Childhood-Onset Epilepsy Linked to Lower Educational Attainment

Key Takeaways

• In a Danish nationwide cohort, childhood-onset epilepsy was associated with lower educational achievement from primary school through adulthood than among reference individuals without epilepsy.
• In adjusted analyses of the full cohort, children with childhood-onset epilepsy were more likely than reference individuals without epilepsy to not complete primary school before age 17 years.
• Ninth-grade performance in both mathematics and language was lower among children with childhood-onset epilepsy than among reference individuals without epilepsy.
• Educational attainment beyond primary school remained lower through adulthood, and the disadvantage was greatest in early-onset, complicated, and psychiatrically comorbid epilepsy, although uncomplicated epilepsy also showed lower performance and attainment.

Epilepsy that begins in childhood can shape a student's path well beyond compulsory schooling, but whether that disadvantage persists into vocational and university-level attainment in adulthood has been less clear. In Denmark, linked national registers allow that trajectory to be followed across ages 15 to 35 years within a single healthcare and education setting. Primary school completion, ninth-grade performance, and later educational milestones were the outcomes of interest.

In Epilepsy and education: a nationwide cohort study in the Journal of Neurology, Neurosurgery & Psychiatry, investigators used Danish national registers to assemble a nationwide population-based cohort of 1,195,138 individuals born between 1987 and 2005 and followed through 2023, including 11,758 with childhood-onset epilepsy before age 15 years. Epilepsy was defined as at least 2 hospital epilepsy diagnoses at least 7 days apart, or 1 epilepsy diagnosis plus 1 filled antiseizure medication prescription. Comparisons included reference individuals without epilepsy matched on sex and age and a 1:1 propensity score-matched cohort using perinatal and parental factors. Outcomes were primary school completion before age 17 years, ninth-grade weighted mean grades in mathematics and language, and highest attained educational level from age 15 to 35 years.

Childhood-onset epilepsy was associated with not completing primary school before age 17 years, with an adjusted odds ratio (aOR) of 3.0 (95% CI 2.8 to 3.1). Ninth-grade weighted mean grades were also lower in mathematics, with an adjusted mean difference (aDiff) of −0.9 (95% CI −0.9 to −0.8), and in language, with an aDiff of −0.6 (95% CI −0.6 to −0.5). Lower performance was still seen in uncomplicated epilepsy and was more pronounced in early-onset, complicated, and psychiatrically comorbid epilepsy.

Across adulthood, educational attainment beyond primary school remained lower in the epilepsy cohort, with rates reduced by 50% to 56% across higher educational levels; however, the authors noted that substantially higher mortality before age 35 (5.7% vs 0.7% in the PS-matched cohort) accounted for an important part of the observed attainment gap. By age 35 years, 9.3% of individuals with childhood-onset epilepsy versus 19.5% of the PS-matched reference cohort had attained the highest educational level. Multivariable analyses showed a similar pattern across vocational and higher education pathways, while many people with childhood-onset epilepsy remained at primary-school level into adulthood.

Clinical details that could influence school performance, including seizure frequency, seizure control, and antiseizure medication adherence, were not available in the registers. Final-grade analyses covered only students with recorded examinations, which may understate disadvantage among children in special-needs schooling or those exempted from exams, and psychiatric comorbidity was identified from hospital diagnoses that likely captured more severe cases. For North American readers, the findings come from a Danish system with universally free education and healthcare and may not map directly onto US or Canadian educational pathways; the authors also noted that among those who completed one educational stage, later progression appeared less different.

The authors concluded that childhood-onset epilepsy was associated with lower primary school completion, lower grades, and lower long-term educational attainment in this Danish registry cohort. They interpreted the pattern as educational disadvantage across the life course, while the observational registry design does not establish that epilepsy itself directly caused the differences.

Clinician Questions

How applicable are these Danish registry findings to North American practice settings?

The cohort reflects a Danish system with universally free education and healthcare, so the observed educational associations may not translate directly to US or Canadian school pathways or access to support services. At the same time, the population-based design suggests the signal was not limited to a highly selected referral sample, which makes the findings informative for counseling while still context dependent.

How was childhood-onset epilepsy defined in the Danish education cohort?

In this cohort, childhood-onset epilepsy meant epilepsy beginning before age 15 years and was identified through registers by either at least 2 hospital epilepsy diagnoses recorded at least 7 days apart or 1 epilepsy diagnosis together with 1 filled antiseizure medication prescription.

Which children with epilepsy had the poorest educational outcomes in this cohort?

The worst educational patterns were reported in early-onset epilepsy, complicated epilepsy, and epilepsy with psychiatric comorbidity, with particularly strong negative associations in intellectual disability, autism spectrum disorder, and attention-deficit/hyperactivity disorder. The authors also reported lower performance and attainment in uncomplicated epilepsy, indicating that the disadvantage was not limited to the most clinically complex subgroups.