Academic self-concept in children with epilepsy and its relation to their quality of life Dana Brabcova1, Pavel Krsek2, Jiri Kohout3, Jiri Jost4, Jana Zarubova5 1
Department of Psychology, Faculty of Education, University of West Bohemia, Plzen, Czech Republic, Department of Pediatric Neurology, Charles University in Prague, 2nd Faculty of Medicine, Motol University Hospital, Praha, Czech Republic, 3Department of Physics, Faculty of Applied Sciences, University of West Bohemia, Plzen, Czech Republic, 4Department of Pedagogy and Psychology, Pedagogical Faculty, University of South Bohemia, Ceske Budejovice, Czech Republic, 5Department of Neurology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Praha, Czech Republic
2
Objectives: Academic achievement in children with epilepsy is a highly studied topic with many important implications. However, only little attention has been devoted to academic self-concept of such children and the relation of academic self-concept to their quality of life. We aimed to examine academic self-concept in children with epilepsy, to assess its relationship to academic achievement and to determine possible correlations between academic self-concept and quality of life. Methods: The study group consisted of 182 children and adolescents aged 9–14 years who completed the student’s perception of ability scale (SPAS) questionnaire to determine their academic self-concept and the modified Czech version of the CHEQOL-25 questionnaire to determine their health-related quality of life. Results: We found that academic self-concept in children with epilepsy was on average significantly lower than in their peers without seizures, especially with regard to general school-related abilities, reading, and spelling. On the other hand, the variance in the data obtained from the group of children with epilepsy was significantly higher than in the whole population and the proportion of individuals with very high academic self-concept seems comparable among children with and without epilepsy. Moreover, it was found that correlations between academic self-concept and academic achievement are significantly lower in children with epilepsy than in the whole population. Discussion: The presented results suggest that considerable attention should be paid to the role of academic self-concept in education of children with epilepsy and to the factors influencing this selfconcept in this group. Keywords: Academic self-concept, Academic achievement, Quality of life, Children, Epilepsy, Learning disabilities
Introduction Epilepsy has a significant impact on various aspects of the life of affected children.1 Worldwide, the prevalence of epilepsy per 1 000 population varies widely from 2.7 to more than 40, although most studies show a range from 4 to 8.2 Age-specific incidence for children aged 6–18 years is usually reported in the range of 50–100 per 100 000 personyears.3 In the Czech Republic, there are around 13 000 children suffering from epilepsy, which corresponds to a prevalence of approximately 6 per 1 000 population.4 The issue of academic achievement in children with epilepsy has been repeatedly addressed. It is important that academic achievement has two main levels – objective and subjective. The objective level regards Correspondence to: Dana Brabcova, Tocnik 4, Klatovy 33901, Czech Republic. Email: [email protected]
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fulfilling certain external norms. The subjective level described usually as academic self-concept shows how good children feel at school and if they have adequate confidence in their abilities.4 Self-concept (not only academic) is a construct having a long history in psychology and education science (see, e.g. Ref. 5 for more detail). In the case of children with epilepsy, this construct may be of particular importance because an improved self-concept may make a child more resilient to the social challenges from the chronic disease as stated by Lee et al. in Ref. 6 As a consequence, academic achievement of a child may be significantly improved. Conversely, a poor self-concept in childhood and adolescence has exhibited associations with a lower quality of life, an increased criminal behavior, a lower educational attainment, and a lower income.7 Previous research has been primarily focused on the objective assessment of academic achievement in children with epilepsy using standardized tests, and
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on determining factors that affect this academic achievement.8–17 After a detailed analysis of findings reported by different studies, Reilly and Neville found that academic achievement in children with epilepsy was on average lower than in the general population.18 However, it is still unclear whether this is caused by a higher proportion of individuals with significantly reduced intelligence in children with epilepsy compared to the whole population or whether children with epileptic seizures perform worse at school even if they are intellectually on the same level as their peers. An important factor in the academic achievement of children with epilepsy is a high prevalence of learning disabilities such as dyslexia (13–32%), dysgraphia (35–56%), or dyscalculia (20–38%) in this group.17 The specific values are strongly dependent on the diagnostic criteria used but there is no doubt that the proportion of individuals with some kind of learning disability is significantly higher among children with epilepsy compared to approximately 7.5% in the general population.19 Some studies suggest that in children with epilepsy but without learning disabilities, academic achievement is comparable with the general population.12 However, only little attention20,21 has been devoted to academic self-concept in children with epilepsy and to its relationship with their academic achievement. Due to the persisting stigmatization of children with epilepsy in school environment,22 it is reasonable to hypothesize that the children may be at particular risk for reduced academic self-concept. The main aims of this study were to examine academic self-concept in children with epilepsy, to explore a relationship between academic self-concept and academic achievement, and finally to determine possible correlations between academic self-concept and quality of life.
Methodology SPAS and CHEQOL-25 questionnaires Academic self-concept was determined using the student’s perception of ability scale (SPAS) questionnaire, which was first introduced by Boersma and Chapman.23 The Czech version of the questionnaire contains a total of 48 dichotomous questions, which are divided into six scales of eight questions. Each scale measures academic self-concept in the following areas: 1. General school-related abilities 2. Mathematics 3. Reading 4. Spelling 5. Writing 6. Confidence The Czech version was validated in 1992.24 It was found that the Czech version had very good psychometric properties. The results for the individual scales
Academic achievement in children with epilepsy
and the total score were converted to sten scores with respect to gender and age of the respondents using tables in the questionnaire manual.23 The questionnaire is suitable for children aged 9–14 years. It is recommended to use sten scores in presentation of the results obtained using SPAS because unconverted rough scores may be confusing if the studied group differs in age and/or gender from the group on which the standardization study was carried out.24 Quality of life was assessed using a modified Czech version of the CHEQOL-25 questionnaire created by Ronen and his colleagues.25 Psychometric properties of the modified Czech version were determined in our previous study26and are fully satisfactory. The use of the questionnaire, authored by Dr. Gabriel Ronen et al., was under license from McMaster University, Hamilton, Canada. The questionnaire consists of a total of 23 questions, with answers on a 4-point scale (1–4 points). Factor analysis revealed the following four areas in which the questionnaire measured the quality of life of children with epilepsy: 1. Interpersonal/social consequences (5 items); 2. Worries and concerns (four items); 3. Intrapersonal/emotional issues (four items); 4. Disclosure and normality (10 items). The results are given using the gross scores on each scale, which are in the range of 5–20 points (scale 1), 4–16 points (scales 2 and 3), and 10–40 points (scale 4). Both questionnaires used in the study are quite simple and fully understandable even for the children with impaired cognitive functions.24,26
Procedure and respondents The study was conducted in selected pediatric neurology departments in the Czech Republic from 2010 to 2012. We obtained consent from parents of the children involved in the study. The completion of the Czech versions of the CHEQOL-25 and SPAS questionnaires by pediatric patients independently of physicians and parents was preceded by a diagnostic questionnaire given to each patient by a neurologist or by a parent (or parents). Two hundred fifty respondents aged 8–15 years were involved in the completion of the questionnaires but only 182 respondents aged 9– 14 years were included in the current study because the Czech version of the SPAS questionnaire is not appropriate for older or younger individuals. Data obtained from all the respondents aged 8–15 years were used for the cross-cultural adaptation of the CHEQOL-25 questionnaire reported in our recent study.26 Note that no control group was involved in the study and the results of our experimental group in the SPAS questionnaire were compared with normative test scores given for the whole population of Czech children aged 9–14 years in Ref. 24. The basic characteristics of the sample of respondents are shown in Table 1. Children aged 9–14 years
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with definite diagnosis of epilepsy with either generalized focal seizures regardless etiology of the condition who have according to DSM-IV27 IQ level corresponding to mild intellectual disability (IQ around 70) or higher were included in the study. Actual seizure frequency was not a limitation for inclusion. All children were treated with one or more antiepileptic drugs. We excluded subjects with significant psychiatric comorbidity and psychiatric medication. The proportion of mildly intellectually disabled respondents was just around 20%. The proportion of subjects with learning disabilities is 35% in our sample. All patients with learning disabilities were carefully diagnosed by an experienced counseling psychologist. In the Czech Republic, diagnostics of learning disability is based on IQ-achievement discrepancy17 and the discrepancy cutoff is in most cases set on 1.5 standard deviations (SD). The final diagnosis is based on DSM-IV27 and is made by a counseling psychologist in accordance with recommendations of International Dyslexia Association. In Table 2, the sample of respondents is characterized in terms of seizure type and frequency. Subjects with daily or weekly seizures were classified as having a high frequency of seizures. The categorization of seizures according to their type was performed in the same way as in Refs. 25 and 26 to maximize comparability of our results.
Statistical analysis In processing the acquired data, we used Microsoft Excel 2003 with the add-on accessory XLSTAT. In addition to classic descriptive statistics, we used the one sample t-test of mean values and the chi-squared test of variance for comparison of experimental group results with the normative test scores of the whole population. Pearson’s correlation coefficient and polychoric correlation coefficient with the appropriate tests of independence were used in order to explore
correlation between academic self-concept in children with epilepsy and their academic achievement and quality of life. Moreover, we used the chi-squared test to determine possible differences in the distribution function between our data and normative test scores valid for the whole population. The results of the t-tests and chi-squared tests are given with the Pvalues of the tests in order to determine the maximum probability of rejection of the correct zero hypothesis (i.e. the hypothesis that there is no difference between the groups, the independence of the two variables, etc.). A test P-value of less than 0.05 was considered statistically significant.
Results Academic self-concept in children with epilepsy Table 3 shows the proportion of children and adolescents who achieved the given results (sten scores). For comparison, the normative test scores for the general population of children and adolescents in this age group are also given. If we use the chi-squared test to test the hypothesis that the distribution of patients with epilepsy is the same as in the general population, we could clearly reject this hypothesis (test statistic chi2 5 75.6, critical value for level of significance of 0.05 and 9 degrees of freedom was only 16.9, the test P-value is much less than 0.001). Thus, there is a significant difference in the overall score between the group of children with epilepsy and the whole population. In the next step, we analyzed particular domains of the academic self-concept in children with epilepsy measured by the appropriate scales of the SPAS questionnaire. Table 4 shows the mean values and SD of sten scores in our group of children with epilepsy and the whole population. Sten scores for the whole population have in all scales a mean of 5.5 and a SD of 2, which is a fundamental property of this type of scaling frequently used in the field of
Table 1 Basic characteristics of respondents (n 5 182) Characteristic 11.8¡1.7 yearsa (range 9–14 years)
Age Gender Male Female Duration of epilepsy Age at seizure onset Mild intellectual disability Yes No Learning disability Yes No Learning disabilityb Reading disorder (dyslexia) Writing disorder (dysgrafia) Math disability (dyscalculia) a b
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84 (46.2%) 98 (53.8%) 5.3¡3.3 yearsa (range 0–14 years) 6.1¡3.5 yearsa (range 0–14 years) 32 (17.6%) 150 (82.4%) 64 (35.2%) 118 (64.8%) 51 (81.0%) 48 (75.0%) 24 (37.5%)
Mean ¡ SD. Thirty-nine individuals suffered from more than one type of learning disability.
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psychological diagnostics. The one-sample t-test (note that we compared our experimental group with the normative test scores) shows that children and adolescents with epilepsy achieve significantly lower mean scores in the area of academic self-concept in comparison with the general population on scales 1 (general school-related abilities), 3 (reading), 4 (spelling), and also on the total SPAS questionnaire score. Particularly striking is the difference in general schoolrelated abilities, reading, and total score (P-value in all cases is less than 0.001). In contrast, no differences in the mean scores were observed in scales 2 (mathematics), 5 (writing), and 6 (confidence). Chi-squared test for variance shows that children and adolescents with epilepsy achieve a significantly higher variance (P-value less than 0.01) in comparison with the general population in all scales of the SPAS questionnaire.
The relationship between academic self-concept and academic achievement In this section, we focus on the level of academic achievement that children and adolescents reached at school in the core subjects of the Czech language and mathematics, and how this assessment correlated with their own academic self-concept. We collected data
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about the academic achievement of 161 respondents out of the total number of 182 respondents who took part in this study. The other respondents stated they had been assessed verbally (10 respondents) or did not complete this part of the questionnaire (11 respondents). Table 5 shows polychoric correlation values between the individual scales of the SPAS questionnaire and grades in the subject areas of the Czech language and mathematics. The average grade in the Czech language on a 5-point scale (with 1 5 best, 5 5 worst) was 2.36 with a SD of 0.97. The average grade in mathematics was 2.32 with a SD of 1.00. For comparison, the values of the relevant correlation coefficients given in the manual of the Czech version of the SPAS questionnaire for the whole population24 are stated in parentheses. Table 5 shows that academic achievement in the core subject of the Czech language correlated most notably with academic self-concept in scales 1 (General school-related abilities), 6 (Confidence), and the total score. In mathematics, the most significant correlations were in scales 2 (Mathematics), 6 (Confidence), and the total score. In both cases, the group of children and adolescents with epilepsy
Table 2 Characteristics of types and frequency of seizures in respondents
Seizure type
Respondents with a high frequency of seizures (n1 5 37)
Respondents with a low frequency of seizures (n2 5 145)
10 11 16 9 3 5
30 47 26 62 8 18
Simple partial Complex partial Absence Tonic or tonic–clonic Myoclonic Other/unclassified
Note. Nine individuals with a high frequency of seizures and 40 individuals with a low frequency of seizures suffered from more than one type of epileptic seizure. Table 3 Comparison of total student’s perception of ability scale (SPAS) questionnaire scores obtained from the general population and from children and adolescents with epilepsy Sten score Frequency in the group of children with epilepsy (n 5 182) Percentage in the group of children with epilepsy (%) Percentage in the general population (%)
1
2
3
4
5
6
7
8
9
10
13 7.1 2.3
26 14.3 4.4
23 12.6 9.2
28 15.4 15.0
23 12.6 19.2
26 14.3 19.2
16 8.8 15.0
11 6.0 9.2
5 2.8 4.4
11 6.0 2.3
Table 4 Comparison of the results obtained from children with epilepsy and the general population for each individual scale of the student’s perception of ability scale (SPAS) questionnaire
Scale 1 – general school-related abilities Scale 2 – mathematics Scale 3 – reading Scale 4 – spelling Scale 5 – writing Scale 6 – confidence Total score
Children and adolescents with epilepsy (n 5 182)
General population (normative test scores)
One-sample t-test P-value
Chi-squared test for variance P-value
4.30¡2.64a
5.5¡2
,0.001
,0.001
5.50¡2.54 4.49¡2.48 5.04¡2.71 5.70¡2.38 5.36¡2.37 4.79¡2.46
5.5¡2 5.5¡2 5.5¡2 5.5¡2 5.5¡2 5.5¡2
0.988 ,0.001 0.022 0.251 0.411 ,0.001
,0.001 ,0.001 ,0.001 ,0.001 ,0.001 ,0.001
a
Mean ¡ SD. Note. The P-values in bold denote cases when the corresponding null hypothesis was rejected at a significance level of 0.05.
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exhibited the same trends as in the general population, although the values of the correlation coefficients are generally slightly lower. In terms of academic achievement, it is evident that children with epilepsy in the monitored group achieved on average slightly worse results in the Czech language than in mathematics.
Correlations between academic self-concept and quality of life Table 6 shows the value of Pearson’s correlation coefficient between the individual scales of the modified Czech version of CHEQOL-25 questionnaire measuring the quality of life of children and adolescents with epilepsy and the scales of the SPAS questionnaire, which we used to determine academic self-concept. Values that are statistically significant for the test of independence at a significance level 0.05 are in bold. Table 6 shows relatively strong correlations between the third scale of the CHEQOL-25 questionnaire (Intrapersonal and Emotional Issues) and academic self-concept in terms of the six scales in the SPAS questionnaire and its overall score. Quite significant correlations were also observed between the first scale of the CHEQOL-25 questionnaire (interpersonal and social consequences) and academic self-concept. Conversely, in the second (worries and concerns) and fourth (disclosure and normality) scales the appropriate correlation coefficients values were considerably smaller.
Discussion Tables 3 and 4 show that children with epilepsy achieved significantly lower results in total academic
self-concept, general school-related abilities, reading, and spelling. Low academic self-concept in reading may be related to the fact that the most common learning disability in our series was reading disorder (Table 1). Better results in mathematics than in the native language were reported by some studies focused on the objective measurement of academic achievement in children and adolescents with epilepsy.18 A recent study from Jamaica showed that children with epilepsy had lower scores compared to their peers on tests of both language and mathematics ability.28 On the other hand, we found a surprising result in writing, where children and adolescents with epilepsy achieved results comparable to the average in the whole population despite the fact that a relatively large percentage of the children with epilepsy had been diagnosed with writing disorder (Table 1). This result appeared to be in conflict with studies reporting writing as an area in which children with epilepsy achieved significantly lower scores than the general population.17 It should be noted that our study aimed to determine academic selfconcept that does not necessarily correspond to academic achievement measured by standardized tests. In Ref. 24, there are examples of children with mild intellectual disability who achieved average results in the area of academic self-concept as measured by the SPAS questionnaire, although their academic achievement was far below average. Moreover, the writing scale in the SPAS questionnaire is focused more on the tidiness of writing than on its factual accuracy. Table 5 shows the correlation between academic self-concept and academic achievement in the core
Table 5 Academic achievement in children with epilepsy and correlation between their academic achievement and academic self-concept, n 5 161 Correlation between academic achievement and academic self-concept
Grade – Mathematics
0.501 (0.631)a 0.376 (0.491) 0.364 (0.498) 0.410 (0.590) 0.259 (0.304) 0.516 (0.647) 0.585 (0.656)
Scale 1 – general school-related abilities Scale 2 – mathematics Scale 3 – reading Scale 4 – spelling Scale 5 – writing Scale 6 – confidence Total score a
Grade – Czech language
0.466 0.538 0.281 0.302 0.144 0.496 0.531
(0.570) (0.627) (0.413) (0.426) (0.273) (0.619) (0.632)
In parentheses is the correlation for the whole population, taken from Ref. 24.
Table 6 Correlation between the quality of life of children and adolescents with epilepsy (CHEQOL-25 questionnaire) and their academic self-concept [student’s perception of ability scale (SPAS) questionnaire], n 5 182 Scale 1 –interpersonal and social consequences Scale 1 – general school-related abilities Scale 2 – mathematics Scale 3 – reading Scale 4 – spelling Scale 5 – writing Scale 6 – confidence Total score
Scale 2 – worries and concerns
Scale 3 – intrapersonal and emotional issues
Scale 4 – disclosure and normality
0.384
0.187
0.575
0.187
0.271 0.258 0.221 0.188 0.413 0.379
0.023 0.207 0.116 20.022 0.169 0.182
0.341 0.401 0.400 0.330 0.493 0.590
0.155 0.035 0.125 0.055 0.166 0.165
Note. The correlations in bold denote values with the rejected hypothesis of independence at a significance level of 0.05.
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subjects of the Czech language and mathematics. Lower values of the correlation coefficients in comparison with the general population may have been related primarily to the high proportion of children with learning disabilities in our sample of respondents. During assessment, school teachers were required to take into account the fact that particular students were suffering from this disorder and this may have led to significant differences between academic self-concept and academic achievement. The relatively strong correlations between scale 1 of the CHEQOL-25 questionnaire and academic-self concept (see Table 6) may have been related to the fact that in children, academic achievement plays a major role in their interpersonal and social relationships. Attention should be devoted also to factors influencing academic self-concept in children with epilepsy. Although the purpose of our paper is not to study such factors in a systematic way, some basic findings related to this topic should be reported and discussed here. First, there are no statistically significant gender differences in academic self-concept (P-value of the two-sample t-test of mean values is higher than 0.05 in all scales). Second, correlation between the duration of epilepsy in years and the total score of the SPAS questionnaire measured by Pearson’s correlation coefficient is 20.124, which is not a statistically significant value for the given number of respondents. Finally, correlation between the frequency of the seizures and the total score measured by the point-biserial correlation coefficient is only 0.061, which is again not a statistically significant value. These findings are in accordance with the data from the literature8,12 regarding factors influencing academic achievement of children with epilepsy. The effect of the type of seizures was not evaluated in our study because many patients suffered from more than one type and it was not possible (due to the size and composition of our sample) to completely cover all the relevant medical factors (such as focus localization), which may have some effect on the results. Some methodological problems related to this topic are discussed in Ref. 29. It would be very useful to investigate how severity of epilepsy (which is given not only by the type of seizures and their frequency) influences academic selfconcept. The effect of antiepileptic drugs, neurotic disorders such as depression or anxiety, and other factors on academic self-concept of children with epilepsy should be also investigated. This will be the topic of our further research. This study clearly shows that there are considerable differences in academic self-concept between children in epilepsy and the whole population that should be taken into consideration. Moreover, correlations between academic self-concept and assessment by
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teachers are lower for children with epilepsy, which may suggests that teachers have problems with assessment of the children. Our results suggest that it is necessary to seek ways to improve self-concept of children with epilepsy. In our opinion, the most important here is the role of teachers and classmates of a child with epilepsy who can significantly contribute to a better feeling of this child in the school environment. Thus, a further development of efficient educational interventions focused on increasing knowledge of teachers and pupils on epilepsy is highly needed. The present study had some limitations associated with its design. As already discussed, the main limitation was that there was no systematic investigation of a possible correlation between academic selfconcept and factors such as seizure type or the presence of specific learning disabilities. Another limitation was related to the determination of correlations between academic self-concept and academic achievement calculated by objective methods in terms of fulfilling norms. In our study, achievement was determined by the teacher of the subject. It would have been better to have measured academic achievement using standardized tests. This topic will be approached by further research.
Disclaimer Statements Contributors No contributors (excluding Authors of the manuscript) were involved. Funding This research project was supported by Quality of Life of Children Living with Epilepsy implemented under the Promising Strategies 2010 Program, which is a program by IBE the International Bureau for Epilepsy, and by the grants GAJU 037/ 2010/S and MH CZ DRO from the University Hospital Motol, Prague, Czech Republic 00064203. DB was supported from Motivational System of the University of West Bohemia, Pilsen, part POSTDOC. Conflicts of interest The authors have no conflicts of interest to declare. Ethics approval Ethical approval was not required.
References 1 Seidenberg M, Berent S. Childhood epilepsy and the role of psychology. Am Psychol. 1992;47:1130–3. 2 Hauser WA, Annegers JF, Kurland LT. Prevalence of epilepsy in Rochester, Minnesota: 1940–1980. Epilepsia. 1991;32(4):429– 45. 3 Banerjee PN, Hauser WA. Prevalence and incidence. In: Engel J, Pedley TA, Aicardi J, Dichter MA, Moshe´ S, Perucca E, et al. editors. Epilepsy: a comprehensive textbook, 2nd edn. USA: Wolters Kluwer; 2007. p. 45–56. 4 Komarek V, Smidova J. The psychosocial impact of epilepsy in Czech children: what are causative factors of differences during ten years interval? Epileptic Disord. 2007;9(Suppl 1):S2–8.
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5 Harter S. The construction of the self: a developmental perspective. New York: The Guilford Press; 1992. 6 Lee A, Hamiwka LD, Sherman EMS, Wirrel EC. Self-concept in adolescents with epilepsy: biological and social correlates. Pediatr Neurol. 2008;38:335–9. 7 Ferro MA, Ferro AL, Boyle MH. A systematic review of selfconcept in adolescents with epilepsy. J Ped Psych. 2012;37:945– 58. 8 Mitchell WG, Chavez JM, Lee H, Guzman BL. Academic predictors of underachievement in children with epilepsy. J Child Neurol. 1991;6:65–72. 9 Williams J, Sharp G, Bates S, Griebel M, Lange B, Spence GT, et al. Academic achievement and behavioral ratings in children with absence and complex partial epilepsy. Educ Treat Child. 1996;19:143–52. 10 Austin JK, Huberty TJ, Huster GA, Dunn DW. Does academic achievement in children with epilepsy change over time? Dev Med Child Neurol. 1999;41:473–9. 11 Schoenfeld J, Seidenberg M, Woodard A, Hecox K, Inglese C, Mack K, et al. Neuropsychological and behavioural status of children with complex partial seizures. Dev Med Child Neurol. 1999;41:724–31. 12 Williams J, Philips T, Griebel ML, Sharp GB, Lange B, Edgar T, et al. Factors associated with academic achievement in children with controlled epilepsy. Epilepsy Behav. 2001;2:217– 33. 13 Oostrom KJ, Smeets-Schouten A, Kruitwagen CLJJ, Peters ACB, Jennekens-Schinkel A. Not only a matter of epilepsy: early problems of cognition and behavior in children with ‘epilepsy only’ – a prospective controlled study starting at diagnosis. Pediatrics. 2003;112:1338–44. 14 McNelis AM, Johnson CS, Huberty TJ, Austin JK. Factors associated with academic achievement in children with recent onset seizures. Seizure. 2005;14:331–9. 15 McNelis AM, Dunn DW, Johnson CS, Austin JK, Perkins SM. Academic performance in children with new-onset seizures and asthma: a prospective study. Epilepsy Behav. 2007;10:311–8. 16 Piccinelli P, Borgatti R, Aldini A, Bindelli D, Ferri M, Perna S, et al. Academic performance in children with rolandic epilepsy. Dev Med Child Neurol. 2008;50:353–6. 17 Fastenau PS, Shen J, Dunn DW, Austin JK. Academic underachievement among children with epilepsy: proportion
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exceeding psychometric criteria for learning disability and associated risk factors. J Learn Disabil. 2008;41:195–207. Reilly C, Neville BR. Academic achievement in children with epilepsy: a review. Epilepsy Res. 2011;97:112–23. Boyle CA, Boulet S, Schieve LA, Cohen RA, Blumnerg SJ, Yeardin-Allsopp M, et al. Trends in the prevalence of developmental disabilities in US children. Pediatrics. 2011;127: 1034–42. Austin JK, Huberty TJ, Huster GA, Dunn DW. Academic achievement in children with epilepsy or asthma. Dev Med Child Neurol. 1998;40:248–55. Huberty TJ, Austin JK, Huster GA, Dunn DW. Relations of change in condition severity and school self-concept to change in achievement-related behavior in children with asthma or epilepsy. J School Psychol. 2000;38:259–76. Williams J. Learning and behavior in children with epilepsy. Epilepsy Behav. 2003;4:107–11. Boersma FJ, Chapman JW. The Student’s perception of ability scale: an instrument for measuring academic self-concept in elementary school children’s. Educ Psychol Meas. 1979;39: 1035–41. Matejcek Z, Vagnerova M. The Student’s perception of ability scale: manual. Bratislava: Psychodiagnostika a didakticke testy; 1992. (in Czech). Ronen GM, Streiner DL, Rosenbaum P. Health-related quality of life in children with epilepsy: development and validation of self-report and parent proxy measures. Epilepsia. 2003;44:598– 612. Brabcova D, Krsek P, Kohout J, Zarubova J. Psychometric properties of the modified Czech version of the children selfreport quality of life measure for children with epilepsy (CHEQOL-25). Epilepsy Behav. 2014;33:31–8. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, Fourth edn. (revised) Washington, DC: American Psychiatric Association; 2000. Chambers RM, Morrison-Levy N, Chang S, Tapper J, Walker S, Tulloch-Reid M. Cognition, academic achievement, and epilepsy in school-age children: a case-control study in a developing country. Epilepsy Behav. 2014;33:39–44. Brabcova D, Kohout J. What are the predictors of quality of life of people with epilepsy? J Neurosci Rural Pract. 2013;4(Suppl 1):S5–6.
Department of Psychology, Faculty of Education, University of West Bohemia, Plzen, Czech Republic, Department of Pediatric Neurology, Charles University in Prague, 2nd Faculty of Medicine, Motol University Hospital, Praha, Czech Republic, 3Department of Physics, Faculty of Applied Sciences, University of West Bohemia, Plzen, Czech Republic, 4Department of Pedagogy and Psychology, Pedagogical Faculty, University of South Bohemia, Ceske Budejovice, Czech Republic, 5Department of Neurology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Praha, Czech Republic
2
Objectives: Academic achievement in children with epilepsy is a highly studied topic with many important implications. However, only little attention has been devoted to academic self-concept of such children and the relation of academic self-concept to their quality of life. We aimed to examine academic self-concept in children with epilepsy, to assess its relationship to academic achievement and to determine possible correlations between academic self-concept and quality of life. Methods: The study group consisted of 182 children and adolescents aged 9–14 years who completed the student’s perception of ability scale (SPAS) questionnaire to determine their academic self-concept and the modified Czech version of the CHEQOL-25 questionnaire to determine their health-related quality of life. Results: We found that academic self-concept in children with epilepsy was on average significantly lower than in their peers without seizures, especially with regard to general school-related abilities, reading, and spelling. On the other hand, the variance in the data obtained from the group of children with epilepsy was significantly higher than in the whole population and the proportion of individuals with very high academic self-concept seems comparable among children with and without epilepsy. Moreover, it was found that correlations between academic self-concept and academic achievement are significantly lower in children with epilepsy than in the whole population. Discussion: The presented results suggest that considerable attention should be paid to the role of academic self-concept in education of children with epilepsy and to the factors influencing this selfconcept in this group. Keywords: Academic self-concept, Academic achievement, Quality of life, Children, Epilepsy, Learning disabilities
Introduction Epilepsy has a significant impact on various aspects of the life of affected children.1 Worldwide, the prevalence of epilepsy per 1 000 population varies widely from 2.7 to more than 40, although most studies show a range from 4 to 8.2 Age-specific incidence for children aged 6–18 years is usually reported in the range of 50–100 per 100 000 personyears.3 In the Czech Republic, there are around 13 000 children suffering from epilepsy, which corresponds to a prevalence of approximately 6 per 1 000 population.4 The issue of academic achievement in children with epilepsy has been repeatedly addressed. It is important that academic achievement has two main levels – objective and subjective. The objective level regards Correspondence to: Dana Brabcova, Tocnik 4, Klatovy 33901, Czech Republic. Email: [email protected]
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fulfilling certain external norms. The subjective level described usually as academic self-concept shows how good children feel at school and if they have adequate confidence in their abilities.4 Self-concept (not only academic) is a construct having a long history in psychology and education science (see, e.g. Ref. 5 for more detail). In the case of children with epilepsy, this construct may be of particular importance because an improved self-concept may make a child more resilient to the social challenges from the chronic disease as stated by Lee et al. in Ref. 6 As a consequence, academic achievement of a child may be significantly improved. Conversely, a poor self-concept in childhood and adolescence has exhibited associations with a lower quality of life, an increased criminal behavior, a lower educational attainment, and a lower income.7 Previous research has been primarily focused on the objective assessment of academic achievement in children with epilepsy using standardized tests, and
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on determining factors that affect this academic achievement.8–17 After a detailed analysis of findings reported by different studies, Reilly and Neville found that academic achievement in children with epilepsy was on average lower than in the general population.18 However, it is still unclear whether this is caused by a higher proportion of individuals with significantly reduced intelligence in children with epilepsy compared to the whole population or whether children with epileptic seizures perform worse at school even if they are intellectually on the same level as their peers. An important factor in the academic achievement of children with epilepsy is a high prevalence of learning disabilities such as dyslexia (13–32%), dysgraphia (35–56%), or dyscalculia (20–38%) in this group.17 The specific values are strongly dependent on the diagnostic criteria used but there is no doubt that the proportion of individuals with some kind of learning disability is significantly higher among children with epilepsy compared to approximately 7.5% in the general population.19 Some studies suggest that in children with epilepsy but without learning disabilities, academic achievement is comparable with the general population.12 However, only little attention20,21 has been devoted to academic self-concept in children with epilepsy and to its relationship with their academic achievement. Due to the persisting stigmatization of children with epilepsy in school environment,22 it is reasonable to hypothesize that the children may be at particular risk for reduced academic self-concept. The main aims of this study were to examine academic self-concept in children with epilepsy, to explore a relationship between academic self-concept and academic achievement, and finally to determine possible correlations between academic self-concept and quality of life.
Methodology SPAS and CHEQOL-25 questionnaires Academic self-concept was determined using the student’s perception of ability scale (SPAS) questionnaire, which was first introduced by Boersma and Chapman.23 The Czech version of the questionnaire contains a total of 48 dichotomous questions, which are divided into six scales of eight questions. Each scale measures academic self-concept in the following areas: 1. General school-related abilities 2. Mathematics 3. Reading 4. Spelling 5. Writing 6. Confidence The Czech version was validated in 1992.24 It was found that the Czech version had very good psychometric properties. The results for the individual scales
Academic achievement in children with epilepsy
and the total score were converted to sten scores with respect to gender and age of the respondents using tables in the questionnaire manual.23 The questionnaire is suitable for children aged 9–14 years. It is recommended to use sten scores in presentation of the results obtained using SPAS because unconverted rough scores may be confusing if the studied group differs in age and/or gender from the group on which the standardization study was carried out.24 Quality of life was assessed using a modified Czech version of the CHEQOL-25 questionnaire created by Ronen and his colleagues.25 Psychometric properties of the modified Czech version were determined in our previous study26and are fully satisfactory. The use of the questionnaire, authored by Dr. Gabriel Ronen et al., was under license from McMaster University, Hamilton, Canada. The questionnaire consists of a total of 23 questions, with answers on a 4-point scale (1–4 points). Factor analysis revealed the following four areas in which the questionnaire measured the quality of life of children with epilepsy: 1. Interpersonal/social consequences (5 items); 2. Worries and concerns (four items); 3. Intrapersonal/emotional issues (four items); 4. Disclosure and normality (10 items). The results are given using the gross scores on each scale, which are in the range of 5–20 points (scale 1), 4–16 points (scales 2 and 3), and 10–40 points (scale 4). Both questionnaires used in the study are quite simple and fully understandable even for the children with impaired cognitive functions.24,26
Procedure and respondents The study was conducted in selected pediatric neurology departments in the Czech Republic from 2010 to 2012. We obtained consent from parents of the children involved in the study. The completion of the Czech versions of the CHEQOL-25 and SPAS questionnaires by pediatric patients independently of physicians and parents was preceded by a diagnostic questionnaire given to each patient by a neurologist or by a parent (or parents). Two hundred fifty respondents aged 8–15 years were involved in the completion of the questionnaires but only 182 respondents aged 9– 14 years were included in the current study because the Czech version of the SPAS questionnaire is not appropriate for older or younger individuals. Data obtained from all the respondents aged 8–15 years were used for the cross-cultural adaptation of the CHEQOL-25 questionnaire reported in our recent study.26 Note that no control group was involved in the study and the results of our experimental group in the SPAS questionnaire were compared with normative test scores given for the whole population of Czech children aged 9–14 years in Ref. 24. The basic characteristics of the sample of respondents are shown in Table 1. Children aged 9–14 years
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with definite diagnosis of epilepsy with either generalized focal seizures regardless etiology of the condition who have according to DSM-IV27 IQ level corresponding to mild intellectual disability (IQ around 70) or higher were included in the study. Actual seizure frequency was not a limitation for inclusion. All children were treated with one or more antiepileptic drugs. We excluded subjects with significant psychiatric comorbidity and psychiatric medication. The proportion of mildly intellectually disabled respondents was just around 20%. The proportion of subjects with learning disabilities is 35% in our sample. All patients with learning disabilities were carefully diagnosed by an experienced counseling psychologist. In the Czech Republic, diagnostics of learning disability is based on IQ-achievement discrepancy17 and the discrepancy cutoff is in most cases set on 1.5 standard deviations (SD). The final diagnosis is based on DSM-IV27 and is made by a counseling psychologist in accordance with recommendations of International Dyslexia Association. In Table 2, the sample of respondents is characterized in terms of seizure type and frequency. Subjects with daily or weekly seizures were classified as having a high frequency of seizures. The categorization of seizures according to their type was performed in the same way as in Refs. 25 and 26 to maximize comparability of our results.
Statistical analysis In processing the acquired data, we used Microsoft Excel 2003 with the add-on accessory XLSTAT. In addition to classic descriptive statistics, we used the one sample t-test of mean values and the chi-squared test of variance for comparison of experimental group results with the normative test scores of the whole population. Pearson’s correlation coefficient and polychoric correlation coefficient with the appropriate tests of independence were used in order to explore
correlation between academic self-concept in children with epilepsy and their academic achievement and quality of life. Moreover, we used the chi-squared test to determine possible differences in the distribution function between our data and normative test scores valid for the whole population. The results of the t-tests and chi-squared tests are given with the Pvalues of the tests in order to determine the maximum probability of rejection of the correct zero hypothesis (i.e. the hypothesis that there is no difference between the groups, the independence of the two variables, etc.). A test P-value of less than 0.05 was considered statistically significant.
Results Academic self-concept in children with epilepsy Table 3 shows the proportion of children and adolescents who achieved the given results (sten scores). For comparison, the normative test scores for the general population of children and adolescents in this age group are also given. If we use the chi-squared test to test the hypothesis that the distribution of patients with epilepsy is the same as in the general population, we could clearly reject this hypothesis (test statistic chi2 5 75.6, critical value for level of significance of 0.05 and 9 degrees of freedom was only 16.9, the test P-value is much less than 0.001). Thus, there is a significant difference in the overall score between the group of children with epilepsy and the whole population. In the next step, we analyzed particular domains of the academic self-concept in children with epilepsy measured by the appropriate scales of the SPAS questionnaire. Table 4 shows the mean values and SD of sten scores in our group of children with epilepsy and the whole population. Sten scores for the whole population have in all scales a mean of 5.5 and a SD of 2, which is a fundamental property of this type of scaling frequently used in the field of
Table 1 Basic characteristics of respondents (n 5 182) Characteristic 11.8¡1.7 yearsa (range 9–14 years)
Age Gender Male Female Duration of epilepsy Age at seizure onset Mild intellectual disability Yes No Learning disability Yes No Learning disabilityb Reading disorder (dyslexia) Writing disorder (dysgrafia) Math disability (dyscalculia) a b
290
84 (46.2%) 98 (53.8%) 5.3¡3.3 yearsa (range 0–14 years) 6.1¡3.5 yearsa (range 0–14 years) 32 (17.6%) 150 (82.4%) 64 (35.2%) 118 (64.8%) 51 (81.0%) 48 (75.0%) 24 (37.5%)
Mean ¡ SD. Thirty-nine individuals suffered from more than one type of learning disability.
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psychological diagnostics. The one-sample t-test (note that we compared our experimental group with the normative test scores) shows that children and adolescents with epilepsy achieve significantly lower mean scores in the area of academic self-concept in comparison with the general population on scales 1 (general school-related abilities), 3 (reading), 4 (spelling), and also on the total SPAS questionnaire score. Particularly striking is the difference in general schoolrelated abilities, reading, and total score (P-value in all cases is less than 0.001). In contrast, no differences in the mean scores were observed in scales 2 (mathematics), 5 (writing), and 6 (confidence). Chi-squared test for variance shows that children and adolescents with epilepsy achieve a significantly higher variance (P-value less than 0.01) in comparison with the general population in all scales of the SPAS questionnaire.
The relationship between academic self-concept and academic achievement In this section, we focus on the level of academic achievement that children and adolescents reached at school in the core subjects of the Czech language and mathematics, and how this assessment correlated with their own academic self-concept. We collected data
Academic achievement in children with epilepsy
about the academic achievement of 161 respondents out of the total number of 182 respondents who took part in this study. The other respondents stated they had been assessed verbally (10 respondents) or did not complete this part of the questionnaire (11 respondents). Table 5 shows polychoric correlation values between the individual scales of the SPAS questionnaire and grades in the subject areas of the Czech language and mathematics. The average grade in the Czech language on a 5-point scale (with 1 5 best, 5 5 worst) was 2.36 with a SD of 0.97. The average grade in mathematics was 2.32 with a SD of 1.00. For comparison, the values of the relevant correlation coefficients given in the manual of the Czech version of the SPAS questionnaire for the whole population24 are stated in parentheses. Table 5 shows that academic achievement in the core subject of the Czech language correlated most notably with academic self-concept in scales 1 (General school-related abilities), 6 (Confidence), and the total score. In mathematics, the most significant correlations were in scales 2 (Mathematics), 6 (Confidence), and the total score. In both cases, the group of children and adolescents with epilepsy
Table 2 Characteristics of types and frequency of seizures in respondents
Seizure type
Respondents with a high frequency of seizures (n1 5 37)
Respondents with a low frequency of seizures (n2 5 145)
10 11 16 9 3 5
30 47 26 62 8 18
Simple partial Complex partial Absence Tonic or tonic–clonic Myoclonic Other/unclassified
Note. Nine individuals with a high frequency of seizures and 40 individuals with a low frequency of seizures suffered from more than one type of epileptic seizure. Table 3 Comparison of total student’s perception of ability scale (SPAS) questionnaire scores obtained from the general population and from children and adolescents with epilepsy Sten score Frequency in the group of children with epilepsy (n 5 182) Percentage in the group of children with epilepsy (%) Percentage in the general population (%)
1
2
3
4
5
6
7
8
9
10
13 7.1 2.3
26 14.3 4.4
23 12.6 9.2
28 15.4 15.0
23 12.6 19.2
26 14.3 19.2
16 8.8 15.0
11 6.0 9.2
5 2.8 4.4
11 6.0 2.3
Table 4 Comparison of the results obtained from children with epilepsy and the general population for each individual scale of the student’s perception of ability scale (SPAS) questionnaire
Scale 1 – general school-related abilities Scale 2 – mathematics Scale 3 – reading Scale 4 – spelling Scale 5 – writing Scale 6 – confidence Total score
Children and adolescents with epilepsy (n 5 182)
General population (normative test scores)
One-sample t-test P-value
Chi-squared test for variance P-value
4.30¡2.64a
5.5¡2
,0.001
,0.001
5.50¡2.54 4.49¡2.48 5.04¡2.71 5.70¡2.38 5.36¡2.37 4.79¡2.46
5.5¡2 5.5¡2 5.5¡2 5.5¡2 5.5¡2 5.5¡2
0.988 ,0.001 0.022 0.251 0.411 ,0.001
,0.001 ,0.001 ,0.001 ,0.001 ,0.001 ,0.001
a
Mean ¡ SD. Note. The P-values in bold denote cases when the corresponding null hypothesis was rejected at a significance level of 0.05.
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exhibited the same trends as in the general population, although the values of the correlation coefficients are generally slightly lower. In terms of academic achievement, it is evident that children with epilepsy in the monitored group achieved on average slightly worse results in the Czech language than in mathematics.
Correlations between academic self-concept and quality of life Table 6 shows the value of Pearson’s correlation coefficient between the individual scales of the modified Czech version of CHEQOL-25 questionnaire measuring the quality of life of children and adolescents with epilepsy and the scales of the SPAS questionnaire, which we used to determine academic self-concept. Values that are statistically significant for the test of independence at a significance level 0.05 are in bold. Table 6 shows relatively strong correlations between the third scale of the CHEQOL-25 questionnaire (Intrapersonal and Emotional Issues) and academic self-concept in terms of the six scales in the SPAS questionnaire and its overall score. Quite significant correlations were also observed between the first scale of the CHEQOL-25 questionnaire (interpersonal and social consequences) and academic self-concept. Conversely, in the second (worries and concerns) and fourth (disclosure and normality) scales the appropriate correlation coefficients values were considerably smaller.
Discussion Tables 3 and 4 show that children with epilepsy achieved significantly lower results in total academic
self-concept, general school-related abilities, reading, and spelling. Low academic self-concept in reading may be related to the fact that the most common learning disability in our series was reading disorder (Table 1). Better results in mathematics than in the native language were reported by some studies focused on the objective measurement of academic achievement in children and adolescents with epilepsy.18 A recent study from Jamaica showed that children with epilepsy had lower scores compared to their peers on tests of both language and mathematics ability.28 On the other hand, we found a surprising result in writing, where children and adolescents with epilepsy achieved results comparable to the average in the whole population despite the fact that a relatively large percentage of the children with epilepsy had been diagnosed with writing disorder (Table 1). This result appeared to be in conflict with studies reporting writing as an area in which children with epilepsy achieved significantly lower scores than the general population.17 It should be noted that our study aimed to determine academic selfconcept that does not necessarily correspond to academic achievement measured by standardized tests. In Ref. 24, there are examples of children with mild intellectual disability who achieved average results in the area of academic self-concept as measured by the SPAS questionnaire, although their academic achievement was far below average. Moreover, the writing scale in the SPAS questionnaire is focused more on the tidiness of writing than on its factual accuracy. Table 5 shows the correlation between academic self-concept and academic achievement in the core
Table 5 Academic achievement in children with epilepsy and correlation between their academic achievement and academic self-concept, n 5 161 Correlation between academic achievement and academic self-concept
Grade – Mathematics
0.501 (0.631)a 0.376 (0.491) 0.364 (0.498) 0.410 (0.590) 0.259 (0.304) 0.516 (0.647) 0.585 (0.656)
Scale 1 – general school-related abilities Scale 2 – mathematics Scale 3 – reading Scale 4 – spelling Scale 5 – writing Scale 6 – confidence Total score a
Grade – Czech language
0.466 0.538 0.281 0.302 0.144 0.496 0.531
(0.570) (0.627) (0.413) (0.426) (0.273) (0.619) (0.632)
In parentheses is the correlation for the whole population, taken from Ref. 24.
Table 6 Correlation between the quality of life of children and adolescents with epilepsy (CHEQOL-25 questionnaire) and their academic self-concept [student’s perception of ability scale (SPAS) questionnaire], n 5 182 Scale 1 –interpersonal and social consequences Scale 1 – general school-related abilities Scale 2 – mathematics Scale 3 – reading Scale 4 – spelling Scale 5 – writing Scale 6 – confidence Total score
Scale 2 – worries and concerns
Scale 3 – intrapersonal and emotional issues
Scale 4 – disclosure and normality
0.384
0.187
0.575
0.187
0.271 0.258 0.221 0.188 0.413 0.379
0.023 0.207 0.116 20.022 0.169 0.182
0.341 0.401 0.400 0.330 0.493 0.590
0.155 0.035 0.125 0.055 0.166 0.165
Note. The correlations in bold denote values with the rejected hypothesis of independence at a significance level of 0.05.
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subjects of the Czech language and mathematics. Lower values of the correlation coefficients in comparison with the general population may have been related primarily to the high proportion of children with learning disabilities in our sample of respondents. During assessment, school teachers were required to take into account the fact that particular students were suffering from this disorder and this may have led to significant differences between academic self-concept and academic achievement. The relatively strong correlations between scale 1 of the CHEQOL-25 questionnaire and academic-self concept (see Table 6) may have been related to the fact that in children, academic achievement plays a major role in their interpersonal and social relationships. Attention should be devoted also to factors influencing academic self-concept in children with epilepsy. Although the purpose of our paper is not to study such factors in a systematic way, some basic findings related to this topic should be reported and discussed here. First, there are no statistically significant gender differences in academic self-concept (P-value of the two-sample t-test of mean values is higher than 0.05 in all scales). Second, correlation between the duration of epilepsy in years and the total score of the SPAS questionnaire measured by Pearson’s correlation coefficient is 20.124, which is not a statistically significant value for the given number of respondents. Finally, correlation between the frequency of the seizures and the total score measured by the point-biserial correlation coefficient is only 0.061, which is again not a statistically significant value. These findings are in accordance with the data from the literature8,12 regarding factors influencing academic achievement of children with epilepsy. The effect of the type of seizures was not evaluated in our study because many patients suffered from more than one type and it was not possible (due to the size and composition of our sample) to completely cover all the relevant medical factors (such as focus localization), which may have some effect on the results. Some methodological problems related to this topic are discussed in Ref. 29. It would be very useful to investigate how severity of epilepsy (which is given not only by the type of seizures and their frequency) influences academic selfconcept. The effect of antiepileptic drugs, neurotic disorders such as depression or anxiety, and other factors on academic self-concept of children with epilepsy should be also investigated. This will be the topic of our further research. This study clearly shows that there are considerable differences in academic self-concept between children in epilepsy and the whole population that should be taken into consideration. Moreover, correlations between academic self-concept and assessment by
Academic achievement in children with epilepsy
teachers are lower for children with epilepsy, which may suggests that teachers have problems with assessment of the children. Our results suggest that it is necessary to seek ways to improve self-concept of children with epilepsy. In our opinion, the most important here is the role of teachers and classmates of a child with epilepsy who can significantly contribute to a better feeling of this child in the school environment. Thus, a further development of efficient educational interventions focused on increasing knowledge of teachers and pupils on epilepsy is highly needed. The present study had some limitations associated with its design. As already discussed, the main limitation was that there was no systematic investigation of a possible correlation between academic selfconcept and factors such as seizure type or the presence of specific learning disabilities. Another limitation was related to the determination of correlations between academic self-concept and academic achievement calculated by objective methods in terms of fulfilling norms. In our study, achievement was determined by the teacher of the subject. It would have been better to have measured academic achievement using standardized tests. This topic will be approached by further research.
Disclaimer Statements Contributors No contributors (excluding Authors of the manuscript) were involved. Funding This research project was supported by Quality of Life of Children Living with Epilepsy implemented under the Promising Strategies 2010 Program, which is a program by IBE the International Bureau for Epilepsy, and by the grants GAJU 037/ 2010/S and MH CZ DRO from the University Hospital Motol, Prague, Czech Republic 00064203. DB was supported from Motivational System of the University of West Bohemia, Pilsen, part POSTDOC. Conflicts of interest The authors have no conflicts of interest to declare. Ethics approval Ethical approval was not required.
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