Procedures for working with children with epilepsy in physical education & recreational settings.

Lucas, Matthew D. ; Lynch, Susan E.

Introduction

Literature concerning participation in physical activities including those in physical education and recreation settings for individuals with epilepsy has historically discouraged participation for a number of reasons including the possibility of injury. This trend seems to be changing, and many now suggest that such participation leads to a variety of benefits (Dubow and Kelly, 2003). This paper will hopefully shed some light onto participation in both the physical education and recreational settings for children with epilepsy. It should be remembered that before working with a child with epilepsy the teacher or recreation personnel should request and review a comprehensive medical record of the child. This review should be done for the purpose of determining such issues as the type of seizures the child experiences and the types of medications that are taken by the child--concepts that will be discussed in this paper. In addition, periodic conversations with the child's parents/guardians should be engaged in for the purpose of noting any changes in the child's treatment and/or condition.

Definition of Epilepsy

According to the Epilepsy Foundation of America, epilepsy is "a physical condition that occurs when there is a sudden, brief change in how the brain works" (National Dissemination Center for Children with Disabilities, 2004). When brain cells are not working properly, a person may experience an epileptic seizure in which consciousness, movement, or actions--or a combination of any of the three--may be altered for a short time. This short time span could be for less than a second to a few minutes. It should be noted that individuals with epilepsy often are more likely to experience seizures because of a variety of adverse factors such as fatigue, stress, hunger, and thirst (National Dissemination Center for Children with Disabilities, 2004).

Types of Seizures

Seizures are divided into two broad categories: generalized and partial. Generalized seizures are produced by electrical impulses from throughout the entire brain, whereas partial seizures are produced (at least initially) by electrical impulses in a relatively small part of the brain. The most common types of seizures and their symptoms are listed below in the two respective broad categories.

General ideas in terms of seizures during physical education and recreation

From a general standpoint, individuals should not be restricted from participation in most activities simply as a result of their diagnosis of epilepsy. Seizures during physical activities such as physical education and recreation are rare (Sirven & Varrato, 1999). If physical education teachers and recreation specialists make appropriate modifications, then children with epilepsy often will be able to safely participate. Furthermore, many physical education and recreation activities can assist in alleviating feelings common to children with epilepsy including depression, low self esteem, and dependence (Dubow and Kelly, 2003). This can be done by organizing activities in which the child experiences success. Dubow and Kelly (2003) note the importance of physical activity for individuals with epilepsy as they state that "growing evidence suggests that more patients with epilepsy benefit from regular exercise, while there is little evidence to show physical activity increases seizure frequency or the risk of injury" (p.500).

Legal Guarantee for Physical Education and Recreation Services for Individuals with Epilepsy in the School Setting

The Individuals with Disabilities Education Act (IDEA) is the federal legislation that guarantees education to children with disabilities and defines a variety of disabilities. In order to receive these services the child must meet IDEA's definition of one of the 13 disability categories. If a child between the ages of 3-21 is determined to have a disability as defined by this federal law, the student is entitled to a "free, appropriate, public education" under IDEA. One of the disability categories that is covered by this law is entitled "Other Health Impairment" (OHI). OHI is defined as:

   having limited strength, vitality or alertness, including a
   heightened alertness to environmental stimuli, that results in
   limited alertness with respect to the educational environment,
   that- (i) Is due to chronic or acute health problems such as
   asthma, attention deficit disorder or attention deficit
   hyperactivity disorder, diabetes, epilepsy, a heart condition,
   hemophilia, lead poisoning, leukemia, nephritis, rheumatic fever,
   and sickle cell anemia; and (ii) adversely affects a child's
   educational performance (I.D.E.A., 2004).

The reader will note that epilepsy is included in the description of OHI--if the disorder adversely affects the child's educational performance--and such individuals are thus guaranteed special education services, such as adapted physical education and recreation services under the law. It is also important to note that if the disability does not affect educational performance, as is often the case, than the student is not eligible for special education services under IDEA. However, these students may fall within the protection of Section 504 of the Rehabilitation Act of 1973, and receive special services, if their seizures have a substantial limitation (permanent or temporary) on one or more major life activities--in this case access to learning (Wrightslaw, 2008). One may wonder how a student who is limited from learning and qualifies for services under Section 504 would not also qualify under IDEA. The answer may simply be that the student is not necessarily behind in educational performance, but he/she may be limited in the activities that he/she is allowed to do because of characteristics of his/ her condition, such as the likelihood of seizures. It is important to note that the suggestions given in this paper are for individuals qualifying for the services in either manner.

In terms of physical education, federal law states that "Physical education services, specifically designed if necessary, must be made available to every child with a disability receiving a free, appropriate, public, education" (I.D.E.A., 2004). The law states that physical education is:

   The development of physical and motor fitness, fundamental motor
   skills and patterns, and skills in aquatics, dance, and individual
   and group games and sports (including intramural and lifetime
   sports). This term includes special physical education, adapted
   physical education, movement education, and motor development
   (I.D.E.A., 2004).

In terms of recreation services, IDEA states that an individual may receive such services, in the education setting, as may be required to assist an individual to benefit from special education (IDEA, 2004). According to IDEA (2004), services of recreation therapists include assessment of leisure and function in schools and community agencies. The American Therapeutic Recreation Association states the following in terms of a recreation therapist:

   A recreation therapist utilizes a wide range of activity and
   techniques to improve the physical, cognitive, emotional, social,
   and leisure needs of their clients. Recreation therapists assist
   clients to develop skills, knowledge, and behaviors for daily
   living and community involvement. The therapist works with the
   client and their family to incorporate specific interests and
   community resources into therapy to achieve optimal outcomes that
   transfer to their real life situations (ATRA, 2005, p. 1).

When discussing the characteristics and educational/recreation implications of epilepsy on children in the physical education and the recreation setting from a general standpoint one should note that epilepsy is only loosely correlated to intelligence (Dreisbach, Ballard, Russo, & Shcain, 1982). However, it should be noted that this standpoint is controversial in that that the age of onset of seizures has been suggested as an important predictor of cognitive function in individuals with epilepsy. Studies, including that by Devinsky & Tarulli (2008), note that if the age of onset is earlier, such as when the individual is a child, cognitive function would be affected more than if the individual was an adult. Another factor that may be associated with cognitive function is the duration of the epilepsy. One recent study noted that individuals who have epilepsy for more than thirty years had significantly lower Full-Scale IQ scores than individuals with the disorder for 15 to 30 years (Devinsky & Tarulli, 2008). An interesting point when noting this declining cognition is that cognitive ability, according to this study, would not seem to show much decline in the public school setting as a child who receives special education services is usually not in school for more than 19 years (3 years old--21 years old). This is in contrast to the effects of a cognitive decline over thirty years which would seem to be more of a factor for an individual in the recreation setting later in life.

As noted, studies are not conclusive in terms of the effects of epilepsy on an individual's level of intelligence. However, more importantly, perceived intelligence--functional intelligence--may be affected as individuals with epilepsy often suffer from varying degrees of memory loss or a difficulty remaining focused. These characteristics can be as a direct result of the disorder or a direct result of popular medications that are used to control seizures (Epilepsy Health Center, 2008). This article addresses challenges of working with children in both the physical education and recreational settings and notes the effects of popular medications used to treat epilepsy.

Possible Challenges of Working with Children with Epilepsy in Physical Education and Recreation Settings

A variety of challenges may become evident when working in physical education and recreation settings with children with epilepsy--some of which have been alluded to. These challenges include those related to the anti-epileptic medications used to treat the disorder and those more directly related to the disorder. Specific challenges of working with children with epilepsy in both of these movement settings will be addressed in the following sub-sections. It is to be remembered that the main goal of the teacher should always be to have the child safely and successfully participate in the settings.

Challenges in physical education and recreation settings as a result of medications

Medications used to treat seizures have a variety of side effects. These side effects are common in both older and newer medications. Older medications include Dilantin, Phenytek (phentoin), Tegretol, Carbatrol (carbamazepine), Valium, Klonopin, and Tranxone. Newer medications include Felbatrol (febamate), Gabritil (tigabine), Keppra (levetiracetam), and Lamictal (lamotrigine). Such side effects of the medications that could be of particular concern for children in the physical education and recreation setting include: imbalance, fatigue, dehydration, lethargy, peripheral weakness, drowsiness, dizziness, double or blurred vision, lack of concentration, coordination problems, and aggression (Epilepsy Health Center, 2008). It is important to note that side effects of these medicines may become prominent as a result of the child gaining/loosing weight or other physiological factors.

Specific challenges in physical education and recreation as a result of epilepsy

Specific challenges as a result of epilepsy that may become evident in the physical education and recreation settings include: (1) safety of the child, (2) difficulty in determining which activities need to be modified for the child as a result of safety concerns, and if so, actually modifying the activities, (3) difficulty getting attention of children with epilepsy, and (4) possible behavior problems and solutions for individuals with epilepsy. Possible solutions to these challenges will be addressed in the following section.

Possible Solutions to Specific Challenges of Working with Children with Epilepsy in Physical Education and Recreation Settings

Before discussing solutions to challenges of working with children with epilepsy it should be stressed that in terms of these children, the possibility of feeling imbalanced, fatigued, lethargic, drowsy, dizzy, or because of double vision, exhibiting lack of concentration and coordination problems usually exists.

Safety of children with epilepsy

Safety of all children is the most important consideration for physical education teachers and recreation leaders to remember when working with children in the physical education and recreation settings. Parents expect that their children will be in a safe environment when they are in these settings and courts have consistently upheld this belief. In terms of the safety of children with epilepsy in the physical education and recreation settings, important considerations to remember include the possibility of the child falling from apparatuses such as from climbing walls and off of balance beams. Thus, these participants should be spotted at all times or be given alternative activities in which to participate that address the same goals of the original activity. As an example of an alternate activity, if a child is not allowed to walk on a balance beam because of a possibility that she may fall, the individual can practice balancing an object such as a beanbag on his/her head. This of course is not working on the same goal as the other children but it is closely related to the activity in which the other children will be participating. Such an alternative activity would be a sound educational practice for the purposes of having a child understand how to balance and learn concepts related to balance. Children without epilepsy should also be given a chance to practice such an alternative activity so as to remove a negative stigma for the child with epilepsy because of isolationism. An opportune time for the children without seizures to practice the alternative activity would be while waiting for their turn on the balance beam. Conventional wisdom would suggest that the more children that are participating in the alternative activity, the better the chance of removing feelings of isolationism for the child with epilepsy.

Also, in terms of the safety of individuals with epilepsy, because of effects of the disorder and the effects of medication used to treat epilepsy, it is possible to have a reduced attention span which may cause the children to be unaware of objects such as balls that may strike them. As a result of this reduced attention span, and the potential problems associated with safety, children with epilepsy should be strategically placed in the physical education and recreation setting to reduce the risk of harm and should be assisted by an adult if the possibility of harm still exists. As an example these individuals should not be allowed to play goalie in a soccer game because of the chance of loosing awareness and being struck by a ball that is intentionally being kicked toward them at a fast pace. Other safety issues include those children who display "drop seizures" and thus may fall to the ground without notice. Because of this, children that have a history of drop seizures should wear protective head equipment such as bicycle helmets, baseball helmets, elbow pads, and kneepads.

Difficulty in determining which activities need to be modified as a result of safety concerns, and if so, actually modifying the activities

If a physical education teacher or a recreation leader is uncertain about whether an activity should be modified because of the safety of the child, it is always important to err on the side of caution and keep in mind the ideas discussed previously. Activities that definitely need to be modified because of safety include those in which children are elevated to a high point such as climbing ropes and climbing walls because of the possibility of falling and swimming because of the possibility of drowning. Also, because of possible side effects of seizure medications, such as a decrease attention level, activities that could possibly cause a blow to the head should always be avoided (Winnick, 2005). Such activities could possibly include those in that more than a few balls are being thrown, kicked, or struck.

In addition to the previously mentioned modifications, it should be emphasized that children with epilepsy should not be forced to participate in activities that may cause an undue amount of stress. As mentioned earlier, such stress has been shown to contribute to a variety of problems such as seizures for some individuals with epilepsy. It is also important to note that individuals with seizure disorders, as should all individuals, always be allowed to remain hydrated during physical activities.

Difficulty getting attention of children for instructional purposes

As mentioned previously, one of the most common side effects of medication used to treat epilepsy is a decrease in the attention level of the children. This has been shown to be a problem for some individuals with epilepsy. Before discussing possible methods of getting the attention of children with epilepsy in the physical education and recreation setting, it should first be remembered that like many individuals with diverse conditions, children with epilepsy are usually not intentionally ignoring the teacher/recreation leader and their behaviors in this respect should not be viewed as being defiant by physical education teachers and recreation leaders. The incredible dosages of medication these individuals are subject to taking often make it difficult to "pay attention".

Possible solutions for physical education teachers and recreation leaders in terms of getting attention of children for instructional purposes should include using a variety of cues to allow the children to become focused. Such instructional cues should include visual cues, verbal cues, and physical assistance. More desirably, a combination of these three methods of cueing should be used as they will hopefully better allow the child with epilepsy to become focused, listen to directions, and remain focused. The physical education teacher or recreation leader should also remember that at particular times the child with epilepsy may not easily be able to participate--because of a variety of factors such as problems with medicine and fatigue--and should be allowed to rest until he/ she can more easily participate.

In addition to the three instructional cues that should be used to gain the attention of the child during the activity, proximity control should also be used as a method to gain attention. Proximity control involves the physical education teacher and recreation leader staying within a close location to the child during the activity--a physical cue. This method could enable the child with epilepsy to remain more alert especially when combined with verbal and visual reminders to do so. The physical education teacher and recreation leader staying in close proximity during the activity also more easily enables the physical education teacher and recreation leader to provide physical assistance for the child when appropriate.

Possible behavior problems and solutions for individuals with epilepsy

One item that has not been discussed much to this point deals with possible behavior problems of children with epilepsy. Before discussing this issue further, the reader should be reminded of the earlier point noting the possibility of teachers and recreation leaders incorrectly viewing some behaviors as defiant when they are actually related to problems with the individual paying attention. Dunn and Austin (2002) do note, however, that childhood epilepsy is of particular concern to psychiatrists because of a frequency associated with behavioral problems. A factor leading to these behavior problems may include the fact noted by Spangenberg and Lalkhen (2006) "that children with epilepsy are often overwhelmed by feelings of embarrassment, frustration and helplessness and display resultant fearfulness, dependence and demanding behaviour" (p.206). Other factors that have been shown to be suggestive of behavior problems for children with epilepsy include types of medications, underlying neurological disorder for the child, family environment, parenting behaviors, and the presence of significant cognitive problems (Sabbagh et al., 2006). It is believed that if the teacher and therapists remember the main goal of having the child safely and successfully participate in the settings, many behavior problems will naturally be alleviated. Such success can reduce feelings of embarrassment, frustration, and helplessness. Of course, this will not alleviate all improper behaviors because of such factors as underlying neurological disorders and the presence of cognitive difficulties, but it will undoubtedly be a step in the right direction.

Conclusion

It is to be remembered that children should not be restricted in participation in many activities in the physical education and recreation settings simply as a result of their diagnosis of epilepsy. However, working with individuals with epilepsy can often be challenging for the physical education teacher and recreational leader. These difficulties can manifest themselves in the safety of the child, in the difficulty in determining which activities need to be modified, and if so, actually modifying activities because of the possibility of safety concerns, and in the difficulty in getting attention of children for instructional purposes.

A variety of simple modifications can be made for children with epilepsy in physical education and the recreational setting for the benefit of the child. These modifications include wearing protective head equipment such as bicycle helmets, elbow pads, and knee pads. In addition, individuals should remain hydrated and should avoid being placed in elevated situations. Modifications for these children should also always include assessing an individual's level of fatigue, possible sleep deprivation, and double/ blurred vision, and avoiding or modifying the level of activity intensity when appropriate.

Modifications to instruction for the purpose of addressing a decrease in the attention level of the children include using a variety of cues to more easily allow the individual to become focused. Such cues should include visual cues, verbal cues, and physical assistance.

This paper has hopefully addressed basic solutions for the physical education teacher and recreation leader in order to improve the education of children with epilepsy in the physical education setting as well as their quality of participation in the recreation setting. It is, once again, also important to reiterate the importance of safety for all students in the physical education setting and participants in the recreation setting and especially as it applies to children that are more susceptible to injury such as children with epilepsy.

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REFERENCES

American Therapeutic Recreation Association (ATRA). (2005). Frequently asked questions about therapeutic recreation. Retrieved June 13, 2008, from http://www.atra-tr.org/aboutfaq.tm

Devinski, O. & Tarulli, A. (2008). Age, frequency, and educational intervention for children with epilepsy: Retrieved May 7, 2008, from http://professionals.epilepsy.com

Dreisbach, M., Ballard, M., Russo, D.C., & Shcain, R.J. (1982). Educational intervention for children with epilepsy: A challenge for collaborative service delivery. Journal of Special Education, 16(1), 111-121.

Dubow, J. & Kelly, J. (2003. Epilepsy in sports and recreation. Sports Medicine. 33 (7), 499-516.

Dunn, D. & Austin, J. (2002). Behavioral issues in pediatric epilepsy. Psychiatric Times, 9, 25.

Epilepsy Health Center. (2008). WebMD Medical reference in collaboration with the Cleveland Clinic: Epilepsy: Medications to treat seizures. Retrieved April 9, 2008, from http://www. webmd.com/epilepsy/medications-treat-seizures

Epilepsy Guide. (2008). Epilepsy: Types of seizures. Retrieved June 14, 2008, from http://www.webmd.com/epilepsy/guide/ types-of-seizures-their-symptoms Individuals with Disabilities Education Act (I.D.E.A.), Pub. L. No. 108-466 (2004).

National Dissemination Center for Children with Disabilities. (2004). Epilepsy. Retrieved April 9, 2008, from http://www. nichcy.org/pubs/factshe/fs6txt.htm

Sabbagh, S., Soria, C., Escolano, S., Bulteau, C. & Dellatolas, G. (2006). Impact of epilepsy characteristics and behavioral problems on school placement in children. ScienceDirect, 9, 573-578.

Sirven, J. & Varrato, J. (1999). Physical Activity and Epilepsy. What are the Rules? Physician and SportsMedicine, 27, 3, 63-64, 67-69.

Spangenberg, J. & Lalkhen, N. (2006). Children with epilepsy and their families: Psychosocial issues. SA Fam Pract, 48(6), 60-63.

Winnick, J. (2005). Adapted Physical Education and Sport. (4th Ed). Champaign, IL: Human Kinetics.

Wrightslaw. (2008). What Is the Difference Between Section 504 and IDEA?. Retrieved June 15, 2008, from http://www.wrightslaw. com/advoc/articles/504_IDEA_Rosenfeld.html

Matthew D. Lucas, Ed.D., C.A.P.E., Assistant Professor--Longwood University

Susan E. Lynch, Ph.D., C.T.R.S., Associate Professor--Longwood University

Generalized Seizures                     Symptoms
(Produced by the entire brain)

1. "Grand Mal" or Generalized            Unconsciousness, convulsions
  tonic-clonic                             muscle rigidity
2. Absence                               Brief loss of consciousness
3. Myoclonic                             sporadic (isolated), jerking
                                           movements
4. Clonic                                Repetitive, jerking movements
5. Tonic                                 Muscle stiffness, rigidity
6. Atonic                                Loss of muscle tone

(Epilepsy Guide, 2008)

Partial Seizures                         Symptoms
(Produced by a small area of the
brain)

1. Simple (awareness is retained)

a. Simple Motor                          a. Jerking, muscle rigidity,
                                           spasms, head-turning
b. Simple Sensory                        b. Unusual sensations
                                           affecting either the
                                           vision, hearing, smell,
                                           taste or touch
c. Simple Psychological                  c. Memory or emotional
                                           disturbances

2. Complex (Impairment of awareness)     Automatisms such as lip
                                           smacking, chewing,
                                           fidgeting, walking and
                                           other repetitive,
                                           involuntary but coordinated
                                           movements.
3. Partial seizure with secondary        Symptoms that are initially
  generalization                           associated with a
                                           preservation of
                                           consciousness that then
                                           evolves into a loss of
                                           consciousness and
                                           convulsions.

(Epilepsy Guide, 2008)