The role of social context in cognitive and neurobehavioural outcomes in epilepsy

Cognitive and psychiatric comorbidities are among the most persistent and disabling challenges experienced by children and adults with epilepsy, with serious implications for daily functioning, health-care utilization, long-term social outcomes and quality of life. Traditionally, research has focused on epilepsy-specific biological risk factors, such as seizure frequency or epilepsy syndrome, but growing evidence indicates that non-medical factors also shape neurodevelopmental, cognitive and neurobehavioural trajectories. This Review explores how individual-level and neighbourhood-level social factors, including income, education, health-care access and neighbourhood deprivation, contribute to disparities in cognitive and neurobehavioural outcomes across the lifespan in people with epilepsy. We propose the SocioBioCognitive Epilepsy framework, which integrates biological and social factors to better explain the heterogeneity of these outcomes, emphasizing critical developmental windows. We also recommend strategies to address social contributors to epilepsy, including self-management programmes, integration of community health workers into care teams and policy initiatives to address social needs in clinical settings. We highlight the need for a paradigm shift in epilepsy care from a seizure-centric model to a strategy that embraces holistic approaches across medical, educational and community domains. Future research should investigate the reversibility of social factors, explore biological mechanisms that link social adversity to brain outcomes and evaluate the real-world impact of integrated interventions.