Exploring the Relationship Between Referral Source, Evaluation Setting, and Cognitive/Behavioral Characteristics in Children Referred for Psychological Evaluation

Background:  There has been little research completed to better understand the process by which children are referred for psychological evaluation. Some have argued that pediatricians and primary care physicians are in a unique position to identify (and refer) “at-risk” children. Other research suggests that parental concerns may serve as a useful tool in the identification and referral of children with developmental and behavioral concerns.

Objectives:  This study aims to explore the demographic and clinical characteristics of children who were seen for (neuro)psychological evaluations in a large clinical outpatient specialty setting. We hypothesize that caregiver-referred children will present with a different symptom profile than those referred by professionals.

Methods:  Participants included 845 children (M_age=10.5, SD=3.3, Range=5-21 years) who received (neuro)psychological evaluation and were diagnosed with autism spectrum disorder (n=94), attention deficit hyperactivity disorder (ADHD; n=620), and/or anxiety (n=41). Demographic information (age, race, sex, and type of insurance) and clinical information (cognitive, behavioral, and adaptive functioning) were extracted from our clinical database. Chart review was completed to confirm diagnosis, assess for missing data, and document referral source (coded as either “caregiver" or “professional”). Cognitive functioning was measured using one of the Wechsler Scales (i.e., WPPSI-IV, WISC-IV, or WAIS-IV). Participants with both Verbal and Performance IQ < 70 were excluded (FSIQ: M=88.5, SD=16.0). Information on externalizing, internalizing, and adaptive behaviors was obtained using composite scores on the Behavior Assessment Scale for Children (BASC-2) and Adaptive Behavior Assessment System (ABAS-2).

Results:  Referral groups were defined as those referred by professionals (63%) or caregivers (29%). There were no significant differences in behavioral symptoms or intelligence scores between referral groups. However, children referred by caregivers had significantly better adaptive scores (ABAS-2, General Adaptive Composite: M=76.8, SD=16.5) than those referred by professionals [(M=73.9, SD=16.3), t(742)=2.3, p=.03]. Results show a significant difference in both the number of diagnoses (single versus comorbid) based on referral source (X² (1, N=773) = 10.4, p<.01), as well as the type of diagnosis (autism versus ADHD) (X²  (1, N=698) = 11.4, p<.01), with professionals being more likely to refer children with comorbidities and ADHD. Professionals were also more likely to refer children with public insurance than private insurance (X²  (1, N=771) = 8.0, p=.02).

Conclusions:  Overall, professionals were more likely to refer children for (neuro)psychological evaluation than their caregiver. Those children referred by professionals were somewhat more involved, having lower adaptive functioning, increased diagnostic comorbidities, and lower SES. Additionally, professionals were more likely to refer children with ADHD than their caregivers, while parents and professionals were equally likely to refer children with ASD. While, there is not a predominant difference in clinical presentation that is associated with referral source, professionals should be aware that families of lower SES may not be effectively recognizing or voicing their child's needs. Further, parents of children with ASD may be in a better position to recognize more subtle symptoms of ASD that do not present in brief office visits. Future investigation into effects of age and type of referring professional (e.g., medical provider vs. school personnel) is suggested.