.
28Bourgeois BF. Determining the effects of antiepileptic drugs on cognitive function in pediatric patients with epilepsy. J Child Neurol 2004;19 Suppl 1:S15-24.
29Aguiar BV, Guerreiro MM, McBrian D, Montenegro MA. Seizure impact on the school attendance in children with epilepsy. Seizure 2007;16:698-702.
30Jacoby A, Austin JK. Social stigma for adults and children with epilepsy. Epilepsia 2007;48 Suppl 9:6-9.
31Bannon MJ, Wildig C, Jones PW. Teachers' perceptions of epilepsy. Arch Dis Child 1992;67:1467-71.
32UNESCO. Education for All 2015 National Review Report. Nigeria: UNESCO; 2015.
33Long CG, Moore JR. Parental expectations for their epileptic children. J Child Psychol Psychiatry 1979;20:299-312.
34Carpay HA, Vermeulen J, Stroink H, Brouwer OF, Peters AC, van Donselaar CA. Disability due to restrictions in childhood epilepsy. Dev Med Child Neurol 1997;39:521-6.