A Physician’s Guide

by Lynn B. Blackburn, PhD, ABPP
Dr. Blackburn is an Assistant Professor of Neurology at Washington University School of Medicine and Director of Pediatric Neuropsychology at St. Louis Children’s Hospital.

The treatment of the child with epilepsy involves attention to more than blood levels, EEG findings, and seizure frequency. Children with epilepsy are at increased risk for learning and behavior problems. Learning problems may stem from whatever is underlying the seizure disorder, from the effects of seizures or inter-ictal activity, and/or from medication side effects. Behavior problems may result from these same sources. In addition, behavior problems may result from parent’s confusion regarding what is fair to expect from a child with epilepsy. Parents often stop discipline or apply discipline inconsistently due to fears that misbehavior may have been a seizure or that medication may be responsible for the bad behavior. A neuropsychologist can assist the physician in his/her treatment of the whole child with epilepsy.

What is neuropsychological assessment?

Neuropsychological assessment is an approach to testing based on an appreciation of functional neuroanatomy and normal brain development. The neuropsychologist is interested in how the child obtains a specific test score as well as in the pattern of test scores. Skills are broken down into component parts, attempting to define a pattern of strengths and weaknesses. The pattern, interpreted in the context of anatomy and developmental stage, is then used to define an intervention plan.

The neuropsychologist responsible for this assessment holds a doctoral degree in Psychology. Graduate course work, often including neuroanatomy and neuroscience courses through a medical school, internship training, and post-doctoral training provide the knowledge base for test interpretation. The general training in clinical psychology included in this program provides a basis for the neuropsychologist to address the emotional and behavioral problems that may be associated with neurological disorders.

When should I consider neuropsychological assessment?

For the child with epilepsy, neuropsychological assessment is appropriate to:

  • Establish a performance baseline for use in documenting the functional effects of a medical intervention. Repeat assessment over time can then be used to determine the effect of the intervention on the child’s developmental course.
  • Address skill specific complaints. Complaints regarding memory, attention and emotional lability are common from the families of children with epilepsy. Neuropsychological assessment can help to identify skill factors and/or emotional factors that are contributing to these complaints.
  • Document current skill pattern as a basis for helping parents to set realistic expectations for their child
  • Determine why seemingly appropriate interventions for the child’s learning or behavior problems are unsuccessful.
  • Identify factors responsible for gradual or sudden changes in the child=s typical usual functioning

How will neuropsychological assessment help my patient management?

The neuropsychological assessment and report will provide you with:

  • A description of the child=s strengths and weaknesses
  • Suggested interventions for remediation of weaknesses or for compensating for weakness
  • Assistance in educating the school regarding the child’s needs, supporting appropriate school programming
  • A means of assessing the functional effects of your medical treatment
  • Parents who have a clearer understanding of their child=s developmental pattern
  • Parents who have a sense of what they need to do to help maximize their child=s development.

How do you refer a patient for neuropsychological assessment?

  • Provide a referral question. What do you want to learn from this assessment?
  • Provide relevant medical records. The pediatric neuropsychologist needs to know about the child’s medical history including information about birth, early development, recurring or chronic medical problems, and medication being given to treat the child. Chart notes typically will provide this information or you can summarize the history in a referral letter.
  • Inform parents that they will need to provide the pediatric neuropsychologist with copies on any previous assessments conducted with the child. If the child is receiving special education services, the neuropsychologist will need a copy of the child’s current Individual Education Plan (IEP), and of any testing done by the school as a basis for this plan.
  • Some insurance plans will require a letter from you indicating the medical necessity of the assessment, i.e. how it will affect your diagnostic assessment or medical management of the patient.
  • Assessment related to a medical condition or to establish a diagnosis for the basis of medical treatment is usually covered.
  • Most insurance plans will deny coverage for assessment used to establish an educational diagnosis (e.g. learning disability). Medical insurance carriers view this as the responsibility of the patient’s school.

How do I locate a pediatric neuropsychologist?

Many pediatric neuropsychologists work in pediatric medical centers, are affiliated with graduate education programs in psychology, or are in medical school settings. Most comprehensive pediatric epilepsy treatment centers have a pediatric neuropsychologist on staff.

What if I have questions about the appropriateness of assessment for a specific patient?

Most neuropsychologists are happy to discusses cases with you. If the patient is not appropriate for neuropsychological assessment, the neuropsychologist should be able to assist you finding an appropriate resource for your patient’s needs.