Abilities and behaviour of epileptic children.

The fifty-six epileptic children in our main sample are below the intellectual standard of a matched control group of normal children, but not seriously so. Test score deficits range from 7.7 points in mental arithmetic to 12.2 points on verbal intelligence and psychomotor abilities. Compared with the distribution of epileptic children in Birmingham, where the survey was carried out, our sample is rather overweighted with residential school cases. If we adjusted our scores in the light of the Birmingham figures our average (composite) score would probably be about three points higher. An analysis of the test results in more detail shows the epileptic children to be especially handicapped, in comparison with the control group, by slowness in thinking (which may be due partly to the effect of drugs, particularly the sedative drugs), immediate memory, and manual dexterity. Although they are backward, too, in numerical reasoning, they compare favourably in this respect with the control group. The epileptic group is more heterogeneous than the control group, with about 60 per cent. more “scatter” in all tests. Boys score higher than girls on all tests and in both the epileptic and control groups. Dividing our main group according to type of seizure, we find that the grand mal cases score highest, with petit mal next. The cases with dual seizures, i.e. with grand mal and petit mal have the lowest scores. Their average quotients are 92.0, 83.6, and 82.7 respectively. Previous surveys have found petit mal cases to be the highest scorers. The children with a positive family history score higher than those with a negative history, while the “Symptomatic” cases have lower scores than the rest of the group. The brain-injured children have the lowest scores of all, especially those cases with hemiplegia or quadriplegia as well as epilepsy. The average deficits of these last two groups are 15 and 30 points respectively. Lower scores were found in the cases with an earlier onset and a longer duration of epilepsy, and also in the children with behaviour disorders. In regard to the latter it is not clear from our data which is cause and which effect, i.e. the behaviour or the lower mentality. The relationship between them may be reciprocal. The grand mal cases with frequent seizures score lower than the infrequent cases in all tests, with an average deficit of 12 points (18 points on arithmetic). On the other hand the frequent petit mal cases average 11 points higher than the infrequent cases. It is interesting that the children with grossly abnormal EEGs show only a minor deficit in comparison with the children whose EEGs are abnormal but not necessarily suggestive of epilepsy. In the psychomotor series the former actually score higher. The normal schools' epileptic children score 13 points higher than those at the residential school, a result which agrees with previous findings, and which, in our survey could have been expected, since the “better” cases are, in general, retained at normal schools. It would appear that between 60 per cent. and 80 per cent. or more of epileptic children attend normal schools, according to the area in which they live. A greater proportion of epileptic children have gone to residential schools from London and Birmingham than from most other areas, especially rural areas. Nowadays the tendency is to retain as high a proportion of epileptic children as possible in the normal schools. The Ministry of Education's Regulations 1953 (1953) state that the children who require the special educational treatment provided in the residential schools are “those pupils who, by reason of epilepsy cannot be educated in ordinary schools without detriment to the interests of themselves or other pupils”. In 1954 the Minister stated (1954) “No handicapped pupil should be sent to a special school who can be satisfactorily educated in an ordinary school. Where a special school is necessary, a day school is preferable if it offers a satisfactory and practicable solution. ” The Sub-Committee on the “Medical Care of Epileptics” (1956) states (p. 19) “It should be the aim of all concerned to ensure that children suffering from epilepsy are, wherever possible, educated in ordinary schools”, though they also suggest “the possibility of creating additional places at existing special schools and the desirability of establishing one or two national special schools for epileptic children with other handicaps”. In our residential group 71 per cent. are below the average range of intelligence (I.Q.s 91 to 110), as against 36 per cent. in the normal schools group. Sixty-four per cent. are below this range in reading and 82 per cent. in arithmetic—against 29 per cent. and 61 per cent. respectively in the normal schools. Donovan (1952) thinks that about 40 per cent. of the epileptic children in his (residential) school would still have to be educated in E.S. N. schools if they were not epileptic. The advantages and disadvantages of a residential school for epileptic children were ably put by the late Dr. J. Tylor Fox (1947). But if we look only at the adverse factors found in our residential group, i.e. the duality, frequency, and severity of seizures, the grossly abnormal EEGs, malbehaviour, and brain injury, as well as the lower intelligence it is evident that the staffs of residential schools are coping with a difficult problem, and it is to their credit that one of them at least manages to discharge 40 per cent. each year with fits controlled and behaviour improved, and, at the same time, endeavour to attain normal educational standards. In some of our residential cases there was an increase in seizures and a deterioration in behaviour soon after their return home. It is clear that test scores of epileptic children are related to many factors, some of which have been mentioned. There are others, such as loss of schooling, the influence of drugs, anxiety, frustration, etc. If a child is unfortunate enough to have a combination of these factors, which may well happen since many of them are positively co-related, he could not be expected to compete on equal terms with others not so handicapped, and would have to receive special consideration. Our survey shows that there is a higher incidence of behaviour disorders in epileptic than in normal children. The behaviour, like the cognitive functions, is also related to many other variables such as brain injury, sex, precipitating cir cumstances, grossly abnormal EEGs, type of seizure, frequent seizures, primogeniture, late milestones, longer duration of the illness, and others. These relationships indicate the complexity of the behaviour problem, and show how invidious it is to generalize about the “Epileptic Personality”. Many such generalizations have been impressionistic. The present survey does not go far enough, and we must hope that others may be moved to carry out a more refined investigation on a larger sample. As stated above, many of the epileptic variables are correlated (χ2) with each other. Table V shows those associations which are at or near the level of statistical significance. Other notable associations have been dealt with in the appropriate sections. Table VI shows the average association of each variable with all the others, and here we find that the ones with the highest “adverse” associations are cerebral injury, dual seizures, and bad behaviour. At the other extreme are grand mal seizures, grossly abnormal EEGs, and positive history of epilepsy. In conclusion we should draw attention to the difficulties encountered in trying to compare results of different surveys. There are many different interpretations placed on terms like “Idiopathic”, “Cryptogenic”, “Symptomatic”, “Minor Epilepsy”, and even “Epilepsy” itself. Different interpretations lead to different frequency classifications. The remedy for this confusion would be, of course, for workers to agree on a system of typology, such as that of Penfield and Jasper (1954), or some modification of it. Such a classification would entail a very thorough examination of cases, which would be beneficial from the viewpoint of treatment as well as research.