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| ORIGINAL ARTICLE |
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| Year : 2016 | Volume
: 53
| Issue : 3 | Page : 188-192 |
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Social skills among epileptic adolescents
Ahmed Osama1, Mohamed Negm1, Amal Zakaria1, Ahmed Salama2
1 Department of Neuropsychiatry, Suez Canal University, Ismailia, Egypt
2 Mansoura International Hospital, Mansoura, Egypt
| Date of Submission | 16-Apr-2015 |
| Date of Acceptance | 02-Jun-2015 |
| Date of Web Publication | 27-Oct-2016 |
Correspondence Address:
Mohamed Negm
Department of Neuropsychiatry, Suez Canal University, Ismailia
Egypt
 Source of Support: None, Conflict of Interest: None  | Check |
Background Epilepsy has been increasingly suspected as a risk factor for psychological, academic, and poor social skills in epileptic adolescents.
Objective The aim of the study was to assess the social skills of epileptic adolescents and compare them with those in nonepileptic healthy adolescents.
Participants and methods The social skills of 86 epileptic adolescents (12–18 years) were compared with those of 86 age-matched and sex-matched healthy adolescents. Social skills were assessed using the Arabic-translated form of the Social Skills Rating System questionnaire – both student form (39 questions) and parent form (52 questions).
Results The mean scores of the ‘student form’ subscales (cooperation, assertion, empathy, and self-control) and the mean scores of the ‘parent form’ subscales (cooperation, assertion, responsibility, self-control, externalizing behavior, and internalizing behavior) were highly significantly lower in epileptic compared with nonepileptic adolescents (P < 0.01). The mean scores of all student form subscales were highly significantly lower in epileptic adolescents with partial seizures with secondary generalization, with generalized tonic clonic seizures, and in those on polytherapy medications (P < 0.01). The mean scores of cooperation, assertion, and empathy of the student form subscales were highly significantly lower in epileptic adolescents with seizure frequency of greater than 4 per year. There was no significant difference in the mean scores of the student form subscales with respect to sex or residence of the epileptic adolescents.
Conclusion Epileptic adolescents have poor social skills that require early assessment and intervention. Keywords: epilepsy, epileptic adolescents, social skills
How to cite this article:
Osama A, Negm M, Zakaria A, Salama A. Social skills among epileptic adolescents. Egypt J Neurol Psychiatry Neurosurg 2016;53:188-92 |
| Introduction | |  |
Epilepsy is one of the most common serious disorders of the brain, affecting about 50 million people worldwide [1]. It has been increasingly recognized as a risk factor for poor social skills in adolescents [2].
Social skills are the individual abilities or characteristics needed to behave competently in social settings [3],[4],[5].
Previously, it had been reported that adolescents with epilepsy have poorer social skills and are less assertive than their siblings [6]. An increased prevalence of poor social competence has been reported in adolescents with epilepsy from preschool to adolescence [7],[8]. Adolescents with epilepsy experience greater social isolation [9],[10] and have more difficulty interacting with peers compared with healthy children [11],[12].
Poor social skills may contribute to adverse long-term psychosocial outcomes in adults with childhood-onset epilepsy [13],[14],[15],[16].
| Aim of the work | | |
The aim of the study was to assess the social skills of epileptic adolescents and compare them with those of nonepileptic healthy adolescents.
| Participants and methods | | |
A case–control study was conducted at the outpatient clinic of the Department of Neuropsychiatry, Suez Canal University Hospital. Study populations were divided into two groups: group 1 (epileptic adolescents) included 86 epileptic adolescents of school age (12–18 years) attending the neuropsychiatry outpatient clinic. Group 2 (nonepileptic adolescents) included 86 healthy school-aged adolescents (12–18 years of age) without known chronic diseases.
The following adolescents were excluded from the study: adolescents with behavioral or psychiatric disturbances, those with chronic medical disease (asthma, diabetes, cardiac disease, and renal disease), those with focal cerebral lesion or cerebral palsy, adolescents with IQ below 70, and nonstudent adolescents.
The diagnosis of epilepsy was confirmed using the standard criteria of two unprovoked seizures[17] or being on antiepileptic drugs (AEDs). The age of onset of seizures ranged from 12 to 18 years, and the duration of seizures ranged from 1 to 10 years.
According to the type of seizures, epileptic adolescents were classified into four groups [18],[19]: partial, partial with secondary generalization, absent, and generalized tonic clonic. When there were multiple seizure types, the most severe type was used as the basis of seizure classification.
According to seizure frequency in the last year, epileptic adolescents were classified into four grades [18],[19]: (a) no seizure in the last year but had at least one seizure the year before; (b) less than four seizures in the last year; (c) four to 26 seizures in the last year; and (d) greater than 26 seizures in the last year.
On the basis of the use of AEDs, epileptic adolescents were classified into two groups [17]: adolescents receiving one AED (monotherapy) and adolescents receiving more than one AED (polytherapy).
The epileptic and control adolescents were subjected to history taking, clinical examination, electroencephalography, and Social Skills Rating System (SSRS) Questionnaire [20], both student form and parent form. The student form consists of 39 questions that measure how often the student exhibits certain social skills. The parent form consists of 52 questions that measure how often the adolescent exhibits certain social skills [20].
Both forms measure cooperation (10 questions in student form and 10 questions in parent form), responsibility (10 questions in parent form), assertion (10 questions in student form and 10 questions in parent form), self-control (10 questions in student form and 10 questions in parent form), empathy (10 questions in student form), and externalizing and internalizing behavior that determines total social skills. Individual subscale scores and a total social skills score were calculated. Individual items were rated from 0 to 2, where 0 indicated poor social skills and 2 indicated higher social skills. The available responses were 0 (never), 1 (sometimes), and 2 (very often). As such domain and facet scores are scaled in a positive direction, with lower scores denoting lower social skills.
The questionnaire was translated into Arabic and a pilot study was conducted to assess the understandability, acceptability, and clarity of its items to the Egyptian population.
Written informed consent was taken from parents of participants and orally from participants. All data are considered confidential and will not be used outside this study without the patient’s approval.
This study was approved by the Ethical Committee of the Faculty of Medicine in Suez Canal University on 30 December 2012.
Statistical analysis
Data were analyzed using the Statistical Package for Social Sciences (SPSS), version 16.0. Tests (IBM, USA, Chicago, Illinois) for statistical significance were performed and P values less than or equal to 0.05 were considered statistically significant (at 95% level of confidence). Descriptive statistics were presented as mean ± SD for quantitative variables and as percentage (%) for qualitative variables. For comparison of means between groups the t-test was used. For relations between qualitative variables, the χ2-test was used.
| Results | | |
This study included 86 epileptic adolescents [47 boys (55%) and 39 girls (45%)]. Their mean age was 15.13 ± 1.39 years. Thirty-three (38%) were from an urban area and 53 (62%) were from a rural area. The control group included 86 adolescents [36 boys (42%) and 50 girls (58%)]. Their mean age was 15.42 ± 1.46 years. Thirty-one (36%) were from an urban area and 55 (64%) were from a rural area. There was no significant difference between the epileptic and control group regarding sex, age, or residence. Of the 86 epileptic adolescents, 14% had absent seizures, 9.3% had partial seizures, 32.6% had partial seizures with secondary generalization, and 44.2% had generalized tonic clonic seizures. Forty-nine percent were on monotherapy and 51% were on polytherapy.
The mean values of the four subscales of the SSRS ‘student form’ were highly significantly lower in epileptic adolescents compared with those in nonepileptic adolescents [Table 1]. The mean values of the six subscales of the SSRS ‘parent form’ were highly significantly lower in epileptic adolescents compared with those in nonepileptic adolescents [Table 2]. | Table 1: The mean and SD of Social Skills Rating System – student form: subscales for epileptic and nonepileptic adolescents
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 | Table 2: The mean and SD of Social Skills Rating System – parent form – subscales for epileptic and nonepileptic adolescents
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No significant difference could be detected in the mean scores of the four student form subscales (cooperation, assertion, empathy, and self-control) between male and female epileptic adolescents. No significant difference was detected in the mean scores of the four student form subscales between urban and rural areas.
The mean scores of cooperation, assertion, empathy, and self-control were highly significantly lower in epileptic adolescents with generalized tonic clonic seizures and in those with partial seizures with secondary generalization compared with epileptic adolescents with absent or partial seizures [Table 3]. | Table 3: The mean and SD of Social Skills Rating System – student form – subscales for epileptic adolescents according to their seizure type
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Epileptic adolescents on polytherapy had highly significantly lower mean scores on the four subscales compared with epileptic adolescents on monotherapy [Table 4]. | Table 4: The mean and SD of Social Skills Rating System – student form – subscales for epileptic adolescents according to type of therapy
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Epileptic adolescents with seizure frequency greater than 4 had highly significantly lower mean scores of cooperation, assertion, and empathy [Table 5]. | Table 5: The mean and SD of Social Skills Rating System – student form – subscales for epileptic adolescents according to seizure frequency
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| Discussion | | |
Epileptic adolescents had poorer social skills compared with nonepileptic adolescents. They had lower scores on all SSRS student and parent form subscales. They were less cooperative and had difficulty in cooperation, including helping others, sharing materials, and complying with rules and directions. They had poor assertion and were less able to ask for information. They were less responsible, less likely to communicate with the elderly, and had poor regard for their property and work. They had poor self-control in behaviors that emerge in conflict situations, such as taking turns and compromising. They had more externalizing behaviors or symptoms of verbal or physical aggression toward others, poor control of temper and proneness to arguing. They had more internalizing problem behaviors, which include anxiety.
In this study the scores of all subscales were highly significantly lower in epileptics compared with those in a study conducted in the USA [21]. This difference could be due to the larger sample size in the current study. Controlling for IQ, socioeconomic status, and seizure variables, Caplan et al.[22] stated that subtle cognitive deficits along with externalizing behaviors were associated with decreased social involvement and low overall social competence. Austin et al.[23] reported an association of social competence deficits with both internalizing and externalizing behaviors in children with chronic epilepsy. Hermann et al.[24] demonstrated an association of poor social competence with neuropsychologic deficits in children with epilepsy. Hamiwka et al.[25] also stated that children with epilepsy were significantly less likely to be identified as a best friend by their classmates.
There was no significant difference in the SSRS subscale in relation to sex and residence, which may reflect that epilepsy-specific factors and comorbidities related to epilepsy are associated with peer difficulties in adolescents with epilepsy. This can be supported by the fact that patients with partial seizures with secondary generalization, those with generalized seizures, patients on polytherapy, and patients who experience more than four seizures per year are significantly less cooperative, less assertive, and less empathic. This comes in agreement with the findings of Caplan et al.[26] who stated that children with epilepsy, particularly those with cryptogenic epilepsy with complex partial seizures, are not competent social communicators. Some studies demonstrate an association with seizure variables [27],[28], whereas others do not [22]. Variability in the findings of these studies might reflect sample differences in terms of size, educational difficulties, and demographic features as well as the inter-relationship between seizure variables.
Curtin and Siegel[29] mentioned that, similar to certain factors in children with chronic illness (social restrictions, illness visibility, being unhappy), epilepsy might interfere with children’s social interactions and time for socializing with peers. In addition, the degree to which a child’s epilepsy is visible to peers may impact a child’s overall social functioning [30].
We can also explain poor skills in our patients by the fact that epileptic patients feel stigmatized by the society and their peers, especially patients with uncontrolled epilepsy. Individuals are stigmatized because they have a feature that is considered undesirable[31] and may subsequently result in their rejection by others [32]. As previously described for chronic illness, the more visible an illness, the more a child is likely to be perceived as dissimilar and the less accepted by his or her peers [29],[30].
These findings suggest that peers’ attitudes and beliefs may create a social atmosphere that contributes to feelings of stigma in the lives of children and adolescents with epilepsy, resulting in decreased social competence and acceptance by peers.
This study does have limitations; first, our participation rates were moderate, resulting in possible selection bias. Second, our groups differed with respect to parental education and socioeconomic status, which may have also influenced our results. Lastly, our study has relied only on parental report. Reports from multiple sources would provide more comprehensive information regarding a child’s social skills.
| Conclusion | | |
Epileptic adolescents have poor social skills when compared with healthy adolescents, which need early assessment and intervention as early identification and intervention before manifestation of chronic symptoms may promote better long-term social outcomes in adolescents with epilepsy.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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