Child Neuropsychology

A Journal on Normal and Abnormal Development in Childhood and

Adolescence

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The WISC-V in children and adolescents with

epilepsy

William S. MacAllister, Moshe Maiman, Marsha Vasserman, Taryn Fay-

Mcclymont, Brian L. Brooks & Elisabeth M. S. Sherman

To cite this article: William S. MacAllister, Moshe Maiman, Marsha Vasserman, Taryn Fay-
Mcclymont, Brian L. Brooks & Elisabeth M. S. Sherman (2019): The WISC-V in children and
adolescents with epilepsy, Child Neuropsychology, DOI: 10.1080/09297049.2019.1571181

To link to this article: https://doi.org/10.1080/09297049.2019.1571181

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CHILD NEUROPSYCHOLOGY
https://doi.org/10.1080/09297049.2019.1571181

The WISC-V in children and adolescents with epilepsy

William S. MacAllistera,b,c,d, Moshe Maimane, Marsha Vassermana,c,f,
Taryn Fay-Mcclymonta,b,c, Brian L. Brooksa,b,c and Elisabeth M. S. Shermang
a
Neuropsychology Service, Alberta Children’s Hospital; bDepartment of Paediatrics, University of Calgary;
c
Alberta Children’s Hospital Research Institute; dDepartment of Neurology, Epilepsy Center, New York
University School of Medicine; eDrexel University; fDepartment of Child Adolescent Psychiatry, Child Study
Center, New York University School of Medicine; gCopeman Healthcare Centre

ABSTRACT ARTICLE HISTORY

Despite its popularity in the neuropsychological evaluation of chil- Received 26 September 2018
dren, the utility of the Wechsler Intelligence Scale for Children – Fifth Accepted 13 January 2019
Edition (WISC-V) has not yet been investigated in children with KEYWORDS
epilepsy. Eighty clinically referred children and adolescents with Epilepsy; intelligence; WISC-V;
epilepsy were administered the WISC-V as part of a comprehensive children; adolescents
assessment and scores were compared to matched controls from the
WISC-V standardization sample. T tests compared WISC-V indices and
subtests between patients and controls and Chi-square analyses
compared the rates of low scores. Correlational analyses assessed
the relationships between epilepsy severity variables (e.g., age of
onset, duration of epilepsy, number of antiepileptic drugs, seizure
frequency). All WISC-V composites and subtests were significantly
lower in patients versus controls and the rate of low scores was
higher in patients than controls for all composites and subtests
with the exception of Figure Weights. The Working Memory Index
and Processing Speed Index were most sensitive to impairment,
while the Verbal Comprehension Index and Fluid Reasoning Index
were least sensitive. Of the epilepsy severity variables, age of seizure
onset and number of antiepileptic drugs were strong predictors of
deficits, whereas seizure frequency was the weakest predictor.
Importantly, no significant differences were seen in children with
right hemisphere epilepsy versus left on the five WISC-V composites,
though a trend was seen towards a lower Visual-Spatial Index in
those with right-sided focal seizures.

Cognitive deficits are frequently seen in pediatric epilepsy; contributing factors include
age of onset, disease duration, seizure etiology, and antiepileptic drug (AED) side effects
(Berg et al., 2008; Berg, Zelko, Levy, & Testa, 2012; Cormack et al., 2007; O’Leary,
Burns, & Borden, 2006; Sherman, Brooks, Fay-McClymont, & MacAllister, 2012). Many
children with epilepsy have deficits that precede seizure onset, suggesting that early
cognitive disruption and later seizure onset are related to a common underlying
pathology (Austin & Fastenau, 2009; Fastenau et al., 2009; Hermann & Seidenberg,
2007; Oostrom, Smeets-Schouten, Kruitwagen, Peters, & Jennekens-Schinkel, 2003).
Further, children with epilepsy have higher rates of learning disabilities/academic

CONTACT William S. MacAllister William.macallister@ahs.ca Alberta Children’s Hospital, 2888 Shaganappi

Trail NW, Calgary, AB T2N 3H6
© 2019 Informa UK Limited, trading as Taylor & Francis Group
2 W. S. MACALLISTER ET AL.

underachievement (Fastenau, Shen, Dunn, & Austin, 2008; Lhatoo & Sander, 2001),
behavioral problems, and psychiatric disorders, in comparison to typically developing
children.
In neuropsychological assessments, intelligence testing typically represents a critical
“first pass” in characterizing a child’s functioning, with specific neuropsychological tests
providing more detailed information. Though the limitations of intelligence testing are
well documented (Baron, 2004), these tasks provide practitioners with a global sense
about how a child is performing relative to their same-aged peers and are critical in
educational planning and future occupational and/or care planning. Several measures of
intellectual functioning are available, but the Wechsler scales remain amongst the most
popular (Rabin, Paolillo, & Barr, 2016) and have been included as a core measure in the
National Institute of Neurological Disorders and Stroke (NINDS) Common Data
Elements for Epilepsy batteries (Loring & Hermann, 2011).
Studies of children with epilepsy utilizing earlier editions of the Wechsler Intelligence
Scale for Children (WISC-R/III) demonstrated that, on average, children with epilepsy
score in the low-average to average range (Guimarães et al., 2007; O’Leary et al., 2006).
Importantly however, a subset of these children do perform well below age expectations.
Sherman et al. (2012) examined the utility of the fourth edition of the WISC (WISC-
IV; Wechsler, 2003) in clinically referred children and adolescents with epilepsy at two
tertiary epilepsy centers (Alberta Children’s Hospital in Calgary, Alberta and NYU
Comprehensive Epilepsy Center in New York). The mean Full Scale IQ (FSIQ) was in
the borderline range; the Processing Speed Index (PSI) was the weakest composite on
average. Importantly, more than a third of the group (37%) had FSIQs in the extremely
low range. Epilepsy severity factors such as age of seizure onset, epilepsy duration, and
number of AEDs predicted poorer performance across subtests, but no differences were
seen for those with left versus right seizure foci.
The fifth edition of the WISC (WISC-V), published in 2014, differs substantially from
prior editions, given its five-factor structure. The Perceptual Reasoning Index (PRI) was
replaced with a Visual Spatial Index (VSI) and a Fluid Reasoning Index (FRI), with Visual
Puzzles and Figure Weights being introduced as primary subtests for these composites.
Further, the Picture Span subtest replaced Letter-Number Sequencing, and the Digit Span
subtest added a sequencing component in an effort to improve the overall sensitivity of
the Working Memory Index (WMI), while Comprehension and Picture Concepts were
dropped as primary subtests. Relative to the WISC-IV, the test authors suggest that the
WISC-V has enhanced clinical utility over the WISC-IV (Wechsler, 2014).
To date, no study has explored the clinical utility of the WISC-V in children and
adolescents with epilepsy. Given the noted differences between WISC-IV and WISC-V,
the applicability of prior findings cannot be assumed. Thus, the goals of this study were
to provide validation for the WISC-V in clinically referred children with epilepsy. More
specifically, we aimed to identify WISC-V index and subscale strengths and weaknesses
compared to a matched sample of children without epilepsy, and to define the relation-
ship between WISC-V scales and clinical variables including epilepsy severity variables
such as age of onset, duration of epilepsy, number of AEDs, and laterality of seizure
focus. Based on previous findings, we hypothesized that our sample of children with
epilepsy would demonstrate significantly poorer performance on the WISC-V relative
 CHILD NEUROPSYCHOLOGY 3

to controls, with age of seizure onset, epilepsy duration, and AED polypharmacy
correlated with WISC-V composites and subscales.

Methods
Participants
Eighty consecutively evaluated children with epilepsy referred for a neuropsychological
evaluation at the NYU Comprehensive Epilepsy Center were included. Children and
adolescents ranged from 6 to 15 years of age, having been referred for neuropsycholo-
gical evaluation as part of their clinical care. Primary inclusion criteria for this study
included a confirmed diagnosis of epilepsy, made in accordance with the International
League Against Epilepsy criteria (Fisher et al., 2014). Diagnosis was rendered by
a neurologist/epileptologist via neurological workup that included electroencephalogra-
phy (EEG) and a clinical interview with each child’s parent. EEG also established the
nature of participants’ seizures, including type (i.e., generalized, focal, or mixed) and
lateralization (i.e., left, right, or bilateral) when possible.
For inclusion in the study, data on all 10 primary subtest scores were necessary.
Further, the child’s primary language had to be English and they had to be capable
of validly participating in the tasks; e.g., no participants had visual impairments or
motor skills impairment of such severity that would invalidate any subtest adminis-
tration. Individuals with other major neurological disorders other than epilepsy were
excluded (e.g., stroke, head injury, tuberous sclerosis complex, etc.) as these are
conditions that have imaging findings and could, in and of themselves, be associated
with cognitive deficits, and are often (but not always) also associated with seizures.
Patients with prior resective epilepsy surgeries were also not included. One child was
excluded due to failure of performance validity tests, clinically judged to be a true
positive. Children presenting with comorbid disorders such as attention deficit/
hyperactivity disorder, learning disabilities, and/or autism spectrum disorders were
not excluded, so long as they were able to appropriately participate in the evaluation
and the measures of interest; this was done to appropriately capture the range of
children presenting to a tertiary epilepsy center and in recognition of the fact that
disorders such as these commonly accompany epilepsy, with the etiological under-
pinnings of epilepsy and these other diagnoses being related to common underlying
neurological factors. The study had received institutional review board approval for
retrospective data analysis.
For each participant, epilepsy severity variables, including age of seizure onset,
disease duration, number of AEDs, and seizure frequency were also documented.
Control data for this study were obtained from the WISC-V American standardiza-
tion sample, matched for age (in one year increments), gender (male/female), race/
ethnicity (Caucasian, Hispanic/Latino, Black/African-American, Asian American, or
Other), and parental education (<9 years, 9–11 years, completed high school, some
college or college degree, >16 years education). More specifically, from the WISC-V
standardization sample, 100 samples were drawn matching the variables of age,
gender, race/ethnicity, and parental education; of these data sets, the “medium
performance sample” was provided for analyses.
4 W. S. MACALLISTER ET AL.

Measures
Wechsler intelligence scale for children – fifth edition (WISC-V)
The WISC-V is an individually administered instrument to assess intellectual functioning
in children with 6–16 years of age. Seven core subtests (i.e., Similarities, Vocabulary, Block
Design, Matrix Reasoning, Figure Weights, Digit Span, and Coding) contribute to the
FSIQ, whereas 10 subtests are required to derive the five main index score composites:
Verbal Comprehension Index (VCI); VSI; FRI; WMI; and PSI. Briefly stated, whereas the
VCI (Similarities and Vocabulary subtests) measures a child’s verbal reasoning abilities, the
VSI (Block Design and Visual Puzzles subtests) measures a child’s visuospatial reasoning
abilities. The FRI (Matrix Reasoning and Figure Weights subtests) provides a measure of
inductive and quantitative reasoning, while the WMI (Digit Span and Picture Span
subtests) assesses working memory and the PSI (Coding and Symbol Search) assesses
speed of thinking and motor speed. The General Ability Index (GAI) and Cognitive
Proficiency Index (CPI) were also calculated. The GAI provides an estimate of general
intellectual ability that is less reliant on working memory and processing speed than FSIQ
and includes Similarities, Vocabulary, Block Design, Matrix Reasoning, and Figure Weights
subtests. Conversely, the CPI provides an estimate of the efficiency with which information
is processed and includes Digit Span, Picture Span, Coding, and Symbol Search. As
documented in the technical manual (Wechsler, 2014), the WISC-V boasts strong psycho-
metric properties including test-retest reliability. Of note, all participants were adminis-
tered the standard paper and pencil version of the WISC-V.

Statistical approach
Descriptive statistics for demographic variables including age at testing, race/ethnicity, sex,
parental education, and handedness were calculated, as were descriptive statistics for epilepsy
severity variables, including seizure type, EEG characteristics, MRI Findings, number of AEDs
at time of assessment, and seizure frequency. Table 1 provides sample characteristics.
Independent sample t-tests were conducted to examine group differences on FSIQ, index
scores, and subtest scores between patients and matched controls. We also further explored
group differences with regard to the percentage of low scores defined as scores falling ≤2
SDs below the normative population (e.g., standard score ≤70 or scaled score ≤4) via chi-
square analyses; t-tests also assessed for differences across WISC-V composites within the
epilepsy group.
Finally, correlational analyses examined the relations between epilepsy severity factors
(i.e., age of onset, disease duration, number of AEDs, and seizure frequency) and WISC-V
factors and subtests. Specifically, Pearson correlations were used for age of onset and
epilepsy duration and Spearman Rho correlations were used for seizure frequency (an
ordinal variable) and number of AEDs (non-normal distribution as determined by the
Kolmogorov-Smirnov test).

Results
Overall, our sample performed in the low average range across FSIQ (M = 85.75,
standard deviation [SD] = 18.98), GAI (M = 88.79, SD = 18.19), and CPI (M = 80.89,
 CHILD NEUROPSYCHOLOGY 5

Table 1. Demographic and neurologic characteristics of the sample of children with

epilepsy (n = 80).
Sex
Age
Ethnicity
Parental Education
Handedness, Right-Handed
Age of Epilepsy Onset
Duration of Epilepsy (years)
Seizure Type
EEG Characteristics
MRI Findings
Number of AEDs
Seizure Frequency
Note. AEDs = antiepileptic drugs.
41 (51.2%) Males
39 (48.8%) Females
M = 9.87; SD = 2.82; Range = 6–15
65 (81.3%) Caucasian
11 (13.8%) Hispanic
1 (1.3%) Asian American
2 (2.5%) African American
1 (1.3%) Other
4 (5.1%) Less than a grade 12 education
11 (13.8%) At least a grade 12 education
5 (6.0%) Some college
60 (75.1%) College or above
69 (86.3%)
M = 5.02; SD = 3.18; Range = birth – 12
M = 4.85; SD = 3.07
40 (50.0%) Focal Epilepsy Syndromes
35 (43.8%) Generalized Epilepsy Syndromes
5 (6.3%) Mixed
2 (2.5%) No epileptiform activity detected
7 (8.8%) Left Hemisphere
9 (11.3%) Right Hemisphere
7 (8.8) Bilateral Left > Right
8 (10.0%) Bilateral Right > Left
13 (16.3%) Multifocal/No Hemispheric predominance
34 (42.5%) Generalized Discharges
47 (58.8%) Normal MRI
8 (10%) Left Hemisphere Lesion
8 (10%) Right Hemisphere Lesion
7 (8.8%) Bilateral Lesions
2 (2.5%) Other Abnormalities/Incidental Findings
8 (10%) No imaging data available
M = 1.38; SD = 0.86; Range = 0–4
11 (13.8%) Daily
16 (20.0%) At least once weekly
6 (7.5%) At least once monthly
13 (16.3%) At least once every six months
34 (42.5%) No current seizures/Seizure free 6 months or more

SD = 18.22). The mean individual indices (VSI, FRI, WMI, and PSI) were also in the
Low Average range with the exception of the mean VCI, which fell in the Average
range. Relative to our control sample, children with epilepsy demonstrated poorer
performance across all composites and factors of the WISC-V (p < .001. Additionally,
26.3% of our epilepsy sample had a FSIQ falling two or more standard deviations below
normative means (i.e., 70 or less). Slightly more participants had low scores on the CPI
(27.5%) than GAI (17.5%), though this difference was not statistically significant (Chi-
Square = 2.29, p = .129). At the individual index level, the most frequently impaired
index was WMI (25.0%), followed by PSI (22.5%), VSI (20.0%), VCI (15%), and FRI
(15%). Again, in comparison to our control group, significantly more children with
epilepsy scored two or more standard deviations below normative means than did the
matched controls across all composites (See Table 2).
At the subtest level, mean scaled scores for the children with epilepsy were high-
est for
6 W. S. MACALLISTER ET AL.

Table 2. WISC-V full scale IQ and index scores.

Mean (SD) Percent with low scores
Epilepsy Control p-value Epilepsy, % Control, % p-value
Full Scale IQ (FSIQ) 85.75 (18.98) 103.7 (14.63) <.001 26.3 1.3 <.001
General Abilities Index (GAI) 88.79 (18.19) 104.29 (14.19) <.001 17.5 1.3 <.001
Cognitive Proficiency Index (CPI) 80.89 (19.66) 101.51 (15.24) <.001 27.5 1.3 <.001
Verbal Comprehension Index (VCI) 92.33 (18.22) 103.59 (16.03) <.001 15.0 2.5 .005
Visual Spatial Index (VSI) 89.50 (20.21) 103.69 (13.62) <.001 20.0 1.3 <.001
Fluid Reasoning Index (FRI) 89.51 (18.19) 104.94 (14.35) <.001 15.0 2.5 .005
Working Memory Index (WMI) 83.98 (17.63) 103.94 (14.66) <.001 25.0 1.3 <.001
Processing Speed Index (PSI) 83.36 (19.64) 98.51 (13.95) <.001 22.5 2.5 <.001
SD = standard deviation. Extremely Low scores defined as scores falling ≤2 SDs below the normative mean of 100 (i.e.,
scores of 70 or less). Independent samples t-tests were used to compare FSIQ and Index Scores (d.f. = 158). Chi-
square analyses were used to compare percentage of participants with extremely low scores (≤2 SDs).

Similarities (M = 8.70, SD = 3.50), Figure Weights (M = 8.66, SD = 3.14), Visual

Puzzles (M = 8.63, SD = 3.98), and Vocabulary (M = 8.50, SD = 3.70). Mean scores were
lowest on the subtests measuring aspects of processing speed and working memory
(Digit Span (M = 7.05, SD = 3.43), Symbol Search (M = 7.09, SD = 3.63), Coding
(M = 7.16, SD = 3.40), and Picture Span (M = 7.34, SD = 3.43)). Independent sample
t-tests revealed that children with epilepsy demonstrated poorer performances than
controls across all subtests of the WISC-V (p < .001). The four subtests that had the
largest percentage of children with low scores (i.e., scaled scores of 4 or less) measured
aspects of processing speed and working memory (i.e., 23.8–26.3%, Picture Span,
Symbol Search, Digit Span, and Coding). Conversely, the Figure Weights, Similarities,
and Vocabulary subtests had relatively fewer children scoring in this range (5.0%, 15%,
and 15% respectively). Overall, relative to the matched control group, children with
epilepsy had significantly lower scores on all subtests with the sole exception of the
Figure Weights (p < .01; See Table 3).
In terms of differences between indices, within the epilepsy group GAI scores were
significantly greater than CPI (p < .001) and VCI scores were significantly higher than WMI
and PSI scores (p < .001). In addition, VSI scores were significantly greater than WMI and
PSI (p < .01). Lastly, FRI scores were significantly higher than PSI and
WMI (p < .003). No statistically significant differences were found between VCI and VSI
scores, VCI and FRI scores, VSI and FRI scores, or WMI and PSI scores (See Table 4).

Table 3. WISC-V subtest scaled scores.

Mean (SD) Percent with low scores
Epilepsy Control p-value Epilepsy, % Control, % p-value
Similarities 8.70 (3.50) 10.50 (3.18) .001 15.0 1.3 .001
Vocabulary 8.50 (3.70) 10.85 (3.19) <.001 15.0 2.5 .005
Block Design 7.60 (3.61) 10.28 (2.89) <.001 21.3 2.5 <.001
Visual Puzzles 8.63 (3.98) 11.09 (2.74) <.001 18.8 3.8 .003
Matrix Reasoning 7.69 (3.77) 10.73 (2.90) <.001 20.0 2.5 <.001
Figure Weights 8.66 (3.14) 10.95 (2.93) <.001 5.0 3.8 .699
Digit Span 7.05 (3.43) 10.76 (2.85) <.001 25.0 1.3 <.001
Picture Span 7.34 (3.43) 10.61 (3.14) <.001 26.3 2.5 <.001
Coding 7.16 (3.40) 9.57 (2.86) <.001 23.8 5.0 <.001
Symbol Search 7.09 (3.63) 9.90 (2.80) <.001 26.3 2.5 <.001
SD = standard deviation. Extremely Low scores defined as scores falling 2 SDs or more below the normative mean of 10
(i.e., scores of 4 or less). Independent samples t-tests were used to compare FSIQ and Index Scores (d.f. = 158). Chi-
square analyses were used to compare percentage of participants with extremely low scores (<2 SDs).
 CHILD NEUROPSYCHOLOGY 7

Table 4. Differences between WISC-V index scores for the children with epilepsy.
T d.f. p-value
Full Scale IQ Index – General Abilities Index −6.57 79 <.001
Full Scale IQ Index – Cognitive Proficiency Index 4.16 79 <.001
General Abilities Index – Cognitive Proficiency Index 5.16 79 <.001
Verbal Comprehension Index – Visual Spatial Index 1.50 79 .137
Verbal Comprehension Index – Fluid Reasoning Index 1.70 79 .093
Verbal Comprehension Index – Working Memory Index 5.07 79 <.001
Verbal Comprehension Index – Processing Speed Index 4.60 79 <.001
Visual Spatial Index- Fluid Reasoning Index −.01 79 .993
Visual Spatial Index – Working Memory Index 3.19 79 .002
Visual Spatial Index – Processing Speed Index 10.23 79 .004
Fluid Reasoning Index – Working Memory Index 8.76 79 .001
Fluid Reasoning Index – Processing Speed Index 3.07 79 .003
Working Memory Index – Processing Speed Index 4.05 79 .724

Those with lateralized epilepsy were considered separately. Patients with greater
right (n = 17) versus left-hemisphere (n = 14) EEG findings did not differ with respect
to age of onset (p = .31), handedness (p = .21), or gender (p = .11), though the right-
sided epilepsy group was older than the left-sided epilepsy group (p = .05). However,
given that the WISC-V generates age-corrected scores, age was not controlled for in
subsequent analyses. Independent sample t-tests showed that side of epilepsy onset was
unrelated to FSIQ (p = .61), GAI (p = .39), CPI (p = .46), VCI (p = .51), FRI (p = .76),
WMI (p = .88), and PSI (p = .28). Interestingly, the VSI was trending (p = .06) in the
direction of the right-sided epilepsy group showing greater impairment relative to the
left-sided epilepsy group. To follow up on this difference, Cohen’s d was calculated to
determine the overall effect size of this difference (d = 0.71, large effect size). Given the
limited number of individuals with lateralized MRI findings, analyses based in imaging
were not presently performed, but will be revisited in subsequent studies.
As shown in Table 5, for the entire epilepsy sample, age of epilepsy onset showed
moderate correlations with all WISC-V Index scores and composites with the excep-
tion of the VSI. Number of AEDs demonstrated moderate correlations with all WISC-
V scores. Specifically, later seizure onset and fewer AEDs correlated with higher
WISC-V FSIQ and index scores. In addition, duration of epilepsy correlated signifi-
cantly with FSIQ, such that shorter epilepsy duration was associated with higher FSIQ
scores. Conversely, duration of epilepsy did not correlate significantly with WISC-V
index scores, with the exception of the VCI, demonstrating a higher VCI with shorter
duration of epilepsy. Lastly, seizure frequency did not correlate significantly with
WISC-V FSIQ and index scores.
A similar pattern was observed at the subtest level. Overall, scores on the verbal
subtests (Similarities, Vocabulary) and nonverbal subtests (Matrix reasoning, Figure
Weights) were inversely related to number of AEDs, as were those of the Visual Puzzles,
Digit Span, and Coding subtests. In addition, verbal subtest (Similarities, Vocabulary)
and processing speed subtest scores (Coding, Symbol Search) were positively related to
age of epilepsy onset, as were scores from the Visual Puzzles, Matrix Reasoning, and
Digit Span subtests. Additionally, with the exception of Similarities and Digit Span, no
subtests scores were significantly related to duration of epilepsy. Lastly, no subtests
scores were significantly related to seizure frequency.
8 W. S. MACALLISTER ET AL.

Table 5. Correlations between WISC-V and epilepsy variables.

Age of Epilepsy Duration of Number of Seizure
Onset Epilepsy AEDs^ Frequency^
Index Scores
FSIQ .347** −.246* −.344** .110
GAI .260* −.216 −.332** .122
CPI .414** −.219 −.272* .054
VCI .276* −.252* −.339* .147
VSI .207 −.112 −.259* .148
FRI .223* −.191 −.298** .069
WMI .383** −.186 −.231* −.017
PSI .377** −.206 −.265* .104
Subtest Scores
Similarities .251* −.270* −.298* .139
Vocabulary .261* −.203 −.341** .146
Block Design .175 −.107 −.183 .094
Visual Puzzles .220* −.116 −.302** .173
Matrix Reasoning .262* −.186 −.302** .097
Figure Weights .154 −.180 −.238* .022
Digit Span .482** −.244* −.285* −.010
Picture Span .194 −.086 −.133 −.020
Coding .378** −.200 −.280* .109
Symbol Search .334** −.195 −.209 .087
Note. AEDs = Antiepileptic Drugs. * = Significant at p < .05 levels; ** = Significant at p < .01 levels.
^Spearman Rho coefficients.

Discussion
The WISC-V differs significantly from its predecessors given its five-factor structure and the
addition of new subtests (Wechsler, 2014). Accordingly, research on earlier editions could not
be assumed to directly apply to the current iteration. Present results indicate that the WISC-V
is sensitive to epilepsy-related cognitive impairments in clinically referred children. In fact,
more than a quarter of these children present with a Full-Scale IQ in the range associated with
intellectual disability. Not surprisingly, the Cognitive Proficiency Index was more frequently
lower than the General Abilities Index, consistent with prior research demonstrating that
working memory and processing speed are areas of particular concern in children with
epilepsy. In fact, as in prior editions of the WISC, the WMI and PSI were again the most
sensitive composites (Sherman et al., 2012). In contrast, the VCI and FRI were the least
sensitive. Of note, all of the Working Memory and Processing Speed subtests had roughly
comparable impairment rates, with about a quarter of the sample showing low scores on these
four subtests. The overall sensitivity of the WISC-V VCI, however, may be somewhat lower
than in prior editions given the elimination of the Comprehension Subtest, which was the
most sensitive VCI Subtest on the WISC-IV (Sherman et al., 2012). At the same time, it is
possible that Comprehension yielded more low scores than other WISC-IV verbal subtests
because it is a less pure measure of verbal intelligence and measures aspects of cognition
outside of this construct, such as social knowledge.
The relatively low sensitivity of the FRI is worthy of some commentary; broadly
defined, the FRI is designed to assess the ability to detect underlying conceptual
relationships among visual objects and use reasoning (Wechsler, 2014). Moreover,
the FRI requires inductive and quantitative reasoning as well as simultaneous proces-
sing and abstract thinking. Briefly, given the prominent executive function deficits
seen in children with epilepsy (MacAllister, Vasserman, Rosenthal, & Sherman, 2014),
 CHILD NEUROPSYCHOLOGY 9

it was anticipated that this would be amongst the more sensitive composites of the
WISC-V. However, this was clearly not seen. In considering the underlying subtests,
there were wide disparities seen across the sensitivity of the Matrix Reasoning subtest
(with 20% having low scores), in comparison to the Figure Weights subtest (with only
5% showing low scores). Furthermore, at a threshold of two or more standard
deviations below normative means, the Figure Weights subtest was the only subtest
that did not show significantly greater rates of impairment in comparison to controls
(i.e., 5% vs. 3.8%). The insensitivity of this subtest fits with our clinical impressions
when using the WISC-V, in that it has been anecdotally perceived as representing an
unusually high outlier in many clinical cases. Given that the overall mean of Figure
Weights was lower than that of controls, but few had impaired scores, it appears that
the subtest has a floor effect, perhaps related to the fact that the earliest items involve
merely visual matching and very little in the way of reasoning.
Epilepsy severity variables including age of seizure onset and number of AEDs had
relatively robust associations with overall cognitive skills. Epilepsy duration had a more
moderate association with WISC-V Index scores and subtests, whereas seizure fre-
quency was largely unrelated to these cognitive scores. These findings are generally
consistent with the literature that shows that epilepsy onset in infancy or early child-
hood has a more deleterious effect on cognition (Berg et al., 2012; O’Leary et al., 2006;
Sherman et al., 2012). AED polypharmacy is also a known risk factor for greater
cognitive morbidity; although AED side effects are a contributor to cognitive difficulties
(Loring & Meador, 2004), AED polypharmacy is also a proxy variable for seizure
intractability; that is, children with intractable epilepsy frequently require multiple
AEDs for seizure control. It is also not surprising that seizure frequency in and of itself
was not significantly related to cognition, though this may seem counterintuitive.
Briefly, seizure severity is more important than frequency in terms of effects on
cognition; a child having several absence seizures daily would likely be far less cogni-
tively impaired than a child having a single episode of convulsive status epilepticus
a year. Future studies should consider seizure severity in addition to frequency.
As in prior versions of the Wechsler scales, there were no significant relationships
between side of seizure onset (as determined by EEG characteristics) and factor scores. It
is often tempting for clinicians to assume that verbal intelligence would be more impaired
in children with left-sided impairment, but this has not been proven with intelligence
measures. Again, it is worth highlighting that IQ measures are not designed with respect to
brain behavior relationships (See Baron, 2004, for review). Interestingly, there was a trend
seen towards lower scores on the visual-spatial index in those with right versus left hemi-
sphere epilepsy, and the overall effect size of this difference was fairly large. This may be
a function of the fact that the WISC-V Visual-Spatial Index is a purer measure of visual-
spatial skills then was the PRI of the WISC-IV or the Performance IQ of the earlier versions
of the WISC, where no such trends were found. Regardless, given the small sample of
strongly lateralized focal epilepsy cases, this warrants investigation in a larger sample.
This study has several limitations that are worthy of mention. First and foremost, it
is important to note that the children included in the present evaluation were
clinically referred children seen at a tertiary epilepsy center. As such, though several
children included had relatively benign epilepsy syndromes, on the whole the sample
had a high seizure burden and high rates of polypharmacy. Accordingly, these results
10 W. S. MACALLISTER ET AL.

might not directly apply to a less severe sample of children with epilepsy seen in
community settings, though future studies are planned to asses more “benign”
epilepsy samples. Second, related to the characteristics of patients seen at this center,
these children by and large come from highly educated families, with three quarters of
the sample having college educated (or greater) parents. Though the use of matched
controls certainly mitigates the implications of this at the group comparison level,
readers should be aware of this when considering the normative-based subtest and
composite scores. Further, the present pediatric epilepsy sample represents a broad
sampling of seizure types. As it is well known that cognitive profiles can differ
substantially across different epilepsy syndromes, future studies should seek to eval-
uate the WISC-V profiles unique to different presentations (e.g., benign rolandic
epilepsy, childhood absence epilepsy, Lenox-Gastaut syndrome, etc.). It is also
worth noting that the results of this WISC-V study cannot be directly compared to
the Sherman et al.’s (2012) WISC-IV investigation. The 2012 investigation included
an international collaboration across two tertiary epilepsy centers whereas the present
sample is based solely in New York, with the latter having fewer intractable cases.
Moreover, the prior study essentially included “all comers” with epilepsy, including
those with additional etiologies (e.g., stroke, head injury) or prior resective surgeries,
whereas the current study chose not to include these competing etiologies and present
a purer epilepsy sample with a relatively lower seizure burden. In short, though at first
glance it would appear that the WISC-V may be yielding higher IQs than its
predecessor, this is likely more related to the sample characteristics.
Perhaps most importantly, however, is the fact that the WISC-V is an intelligence
test. As such, it is designed expressly for measuring intelligence, and not more specific
cognitive domains. In short, though it is clearly sensitive to cognitive dysfunction in
children with epilepsy, it is not sufficient for measuring other cognitive problems that
are common in children with seizure disorders. Specifically, the WISC-V is not appro-
priate for measuring verbal and visual memory, sustained attention, complex executive
functions, or more specific language deficits that are common in children with epilepsy.
In short, though intelligence testing may be a core component of assessment, it is only
one piece of a comprehensive neuropsychological evaluation.

Acknowledgments
The authors wish to thank Susan Raiford, PhD. and Ying Meng for their assistance in preparing
the datasets for this manuscript.

Disclosure statement
No potential conflict of interest was reported by the authors.

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