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Learning disability: Occurrence and long-term consequences in childhood-

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 Epilepsy & Behavior 5 (2004) 937–944
www.elsevier.com/locate/yebeh

Learning disability: occurrence and long-term consequences

in childhood-onset epilepsy
Matti Sillanpää*
Departments of Child Neurology and Public Health, University of Turku, Turku, Finland

Received 2 April 2004; revised 16 August 2004; accepted 17 August 2004

Abstract

This study analyzed the occurrence of learning disability (LD) in adults with childhood-onset epilepsy and the impact of LD on
medical and social outcome. Any LD occurred in 76%: in 57% of mentally normal (IQ > 85), in 67% of mentally near-normal
(IQ = 71–85), and, self-evidently, in all mentally retarded (IQ < 71) adults. Half of the patients (51%) with LD had mental retarda-
tion. In multivariate analysis, mental retardation and subsequent LD were predicted by occurrence of cerebral palsy (odds ratio
[OR] = 3.83; 95% confidence interval [CI] = 1.77–8.28, P = 0.0006), onset of epilepsy before the age of 6 years (OR = 3.63, 95%
CI = 1.57–8.42, P = 0.0026), and poor early effect of drug therapy (OR = 2.78, 95% CI = 1.43–5.39, P = 0.0025). Among mentally
normal or near-normal subjects, a symptomatic etiology of epilepsy was the only predictor (OR = 7.72, 95% CI = 3.02–19.76). The
degree of LD significantly affected medical, social, and educational long-term outcomes.
Ó 2004 Elsevier Inc. All rights reserved.

Keywords: Learning disability; Mental retardation; Near-normal intelligence, Epilepsy; Status epilepticus; Prognosis; Relapse; Social competence;
Reproductive activity; Driving license

1. Introduction There are still only few epidemiological research-

People with epilepsy have for centuries been believed
to be notorious underachievers at school or incapable of
attending school due to a cognitive deficit. The belief has
invariably been based on studies about epilepsy in spe-
cial schoolchildren and institutionalized patients and,
thus, biased by selection [1]. Indeed, a WHO report
found the main problem to be the lack of truly unbiased
samples for testing [2]. Early data from institutions
showed 35–60% of the mentally retarded to have epi-
lepsy [3,4]. More recent, population-based studies [5–7]
found epilepsy in 23–33% of mentally retarded people.
On the other hand, among those with epilepsy, 31–
41% are reportedly retarded [8–12].
*
Fax: +358 2 333 8439.
E-mail address: matti.sillanpaa@utu.fi.
based data on cognitive deficits causing learning distur-
bances in people who have epilepsy. One fundamental
problem is the inconsistent use of the terms mental
retardation (MR) and learning disability (LD). No
consensus so far exists, because, in a very recent discus-
sion, some would like to keep the terms separated [13],
some others want to have the term LD as an umbrella
term for all conditions with learning disability [14], and
the remaining authors simply do not discuss the prob-
lem. Most of the prevalence studies are cross-sectional
and give only rates of prevalence of MR [8,10–12,15–
19], omitting those who have LD but normal intelli-
gence (IQ > 70) [20]. In the National Child Develop-
ment Study of 15,496 children, 64 children had
developed epilepsy by the age of 11. At that age, 43
were in normal schools, 20 were in special schools,
and 1 child was at home [10]. In a Scandinavian study
of 36,500 children, 155 had epilepsy. Of them, 20% had

1525-5050/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.yebeh.2004.08.008
938 M. Sillanpää / Epilepsy & Behavior 5 (2004) 937–944
both MR and cerebral palsy and an additional 21%
had MR only [11]. In another Scandinavian popula-
tion-based study, MR occurred in 39% of 198 children
with epilepsy who were derived from an unselected
population of 38,500 children [17]. Still another Scandi-
navian population study of 49,000 children [12] re-
ported MR in 38% (mild in 14% and severe in 24%).
Cerebral palsy was much more common among chil-
dren with severe MR (49%) than among those with
mild MR (14%). From the same patient series, Beck-
ung et al. [21] later recruited those who had no other
neurological deficits, such as MR, cerebral palsy, and
similar deficits, for the assessment of their sensory
and motor function. Thirty percent of their study sub-
jects with epilepsy but without additional neurological
impairments exhibited gross motor functional deficits
in balance, coordination, and speed. The study did
not consider the intelligence level among these nonre-
tarded subjects.
Brorson and Wranne [22] followed 194 of 195 chil-
dren for 12 years with respect to survival and seizure
prognosis. An initial ‘‘neurodeficit’’ or abnormal neuro-
logical examination, MR, or frequent seizures or any
combination proved to be a negative prognostic factor.
Forty-one percent of patients with a neurological deficit
and 79% of those without any neurodeficit were in 3-
year terminal remission at the end of follow-up.
Camfield et al. [23] classified their patients with re-
spect to intelligence level into four groups: normal, mild
to severe mental retardation, learning disorder, and
learning disorder with behavioral disorder. The latter
two groups were not defined. Twelve percent were clin-
ically assessed as mentally retarded and 16% had a
learning disorder. No data were given on the remaining
4%. A Japanese clinic-based follow-up study [18] found
a significantly higher remission rate in the mentally nor-
mal than in the mentally retarded (IQ < 70) (76% vs
37%). Again, no distinct difference was observed be-
tween MR and LD, but 72% attended regular classes
in an ordinary school. Of 49 mentally retarded, 14% at-
tended regular classes at ordinary schools; 27% attended
special classes at ordinary schools, and the remaining
41% were at schools for handicapped, in institutions,
or invalids at home.
Our purpose was to study the occurrence of LDs and
their effects on medical and social outcomes and factors
that might affect outcome. We hypothesized that, even
in the long run, the outcome is not as favorable in the
learning disabled as in patients with no LD.
2. Subjects and methods
The study group was derived from a population-
based cohort. It included all children aged less than
16 years, who were resident in a geographically defined
catchment area of the University Central Hospital of
Turku at the end of 1964, had epilepsy [24–26], and
had at least one epileptic seizure in 1961–1964 (‘‘active
epilepsy’’). In 1972, the cases were identified on the ba-
sis of patient records of hospitals, institutions, daycare
centers, special schools, and private surgeons, as well
as of the National Health Service records, which cover
all citizens resident in Finland. The case identification,
made by one investigator only (M.S.), was very exten-
sive, and continuing surveillance of the national registry
revealed only three patients who met the inclusion crite-
ria but had not been included in the study. Based on
this recruitment procedure, altogether 245 patients
could be ascertained as patients who met the inclusion
criteria.
The cohort was followed for 45 years. Three patients
died before the age of 3 and were considered too young
for the assessment of LD. Thus, 242 patients (132 males,
110 females) were available for the study. Data were col-
lected retrospectively for the first 10 years and then pro-
spectively in examinations performed every fifth year for
the last 35 years of follow-up. In 1992, after a total fol-
low-up of 35 years, patients completed a detailed ques-
tionnaire and thorough face-to-face interview, physical
examination, assessment of physical fitness, and deter-
mination of cardiovascular, liver, and bone marrow
function and fat metabolism using clinical examination
and laboratory investigation. All the children were less
than 16 years of age at the beginning of follow-up
(mean, 4.7 years; range, 3–15). Follow-up extended to
the year 2002 or to death. Fifty-seven patients died be-
fore 2002. The mean age at the end of follow-up was
36 (range, 5–55) years. The study design, and some med-
ical and social data, including social and educational
outcomes by evolution of seizure status and medication,
have been reported previously [19,27].
The Finnish Public Health Care Administration sys-
tem covers a childÕs life from the fetal period to the
age of 16. Public health center districts, the smallest
administrative units, constitute a countrywide network.
A health care center includes a maternity health care
clinic, childrenÕs welfare clinic, and school health care
organization. In addition, municipal special child guid-
ance clinics provide clinical, psychological, and similar
services. The public organization covers virtually 100%
of children, and is capable of detecting any child with
health problems, including psychological problems, such
as a LD.
Epilepsy, types and etiology of seizures, and epilepsy
syndromes have been defined by the International Lea-
gue Against Epilepsy [27]. Uncomplicated epilepsy is de-
fined as epilepsy without any additional neurological
impairments, such as cerebral palsy and MR [27]. Cere-
bral palsy is defined as a chronic, nonprogressive cere-
bral disorder in young children that results in impaired
motor function [28]. A subject is defined as mentally
 M. Sillanpää / Epilepsy & Behavior 5 (2004) 937–944
normal and, accordingly, as having a normal intelligence
level (IQ > 85), if he or she had a normal cognitive
development and accomplished acceptably in the main-
stream school system (compulsory school for 7- to 16-
year-olds) without any special or remedial education.
A subject is considered near-normal if the IQ is 71–85
and he or she has received special education. Mentally
normal and mentally near-normal are also called men-
tally nonretarded. MR is defined as a lifelong disorder
characterized by an inability to care for oneself like oneÕs
peers because of a low intelligence level (IQ < 70) until
the age of 18 [29]. A subject is defined as mildly mentally
retarded if his or her IQ is 50–70, and severely mentally
retarded patients if the IQ is <50. Socioeconomic status
is defined according to the criteria of the Central Statis-
tical Office of Finland [30]. Passing a Finnish matricula-
tion examination is approximately equal to passing the
first university year in the United States [27].
Severe MR is clinically obvious but was assessed by
a clinical psychologist in most cases. Test results (ver-
bal, performance, total) were available in the patient re-
cords. Virtually all mildly mentally retarded patients
were assessed on clinical grounds, and in most cases
several times, by a psychologist, because a psycholo-
gistÕs statement was necessary for public special educa-
tion services, and the mainstream schools did not have
to accept mentally retarded pupils for education with-
out the psychological assessment and subsequent extra
resources for classroom teaching. A subject had a spe-
cific LD, if he or she, even though able to read, write,
and calculate, had specific difficulties in learning these
skills, was an overall slow learner, or had any other
learning difficulty requiring special education any time
at school. Again, for school administrative reasons, vir-
tually all these children were assessed by a psychologist.
We also had detailed data on their primary and voca-
tional education, later working history, reproductive
activity, licensure for driving, and socioeconomic sta-
tus. However, for certainty reasons, the 35-year fol-
low-up questionnaire included a question ‘‘Have you
ever (at school age or later) had difficulties in reading,
writing, or language?’’ In addition, at the same time,
participants were clinically assessed by one and the
same experienced clinician using a structured study
form for motor dysfunction, language difficulties, atten-
tion deficits, LD, behavioral problems, special school
education, and school achievements. All the patients
who had a LD had had it since school years; none of
them had a LD of acquired origin.
For statistical analyses, PearsonÕs v2 test with Fischer
exact test (two-tail) and YatesÕs correction when appro-
priate were used for univariate analyses, Mann–Whitney
test for continuing variable comparisons, and stepwise
logistic regression analysis for multivariate analyses
and odds ratios and relative risks. Computations were
carried out using SAS statistical software. P values
939
<0.05 were interpreted as statistically significant. The
Joint Ethics Review Committee of the Turku University
Medical School and the Turku University Central Hos-
pital approved the study design.
3. Results
3.1. Occurrence
One-fourth (24%) of 242 patients had no LD whatso-
ever. One hundred and eighty-two (76%) had some type
of LD to some degree. The occurrence was very signifi-
cantly bound to the intelligence level. LDs occurred in
57% of subjects with an IQ greater than 85, in 67% of
those with an IQ of 71–85, and, self-evidently, in 100%
of the mentally retarded. Half of the patients (51%) with
LDs had MR. Of all subjects, 78% attended regular clas-
ses at ordinary schools, 12% attended special classes at
ordinary schools, 9% attended training schools for men-
tally handicapped, and the remaining 1% attended other
types of schools. Reading, writing, and speech problems
in mentally nonretarded patients occurred transiently or
mostly permanently in 19, 19, and 40%, respectively.
Subjects with near-normal intelligence (IQ 71–85) had
significantly more often than mentally normal patients
received special education (45% vs 3%, P < 0.0001)
and failed to pass compulsory school (10% vs 0%,
P = 0.035). The mentally near-normal subjects also
had hyperkinetic features in their behavior more often
than the mentally normal subjects (44% vs 8%,
P < 0.0001). Compared with nonretarded subjects with
other types of epilepsy, reading disability occurred less
often in those with rolandic epilepsy (P = 0.0122,
RR = 0.15, 95% CI = 0.02–1.08), but more often in
those with minor motor seizures (West syndrome and
Lennox–Gastaut syndrome) (P = 0.0322, RR = 2.73,
95% CI = 1.64–4.60). The incidence of writing difficul-
ties did not significantly differ by epilepsy type. Speech
disorders were more often associated with temporal lobe
epilepsy (P = 0.0289, RR = 2.07, 95% CI = 1.15–3.73)
and epilepsy with minor motor seizures (P < 0.0001,
RR = 4.70, 95% CI = 3.37–6.57).
One hundred patients had uncomplicated epilepsy.
Nineteen (19%) with uncomplicated epilepsy reported
reading problems, 18% writing difficulties, and 15%
speech problems at school age and/or later. LD oc-
curred significantly less often in patients with rolandic
epilepsy than in patients with other types of epilepsy
(6% vs 35%, P = 0.0122), and speech problems more of-
ten in patients with temporal lobe epilepsy than other
types of epilepsy (37% vs 18%, P = 0.0289, RR = 2.7,
95% CI = 1.19–6.15) compared with controls. LD was
not significantly more common among subjects with
temporal lobe epilepsy than among controls (P =
0.0742, RR = 1.95, 95% CI = 0.93–4.07).
940 M. Sillanpää / Epilepsy & Behavior 5 (2004) 937–944

3.2. Predictors of occurrence
In univariate analysis, significant predictors of the
occurrence of MR included cerebral palsy, poor early ef-
fect of drug therapy, early (<6 years) onset of epilepsy,
and status epilepticus (Table 1). A stepwise logistic
regression analysis of the significant single determinants
showed that independent predictors of the occurrence of
MR and subsequent LD were cerebral palsy (OR = 3.83,
95% CI = 1.77–8.28, P = 0.0006), onset of epilepsy be-
fore the age of (3.63, 1.57–8.42, P = 0.0026), and poor
early effect of drug therapy (2.78, 1.43–5.39, P = 0.0025).
In univariate analysis, among the mentally nonre-
tarded subjects, symptomatic etiology of epilepsy, con-
comitant cerebral palsy, and poor early effect of drug
therapy were significantly associated with LD, closely,
but statistically nonsignificantly, followed by status epi-
lepticus, male sex, and MR in relatives (Table 2). In
multivariate analysis between the significant predictors,
a symptomatic etiology of epilepsy was the only predic-
tor of the occurrence of LD in mentally nonretarded pa-
tients (OR = 7.72, 95% CI = 3.02–19.76).
3.3. Seizure outcome
LD of any kind and seizure outcome are closely inter-
related. Table 3 shows that 90% of mentally normal sub-
jects with no LD, approximately 70% of mentally
normal subjects with LD, and 54% of the mentally re-
tarded subjects achieved 5-year or longer seizure-free
periods at any stage of follow-up (remission ever),
whether on medication or not. Intelligence level did
not determine seizure outcome among either the men-
tally retarded or the nonretarded subjects.
With respect to the occurrence of relapses, again, pa-
tients with any degree of MR and those with any LD,
regardless of MR, relapsed significantly more often than
others (Table 4). The relapse rate was very high among

Table 1
Predictors of the occurrence of mental retardation among adult patients with childhood-onset epilepsy
Predictor Mental retardation P OR 95% CI
N Yes No
n % n %
Cerebral palsy <0.0001
No 189 54 28.6 135 71.4 1.0
Yes 53 38 71.7 15 28.3 6.33 3.22–12.45
Poor early drug effect <0.0001
No 131 38 29.0 93 71.0 1.0
Yes 75 43 57.3 32 42.7 3.29 1.82–5.95
Onset of epilepsy <0.0001
>6 years 66 12 18.2 54 81.8 1.0
66 years 176 80 45.4 96 54.6 3.75 1.88–7.49
Status epilepticus 0.0151
No 167 55 32.9 112 67.1 1.0
Yes 75 37 49.3 38 50.7 1.98 1.14–3.46
Gender 0.1385
Female 112 37 33.0 75 67.0 1.0
Male 130 55 42.3 75 57.7 1.49 0.88–2.51
Epilepsy type 0.6093
All but TLE 160 59 36.9 101 63.1 1.0
TLE 88 33 40.2 49 59.8 1.15 0.67–1.99

Table 2
Predictors of learning disability in 149 nonretarded patients with childhood-onset epilepsy
Predictor N LD (%) P OR 95% CI
Etiology of epilepsy <0.0001
Idiopathic 68 64.7 1.0
Cryptogenic 54 51.8 0.59 0.28–1.22
Symptomatic 120 93.3 7.64 3.19–18.28
Cerebral palsy 53 92.4 0.0015 4.90 1.69–14.24
Poor early drug effect 75 88.0 0.0026 3.22 1.46–7.10
Status epilepticus 75 84.0 0.0517 2.00 0.99–4.04
Male sex 130 80.8 0.0630 1.75 0.97–3.23
MR in relatives 46 84.8 0.1353 1.93 0.81–4.62
Onset of epilepsy <6 years 137 77.8 0.2820 1.43 0.75–2.70
Temporal lobe epilepsy 82 78.1 0.5990 1.19 0.63–2.22
 M. Sillanpää / Epilepsy & Behavior 5 (2004) 937–944 941

Table 3
5-Year remission ever of seizures on/off medication in adults with childhood-onset epilepsy on 45-year follow-up by learning disability
LD N n % Probability of relapse OR 95% CI
Occurrence of LD 0.0003
No LD 58 52 89.7 4.30 1.75–10.56
Any LD 184 123 66.8 1.0
Retarded (IQ < 71) 93 50 53.8 0.4811
Mild (IQ 50–70) 11 7 63.6 1.59 0.43–5.84
Severe (IQ < 50) 82 43 52.4 1.0
Nonretarded 91 73 80.2 0.7366
Mentally normal 68 54 79.4 1.23 0.36–4.20
Mentally near normal 23 19 82.6 1.0
Nonretarded vs retarded <0.0001 3.49 1.81–6.73

Table 4
Occurrence of relapse on/off medication after the first 5-year remission of seizures in adults with childhood onset epilepsy on 45-year follow-up by
learning disability
LD N n % P OR 95% CI
Occurrence of LD 0.0007
No LD 52 16 30.8 1.0
Any LD 123 72 58.5 3.17 1.59–6.33
Retarded (IQ < 71) 50 36 72.0 0.0091
Mild (IQ 50–70) 7 2 28.6 1.0
Severe (IQ < 50) 43 34 79.1 9.44 1.57–56.95
Nonretarded 73 36 49.3 0.3838
Mentally normal 54 25 46.3 1.0
Mentally near-normal 19 11 57.9 1.59 0.55–4.59
Retarded vs nonretarded 0.0112 2.64 1.22–5.70

patients with IQs less than 50 compared with those
whose IQ was 50 or greater.
A 5-year terminal remission was significantly more
common in the mentally retarded subjects than in the
retarded subjects (OR = 5.21, 95% CI = 2.20–12.33,
P < 0.0001), as well as in patients with no LD compared
with the learning disabled (3.06, 1.35–6.94, P = 0.0045).
Similarly, a 5-year terminal remission without medica-
tion was more common among the mentally nonre-
tarded subjects (8.55, 3.43–21.28, P < 0.0001) and
among those with no LD (3.91, 1.89–8.09, P = 0.0001).
3.4. Social outcome
Eleven percent of the patients with LD but normal
intelligence and 33% of those with near-normal intelli-
gence were pensioned for employment disability
(P = 0.0214). One percent of mentally normal and 10%
of mentally near-normal subjects were independent
(P = 0.0960). Among mentally retarded people, depen-
dency in daily activities increased significantly
(P = 0.0001) with decreasing mental level: of patients
with mild, moderate, severe, or profound mental retar-
dation, 11, 20, 60, and 100%, respectively, were com-
pletely or virtually completely dependent in activities
of daily living. The corresponding figures for occasional
or permanent institutionalization were 20, 53, 81, and
95%.
One-fourth of controls but almost half the subjects
with uncomplicated epilepsy but normal intelligence
and almost 90% of those with near-normal intelligence
had had to settle for primary education only or less than
primary education (Table 5). The risks of unemploy-
ment, living single, and having no children were higher
among near-normal than normal subjects. Except for
one person who had a special college education, none
of the mentally retarded subjects, though not exempted
from compulsory education, could pass the matricula-
tion examination. The lower the intelligence level, the
greater the risk of not passing. The same trend could
be seen throughout the line: the intellectually less advan-
taged had in fewer cases vocational training, paid work,
a partner, or children. Interestingly, roughly the same
percentages of controls and subjects with epilepsy only
passed the matriculation examination. Similarly, socio-
economic status did not significantly differ between the
two groups.
4. Discussion and conclusions
In our population-based, unselected study, 76% of
subjects had at least one mild to severe learning disabil-
ity. Half of the patients had MR, and the other half,
near-normal to normal intelligence. The criteria applied
for LD were fairly strict and the results are based on sev-
942 M. Sillanpää / Epilepsy & Behavior 5 (2004) 937–944

Table 5
Social outcome of patients with epilepsy and learning disability compared with controls
Variable intelligence level Controls Age >85 Age 71–85 Age <70
N(%) N(%) P RR N(%) P RR N(%) P RR
(95% CI) (95% CI) (95% CI)
Primary education only 23(23) 42(47) 0.001 2.03 18(86) <0.001 3.69 61(98) <0.001 4.23
(1.33–3.09) (2.48–5.49) (2.96–6.07)
Failure to pass matriculation 74(75) 69(78) 0.733 1.04 21(100) 0.006 1.34 62(100) <0.001 1.34
examination (0.88–1.22) (1.19–1.50) (1.19–1.50)
No vocational training 51(52) 59(66) 0.054 1.29 20(95) <0.001 1.85 62(100) <0.001 1.94
(1.01–1.64) (1.49–2.29) (1.60–2.35)
Unemployed 8(8) 26(28) <0.001 3.39 13(59) <0.001 7.09 63(100) <0.001 12.0
(1.62–7.10) (3.35–15.0) (6.18–23.30)
Not living with partner 10(10) 29(32) <0.001 3.12 15(68) <0.001 6.75 63(97) <0.001 9.59
(1.61–6.04) (3.51–12.97) (5.32–17.30)
No children 16(17) 41(45) <0.001 2.65 20(95) <0.001 5.65 65(100) <0.001 5.94
(1.60–4.37) (3.58–8.93) (3.80–9.28)
No driverÕs license 11(11) 32(35) <0.001 3.13 11(52) <0.001 4.71 63(100) <0.001 9.00
(1.68–5.84) (2.36–9.40) (5.15–15.71)
Lower socioeconomic status 51(52) 57(62) 0.188 1.20 20(95) <0.001 1.85 62(100) <0.001 1.94
(0.94–1.54) (1.49–2.29) (1.60–2.35)

eral successive examinations including face-to-face inter-
views and clinical examinations. Patients with epilepsy
are generally considered to be at a threefold risk for cog-
nitive or other mental problems [31]. Our results are in
keeping with these data. In another study of ours in
1987, all the parents of children aged 8 to 9 years from
ordinary schools in the same area as the study patients
reported one or more LDs in 15–20% and their teachers
in 31% (unpublished data). Interestingly, the LD rate
was exactly the same in a recent study of 11-year-old
schoolchildren in the same city [32]. A specific LD has
been reported in 10 to 21% of adults with TLE [33].
The figure is essentially the same as in our patients with
uncomplicated epilepsy of any type. Of specific LDs,
reading disability occurred in our sample significantly
more often in subjects with West syndrome or Len-
nox–Gastaut syndrome, but significantly less often in
subjects with rolandic epilepsy compared with other epi-
lepsy types. Speech difficulties are known to be associ-
ated with epilepsy-[34] related LD either transiently or
constantly [35–37]. In our study, the risk associated with
uncomplicated epilepsy was 2.7-fold.
Reasons for LD among patients with epilepsy are
probably the direct effects of seizures, particularly in
children with early age of onset, processes behind the
epilepsy syndrome, effects of concomitant and often pre-
ceding neuropsychological deficits, adverse effects of
drug therapy, and social stigma [38]. A less favorable so-
cial outcome of mentally near-normal may be preferably
explained by a virtually lower performance potential.
However, one cannot exclude the possible effect of social
stigma on the less successful future of mentally normal
adults with uncomplicated epilepsy in childhood. Socie-
tal misunderstanding and generalization of all people
with epilepsy as the same [39] by families [40], educators
[41], other people with epilepsy [42], and even patients
themselves have though unintended, effects such as so-
cial and educational displacement and omission. Our re-
sults might indicate this effect; more subjects than
expected had a compulsory primary education only,
but if they did proceed with education, they passed the
next academic step, the matriculation examination, vir-
tually as often as controls. Epilepsy is a stigma in Wes-
tern societies [43,44], and an invisible handicap is an
even more labeling factor [45]. Epilepsy and LD pose
a challenge for our time to minimize the effects of both
the medical and social disadvantages of epilepsy [34].
Our study is one of the few population-based analy-
ses of LD among both mentally retarded and mentally
normal or near-normal patients with epilepsy. The per-
centage of mentally retarded in the present study
(38%) is well in line with the previous studies (range,
33–54%) [11,12,15–18,46]. MR was more common
among our patients with prevalent cases (55%) than
among those with incident cases (25%) [22]. The figures
of Camfield et al. [23], which were lower than those in
the previous studies and in our study both for mental
retardation and LD among children with normal intelli-
gence, are explained largely by their different study pop-
ulation. Furthermore, in the Camfield et al. study, the
youngest patients might have been too young for assess-
ment, and the actual LD rate might therefore be higher.
The present study demonstrates a relationship be-
tween low cognitive function and poor seizure outcome.
Although some authors have not found any difference in
outcome related to the severity of intellectual disability,
several others have reported such a relationship
[3,5,6,15,16,22,47,48]. An association of cerebral palsy
with epilepsy increased the prevalence of mental retarda-
tion up to 41% in our patients. Similar figures (38–43%)
 M. Sillanpää / Epilepsy & Behavior 5 (2004) 937–944
have been reported [3,11,12,17,49,50]. The risk of the co-
occurrence of LD with epilepsy increases with increasing
severity of cognitive deficit. However, in our subjects
with normal intelligence (IQ > 85), LD was more com-
mon than in controls. The same observation has been re-
ported both in adults [51] and in children [52,53], whose
memory function in particular has been vulnerable.
In line with our study, early age at onset of epilepsy is
an indicator of poor seizure outcome in LD, particularly
in severe LD [50,54]. Furthermore, the higher rate of re-
lapses in patients with MR than in the mentally normal
was confirmed [18,22,48,55].
Social and educational outcomes are affected by LD.
Less basic and vocational education, fewer marriages
and children, higher rate of disability pension for unfit
to work, and higher rate of institutionalization have also
been reported in previous studies [18,56]. Intellectual
deficits are of greater importance than personality dis-
turbances in social adjustment [48].
In conclusion, learning disability is a common feature
of patients with childhood-onset epilepsy of any kind
and affects medical, social, and educational outcomes.
Poor seizure outcome and learning disability occur more
often than expected in epileptic subjects who are men-
tally normal, followed by mentally near-normal and
mentally retarded subjects. Although the social conse-
quences may be in part related to social stigma, there
is no doubt that biological factors play an important
role in adjustment and social accomplishment. Future
prospective population-based studies should be designed
to evaluate how much the causative factors differ be-
tween these subgroups and how well progress in modern
diagnostic technology and antiepileptic drug develop-
ment and improvement in public attitudes may decrease
learning problems in people with epilepsy.
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