June 1, 2013 Features

Baseline Benefits

We may not know why children with epilepsy have speech and language challenges, but we do know they often struggle socially and academically. Armed with baseline and subsequent assessments, SLPs can provide the intervention these children need.

When a child begins to play contact sports, parents, educators and physicians agree that it's a good idea to first give them baseline neurological testing. Why? Because if the child sustains a concussion or traumatic brain injury during play, neurological retesting of cognitive communication abilities can help determine that child's readiness to get back in the game.

130601_Baseline_Benefits.jpgWe suggest, given the research on changes in brain function, a similar strategy for children diagnosed with epilepsy, whose speech and language abilities may decline over the course of the disorder. With a baseline assessment performed shortly after a child's diagnosis, clinicians can track changes in brain function and provide intervention and accommodations to help the child with the resulting academic and social struggles.

Epilepsy is the most common of all childhood neurologic disorders. Each year, 45,000 new cases are diagnosed in children younger than 15, leading to a prevalence of approximately 325,000 school-aged children with a seizure disorder, according to the Epilepsy Foundation of America. Based on these figures, childhood seizure disorder is as common as most developmental disorders on the speech-language pathologist's caseload.

Epilepsy is associated with difficulties in academic, social and emotional functioning, including long-term outcomes such as dropping out of school, unemployment and social isolation. Despite growing evidence that children with epilepsy are at elevated risk for a broad range of academic problems, including language use, there is virtually no coverage of this population in literature on childhood communication disorders.

There are several possible reasons why children with epilepsy are at speech and language risk. One of the most common types of childhood epilepsy is characterized by focal seizures in the temporal lobe region, the area of the brain primarily responsible for speech and language processing. (Seizures themselves may cause brain damage—particularly if they are severe—but the damage is usually subtle, according to the National Institute of Neurological Disorders and Stroke.) The underlying problem that caused the seizures or the medications used to control seizure activity are other potential sources of neurological changes. Often, the cause in any given child is unclear.

Evolving research

Research (see sources list online) suggests that, over time, children with epilepsy struggle more than their peers to keep up academically, with their language skills at particular risk. But it may be difficult to document the difficulties unless the child has had a full speech-language evaluation shortly after diagnosis. Although medical and psycho-educational associations now recommend baseline assessment of children soon after diagnosis of a seizure disorder, there is no such recommendation with the communication sciences and disorders literature.

Our team has conducted research to help demonstrate evidence of speech and language difficulties in children with epilepsy. We have presented preliminary findings from the POLER Project (Plasticity of Language in Epilepsy Research), funded by the National Institute of Neurological Disorders and Stroke, at a number of recent ASHA conventions. Feedback from practicing SLPs indicates they share our concern that the professional literature offers little information to support their concerns that children with epilepsy are "losing ground" over time, nor does it offer recommendations for active monitoring of their communication and language/literacy skills.

Our recently completed work, published in the March-April 2013 International Journal of Language and Communication Disorders, analyzed language performance in two cohorts of children with epilepsy and their age- and gender-matched peers. Data from this group of 25 children clearly demonstrated that children with chronic epilepsy performed worse on standardized language tests, whereas the children more recently diagnosed with epilepsy performed very similarly to unaffected peers. Moreover, on a story generation task, the children with chronic seizures used simpler language, less-sophisticated vocabulary and poorer narrative structure. In addition, naïve adults who listened to the stories scored them as significantly poorer in quality than those produced by the unaffected peers and children with new-onset seizures (see "A Tougher Time on Language Tasks").

The notion that some children may be at risk for acquired or progressive problems in communication is becoming more common. Many jurisdictions now recommend, for example, that students who play contact sports should receive baseline assessments, so that we can document the effects of closed-head injury or concussion on the child's underlying communication skills. The same monitoring is advised for children with epilepsy, particularly when the focus is localized to language processing areas.

It is still not clear why children with chronic seizures have a higher risk of problems: Does the brain dysfunction that provokes seizures also impair skill development and/or use? Do the seizures themselves damage the developing brain? Do seizure-control medications negatively affect memory, language and/or attention? Answers may vary.

We see children who are well-controlled with medication (and thus do not have ongoing seizures) who nonetheless have cognitive problems, and we also see children whose daily performance is tightly coupled to changes in medication and/or seizure control. Detangling these issues is of scientific concern, but the functional ramifications are the same and should be addressed to give children with epilepsy maximum support across childhood.

To qualify a child with epilepsy for services, we must document that the disorder affects performance, but this documentation may not be evident without a baseline language skills assessment performed soon after the diagnosis of seizure disorder. Most insurance will cover assessment if it is recommended by the professionals working with the children with epilepsy, because of the significant risk to the child's academic, social and vocational prospects.

Our psychology colleagues routinely obtain insurance coverage for neuropsychological evaluation of children with epilepsy. Neuropsychological services are designated as "medicine, diagnostic" by the federal Health Care and Financing Administration, are included in "Central Nervous System Assessment" CPT codes (Common Procedural Terminology © American Medical Association), and have corresponding ICD (International Classification of Diseases) diagnoses.

Although neuropsychological evaluations span many domains, a key area is language function. A National Academy of Neuropsychology position paper [PDF] notes that for some children, a typical school-based psychoeducational evaluation may be sufficient to identify emerging learning problems, but emphasizes the importance of identifying brain-related dysfunction through, perhaps, a more detailed neuropsychological assessment of cognitive abilities. Results allow clinicians to begin academic and behavioral interventions early and may reduce the likelihood that the child will experience continued failure, which may lead to more severe emotional or behavioral difficulties.

Our group also found that children with epilepsy show disruption in lateralization and honing of cortical language networks, which lasts in typical children until age 10. Thus, functional imaging demonstrates that the language difficulties in children with epilepsy result from atypical language networks and may have a unique window of opportunity for intervention.

SLPs' role

Other than conducting a baseline assessment, and providing treatment if the child is experiencing difficulties, what else should SLPs consider in working with a child with epilepsy?

  • The Epilepsy Foundation and NIH note that many children with epilepsy experience negative reactions from peers and even educators, and that the effects of these attitudes bear striking similarity to the growing literature on the social consequences of stuttering or language-learning disability. SLPs can help children with epilepsy learn to combat teasing through education and empowerment.
  • Because anti-seizure drugs may affect concentration and memory, children with epilepsy may need accommodations such as additional time on assignments or tests or written reinforcement of lessons or instructions.
  • School and clinical personnel working with a child with epilepsy should know appropriate responses to seizures. The Epilepsy Foundation offers simple instructions and visual aids that can be posted in any room or placed in a child's binder. The National Institute of Neurological Disorders and Stroke recommends that parents work with the school system to find reasonable ways to accommodate any special needs their child may have, although establishing a baseline and continued monitoring is not yet commonplace.

We often hear our colleagues in the schools or across professions who are not familiar with epilepsy describe the condition as "medical," believing there is little benefit from intervention "until the seizures are taken care of." We want to dispel this myth, because it may be precisely such delays in implementing interventions that place children with epilepsy at risk for poor outcomes. An added benefit of closer language monitoring is that it may signal a need for changes in medication, as subclinical seizures may manifest as performance changes or deficits.

Children with epilepsy deserve the same consideration as student athletes: a baseline language assessment, even if the child displays no outward signs of speech and language difficulties. For student athletes, these studies can help assess an athlete's readiness to return to the playing field after concussion. For children with epilepsy, such studies will help determine when speech and language treatment is required and when a child's seizure activity has changed. And perhaps these assessments and treatments will help children with epilepsy keep up with their peers and overcome the risk of social and academic difficulties.

Nan Bernstein Ratner, EdD, CCC-SLP, is professor and chairman of the Department of Hearing and Speech Sciences at the University of Maryland, College Park. Her primary research areas are fluency development and disorders, psycholinguistics, and the role of adult input and interaction in child language development. She is an affiliate of ASHA Special Interest Group 4, Fluency and Fluency Disorders. nratner@umd.edu

William D. Gaillard, MD, is a pediatric neurologist at the Center for Neuroscience and Behavioral Medicine of the National Children's Medical Center (Washington, D.C.), where he is director of the Epilepsy, Neurophysiology, and Critical Care Neurology Division and director of the Comprehensive Pediatric Epilepsy Program. He is also associate director of the Center for Neuroscience Research at the Children's Research Institute and director of the Adult Continuity Program/Transition Clinic Team at Georgetown University Hospital. wgaillar@childrensnational.org

Madison M. Berl, PhD, is a clinical neuropsychologist on the epilepsy and neuropsychology faculty of the Center for Neuroscience and Behavioral Medicine at the National Children's Medical Center. She is also a principal investigator at the Children's Research Institute's Center for Neuroscience Research and an assistant professor at the George Washington University School of Medicine and Health Sciences in Washington, D.C. mberl@childrensnational.org

Amy Strekas, MA, CCC-SLP, is a clinician at the American Institute for Stuttering (New York City), a nonprofit that offers treatment to people who stutter and clinical training to SLPs interested in acquiring stuttering treatment expertise. She is an affiliate of SIG 4. astrekas@gmail.com

cite as: Ratner, N. B. , Gaillard, W. D. , Berl, M. M.  & Strekas, A. (2013, June 01). Baseline Benefits. The ASHA Leader.

A Tougher Time on Language Tasks

Compare these excerpts from a common picture book narrative from two 7-year-old children in the POLER project (Plasticity of Language in Epilepsy Research), which is examining the speech and language capabilities of children with epilepsy. Child A, who has had epilepsy for more than three years, clearly struggles to communicate the information well. Child B is an age- and gender-matched typical peer. As these samples demonstrate, children with epilepsy do not necessarily tell shorter stories or use shorter utterances, but their language is not as informative and their narrative structure is less well-developed.

Child A

Um a little boy's sleeping.
And and the frog the frog is getting the jar.
And it's nighttime.
And then the frog's gone.
And then the doggie says oh no.
And then he says and then he says froggie!
And then the dog says froggie and then the dog says froggie!
And then the ... I don't know what to do said the little boy.
The dog just ran away and out into the front yard.
He said you mean little doggie come with me.
And now everybody had twice said froggie.
Every one of them said froggie.
The dog made the dog then the dog made the honey thing fall down.
And then the boy said froggie again.
And the tree falled.
Okay then the dog then the dog ran.

Child B

Frog, where are you?
One day with there was a boy and his dog and a frog.
One day he fell asleep on his bed with his dog.
And the frog got out.
When the boy woke up, he noticed the jar was empty.
And the frog was gone.
The boy looked in a boot.
Inside the jar the dog looked.
The dog looked out the window with the jar on his head .
And the boy called the frog.
But he wasn't there.
And then the dog fell out of the window.
And the glass cracked.
And he was upset.
So the boy came down and searched and searched.
They both called the frog.
But he never came.
They they yelled and yelled, but nothing.



Sources

Caplan, R., Siddarth, P., Vona, P., Stahl, L., Bailey, C., Gurbani, S., … Shields, W. D. (2009). Language in pediatric epilepsy. Epilepsia, 50, 2397–3407.

Fjordbak, B. S. (2011). Protecting student athletes: Growing number of states pass concussion-related legislation. The ASHA Leader, 16(10). Available at http://www.asha.org/Publications/leader/2011/110830/Protecting-Student-Athletes--Growing-Number-of-States-Pass-Concussion-Related-Legislation/.

Gutowski, L., Berl, M., Bernstein Ratner, N., & Gaillard, W. (2005, November). Narrative abilities in children with epilepsy and their typically developing peers. American Speech-Language-Hearing Association Annual Convention, San Diego.

King, L., Strekas, A., Weber, D., Berl, M., Gaillard, W., & Bernstein Ratner, N. (2006, November). Expressive language skills of children with recent-onset epilepsy. American Speech-Language-Hearing Association Annual Convention, Miami.

Loring, D. (2010). Teaching the teachers: Data to benefit school systems and doctors about children with newly diagnosed epilepsy. Epilepsy Currents, 10, 38–39.

Pal, D. (2011). Epilepsy and neurodevelopmental disorders of language. Current Opinion in Neurology, 24, 126–131.

Silver, C. H., Blackburn, L. B., Arffa, S., Barth, J. T., Bush, S. S., Koffler S. P., … Elliott, R. W. (2006). The importance of neuropsychological assessment for the evaluation of childhood learning disorders NAN Policy and Planning Committee. Archives of Clinical Neuropsychology, 21(7), 741–744.

Strekas, A., King, L., Weber, D., Berl, M., Gaillard, W., & Bernstein Ratner, N. (2006, November). An investigation of chronic epilepsy in children: Language profiles. American Speech-Language-Hearing Association Annual Convention, Miami.

Strekas, A., Bernstein Ratner, N., Berl, M., & Gaillard, W. D. (2012). Narrative abilities of children with epilepsy. International Journal of Language and Communication Disorders. DOI: 10.1111/j.1460-6984.2012.00203.



  

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