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BHIPP Bulletin

Volume 7, Issue 12

June 2022

When to refer children for further evaluation: Understanding different types of psychological testing

This month's BHIPP Bulletin is a contribution from Carisa Parrish, PhD, Associate Professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins School of Medicine, Director of Pediatric Health Psychology, Johns Hopkins Children's Center and BHIPP Consultant. Additionally, this month's BHIPP Resilience Break focused on "Types of Mental Health Evaluations and When to Recommend Them" presented by Antonia Girard, PsyD, BHIPP Consultant. To view the full session recording, slides, and related resources: click here!

Parents, pediatricians, and teachers routinely consider whether a child would benefit for further evaluation for developmental, behavioral, learning, and psychiatric concerns. There are a number of reasons that could prompt a pediatrician to suggest a referral for further psychological testing. Keep reading for a review of how to support caregivers with ongoing behavioral health screening, domains of psychological testing, and 3 types of psychological testing. 

Reason for referral

Referrals for psychological testing come from numerous sources, including pediatricians, teachers, parents, psychologists, and psychiatrists. As with other aspects of physical health, there are a routine set of screening tools that are used universally to systematically identify emotional, behavioral, cognitive/academic, and social problems. 

There are many well-validated screening tools for a range of common childhood problems (e.g., Ages and Stages Questionnaire for developmental milestones, CHAT for autism spectrum disorder, SCARED for anxiety, PHQ for depression, Vanderbilt for ADHD and associated problems), and use of a well-validated screening may be a great place to start. Monitoring and/or treating an identified problem using a well-validated screening tool may help filter out common problems with effective treatments before moving to a psychological evaluation. Although these screening tools may not seem as objective, reliable, or valid as a thermometer or scale, these well-validated behavioral health tools could point to emotional stress, learning vulnerabilities, or behavior problems that are actually excessive for a child’s age! This pre-screening may help pediatricians determine who would benefit from further psychological testing. 

Even in the absence of these handy screening tools, pediatricians, parents, and other trained professionals who work with children often observe that something in a child’s development or functioning seems problematic. This observation of concern may be discussed with parents and teachers, and if there is a reasonable hypothesis regarding the concern (e.g., a recent life stressor, a sustained pattern of temperament), children may receive additional support or a referral for therapy or a psychiatrist appointment as a first-line approach to clarifying a child’s difficulty. However, if a child displays persistent difficulties that do not respond to a first or second effort at improving the problem, or there are multiple competing hypotheses to explain the problem, then pediatricians should consider referring that child for a psychological evaluation.

Why refer?


A child may be referred for a psychological evaluation if there are any concerns with cognitive abilities (including language and concentration), learning, emotional functioning, social skills, or behavior.

Domains of psychological testing

Pediatric neuropsychologists, child psychologists, and school psychologists are trained to administer a range of tools to assess children’s development and functioning across domains of attention, behavior, cognition, emotions, language, learning, memory, socialization, and temperament. Tests may assess executive functioning, intelligence, academic achievement, and disorders affecting behavior and mood. Psychological tests can help identify developmental delays across all domains, including learning disabilities, intellectual disabilities, autism spectrum disorders, and ADHD. When emotional and behavioral disorders are present, psychological assessments can help clarify whether these are associated with cognitive and learning problems.


Just as pediatricians can measure height and weight, velocity and growth (or lack thereof), psychologists can measure whether a child who seemed like a vulnerable reader in second grade presents with a definite learning disability needing an IEP as a 4th grader. These domains can be measured and compared with a normative population to derive a standardized score and percentile. A child with weight less than the 3rd or 5th percentiles can be diagnosed with failure to thrive, and those with weight exceeding the 85th and 95th percentiles can be considered in the overweight and obesity categories; likewise, a child with general cognitive abilities less than the 1st percentile can be diagnosed with an intellectual disability, and a child rated by parents and teachers as displaying hyperactivity/impulsivity and/or inattention that exceeds the 85th or 95th percentile can be diagnosed with ADHD. 

Clinical psychologists typically spend 5-7 years in doctoral programs (PhD, PsyD), 1 year on a predoctoral internship, and 1-2+ years on postdoctoral fellowships. Training includes diagnosis, consultation, therapeutic interventions, psychological assessment, and research. Passing the national exam in psychology and state jurisprudence exam are the final steps in eligibility for licensure as a psychologist. Clinical neuropsychologists focus more exclusively on assessment, and board-eligibility typically culminates in a 2-year specialty fellowship in neuropsychological assessment. School systems may employ a doctoral-level psychologist or a school psychologist with a masters degree. School psychologists and psychologists employed in educational settings may not focus on symptoms related to psychiatric disorders, as their focus is primarily on academic progress and educational plans. However, some clinical psychologists and neuropsychologists may not provide educational testing because it is not covered by insurance, and some psychologists see this testing as the responsibility of the school.


Who should I refer to?

Pediatricians are strongly encouraged to develop a network of trusted, well-vetted colleagues in clinical psychology who provide the type of testing that is most appropriate to a patient’s needs. Consider referring a child to a well-established clinic at an academic medical center if there are not colleagues locally. BHIPP can assist you with referrals to well-established practices of psychological and/or neuropsychological testing.


  • If a child is struggling in school and struggling with learning, parents should seriously consider requesting a Student Support Team (SST) meeting, along with requesting a referral for educational testing.
  • For general concerns that span psychological symptoms, learning, and behavior, referral to a child psychologist may be most appropriate. For example, if a child has been in mental health treatment (psychiatric medication and/or therapy) and not experiencing relief of symptoms, or the mental health clinician is unsure of the child’s psychiatric diagnosis, that is sufficient to prompt a referral for a psychological evaluation. Perhaps the pediatrician believes that a child likely has a particular disorder that could be treated appropriately in primary care (e.g., ADHD), but wants to be vigilant for comorbid conditions that require educational supports (e.g., learning disability) or further psychological treatment (e.g., anxiety, depression). In that case, referral for a psychologist may be more appropriate, as treatment recommendations are desired.
  • If a child has a neurological disorder or has experienced a traumatic brain injury, a referral to a pediatric neuropsychologist in particular may be most appropriate for ensuring that specific tests of executive functioning, memory, and attention are selected for developmental monitoring.

As always, if you have questions about the behavioral health needs of your patients, we encourage you to call the BHIPP consultation line at 

855-MD-BHIPP (632-4477), open 9am-5pm Monday-Friday, for resource/referral networking or consultation support.

We will keep you informed about all our services and training events through our website (www.mdbhipp.org) and monthly e-newsletters. Additionally, BHIPP is on LinkedIn, Twitter, and Facebook. We invite you to follow us there to stay up-to-date on upcoming training events, pediatric mental health research, and resources for providers, families and children.

A Special Note from the Author

Dear BHIPP colleagues,

It has been my pleasure to serve as a BHIPP consultant and newsletter contributor over the past year. It is bittersweet for me to share that I am moving into a new role professionally. I have enjoyed my 15 years at Johns Hopkins, and I am excited to share that I will be joining the faculty at Children's Mercy Hospital in Kansas City, Missouri. Thank you for letting me share my knowledge with you this year!


With gratitude,

Carisa Parrish

References and Resources

American Psychological Association: 

Pediatric Neuropsychology (parent brochure about pediatric neuropsychology)

Understanding Psychological Testing and Assessment

American Academy of Pediatrics:

Screening Tools: Pediatric Mental Health Minute Series

Collaborative Mental Health Care:

Child & Youth Mental Health Toolkits

Centers for Disease Control and Prevention:

Improving Access to Mental Health Care through Behavioral Health Integration

BHIPP Announcements

In a recent panel, the American Academy of Pediatrics explored strategies for pediatric clinicians to foster an antiracist environment. Hear from a pediatrician, and youth and caregiver representatives in this series of videos and find additional resources here: https://bit.ly/3xJmOKj

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BHIPP is supported by funding from the Maryland Department of Health, Behavioral Health Administration and operates as a collaboration between the University of Maryland School of Medicine, the Johns Hopkins University School of Medicine, Salisbury University and Morgan State University.

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