School performance in a cohort of children with CNS inflammatory demyelination

Abstract

Background

Acute CNS inflammatory demyelination in childhood may induce permanent cognitive impairment. However, there has been no epidemiological assessment of prognostic factors for school performance in a cohort of children with such a disease.

Methods

The cohort consisted of 344 children from the French “KIDSEP” neuropediatric cohort with at least one clinically defined attack of CNS inflammatory demyelination occurring before the age of 16 years, and with at least two years of follow-up (inclusion from 1990 to 2003, follow-up until June 2007). We used multivariate survival analysis (Cox model) to evaluate the prognostic value for grade retention between the start of elementary school (∼6 years of age) and the end of high school (∼17–18 years of age), of variables related to both the socioeconomic status of the parents and the characteristics of the disease at onset.

Results

The cohort was monitored for a mean of 8.0 ± 3.4 years. Grade retention after disease onset was recorded for 151 patients (43.9%). The risk of grade retention was significantly higher for boys, children from families with lower social status and poorer housing conditions, children over the age of 11 years at disease onset and children suffering optic neuritis or brainstem dysfunction at the first attack or irreversible disability, even if only moderate, following the first attack.

Conclusions

The risk factors for poor school performance are related to low socioeconomic status and to factors predictive of a relapsing severe course of the disease, leading to the diagnosis of multiple sclerosis.

Introduction

The prognostic factors for permanent motor disability in acute inflammatory demyelination of the central nervous system (CNS) in childhood have been studied in cohorts, mostly in the subpopulation of patients with multiple sclerosis (MS).1, 2, 3, 4, 5, 6 The following risk factors for a severe outcome (relapse and/or severe disability) were retained from multivariate survival analysis in a cohort of childhood MS: female sex, time between first and second attacks of less than one year, childhood MS MRI criteria at first attack (lesions perpendicular to the long axis of the corpus callosum and/or the presence of only well defined lesions), absence of severe mental state changes at onset, and a progressive course.⁵ Some of these factors were also found by the other authors. Risk factors for relapse, qualifying for MS diagnosis, retained from multivariate survival analysis in a cohort of children with acute CNS inflammatory demyelination were: age at onset of disease ≥ 10 years, MS-suggestive initial MRI, optic nerve lesion, absence of severe mental state changes at onset or of isolated myelitis.⁴ In this study occurrence of severe disability was associated with a polysymptomatic onset, sequelae after the first attack, further relapses, and progressive MS. Several descriptive series of children assessed with batteries of neuropsychological tests confirmed the cognitive impairment in childhood MS.7, 8, 9 Conversely, neither the permanent and long-term cognitive impairment that such disease may induce has been studied epidemiologically, nor the school performances.

Studies on various chronic diseases have reported impaired school performances in children and adolescents with diabetes, asthma or sickle cell anemia.10, 11, 12, 13, 14, 15 In these studies, disorders affecting school performance were mostly assessed by determining the duration of absences from school, academic marks and neuropsychological test results. A low socioeconomic status (SES) and a low level of education of the family were the major predictive factors for disturbed schooling, together with disease burden. Grade retention was found to be a good proxy for school performance in the French educational system.¹⁶ A study of all the countries of the European Union recently showed that a low SES of the family was predictive of poor school performance, as assessed by grade retention, in France.¹⁷ Moreover, grade retention is a validated outcome for the measure and prediction of school performance, both for general population of children and among children with chronic disease, in different countries outside European Union.18, 19, 20, 21, 22, 23

No epidemiological study of school performance in childhood cases of acute inflammatory demyelination of the CNS has been carried out, despite the high probability of learning disorders in such patients, in whom the disease affects the developing CNS. We therefore carried out this study to evaluate the prognostic factors for impaired school performance, taking into account both the SES of the family and the characteristics of the disease at presentation.