Commentary: Toward a More Rational System for Delivering Pediatric Neuropsychological Services

Chronic and acute medical conditions of childhood often affect the brain and its functional development, with varying outcomes and varying degrees of severity. These conditions include not only neurological and neurogenetic disorders, but also medical conditions and their treatments. With growing awareness of these risks has come growing demand for pediatric neuropsychology services, raising its own set of concerns. In the current issue, Hardy et al. present a thoughtful and provocative Topical Review, entitled “A Prevention-Based Model of Neuropsychological Assessment for Children with Medical Illness.” They argue that too often referral to neuropsychology occurs after problems have arisen and become clinically worrisome, rather than earlier in the developmental process when prevention strategies might mitigate sequelae. For some conditions, such as brain tumor or stroke, the likelihood of serious neuropsychological sequelae is predictably high, whereas for others, such as leukemia or diabetes, outcomes are less predictable. In these more ambiguous situations in particular, a reliable and valid strategy for identifying children at greater risk would be an important advance. In addition to the concerns about prevention, the review is relevant more broadly to the current system of delivering neuropsychological services. Despite the evolution of health care delivery models over the years, the model of providing neuropsychological services has remained relatively static. Most often, a physician or parent makes a referral to the neuropsychologist, generally on the basis of some clinical appraisal of perceived need or a practice pattern, after which the child typically receives a comprehensive evaluation, with many hours of testing, yielding a lengthy and detailed report. Referral for services, however, can also depend on a variety of factors apart from the child’s actual functioning, such as the attitudes and experience of individual medical personnel, the advocacy skills of parents, or the policies of insurance carriers. Thus, for some children, this extensive evaluation may be necessary, others may not need such an intensive approach, while still others who need it may not gain access. As a result of this somewhat ad hoc model, in many settings the neuropsychology resources do not meet the perceived need, leading to long wait lists, demands for increased staff, and/or the inability of children with greater need to receive services in a timely fashion. Too often, determination of need falls to insurance carriers, who impose seemingly arbitrary criteria without regard for individual considerations. They reimburse not for quality or outcomes, but for procedures, potentially rewarding extensive and perhaps unnecessary testing that can be more reliably documented than expertise or benefit. It is within this context that this Topical Review proposes a systematic, tiered model for delivering neuropsychological services, applying principles from public health and assessment utility to the practice of pediatric neuropsychological assessment. The review argues for universal monitoring in medical clinics by nonpsychologist professionals, using questionnaires and computer-based instruments, to identify risk early in a child’s medical course, as well as to conduct ongoing monitoring of behavior and cognition. Those meeting certain criteria can be referred for a more