Children and Adolescents with Epilepsy

By:  Stefania Pierce

Children and Adolescents with Epilepsy

Children and adolescents with epilepsy (CWE) face a complex array of challenges that extend beyond the biological management of this condition. Research consistently demonstrates that CWEs are at a significantly elevated risk for cognitive impairments, which negatively affect their academic achievement across multiple domains. These cognitive difficulties often coexist with heightened rates of psychiatric and behavioral disorders. Social functioning is also frequently disrupted in CWE, which hinders peer relationships and increases the risk for social isolation and bullying. The psychosocial burden of epilepsy is also compounded by stigma, family dynamics, and medication side effects, all of which can contribute to emotional distress and behavioral challenges (Williams, 2003; Lordo et al., 2017; Menlove & Reilly, 2015; Austin et al., 2004).

Despite the significant psychosocial and medical challenges, many CWE report a relatively positive quality of life. Understanding how neurological, psychological, social, and familial factors affect CWE is crucial for developing comprehensive treatment approaches that support not only seizure control but also emotional well-being, academic success, and social literacy. This essay explores the impacts of epilepsy on children and adolescents, beyond medical and biological factors, emphasizing the need for tailored interventions that can address the broad spectrum of challenges faced by this population.

Cognition, Memory, Attention, and Executive Function Deficits

Research has shown that CWEs exhibit cognitive impairments, particularly in the areas of memory and executive functioning. These mental challenges are not present uniformly; instead, their severity and nature are influenced by multiple neurological and clinical variables. Specifically, the type of epilepsy the child is diagnosed with, age of seizure onset, degree of seizure control, and duration of the disorder all play important roles in shaping cognitive outcomes in CWE. (Lopes et al., 2014; Menlove & Reilly, 2015; van Iterson et al., 2014).

Among the various epilepsy types, frontal lobe epilepsy and temporal lobe epilepsy have been most consistently found to be associated with significant cognitive deficits, particularly those involving memory. (Tulving, 1995) The temporal lobes play a critical role in memory coding and retrieval. This includes episodic memory, which is the recall of personally experienced events, and semantic memory, which is knowledge of the world and factual information. (Tulving, 1995) Disruption in these brain regions, as seen in temporal lobe epilepsy, has been shown to impair both semantic and episodic memory (Smith & Lah, 2011; Tulving, 1995). The lateralization of the seizures within the temporal lobes also allows for further specification of the type of expected memory impairments in CWE. Children with left temporal lobe epilepsy are more likely to struggle with verbal memory tasks, such as recalling word lists or understanding verbal information, due to the left hemisphere’s specialization in language, than

CWEs who have right temporal lobe epilepsy. (Cohen, 1992) In contrast, those with right temporal lobe epilepsy are more likely to experience visual or spatial memory deficits, such as difficulties remembering faces, visual patterns, or navigating environments (Cohen, 1992).

Difficulties related to attention are also commonly observed in CWE, even in the absence of a formal Attention Deficit Hyperactivity Disorder (ADHD) diagnosis (Williams & Sharp, 1999; Austin et al., 2001). These attentional difficulties can present as problems with sustained focus, distractibility,or difficulty shifting focus between tasks. These skills are crucial for successful academic engagement. Impairments in these areas can lead to poor school performance and difficulty meeting day-to-day demands (Modi et al., 2019; Turner et al., 2018). When coupled with slower processing speed, or the reduced pace at which a child can take in, interpret, and respond to information, these cognitive challenges further impede a child’s ability to manage time effectively, complete assignments, or participate in classroom discussions (van Iterson et al., 2014; Menlove & Reilly, 2015).

In addition, antiepileptic drugs, especially when multiple medications are used simultaneously (a practice known as polypharmacy), have been shown to further impair cognitive function, including memory and attention (Lordo et al., 2017; Menlove & Reilly, 2015). The mental awareness side effects of AEDs can vary by medication type and dosage, making careful management of treatment plans essential in minimizing neuropsychological burden. These deficits in attention, executive functioning, flexibility, and speed do not typically occur in isolation, but instead interact in ways that amplify their negative effects on learning and behavior. As a result, children experiencing attention difficulties may appear disorganized, inattentive, or unmotivated when, in fact, they are grappling with underlying neurocognitive barriers linked to their epilepsy. Early identification and targeted support are essential for improving outcomes in this population.

Academic Underachievement and Learning Disabilities

The cognitive challenges faced by children with epilepsy, particularly deficits in memory, attention, and executive functioning, directly shape how children engage with learning environments and perform in academic settings. Schools often place high demands on sustained attention, verbal processing, working memory, and organizational skills, all of which are areas vulnerable to disruption in CWE. As a result, cognitive deficits frequently translate into tangible academic underachievement, which can affect a child’s self-confidence, motivation, and long-term educational goals. Understanding the relationship between neuropsychological functioning and school performance is, therefore, essential in addressing the broader developmental needs of this CWE.

CWE have been found to demonstrate decreased rates of learning and patterns of accelerated forgetting, meaning that even when they initially learn information, they are more likely to forget it over time compared to their peers (Van Iterson, 2019). This pattern may reflect underlying disruptions in memory consolidation, described as the process by which short-term memories are converted into long-term storage in the brain. Memory impairments in CWE are rarely isolated; they are often present in a multifaceted way, affecting various types of information retention, and tend to be persistent, even following surgical interventions aimed at controlling seizures (Smith, Elliott, & Lach, 2006; Law, Kerr, & Smith, 2015). Verbal memory deficits are very common and negatively affect CWE, given that they can interfere with a child’s ability to retain language-based information such as reading material, classroom instructions, or conversations with peers. These types of deficits have been strongly linked to lower academic performance, lower self-esteem, and a decreased quality of life, as these skills are essential in functioning in a school environment and within social situations. (Hrabok et al., 2013; Kernan et al., 2012; Salinas et al., 2018; Schraegle et al., 2016; Sepeta et al., 2017).

Academic underachievement is a well-documented outcome for CWE. These children are at a significantly elevated risk for learning difficulties, even when compared to children of a similar age with other chronic medical conditions. (Stores, 1978) The main reasons CWE struggle with academics can be traced back to impairments in verbal memory and executive function, both of which directly affect a child’s ability to learn, retain, and apply information in academic settings (Chapieski et al., 2011; Fastenau et al., 2008; Vasserman et al., 2022). Issues in processing or retaining verbal memory in these children can lead to difficulties in adopting language-based skills, such as reading comprehension, and executive dysfunction may manifest as poor organization or difficulties maintaining focus. Research indicates that children with epilepsy demonstrate challenges in multiple academic areas, including mathematics, spelling, reading comprehension, writing to dictation, and general knowledge acquisition (Williams & Sharp, 1999). These difficulties are not only detrimental on their own, but are compounded by the cumulative effects of recurrent seizures, medication side effects, and frequent school absences. (Williams & Sharp, 1999) Children with symptomatic epilepsy, a type of epilepsy in which seizures are secondary to identifiable brain abnormalities or damage, tend to show the most pronounced educational challenges. This group is at the highest risk for academic underachievement, while children with idiopathic or less severe forms of epilepsy are more likely to perform within the typical academic range (Williams et al., 1996; Austin et al., 1999). The presence of underlying neurological abnormalities, therefore, appears to be a key determinant of academic success. While academic difficulties are prevalent among children with epilepsy, it is important to recognize that these challenges are not the same across all cases. The severity and nature of academic underachievement often depend on a range of epilepsy-specific factors, so understanding which of these variables affect particular CWE offers greater insight into the expected educational difficulties that a child may face.

The prevalence of learning disorders is significantly higher in CWE compared to both the general pediatric population and children with other chronic conditions (Stores, 1978; Seidenberg et al., 1986; Aldenkamp, 1983, 1987). However, these learning challenges, similarly to academic underachievement, are not uniform across all CWE. Instead, they vary based on multiple epilepsy related factors, including seizure frequency, type of epilepsy syndrome, age of symptom onset, and treatment history (Pavlou & Gkampeta, 2011; Aldenkamp et al., 2005). Frequent or prolonged seizures can impair alertness and reduce memory consolidation, hindering a child’s ability to learn and retain new material (Aldenkamp & Arends, 2004). Children with symptomatic epilepsy, such as temporal or frontal lobe epilepsy, are more likely to experience verbal memory impairment in left temporal lobe epilepsy, and visual memory problems in children with right temporal lobe epilepsy, so it is expected that there would be learning difficulties relating to those impairments (Cohen, 1992). Earlier onset of epilepsy, especially during key developmental stages, has also been linked to more severe and widespread issues in school due to a higher prevalence of cognitive impairments (Van Iterson et al., 2014). These disruptions can interfere with the acquisition and retention of essential academic skills, such as reading comprehension and mathematical reasoning. Children with a longer duration of epilepsy often show worsening cognitive outcomes over time, suggesting a cumulative effect on brain function as time goes on (van Iterson et al., 2014). The type and intensity of treatment further influence academic risk. CWE on multiple antiepileptic drugs may experience greater side effects, such as reduced attention and slowed processing speed, which can directly affect classroom performance (Lordo et al., 2017; Menlove & Reilly, 201; Aldenkamp & Arends, 2004; Williams, 2003). In addition, seizure duration plays a compounding role. Children who have experienced seizures lasting longer periods have been shown to demonstrate greater cognitive decline over time compared to other children with epilepsy. (van Iterson et al., 2014). Alongside physical limitations accompanying the condition, children with epilepsy must also deal with the psychological burden, which can also interfere with alertness, concentration, and information retention, further limiting academic progress.

Despite cognitive challenges, research has shown that the overall IQ distribution in children with epilepsy tends to resemble that of the general pediatric population. (Hauser, 1990) However a notable exception was found in CWE who have significant neurological abnormalities, such as structural brain lesions, or those who are diagnosed with severe epileptic syndromes (ex. Lennox-Gastaut or Dravet syndrome) are at greater risk of experiencing moderate to severe generalized cognitive delays, which can shift the IQ distribution downward in these particular individuals (Hauser, 1990). All together, the research has shown that CWE are at increased risk for academic underachievement across various subjects, and their risk for school failure is highest when epilepsy is symptomatic or poorly controlled (Williams et al., 1996; Austin et al., 1999).

Psychiatric Comorbidities and Emotional Well-Being

Research has shown that CWEs present a higher risk for psychiatric and behavioral comorbidities, including anxiety, depression, and attention difficulties, than peers in the same age group (Modi et al., 2019; Salpekar & Mula, 2019). Heightened levels of these psychiatric symptoms are found in CWE compared to their healthy peers and even compared to children

with other chronic illnesses. (Bolter, 1986). These difficulties present not only as a result of the medical aspects of epilepsy but are often an important part of the condition’s broader impact on children and adolescents. Adolescents in particular (typically associated with teenagers but spans ten to twenty-four) often face detrimental developmental disruptions. Social immaturity and low self-esteem (both commonly reported in adolescents with epilepsy) can make it difficult to form age-appropriate relationships, navigate peer interactions, and develop a cohesive sense of identity during critical stages of emotional growth (Apter et al., 1991). These struggles may lead to social isolation and internalized shame, which can escalate emotional distress. As a result, such internal struggles increase the risk of suicidal ideation and behaviors for this population, particularly when stigma, misunderstanding, and a lack of supportive relationships are present (Bell et al., 2009).

A number of interrelated factors contribute to this emotional instability commonly reported in CWE. Antiepileptic drugs, while essential for seizure control, frequently produce side effects that can complicate the ability of children to regulate their emotions and behavior. Children taking these medications may experience irritability, fatigue, or cognitive slowing. (Lordo et al., 2017; Menlove & Reilly, 2015). These cognitive and mood-related side effects can interfere with the child’s ability to concentrate in school, regulate impulses, or maintain energy throughout the day, contributing not only to academic underachievement but also to issues in social settings. Beyond the biological effects of treatment, social context also plays a critical role in shaping psychological outcomes in CWE. CCWEs face a stigma around their condition that contributes to lowered expectations from peers, parents, and teachers. Misconceptions that epilepsy is linked to intellectual disability or emotional instability can lead teachers to underestimate the capabilities of a child, and in the same way, overprotectiveness from parents, often driven by fear and uncertainty, may unintentionally reinforce a child’s sense of helplessness. (Williams, 2003).

These emotional and cognitive challenges give rise to broader patterns of behavioral difficulties. As children struggle to manage the combined effects of medication side effects, social stigma, and internalized stress, behavioral issues can begin to surface, manifesting in ways that further disrupt daily functioning. Approximately 22% of CWE exhibit moderate to severe behavioral disturbances, the most common including aggression, impulsivity, oppositional behaviors, and emotional dysregulation (Freilinger et al., 2006). These problems are most commonly seen in children with early-onset epilepsy, those with symptomatic epilepsy, or those with underlying structural or metabolic brain abnormalities. In these cases, the combination of neurological dysfunction and psychosocial adversity creates a complex picture, where medical, cognitive, emotional, and environmental factors interact, compounding into behavior problems. Without adequate support and intervention, this cycle can undermine both academic achievement and social development, leaving lasting impacts on adolescence and adulthood.

Family and Peer Relationships

Social competence is another area of functioning often disrupted in CWE, particularly in those with temporal lobe epilepsy..Children with temporal lobe epilepsy have a higher likelihood of struggling to interpret social cues, limiting their ability to navigate peer relationships effectively (Stewart et al., 2019). Language impairment and reduced capacity for social information processing (both common symptoms in CWE regardless of diagnosis type) can also hinder the development of age-appropriate interpersonal skills, even in children who score within the average range on standardized assessments of social competence (Crick & Dodge, 1994; Berg et al., 2007). As a result of these challenges, they are at heightened risk for social issues such as peer rejection, social withdrawal, and bullying, regardless of their seizure control status (Apter et al., 1991; Høie et al., 2008; Hamiwka et al., 2009; Byars, 2014). These difficulties can also be compounded by a low IQ, early seizure onset, and deficits in language and executive function (Caplan et al., 2005; Herman et al., 1998; Drewel et al., 2009). Parents of CWE frequently report their children’s social experiences as significantly more negative compared to their typically developing peers, further emphasizing the social burden associated with living with epilepsy at a young age (Davies et al., 2003). Behavioral concerns such as mood instability and attention problems can intensify these difficulties, creating a complex interplay that can affect a child’s ability to function in a social setting(Rantanen et al., 2012).

While individual cognitive and neurological factors contribute significantly to social difficulties in CWE, the broader context in which these children develop, particularly the family environment, also plays an important role. Social challenges rarely emerge in isolation; they are often shaped and reinforced by the child’s immediate relationships and the emotional climate at home. Understanding the influence of family dynamics is therefore essential in fully grasping the psychosocial trajectory of children with epilepsy and to identify opportunities for intervention and support. Research has consistently shown that maladaptive family dynamics can intensify psychological issues in CWE. For example, poor family understanding of the condition, low parental confidence in caring for a child with epilepsy, and negative parent-child interactions have all been found to be significantly associated with increased emotional and behavioral problems in this population (Austin et al., 2004; Nicholas & Pianta, 1994). Stress within the home, a perceived low level of social support, and maternal negativity have also been found to further exacerbate these challenges, highlighting the sensitivity of CWE to environmental stressors (Carlton-Ford et al., 1997; Hoare & Kerley, 1991). Conversely, a positive and supportive family environment can serve as a protective factor, enhancing emotional resilience and improving clinical outcomes in CWE. High parental competence, consistent or meaningful family rituals, and a high level of perceived emotional support have been linked to improved self-management, higher medication adherence, and reduced psychological distress. (Mendes, Crespo, & Austin, 2018; Turner et al., 2018). Supportive, well-informed, and emotionally responsive caregiving has the potential to buffer the adverse effects of epilepsy on social and emotional development, highlighting the critical role of family-based interventions in treating CWE. Addressing social competence, therefore, requires a holistic approach that considers both the child’s neurodevelopmental profile and the relational contexts that shape their daily experiences to best assess the psychosocial needs of the child.

Quality of Life and Coping with Epilepsy

Despite the significant psychosocial and medical challenges associated with epilepsy, many CWE report a relatively positive quality of life, a phenomenon referred to as the “disability paradox” (Albrecht & Devlieger, 1999). The disability paradox highlights the ability of individuals with chronic health conditions to perceive their well-being more positively than external observers might expect. However, this resilience exists alongside genuine difficulties that often compromise the quality of life for CWE. Factors contributing to a decreased quality of life in CWE are the unpredictable nature of seizures, emotional dysregulation, and restrictions placed on their independence and autonomy (Guerrini, 2006; Høie et al., 2008; Streiner, 2025). Assessment tools such as the Pediatric Quality of Life InventoryTM (PedsQLT) Epilepsy Module have been instrumental in measuring the health-related quality of life (HRQoL) in this population, providing an insight into how epilepsy affects the emotional, social, cognitive, and physical domains of functioning (Bernat et al., 2024; Follansbee-Junger et al., 2016). These tools emphasize that quality of life is not only determined by seizure control, but also by the broader psychosocial and emotional context in which the child lives. Emotional well-being in CWE is delicately linked to clinical variables such as seizure frequency, epilepsy severity, and side effects from antiepileptic drugs (Austin et al., 1994; Connolly et al., 2006; Sabaz et al., 2001; Turkey et al., 2008). Frequent seizures and more severe forms of epilepsy are consistently associated with heightened anxiety, depression, and lower self-esteem in this population, which in turn diminishes overall life satisfaction.

A variety of interventions have been explored to mitigate both the neurological and psychological burden of epilepsy. For example, dietary treatments such as the ketogenic diet have shown promise not only in reducing seizure frequency but also in improving mood and behavioral regulation (Freeman et al., 1998). In more severe cases, surgical interventions may considered. Although invasive and associated with inherent risks, epilepsy surgery has demonstrated potential to enhance cognitive functions such as memory and executive processing, particularly when seizure freedom is achieved (Law, Kerr, & Smith, 2015; Smith, Elliott, & Lach, 2006). Ultimately, decisions regarding interventions, whether pharmacological, dietary, or surgical, must involve a careful balancing of risks, benefits, and family preferences. Each treatment pathway should be tailored to the unique neurological profile, emotional functioning, and life context of the individual child, aiming not only for seizure reduction but also for the enhancement of overall well-being and autonomy.

Conclusion

Children and adolescents with epilepsy face a complex set of challenges that extend well beyond seizure control. The cognitive impairments, particularly in memory, attention, and executive functioning, can significantly hinder academic performance and increase the risk for learning disorders in this population. Equally concerning are the psychiatric comorbidities, including anxiety, depression, and behavioral disturbances, which further complicate emotional development and social integration. Social functioning is commonly impaired, with many CWE experiencing difficulty interpreting social cues, building peer relationships, and resisting the stigmatization associated with epilepsy. These challenges are often exacerbated by negative family dynamics, misunderstanding by educators, and broader societal stigma.

Despite these obstacles, many CWEs demonstrate remarkable resilience and report a relatively positive quality of life. This paradox highlights the importance of protective factors, such as strong family support, informed caregiving, early interventions, and inclusive educational practices, in shaping positive outcomes. The evidence indicates that the impact of epilepsy cannot be fully understood or addressed through medical treatment alone. Instead, a holistic, interdisciplinary approach is needed, one that integrates medical, cognitive, psychological, social, and educational support. Tailoring interventions to the individual needs of each child and family is critical for improving functioning across all domains and ensuring that children with epilepsy are not only surviving, but thriving.

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