Neuropsychology Review

https://doi.org/10.1007/s11065-021-09491-7

REVIEW

Working Memory in Pediatric Epilepsy: A Systematic Review

and Meta‑Analysis
Belinda J. Poole1,2 · Natalie L. Phillips1,2 · Elizabeth Stewart1,2 · Irina M. Harris1 · Suncica Lah1,2

Received: 20 August 2019 / Accepted: 21 February 2021

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021

Abstract
Working memory is a multicomponent system that is supported by overlapping specialized networks in the brain. Baddeley’s
working memory model includes four components: the phonological loop, visuo-spatial sketchpad, the central executive,
and episodic buffer. The aim of this review was to establish the gravity and pattern of working memory deficits in pediatric
epilepsy. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guided electronic
searches. Sixty-five studies were included in the review. Meta-analyses revealed significant impairments across each working
memory component: phonological loop (g = 0.739), visuo-spatial sketchpad (g = 0.521), and central executive (g = 0.560)
in children with epilepsy compared to controls. The episodic buffer was not examined. The pattern of impairments, however,
differed according to the site and side of seizure focus. This suggests that working memory components are differentially
vulnerable to the location of seizure focus in the developing brain.

Keywords Working memory · Epilepsy · Academics · Pediatric · Phonological Loop · Visuospatial Sketchpad · Central
Executive

Introduction pattern of brain activation for each working memory com-

Working memory is a limited-capacity system that tem-
porarily processes, manipulates and stores information in
mind (Baddeley, 1996a). The traditional working memory
model by Baddeley and Hitch (1974), was comprised of
three components: two temporary storage systems known
as the phonological loop and visuo-spatial sketchpad, which
are coordinated by the central executive, which processes
and manipulates information. In 2000, Baddeley added the
fourth component to the model: the episodic buffer, which
binds episodic and semantic information into integrated
chunks.
Working memory components rely on a set of overlap-
ping, yet specialized and distributed brain networks that have
particular reliance on frontal lobe regions (see D’Esposito,
2007 for a review). Neuroimaging studies indicate that the
* Suncica Lah
suncica.lah@sydney.edu.au
1
School of Psychology, University of Sydney, Sydney,
NSW 2006, Australia
2
ARC Centre of Excellence in Cognition and its Disorders,
Macquarie University, Sydney, NSW 2109, Australia
ponent changes over development, with different patterns
identified for children, adolescents and adults with more
complex working memory tasks, such as those that require
the manipulation of information in mind (Tau & Peterson,
2010). It is proposed that the neural circuits that support
working memory have prolonged maturation, with the larg-
est gains occurring between 5 to 19 years of age (Alloway
& Alloway, 2013; Gathercole et al., 2004). This is consistent
with the protracted development of the dorsolateral prefron-
tal cortex that matures by adulthood (Gibb & Kolb, 2015;
Teffer & Semendeferi, 2012). Thus, for complex working
memory tasks, the networks have refined by early adulthood,
which allows for improved working memory capacity (Tau
& Peterson, 2010).
Research has shown that working memory components
have different functions and rely on different neural networks
in the brain (D’Esposito, 2007; Baddeley, 1996a). The pho-
nological loop temporarily holds speech and acoustic based
information, which decays after two to three seconds without
rehearsal. This storage component is important for articu-
lation and rehearsal of verbal material (Baddeley, 1996b),
and for language acquisition (Baddeley, 2003). For typically
developing children, the phonological loop is important for

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long term phonological learning, vocabulary learning, early
reading skills, and general math skills (Baddeley, 2012;
Friso-van den Bos et al., 2013; Passolunghi et al., 2007). In
neuroimaging studies, the neural networks that have been
implicated in the phonological loop are the sensorimotor cir-
cuit located in the language dominant left hemisphere of the
brain, and the inferior parietal lobe and Broca’s area (Aboitiz
et al., 2010; Smith & Jonides, 1997). The phonological loop
also relies on the posterior temporal region and ventrolateral
prefrontal cortex (Aboitiz et al., 2010).
The visuo-spatial sketchpad is considered the visual-spatial
equivalent of the phonological loop, which can temporarily
hold approximately three or four objects in mind (Baddeley,
1996a; Baddeley, 2003). The visuo-spatial sketchpad is impor-
tant for spatial orientation and geographical knowledge, as it
is involved in knowing how to use and manipulate objects in
space (Baddeley, 2003). The visuo-spatial sketchpad has also
been implicated in early mathematical skills, such as number
writing and symbolic magnitude comparisons (Friso-van den
Bos et al., 2013; Simmons et al., 2012). In neuroimaging stud-
ies, the visuo-spatial sketchpad has been found to recruit neu-
ral networks in the right hemisphere, with activation occurring
in the inferior frontal region, occipital and superior parietal
cortex in response to spatial-based tasks, and in the inferior
temporal cortex in response to object-based tasks (Nagel et al.,
2013; Smith & Jonides, 1997; Wager & Smith, 2003).
The central executive is a domain-general component that
is involved in the attentional control over working memory
processes. This attentional control involves focusing, dividing
and switching attention and also integrates working memory
with long term memory stores (Baddeley, 2003). The central
executive is proposed to have the largest impact on general
cognition (Baddeley, 1996b) and is related to general intel-
ligence (Conway et al., 2003). Studies have also found that
mathematical skills, such as simple arithmetic and problem
solving accuracy, are supported by the central executive, in
combination with other working memory components such
as the phonological loop and visuo-spatial sketchpad (Cragg
et al., 2017; Friso-van den Bos et al., 2013; Peng et al., 2016;
Raghubar et al., 2010; Simmons et al., 2012; Swanson &
Fung, 2016). Neuroimaging findings suggest that the cen-
tral executive is dependent on the dorsolateral prefrontal
cortex and the parietal cortex (Curtis & D’Esposito, 2003;
D’Esposito, 2007).
The most recent addition to the working memory model is
the episodic buffer, which binds episodic and semantic infor-
mation into integrated chunks (Baddeley, 2000). The episodic
buffer is important for linking the components of working
memory to perception and long-term memory (Baddeley,
2012). However, the episodic buffer is the least studied and
least understood component of working memory, due to a lack
of consensus with the conceptualization of this process (de
Pontes Nobre et al., 2013). Nonetheless, the episodic buffer is
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Neuropsychology Review
thought to be an additional storage component that is coordi-
nated by the central executive (Baddeley, 2000). Neuroimaging
studies have found that the episodic buffer activates anterior
and posterior regions of the brain, with the right prefrontal
cortex important for integrating verbal and spatial information
(Baddeley, 2000; Prabhakaran, Narayanan, Zhao, & Gabriel,
2000).
Working Memory in Epilepsy
Epilepsy is characterized by recurrent unprovoked seizures
or epileptic discharges (Fisher et al., 2014). Working mem-
ory deficits are common in children with epilepsy (Elger
et al., 2004). Working memory deficits in children with epi-
lepsy may be related to seizures themselves, but also to the
location of pathology or seizure focus. Seizures themselves
are likely to corrupt or wipe out information from working
memory, as information is held in working memory only
temporarily, making it extremely vulnerable to disruption.
In addition, over time, recurrent seizures may interfere with
the structural development and functional organization of
the brain (Badawy et al., 2012; Vingerhoets, 2006). In turn,
the cumulative effect of recurrent seizures may interfere with
maturation of brain networks that support working memory,
and reduce working memory capacity. Higher frequency of
seizures, longer duration of seizure disorder, and an ear-
lier age of seizure onset, which have been associated with
an increased risk of cognitive difficulties in children with
epilepsy (Vingerhoets, 2006), may also be associated with
working memory deficits.
Seizures can be generalized or focal, and can also be
associated with other symptoms that form an epilepsy syn-
drome, such as benign epilepsy with centro-temporal spikes
(BECTS; Berg et al., 2010; Fisher et al., 2014; Scheffer et al.,
2017). Generalized seizures arise simultaneously in both
hemispheres (Helmstaedter & Witt, 2012; Mattson, 2003).
As such, these seizures are likely to disrupt all components
of working memory. A meta-analysis examining cognitive
functioning in children and adults with generalized epilepsy
found moderate to large impairments in working memory,
suggesting that working memory overall is vulnerable to
generalized seizures (Loughman et al., 2014). The impact of
generalized seizures on each component of working mem-
ory, however, was not examined in that meta-analysis. Focal
seizures, on the other hand, emanate from a particular site
(i.e. temporal, frontal) within one hemisphere of the brain
(Helmstaedter & Witt, 2012). Hence, the impact of focal
seizures on working memory could be selective, and might
involve one component of working memory, while sparing
the other components. For instance, left temporal lobe epi-
lepsy may result in greater disruption in phonological loop
capacity compared to right temporal lobe epilepsy, due to the
reliance of phonological loop networks on the left temporal
Neuropsychology Review
regions of the brain (Aboitiz et al., 2010). Among patients
with frontal lobe epilepsy, it might be expected that the cen-
tral executive would have the greatest impairment across
epilepsy subtypes, due to the reliance of the central execu-
tive on the dorsolateral prefrontal cortex (Baddeley, 1996b).
However, due to the overlap of neural networks that sup-
ports working memory, and the spread of focal seizures to
other brain regions, it is possible that multiple components
of working memory might be disrupted by the presence of
focal seizures, especially as children activate diffuse rather
than specialized brain networks when performing working
memory tasks (Tau & Peterson, 2010).
Working memory deficits in children and adolescents
with epilepsy may have significant functional implications.
Research has shown that children with epilepsy have perva-
sive difficulties in academic skills, particularly in mathematics
(Black & Hynd, 1995; Jackson et al., 2013; Rathouz et al.,
2014; Seidenberg et al., 1986). Two studies that have exam-
ined academic correlates of working memory deficits in chil-
dren with epilepsy found that working memory was related
to academic problems in a mixed group of epilepsy cases
(Danguecan & Smith, 2017; Fastenau et al., 2004). Fastenau
et al. (2004) used a composite measure of working memory
and executive functions, which included processing speed and
cognitive flexibility, and found that impairments in this
composite score were associated with deficits in reading, writ-
ing and mathematical performance in children with epilepsy.
This finding is consistent with Danguecan and Smith (2017),
who found an association between higher seizure status (the
presence of seizures in the past 12 months) and poor verbal
working memory capacity (comprised of phonological loop
and central executive tasks), which in turn, predicted poor
academic skills. These studies suggest that working memory
difficulties relate to low academic outcomes in children with
epilepsy, including those with focal and generalized seizures.
These results are consistent with research on typically devel-
oping children, which suggests that working memory deficits
are related to academic problems (Gathercole et al., 2016).
However, no studies have systematically examined whether
each component of working memory is differentially impaired
in children with different types of epilepsy, and whether
the site or side of seizure focus in children with focal seizures
plays a role in the pattern of working memory deficits. These
findings could assist in differential diagnosis, enable early
identification of children at risk, fine-tune neuropsychological
management of children with epilepsy and ameliorate associ-
ated functional difficulties.
The primary aim of this review is to determine whether
working memory components are impaired in children
and adolescents with epilepsy. The secondary aim of this
review is to determine whether working memory compo-
nents are differentially impacted by site or side of epi-
lepsy. The final aim is to evaluate whether the pattern
and severity of working memory deficits are related to
(i) demographic factors such as the age at testing, and
(ii) other epilepsy factors such as the age of onset of sei-
zure disorder, duration of epilepsy, seizure frequency,
medication, and surgical status. Furthermore, we aimed
to determine relations between working memory and (i)
neuroimaging results, and (ii) functional deficits (espe-
cially academic difficulties) in children and adolescents
with epilepsy.
Method
Protocol Registration
The systematic review protocol was registered with the
International Prospective Register of Systematic Reviews
(PROSPERO; registration number CRD42016053012). The
Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) statement and guidelines were used to
conduct searches, guide data extraction, summarize evidence
and report results (Moher et al., 2009).
Search Strategies
Databases including PsychInfo, MEDLINE and EMBASE
were searched via OvidSP to identify eligible studies. The
last search was conducted on the 1­ 4th of July 2020. The fol-
lowing search terms were used [(exp. Epilepsy) AND (exp.
working memory OR exp. Short Term Memory)] and all
search terms were exploded. Studies were limited to those
that included children (0 to 18 years old), human partici-
pants, and were published in peer-reviewed journals in the
English language. The ancestry method was used to examine
reference lists of eligible empirical papers and also relevant
reviews, which were searched to identify additional studies
for inclusion. Full text articles of additional studies that were
identified from reviews and ancestry search were evaluated
against inclusion/exclusion criteria.
Study Selection Criteria
Studies were included if they:
(i) reported original empirical research,
(ii) included patients with a diagnosis of epilepsy
(including epilepsy syndromes) irrespective of
comorbidities or pre-existing conditions, such as
learning difficulties or attention-deficit/hyperactiv-
ity disorder (ADHD),
(iii) included children and adolescents between 0 to 18
years of age,
13

(iv) used a standardized psychometric instrument or
an experimental working memory task to conduct
an objective assessment of at least one compo-
nent of Baddeley’s (2000) working memory model
(i.e., phonological loop, visuo-spatial sketchpad,
central executive, or episodic buffer). When a
composite score was reported for a set of tasks
that measured different components of working
memory (i.e., the Digit Span subtest or the Work-
ing Memory Index Score from various versions of
Weschler Intelligence Tests), authors were con-
tacted to provide scores for each working memory
component separately,
(v) reported working memory, raw or scaled, scores
obtained by children with epilepsy and a neurologi-
cally healthy control group, or scaled scores obtained
from normative data of a standardized test battery,
(vi) were published in peer-reviewed journals in the Eng-
lish language.
Studies were excluded if they:
(i) were review papers or single case studies,
(ii) were dissertations, abstracts, or conference presenta-
tions,
(iii) did not report or provide data on the separate scores
of distinct working memory components,
(iv) had overlapping participant samples with previous
published studies,
(v) provided composite working memory scores (i.e.
a score that involved more than one component of
working memory) rather than scores for each work-
ing memory component separately, and either indi-
cated that they were not able to provide the requested
data, or did not respond to two e-mails sent two
weeks apart within four weeks of the first e-mail,
(vi) used a task that involved working memory but relied
to a large extent on other cognitive abilities (i.e.,
fluid reasoning and verbal comprehension, semantic
knowledge, or solving word-based problems), such
as the Arithmetic subtest from one of the Weschler
Intelligence scales or the Picture Span subtest from
the Weschler Intelligence Scale for Children, 5­ th edi-
tion (WISC-V; Weschsler, 2014; Saklofske, Weiss,
Prifitera, & Holdnack, 2015),
(vii) did not provide a working memory score (raw or
scaled) for number of correct responses (i.e., reported
reaction times, or omission or commission errors
instead),
(viii) employed a subjective measure of working memory,
such as various questionnaires.
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Neuropsychology Review
Selection
The titles and abstracts were assessed against inclusion
criteria by two reviewers (BP and NP or SL). If there was
insufficient information in the title and abstract to determine
whether the study met inclusion and exclusion criteria, or if
the two raters disagreed, the full text article was obtained.
Studies that clearly did not meet inclusion and exclusion
criteria according to both raters were not reviewed at the
full-text stage. Two reviewers (BP and NP or SL) assessed
all full text articles against inclusion criteria and the final
decision was determined by consensus.
Data Items and Summary Measures
For each eligible article, the following data were extracted
(i) descriptive statistics of age at testing, sample size of epi-
lepsy and control groups, and (ii) relevant epilepsy variables
(if reported) epilepsy diagnosis or site of seizure focus, age
of seizure onset, and duration of seizures. Data relevant to
outcome were also extracted from eligible articles (i) work-
ing memory task and test scores (either as means or standard
deviations, standard scores, or t-values and p-values), (ii)
any academic measures (math, reading or writing), and (iii)
neuroimaging findings if conducted.
Each working memory tasks was classified by two authors
(BP and NP; or BP and SL) according to the pre-determined
criteria. Any disagreement in classification was discussed
until a consensus was reached. The classification of tasks
was guided by previously published meta-analyses on work-
ing memory (e.g. Phillips et al., 2015; Peng et al., 2016) and
descriptions of tasks provided by Henson (2001), which
referred to the original working memory model, and descrip-
tions of tasks for the episodic buffer provided by de Pontes
Nobre et al. (2013). Henson pointed out that the WM model
differentiates between i) verbal or visuospatial information,
ii) passive and temporary storage of information or active
rehearsal, and iii) maintenance and manipulation of infor-
mation in mind. Tasks that measure the phonological loop
and visuo-spatial sketchpad include simple span tasks that
require passive storage and immediate recall of verbal or
visuo-spatial material in a serial manner. Examples of these
tasks in standardized assessment batteries include verbal digit
and word span tasks that measure the phonological loop, or
visuo-spatial block span tasks that measure the visuo-spatial
sketchpad. Another measure of phonological loop relates to
item recognition tasks (such as the Sternberg item recogni-
tion test) that taps into three processes – encoding, rehearsal
and retrieval of material. The task involves presenting items
to encode, followed by a delay period and probe. Measures of
the central executive can tap into different processes, such as
Neuropsychology Review
the storage and manipulation of information in either verbal
of visuo-spatial span tasks. Examples include transformation
span such as digit or visuo-spatial span recalled backwards or
in a set sequence. These span tasks can be used to measure
central executive, as they involve switching between storage,
processing, and retrieving the material in a serial order. Mon-
itoring tasks such as the n-back task are a non-span measure
of central executive and require monitoring and updating
material, whilst inhibiting responses that are incorrect. Self-
ordered pointing tasks are a generation-based non-span task
of central executive that require monitoring and updating
information, whilst generating choices. Dual-tasks include
coordinating and switching between concurrent tasks, which
has a strong demand on working memory capacity. Finally,
tasks that measure the episodic buffer are argued to recruit
processes in binding and chunking information, such as a
sentence recall task (de Pontes Nobre et al., 2013).
Quality Analysis
The Newcastle-Ottawa Scale (NOS; Wells et al., 2000) was
used to determine the quality of each study by two inde-
pendent reviewers (BP and NP). The NOS has been recom-
mended by the Cochrane collaboration to assess the quality
and risk of bias in observational studies and non-randomized
studies (Higgins & Green, 2011). The NOS uses a star sys-
tem to evaluate the quality of each paper, with a total score
between 0 to 9 stars. A greater number of stars indicates
better quality. The NOS assesses for the least risk of bias
across three domains: selection, comparability, and outcome.
One star was allocated for each of the following criteria
for Selection (i) defined cases of epilepsy diagnosis using
more than one source or record (e.g. neurologist assessment,
electroencephalography (EEG), magnetic resonance imag-
ing (MRI), or other neuroimaging findings), (ii) recruited
epilepsy cases from consecutive referrals or referrals that
are representative of the sample, (iii) selection of controls
described either from the community or the same com-
munity as cases (e.g., hospital or school controls), and (iv)
defined controls as being neurologically healthy, or with no
history of epilepsy or seizures. A maximum of 4 stars could
be awarded for Selection. In some studies, no control group
was used as a comparison, thus for Selection a maximum of
two stars was awarded for (i) adequate definition of epilepsy
diagnosis, and (ii) representativeness of sample.
One star was allocated for each of the following criteria
for Comparability (i) study controlled for age at test, and (ii)
study controlled for any other factor with a maximum of two
stars awarded for Comparability. Studies that only matched
age received one star for comparability. In some studies,
no comparison or second epilepsy comparison group was
utilised, thus these studies received an NA (not applicable)
for this category.
One star was allocated for each of the following criteria for
Outcome (i) ascertainment of outcome measuring at least one
of the four working memory components, using a validated
measure or described in enough detail to be replicated, (ii)
used the same method of measuring working memory for
cases and controls, and (iii) same non-response rate reported
for cases and controls with a maximum of three stars awarded
for Outcome. Studies that did not have a control group or
second epilepsy comparison group could only be awarded a
maximum of one star for this category (i) ascertainment of
outcome measuring one working memory component.
Data Analysis
Data was analyzed using the Comprehensive Meta-Analysis
(CMA) software, version 3.3.070 (Borenstein et al., 2014).
The standardized mean difference in working memory test
scores between epilepsy and control groups was measured
using Hedges’ g, as it corrects for biases in small samples
that can lead to an overestimation of standardized mean dif-
ferences (Borenstein, 2009). Effect sizes were interpreted
as small (0.2), moderate (0.5) and large (0.8) consistent
with interpreting Cohen’s d (Cohen, 1988; Perdices, 2018).
Negative effect sizes indicated poorer performance in the
epilepsy group relative to control. A random effects model
was used for the meta-analysis and a two-tailed signifi-
cance level of p < .05 was used for all analyses. Heteroge-
neity of working memory outcomes between studies was
examined using the Q statistic, Tau squared ­(T2), and the
I2 statistic. I2 values of 25% is categorized as low, 50% is
moderate, and 75% is high (Higgins & Thompson, 2002).
Variation in effect size across studies is reported using pre-
diction intervals (Borenstein et al., 2017).
The primary analyses examined each working memory
component as a function of epilepsy type (i) focal,
namely, temporal lobe epilepsy [TLE], which was also sub-
divided according to side of TLE (i.e., TLE in the left hemi-
sphere, right hemisphere, and also bilateral hemispheres,
which included studies that reported working memory
results for bilateral BECTS), frontal lobe epilepsy [FLE],
and focal epilepsies outside the frontal-temporal lobes
[Extra-FLE/TLE], (ii) generalized, namely, genetic gen-
eralized epilepsy [GGE] previously known as idiopathic
generalized epilepsy [IGE], and (iii) for all other epilepsy
types and syndromes combined (pooled group). The analy-
ses for the pooled group was not pre-specified or planned in
the pre-registration. This review included an effect size for
the phonological loop, visuo-spatial sketchpad and central
executive across epilepsy groups due to the large number of
studies that included samples of mixed epilepsy types and
13

syndromes. This analysis was reported first in the results
section, as it was more suitable to the presentation of the
results, followed by subgroup analyses for the site and side
of epilepsy.
If studies reported more than one measure of a working
memory component, an average effect size was calculated.
For studies that had more than one epilepsy group, but only
had one control group or normative data sample, the number
of participants in the control group or normative data sample
was divided evenly across each epilepsy group to ensure that
the analyses were not over-inflated. For studies that had data
replicated across different publications, the initial study was
used in the analyses.
Meta-regressions were conducted for continuous modera-
tor variables, including age at testing, age of onset, and dura-
tion of seizure disorder. Funnel plots and Egger’s regression
test were used to assess publication bias (Egger et al., 1997)
with significant results (p <.05) indicating asymmetry is pre-
sent with the studies. Duval and Tweedie’s (2000) trim and
fill procedure was planned to correct for publication bias if
identified in the meta-analyses.
A sensitivity analysis was conducted to examine whether the
pooled effect size for phonological loop, visuo-spatial sketchpad
and central executive were influenced by the risk of bias (i.e.,
based on the selection quality criteria of the NOS). Using the
full scale can be problematic, as it is not clear what degree of
bias is introduced if different criteria were not met (Lundh &
Gøtzsche, 2008). Thus, a component-based approach can be
more targeted to a risk of bias. The items from the Selection
criteria were deemed critical for differentiating between high
and low quality studies. This is because study population is an
important factor to ensure generalizability of the meta-analysis
to epilepsy populations, and that appropriate comparisons were
made with controls that were free from neurological disorders.
Unfortunately, no threshold score distinguishes between good
and poor quality studies (Wells et al., 2000), thus studies with
greater than 50% (i.e. three or four out of four; or two out of two)
items endorsed was considered High Selection quality and stud-
ies that received 50% or lower (i.e. one or two out of four, or one
out of two) were considered Low Selection quality. These analy-
ses were not pre-specified or planned in the pre-registration.
Results
Study Selection
A flow chart describing the process of study selection is
shown in Fig. 1. The search retrieved a total of 634 refer-
ences, of which 177 were duplicates. An additional 36 refer-
ences were identified through other sources.
13
Neuropsychology Review
Of the remaining 493 articles, 214 were excluded after
reviewing the titles and abstracts, as they did not meet
inclusion criteria. The remaining 279 full text articles were
obtained. After reviewing the full text articles, 214 papers
were excluded for the following reasons (i) Studies were not
peer-reviewed published empirical papers (n = 56), (ii) Stud-
ies that did not recruit predominately children and adoles-
cents, or included data from adults in the results (n = 52),
(iii) Studies that did not measure working memory, or used
a behavioral self-report measure of WM that was not eligi-
ble for inclusion (n = 31), (iv) Studies that did not recruit
participants with epilepsy (n = 8), (v) Studies were not pub-
lished in the English language (n = 1), (vi) Studies that had
overlapping participant data from previous published papers
that were included in the meta-analysis; (n = 8), (vii) Studies
that did not include a measure of at least one component of
working memory (i.e. phonological loop, visuo-spatial sketch-
pad, central executive, episodic buffer), and authors did not
respond to a request for the specific data request within four
weeks of contact, or were unable to provide the data requested
(n = 51), (viii) Studies were excluded for “other” reasons (n =
7). Of those, six studies did not report working memory scores
that had “number of correct responses” (i.e. reported commis-
sion and omission errors and reaction time scores). One of the
six studies used an experimental measure of working memory
but had no comparison group or normative data.
Study Characteristics
The characteristics of the studies and the results of the qual-
ity analysis are represented in Table 1. Of the 65 studies, all
were cross-sectional, with the exception of one intervention
study. Thirty-nine studies included a control group and 26
studies used normative data.
There were 2919 children with epilepsy across studies, 152
with FLE, 357 with TLE (88 LTLE; 58 RTLE; 33 BTLE; 178
not differentiated in reported results), 36 with Extra-TLE or
FLE and 269 participants had IGE or GGE. The remaining
2105 participants from 22 studies were pooled together into
a mixed or other epilepsy types and areas of seizure focus.
The mean age of participants was 10.86 (SD = 1.41)
years, with a range from 8.2 to 16.5 years across studies.
The mean age of epilepsy onset was 6.32 (SD = 1.67) years,
which ranged from 0.52 months to 12 years. The mean dura-
tion of epilepsy was 4.59 (SD = 2) years, with a range from
0.56 months to 8 years.
Quality Ratings
The results of the NOS quality assessment are also pre-
sented in Table 1. Across studies, epilepsy cases were mostly
clearly defined, with the majority of papers using more than
Neuropsychology Review

Records idenfied through Addional records idenfied

database searching PsychINFO,
Idenficaon
through other sources
MEDLINE & EMBASE (n = 36)
(n = 634)

Records aer duplicates removed

(n = 493)
Screening

Records screened Records excluded

(n = 493) (n = 214)

Full-text arcles assessed Full-text arcles excluded,

for eligibility with reasons
Eligibility

(n = 279) (n = 214)

• Not Empirical (n= 56)

• Not Child (n= 52)
Studies included in • Not WM (n= 31)
qualitave synthesis • Not Epilepsy (n= 8)
(n = 65) • Not English (n= 1)
• Other (n= 7)
• Parcipant data
Included

• overlap (n= 8)
Studies included in • No Response/
quantave synthesis • Requested data
(meta-analysis) • unavailable (n= 51)
(n = 65)

Fig. 1  PRISMA flow diagram of study searches and selection process

one method to determine the presence of epilepsy (n= 57).
Methods used to determine epilepsy diagnosis included a
neurologist review against diagnostic criteria, using imaging
or electroencephalography (EEG) results. Only a few studies
(n= 11) recruited epilepsy cases using consecutive referrals,
thus there is a potential for selection bias. Of the 39 studies
that included a control group for comparison, 29 recruited
from community or hospital samples, ensuring representa-
tiveness of the control group. The remaining studies either
did not provide sufficient details regarding the recruitment
of control children, or retrospectively chose a subgroup of
children from hospital databases or a subset from a norma-
tive sample group. The definition of control groups as being
neurologically healthy or without a history of epilepsy or
seizures was present in most studies (n= 32).
The majority of studies matched groups on at least one
criterion (n = 43), and of those studies, 32 matched groups
on a second factor (e.g. gender, FSIQ, SES). All 65 studies
used at least one validated measure of working memory and/
or a well-defined description of the working memory meas-
ure was utilized. All studies that had two groups or more (n
= 46) used the same working memory measure for all groups

13
 Table 1  Study Characteristics and Quality Ratings (Risk of Bias)
Study Characteristics Quality Rating: Risk of B
­ iasa

13
Author (year) Study Design Sample Age at Testing: mean Age of onset: mean Duration of epilepsy: Selection Comparability Outcome
(SD) in years (SD) in years mean (SD) in years (max 4 (max 2 stars)c (max 3
stars)b stars)d

Acha et al. (2015) Cross-Sectional Dravet Syndrome (DS) DS: 11.35 (*range 0.52 (0.2) - ★★ ★ ★★
n = 8; 8-16); Controls: not
Controls n = 8 reported
Asato et al. (2011) Cross-Sectional Mixed Epilepsy (ME) ME: 12.57 (2.55); 8.35 (3.76) 3.52 (2.74) ★★★★ ★★ ★★
n = 44; Controls: 12.73
Controls n = 44 (2.62)
Total Sample 55%
male
Baglietto et al. (2001) Prospective Cohort BECTS n = 9; Con- BECTS: 8.9 (*range 6.76 (2.43) - ★★ ★★ ★★
Study trols n = 9 6-11); Controls:
Total sample 55% male matched
Borden et al. (2006) Cross-Sectional Mixed Epilepsy n = 31 ME: Not reported 7.00 - ★★ ★★ ★★
(ME: 38% male); (*range 6-16); Con-
Controls n = 31 trols: Not reported
Boscariol et al. (2015) Cross-Sectional Mixed Epilepsy ME: 11.56 (1.79); 4.05 (2.88) - ★★★ 0 ★★
(Rolandic + TLE) n Controls: 10.52
= 19; (1.92)
Controls n = 16;
Total Sample 63%
male
Braakman et al. (2013) Cross-Sectional FLE n = 32; FLE: 11.3 (1.3); Con- 4.9 (2.8) 6.1 (2.8) ★★★ ★ ★★
Controls n = 41; trols: 10.5 (1.5)
Total Sample 51%
male
Cimadevilla et al. Cross-Sectional GGE n = 10; GGE: 9.05 (*range 7.51 (1.1) 1.54 (1.09) ★ ★★ ★★
(2014) Control n = 10; 8-9); Controls:
Total Sample 100% Matched
male
Cohen (1992) Cross-Sectional LTLE n = 12; LTLE: 9.96 (3); RTLE: LTLE: 4.4 (2.69); LTLE: 5.57 (3.46); ★ ★ ★★
RTLE n = 12; 12.08 (2.78); RTLE: 5.08 (3.67) RTLE: 7.39 (3.71)
Control n = 70; Controls: Matched
Total Sample 54%
male
Cormack et al. (2012) Cross-Sectional TLE; LHS n = 17; LHS = 11.7 (3.2); LHS = 4.2 (2.9); - ★ ★ ★★
LDNT n = 11; RHS LDNT = 11.2 (2.8); LDNT = 5.3 (3.5);
n = 7; RDNT n = RHS = 12.5 (2.7); RHS = 3.3 (1.6);
9; Controls n = 22; RDNT = 12.8 (3.2); RDNT = 5.6 (2.9)
Total Sample 48% Controls 13.5 (3.3)
male
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 Table 1  (continued)
Study Characteristics Quality Rating: Risk of B
­ iasa
Author (year) Study Design Sample Age at Testing: mean Age of onset: mean Duration of epilepsy: Selection Comparability Outcome
(SD) in years (SD) in years mean (SD) in years (max 4 (max 2 stars)c (max 3
stars)b stars)d

Croona et al. (1999) Cross-Sectional BECTS n = 17 (41% BECTS: 12.5 (*range 5.5 - ★★★★ ★★ ★★
Neuropsychology Review

male); Controls n 7-14); Controls:

= 17 Matched
D’Agati et al. (2012) Cross-Sectional CAE n = 15; Controls CAE: 11.4 (2.2); 8.8 (1.74) - ★★ ★★ ★★
n = 15; Total Sample Controls 10.7 (2)
53% male
D’Alessandro et al. Cross-Sectional Benign Partial Right All Epilepsy: 10.7; - - ★★ 0 ★★
(1990) n = 11; Left n = 18; Controls 11 (*range
Bilateral n = 15; 9-13)
Controls n = 9; Total
Sample 90% male
Datta et al. Cross-Sectional BECTS n = 27; Con- BECTS: 9.9 (1.5); 7.88 (1.65) - ★★ 0 ★★
(2013) trols n = 19; Total Controls: 10.9 (1.6)
Sample 59% male
Filippini et al. Cross-Sectional BECTS n = 15; Con- BECTS: 8.8 (2.4); - - ★ 0 ★★
(2016) trols n = 15; Total Controls: 9.2 (2.5)
Sample 53% male
Gascoigne et al. Cross-Sectional IGE n = 20 10.76 (2.47) 6.09 (3.25) 4.54 (2.18) ★★★ ★ ★★
(2012) Controls n = 41
Gencpinar et al. (2016) Cross-Sectional CAE n = 19; Controls CAE: 12.22 (2.5); - 2.41 (1.21) ★★ ★★ ★★
n = 19; Total Sample Controls: 11.2 (2.53)
61% male
Germano et al. (2020) Cross-Sectional Mixed Epilepsy n = ME: 9.47 (2.07); Con- 5.5 - ★★★★ 0 ★★
35; Controls n = 22; trols: 9.92 (1.13)
Total sample 54.4%
male
Giordani et al. (2006) Cross-Sectional BECTS n = 200; Total BECTS: 8.2 (2.2) - - 1/2 0 ★★
Sample 58% male
Goldberg-Stern et al. Cross-Sectional BECTS n = 36; Con- BECTS: 9.53; Con- - - ★★★ ★ ★★
(2010) trols n = 15 trols: 11.2 (*range
6-15)
Gonzalez et al. (2007) Cross-Sectional RTLE n = 22; RTLE: 11.41 (3.11); RTLE: 6.74 (3.65); RTLE: 4.67 (4.04); 1/2 ★★ ★★
LTLE n = 21; Total LTLE 12.75 (2.59) LTLE: 6.77 (4.51) LTLE: 5.98 (4.04)
Sample 53% male
Guimaraes et al. (2007) Cross-Sectional TLE n = 25; Controls Not reported (*range 4.6 (2.9) 8 (4.0) ★★★ 0 ★★
n = 25 7-15)

13
 Table 1  (continued)
Study Characteristics Quality Rating: Risk of B
­ iasa

13
Author (year) Study Design Sample Age at Testing: mean Age of onset: mean Duration of epilepsy: Selection Comparability Outcome
(SD) in years (SD) in years mean (SD) in years (max 4 (max 2 stars)c (max 3
stars)b stars)d

Gülgönen et al. (2000) Cross-Sectional Idiopathic OLE n = OLE: 9.9 (2.96); Con- - - ★★★ ★★ ★★
21; trols: 9.9 (2.96)
Controls n = 21; Total
Sample 64% male
Hernandez et al. Cross-Sectional FLE n = 16; FLE: 11.34 (2.77); FLE: 7.77 (3.07); FLE: 3.82 (3.76); ★ 0 ★★
(2002) TLE n = 8; TLE: 12.44 (2.81); TLE: 9.06 (3.5); TLE: 3.64 (2.17);
GGE n = 8; GGE: 11.15 (2.89); GGE: 8.21 (3.54) GGE: 2.84 (2.28)
(Mixed Epilepsy sam- Controls: (*range
ple 63% male); 7-16)
Controls n = 200
Hershey et al. (1998) Cross-Sectional LTLE n = 15; LTLE: 11.24 (2.6); LTLE: 5.6 (2.9); LTLE: 5.8 (3.9); ★★★ ★★ ★★
RTLE n = 13 Controls RTLE: 11.16 (2.4); RTLE: 5.7 (3.7) RTLE: 5.5 (4.9)
n = 19; Total Sample Controls: 11.53 (2.7)
62% male
Holley et al. (2014) Cross-Sectional Mixed Epilepsy n = ME: 9.97 (2.04); Con- - - ★ ★★ ★★
23; trols: 9.29 (1.23)
Controls n = 50; Total
Sample 45% male
Holtmann et al. (2006) Cross-Sectional BECTS with ADHD BECTS: 9.7 (2.1); - - ★★ ★★ ★★
n = 16; Controls n Controls 9.4 (1)
= 16
Hrabok et al. (2014) Cross-Sectional Mixed Epilepsy n = ME: 10.88 (3.09) 5.01 (4.26) - 1/2 NA 1/1
104;
52% male
Jambaqué et al. (2007) Prospective Cohort LTLE n = 12; LTLE: 10.8 (2.5); LTLE: 4.4 (3.7); - 1/2 0 ★★
Study RTLE n = 8; RTLE: 12.8 (1.7) *pre- RTLE: 6.7 (3.2)
Total Sample 65% operative
male
Jiang et al. (2014) Cross-Sectional IGE n = 42 16.5 (14-19.25 12 (10-15 median) 4 (2.5-6.16 median) ★ ★★ ★★
Controls n = 47 median)
Kernan et al. (2012) Cross-Sectional CPS n = 51; CPS: 10 (3); CAE: 9 CPS: 6 (3); CAE: 3 (2) CPS: 4 (2); CAE: 3 (2) ★★★ ★★ ★★
CAE n = 31; Controls (2); Controls: 10 (3)
n = 51; Total Sample
49% male
Kerr & Blackwell Intervention Mixed Epilepsy n = Waitlist: 10.6 (2.7); Waitlist: 4.4 (3.2); Waitlist: 6.2 (3.6); 1/2 NA 1/1
(2015) 77 (total sample at Intervention: 11.1 (3) Intervention: 5.5 Intervention: 5.7
baseline); (3.8) (2.8)
52% male
Neuropsychology Review
 Table 1  (continued)
Study Characteristics Quality Rating: Risk of B
­ iasa
Author (year) Study Design Sample Age at Testing: mean Age of onset: mean Duration of epilepsy: Selection Comparability Outcome
(SD) in years (SD) in years mean (SD) in years (max 4 (max 2 stars)c (max 3
stars)b stars)d

Kadish et al. (2013) Prospective Cohort CAE and JAE n = 22; 13.3 (2.8) 8.3 (3.2) 5.0 (3.4) 0/2 NA 1/1
Neuropsychology Review

Study 50% male

Kibby et al. (2014) Cross-Sectional Focal Epilepsy; Left L: 11.13 (2.6); 5.26 (3.5) 5.54 (4.25) 2/2 ★★ ★★
(L) n = 63; R: 10.18 (2.38);
Right (R) n = 62; B: 10.57 (2.81); Con-
Bilateral (B) n = trols: 10.1 (2.47)
18; Controls n = 63;
Total Sample 54%
male
Kibby et al. (2019) Cross-Sectional FLE n = 27; Controls FLE: 10.98 (2.79); 5.6 (3.57) 5.42 (3.89) 2/2 ★★ ★★
n = 32; FLE 48.1% Controls: 9.97 (2.65)
male
Lima et al. (2017) Cross-Sectional TLE n = 19 TLE= 11.74 (2.05) TLE= 4.36 (3.16) TLE= 6.79 (3.66) ★★★ ★★ ★★
BECTS n = 20 BECTS= 10.95 (2.33) BECTS= 6.55 (2.95) BECTS= 3.26 (2.28)
Longo et al. (2013) Cross-Sectional FLE n = 19; FLE: 11.63 (2.73); FLE: 6.03 (3.15); - 1/2 ★★ ★★
TLE n = 47; TLE: 13.91 (2.64) TLE: 7.34 (4.26)
Total Sample 45%
male
Lopes et al. (2013) Cross-Sectional FLE n = 30 FLE=10.13 (2.73) FLE=6.40 (3.10) FLE=2.30 (3.02) ★ ★★ ★★
CAE n = 30 CAE=9.93 (2.54) CAE=6.83 (2.32) CAE=1.89 (1.50)
BECTS n = 30 BECTS=9.77 (2.43) BECTS=6.77 (2.43) BECTS=1.74 (2.20)
Lopes et al. (2014) Cross-Sectional FLE n = 30 FLE= 10.13 (2.73) FLE= 6.4 (3.1) FLE= 2.30 (3.02) ★ ★★ ★★
CAE n = 30 CAE= 9.93 (2.54) CAE= 6.83 (2.32) CAE= 1.89 (1.50)
BECTS n = 30 BECTS= 9.77 (2.43) BECTS= 6.77 (2.43) BECTS= 1.74 (2.20)
Love et al. Cross-Sectional Mixed Epilepsy n = 54 11.59 (3.34) 6.32 (3.87) 5.68 (3.82) 2/2 0 1/1
(2016)
MacAllister et al. Cross-Sectional ME with ADHD-I n ME ADHD-I: 10.77 ME ADHD-I: 6.13 - 1/2 0 ★★
(2012) = 31; (3.36); ME ADHD- (3.65); ME ADHD-
ME with ADHD-C n C: 9.6 (2.69) C: 4.3 (2.69)
= 15;
Total Sample 59%
male
Malfait et al. (2015) Cross-Sectional BECTS n = 15 11.08 (1.33) 7.83 3.08 (0.5) ★★ ★★ ★★
Mankinen et al. (2014) Cross-Sectional TLE n = 21; TLE: 11.7 (2.1); Con- Girls: 9.5 (3.1); Boys: Girls: 2.4 (2.3); ★★★ ★★ ★★
Controls n = 21; trols: matched 8.8 (3.1) Boys: 2.7 (1.9)
Total Sample 48%
male

13
 Table 1  (continued)
Study Characteristics Quality Rating: Risk of B
­ iasa

13
Author (year) Study Design Sample Age at Testing: mean Age of onset: mean Duration of epilepsy: Selection Comparability Outcome
(SD) in years (SD) in years mean (SD) in years (max 4 (max 2 stars)c (max 3
stars)b stars)d

Melbourne Chambers Cross-Sectional Mixed Epilepsy n = ME: 9.6 (1.7); Con- 5.5 (1.7) 3.92 ★★★★ 0 ★★
et al. (2014) 33; Controls n = 33; trols:
Total Sample 67%
male
Northcott et al. (2007) Cross-Sectional BECTS n = 40; Con- BECTS: 8.6; - - ★★★ ★★ ★★
trols n = 40; Total Controls: matched
Sample 60% male (*range 6-12)
Operto et al. (2019) Cross-Sectional BECTS n = 20; 75% 10.3 (1.78) - - ★★★★ 0 ★★
male
Piccinelli et al. (2008) Cross-Sectional Rolandic n = 20; Con- Rolandic: 10.3 (1.7); 7.9 - ★★★ ★★ ★★
trols n = 21; Total Controls 10.4 (1.8)
Sample 41% male
Reilly et al. (2015) Prospective Cohort Mixed Epilepsy n = 10.79 (*range 5-16) - - 1/2 NA 1/1
Study 69;
52% male
Rzezak et al. (2012) Cross-Sectional TLE n = 36; Controls TLE: 11.78: (2.26); 4.58 (3.34) 6.7 (3.07) ★★★ ★★ ★★
n = 28 Controls: 11.96 (2.3)
Sart et al. Cross-Sectional IPE n = 30; IPE: 10.8 (2.06); Con- 7.53 (2.18) - ★★★ ★★ ★★
(2006) Controls n = 30 trols: 10.8 (2.05)
Schaffer et al. Cross-Sectional IGE n = 33; IGE: 10.88 (1.52); *diagnosis 9.5 (0.7) 4.34 (2.2) ★★★ ★★ ★★
(2015) Controls n = 27 Controls: 10.18 (1.4)
Schouten et al. (2002) Cross-Sectional Mixed Epilepsy n = ME: 9.1 (2.7); Con- - - ★★ ★★ ★★
69; trols: 9.1 (2.8)
Controls n = 66
Sepeta et al. (2017) Cross-Sectional Mixed Epilepsy n = ME: 10.2; Controls 5.99 4.19 ★★★ ★★ ★★
70; 10.3
Controls n = 70
Sinclair et al. (2005) Cross-Sectional Posterior and Occipital 12.14 - - 2/2 NA 1/1
Lobe Epilepsy n
= 15
Stewart et al. (2018) Cross-Sectional GGE n = 22; Controls GGE: 12.82 (2.82); 6.36 (3.55) 6.17 (3.79) ★★★ ★ ★★
n = 22; Total Sample Controls: 12.43
40.9% male (2.26)
Stewart et al. (2019a, Cross-Sectional TLE n = 22; Controls TLE: 13.87 (2.21); 7.79 (4.61) 5.67 (4.1) ★★★ ★ ★★
2019b) n = 22; Total Sample Controls: 12.43
47.7% male (2.26)
van den Berg et al. Cross-Sectional FLE n = 32; 56% male FLE: 9.2 (1.6) 4.6 (2.8) 4.6 (2.7) 2/2 ★ ★★
(2019)
Neuropsychology Review
 Table 1  (continued)
Study Characteristics Quality Rating: Risk of B
­ iasa
Author (year) Study Design Sample Age at Testing: mean Age of onset: mean Duration of epilepsy: Selection Comparability Outcome
(SD) in years (SD) in years mean (SD) in years (max 4 (max 2 stars)c (max 3
stars)b stars)d

van Iterson & de Jong Cross-Sectional Mixed Epilepsy n = - 5.6 (3.1) 4.1 (2.8) ★★ ★ ★★
Neuropsychology Review

(2018) 327
Verly et al. (2017) Cross-Sectional BECTS n = 15 10.05 (2.03) 7.03 (1.05) - 1/2 ★★ 1/1
Vinţan et al. (2012) Cross-Sectional BECTS n = 18 8.88 (2.34) 6.97 (1.86) - ★★ ★ ★★
Welsh et al. (2012) Cross-Sectional Mixed Epilepsy n = 54 13 (3.8) - - 2/2 NA 1/1
Williams & Haut Cross-Sectional Mixed Epilepsy n = 43 11.22 (3.05) 6.6 (3.92) - 1/2 0 ★★
(1995)
Williams et al. (1996) Cross-Sectional Complex Partial n 10.08 (*range 5.9 – Range: 5.6 – 7.36 - 1/2 NA 1/1
= 43 16.17)
Absence Epilepsy n
= 41
Williams et al. (1998) Cross-Sectional Mixed Epilepsy n = 79 10.2 (2.92) - - 1/2 NA 1/1
Williams et al. (2001) Cross-Sectional Mixed Epilepsy n = 65 10.4 (1.67) - - 1/2 NA 1/1
Yildiz-Coksan et al. Cross-Sectional CAE n = 19; 31.58% 11.25 - *range 4 months – 12 ★★★ ★★ ★★
2019 male years

Mixed Epilepsy epilepsy sample made up of two or more epilepsy syndromes or types of seizure focus, FLE frontal lobe epilepsy, TLE temporal lobe epilepsy (RTLE and LTLE indicates focus
to the right or left hemisphere respectively), TLE LHS temporal lobe epilepsy with left hippocampal sclerosis, TLE RHS temporal lobe epilepsy with right hippocampal sclerosis, LDNT/ RDNT
Left or Right Hemisphere Dysembryoplastic Neuroepithelial Tumors, BECTS Benign Childhood Epilepsy with Centro-Temporal Spikes (also known as Rolandic Epilepsy [RE] or Benign Par-
tial Epilepsy [BPE]), IGE idiopathic genetic epilepsy, GGE generalized genetic epilepsy, CAE Childhood Absence Epilepsy, JAE Juvenile Absence Epilepsy, CPS Complex Partial Seizures Idi-
opathic, OLE Idiopathic Occipital Lobe Epilepsy, ADHD attention deficit hyperactive disorder, ADHD-I ADHD inattentive subtype, ADHD-C ADHD-Combined subtype, IPE Idiopathic Partial
Epilepsy, Benign Partial Epilepsy
a
A greater number of stars within each category indicates better quality and reduced risk of bias according to the NOS. One star was allocated for each of the following criteria for Selection: (i)
adequate definition of epilepsy diagnosis, (ii) representativeness of sample, (iii) selection of controls, (iv) definition of controls; with a maximum of 4 stars. One star was allocated for each of
the following criteria for Comparability: (i) study controlled for age at test, (ii) study controlled any for other factor; with a maximum of two stars. One star was allocated for each of the follow-
ing criteria for Outcome: (i) ascertainment of outcome measuring one working memory component, (ii) same method for cases and controls, (iii) same non-response rate reported for cases and
controls; with a maximum of three stars.
b
In some studies, no control group was used as a comparison, thus for Selection a maximum of two stars was allocated for: (i) adequate definition of epilepsy diagnosis and (ii) representative-
ness of sample.
c
In some studies, no comparison or second epilepsy comparator group was utilised, thus these studies received an NA (not applicable) for this category.
d
For studies that did not have a control group or second epilepsy comparator group could only be awarded a maximum of one star for this category: (i) ascertainment of outcome measuring one
working memory component.

13

(either multiple epilepsy groups or control groups). No stud-
ies included in this review reported the non-response rate for
the epilepsy and control groups.
Study Characteristics – Working Memory Measures
The description of each working memory task and overall
findings for each study are outlined in Table 2.
Phonological Loop
Of the 49 studies that utilized a measure of the phonological
loop, most studies used a simple digit span task (n = 38),
other studies used the simple number-letter spans (n = 8),
verbal or word spans (n = 3), sentence memory (n = 4), non-
word repetition (n = 1) and the Sternberg item recognition
test (SIRT; n = 1).
Visuo‑Spatial Sketchpad
Of the 27 studies that utilized a measure of visuo-spatial
sketchpad, most studies used a simple block span recall task
(n = 12), other studies used the finger windows task (n = 9),
spatial span (n = 4), and picture locations (n= 2).
Central Executive
The central executive was assessed using both verbal (n =
41) and visuo-spatial tasks (n = 6). Of the 41 studies that
utilized a verbal measure of central executive, the major-
ity of studies used a transformation span task. One study
utilized a digit learning task. For a visuo-spatial measure of
central executive, the majority of studies used a transforma-
tion span task, such as block span backwards (n = 4), which
requires a participant to follow a visual-spatial sequence
then recount that sequence backwards. Two studies used a
generation task.
Episodic buffer
No studies examined the episodic buffer.
Meta‑Analyses
The phonological loop was the most commonly measured
component of working memory (n = 49) across all epilepsy
subtypes. The central executive was measured in 41 studies,
and the visuo-spatial sketchpad was measured in 27 studies
across all epilepsy subtypes.
The meta-analysis evaluated the magnitude and sig-
nificance of the differences in working memory outcomes
between children with epilepsy compared to typically devel-
oping children. Table 3 provides the mean weighted effect
13
Neuropsychology Review
sizes as a function of epilepsy group for each component of
working memory.
Phonological Loop
Children with epilepsy, pooled across all subtypes, performed
significantly worse than typically developing children on
measures of the phonological loop (k = 49, g = -0.739, 95%
CI -0.834, -0.643, p < .001; See Fig. 2). There was signifi-
cant, moderate heterogeneity between studies in measures of
the phonological loop across epilepsy types (Q = 154.820,
df = 68, p < .001, T­ 2 = 0.069, I­ 2 = 56.078, 95% prediction
interval -1.2764, -0.2015).
Further analyses according to the site of seizure focus
found that, relative to typically developing children, signifi-
cant phonological loop impairments were found for children
with TLE (k = 11, g = -0.706, 95% -0.946, -0.466, p < .001),
FLE (k = 5, g = -1.233, 95% CI -1.755, -0.711, p < .001)
extra-TLE or FLE (k = 2, g = -0.479, 95% CI -0.917, -0.040,
p = .032), and GGE (k = 7, g = -0.601, 95% CI -0.852,
-0.349, p = <.001). There was no significant heterogeneity
observed within each subgroup (ps >.05), with the excep-
tion of FLE (Q = 17.606, df = 4, p = .001, T ­ 2 = 0.259, ­I2 =
77.280, 95% prediction interval -3.061, 0.595).
When examining the pattern of phonological loop out-
comes according to side of seizure focus, the phonological
loop was impaired for left TLE (k = 4, g = -0.647, 95% CI
-1.212, -0.082, p = .025) and right TLE (k = 4, g = -0.738,
95% CI -1.113, -0.363, p < .001). Bilateral TLE resulted
in the largest impairment in the phonological loop across
seizure focus (k = 2, g = -1.347, 95% CI -2.189, -0.505,
p = .002; See Fig. 3). No significant heterogeneity was found
for each subgroup (ps >.05).
Visuo‑spatial Sketchpad
Children with epilepsy, pooled across all subtypes, performed
significantly worse than typically developing children on meas-
ures of the visuo-spatial sketchpad (k = 27, g = -0.521, 95% CI
-0.664, -0.379, p < .001; See Fig. 4). Across epilepsy subtypes,
there was significant, moderate heterogeneity between studies
in measures of the visuo-spatial sketchpad (Q = 100.321, df =
40, p < .001, T­ 2 = 0.101, I­ 2 = 61.802, 95% prediction interval
-1.1923, 0.1503).
Further analyses according to the site of seizure focus
found significant visuo-spatial sketchpad impairments in
children with TLE (k = 7, g = -0.313, 95% -0.571, -0.055,
p = .018), FLE (k= 2, g = -0.631, 95% -1.135, -0.127, p =
.014), and GGE (k = 4, g = -0.530, 95% CI -0.900, -0.159,
p = .005), relative to typically developing children. An
insufficient number of studies measured the visuo-spatial
sketchpad for children with extra-TLE or FLE. Tests of
heterogeneity were not significant for each site of epilepsy
subgroup (ps >.05)
 Table 2  Working Memory Outcomes in Children and Adolescents with Epilepsy
WM Component Study Epilepsy Type WM Task Findings Other factors Neuroimaging Academics

Phonological Loop Acha et al. (2015) Dravet Syndrome Verbal Span Dravet vs. Controls: No age interaction - -
Significant Dravet <
Controls
Boscariol et al. (2015) Mixed (BECTS and Nonwords Repetition Ep vs. Controls: - - -
Neuropsychology Review

TLE) Task (PPVT) Significant Ep <

Controls
Braakman et al. FLE Sternberg Item Recog- FLE vs. Controls: - Lower cerebral acti- Not examined with
(2013) nition Test (SIRT) Significant, cor- vation during SIRT WM results
rect trials FLE < but not significant
Controls
Cimadevilla et al. Mixed (mostly Digits Forward Ep vs. Controls: Not - - -
(2014) BECTS and CAE) (WISC-IV) Significant
Cohen (1992) TLE Digits Forward (CMS) Left TLE vs. Con- - - -
trols: Significant
LTLE < Controls.
Right TLE vs.
Controls: Not Sig-
nificant
Cormack et al. (2012) TLE Digits Forwards TLE vs. Controls: Not - - -
(WISC-III) Significant
Croona et al. (1999) BECTS Digits Forward BECTS vs. Controls: - - -
(WISC-III) Not Significant
D’Agati et al. (2012) CAE Digits Forwards CAE vs. Controls: - - -
(WISC-III) Not Significant
D’Alessandro et al. BECTS Digits Forward BECTS vs. Controls: - - -
(1990) (WMS) Not Significant
Filippini et al. (2016) BECTS Digits Forward BECTS vs. Controls: - - Not examined with
(TEMA) Not Significant WM results
Gascoigne et al. IGE Digits Forward IGE vs. Controls: Not - - -
(2012) (WISC-IV) Significant
Germano et al. (2020) Mixed (Mostly Digits Forward Ep vs. Controls: Ep < - - Not examined with
BECTS & CAE) (WISC-III) Controls WM results
Giordani et al. (2006) BECTS Number Letters BECTS vs. Norms: Significant interac- - -
(WRAML) Significant NL < tion seizure type vs.
Norms WRAML subtests
Gonzalez et al. (2007) TLE Digits Forward Right TLE vs. Left - - -
(WISC-III) TLE: Not Signifi-
cant
Guimaraes et al. TLE Digits Forward TLE vs. Controls: - - -
(2007) (WISC-III) Significant TLE <
Controls

13
 Table 2  (continued)
WM Component Study Epilepsy Type WM Task Findings Other factors Neuroimaging Academics

13
Gulgonen et al. (2000) Occipital Lobe Epi- Number Letters & OLE vs. Controls: NL - - -
lepsy (OLE) Sentence Memory Not Significant; SM
(WRAML) Significant OLE <
Controls
Hershey et al. (1998) TLE Verbal Span TLE vs. Controls: Not - - -
Significant
Holtmann et al. BECTS with ADHD Digit Span (WISC-III) BECTS vs. Controls: - - -
(2006) Not Significant
Hrabok et al. (2014) Mixed (mostly Gener- Digits Forward Ep vs. Norms: - - -
alized and FLE) (WISC-IV) Significant Ep <
Norms
Jiang et al. (2014) IGE Digits Forwards IGE vs. Controls: - - -
(WISC-III) Significant
IGE < Controls
Kadish et al. (2013) CAE Digits Forward CAE vs. Norms: Not - - -
(HAWIK-IV) significant
Kernan et al. (2012) CAE & CPS Digits Forward CAE vs. Controls: CAE: Younger age - -
(TOMAL) Not Significant of onset associated
CPS vs. Controls: Not with sig poor per-
significant formance on DF
Kerr et al. (2015) Mixed (mostly Gener- Digits Forward Ep vs. Norms: Sig- - - -
alized Epilepsy) (WMTB-C) nificant
Ep < Norms
Kibby et al. (2014) Mixed Focal Epilepsy Numbers Forward Focal vs. Controls: Left, right and bilat- - -
(CMS) Significant Focal < eral focus signifi-
Controls cantly impaired
Kibby et al. (2019) FLE Numbers Forward FLE vs. Controls: - - -
(CMS) FLE < Controls
Lima et al. (2017) TLE & BECTS Digits Forward BECTS vs. Controls: - - -
(WISC-III & IV) Not Significant
TLE vs. Controls: Not
Significant
Longo et al. (2013) FLE & TLE Digit Span Forward FLE vs. Controls: No correlation - -
(WISC-III; WAIS- Significant FLE < between age of
III; WPPSI-III; Controls onset and DSF
WISC-IV) TLE vs. Controls:
Significant
TLE < Controls
Lopes et al. (2013) FLE, CAE & BECTS Digits Forward FLE, CAE, BECTS Digit Span not related - -
(WISC-III) vs. Controls: Sig- to age of onset,
nificant duration or seizure
All groups < Controls frequency
Neuropsychology Review
 Table 2  (continued)
WM Component Study Epilepsy Type WM Task Findings Other factors Neuroimaging Academics

Love et al. (2016) Mixed (mostly Focal Digits Forward Ep vs. Norms: BRIEF WM Impaired - -
Epilepsy) (WISC-IV; WASI- Ep < Norms
II)
MacAllister et al. Mixed Epilepsy Digits Forward Ep with ADHD-I/C DSF not correlated - -
Neuropsychology Review

(2012) with ADHD-I or (WISC-IV/ WAIS- vs. ADHD-I/ C: with seizure fre-
ADHD-C IV) Significant Ep < quency, age of onset
ADHD or number of AEDS
Malfait et al. (2015) BECTS Digits Forward BECTS vs. Controls: - Reading and WM pre- -
(WISC-IV) BECTS < Controls dicted activation in
temporal areas for
BECTS
Mankinen et al. TLE Digits Forward TLE vs. Controls: Not Age of onset associ- - -
(2014) (WISC-III) Significant ated with DSF
Melbourne-Chambers Mixed Epilepsy (Par- Digit Span Forward Ep vs. Controls: Ep < - - Not examined with
et al. (2014) tial and Generalized (WISC-R) Controls WM results
Epilepsy)
Northcott et al. (2007) BECTS Number Letters & BECTS vs. Controls: NL sig after control- - -
Sentence Memory Significant NL and ling for IQ
(WRAML) SM < Controls
Piccinelli et al. (2008) BECTS Digits Forward BECTS vs. Controls: - - Not examined with
(TEMA) Not Significant WM results
Reilly et al. (2015) Mixed (Generalized Digit Forward Ep vs. Norms: - - -
and Focal Epilepsy) (WMTB-C) Ep < Norms
Rzezak et al. (2012) TLE Digits Forward TLE vs. Controls: - - -
(WISC-III) & DSF Not Signifi-
Number Letter cant; NL Significant
(WRAML) TLE < Controls
Schaffer et al. (2015) Mixed Digits Forward Ep vs. Controls: - - -
(mostly BECTS (TOMAL) Ep < Controls
and Generalized
Epilepsy)
Schouten et al. (2002) Mixed (Generalized Word Span Forward Ep vs. Controls: Not - - Repeating a year at
and Focal Epilepsy) Significant school related to poor
word span
Sepeta et al. (2017) Mixed Focal Epilepsy Digits Forward Focal vs. Controls: - - -
(WISC-IV) Not Significant
Sinclair et al. (2005) Occipital and Parietal Digits Forward Ep vs. Norms: Ep < No change in memory - Not examined with
Lobe Epilepsy (WISC-III) Norms scores pre and post- WM results
surgery
van den Berg et al. FLE Digits Forward FLE vs. Norms: Ep < - - -
(2019) (WISC-III-NL) Norms

13
 Table 2  (continued)
WM Component Study Epilepsy Type WM Task Findings Other factors Neuroimaging Academics

13
van Iterson et al. Mixed (Generalized Digits Forward Ep vs. Controls: Younger age of onset - -
(2018) and Focal Epilepsy) (WISC-III) Epilepsy < Controls and shorter duration
associated with
higher DSF
Verly et al. (2017) BECTS Number Repetition BECTS vs. Norms: - - -
Forward (CELF-4) BECTS < Norms
Welsh et al. (2012) Mixed (General- Digit Forward (WISC- Ep vs. Norms: - - -
ized and Partial IV) Ep < Norms
Epilepsy)
Williams et al. (1995) Mixed (mostly Com- Number Letter (NL) Ep vs. Norms: Sig- NL significantly more - -
plex Partial) & Sentence Memory nificant impaired than SM
(SM; WRAML) Ep < Norms
Williams et al. (1996) Partial & Absence Digits Forward Digit span low Polytherapy related to - -
Seizures (WISC-R), Number average to average greater impairment
Letter (NL) & Sen- range; NL low aver- in NL scores
tence Memory (SM; age range
WRAML)
Williams et al. (1998) Mixed (mostly Com- Number Letter Ep vs. Norms: - - -
plex Partial) (WRAML) Ep < Norms (border-
line – low average
range)
Williams et al. (2001) Mixed (mostly Com- Number Letter Ep vs. Norms: - - Verbal IQ and NL sig-
plex Partial) (WRAML) Ep < Norms (low nificantly associated
average range) with academic skills
Visual Spatial Sketch- Baglietto et al. (2001) BECTS Corsi Blocks BECTS vs. Controls: - - -
pad Significant, BECTS
< Controls
Croona et al. (1999) BECTS Block Span BECTS vs. Controls: - - -
Not Significant
D’Agati et al. (2012) CAE Corsi Blocks CAE vs. Controls: - - -
Not Significant
D’Alessandro et al. BECTS Corsi Blocks BECTS vs. Controls: - - -
(1990) Not Significant
Datta et al. (2013) BECTS Corsi Blocks BECTS vs. Controls: - Not examined with Not examined with
Not Significant WM results WM results
Gascoigne et al. IGE Block Recall IGE vs. Controls: Not - - -
(2012) (WMTB-C) Significant
Giordani et al. (2006) BECTS Finger Windows BECTS vs. Norms: - - -
(WRAML) Significant BECTS
< Norms
Neuropsychology Review
 Table 2  (continued)
WM Component Study Epilepsy Type WM Task Findings Other factors Neuroimaging Academics

Goldberg-Stern et al. BECTS Corsi Blocks Left, Right and Bilat- No difference in Corsi - Not examined with
(2010) eral vs. Controls: Block performance WM results
Not Significant with seizure fre-
quency
Neuropsychology Review

Gonzalez et al. (2007) TLE Corsi Blocks Forward Right TLE vs. Left - - -
TLE: Not Signifi-
cant
Gulgonen et al. (2000) Occipital Lobe Epi- Finger Windows OLE vs. Controls: - - Not examined with
lepsy (OLE) (WRAML) Not Significant WM results
Hershey et al. (1998) TLE Spatial Span TLE vs. Controls: Not - - -
Significant
Holley et al. (2014) Mixed (CAE, Gener- Spatial Span Ep vs. Controls: - - -
alized and Partial) (AWMA) Significant Ep <
Controls
Jambaque et al. (2007) TLE Corsi Blocks TLE vs. Norms: Not Age of onset had no - -
Significant significant impact
Kerr et al. (2015) Mixed (mostly Gener- Spatial Span Forward Ep vs. Norms: SSF significant treat- - -
alized Epilepsy) (SSF; WISC-IV Ep < Norms ment improvement
Integrated) with Cogmed
Kibby et al. (2014) Mixed Focal Epilepsy Picture Locations Right and Bilateral - - -
(CMS) Focus vs. Controls:
Significant. Left
Focus n.s.
Kibby et al. (2019) FLE Picture Locations FLE vs. Controls: Not - - -
(CMS) Significant
Lima et al. (2017) TLE & BECTS Finger Windows BECTS vs. Controls: - - -
(WRAML) Not Significant
TLE vs. Controls: Not
Significant
Lopes et al. (2014) BECTS, CAE & FLE Corsi Block Tapping FLE < Control; CAE - - -
Task vs. Controls: Not
Significant; BECTS
vs. Contols Not
Significant
Melbourne-Chambers Mixed (Partial and Corsi Block Tapping Ep vs. Controls: Not - - Not examined with
et al. (2014) Generalized Epi- Task significant WM results
lepsy)
Northcott et al. (2007) BECTS Finger Windows BECTS vs. Controls: - - -
(WRAML) Significant BRE <
Controls

13
 Table 2  (continued)
WM Component Study Epilepsy Type WM Task Findings Other factors Neuroimaging Academics

13
Reilly et al. (2015) Mixed (Generalized Block Recall Ep vs. Norms: - - -
and Focal) (WMTB-C) Ep < Norms
Rzezak et al. (2012) TLE Finger Windows TLE vs. Controls: Not - - -
(WRAML) Significant
Sart et al. (2006) IPE Finger Windows IPE vs. Controls: Not - - Not examined with
(WRAML) Significant WM results
Vintan et al. (2012) BECTS Spatial Span (CAN- BECTS vs. Controls: - - -
TAB) Not Significant
Williams et al. (1995) Mixed (mostly Com- Finger Windows Ep vs. Norms: - - -
plex Partial) (WRAML) Ep < Norms
Williams et al. (1996) Partial & Absence Finger Windows Ep vs. Norms: - - -
Seizures (WRAML) Ep < Norms -Low
average range
Williams et al. (1998) Mixed (mostly Com- Finger Windows Ep vs. Norms: - - -
plex Partial) (WRAML) Ep < Norms (border-
line – low average
range)
Central Executive Borden et al. (2006) Mixed (mostly Com- Sequencing (CMS) Ep vs. Controls: Not - - -
(Verbal) plex Partial) Significant
Cimadevilla et al. Mixed (mostly Digits Backward Ep vs. Controls: Not - - -
(2014) BECTS and CAE) (WISC-IV) Significant
Cormack et al. (2012) TLE Digits Backwards TLE vs. Controls: Not - - -
(WISC-III) Significant
D’Agati et al. (2012) CAE Digits Backwards CAE vs. Controls: - - -
(WISC-III) Not significant
Datta et al. (2013) BECTS Letter Number BECTS vs. Controls: - - -
Sequencing (WISC- Not Significant
IV)
Gascoigne et al. IGE Digits Backward IGE vs.Controls: Not - - -
(2012) (WISC-IV) Significant
Gencpinar et al. CAE Serial Digit Learning CAE vs. Controls: - - -
(2016) Significant CAE <
Controls
Gonzalez et al. (2007) TLE Digits Backwards Right TLE vs. Left - - -
(WISC-III) TLE: Not Signifi-
cant
Guimaraes et al. TLE Digits Backward TLE vs. Controls: Not - - -
(2007) (WISC-III) Significant
Holley et al. (2014) Mixed (CAE, Gener- Backward Recall Ep vs. Controls: Not - - -
alized and Partial) (AWMA) Significant
Neuropsychology Review
 Table 2  (continued)
WM Component Study Epilepsy Type WM Task Findings Other factors Neuroimaging Academics

Hrabok et al. (2014) Mixed (mostly Gener- Digits Backward Ep vs. Norms - - -
alized and FLE) & Letter Number Ep < Norms
Sequencing (WISC-
IV)
Neuropsychology Review

Jiang et al. (2014) IGE Digits Backward IGE vs. Controls: - - -

(WISC-III) Significant IGE <
Controls
Kadish et al. (2013) CAE Digits Backward CAE vs. Norms: Not - - -
& Letter Num- Significant
ber Sequencing
(HAWIK-IV)
Kernan et al. (2012) CAE & CPS Digits Backward CAE vs. Controls: - - -
(TOMAL) Not Significant
CPS vs. Controls: Not
significant
Kerr et al. (2015) Mixed (mostly Gener- Digit Span Backward Ep vs. Norms: DSB sig treatment - -
alized) (DSB; WMTB-C) Ep < Norms improvement with
Cogmed
Kibby et al. (2014) Mixed Focal Epilepsy Numbers Backwards Focal vs. Controls: - - -
(CMS) & Sequences Not Significant
(CMS)
Kibby et al. (2019) FLE Numbers Backwards FLE vs. Controls: Not -
(CMS) & Sequences Significant
(CMS)
Lima et al. (2017) TLE & BECTS Digits Backwards TLE vs. Controls: Not TLE < BECTS sig- - -
(WISC III & IV) Significant. nificant difference
BECTS vs. Controls:
Significant BECTS
> Controls
Longo et al. (2013) FLE & TLE Digit Span Backwards FLE vs. Controls: No correlation - -
(WISC-III; WAIS- Significant FLE < between Age Onset
III; WPPSI-III; Controls and DSB
WISC-IV) TLE vs. Controls:
Significant
TLE < Controls
Lopes et al. (2013) FLE, CAE & BECTS Digits Backwards FLE, CAE, BECTS Digit Span not related - -
(WISC-III) vs. Controls: Sig- to age of onset,
nificant duration or seizure
All groups < Controls frequency

13
 Table 2  (continued)
WM Component Study Epilepsy Type WM Task Findings Other factors Neuroimaging Academics

13
Love et al. (2016) Mixed (mostly Focal Digits Backward Ep vs. Norms: BRIEF WM Impaired - -
Epilepsy) & Letter Number Ep < Norms
Sequencing (WISC-
IV; WASI-II)
MacAllister et al. Mixed Epilepsy Digits Backward Ep with ADHD- Negative correlation - -
(2012) with ADHD-I or (WISC-IV/ WAIS- I vs. ADHD-I with DSB and sei-
ADHD-C IV) alone: Significant; zure frequency and
Ep with ADHD-C number of AEDs
vs. ADHD-C alone: with Epilepsy +
Not Significant ADHD-C
Malfait et al. (2015) BECTS Digits Backward BECTS vs. Controls - Reading and WM pre- -
& Letter Number BECTS < Controls dicted activation in
Sequencing (WISC- temporal areas for
IV) BECTS
Mankinen et al. TLE Digits Backward TLE vs. Controls: Not - - -
(2014) (WISC-III) Significant
Melbourne-Chambers Mixed Epilepsy Digits Backward Ep vs. Controls: Not - - Not examined with
et al. (2014) (WISC-R) Significant WM results
Operto et al. (2019) BECTS Letter Number Ep vs. Norms: Not Not examined with - -
Sequencing (WISC- Significant WM results
IV)
Piccinelli et al. (2008) Rolandic Epilepsy Digits Backwards RE vs. Controls: Not - - -
(RE) (TEMA) Significant
Reilly et al. (2015) Mixed (Generalized Digit Backward & Ep vs. Norms: - - -
and Focal) Counting Recall Ep < Norms
(WMTB-C)
Rzezak et al. (2012) TLE Digits Backwards TLE vs. Controls: Not - - -
(WISC-III) Significant
Schaffer et al. (2015) Mixed Digits Backwards Ep vs. Controls: - - -
(mostly BECTS and (TOMAL) Ep < Controls
Generalized)
Schouten et al. (2002) Mixed (Idiopathic and Word Span Backward Ep vs. Controls: Not - - -
Cryptogenic) Significant
Sepeta et al. (2017) Mixed Focal Epilepsy Digits Backward Focal vs. Controls: - - -
(WISC-IV) Not Significant
Sinclair et al. (2005) Occipital and Parietal Digits Backward Ep vs. Controls: Ep < No change in memory - Not examined with
Lobe Epilepsy (WISC-III) Controls scores pre and post- WM results
surgery
Stewart et al. (2018) GGE Digits Backwards GGE vs. Controls: - - -
(AWMA) GGE < Controls
Neuropsychology Review
 Table 2  (continued)
WM Component Study Epilepsy Type WM Task Findings Other factors Neuroimaging Academics

Stewart et al. (2019a, TLE Digits Backwards TLE vs. Controls: Not WM not sig cor- - -
2019b) (AWMA) Significant related with age
of onset, duration,
seizure frequency or
Neuropsychology Review

no. of AEDs
van den Berg et al. FLE Digits Backwards FLE vs. Norms: FLE - - -
(2019) (WISC-III-NL) < Norms
van Iterson et al. Mixed (Generalized Digits Backwards Ep vs. Controls: Older age of onset - -
(2018) and Focal) (WISC-III) Epilepsy < Controls and longer duration
for children aged associated with
5 - 11 higher DSB
Verly et al. (2017) Rolandic Epilepsy Number Repetition RE vs. Norms: Not - - -
(RE) Backwards (CELF- Significant
4)
Welsh et al. (2012) Mixed (Generalized Digit Backward Ep vs. Norms: - - -
and Partial) (WISC-IV) Ep < Norms
Williams et al. (1996) Partial & Absence Digits Backwards Ep vs. Norms: - - -
Seizures (WISC-R) Digit span scores
within the low to
low average range
Yildiz-Coksan et al. CAE Letter Number CAE vs. Controls: - - Not examined with
(2019) Sequencing CAE < Controls WM results
(WISC-IV)
Central Executive Asato et al. (2011) Mixed (mostly Partial Spatial Generation Ep vs. Controls: - - -
(visuo-spatial Epilepsy) Task (CANTAB) Significant Ep <
sketchpad) Controls
Datta et al. (2013) BECTS Corsi Blocks Back- BECTS vs. Controls: - Not examined with Not examined with
wards Not Significant WM results WM results
Goldberg-Stern et al. BECTS Corsi Blocks Back- Left, Right and Bilat- No difference in Corsi - Not examined with
(2010) wards eral vs. Controls: Block performance WM results
Not Significant with seizure fre-
quency
Gonzalez et al. (2007) RTLE & LTLE Corsi Blocks Back- Right TLE vs. Left - - -
wards TLE: Not Signifi-
cant

13
 Neuropsychology Review

When examining the pattern of visuo-spatial sketch-

Ep Epilepsy group, Mixed epilepsy sample made up of two or more epilepsy syndromes or types of seizure focus, Norms Normative data sample, FLE frontal lobe epilepsy, TLE temporal lobe

lent), TOMAL Test of Memory and Learning, WMTB-C Working Memory Test Battery for Children, WAIS Wechsler Adult Intelligence Scale, WPPSI Wechsler Preschool and Primary Scale of
epilepsy (RTLE and LTLE indicates focus to the right or left hemisphere respectively), BECTS Benign Childhood Epilepsy with Centro-Temporal Spikes (also known as Rolandic Epilepsy [RE]
or Benign Partial Epilepsy [BPE]), IGE idiopathic genetic epilepsy, GGE generalized genetic epilepsy, CAE Childhood Absence Epilepsy, JAE Juvenile Absence Epilepsy, CPS Complex Par-
tial Seizures Idiopathic, OLE Idiopathic Occipital Lobe Epilepsy, ADHD attention deficit hyperactive disorder, ADHD-I ADHD inattentive subtype, ADHD-C ADHD-Combined subtype, IPE
Idiopathic Partial Epilepsy, Benign Partial Epilepsy, PPVT Peabody Picture Vocabulary Test, WISC Wechsler Intelligence Scale for Children, CMS Children’s Memory Scale, WMS Wechsler
Memory Scale; TEMA Test of Early Mathematics, WRAML Wide Range Assessment of Learning and Memory, HAWIK Hamburg-Wechsler-Intelligenztest für Kinder (German WISC equiva-

Intelligence, WASI Wechsler Abbreviated Scale of Intelligence, CELF Clinical Evaluation of Language Fundamentals, AWMA Automated Working Memory Assessment, CANTAB Cambridge
pad according to side of seizure focus, the visuo-spatial
sketchpad was not significantly impaired for left TLE (k
= 3, g = -0.265, 95% CI -0.888, 0.359, p = .406) or right
Academics

TLE (k = 3, g = -0.160, 95% CI -0.606, 0.285, p = .48).

The visuo-spatial sketchpad was significantly impaired
with bilateral TLE seizure focus (k = 2, g = -0.873, 95%
-

CI -1.681, -0.064, p = .034; See Fig. 5). Tests of het-

erogeneity were not significant for each side of epilepsy
subgroup (ps >.05).
Neuroimaging

Central Executive

Children with epilepsy, pooled across all subtypes, per-

-

formed significantly worse than typically developing

ment improvement
No significant treat-

children on measures of central executive (k = 44 g =

with Cogmed

-0.560, 95% CI -0.709, -0.411, p < .001; See Fig. 6).

Other factors

There was a significant large heterogeneity between

studies of central executive (Q = 326.685, df = 62, p <
.001, ­T 2 = 0.256, I­ 2 = 81.021, 95% prediction interval
-

-1.5925, 0.4725).
Further analyses according to the site of seizure focus
Ep vs. Norms: Not

found significant central executive impairments in chil-

Ep vs. Norms:

dren with TLE (k= 10, g = -0.401, 95% -0.761, -0.041, p

Ep < Norms
significant

= .029), FLE (k = 5, g = -1.263, 95% CI -2.386, -0.139,

Findings

p= .028) and GGE (k = 11, g = -0.508, 95% CI -0.730,

Neuropsychological Test Automated Battery, BRIEF Behavior Rating Inventory of Executive Function

-0.286, p= .001) relative to typically developing chil-

dren. The TLE group and FLE had significant moderate
Self Ordered Pointing

ward (SSB; WISC-

Spatial Span Back-

to large heterogeneity in central executive (TLE: Q =

IV Integrated)

42.326, df = 13, p < .001, ­T2 = 0.282, ­I2 = 69.463, 95%

prediction interval -1.6968, 0.8948); FLE: Q = 77.999,
WM Task

df = 4, p < .001, ­T 2 = 1.537, ­I 2 = 94.872, 95% predic-

Task

tion interval -5.6101, 3.0841). Visual inspection of the

funnel plot revealed an outlier (i.e. Longo et al., 2013) in
the TLE group. Removal of this study from the subgroup
analysis resulted in a significant, small effect size for
FLE, TLE, IGE
Epilepsy Type

central executive impairments (k = 8, g = -0.323, 95%

CI -0.533, -0.113, p = .003) and a reduction in heteroge-
Mixed

neity, which was small and non-significant (Q = 6.145,

df = 12, p= .909, ­T 2 = 0.00, ­I 2 = 0.00, 95% prediction
interval –0.5852, -0.0608). For the FLE group, the fun-
nel plot revealed two outliers (i.e. Longo et al. 2013 and
Kerr et al. (2015)
Hernandez et al.

van den Berg et al. 2019). Removal of these studies from

the subgroup analysis resulted in a significant, small-to-
moderate effect size for central executive impairments (k
(2002)
Study

= 3, g = -0.482, 95% CI -0.874, -0.090, p = .016), and

a reduction in heterogeneity, which was small and non-
significant (Q = 0.266, df = 2, p = .875, T ­ 2 = 0.00, I­ 2 =
Table 2  (continued)

0.00, 95% prediction interval -3.0232, 2.0592).

WM Component

When examining the pattern of central executive out-

comes according to side of seizure focus, the central
executive was not significantly impaired for either left
TLE (k = 2, g = -0.342, 95% CI -0.722, 0.038, p = .078)

13
Neuropsychology Review

Table 3  Mean weighted effect sizes as a function of epilepsy group

Overall Epi- TLE FLE Extra-TLE/ GGE
lepsy FLE
WM Compo- Overall Left Right Bilateral
nent

Phonological g = -0.739 g = -0.706 g = -0.647 g = -0.738 g = -1.347 g = -1.233 g = -0.479 g = -0.601

Loop 95%CI (-0.834, 95%CI (-0.946, 95%CI (-1.212, 95%CI (-1.113, 95%CI (-2.189, 95%CI (-1.755, 95%CI (-0.917, 95%CI (-0.852,
-0.643) -0.466) -0.082) -0.363) -0.505) -0.711) -0.04) -0.349)
k= 49 k= 11 k= 4 k= 4 k= 2 k= 5 k= 2 k= 7
Visuo-spatial g = -0.521 g = -0.313 g = -0.265 g = -0.160 g = -0.873 g = -0.631 - g = -0.530
Sketchpad 95%CI (-0.664, 95%CI (-0.571, 95%CI (-0.888, 95%CI (-0.606, 95%CI (-1.681, 95%CI (-1.135, 95%CI (-0.9,
-0.379) -0.055) 0.359) 0.285) -0.064) -0.127) -0.159)
k= 27 k= 7 k= 3 k= 3 k= 2 k= 2 k= 4
Central g = -0.560a g = -0.401 g = -0.342 g = -0.392 - g = -1.263 - g = -0.508
Executive 95%CI (-0.709, 95%CI (-0.761, 95%CI (-0.722, 95%CI (-0.95, 95%CI (-2.386, 95%CI (-0.73,
-0.411) -0.041) 0.038) 0.167) -0.139) -0.286)
k= 44 k= 10 k= 2 k=2 k= 5 k= 11

Cells in bold indicate a significant result (p<.05)

a
Adjusted effect size g = 0.805 (95%CI -0.945, -0.644) after trim and fill procedure (21 studies trimmed)

or right TLE (k = 2, g = -0.392, 95% CI -0.950, 0.167, seizure focus or with extra-TLE/FLE. Tests of hetero-
p = .169; See Fig. 7). An insufficient number of studies geneity were not significant for each side of epilepsy
measured the central executive for children with bilateral subgroup (ps >.05).

Fig. 2  Forest plot of individual and pooled effect sizes (Hedges’ g) Pooled epilepsy group effect size includes TLE studies (shown in
with 95% confidence interval for the phonological loop. Effect sizes Fig. 3). Relative weight percentage for FLE, Extra TLE/FLE, and
are organized by FLE, Extra- TLE/FLE, GGE and mixed/other. Note: GGE relate to the group summary scores, not the pooled effect size

13

Fig. 3  Forest plot of individual and pooled effect sizes (Hedges’ g)
with 95% confidence interval for the phonological loop. Effect sizes
are organized by left TLE, right TLE, bilateral and mixed TLE
Meta‑Regression of Moderator Variables
Phonological Loop
Meta-regression conducted with the pooled epilepsy group
revealed a significant positive association with age of onset
and phonological loop (R = 0.0826, 95% CI 0.0091 – 0.156,
z = 2.22, p = .0276). Lower scores on phonological loop
tasks were associated with a younger age of epilepsy onset.
No significant associations were found between age at test-
ing and duration of epilepsy (ps >.05).
Visuo‑Spatial Sketchpad
There was also a significant positive association with age of
onset with the visuo-spatial sketchpad (R = 0.1564, 95% CI
0.0186 – 0.2942, z = 2.22, p = .0261) in the pooled epilepsy
group. Lower scores on visuo-spatial sketchpad tasks were
associated with a younger age of epilepsy onset. In addition,
there was also a significant negative association found with
duration of epilepsy disorder and visuo-spatial sketchpad
(R = -0.0967, 95% CI -0.1901 – -0.0034, z = -2.06, p =
.0422). A longer duration of epilepsy disorder was asso-
ciated with poorer performance on visuo-spatial sketchpad
13
Neuropsychology Review
groups. Relative weight percentage for Left TLE, Right TLE and
Bilateral TLE relate to the group summary scores, not the pooled
effect size
tasks. Association between visuo-spatial sketchpad and age
at testing was not significant (p >.05).
Central Executive
Meta-regression conducted with the pooled epilepsy group
indicated no significant associations between age of onset,
age at testing and duration of epilepsy disorder (ps >.05).
Systematic Review of Other Moderator Variables
Seizure Frequency
Three studies examined the relationship between working
memory components and seizure frequency (Goldberg-Stern
et al., 2010; MacAllister et al., 2012, Stewart et al., 2019a,
2019b). For measures of the phonological loop, MacAllister
et al. (2012) found that the digit span forward task was not
significantly correlated with seizure frequency in children
with comorbid epilepsy and ADHD. For measures of the
visuo-spatial sketchpad, Goldberg-Stern et al. (2010) found
no significant difference between Corsi Block forward perfor-
mance for children with benign childhood epilepsy with cen-
trotemporal spikes (BECTS) that had 1-3 seizures compared
Neuropsychology Review
Fig. 4  Forest plot of individual and pooled effect sizes (Hedges’ g)
with 95% confidence interval for the visuo-spatial sketchpad. Effect
sizes are organized by FLE, Extra- TLE/FLE, GGE and mixed/other.
to children that had more than 3 seizures. For measures of
the central executive, MacAllister et al. (2012) found a sig-
nificant negative correlation between digit span backwards
and seizure frequency for children with epilepsy and ADHD
– combined inattentive and hyperactive subtype, with higher
seizure frequency associated with poorer central executive
performance. The relationship between digits backward and
seizure frequency was not significant for children with epi-
lepsy and ADHD inattentive only subtype. Similarly, Stewart
et al. (2019a, 2019b) found no significant relationship between
digits backwards and seizure frequency for children and ado-
lescents with temporal lobe epilepsy. Goldberg-Stern et al.
(2010) found no significant difference between Corsi Block
Backwards performance for children with BECTS that had
1-3 seizures compared to children with more than 3 seizures.
Anti‑Epileptic Drugs (AEDs)
Three studies examined the relationship between working
memory components and number of AEDs (MacAllister
et al., 2012; Williams et al., 1996, Stewart et al. 2019a,
2019b). For measures of the phonological loop, MacAllister
et al. (2012) found that the digit span forward task was not
significantly correlated with number of AEDs in children
with comorbid epilepsy and ADHD. Williams et al. (1996)
found that polypharmacy (two AEDs) was associated with
Note: Pooled epilepsy effect size includes TLE studies (shown in
Fig. 5). Relative weight percentage for FLE and GGE relate to the
group summary scores, not the pooled effect size
significantly greater impairment in the number-letter task
compared to children with monotherapy. For measures of
the central executive, MacAllister et al. (2012) found a sig-
nificant negative correlation between digit span backwards
and number of AEDs for children with epilepsy and ADHD
– combined inattentive and hyperactive subtype, with higher
number of medications associated with poorer central execu-
tive performance. The relationship between digits backward
and number of AEDs was not significant for children with
epilepsy and ADHD inattentive only subtype. Stewart et al.
(2019a, 2019b) found no significant relationship between
digits backwards and number of AEDs for children and ado-
lescents with temporal lobe epilepsy.
Surgical Outcomes
Two studies examined working memory component scores
pre and post epilepsy surgery (Jambaqué et al., 2007; Sinclair
et al., 2005). Jambaque et al. (2007) found significant
improvement post-surgery in the phonological loop and
visuo-spatial sketchpad for children with left and right
TLE. In contrast, Sinclair et al. (2005) found no change in
post-operative scores in a range of memory tasks, includ-
ing working memory task, for children with extra-TLE or
FLE (i.e., occipital and parietal lobe epilepsy) relative to
pre-surgery scores.
13

Fig. 5  Forest plot of individual and pooled effect sizes (Hedges’ g)
with 95% confidence interval for the visuo-spatial sketchpad. Effect
sizes are organized by left TLE, right TLE, bilateral and mixed TLE
Neuroimaging
One study used functional magnetic resonance imaging (fMRI)
techniques to examine working memory tasks in children with
epilepsy (Braakman et al., 2013). Braakman et al. (2013)
included children with FLE and measured the SIRT (phonolog-
ical loop) in the scanner. Children with FLE were found to have
a global decrease in brain connectivity compared to healthy
control children. This study also found that children with FLE
had lower cerebral activation during the SIRT task, but this
was not significant after controlling for multiple comparisons.
Academic Skills and Achievement
Two studies examined relations between working memory
components and academic achievements (Schouten et al.,
2002; Williams et al., 2001). Shouten et al. (2002) found that
children with epilepsy who had repeated a year at school and
needed special education assistance had poorer phonologi-
cal loop (word span forward) and central executive (word
span backwards) scores compared to control children who
had not repeated a year and did not have special educational
assistance. In contrast, Williams et al. (2001) found that the
13
Neuropsychology Review
groups. Relative weight percentage for Left TLE, Right TLE and
Bilateral TLE relate to the group summary scores, not the pooled
effect size
phonological loop, measured with the number letter task, did
not significantly account for more variance in early academic
skills (reading recognition, spelling, grammar and math con-
ceptual skills) over and above verbal intelligence alone.
Publication Bias
No significant publication bias was detected with Egger’s
regression test for the phonological loop and visuo-spatial
sketchpad across studies (ps= .515 - .871). Publication bias
was significant for measures of the central executive (p =
.031). Duval and Tweedie’s (2000) trim and fill procedure,
adjusted values for 21 studies and revealed an increase in the
effect size for central executive (g = -0.804, 95% CI -0.945,
-0.664, Q = 497.504).
Sensitivity Analysis
On phonological loop measures, children with epilepsy,
pooled across all subtypes, performed significantly worse
than typically developing children in studies that were con-
sidered high selection quality (k = 22, g = -0.701, 95%
CI -0.499, -0.903, p < .001), with significant moderate
Neuropsychology Review
Fig. 6  Forest plot of individual and pooled effect sizes (Hedges’ g)
with 95% confidence interval for the central executive. Effect sizes
are organized by FLE, Extra- TLE/FLE, GGE and mixed/other. Note:
heterogeneity found for these studies (Q = 70.312, df = 24,
p < .001, ­T2= 0.153, I2 = 65.867, 95% prediction interval
-1.5448, 0.1428). For studies that were considered low selec-
tion quality, effect sizes were slightly larger in magnitude on
measures of phonological loop (k = 27, g = -0.754, 95% CI
-0.649, -0.858, p < .001), but significant moderate heteroge-
neity remained (Q = 83.992, df = 43, p < .001, T ­ 2= 0.045, I2
= 48.804, 95% prediction interval -1.2044, -0.3036).
On visuo-spatial sketchpad measures, children with epi-
lepsy, pooled across all subtypes, performed significantly
worse than typically developing children in studies that were
considered high selection quality (k = 11, g = -0.427, 95%
CI -0.216, -0.638, p < .001), and the effect size was slightly
larger in studies that were considered low selection qual-
ity. (k = 16, g = -0.541, 95% CI -0.718, -0.365, p < .001).
Heterogeneity was non-significant (Q = 9.303, df = 12, p =
Pooled epilepsy effect size includes TLE studies (shown in Fig. 7).
Relative weight percentage for FLE and GGE relate to the group
summary scores, not the pooled effect size
.677, ­T2= 0.00, I2 = 0.00, 95% prediction interval -0.6705,
-0.1835) and significant (Q = 89.468, df = 27, p < .001, ­T2=
0.124, I2 = 69.821, 95% prediction interval -1.3207, 0.2387)
for studies with high and low selection quality, respectively.
Finally, on central executive measures used in in studies
that were considered high selection quality children with
epilepsy collapsed across subtypes obtained significantly
lower scores relative to typically developing children (k =
21, g = -0.527, 95% CI -0.207, -0.847, p = .001). In this
instance, significant and large between study heterogeneity
was found (Q = 185.042, df = 22, p < .001, T ­ 2 = 0.503, I2
= 88.111, 95% prediction interval -2.0502, 0.9962). Visual
inspection of the funnel plot revealed a significant outlier
(i.e. van den Berg et al., 2019 and Lima et al., 2017 BECTS
subgroup only). On removal of the two outliers, the effect
size decreased (k = 20, g = -0.468, 95% CI -0.299, -0.638,
13

Fig. 7  Forest plot of individual and pooled effect sizes (Hedges’ g)
with 95% confidence interval for the central executive. Effect sizes
are organized by left TLE, right TLE, bilateral and mixed TLE
p < .001), however, significant moderate heterogeneity
remained (Q = 40.161, df = 20, p = .005, ­T2 = 0.068, I2 =
50.201, 95% prediction interval -1.0454, 0.1094). For stud-
ies that were considered low selection quality had a higher
effect size was observed on measures of central executive (k
= 23, g = -0.581, 95% CI -0.736, -0.425, p < .001). How-
ever, significant moderate heterogeneity remained (Q =
141.032, df = 39, p < .001, ­T2 = 0.151, I2 = 72.347, 95%
prediction interval -1.4057, 0.2437).
Discussion
To our knowledge, this is the first meta-analysis examining
working memory outcomes in children and adolescents with
epilepsy. The primary aim of this review was to (i) establish
whether working memory components are impaired in chil-
dren with epilepsy, (ii) determine whether working memory
components are differentially impacted by site or side of
epilepsy, (iii) evaluate whether the pattern and severity of
13
Neuropsychology Review
groups. Relative weight percentage for Left TLE and Right TLE
relate to the group summary scores, not the pooled effect size
working memory deficits were related to demographic fac-
tors (i.e., age and testing), and (iv) other epilepsy factors
(i.e., age of onset of seizure disorder, duration of epilepsy,
seizure frequency, medication, and surgical status). The final
aims were to determine relations between working memory
and (i) neuroimaging results and (ii) functional deficits (i.e.
academic difficulties in reading and mathematics) in children
and adolescents with epilepsy.
We found that all working memory components that were
studied (phonological loop, visuo-spatial sketchpad, central
executive) were impaired in children with epilepsy, with the
exceptions of the episodic buffer which has not been studied.
However, the patterns of impairments differed in relation
to the site and side of epilepsy focus. Phonological loop
impairments were found in children with focal (TLE, FLE,
extra-TLE/FLE) and generalized epilepsy (GGE). For side
of epilepsy, phonological loop was significantly impaired
in left, right and bilateral TLE. Visuo-spatial sketchpad and
central executive were selectively impaired. Visuo-spatial
sketchpad was impaired in children with bilateral TLE
Neuropsychology Review
and GGE. Central executive was impaired in children with
TLE, FLE and GGE. A younger age of epilepsy onset and
longer duration of epilepsy disorder were associated with
greater impairments in visuo-spatial sketchpad. Longer dura-
tion of epilepsy disorder was associated with lower central
executive.
Of the three working memory components, phonological
loop was found most sensitive to disruption in children with
epilepsy. Although impairments in phonological loop were
found irrespective of the site of seizure focus, the magnitude
of impairments in phonological loop varied. The largest pho-
nological loop impairments were documented in children
with FLE and bilateral TLE. Previous studies in adults have
shown that the phonological loop relies on the left hemi-
sphere of the brain, and recruits networks in the inferior pari-
etal lobe, posterior temporal region and ventrolateral pre-
frontal cortex (Aboitiz et al., 2010; Smith & Jonides, 1997).
As a result, phonological loop impairments were expected
to be found in patients with TLE, in particular left TLE. Sur-
prisingly, the magnitude of phonological loop impairments
was comparable in children with left TLE and in children
with right TLE. This lack of side of epilepsy focus effect
on phonological loop in children with epilepsy is at odds
with adult studies showing a left hemisphere specialization
for phonological loop tasks. The lack of side of epilepsy
focus effect on phonological loop in children with epilepsy,
however, is consistent with the developmental changes in
functional organization of working memory circuitry from
childhood to early adulthood, which progress from engaging
diffuse brain networks to lateralized, specialized networks in
completing working memory tasks (Kwon, 2010). Of note,
the magnitude of the impairment in phonological loop for
children with bilateral TLE was almost double the mag-
nitude of the impairment in children with unilateral TLE,
suggesting that the temporal lobe networks are critical for
phonological loop tasks, even in children.
For children with FLE, large deficits in phonological loop
were also found. This finding is consistent with adult neuro-
imaging literature that shows recruitment of the prefrontal
cortex in phonological loop tasks (D’Esposito, 2007). Inter-
estingly, children with GGE whose seizures do not emanate
from the frontal or temporal lobes, were also found to have
moderate to large impairments in phonological loop. How-
ever, previous studies have provided evidence of deficits
in executive functioning in children and adults with GGE,
including impairments in working memory (Loughman
et al., 2014). Finally, to our surprise, the phonological loop
was also impaired in children with extra-TLE or FLE, albeit
the magnitude of phonological loop impairment was smaller
than in children with TLE and FLE. We note that functional
disruption of frontal and temporal lobes has been previously
documented in patients with extra-TLE or FLE (Helmstae-
dter & Witt 2012). Thus, the frontal and temporal-type
dysfunctions found across the different sites of epilepsy,
may provide a parsimonious account for phonological loop
deficits found irrespective of the site of epilepsy focus.
Unlike the phonological loop, where impairments were
found in every child epilepsy group, the visuo-spatial sketch-
pad was differentially impaired. Deficits in the visuo-spatial
sketchpad were found in children with FLE, bilateral TLE,
and in children with GGE. However, while children with
bilateral TLE had large impairments in visuo-spatial sketch-
pad, children with FLE and GGE had moderate impairments
in visuo-spatial sketchpad. Finding visuo-spatial sketchpad
impairment in children with FLE is at odds with previous
research that shown intact storage components (phonological
loop and visuo-spatial sketchpad) in adults with prefrontal
cortex lesions (see Müller & Knight, 2006). Unlike adults
who have fully developed visuo-spatial sketchpad, children’s
visuo-spatial sketchpad is still developing (Kwon et al.,
2002). Thus, it is possible that the developing visuo-spatial
sketchpad involves different brain networks than the fully
developed visuo-spatial sketchpad. As a result, in children,
the visuo-spatial sketchpad may be vulnerable to focal sei-
zures arising from the frontal lobes, but also to generalized
seizures experienced by children with GGE.
Children with unilateral TLE did not show deficits in
visuo-spatial sketchpad irrespective of the side of epilepsy
focus. This lack of significance may be due to (i) only three
studies providing data for this patient population and (ii)
the task used in the studies lacking sensitivity to deficits in
visuo-spatial sketchpad that could arise from temporal lobe
seizure focus. While the three studies used a spatial span task
(the Corsi Block-tapping task) to assess visuo-spatial sketch-
pad, neuroimaging studies showed that object span tasks, but
not spatial span tasks recruit the network that involves the
inferior temporal cortex (Nagel et al., 2013; Smith & Jon-
ides, 1997; Wager & Smith, 2003). Given that visuo-spatial
sketchpad impairment was observed in children with bilat-
eral TLE, however, it is possible that visuo-spatial sketch-
pad is compromised when seizures impact both temporal
lobes rather than only one. In regards to children with extra-
TLE or FLE, the only study that measured the visuo-spatial
sketchpad revealed an impairment (Gülgönen et al., 2000).
Hence, the integrity of visuo-spatial sketchpad in children
with extra-TLE/FLE requires further investigation.
With respect to the central executive, deficits were found
for children with FLE, TLE and GGE. While the largest
impairment in central executive was documented for chil-
dren with FLE, this finding should be interpreted with cau-
tion as there were two outliers in the analysis (i.e., Longo
et al., 2013 & van den Berg et al., 2019). A removal of these
two outliers resulted in a marked reduction in effect size,
which dropped from a large to a small-to-moderate deficit in
central executive for children with FLE. Nevertheless, defi-
cits in central executive found in children with FLE were still
13

significant, and consistent with neuroimaging studies, which
found that in combination with the parietal cortex, the dorso-
lateral prefrontal cortex was critical for the central executive
(Curtis & D’Esposito, 2003). In children with TLE, central
executive impairments were smaller in magnitude than in
children with FLE.
There is emerging evidence of central executive deficits in
children and adults with TLE, which may suggest that work-
ing memory processes are interrupted due to the propagation
of seizures from the temporal to the frontal lobes, or that
these seizures disrupt the subcortical structures that support
working memory, such as the hippocampus, caudate, and
thalamus (see O’Muircheartaigh & Richardson, 2012; Stret-
ton & Thompson, 2012 for a review). Another possibility is
that the moderate impairment of phonological loop in chil-
dren with TLE has a detrimental effect on children to effec-
tively utilize the central executive. For instance, a neuroim-
aging study found that performance on digits backwards,
which was the most common measure of central executive in
this review, also activated areas important for the phonologi-
cal loop (Gerton et al., 2004). The current review, however,
did not reveal significant central executive deficits in chil-
dren with unilateral TLE. For children with GGE, whose sei-
zures propagate rapidly and simultaneously across the cortex
in both hemispheres (Helmstaedter & Witt, 2012; Mattson,
2003), a significant, and moderate impairment was found in
central executive. In summary, this review revealed that in
children with epilepsy the central executive is vulnerable to
seizures arising outside of the frontal lobes, but is markedly
impaired in children with FLE.
We also examined whether other epilepsy variables,
such as age at testing, age of epilepsy onset, and duration
of epilepsy disorder relate to working memory using meta-
regression. Age at testing was not significantly related to any
of the working memory components, which is unsurprising
as the majority of tasks of working memory included in this
review were age standardized. A younger age of epilepsy
onset, however, was associated with greater impairments
in the phonological loop and visuo-spatial sketchpad, but
it was not associated with the central executive. We found
that longer duration of epilepsy disorder was associated with
greater impairments in visuo-spatial sketchpad, but not the
phonological loop or central executive. It is unclear as to
why individual components of working memory differen-
tially relate to age of onset and duration of epilepsy disorder,
as (i) the three components of working memory are found
to develop linearly from six years of age until adolescence
(Gathercole et al., 2004) and (ii) young age of seizure onset
and longer duration of epilepsy were both found to be detri-
mental for development (Sanchez & Jensen, 2001; Whelan
et al., 2018). For example, a longer duration of epilepsy was
associated with lower subcortical volume and cortical thick-
ness in a worldwide study that involved 2149 individuals
13
Neuropsychology Review
with epilepsy (Whelan et al., 2018). Nonetheless, it appears
that the two slave components of phonological loop and
visuo-spatial sketchpad are at greater risk with a younger
age of epilepsy onset, whereas impairments in the central
executive are not sensitive to either age of onset or duration
of epilepsy.
Given that only a small number of studies reported rela-
tions between working memory and other variables of inter-
est (seizure frequency, AED medication, surgery outcomes,
neuroimaging findings and academic skills and achieve-
ment), these variables were examined in systematic review
only. Three studies that examined the impact of seizure fre-
quency on working memory components gave conflicting
findings. Higher seizure frequency was significantly associ-
ated with poorer central executive performance in a mixed
group of epilepsy cases with a comorbid diagnosis of ADHD
(combined inattentive and hyperactive subtype; MacAllister
et al., 2012), but no correlations were found for the pho-
nological loop. In contrast, Stewart et al., (2019a, 2019b)
found no relationship between seizure frequency and cen-
tral executive function in children with TLE. However, that
study found no deficits in central executive in these children,
compared to typically developing children. Finally, Gold-
berg-Stern et al. (2010) found no difference in visuo-spatial
sketchpad and central executive of children with BECTS
that had low seizure frequency compared to children with
BECTS that had high seizure frequency, and this study also
found no impairments in either visuo-spatial sketchpad
or central executive relative to healthy controls. For AED
medication, Williams et al. (1996) found that phonological
loop was impaired in children taking two AEDs compared
to children taking one AED. In another study that included
children with epilepsy and comorbid ADHD, higher number
of AEDs was associated with poorer central executive, but
not with phonological loop (MacAllister et al., 2012).
Surgery could carry a risk of decline in working mem-
ory. Specifically, unilateral temporal lobectomy may be fol-
lowed by a decline in slave components (phonological loop
or visuo-spatial sketchpad) of the working memory system,
as the left temporal lobe is involved with phonological loop
and the right temporal lobe hemisphere is important for the
visuo-spatial sketchpad (Smith & Jonides, 1997). To date
only one study examined changes in phonological loop
and visuo-spatial sketchpad from pre- to post- unilateral
temporal lobectomy (Jambaqué et al., 2007). Contrary to
the expectation, both phonological loop and visuo-spatial
sketchpad had improved in children who underwent either
right or left temporal lobectomy approximately one-year
post surgery. In contrast, in a study that examined changes
in working memory in children who underwent posterior
resection (i.e. parietal or occipital) for intractable epilepsy
found no change in phonological loop pre- to one-year-post-
surgery (Sinclair et al., 2005). This discrepancy in findings
Neuropsychology Review
may be due not only to the differences in the site of surgery,
but also to differences in study samples. Sinclair and col-
leagues included children with mild intellectual disabilities
and variable seizure outcomes post posterior surgeries. In
contrast, Jambaqué and colleagues included children who
were free of intellectual disability and were seizure free
post-surgery, hence had greater developmental potential
pre-surgery, which was released rather than disrupted by
seizures post-surgery.
Neuroimaging findings were related to working memory
data in one study only. The study included children with FLE
and healthy control children. Structural and functional MRI
were employed. Children with FLE displayed large deficit
in phonological loop, a decreased connectivity throughout
the brain, but comparable pattern of brain activation relative
to healthy control children (Braakman et al., 2013). Fur-
ther, when cognitively impaired patients were compared
to cognitively intact patients, a difference was found in a
subset of connections, namely, frontal lobe connections. No
other studies in this review utilized neuroimaging methods
to investigate visuo-spatial sketchpad or central executive
components of the working memory system.
There are well-established risks of academic learning
difficulties in children with reduced working memory the
general population (Gathercole et al., 2016; Gathercole &
Pickering, 2000). Thus, it is surprising to find only two stud-
ies that examined the relationship between working memory
components (phonological loop and central executive) and
academic skills. One study indicated that impaired phono-
logical loop was associated with poorer outcomes in early
academic skills (reported as a combined score of word read-
ing, spelling, grammar and conceptual math skills) (Wil-
liams et al., 2001). This association was not significant, how-
ever, when controlling for verbal intelligence. Another study
found that children with epilepsy who had repeated a year
at school and required special educational assistance had
poorer phonological loop and central executive, as measured
by a word span task (forward and backwards) compared to
typically developing children (Schouten et al., 2002).
No studies included in this review examined the relation-
ship between visuo-spatial sketchpad and central executive
and specific academic outcomes (such as reading, writing
and mathematics) in children and adolescents with epilepsy.
This is surprising, given that poor central executive function-
ing has been associated with deficits in reading and math-
ematical skills in typically developing children (Gathercole
et al., 2016; Peng et al., 2016) and in children with learning
difficulties (Alloway, 2009) and reading disabilities (Swan-
son et al., 2009). Nevertheless, the impact of working mem-
ory (but not central executive specifically) on academic out-
comes in children with epilepsy has been identified, with one
study (which was not included in the meta-analysis) revealed
that verbal working memory (comprised of a phonological
loop and central executive composite score) moderated aca-
demic outcomes, specifically word reading, spelling, and
arithmetic (Danguecan & Smith, 2017). These results indi-
cate that verbal working memory likely plays a role in math-
ematics in children with epilepsy. Given that Danguecan and
Smith (2017) used a composite measure of working memory
and a mixed epilepsy group, it is unclear whether deficits in
either the phonological loop or the central executive under-
pin difficulties with mathematics in this clinical population,
and what role does the visuo-spatial sketchpad have in math
difficulties in epilepsy. This is important, given that dif-
ferent components of working memory relate to different
academic skills, and that this review has found that each
component of working memory is differentially impaired
across epilepsy types. Thus, further research is needed on
the relationship between working memory components and
specific academic skills across different epilepsy groups, in
order to provide early identification and targeted intervention
for children with epilepsy.
Limitations of the Literature and Current Review
Several limitations of the current review, including the state
of the literature, needs to be acknowledged. A large number
of studies were excluded from this review (n= 51), as they
did not report separate outcomes for different working mem-
ory components. The excluded studies typically reported a
composite score, including both storage (phonological loop)
and attentional control (central executive) components, as
these studies mainly used test batteries for assessment of
intellectual skills, such as the WISC, which include subtests
that measure working memory, but do not provide separate
scores for phonological loop and central executive compo-
nents of working memory. Of the studies that were included,
only a small number of studies examined the visuo-spatial
sketchpad and no studies included in this review utilized a
measure of episodic buffer, which is an important interface
between each component of working memory and episodic
long-term memory (Baddeley, 2000). The lack of studies
that have examined each of the working memory compo-
nents suggest that examination of working memory in epi-
lepsy has been largely a-theoretical and the assessment of
working memory has been a side variable.
Another limitation of the literature was that few studies
reported working memory outcomes separately for epilepsy
subtypes (i.e. TLE, FLE, extra-TLE or FLE). Given that
visuo-spatial sketchpad and central executive were selec-
tive according to site of epilepsy focus, studies that included
mixed epilepsy subtypes may lack sensitivity for the dis-
tinct pattern of working memory impairments that may be
disrupted by location of seizure focus. For instance, in this
review, a small number of studies differentiated between
left, right and bilateral seizure focus in focal epilepsies. No
13

studies included in this review examined impact of side of
seizure focus on working memory in children with FLE or
extra-TLE or FLE. Only two studies included in this review
had seizure foci outside the temporal and frontal lobes
(extra-TLE or FLE). With respect to epilepsy variables, few
studies examined the impact of seizure frequency, medica-
tion, or surgery status on working memory outcomes. Given
that age of onset and duration of seizure disorder had a sig-
nificant negative effect on the slave components of working
memory, chronic and difficult to control seizures may have
a negative impact on working memory, which can lead to
greater risk of functional problems, such as academic under-
achievement. Children with chronic and difficult to control
seizures also often require polypharmacy, which is known to
have an adverse outcome on cognition (Vingerhoets, 2006),
but the impact of AEDs on each component of working
memory is less known.
The quality analysis indicated that there is potential for
selection bias across studies, as most studies did not recruit
participants through consecutive referrals and no studies
reported the non-response rate for either epilepsy or control
children. In this review, there was significant heterogeneity
observed across studies, which may reflect the diverse nature
of epilepsy subtypes and syndromes, and the etiology of
epilepsy that can vary substantially across cases. Sensitivity
analyses revealed that higher selection quality was associ-
ated with less heterogeneity. Whilst higher selection qual-
ity was associated with a reduction in effect size (small to
moderate), these remained significant. In contrast, studies of
low selection quality had slightly larger effect sizes but also
large and significant heterogeneity, suggesting that bias may
be present in those studies.
Regarding methodological limitations of this review, only
papers published in the English language were included.
Hence some relevant papers published in languages other
than English could have been missed. Unfortunately, we did
not have resources to review papers that were not published
in the English language. This review also excluded papers
that used validated measures of working memory, but did
not report scores of “number of correct items” recalled, such
as studies that used measures that rely on reaction times or
omission and commission errors, thus limiting the review to
mostly span-based measures of working memory. Finally,
we included only peer reviewed published papers. While
relevant papers from the grey literature could have been
missed, these papers have not undergone peer reviews as
yet, and may have been of more mixed quality. As a result,
this could potentially inflate publication bias of included
studies. However, given that the majority of studies in this
review reported working memory results as a side variable
from a large body of assessment tasks, the risk of publication
bias is less likely to be over inflated.
13
Neuropsychology Review
Future Directions
First, future studies should assess and report findings for
each working memory component, including the episodic
buffer, which has not been examined in children with epi-
lepsy, and establish functional correlates of working mem-
ory impairments in children with epilepsy. This is important,
as studies conducted with general populations have indi-
cated that each component of working memory is associ-
ated with different neural networks and functional outcomes
(D’Esposito, 2007; Smith & Jonides, 1997; Wager & Smith,
2003).
Second, future studies should be theoretically guided and
used to test cognitive models in the developing brain. Stud-
ies of children with epilepsy with seizure focus in different
brain regions can inform us which brain regions are essential
for development of certain working memory components.
Third, future studies should further investigate relations
between each component of working memory and aca-
demic achievement in children with epilepsy as for typically
developing children, differential relations have been found
between components of working memory and academic
underachievement. For instance, impaired reading ability
had a greater relationship to verbal working memory (i.e.
measures that comprised the phonological loop and verbal
central executive), than visuo-spatial working memory (i.e.
measures that comprised the visuo-spatial sketchpad and
central executive for visual material). Whereas math perfor-
mance, was related to both verbal and visuo-spatial compos-
ites of working memory (Gathercole et al., 2016). Further-
more, there is evidence that the visuo-spatial sketchpad and
central executive is important for learning and acquiring new
math skills and concepts, however, the phonological loop
becomes more important once the skill has been learned and
children get older (Raghubar et al., 2010).
The current review indicated that an earlier onset of epi-
lepsy was related to poorer phonological loop and visuo-spatial
sketchpad, however, the potential subsequent impact of ear-
lier epilepsy onset on arithmetic performance in these children
remains unknown. This is important to investigate, as children
with epilepsy have been found to be at risk of academic dif-
ficulties, which tend to be particularly pronounced in math
(Black & Hynd, 1995; Jackson et al., 2013; Rathouz et al.,
2014; Seidenberg et al., 1986, Danguecan & Smith, 2017).
Fourth, future studies should focus on interventions for
working memory deficits in children with epilepsy. While
our review has revealed a solid body of evidence showing
that children with epilepsy are at risk of working memory
deficits, intervention studies are almost absent. The excep-
tion is a study that evaluated efficacy of a computerized
working memory training (Cogmed) program in school-
aged children with epilepsy (Kerr & Blackwell, 2015). The
Neuropsychology Review
program aims to increase working memory capacity, and
involves intense, repetitive, daily exercises and training to
capacity. On completion of training, children in the interven-
tion group significantly greater gains in the central execu-
tive and visuo-spatial sketchpad, but not the phonological
loop, components of the working memory. The finding of
this intervention study suggests that a computerized work-
ing memory training may be useful for children with epi-
lepsy that have reduced visuo-spatial sketchpad and central
executive, such as children with FLE and GGE. In contrast,
Cogmed working memory training may not be effective for
children with unilateral TLE, as they have impaired pho-
nological loop, but not central executive and visuo-spatial
sketchpad. Whilst finding that Cogmed increased capac-
ity of some working memory components in children with
epilepsy is very encouraging, it is important to notice two
limitations of this pioneering study. First, the study had a
waitlisted controlled designed rather than a randomized
controlled design that can be used with Cogmed delivered
to pediatric patients with neurological insults (e.g., Phillips
et al., 2016) and would provide a more robust evidence for
intervention efficacy. Second, studies conducted with gen-
eral pediatric populations have provided conflicting evidence
in relation to gains made in working memory capacity either
generalizing to other cognitive domains or leading to gains
in academic performance or behavioral functioning (for
reviews see Melby-Lervag & Hulme, 2013, Spencer-Smith
& Klingberg, 2016). In children with epilepsy, there was no
evidence of transfer of gains made in working memory to
fluid reasoning on completion of Cogmed training (Fuentes
& Kerr, 2017). To our knowledge, no studies to date exam-
ined whether increase in working memory capacity is asso-
ciated with improvements in either academic or behavioral
skills in children with epilepsy.
Given the limited evidence of functional gains being
made on completion of computerized working memory
training in the general pediatric population, it is important
to consider another type of working memory intervention,
the one that aims to alleviate functional difficulties associ-
ated with poor working memory rather than increase work-
ing memory capacity as such. This type of working memory
intervention involves reducing the load on children’s work-
ing memory by teaching children internal strategies and
controlling environment to better match children’s working
memory capacity, prevent information overload and increase
the likelihood of tasks being successfully completed (Gath-
ercole & Alloway, 2008). The main techniques used involve
teaching memory boosting strategies, using external mem-
ory aides, and breaking down instructions into shorter and
less complex chunks of information. However, this is also
an under-researched area, as few ‘every day’ interventions
of working memory have been subjected to a randomized
control trial, and has mixed evidence for improvement in
academic skills (see Rowe et al, 2019 for a review). For
instance, only one study evaluated a classroom-based inter-
vention in children with low working memory capacity
(Elliot et al., 2010). This study found no improvement in
working memory capacity or gains in academic achieve-
ment with two classroom-based interventions for teachers.
On the other hand, a more recent study found improvements
in mathematics and spelling, but not reading or classroom
engagement, after a working memory intervention called
‘Memory Mates’ in typically developing children (Colmar
et al., 2020). However, the efficacy of this program for chil-
dren with low working memory capacity remains unknown.
Just recently, a proof of concept uncontrolled trial of a
web-based intervention for difficulties in executive function-
ing, that included but was not limited to working memory,
showed an improvement in parental ratings of their children
working memory in everyday life from pre-to post training
(Modi et al., 2019). No objective measure of working mem-
ory was used. While the intervention was web-based, the
intervention included learning modules (rather than repeti-
tive practices used in many computerized working memory
interventions), and problem-solving videoconferences with
a therapist during which solutions to challenges that arose
form deficits in executive functions in everyday life could be
solved. Whether parents’ reported improvements in working
memory are also found on objective measures of working
memory is unknown. Similarly, whether improvements are
also evident in children’s classrooms, social functioning, and
academic skills is also unknown.
Fifth, it is important to keep in mind that the in the gen-
eral population implications of working memory dysfunc-
tion are not just related to academic achievement. Limited
central executive has also been related to poorer social
development, including peer rejection and reduced social
competence (McQuade et al., 2013). Furthermore, working
memory was found to be a strong predictor of one of the
core social-cognitive skills in typically developing children:
theory of mind (Mutter et al., 2006), which was found to be
impaired in children with GGE (Jiang et al., 2014; Stewart
et al., 2018) and in children with TLE (Stewart et al., 2019a,
2019b). Hence, central executive capacity may need to be
considered in programs designed to improve social cogni-
tive skills, such as cognitive behavioral intervention with
theory of mind training for children with epilepsy (Stewart
et al., 2019).
Taken together, it is likely that targeted and fine-tuned
neuropsychological assessment can provide a greater under-
standing of the nuances of the working memory profile in
childhood epilepsy, with the aim to identify any risk factors
for academic and social skill development. Thus, early iden-
tification of working memory difficulties can pave the way
for early interventions which will use strategies adjusted to
each child’s working memory features.
13

Conclusions
To our knowledge, this is the first comprehensive system-
atic review and meta-analysis to examine working memory
in children with epilepsy. We found that children and ado-
lescents with epilepsy are at risk of working memory defi-
cits that involve each component of the traditional working
memory model: the phonological loop, visuo-spatial sketch-
pad and central executive. There were no studies, however,
that examined the component of the model that was added
in 2000: the episodic buffer. The magnitude of working
memory impairments differed depending on the working
memory component; moderate impairments were found for
the visuo-spatial sketchpad and central executive, and mod-
erate to large impairments were found for phonological loop.
Moreover, the pattern of working memory deficits differed
according to site or side of epilepsy for the central execu-
tive and visuo-spatial sketchpad, but not the phonological
loop. That is, phonological loop was significantly impaired
across all sites and sides of seizure focus. In contrast, the
visuo-spatial sketchpad was selectively impaired in chil-
dren with TLE and GGE. Similarly, the central executive
was selectively impaired for FLE, GGE and TLE groups.
Children with FLE had large deficits in phonological loop
and central executive, with no studies examining the visuo-
spatial sketchpad for this group.
Identifying the pattern of working memory deficits
according to site and side of seizure focus can improve
differential diagnosis of children with epilepsy and pro-
vide clinicians with a detailed understanding of the risk of
working memory difficulties, along with the neurological
and functional impact that these difficulties may have. The
lack of studies included in this review that examined the
role of working memory components and academic skills
is surprising, given the increasing literature of working
memory and academic skills in typically developing chil-
dren and learning disordered children, and the implica-
tions for interventions. Greater understanding of working
memory problems in children with epilepsy can lead to
targeted interventions, such development and implemen-
tation of interventions that aim to improve capacity of
a specific working memory component in combination
with adaptive and problem-solving approaches that could
enhance generalization and functional outcomes.
Acknowledgements No potential conflict of interest was reported by
the authors. This work was supported by the Australian Government
with a Research Training Program (RTP) Stipend Scholarship. We
would like to thank the researchers who were very generous in pro-
viding access to their data upon request. We would also like to thank
Professor Jennifer Chan, Sarah Hamilton, Dr. Dan Quintana, and Dr
Michael Borenstein for their statistical advice at various stages of this
manuscript.
13
Neuropsychology Review
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