Cognitive screening informs referrals for neuropsychological evaluation in children with epilepsy.

Objective: This study aimed to evaluate the effectiveness of current neuropsychology referral methods for children with epilepsy and develop data-informed recommendations for use of performance-based cognitive screening measures to improve these processes.

Methods: Children with epilepsy who had been referred to neuropsychology (n = 51) or had never been referred (n = 34) completed four brief tablet-based screening tests from the National Institutes of Health Toolbox Cognition Battery along with a comprehensive neuropsychological test battery. Demographics, medical information, and parent questionnaires were gathered.

Results: Mean performance on the neuropsychological test battery was worse in the referral group (p = .008, d = .52), but percentage of patients who presented with cognitive impairment (at least two scores 1.5 SD below the mean) did not differ. Demographics did not predict performance on the comprehensive neurocognitive battery (p = .46, $R_{\text{change}}^2$  = .06). Medical variables added some predictive value (p = .004, $R_{\text{change}}^2$  = .25). Parent questionnaires added minimal value (p = .066, $R_{\text{change}}^2$  = .05) beyond the previous variables. Performance on the cognitive screening battery added significant predictive value (p < .001, $R_{\text{change}}^2$  = .31) above demographics, medical variables, and parent questionnaires, explaining 31% additional variance in performance on the comprehensive neuropsychological battery. Stepwise analysis suggested that only three screening tests, totaling 15 min of administration time, were necessary. A cutoff score of .70 SD below the mean on any of those screening tests had high sensitivity (.90) while maintaining specificity > .50. A cutoff score of 1 SD below the mean provided better balance of sensitivity (.74) and specificity (.70).

Significance: Brief and easy to administer performance-based cognitive screening may add value and reduce bias when making decisions about neuropsychology referrals for children with epilepsy. An ideal clinical model could include neuropsychology consultation with chart review, clinical interview, questionnaires, and brief cognitive screening to inform referrals for more comprehensive evaluation. In settings where this is not possible, cognitive screening may be a useful and minimally resource-intensive method for informing referral decisions.