Neuropsychologic testing in neurology clinics is often necessary
to document cognitive and general intellectual abilities in
children with acquired or inborn forms of encephalopathy. Availability
of testing is limited, however, because of expense, length of
time to complete testing, and difficulty of using long reports
in a busy clinic. Our protocol addressed these limitations by
contracting with an out-of-plan psychologist to perform selected
complementary standardized psychometric tests as an extension
of the neurologic evaluation.
Methods: Sixty-nine children were referred from primary
care clinics because of diagnostic uncertainty or treatment
failure. Children received complete neurologic assessment, after
which a neuropsychology battery of tests was administered to
screen aspects of cognitive functioning. Psychosocial questionnaires
also were administered to collect input from parents, teachers,
and the children themselves. Findings were presented in a tabular
format organizing specific test scores with standard deviations,
followed by a brief narrative conclusion. A synthesis of findings
was provided to parents at a follow-up visit with the neurologist
and psychologist. Differences in viewpoints were reconciled
before a treatment plan was given.
Of undiagnosed children, 70% were found to have attention difficulties,
58% had unrecognized learning disorders, and 17% had major mood
disturbance. A postvisit survey of parents reflected satisfaction
with the protocol, and 80% of parents expressed relief that
the child's problems were objectively defined. Costs were about
30% to 40% of alternative types of independent, nonintegrated
Discussion: This service lessened demands in the primary
care clinics because parents were motivated and were specifically
directed to pursue specific medical and support services. This
plan could be adapted to other specialty clinics, such as psychiatry
or developmental pediatrics.
The Problem: Cost
and Complexity of Pediatric Neuropsychological Evaluation
most children can be diagnosed and treated for attention deficit hyperactivity
disorder (ADHD) and mood disorders, learning problems are more difficult
to define in primary care clinics. Furthermore, children with clearly
defined primary encephalopathic conditions of
ten have secondary comorbid disorders impacting mood, learning, and
central processing, even with stable primary conditions such as cerebral
palsy, seizures, or developmental delay. For instance, an anxious, moody,
misbehaving child with well-controlled complex partial seizures may
appear to be depressed. However, emergence of these symptoms only during
the week and not on weekends or holidays points to the possibility of
a specific learning dis
ability or central processing problem and indicates the need for neuropsychologic
feasibility of traditional neuropsychologic assessment has been questioned
by managed care administrators because these full evaluations are costly.1,2
Cost containment is a constraint that leads to an artificial division
between medical and psychologic services because of the high cost of
all but the most urgent neuropsychologic referrals. Such conflict between
and cost is frequently highlighted in the pediatric neurology clinic,
where many children have encephalopathic conditions that result in associated
learning disabilities, behavioral problems, and mood problems. In addition,
medical personnel often do not have the skills or the time to perform
age-normative standardized testing of cognitive and behavioral measures
in the clinic that adequately answer clinical questions. The customary
method of evaluating these cognitive and behavioral issues consists
of referral for a complete neuropsychologic assessment; as an alternative,
children may be referred to their school for testing. However, school
districts vary in assessment capability and are being pressed to provide
more services despite shrinking resources. This situation leads to service
omissions, especially for children with nondisruptive neurologic and
with a comprehensive neuropsychologic report, a neurologist may encounter
difficulty that limits the usefulness of consultation: The patient may
have to wait for an extended period to obtain an appointment, and then
the psychologist's report may be delayed
for two months or more; these reports often exceed 15 or 20 pages and
do not necessarily discuss problems that the neurologist must address
in the limited time available in the clinic; in addition, this psychologic
assessment is costly, sometimes two to three thousand dollars each.
Families whose children are evaluated frequently do not understand what
was discovered with the neuro-psychological testing and are unable to
relate the results to school and family life or to the medical diagnosis.
Approach to Effective, Efficient Pediatric Neuropsychologic Evaluation
overcome these limitations, a neuropsychologic screening assessment
battery was developed and implemented in the pediatric neurology clinics
of Kaiser Permanente Northwest. This screening was structured to complement
the neurologic examination and was initiated after a pediatric neurologist
or a developmental pediatrician determined the need for this assessment
by identifying specific areas of functional concern. Children referred
for assessment were frequently failing in school, were considered ineligible
for special educational services, or had disruptive behavior that interfered
with family and social functioning. Moreover, these children frequently
completed standard learning disability assessment through their school
district as well as nondiagnostic screening for ADHD or other behavioral
disorders through a primary care clinic before being referred to the
pediatric neurology clinic.
purpose of this project was to develop an economical, efficient neuropsychologic
screening process that could be integrated into a busy clinical setting
to develop a more sophisticated and effective neurologic examination
and treatment plan. In our protocol, the neuropsychologic assessment
period was limited to a half-day clinic and was adapted to each patient
on the basis of the neurologist's assessment. Neuro-psychologic evaluation
with a limited focus was made possible by integration with neurologic
assessment, especially the mental status examinations. Selection of
psychometric tests was designed to highlight specific areas of weakness
while confirming areas of strength or normal function. The children
referred often had complex clinical findings that required further testing
to more clearly define their functioning.
addition, we surveyed parents to determine whether they found the evaluation
valuable. This report describes evaluation measures and procedures,
summarizes outcomes for the first 69 patients evaluated, and presents
results of the parental feedback survey.
levels of screening in the primary care and neurology clinics led to
selection of subjects who had mood disruption and school failure and
whose parents were frustrated with the child's
behavior. Medical evaluation consisted in obtaining the medical history,
administering physical examination, reviewing the semistructured psychologic
narrative, and administering tests of neurologic and mental status.
Neurologic evaluation was done during a routinely scheduled clinic visit.
patients aged 4 years to 20 years (mean age, 12 years) were evaluated
by either a pediatric neurologist or a developmental pediatrician who
formulated a specific hypothesis regarding areas of suspected cognitive
deficits, behavioral problems, or mood disturbance. A neuropsychologist
performed a screening evaluation within the next two weeks to identify
specific areas of problems or deficits and to confirm other areas of
normal function and skills. The neuropsychologist was an outside consultant
paid by KP at a contracted rate for each evaluation. This service also
included brief follow-up discussion with both the family and the neurologist.
screening examination used standardized age-normative measures, lasted
approximately 3.5 hours, and included tests of dominant-hemisphere (language)
and nondominant (perceptual and constructional) abilities and memory.
Frontal lobe function was correlated with tests of executive function;
attention and information processing speed were assessed independently.
Psychosocial and mood problems were identified from responses to standardized
questionnaires and from structured interviews.
most patients, three or four neuropsychologic tests were administered
to review cognitive ability specific to a domain; additional testing
was administered to identify problem areas (Table 1). Measures of dominant-hemisphere
functioning included tests of expressive language, verbal memory (both
short-term and long-term), verbal learning, and anomia/naming. Measures
of nondominant hemisphere functioning included visual-spatial reasoning,
basic perception, complex perception, and visual construction as well
as visual memory. Attentional abilities were documented through measures
of processing speed and attention. Executive functioning was evaluated
using tests of problem-solv
ing and mental flexibility, fluency, inhibition, and simultaneous processing.
Psychosocial functioning was characterized by interviews and by parental
responses to standardized questionnaires. All measures were recorded
as age-normative standard scores with standard deviations.
were summarized in tabular and narrative formats. A table of results
using Microsoft® Excel was organized (Table 2)
that compares the patient's standard scores (and standard deviation)
with population mean scores. The table was followed by a brief narrative
results describing implications for life at school and in the family.
An example of the table is shown (Table 2). The psychologist and the
neurologist met briefly with each family to present results and to answer
questions. The impact of this assessment was estimated through direct
feedback as well as from responses to a questionnaire.
of the 69 referred children were found to have clinically significant,
neuropsychologically defined problems in addition to the primary neurologic
diagnoses or school assessment findings: 70% had abnormalities of attention,
58% had learning disabilities unrecognized by their school, and 17%
had major symptoms of mood disorder. The neuropsychologic findings led
to major reorientation in educational, medical, and supportive approaches
not otherwise considered previously for these children.
brief report format worked effectively in the clinic: Within fully scheduled
clinics, the neurologist could access all pertinent, specific information
from the table and one-page narrative and could quickly apply this information
to formulating the diagnosis and planning treatment. When medical and
psychologic viewpoints apparently conflicted, these were easily resolved
in a discussion with the parents, the neurologist, and the psychologist
at a follow-up clinic visit. Calculated on the basis of local billing
rates, cost of the evaluation service was approximately a third of comparable
independent lowest-cost, noncontract referral consultations.
families were greatly relieved that a child's dysfunction was recognized
and explained in terms of anatomic and physiologic principles instead
of being ignored or causing the child to be considered untreatable.
This response to the children's dysfunction also removed both the suggestion
of willful misconduct by the child and any parental feeling of shame;
instead, parents were shown a more realistic view of the child's weaknesses
and strengths. Parents felt more encouraged to take a more positive
approach in helping their children.
from parents and participating neurologists indicated high levels of
satisfaction with the program. Parents coming into the clinic often
reported that their child was not well understood and was struggling
in the school system as well as socially. Of the parents who completed
the survey, 80% rated the service as highly satisfactory; 82% reported
that the evaluation complemented their consultation with the physician;
and 74% indicated that they had learned new information about their
child's strengths and weaknesses. The survey report showed that 80%
found the evaluation useful for understanding their child and enabled
them to be more effective advocates when seeking specific accommodation
and services for the child.
example of the unique integrated assessment used in the project was
encountered in the case of a teenager who was thought to have dyslexia
and attention problems because she could not read well or finish her
school or homework tasks on time. Because of both her inability to make
adequate progress and the numerous hours she was spending on homework,
she became increasingly frustrated in her first year of high school.
Her reluctant verbalization tended to be simple or reflexive, even though
school testing found a relatively high verbal reasoning ability. Inadequate
compensatory techniques (eg, arguing and avoidance strategies) as well
as frequently irritable mood also were observed. On the basis of these
symptoms, school-based testing resulted in two diagnoses: oppositional
ant disorder and attention deficit disorder. Additional school testing
showed no deficit in decoding or reading single words and showed above-average
general intellectual ability with no delay in academic achievement.
examination showed that she had poor reading fluency and an upper motor
pattern of weakness affecting the left deltoid, triceps, iliopsoas,
and hamstring muscles. She also had sensory perceptual deficit in recognizing
numbers traced on the left palm while her eyes were closed. The appendicular
upper motor pattern of weakness and sensory perception deficit was consistent
with dysfunction of the right parietal and frontal areas.
Neuropsychologic screening assessment showed good performance in the
dominant hemisphere tasks of naming, decoding, and verbal learning.
Testing of the nondominant hemisphere showed average basic perceptual
skills as documented on the line orientation task, but relatively weak
results were seen for the higher-order drawing recall task as measured
using the Rey-Osterrieth Complex figure. This task required higher-order
integration of spatial organizational skills.3,4
evaluation showed also that although the patient had good basic language
skills, her ability to synthesize thematic elements and develop new
ideas was much weaker than her ability to define words and comprehend
spoken language. For example, although she could define words well,
she had difficulty with the Similarities Subtest from the Wechsler
Abbreviated Scale of Intelligence,5 which provided a
measure of conceptual reasoning. A key piece to this puzzle was the
patient's difficulty completing the recall components on the complex
figure test. Although she accurately recalled details of the complex
figure, the limitations she experienced reflected a lack of organization
or schema by which she could accurately organize the complex figure.
findings were consistent with the patient's mother's observation that
the patient could not process words in the context of a paragraph or
page of text, even though she could perform well with lists of isolated
words. This deficit is consistent with a right frontoparietal lesion:
The right hemisphere is uniquely specialized for spatial, perceptual,
and constructional comprehension and for overall organization of behavior
output and perception. The deficit is also consistent with modern functional
neuroimaging studies, which show an important role of the right hemisphere
in language processing.6,7 Integration of the information
obtained from both neuropsychologic and neurologic examination provided
a more complete picture of brain functioning than either discipline
could have achieved by itself.
have outlined a modified, multidisciplinary, economically efficient
process for evaluating selected children with diagnostic or treatment
failure. This approach is unique because it is integrated into the workflow
of a fully scheduled clinic but costs about two-thirds less than nonintegrated
neuropsychologic evaluation. Our process also offers another unique
feature: incorporation of a feedback mechanism to resolve contradictory
data and inappropriate conclusions. The neurology clinic seemed an appropriate
setting for thiapproach because neurologic brain involvement has a high
probability of affecting learning, central processing, and mood regulation.
This model could also be used in other clinics (eg, psychiatry or developmental
medicine) if support is provided and if access-related issues are well
project showed the utility of neuropsychologic screening evaluation
on several levels:
The evaluation identified neuropsychologic problems previously undiscovered
by other testing; the brief report format worked effectively in the
clinic; conflicting medical and psychologic viewpoints were easily resolved
at a follow-up clinic visit; and the evaluation service was much less
costly than other, noncontract referral consultations.
interdisciplinary approach yielded a more complete picture of brain
and behavioral inter-
relationships without having the disadvantages of major expense, delay,
or misunderstanding--disadvantages to be expected in creating a multidisciplinary
clinic with multiple clinicians evaluating only two or three patients
per day or sending children to an outside clinic for testing. The essential
component of this economy (ie, focused integration of medical and psychologic
viewpoints during evaluation and during summation of test results) departs
from the typical psychologic model (an extended standardized battery
of tests), where the process of gathering information does not target
a specific set of symptoms. Our model provides patients and their families
with integrated information.
multidisciplinary approach has many other conceivable applications in
a medical practice. Any medical or accidental intervention that can
produce an encephalopathic condition could be an appropriate subject
for this assessment. For instance, children with head injury may have
subtle changes in behavior, attention, mood, and learning. Specific
standardized neuropsychologic testing linked to neurologic findings
could not only confirm the primary diagnosis but may also be useful
in therapeutic decisions and prognosis. In other instances, drugs such
as anti-epileptic agents can affect nonictal brain functioning, and
these effects must be distinguished from seizures by means of integrated
neuropsychologic-neurologic analysis. Clear definition of these issues
can further redirect the care plan, which, if correctly determined,
can improve effects of treatment. This result, in turn, decreases utilization
of medical services in a patient population that makes heavy demands
on the time of clinic staff;8 and this reduced utilization
subsequently improves a patient's quality of life. This approach
is specifically applicable to a specialty clinic and may, with modification,
have limited use in a primary care clinic.
perception that neuropsychologic testing is a time-consuming, costly,
inefficient service for most neurology patients represented a prominent
challenge to development of this program. Because of the importance
of obtaining functional information, a concerted effort has been made
to develop brief assessment that leads directly to treatment plans.9
Strong emphasis on the interview to determine the clinical intervention--as
opposed to using the full battery of available psychologic tests--led
to de-emphasizing psychologic assessment.1 This project addressed
this limitation by developing a more focused role for limited, selected
protocol was designed to meet criteria commonly defined by the medical
model of consultation. In the medical consultative model, clinicians
receive brief highlights relevant to the referral question.10
The utility of developing brief consultative reports to specialists
is well established and frequently used; however, the literature on
efficacy and cost of brief versus extended modification of the neuropsychologic
battery is limited.11
an interdisciplinary approach of physician and psychologist to
produce a more complete picture of brain and behavioral interrelationships.
a neuropsychological screening evaluation when it is a limited,
selected standardized assessment based on a specific set of symptoms.
psychosocial functioning through interviews and parental responses
to standardized questionnaires.
the medical and psychological viewpoints during evaluation and
during summation of test results for patients and parents.
differences in viewpoints before giving a treatment plan.
few reports of protocols in a managed care setting have compared brief
psychologic assessment correlated with neurologic examination. Future
development of this form of assessment will require further validation
of our modification and will focus on integrating use of standardized
neuropsychologic, electrophysiologic, and imaging studies to understand
the links between brain function and structure.
authors express their thanks to Dr Robert Butler for advice in the development
of this program.
Stout CE, Cook LP. New areas for psychological assessment in general
health care settings: what to do today to prepare for tomorrow. J
Clin Psychol 1999 Jul;55(7):797-812.
Slaughter J, Johnstone G, Petroski G, Flax J. The usefulness of the
Brief Symptom Inventory in the neuropsychological evaluation of traumatic
brain injury. Brain Inj 1999 Feb;13(2):125-30.
Lezak MD. Neuropsychological assessment. 3rd ed. New York: Oxford
University Press; 1995.
Spreen O, Strauss E. A compendium of neuropsychological tests: administration,
norms, and commentary. 2nd ed. New York: Oxford University Press;
Psychological Corporation. Weschler Abbreviated Scale of Intelligence.
San Antonio (TX): The Psychological Corporation; 1999.
Watkins KE, Vargha-Khadem F, Ashburner J, et al. MRI analysis of an
inherited speech and language disorder: structural brain abnormalities.
Brain 2002 Mar;125(Pt 3):465-78.
Caplan R, Dapretto M. Making sense during conversation: an fMRI study.
Neuroreport 2001 Nov 16;12(16):3625-32.
Berman B. The academic children's hospital primary care clinic: responding
to the challenges of a changing health care environment. Clin Pediatr
(Phila) 2000 Aug;39(8):473-8.
Kubiszyn TW, Meyer GJ, Finn SE, et al. Empirical support for psychological
assessment in clinical health care settings. Prof Psychol 2000 Apr;31(2):119-30.
Armengol CG, Kaplan E, Moes EJ, editors. The consumer-oriented
neuropsychological report. Lutz (FL): Psychological Assessment Resources;
Piotrowski C. Assessment practices in the era of managed care: current
status and future directions. J Clin Psychol 1999 Jul;55(7);787-96.