SAERA: Advanced Education and e-Learning

By Sharlene McHolm, doctor of education and Master in Applied Neuroscience student

Abstract

One of the most well-known neurological disorders affecting the central nervous system is epilepsy. This condition affects approximately 0.5% to 1% of children and is the most frequent chronic neurological condition (Mayo Clinic, 2022). Globally, more than 291 million children (less than 20 years old), live with epilepsy. More shockingly, 95% of these children are from low to middle income countries (Olusanya, et al., 2020). Worldwide, it is estimated that 5.1% of these children (0-15 years) live with moderate disabilities and 0.7% children live with severe disability (WHO, 2004). Coupling this with the ineffective response for 30% of drug-resistant epileptics, understanding its implications to learning is critical. Furthering the need to understand this neurological disorder’s impact, approximately 25% of epileptics also have Learning Disorders (LD) (Beghi et al., 2006). The loss of learning, directly connected to this neurological disorder has suppressed educational opportunities for millions of deserving youths. With attention to the causes, implications and treatments of epilepsy, educators can employ compensational techniques to enhance the child with epilepsy’s learning outcomes.

Neurological Causes of Epilepsy

Epilepsy is a central nervous system disorder that damages the brain over time. In the simplest terms, epilepsy is caused by an imbalance in the brain’s electrical current. While a person is seizing, the normal electrical current has been disrupted by a hypersynchronous or abnormal neuronal firing (Brennan & Henshall, 2020). The alteration in the normal pattern of electrical flow can cause a wide array of disruptions from pauses in movement for less than 5 seconds to full body generalize clonic seizures that lead to a loss of consciousness. These prolonged seizures are shown to lead to the loss of specific brain cells or apoptosis. Depending upon the frequency and focal point of the seizures, learning and memory can be greatly affected.

Classifications of Epilepsy

Epilepsy is a condition with many subtypes and varying characteristics. Educators’ ability to recognise these different types and symptoms prior to seizing will assist in protecting the child from physical harm while preserving dignity. Some signs and symptoms may include periods of confusion, blank stares, stiffening of muscles, lack of awareness or fainting, jerking-  movement of limbs and/or a strong sense of panic or fear.

Clonic seizures (previously known as grand mal seizures) are typically bilateral and generalized. If they start on one side of the body and then spread to both sides of the body they are identified as focal to bilateral tonic-clonic seizures. During status epilepticus the full body or one side of the

Body is involved. A loss of speech is typically combined with body jerking and the possibility of loss of bodily controls (drooling, urination or bowel movements). These seizures can last up to five minutes before it is deemed a medical emergency. Medications in the lorazepam, diazepam, clonazepam or midazolam families are the most common rescue drugs. They are given sublingually, or in the buccal cavity or nasal spray administration. In some situations, they can be administered rectally.

Other seizure types include myoclonic (15 seconds in duration or less, typified with short jerking and a clearness of mind), atonic seizures (also 15 second or less, but results in full muscle relaxation), non-clonic seizures (previous known as petite mal), focal aware and focal impaired seizures (localized seizures where the person is conscious or unconscious) and finally absence or atypical absence seizures (5 seconds or less). In a busy classroom, many of the later seizures can go unnoticed. Absence seizures can easily be confused with “day dreaming” and, therefore, these children are not diagnosed as quickly as myoclonic, clonic or atonic seizures.

Despite the range of expression, all of these types of seizures will have significant implications to learning profile and educational outcomes for these children.

Damage to the Brain

Determining the pathogenesis of epilepsy is complex. As epilepsy can be caused by traumatic brain injuries, brain structure generic abnormalities, infectious disease, storks or tumours, absolute damage to the brain can vary. It can be stable in its focus and impact or it can spread to other regions of the brain. The variability and transitory nature of the disease makes epilepsy protocols also variable.

The blood-brain barrier is the highly selective barrier that keep the circulating blood separate from the brain extracellular fluid. Alterations to the Blood-Brain Barrier through albumin extravasation and diapedesis of the leucocytes from the blood into the brain induces the epileptogenesis (Löscher & Friedman, 2020). Seizures themselves may regulate the Brain- Blood Barrier, leading to a chain reaction of modifications in the astrocytes and eventually the very neuronal networks themselves.

Brain tissue shows the effects of ongoing seizure activity. Common features include neuronal loss, gliosis, inflammatory markers and microscopic and macroscopic reorganisation of networks. Non-coding RNA genes called microRNAs (miRNAs) inhibit protein-coding, thereby changing multiple aspects of the cell structure in its function (Brennan & Henshall, 2020). Axonal and dendritic structures along with neurotransmitter receptors, ion channels and transporters equate to a compromised neurophysiological function (Brennan & Henshall, 2020).

Therapies and Treatments – Medication

There are approximately 30 different Anti-Seizure Medications (ASM) currently on the market, with a number of additions being made in the last decade. The most common drugs are in the lorazepam, diazepam, phenytoin, clonazepam, carbamazepine, gabapentin or midazolam families (Mayo Clinic, 2022). Cannabidiol oral solutions and cenobamate are recent additions to the option list.

Therapies and Treatments – Deep Brain Stimulation

The interest in Deep Brain Stimulation (DBS) has been considered for many brain abnormalities and epilepsy is one of them. With recent U.S. Food and Drug Administration’s FDA approval for DBS in bilateral stimulation of the anterior nucleus of the thalamus (ANT) to reduce seizure frequency in adults (Salanova, 2018), additional research in children is required. Although some positive findings have occurred, case studies are small (Silva, et al. 2021).   Silva and colleagues (2021) studied the outcomes of an implanted neurostimulator in the hippocampal and ipsilateral temporal neocortical leads in the temporal lobe of an epileptic. With 1.5 years of data, it was seen to suppress hippocampal low frequency local field potentials. The neurostimulator was also able to modulate the functional connectivity between the hippocampus and neocortex.  In this particular case, Silva and colleagues (2021) concluded that DBS offered hope for future generation devices for drug resistant individuals. In temporal lobe epilepsy, patients experience inflammation, particularly in the hippocampal region (Ferreira, et al., 2018). In animal research, DBS has shown that cognitive impairment can be reduced through anterior thalamic nucleus deep brain stimulation. During status epilepticus, it was seen that memory deficits were apparent. Despite there was a significantly higher number of cells in the CA1 region of the brain and the dentate gyrus, it did not result in improved memory. Memory deficits were not mitigated.  These two studies represent gains in adjunctuary therapies research, yet lack the broad impact to provide assistance to children.

Epilepsy and Learning 

Educational underachievement and challenges to learning plagues the path of most children with epilepsy. The areas of greatest challenge are memory, attention, and speed of information processing. This stands to reason considering the common nature of temporal lobe involvement in seizure activity. Aldenkamp and colleagues (2005) evaluated educational achievement based upon four characteristics of epilepsy – a) the type, b) the frequency of epileptiform electroencephalographic (EEG) discharges and the effect of antiepileptic treatment. It was found that the greater the brain involvement, the higher frequency and duration of the seizures, more significant gaps in learning resulted. Those children with underlying etiological brain dysfunction or damage had lower intelligence and lower cognitive functioning.

Consideration and attention have also been drawn to antiepileptic drugs’ (AED) implication to childhood learning. Frank and colleagues (2021) have suggested that newer AED’s show less cognitive and behavioural adverse effects. Older medication formulations have anecdotally been seen to cause a “dulling” of the child’s behaviour and personality (Frank et al. 2021).

Children with temporal lobe epilepsy are associated with decreased local gyrification in the rostral, caudal middle frontal gyrus, inferior precentral cortex insula inferior parietal cortex, lateral occipital cortex, rostral anterior cingulate and medial orbital frontal regions (Hwang et al., 2019). This leads to slower processing speeds of information. In the educational context, a slower processing speed has implications to all aspects of learning. Students with epilepsy require additional time in aspects of learning – including reading, reasoning and writing. They struggle to automate new skills and will require greater repetition to integrate their learning.

Children with epilepsy have many factors that disadvantage their educational careers. As neuroscientists, we must further the research to lessen the impact of abnormal hypersynchronous neural firing. As educators, we must develop plans to support these neurodivergent learners. Only when neuroscience and education come together, will we provide the necessary supports for these young learners.

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