Vocational and educational problems of epileptic patients

Intelligence and epilepsy: The early era

This contribution to the commemoration of the 20th anniversary of Epilepsy & Behavior addresses the topic of epilepsy and intelligence, an early focus of interest in the history of the neuropsychology of epilepsy. The path through which the earliest measures of intelligence found their way to epilepsy research is reviewed followed by an overview of the subsequent themes of research, points of disagreement, advances in research using measures of intelligence, and developing awareness of the limitations associated with reliance on intelligence tests. Special Issue: Epilepsy & Behavior's 20th Anniversary.

Descriptive epidemiology: prevalence, incidence, sociodemographic factors, socioeconomic domains, and quality of life of epilepsy: an update and systematic review

INTRODUCTION

The purpose of this study was to investigate the contributions of quality of life (QOL), sociodemographic factors (age, sex, etc.), residential areas, general attitudes toward epilepsy, socioeconomic domains, prevalence and incidence in epileptic patients from Iran.

MATERIAL AND METHODS

A systematic literature search was conducted, including database searches in PubMed, Medline, Embase, ScienceDirect, Scopus, ISC, Health, Web of Science, and the Cochrane Library Database of relevant articles, personal files and systematic reviews to identify studies examining risk factors in epilepsy.

RESULTS

This review article shows that certain socio-demographic and socio-economic factors, geographic variation in epidemiologic patterns of epilepsy as well as clinical factors may be crucial in determining QOL in epilepsy patients and provides further evidence supporting the validity of the scale in QOL based on consideration of different target groups in different areas.

CONCLUSIONS

Prevalence of epilepsy appears to be correlated with socioeconomic status in the lower socioeconomic groups. Also demographic characteristics, socio-economic factors and clinical presentation are linked to different QOL of these patients among nations. The educational program has a beneficial effect on self-management behaviors in patients with epilepsy. More work needs to be done to improve tools that help to evaluate efficiently the health-related quality of life of people with epilepsy.

Clinical characteristics associated with psychosocial functioning among patients with uncomplicated epilepsy in Spain

OBJECTIVE

To identify the clinical characteristics associated with poor psychosocial functioning among Spanish patients with epilepsy but no other neurological or psychiatric disorder.

METHODS

Between May and September 2001 a survey among patients with epilepsy was carried out in 32 Spanish health care centres. The selection criteria of patients were attendance to a routine neurologist visit, to be aged between 25 and 64 and not having another additional neurological handicap (n=812). Psychosocial function was elicited through six indicators: educational level, marital status, unemployment status, restricted car driving, self-perception of epilepsy as an important limiting factor in the educational level achieved and, among unemployed, as the cause of their unemployment. Multiple logistic regression models were fitted in order to calculate adjusted odds ratios (aOR) and their 95% confidence intervals.

RESULTS

After simultaneously adjusting for socio-demographic variables and clinical characteristics, the six outcomes analysed increased with seizure frequency. Moreover, all the outcomes except low educational level were also related to early age at onset of epilepsy. Although no relation with objective educational level was found, there was a strong association between early age at onset of symptoms and self-perception of epilepsy as an important limiting factor of educational achievement.

CONCLUSION

These findings emphasize the need for more effective treatment of epilepsy and also highlight the importance of a psychosocial approach to management of epilepsy for patients with an early onset of symptoms in order to prevent social limitations in adult life.

Prevalence of epilepsy and comorbidity of psychiatric disorders in Iran

PROBLEM

To determine the lifetime prevalence of self- and other relative informants-reported epilepsy in nationwide study among Iranian adults of aged 18 years and over and to study the association of epilepsy with lifetime history of the psychiatric disorders.

METHOD

Twenty-five thousand one hundred and eighty individual were selected through a randomized clustered sampling method from all the Iranian households; interviewed and used epilepsy questionnaire face-to-face at home in year 2001. From 12,398,235 households residing in Iran, 7795 families selected from 1559 clusters, 997 clusters were in urban and 582 were in rural areas, each cluster with 5 households were studied. The response rate was 90%.

RESULTS

The prevalence of epilepsy was 1.8%. Epilepsy was more common in females, unemployed and higher educational level. It was not significantly associated with the age group, marital status and residential areas. The most common psychiatric disorders in subjects with epilepsy were major depressive disorder and obsessive compulsive disorder. The rate of lifetime suicidal attempt was 8.1%.

CONCLUSION

Lifetime prevalence of epilepsy in Iran is not low. As the other communities, it is more common in females and unemployed. However, in contrast with the other studies, it was not more common among some age groups and unmarried and low educated subjects.

Work beliefs and work status in epilepsy

PURPOSE

The goal of this study was to determine differences in work beliefs between people with epilepsy who work and those who do not work.

METHODS

One hundred thirteen subjects (58 females, 55 males) 41.56+/-11.42 years of age and with a seizure duration of 22.88+/-12.96 years (means+/-SD) were assessed.

RESULTS

Forty percent worked full-time, 10% worked part-time, and 50% did not work. Twelve of the fifty-six who worked had more than one seizure per month, compared with 29 of 57 who did not work. There were significant differences between the working and nonworking groups: The nonworking group believed that (1) they had to work to be "normal," (2) they did not have enough education, (3) not having a job was the only barrier to independent living, (4) their families feared work injuries, (5) working represented a risk of injury, (6) they would hurt others if they had a seizure at work, (7) their families did not want them to work, and (8) seizures would negatively affect job performance.

CONCLUSION

Work beliefs are important factors contributing to work status.

Employers' attitudes to employment of people with epilepsy: still the same old story?

PURPOSE

One area of life quality known to be compromised by having epilepsy is employment, and one factor contributing to the employment problems of people with epilepsy (PWE) is employer attitudes. Much research on this topic is now outdated and given the changing legal, medical, and social contexts in which PWE live, we therefore reexamined employer attitudes in the United Kingdom.

METHOD

A mail survey of a random sample of U.K. companies selected to be representative of the 14 U.K. economic regions and proportional to the number of employees.

FINDINGS

The overall response rate was 41% (n = 204). Twenty-six percent of respondents reported having experience of employing PWE. Sixteen percent considered that there were no jobs in their company suitable for PWE; 21% thought employing PWE would be "a major issue." Employers were uniformly of the view that PWE, even when in remission, should disclose their condition to a prospective employer. Seizure severity, frequency, and controllability were all considered important features of epilepsy in the context of employment. Epilepsy created high concern to around half of employers, including the likelihood of it being linked to a work-related accident. Employers were willing to make accommodations for PWE, in particular job sharing, temporary reassignment of duties, and flexible working hours. Attitudes to employment of PWE were influenced by company size and type and previous experience of doing so.

CONCLUSIONS

We conclude that it is still the same old story for employers' attitudes toward PWE, though happily for PWE, with some room for optimism.

Socioeconomic variation in incidence of epilepsy: prospective community based study in south east England

OBJECTIVE

To determine the incidence of epilepsy in a general practice population and its variation with socioeconomic deprivation.

DESIGN

Prospective surveillance for new cases over an 18 or 24 month period.

PARTICIPANTS

All patients on practice registers categorised for deprivation with the Carstairs score of their postcode.

SETTING

20 general practices in London and south east England.

MAIN OUTCOME MEASURE

Confirmed diagnosis of epilepsy.

RESULTS

190 new cases of epilepsy were identified during 369 283 person years of observation (crude incidence 51.5 (95% confidence interval 44.4 to 59.3) per 100 000 per year). The incidence was 190 (138 to 262) per 100 000 in children aged 0-4 years, 30.8 (21.3 to 44.6) in those aged 45-64 years, and 58.7 (42.5 to 81.0) in those aged > or =65 years. There was no apparent difference in incidence between males and females. The incidence showed a strong association with socioeconomic deprivation, the age and sex adjusted incidence in the most deprived fifth of the study population being 2.33 (1.46 to 3.72) times that in the least deprived fifth (P=0.001 for trend across fifths). Adjustment for area (London v outside London) weakened the association with deprivation (rate ratio 1.62 (0.91 to 2.88), P=0.12 for trend).

CONCLUSIONS

The incidence of epilepsy seems to increase with socioeconomic deprivation, though the association may be confounded by other factors.

Epilepsy in Estonia: a quality-of-life study

PURPOSE

To study the impact of epilepsy and its treatment on people with epilepsy in Estonia and to analyze how it is affected by the characteristics of epilepsy.

METHODS

Clinical and demographic data about patients were obtained from medical notes and mailed self-completed questionnaires (including the RAND 36-Items Health Survey 1.0 (RAND-36)).

RESULTS

Information was collected from 203 patients aged 20-74 years, who all had active epilepsy. A third of the respondents had been seizure free during the last year. Eighty-four percent were receiving monotherapy. More than half of respondents felt stigmatized by epilepsy, 24.7% of them highly so. A third were working full-time, 31.9% were underemployed workers, and 11%, unemployed. Sixty-two percent of these same unemployed or underemployed workers considered their epilepsy to be a significant reason for this situation. Overall, 44% believed they had been treated unfairly at work or when trying to get a job. Study respondents scored lower in all domains on the RAND-36 than did persons from the control group. The biggest differences were found in five domains: Social functioning, Role limitations-physical, Role limitations-emotional, General health, and Vitality.

CONCLUSIONS

The clinical characteristics of this study were similar to those of most other series of prevalence cases of epilepsy. The level of employment among persons with epilepsy was not lower than that in the general population. The percentage of stigmatization was high. There were significant differences in the way respondents scored on the stigma scale and on the RAND-36 domains when measuring their health status, depending above all on seizure frequency and type.

Felt stigma and impact of epilepsy on employment status among Estonian people: exploratory study

This article examines the impact of epilepsy and its treatment on employment status and the extent of stigma among patients with epilepsy. Clinical and demographic data concerning patients examined during a recent epidemiological survey were obtained from medical notes and postal self-completed questionnaires. Information was collected from 90 patients aged 16-70 years. A third of the respondents had been seizure-free during the last year. Thirty-nine percent were working full-time, 24% were working part-time and 11% were unemployed. Sixty-three percent from those working part-time or unemployed considered their epilepsy to be a significant reason for this. Overall, 55.4% believed they had been treated unfairly at work or when trying to get a job. Fifty-one percent of respondents felt stigmatized by epilepsy, 14% of them highly so. The level of employment among epileptic people was not lower than in the general population. The percentage of stigmatization in general and the percentage of the severely stigmatized was as high or even higher than in other studies. Occurrence of stigma and its severity depended first and foremost on the type of seizures. The frequency of seizures was not clearly related to this.

Social aspects of epilepsy in the adult in seven European countries. The RESt-1 Group

PURPOSE

The social implications of epilepsy are ill-defined, and there are no comparative findings from different countries. A multicenter cohort study has recently been completed on the risk of morbidity and accidents. The main social issues in the study population (patients with epilepsy and control subjects) are investigated and correlated to the clinical features of the disease.

METHODS

Seven hundred six adult patients with idiopathic or remote symptomatic epilepsy and 662 matched controls without epilepsy were enrolled by secondary and tertiary centers in seven European countries (Italy, Germany, Spain, the Netherlands, England, Portugal, and Russia). At entry, patients and controls were interviewed, and data were collected on social variables (education, current occupation, marital status, driving, involvement in sports, and insurance). The main clinical features of epilepsy (seizure types, frequency and timing, disease duration, and syndrome) were also recorded.

RESULTS

The sample included 690 men and 678 women aged 18 to 86 years. The level of education (mostly basic or high school) was slightly higher among patients with epilepsy. More patients than controls were single (56% versus 50%) or unemployed (18% versus 13%). Fewer patients than controls held a driver's license (44% versus 67%) or practiced sports (30% versus 41%). The distribution of each social variable varied significantly across countries, but with few exceptions, the differences between patients and controls were fairly similar. Based on multivariate analysis, for patients with epilepsy the odds ratio for driving was 0.27, and the corresponding odds ratios for sports involvement, better education, better occupation, and insurance were 0.59, 1.30, 0.60, and 1.49. Among patients with epilepsy, social variables were correlated to seizure remission and selected clinical features.

CONCLUSIONS

Comparative findings from different European countries support the concept that epilepsy has a considerable impact on driving and-to a lesser extent-on education, occupation, leisure activities, and insurance. The social implications of epilepsy in this sample are partly related to its severity and clinical features.

Long-term medical, educational, and social prognoses of childhood-onset epilepsy: a population-based study in a rural district of Japan

The long-term prognosis of childhood-onset epilepsy has rarely been studied in a general population. We examined the long-term medical, educational, and social outcomes in individuals with a history of childhood-onset epilepsy aged 20 years or older in a defined area of Japan. Furthermore, the patients' recognition of epilepsy as well as the parents' concerns about the prognosis of epilepsy were also surveyed. After a mean follow-up period of 18.9 years, we had sufficient data on 148 surviving patients aged 20-38 years (mean, 26. 0 years) and seven dead patients. The follow-up rate was 92.8%. In the overall group, the percentages of those who had had each of the following were as follows: (a) 5-year remission, 62.8%; (b) a relapse of seizures, 17.4%; (c) psychiatric complications, 2.7%; (d) mortality, 4.5%; (e) attendance at regular classes of an ordinary school during compulsory education, 71.6%; (f) entrance to high school, 65.5%; (g) employment, 67.4%; (h) marriage, 23.0%; and (i) acquisition of a driver's license, 54.7%. The educational and social variables of the control population were as follows: (e) 99.1, (f) 97.0, (g) 96.6, (h) 51.9, and (i) 94.8%. In the 99 patients of normal intelligence, the results of the same analysis were as follows: (a) 75.8, (b) 10.7, (c) 0, (d) 0.6, (e) 100, (f) 96.0, (g) 95.2, (h) 33.3, and (i) 77.8%, in contrast to the corresponding variables of the 49 patients with mental retardation, that is, (a) 36.7, (b) 44.4, (c) 8.2, (d) 12.2, (e) 14.3, (f) 6.1, (g) 20.4, (h) 2.0, and (i) 4.1%, respectively. The best predictors of seizure remission included an early response to therapy, a low frequency of seizures or an absence of status epilepticus prior to therapy, and normal mental development. As for the current awareness of epilepsy and its prognosis, nearly 40% of the patients did not know the true name of their illness, and the same proportion of parents were still anxious about the prognosis even if their children had been taken off medication. Our data show that the majority of patients with childhood-onset epilepsy have a favorable long-term medical prognosis in terms of seizure remission and psychiatric complications, whereas they have a higher mortality rate and lower levels of educational background as well as employment and marital status compared with the general population. However, except for the low marriage rate for the younger age group and the low rate of holding a driver's license, patients of normal intelligence appear to have more favorable long-term prognoses in terms of educational and social aspects as well. In Japan, individuals with epilepsy may not seek a driver's license because of the law.

Cross-cultural differences in health-related quality of life of people with epilepsy: findings from a European study

PURPOSE

To examine between-country differences in health-related quality of life (HRQOL) of adults with epilepsy across a large number of European countries.

METHODS

Self-completion postal questionnaire sent to large sample of adults with epilepsy, recruited from epilepsy support groups or epilepsy outpatient clinics. The questionnaire was developed in English and translated. Back-translations from each language were checked for accuracy. The questionnaire sought information on clinical and socio-demographic details, and contained a number of previously validated scales of psychosocial well-being (the SF-36, the perceived impact of epilepsy scale, and a feelings of stigma scale).

RESULTS

Controlling for socio-demographic and clinical characteristics, significant between-country differences were found in scores on the perceived impact of epilepsy scale, on seven of the eight SF-36 domains, and on the feelings of stigma scale. Respondents in Spain and the Netherlands fared consistently better, whilst those in France fared poorest, compared to those in other countries in terms of the various HRQOL measures used.

CONCLUSION

Several possible reasons for the cross-cultural differences in HRQOL are proposed. Clearly, there is no single explanation and there may also be reasons which we have overlooked. This study emphasises the need for further comprehensive research in order that the position of people with epilepsy in different countries be more thoroughly understood in the social context.

Quality of life of people with epilepsy: a European study

PURPOSE

To study the impact of epilepsy and its treatment on people with epilepsy in Europe. We therefore aimed to collect data from as many countries as possible.

METHODS

Clinical and demographic details and information about psychosocial functioning was collected using self-completed questionnaires mailed to members of epilepsy support groups.

RESULTS

Quality of life data was collected from >5,000 patients living in 15 countries in Europe. Over a third of all respondents had frequent seizures, and a fifth believed that their seizures were not well enough controlled by antiepileptic medication. Reported levels of side effects from medication were high. A significant number of respondents reported changing their medication because of side effects or poor control. Respondents reported that epilepsy and its treatment had a significant impact on a number of different aspects of their daily lives. Half of all respondents felt stigmatised by their epilepsy. There were significant differences by seizure type and frequency in the way respondents scored on measures of the perceived impact of their condition, the stigma associated with it and their health status as measured by a generic scale, the SF36.

CONCLUSIONS

This study confirms the findings of previous smaller-scale studies that reducing side effects and achieving better control of seizures are key to improving the quality of life of people with epilepsy, as is reducing the stigma and handicap associated with it.

Epilepsy

Diagnosis and management of the epilepsies are routinely performed by primary care physicians. In the United States, only 17% of patients with new-onset epilepsy are examined by neurologic specialists, and even fewer patients employ neurologists for their ongoing care. With the changes dictated by the evolving health care system in the United States, the responsibilities for the treatment of patients with epilepsies by primary care physicians will continue to increase. At the same time, there has been an explosion of new information about the diagnosis, evaluation, natural history, and neurobiologic aspects of epilepsy. New medical and surgical treatments are being introduced with a quickening pace. Finally, the concept that certain epilepsies may be progressive and that early identification and aggressive treatment represent one's best chance for establishing control for these patients has gained widespread confirmation from both clinical and animal model studies. The past standard of care is quickly ending. No longer should a patient or a physician accept only partial seizure control. This monograph attempts to lay the basis for improved understanding of epilepsy so that our patients will be seizure free without side effects and will be able to fully participate in our society.

The clinical course of epilepsy and its psychosocial correlates: findings from a U.K. Community study

As part of a large community-based study, we retrospectively examined the clinical course of epilepsy in an unselected population of people who had a recent history of seizures or were receiving antiepileptic drugs (AEDs). Clinical information was collected from medial records, and information about psychosocial functioning was obtained by means of postal questionnaires sent to identified subjects. The response rate to the postal questionnaire was 71%. There were some deficiencies in the recording of clinical data, which is not unusual since data were taken from records held by primary physicians rather than from hospital clinics. Nevertheless, findings regarding the clinical course of epilepsy corresponded to those of earlier studies. Fifty-seven percent of the sample had had at least a 2-year seizure-free period and 46% of subjects were currently in a remission of at least 2-year duration. There was a clear relationship between current seizure frequency and levels of anxiety and depression, perceived impact of epilepsy, perceived stigma, and marital and employment status. The relationship of seizure frequency and other clinical variables to psychosocial function was explored by multivariate analysis techniques. The amount of variation in scores on the various measures of function accounted for by the clinical variables was small. The most important predictor was current seizure activity, which was the first variable to enter the regression analyses for six of the eight measures of psychosocial function considered. Age at epilepsy onset also emerged as a significant predictor for depression, stigma, and marital status. In individuals with epilepsy in remission, there was little evidence that psychosocial functioning was associated with length of remission, a finding which may in part reflect the nature of this study population. The results indicate that there are several more important predictors of psychopathology and social dysfunction in epilepsy and suggest several implications for treatment interventions.

Impact of epilepsy on employment status: findings from a UK study of people with well-controlled epilepsy

This paper examines the current employment status and recent employment history of 494 individuals with epilepsy whose seizures were well-controlled or in remission. Information about employment status and history was obtained by means of self-completion questionnaires, sent to eligible subjects by post. The sampling frame from which subjects were recruited were neurology out-patient departments across the UK. The majority of subjects had epilepsy in remission: only 15% had had a seizure in the last year and only 25% reported one in the last two years. A high proportion of respondents were currently in employment. Of those who were not, few attributed this to their epilepsy; nor did epilepsy seem to have a significant impact on recent employment history. In spite of the lack of evidence of any actual discrimination, a third of respondents nevertheless felt their condition affected their ability to obtain employment. The findings from earlier studies of high unemployment rates partly reflect bias in the samples studied. Our data provide evidence that where seizures are well-controlled and uncomplicated by other handicap, people with epilepsy do not generally experience problems with employment.

Neuropsychological aspects of learning disabilities in epilepsy

Cognitive impairment is regarded as the link between epileptic conditions and the inability to learn in school. The neuropsychological approach to learning disabilities in epilepsy, therefore, first concentrates on analyzing the differential effects of epileptic factors on cognitive function. The impact of seizure activity, localization of epileptogenic foci, and antiepileptic treatment on cognitive functioning can be evaluated based upon the results of continuous assessment with a computerized neuropsychological test system. Second, learning disabilities may be evaluated on observations made during classroom performance. Three issues seem to predominate in learning studies among disabled children with epilepsy: test-retest variability, deterioration, and the supposed specificity of the learning disabilities.

Mental deterioration in epilepsy

A variety of factors could potentially influence the occurrence of mental deterioration in epilepsy, including seizure type, age of seizure onset, seizure duration, and seizure severity. The available literature suggests that measures of severity are more predictive of progressive decreases in intellectual functioning. There is also evidence suggesting that seizure severity and cognitive deterioration might both be the result of underlying pathophysiologic abnormalities in some cases. In the majority of patients with epilepsy, however, with relatively less severe disease, there is little evidence for cognitive deterioration. Total seizure number also has an inverse correlation with level of psychosocial functioning in some studies, whereas others have found that patients with emotional difficulties have fewer seizures. In the case of emotional deterioration, the impact of interpersonal relationships and other environmental factors upon psychosocial outcome seems clear, and the evidence for specific pathophysiologic explanations for emotional deterioration, less convincing.

Stigma in patients with early epilepsy: a national longitudinal study

Forty six cases of epilepsy were identified from the National Survey of Health and Development. An index of social visibility at school was constructed from teachers' reports of survey members' behaviour at 15 years of age. For the sample as a whole this index was significantly associated with poorer educational outcomes, after adjusting for social background and measured attainment, but was not associated with poor occupational achievement. However the index did not differentiate between epileptic and non-epileptic children. Although cases with epilepsy were shown to be more at risk of psychiatric disturbance, it is concluded that their lives were less disrupted than might have been expected, and that there is no evidence from this study that stigma affects the lives of those whose epilepsy was not complicated by other pathologies.

Patient perspectives on epilepsy in a developing country

Adolescent and adult epileptic patients attending the Neurological Clinics at the Lagos University Teaching Hospital were interviewed to assess patient perspectives of epilepsy. Although all of them admitted to having recurrent seizures, 35.9% did not accept that they had epilepsy. Among those who accepted the diagnosis, only 34.5% were willing to disclose it to other people. The majority thought that people generally fear epilepsy and avoid contact with epileptic patients. Most of the patients did not know the causes of epilepsy. The majority, however, had many positive views on epilepsy and favorable attitudes toward other epileptic patients. Although many of them rated epileptic persons lower than nonepileptic persons with respect to contribution to society, hard work, temperament, and ability to make close friends, a majority thought that epileptic patients were not disabled and had the same intelligence, ambition, and ability to be educated as nonepileptic persons. Only 50.4% of them thought epileptic persons should not drive motor vehicles, and 19.7% thought epilepsy should be reported to the licensing authority. On their treatment 62.4% were satisfied with medical treatment alone, whereas 32.5% combined medical treatment with "native medicine" or spiritual church healing.

Occupational adjustment following neurosurgical treatment of epilepsy

Occupational adjustment was investigated in a group of 32 adult epileptic patients followed for 1 to 10 years after cortical resection for intractable seizures. An employment status rating was assigned according to the following scale: (1) employed (working 75 to 100% of full time); (2) underemployed (25 to 74%); and (3) unemployed (0 to 24%). The number of patients employed increased from 14 to 23, whereas the number of underemployed decreased from 8 to 0. The unemployed group showed little change. An improvement or maintenance of employment status was correlated directly with improved postoperative seizure control. Conversely, poor occupational adjustment was often associated with fair or poor seizure control following operation. Unemployment was also related to the presence of preoperative psychiatric disorders, a history of past unemployment, and cognitive disturbances affecting nondominant hemisphere function. Although improvement in seizure control is important, this investigation suggests it is only one of many influences on the occupational adjustment of patients following surgical treatment of epilepsy.

Program evaluation in epilepsy rehabilitation

The Vocational Services Program of the University of Washington Regional Epilepsy Center is described, and data relating to the first 106 clients who entered the program are examined. A major emphasis of the study was characteristic differences between those clients later competitively employed and program dropouts. Other study purposes related to examining client satisfaction ratings of different aspects of services and establishing whether a relationship existed between seizure occurrences and job loss. Stepwise discriminant function analysis indicated that "months employed in the last 24" appeared to be the stable discriminator between the employed and dropout groups. The group later employed averaged 12 of the prior 24 months in employment, whereas dropouts approximated 7. Associated psychiatric/addictions treatment was initially a key outcome discriminator, but it did not hold up on cross-validation. Subjects were more satisfied with individualized client services (e.g., counseling sessions) than with group activities (e.g., Job Club). As opposed to seizures, emotional/attitudinal difficulties with this rehabilitation population appeared to be the primary reason for job loss. A work adjustment or job station program can be critical for these individuals and others with neurological impairments. The importance of counselor follow-up after the initial job placement is also underscored. This program, with about half of its clients entering unsubsidized jobs, basically replicated the results of other community-oriented epilepsy rehabilitation programs.

Doctors' perspectives of epilepsy

This study reports the results of a questionnaire designed specifically to define doctors' perspectives of epilepsy. Sixty-two percent of the registered junior medical staff of a major Australian teaching hospital responded to a questionnaire that established information regarding doctor identification, cognition concerning epilepsy and its management, and doctors' attitudes. The results gave evidence of a lack of knowledge regarding epilepsy and its management, as well as a lack of ability to maintain critical evaluation of new material. Many of the negative attitudes about people with epilepsy that have been identified within the general community were also found within the medical profession. This study determined that there is a real need to reappraise the approach to teaching the medical profession about epilepsy.

The stigma of epilepsy as a self-concept

To study the extent to which persons with epilepsy feel stigmatized by the disorder, a sample of 445 individuals with epilepsy is analyzed. By first defining stigma in quantifiable terms and then by assessing the prevalence of stigma among the individuals studied, two alternative models that postulate the causes of stigma are investigated. The first model, a simple medical approach, assumes that because epilepsy is stigmatizing for an individual with the disorder, a direct relationship exists between the severity of the individual's seizure and the perception of stigma. The second model, a sociopsychological approach, assumes that the effects of seizure severity on the perception of stigma are mediated by other individual characteristics. The results of the study suggest, first, that persons with epilepsy do not universally feel stigmatized by the disorder. Second, by investigating the validity of these assumptions with regression and path analysis techniques, the findings support the premise of the sociopsychological model. The relationship between the severity of seizures and the perception of stigma due to the disorder is found to be highly dependent on other characteristics in the individual with epilepsy, such as the perception of employment discrimination, the perception of limitations imposed by the disorder, and the years of school attained by the individual.

Record in grade school of pupils with epilepsy: an epidemiological study

In the area of Cesena, Italy, the prevalence of epilepsy was about 3/1,000 among the 13,000 children of school age, 6-14 years. Only half the epileptic pupils had a normal scholastic record. One-third were in special classes, nearly all because of mental retardation due either to birth injury or to damage in infancy. The others (17%) were behind by one or more classes, mainly because of a depressive reaction owing (in half of the intelligent epileptics) mainly to classmates' fear of seizures and to the hostility of classmates' parents after the pupil had a grand mal seizure in school. Teachers had usually not learned how to manage either seizures in the classroom or the problems of pupils with epilepsy.

Childhood seizures: a 25-year follow up. Social and medical prognosis

Over 200 children from a group of 628 were followed up after 25 years. The children were identified as having had at least one seizure. Particular attention was given to the long-term prognosis in relation to medical, social, and educational problems. Although nearly two-thirds of the sample suffered minimal ill-effects, the problems of the remainder were considerable. 10-1% had died. Of the survivors 11-2% were confined to institutions, and 6-6% were invalids at home. Just under a quarter had chronic epilepsy. While overall the educational achievement of the sample was good, there was also a considerable number of educational problems. Continuing epilepsy was associated with greatly reduced educational and occupational achievement compared with the group in remission. The study reveals the considerable cost of epilepsy to the community in both human and material terms. It also reveals why epilepsy is regarded as a frightening illness.