Pediatric Neuropsychology is a branch of psychology concerned with the management of those behavioral and learning problems that are associated with brain impairments in child and adolescent populations. Pediatricians or neurologists often discover puzzling behavioral or learning problems in their patients. Concerns about a child’s dyslexia, attentional disorder, or aggressive behavior often lead parents to seek professional advice. A mother may complain that her 7 year old is more hyperactive since that concussion last year; but is this a brain problem? An adolescent with a history of encephalitis as a child shows poor response to normal discipline; what should the parents do? A mother with a history of alcoholism is concerned about whether her past drinking during pregnancy has produced her child’s reading disorder. How do you manage the temper tantrums of a child with a seizure disorder? These and other questions require a neuropsychological assessment of the child or adolescent’s brain function to identify both the strengths and weaknesses, and to plan effective interventions.

Neuropsychological assessment is frequently a helpful adjunct to a pediatric medical examination. This is true in many cases of neurological disorder but also in disorders of attention, learning, or behavior where brain impairments are suspected. This brief primer is designed to answer questions about Pediatric Neuropsychology. It will address the history of neuropsychological assessment, what is included in a neuropsychological assessment, what types of cases it is most helpful for, and how one refers patients.

Neurological assessment of pediatric patients requires an understanding of the many factors that can affect the child’s normal brain development. For example, there is a significant difference between developmental dyslexia (e.g., where the child cannot learn to read) and acquired dyslexia (where the child loses a previously learned reading skill). Interventions can be different depending on the type of dyslexia as well as the age of the patient. Treatment of behavioral problems also needs to be adjusted for age as well as type of brain disorder. In addition, there are special testing approaches needed, particularly for children with attentional disorder. For questions about adult or geriatric neuropsychology, the reader is referred to Loring and Meador (1995). For more information about Pediatric Neuropsychology, see Hynd (1988).

Neuropsychological assessment has been used by physicians for over 40 years. Most of this use began after the 1995 studies by Ralph Reitan, which demonstrated a 96% hit rate for detecting brain lesions by using the Halstead-Reitan Battery (HRB) with no other information. Follow-up studies have shown 80-96% hit rates, which exceeds the hit rates for the standard neurological examination or for some lab tests like the EEG. Additional studies showed excellent hit rates for using the HRB to determine whether the lesion was in the left or right hemisphere (92% hit rate), and to localize its exact quadrant (79% hit rate). Based on this lesion-finding ability of the HRB, neurosurgeons, for years, used neuropsychological testing to assist in localizing lesions prior to surgery.

With the advent of the CT and MRI scan, this lesion-finding function of the HRB has been less important, since structural scans were even more effective at lesion-finding. However, structural scans do not give the physician any indication as to how the lesion affects the function of the brain. Therefore, neurosurgeons and neurologists have continued to use neuropsychological testing to provide a comprehensive functional examination that shows all the strengths and weaknesses in the functions of the brain.

While a standard mental status examination provides a good screening of mental skills, a neuropsychological assessment allows for an in-depth and comprehensive evaluation and development of strategies for remediation and methods of management of neurobehavioral disorders.

There is some variability from one Neuropsychologist to another, but the most common battery of tests is the Halstead-Reitan Battery (HRB). This includes the Category Test, Tactual Performance Test, Seashore Rhythm Test, Speech Perception Test, Finger Tapping Test, and the Trail Making Test. Using normative data, the results of these tests are used to calculate an Impairment Index. Additional tests usually included with the HRB are the Aphasia Screening Test, Sensory-Perceptual Examination, and Grip Strength on a Dynamometer. Also, the Wechsler Intelligence Scale for Children (WISC III) is included in the battery. Most neuropsychologists also include measures of memory and measure of school achievement. In some cases a more extensive language evaluation will also be added.

Children aged 5 and older are appropriate for neuropsychological assessment. Neurological cases or cases of neurodevelopmental disorder are the most commonly referred. The incidence of such conditions is estimated to range from 10% to 15% of children. However, not all such cases require neuropsychological evaluation. Generally speaking, those with known or suspected brain disorder, or those that are complicated or non-responsive to treatment, are prime candidates. Usually these patients with mild to moderate impairments will benefit most from neuropsychological assessment. In contrast, retarded patients or those with severe diffuse brain impairments are less likely to gain significant new information from neuropsychological exams. Although any ADHD case deserves a psychological assessment, the more complicated ADHD cases, or those non-responsive to treatment, might benefit from neuropsychological assessment. Neuropsychological testing adds a new perspective to the diagnostic puzzle, and this can lead to a clearer picture of the interventions needed.

This can apply to ADHD problems, learning disabilities, or to neurological disease. Children with traumatic brain injuries, fetal alcohol effect, brain tumors, hydrocephalus, seizure disorders, or post encephalitis residuals have functional impairments which may have serious consequences in terms of school performance. There may also be problems in social success, family interaction, and general psychological functioning. Impairments may include problems in reasoning, memory, planning, problem solving, attention, impulse control, and sensory-perceptual skills. Such neuropsychological impairments need to be identified so that interventions can be planned to prevent or minimize their effect. Lastly, children prone to impulsive aggression (with little or no provocation) often have brain problems which can be identified on neuropsychological assessment. The assessment can be helpful to the physician in selection of types of therapy, types of medication, family needs, and school interventions.

First of all, referring physicians should be aware of the qualifications of the psychologist doing the neuropsychological examination. Any clinical psychologist can use neuropsychological tests, but only those who are Board Certified have demonstrated a specialty in the field of Neuropsychology.

Ideally, referrals should be based on specific questions such as:

1. Is this mildly brain injured child ready to return to school, and if so how can the teachers manage his impulsivity?

2. What are the strengths and weaknesses of this learning disabled child, and what strategies should the teachers use to maximize learning?

3. How can we best manage this hydrocephalic child who has been having temper tantrums and does not respond to normal discipline?

4. Does this child with ADHD also have other neuropsychological impairments that are going to impact on his relationships with his peers and siblings, or affect his learning?

5. Is this adolescent girl demonstrating normal rebellious behavior, or is this related to her childhood head injury (and if so what do we need to do differently to help)?

6. Is there a behavioral treatment that can manage the oppositional behavior of this 10 year old with a history of a seizure disorder?

Hynd, G.W. (1988). Neuropsychological Assessment in Clinical Child Psychology, Newbury Park, Sage Publications.

Loring, D.W. and Meador, K.J. (1995). Neuropsychology for Neurologists, paper presented at the American Academy of Neurology, Seattle, Washington, May, 1995.

Please call (800) 272-4641 to arrange for a neuropsychological assessment or additional information. Comprehensive Neurobehavioral Systems provide neuropsychological assessments in Austin, Texas.