The Need: Demand and Capacity
Across clinical neuropsychology, and pediatric neuropsychology in particular, demand has increasingly outpaced supply – there are too few specialists to assess patients in need of evaluation based on traditional neuropsychological care models. Waitlists of six months to years for comprehensive evaluations are common at children’s hospitals, and the shortage of board-certified neuropsychologists continues to persist in the context of limited accredited training programs at both the pre- and postdoctoral level.
Neuropsychology also remains poorly understood by many referring providers and families, who often do not have a solid understanding of why they were referred. Requesting full days off work and school can introduce unnecessary hardship, particularly for medically complex patients with multiple other required appointments. The expectation to commit to an evaluation before anyone from the neuropsychology team has even met the child can also impede buy-in and follow-through, resulting in no shows and late cancellations. Misperceptions related to neuropsychology may also lead to referrals that are better served by another specialty.
The result is a bottleneck from both directions – specialists stretched across long waitlists determining the scope of an evaluation based only on readily accessible information, and families burdened by a uniform approach that may not fit their needs. Neither serves the goal of providing individualized, efficient, and “right-sized” care.
The Model: Neuropsychological Consultation
The “Neuropsychological Consultation Model” is designed to address these barriers directly by shifting the default entry point for referrals away from automatic in-person testing. Within this framework, referrals to neuropsychology begin with a 60-minute consultation — typically conducted virtually — before any decision is made about testing. The neuropsychologist reviews the medical record and referral question in advance so the consultation itself can focus on orienting families to neuropsychology and answering their questions, collecting data typically not included within the medical record (e.g., scores from prior psychoeducational evaluations completed through school districts or outside providers), and conducting a neurobehavioral status examination of the patient (sometimes in conjunction with short, standardized measures administered virtually).
Based on this initial consultation, further in-person testing may not be necessary to answer the referral question and respond to patient needs, as recommendations and/or monitoring may be more appropriate. When further testing is warranted, the consultation helps inform testing duration and timing (e.g., working around a child’s nap schedule or coordinating the visit alongside other hospital appointments to reduce travel burden). Additional benefits within a pediatric setting include establishing rapport to ensure a smoother transition to testing (if indicated), shortening assessment days to maximize effort, and allowing parents to discuss concerns privately.
Consultation appointments also create a lower-cost opportunity to correct referrals better suited for other specialties. For example, a brief consultation can identify patients with more pronounced need for mental health services (e.g., psychiatry/psychology referral) or immediate health needs (e.g., sleep study) within an hour rather than after a full testing day, allowing families to access appropriate care sooner. While ensuring appropriate referrals through provider education and waitlist precautions prior to scheduling is preferable, the consultation model provides a structural safeguard when other measures are unsuccessful.
Neuropsychological consultation can be used for follow-up as well – historically, once a child completed a comprehensive neuropsychological evaluation, they likely would not return for neuropsychological support for three or more years. Because the consultation model allows increased flexibility, more frequent brief follow-ups are feasible — allowing real-time problem-solving as a child’s medical condition and/or environment changes, rather than waiting years for the next data point. For many pediatric conditions, associated neuropsychological profiles remain relatively stable and once documented, do not necessarily require full repetition of all previously-administered measures. In contrast, patient needs pertaining to established profiles may constantly evolve, requiring more frequent updating of recommendations and treatment plans as environmental demands increase. Many of these follow-up questions can be answered through consultation and a combination of parent/child interview, brief examination, potential targeted “spot checking” through standardized measures, and clinical judgment. Patients can then return for further consultation as they implement recommendations, with additional testing only as needed.
Illustrative Vignette
Consider an example compiled from patterns common within our practice: an older adolescent treated for cancer in early childhood, with documented cognitive late effects and longstanding school-based supports, began struggling academically after transitioning to college. Her oncology team referred her for re-evaluation due to “new onset memory problems.” During the consultation, it became clear the concern was not a new cognitive change – her high school Individualized Education Program (IEP) had not carried over to higher education, and she had lost her testing accommodations entirely. A brief virtual list-learning measure indicated a stable learning/memory profile relative to prior documented testing, with no additional concerns identified.
Rather than a full re-evaluation, the consultation resulted in updated documentation, review of applicable recommendations, and guidance on requesting a Section 504 Plan through the University’s Office of Disabilities. At follow-up with her oncologist, she was reported to be doing much better with supports in place.
Implementation Considerations
Adopting a consultation-first model requires navigating several practical barriers. Billing presents one challenge, as neuropsychological testing codes require administration of two or more standardized measures – a threshold the consultation is intentionally designed not to meet, and coding it as such could also limit future authorization for testing if warranted. Neurobehavioral status exam (NBSE) codes, by contrast, can accommodate a consultation-style visit and be repeated across subsequent follow-ups without the same authorization risk; when an NBSE code is not authorized, behavioral health codes may serve as an alternative. Coding strategies should be confirmed against local payer and state requirements, as coverage varies considerably.
Institutional support is equally important. Shifting the default entry point away from automatic full-day testing requires education about the model, as well as buy-in from scheduling, administration, and referring departments.
Discussion: Implications Beyond Pediatric Neuropsychology
This consultation model is, at its core, a triage innovation — and triage-based thinking is not new to our field, even if an initial consultation appointment is a less common way of enacting it. Hardy and colleagues’ (2017) prevention-based model of neuropsychological service delivery for children with medical illness proposed a tiered approach: universal monitoring for broad populations, targeted screening for those at higher risk, and comprehensive assessment reserved for those who need it, with each tier informing whether the next is warranted. Baum et al. (2017) formalized consultation as a distinct service level in pediatric oncology – explicitly defined as neuropsychologist-delivered care that does not involve testing, focused instead on guidance, psychoeducation, and determining whether testing is necessary. More broadly, a “stepped model of care” has been proposed as a general framework for embedding neuropsychology in primary care settings — offering screens, brief assessments, or full batteries depending on need, with reported gains in access and efficiency (Lanca, 2018). Colvin and Hall (2026) provide the most current synthesis of this work, describing triage strategies, consultations, and targeted evaluations as complementary tools for expanding access across inpatient and outpatient pediatric practice.
Applications of these various models have emerged across specific populations. Walsh et al. (2016) presented a surveillance and screening model as a bridge to more comprehensive evaluation in pediatric neuro-oncology, a population where need far exceeds clinical capacity. Specific screening batteries and approaches were subsequently developed for survivors of childhood cancer (e.g., Whitaker & Kayser, 2022), with neuropsychologists working in oncology becoming early adopters of surveillance, screening, and triage models following Walsh et al.’s (2016) seminal work. Beyond oncology, Patrick et al. (2025) proposed a similar idea in epilepsy populations, combining chart review, interview, questionnaires, and brief performance-based cognitive screening to determine whether a referral warrants more comprehensive evaluation. Mietchen et al. (2025) implemented telehealth triage consultation appointments for referrals with non-specific learning, attention, and behavioral concerns, finding that a quarter of patients did not require evaluation.
At our institution, the neuropsychological consultation model has become the standard entry point for outpatient pediatric neuropsychology referrals across populations, rather than a service line developed for a specific diagnostic group or a step reached only after preliminary triage. Our experience suggests that an effective initial consultation does not require routine administration of standardized screening measures – a structured conversation, examination, and records review (including outside records) are together often enough to determine appropriate next steps. This is consistent with the observation that few well-validated performance-based cognitive screening measures exist for pediatric populations, in part because normative expectations shift continuously across development (Colvin & Hall, 2026).
This model is not a substitute for comprehensive evaluation when warranted. Rather, it recognizes that not every patient requires hours of testing and that a specialist’s time is better allocated when that determination is made collaboratively and early rather than assumed by default. In a workforce-limited field, this approach can improve access, reduce waitlists and patient burden, and better match care to patient needs. Although developed within pediatric neuropsychology, the underlying principle is applicable to any ABPP specialty facing similar barriers: specialty care should be tailored to patient needs rather than delivered through a one-size-fits-all model.
References
Baum, K. T., Powell, S. K., Jacobson, L. A., Gragert, M. N., Janzen, L. A., Paltin, I., Rey-Casserly, C. M., & Wilkening, G. N. (2017). Implementing guidelines: Proposed definitions of neuropsychology services in pediatric oncology. Pediatric blood & cancer, 64(8), 10.1002/pbc.26446. https://doi.org/10.1002/pbc.26446
Colvin, M., & Hall, T. A. (2026). Advancing Access to Neuropsychological Services for Children and Adolescents. In M. Lanca & R. Fallows (Eds.), Advancing Neuropsychology Through Population Health. Springer, Cham. https://doi.org/10.1007/978-3-032-22457-6_5
Hardy, K. K., Olson, K., Cox, S. M., Kennedy, T., & Walsh, K. S. (2017). Systematic review: A prevention-based model of neuropsychological assessment for children with medical illness.Journal of Pediatric Psychology, 42(8), 815–822.
Lanca, M. (2018). Integration of Neuropsychology in Primary Care. Archives of Clinical Neuropsychology, 33(3), 269–279.
Mietchen, J. J., Cieminski, T. M., & Kessler-Jones, A. M. (2025). Your clinical interview is data: The benefit of telehealth appointments to triage referrals made to pediatric neuropsychology. The Clinical neuropsychologist, 39(5), 1266–1285. https://doi.org/10.1080/13854046.2025.2456160
Patrick, K. E., Shields, A. N., Dustin, H. A., Patel, A. D., & McNally, K. (2025). Cognitive screening informs referrals for neuropsychological evaluation in children with epilepsy.Epilepsia (Copenhagen), 66(8), 2916–2929.
Walsh, K. S., Noll, R. B., Annett, R. D., Patel, S. K., Patenaude, A. F., & Embry, L. (2016). Standard of care for neuropsychological monitoring in pediatric neuro-oncology: Lessons from the Children’s Oncology Group (COG).Pediatric Blood & Cancer, 63(2), 191–195.
Whitaker, A. M., & Kayser, K. (2022). Neuropsychological surveillance model for survivors of pediatric cancer: A descriptive report of methodology and feasibility.The Clinical Neuropsychologist, 36(7), 1746-1766.
Ashley M. Whitaker, PhD, ABPP
Correspondence: ashleymarie.whitaker@gmail.com