Mapping neuropsychological care in pediatric epilepsy: a national survey by the Italian chapter of the international league against epilepsy (LICE)

Abstract

Background and purpose

Neuropsychological assessment is essential in pediatric epilepsy care, yet its implementation in clinical practice remains insufficiently characterized. This study describes neuropsychological practices across Italian pediatric epilepsy centers.

Methods

A national, cross-sectional, online survey was conducted between December 2024 and March 2025 by the Italian League Against Epilepsy. The 59-item survey assessed professional profiles, clinical practices, use of technology, and training needs. Eligible participants were psychologists and neuropsychologists involved in pediatric epilepsy care.

Results

Twenty-three centers completed the survey (response rate 59.0%). Assessment was systematically integrated within multidisciplinary teams across diagnostic, treatment, and follow-up phases. Primary referral drivers were cognitive concerns, treatment effects, and neuropsychiatric comorbidities. Core cognitive domains were consistently assessed, though test selection varied substantially: most centers used flexible approaches, whereas 43.5% implemented standardized protocols. Screening for intellectual disability, attention-deficit/hyperactivity disorder, and learning disorders was widely applied, while severe intellectual disability evaluations relied primarily on qualitative methods. Tele-neuropsychology was used selectively for follow-up rather than primary evaluation.

Conclusions

This study provides the first comprehensive national mapping of pediatric epilepsy neuropsychology practices. Neuropsychological assessment is a well-established component of pediatric epilepsy care in Italy, broadly consistent with international recommendations. However, variability in organization and assessment practices highlights the need for harmonized protocols, increased resources, and specialized training. Multidisciplinary and flexible models, alongside the cautious integration of digital tools, may enhance care and improve long-term outcomes

Graphical abstract

Highlights

• •Neuropsychology is embedded in Italian pediatric epilepsy care pathways.
• •Clinical goals are consistent across centers despite tool heterogeneity.
• •Neuropsychologists identify cognitive and psychiatric comorbidities.
• •Harmonization of assessment practices represents the next challenge for the field.

1. Introduction

Clinical neuropsychology is a discipline dedicated to understanding brain-behavior relationships and applying this knowledge to the assessment and management of human problems, particularly of human functioning (American Psychological Association, 2020) [1]. Within the clinical management of epilepsy, neuropsychological assessment is now considered a fundamental standard of care, contributing to diagnosis, treatment planning and outcome monitoring [2]. Moreover, neuropsychology applied to epilepsy plays a crucial role not only in clinical practice but also in advancing research, informing clinical trials, and supporting precision medicine approaches. The International League Against Epilepsy (ILAE) defines the neuropsychological assessment as a comprehensive, multidimensional process that integrates standardized testing with clinical history and neurodiagnostic data [2]. This process is essential for establishing cognitive baselines at diagnosis and providing longitudinal monitoring to track disease progression and treatment effects [2]. Historically, neuropsychology of epilepsy was grounded in a localization or "lesion" model, in which cognitive impairments were interpreted in relation to focal brain dysfunction and epilepsy-related disease characteristics such as etiology, age at seizure onset, duration of epilepsy and anti-seizure medications (ASMs) exposure [3]. However, accumulating evidence from neuroimaging, neuropathological, genetic, and clinical research studies has challenged this model [3], [4]. These studies indicate that neurobehavioral comorbidities are often present at, or even before, the first recognized seizure, and before the potential impact of recurrent seizures or ASMs [4]. Moreover, similar neurocognitive impairments are now observed across diverse epilepsy syndromes, reflecting widespread distributed structural abnormalities in gray and white matter and consistent with the more recent conceptualization of epilepsy as a network disorder [3]. Cognitive, neuroimaging, neuropathology and clinical research have prompted a shift from the classical model to the "next generation" model [4]. While epilepsy related variables remain embedded in this framework, the new paradigm incorporates a broader array of genomic, medical, social, and lifestyle factors. Psychiatric comorbidities, psychosocial influences, and socioeconomic status are now recognized as important determinants of cognitive outcomes. Consequently, neuropsychological interpretation increasingly requires consideration of multiple interacting biological and environmental influences [4]. By identifying individual neurobehavioral phenotypes, clinicians can adopt a multidimensional approach that addresses the vast heterogeneity of the condition, acknowledging that while some patients face significant challenges, a substantial proportion maintain intact cognition and a high quality of life [4]. Despite the central role of neuropsychological assessment in epilepsy care, relatively little is known about how these principles are translated into routine clinical practice, particularly in pediatric settings.

To better understand how neuropsychological assessment is implemented in pediatric epilepsy care, the Cognitive Neurology and Childhood Epilepsy Neuropsychology Study Group of the Italian League Against Epilepsy (LICE - Lega Italiana Contro l’Epilessia) conducted a national survey. The present study aims to map current clinical practices, identify commonly used tools, highlight areas for improvement, and provide insights for clinicians and researchers. Ultimately, this research seeks to enhance the clinical utility of neuropsychological care, aligning it with a modern precision approach to improve long-term outcomes for children with epilepsy.

2. Materials and methods

2.1. Study design

This was a national, cross-sectional, semi-anonymous, online, survey-based study conducted between December 2024 to March 2025.

The Cognitive Neurology and Childhood Epilepsy Neuropsychology Study Group of LICE developed an online survey aimed at investigating current neuropsychological assessment practices in pediatric patients with epilepsy. The working group (WG) was composed of eight psychologists and two child neuropsychiatrists, all with established clinical and research expertise in epilepsy-related neuropsychology.

2.2. Participants

Participants were eligible for inclusion if they were: [1] responsible for the neuropsychological assessment of pediatric patients with epilepsy [2] actively practicing in a pediatric epilepsy center or a neuroscience department within the RIN (the IRCCS Neuroscience and Neurorehabilitation) network.

Participation was voluntary and without incentives.

2.3. Survey instrument

The survey was developed between March and September 2024 through a series of online meetings of the WG. Item generation was informed by the clinical experience of the team and a review of relevant literature.

The development process followed a structured, iterative approach: an initial draft was created and subjected to three successive rounds of revision by the full WG to assess content relevance, clarity, and wording. Following these plenary discussions, three representatives from the group (CC, TM, SC). synthesized the feedback to produce the definitive version. This rigorous process ensured that all items were clear, relevant, and strictly aligned with the study objectives.

The finalized survey, implemented and distributed via Google Forms, consisted of 59 questions—including multiple-choice and open-ended items—with an estimated completion time of approximately 25 minutes. The survey was organized into four main domains:

• •Professional Profile of the Respondent: background, center characteristics, years of clinical experience, and composition of the neuropsychological assessment team.
• •Current Practices in Neuropsychological Assessment: annual patient numbers, age range, cognitive domains assessed, instruments used, session duration, and feedback procedures.
• •Use of Technology: adoption of digital tools for test administration and scoring.
• •Future Perspectives and Training Needs: respondents’ views on the field’s future directions and perceived educational or training gaps.

The full survey is available as supplementary material.

The survey was pilot tested by three senior neuropsychologists (SC, FO, TM).

2.4. Survey distribution

The survey was conducted between December 2024 and March 2025. It was initially distributed via the LICE Secretariat account to the directors of pediatric epilepsy centers affiliated with the organization. These directors were requested to forward the invitation to the psychologists responsible for neuropsychological assessments within their units. Furthermore, the survey was disseminated to the heads of departments within the RIN network. These referents subsequently forwarded the survey to the psychologists in charge of clinical evaluations for pediatric patients with epilepsy.

To enhance participation, two reminder emails were sent by the WG leader to centers that had not yet responded—specifically, at two and four weeks following the initial invitation. Overall, the survey was sent to 39 centers: the 24 LICE-accredited Centers for Childhood Epilepsy active at the time of distribution and the 15 pediatric centers of the RIN network.

Responses could not be modified once submitted.

2.5. Data collection and handling

Data was stored securely in Google form and exported to Microsoft Excel for cleaning. Because of the semi-anonymous design, incomplete responses could not be followed up. No imputation was performed for missing data, and no additional verification methods (e.g., logic checks or cross-validation) were applied.

2.6. Statistical analysis

Descriptive statistics (frequencies, percentages, means, medians, and ranges) were used to summarize demographic and response data. Frequency distributions were calculated for closed- ended responses. Open-end responses were reviewed for qualitative content and described or categorized where appropriate.

This study followed the Checklist for Reporting of Survey Studies (CROSS) guidelines unless otherwise specified.

3. Results

3.1. Respondents characteristics

A total of 23 of the 39 invited centers completed the survey (overall response rate 59.0%, Fig. 1): 17 of the 24 LICE-accredited Centers for Childhood Epilepsy (70.8%) and 6 of the 15 pediatric centers of the RIN network (40.0%). Among these, fourteen (14/17, 82%) were IRCCS (Scientific Institutes for Research, Hospitalization and Healthcare). Ten centers (10/23, 43.5%) reported having an outpatient service dedicated to neuropsychological assessment.

Fig. 1.

Regarding institutional affiliation, four respondents (4/23, 17.4%) were affiliated with a Psychology Unit, whereas nineteen (19/23, 82.6%) were affiliated with a Neurology or Psychiatry Unit.

3.2. Organization and delivery of neuropsychological assessments across participating centers

Neuropsychologists were involved in conducting assessments in 15 of the 23 centers (65.2%), frequently within multidisciplinary teams that also included developmental psychologists (8/23, 34.8%), psychologists (7/23, 30.4%), and trainees or residents in psychology, neuropsychology, or medicine (6/23, 26.1%). Child neuropsychiatrists (2/23, 8.7%), speech and language therapists (1/23, 4.3%), and neurologists (1/23, 4.3%) also contributed in some centers. As multiple professional figures could be reported, percentages are not mutually exclusive. Overall, at least one psychologist or neuropsychologist was involved in 21/23 centers (91.3%), while in 2 centers (8.7%) assessments were conducted by other professionals (Table 1). School-age children (6–11 years) were the population most frequently assessed, with more than half of participating centers (13/23, 56.5%) identifying this age group as their primary referral population. Preschool children (3–5 years) ranked second (5/23, 21.7%), whereas infants (0–2 years), adolescents (12–18 years), and young adults (19–39 years) were much less frequently identified as the predominant age group (3/23, 13.0% each).

Table 1.

The table summarizes center-level organizational characteristics of neuropsychological assessment in pediatric epilepsy, including professional involvement, assessment procedures, eligibility criteria, duration, clinical setting, and follow-up practices. Data are reported as number of centers (n) and percentage (%) out of the total sample (N = 23), unless otherwise specified.

Organization and delivery of neuropsychological assessment across participating centers.

Domain	Number of centers (%)
Professional involvement
At least one psychologist/neuropsychologist involved	21 (91.3)
Neuropsychologist only	4 (17.4)
Multidisciplinary team	17 (73.9)
No psychologist/neuropsychologist involved	2 (8.7)
Assessment procedures
Child and caregiver interview conducted	20 (87.0)
Test scoring performed internally	18 (78.3)
Eligibility for assessment
Assessment offered to all children with epilepsy	8 (34.8)
Assessment not routinely offered to all	15 (65.2)
Assessment duration
Most frequent direct assessment time: ~3 hours	10 (43.5)
Assessment completed in 2 sessions	11 (47.8)
Total evaluation >2 hours (including scoring/report)	17 (74.0)
Presurgical evaluations >2 hours	9 (—)⁎
Setting
Outpatient (Public Health Care prescription)	7 (34.8)
Outpatient + inpatient	7 (34.8)
Day hospital	6 (26.0)
Research setting	4 (17.4)
Follow-up
Follow-up routinely conducted	23 (100)

^⁎Percentages are reported when the denominator corresponds to the total number of centers (N = 23). For presurgical evaluations, only absolute frequencies are reported, as not all centers perform presurgical assessments.

Referral indications highlighted the broad integration of neuropsychological assessment across the clinical pathway. Nearly all centers reported referrals for the evaluation of global cognitive functioning (22/23, 95.7%), while approximately three-quarters also assessed potential cognitive adverse effects of antiseizure medications (18/23, 78.3%), selective cognitive deficits (17/23, 73.9%), and developmental or neuropsychomotor functioning (17/23, 73.9%). Presurgical evaluations and assessment of academic abilities were each reported by 16 centers (69.6%), whereas comprehensive neuropsychological profiling was indicated by 12 centers (52.2%). Less frequent referral indications included participation in clinical or pharmacological trial protocols (9/23, 39.1%), ictal assessment (5/23, 21.7%), ketogenic diet monitoring (3/23, 13.0%), and postictal evaluation (3/23, 13.0%).

Consistent with the referral patterns described above, neuropsychological evaluations were primarily requested to support the management of clinically complex cases and treatment-related decision-making. The most frequently reported indications were the assessment of neuropsychiatric comorbidities (22/23, 95.7%) and the evaluation of cognitive adverse effects associated with changes in antiseizure medications (17/23, 73.9%). Other common indications included the diagnostic assessment of intellectual disability or specific learning disorders for certification purposes (15/23, 65.2%), characterization of the neuropsychological profile to guide rehabilitation planning (14/23, 60.9%), and referral to local child and adolescent mental health services (12/23, 52.2%). Less frequent indications included presurgical risk–benefit evaluation (11/23, 47.8%), monitoring of ketogenic diet and other treatment interventions (7/23, 30.4%), and assessment of language lateralization (4/23, 17.4%).

Finally, the assessment process across centers was characterized by a predominantly individualized approach, although a substantial proportion of services also reported the use of standardized procedures. In more than half of centers, the evaluation process was based on a personalized and flexible approach (12/23, 52.2%), while standardized protocols were used in 10/23 centers (43.5%). One center (1/23, 4.35%) reported the use of predefined groups of tests or tasks routinely applied according to specific epilepsy diagnoses. Across all procedures reported in this section, responses refer specifically to the involvement of neuropsychologists within the assessment process, rather than to the mere availability of specific diagnostic techniques at each center. Overall, language hemispheric dominance was most commonly assessed through non-invasive and clinically accessible approaches, with handedness evaluation representing the most frequently reported method (11 centers). This was followed by functional MRI protocols in which neuropsychologists contributed to task selection and/or interpretation (7 centers), while eight centers reported that language dominance was not evaluated within neuropsychological pathways. Dichotic listening and transcranial magnetic stimulation were not reported as part of neuropsychological assessment practices. More invasive procedures, including the Wada test (2 centers) and SEEG-based protocols (2 centers), as well as functional MRI with internally developed protocols (4 centers), were reported in a limited number of centers and typically involved multidisciplinary collaboration.

Responses to the open-ended question showed convergence around several recurring themes, including the need for structured educational opportunities (13/23, 56.5%), supervised clinical experience and mentorship in specialized epilepsy centers (8/23, 34.8%), epilepsy-specific training (8/23, 34.8%), multidisciplinary learning through case discussions and collaboration (7/23, 30.4%), and, less frequently, shared assessment protocols (3/23, 13.0%). These findings suggest a perceived need for more structured and standardized training pathways in pediatric epilepsy neuropsychology.

Finally, the adoption of technological tools in clinical neuropsychological practice appeared overall cautious and selective, with a clear pattern favoring follow-up and supportive activities over formal diagnostic assessment. Across centers, tele-neuropsychology was primarily considered appropriate for periodic follow-up and feedback sessions (15/23, 65.2%), as well as for psychological support and psychoeducation, whereas its use for comprehensive first evaluations was rarely endorsed (1/23, 4.3%). This cautious perspective was reflected in current clinical practice, where videoconference interviews were used at least occasionally by over half of respondents, while the remote administration of standardized neuropsychological tests remained uncommon, with 65.2% (15/23) reporting that this approach was never used. The main barriers to wider implementation concerned the lack of validated norms for tele-neuropsychological testing (11/23, 47.8%) and limited financial resources for tests, licenses, and hardware (10/23, 43.5%).

3.3. Evaluation procedures

Neuropsychological assessment procedures showed a high degree of consistency across centers with respect to the core domains routinely explored, alongside greater heterogeneity in the specific instruments adopted. All respondents (23/23, 100%) reported routinely assessing cognitive functions, executive functions, visuospatial and perceptual abilities, memory, speech and language, and social, behavioral, and emotional functioning. Developmental or psychomotor profile was also almost universally included (22/23, 95.7%), while motor functions (20/23, 87.0%) and academic skills (19/23, 82.6%) were assessed in the majority of centers. By contrast, considerable variability emerged in the test batteries employed across services. A detailed list of the assessment tools is provided in Table 2.

Table 2.

Neuropsychological instruments reported by participating Italian pediatric epilepsy centers, organized according to the primary functional domain assessed. Data are presented as the number and percentage of participating centers reporting routine use of each instrument (N = 23). Percentages refer to the proportion of centers using each instrument and are not mutually exclusive, as each center could report multiple instruments within the same functional domain. Instruments are grouped according to their primary clinical application; several instruments assess multiple domains and may therefore be used beyond the category in which they are listed. Reference numbers correspond to the bibliography.

Domain and test used to assess it	Description	N	%
Cognition [1]	Standardized measures of intellectual functioning and non-verbal reasoning.
Wechsler Intelligence Scale for Children Italian version (WISC-III, WISC IV, WISC V) [5], [6], [7]		22	95.65
Wechsler Preschool and Primary Scale of Intelligence Italian version (WPPSI, WPPSI-III, WPPSI-IV) [6], [8], [9]		22	95.65
Wechsler Adult Intelligence Scale Italian version (WAIS) [10]		19	82.61
Raven's Progressive Matrices Italian version [11]		19	82.61
Leiter International Performance Scale – Third Edition Italian version (Leiter-3) [12]		17	73.91
Operazioni Logiche e Conservazione (OLC) [13]		3	13.04
Cattell's Fluid Intelligence Test, Scale 2 Italian version (CFT 20-R) [14]		1	4.35
Others Intelligence and Development Scales (IDS-2) [15]		1	4.35
Developmental Profile	Standardized developmental scales assessing global and domain-specific developmental functioning in infants and young children, including cognitive, motor, language, and adaptive domains.
Griffiths Scales of Child Development (Griffiths II, Griffiths III) [16], [17]		21	91.30
Bayley Scales of Infant and Toddler Development (Bayley II, Bayley III) [18], [19]		8	34.78
Developmental Profile-Third Edition Italian version (DP-3) [20]		4	17.39
Adaptive behaviour	Standardized measures of adaptive functioning assessing communication, daily living skills, socialization, and autonomy across developmental stages
Vineland Adaptive Behavior Scales II Italian version (VABS-II) [21]		20	86.96
Adaptive Behavior Assessment System italian version (ABAS) (ABAS-2, ABAS-3) [22], [23]		2	8.70
Diagnostic Adaptive Behavior Scale Italian version (DABS) [24]		4	17.39
Domain not assessed		2	8.70
Speech and Language Lexical Production	Measures of expressive lexical abilities assessing naming accuracy, word retrieval, and lexical access.
Picture Naming (WPPSI-III/IV) [6], [9]		23	100
Boston Naming Test [25], [26]		23	100
Denominazione ed Articolazione/ Denominazione (Batteria per la Valutazione del Linguaggio in Bambini dai 4 ai 12 anni BVL) [27]		23	100
Produzione Lessicale - Test neuropsicologico Lessicale (TNL) [28]		23	100
Denominazione - Batteria di Valutazione Neuropsicologica (BVN) [29], [30]		23	100
Speech and Language Lexical Comprehension	Measures of receptive vocabulary and lexical comprehension, assessing understanding of spoken words and concepts.
Peabody Picture Vocabulary (PPVT) [31]		18	78.26
Comprensione Lessicale -(BVL 4–12) [27]		18	78.26
Comprensione Lessicale - (TNL) [28]		18	78.26
Speech and Language Syntactic Comprehension	Measures of syntactic and grammatical comprehension assessing understanding of sentence structure, morphosyntactic relations, and verbal instructions.
Token Test - (BVN) [29], [30]		21	91.30
Test for Reception of Grammar (TROG) [32]– (BVN) [30]		21	91.30
Test di comprensione Grammaticale per bambini (TCGB) [33]		21	91.30
Comprehension of Instructions (NEPSY- II) [34]		21	91.30
Grammatical Comprehension tasks – BVN, BVL, TRGB [27], [29], [30], [35]		21	91.30
Prova di comprensione grammaticale con oggetti (PCGO) [36]		21	91.30
Comprensione grammaticale - (BVL 4-12) [27]		21	91.30
Speech and Language Syntactic Production	Measures of expressive syntactic abilities assessing sentence generation, grammatical repetition, and narrative production.
Comprensione grammaticale - (BVL 4–12) [27]		15	65.22
Test di Ripetizione Grammaticale per Bambini (TRGB) [35]		15	65.22
Spontaneous Narrative – Frog Story-based task [37]		7	30.43
Motor Domain	Measures of motor, praxis, and visuomotor abilities assessing gross and fine motor coordination, constructional skills, motor planning, and visual–motor integration.
Peabody Developmental Motor Scales – Second Edition (PDMS-2) [38]		13	56.52
Movement Assessment Battery for Children – Second Edition (MABC-2) [39]		13	56.52
Griglia di Analisi delle Prassie Transitive (GAP-T) [40]		2	8.69
Coding (WISC/WAIS) [5], [7], [10], [41]		22	95.65
Rey–Osterrieth Complex Figure (ROCF) Copy [42]		19	82.61
Design Copying (NEPSY-II) [34]		15	65.22
Block Construction (NEPSY-II) [34]		15	65.22
Developmental Test of Visual-Motor Integration (VMI) [43]		15	65.22
Visuomotor Precision (NEPSY-II) [34]		14	60.87
Discriminazione visiva – BVN [29], [30]		12	52.17
Other: Griffiths Motor Scale [17], [44]		4	17.39
Other: Praxis Imitazione - Batteria di Valutazione Neuropsicologica (BVN) [29], [30]		1	4.35
Other: Clinical Neurophysiatric Evaluation		1	4.35
Other: Imitating Hand Positions (NEPSY-II) [34]		1	4.35
Executive Functions Cognitive Inhibition (Interference Control)	Measures of cognitive inhibition and interference control assessing the ability to suppress automatic responses and manage competing stimuli.
Response Set (NEPSY-II) [34]		17	73.91
Inhibition (NEPSY-II) [34]		17	73.91
Stroop Test - Batteria Italiana per l’Attenzione (BIA) [45]		10	43,48
Giorno e notte - Batteria per le Funzioni Esecutive in Età Prescolare (BAFE) [46]		3	13.04
Stroop giorno e notte- Funzioni Esecutive in Età Prescolare (FE-PS 2-6) [47]		3	13.04
Confronta le figure- FE-PS 2-6 (63)		3	13.04
Executive Functions Selective and Focused Attention	Measures of selective and focused attention assessing the ability to allocate, maintain, and shift attentional resources while filtering out irrelevant stimuli.
Visual attention (NEPSY-II) [34]		17	73.91
Bells Test [48], [49]		17	73.91
Auditory Attention (NEPSY-II) [34]		17	73.91
Cancellation (WISC-IV) [5]		16	69.57
Test delle campanelle modificato [48]
Attenzione visiva selettiva- BVN [29], [30]		12	52.17
Sustained Attention (Leiter-3) [12]		12	52.17
Attenzione uditiva selettiva - BVN [29], [30]		11	47.83
Cancellazione_ Measure of executive attention (Batteria MEA) [50]		2	8.70
Other: Attentive Matrices (Batteria Scarpa) [51]		13	56.52
Executive Functions Response Inhibition	Measures of response inhibition assessing the ability to suppress or delay motor responses and regulate behavior in accordance with task demands.
Statue (NEPSY-II) [34]		1	4.35
Traccia un cerchio - FE-PS 2-6 (63)		1	4.35
Incarto il pacchetto- FE-PS 2-6 (63)		1	4.35
L’elefante e l’orso- FE-PS 2-6 (63)		1	4.35
Executive Functions - Working Memory (Verbal)	Measures of verbal working memory assessing the temporary storage and manipulation of verbally presented information.
Backward span - Batteria di Valutazione Neuropsicologica (BVN) [29], [30]		18	78.26
Executive Functions Working Memory (Visuospatial)	Measures of visuospatial working memory assessing the temporary storage and manipulation of visual and spatial information.
Rey–Osterrieth Complex Figure (ROCF) Recall [42]		21	91.30
Corsi Block-Tapping Test [29], [30], [52]		19	82.61
Memory for Faces (NEPSY-II) [34]		17	73.91
Memory for Designs (NEPSY-II) [34]		13	56.52
Benton Visual Retention Test (BVRT) – Immediate Recall [53]		4	17.39
Keep in Mind - Funzioni Esecutive in Età Prescolare (FE-PS 2-6) [47]		4	17.39
Jar Sorting Task - Batteria per le Funzioni Esecutive (BAFE) [46], [47], [50]		3	13.04
Figure Recognition (IDS-2) [15]		2	8.70
Color Matrices (MEA battery) [50]		1	4.35
Others Tema Test [54] Batteria Scarpa [51]		2 1 1	8.70 4.35 4.35
Executive Functions Cognitive flexibility	Measures of cognitive flexibility assessing the ability to shift between mental sets, adapt to changing rules, and switch efficiently between tasks or response strategies.
Inhibition (NEPSY-II) [34]		17	73.91
Trail Making Test (TMT A & B) [51]		14	60.87
Wisconsin Card Sorting Test (WCST) [55]		6	26.09
Color and shape game Funzioni Esecutive in Età Prescolare (FE-PS 2-6) [47]		4	17.39
Lever Switch - MEA Battery [50]		2	8.70
Executive Functions Higher order Executive Functions	Measures of higher-order executive functions assessing planning, problem solving, and goal-directed behavior.
Tower of London [56]		20	86.96
Others		2	7.80
Verbal Memory	Measures of verbal learning and memory assessing encoding, immediate and delayed recall, and narrative memory for verbally presented information.
Selective Word Recall - Batteria di Valutazione Neuropsicologica (BVN) [29], [30]		16	69.57
List Memory (NEPSY) [34]		15	65.22
Paired-Associate Learning (NEPSY) [34]		14	60.87
Narrative Memory (NEPSY-II)		16	69.57
Prose Memory - Batteria di Valutazione Neuropsicologica (BVN) [29], [30]		14	60.87
Rey Auditory Verbal Learning Test (RAVLT) [57]		7	30.34
Academic Achievement	Measures of academic achievement assessing reading, writing, spelling, mathematical skills, and related phonological and metalinguistic abilities across school-age development.
Battery for the Evaluation of Developmental Dyslexia and Dysorthography (DDE-2) [58]		17	73.91
MT Avanzate 3 Clinica – Reading, Writing, Text Comprehension, Mathematics [59], [60]		17	73.91
MT 16-19 Battery – Reading, Writing, Text Comprehension [61]		16	69.57
Batteria per la valutazione clinica della scrittura e della competenza ortografica (BVSCO 2/BVSCO 3) Writing [62], [63]		14	60,87
Batteria per la Discalculia Evolutiva – 2nd edition (BDE-2) Maths [64]		14	60,87
Prove MT-3 clinica - Reading, Text Comprehension [65]		14	60,87
AC-MT – Arithmetic Competence [66], [67]		12	52.17
Test of Metalinguistic and Phonological Awareness (CMF) [68]		10	43.48
Assessment di Lettura e Comprensione per l’Età evolutiva (ALCE) Reading, Text Comprehension [69]		7	30.43
Evaluation of Handwriting Quality and Speed (BHK) [70]		6	21.74
Comprensione orale e trattamento (CO-TT) [71]		6	21.74
Batteria per la Valutazione dell’Intelligenza Numerica - BIN 4-6 [72]		4	17.39
Liste Martini [73]		4	17.39
Test di comprensione del testo ORale (TOR) [74]		3	13.04
Domain not assessed		3	13.04
Quality of Life	Measures of health-related quality of life assessing physical, emotional, social, and school functioning, as well as epilepsy-specific quality of life.
Pediatric Quality of Life Inventory (PedsQL) [75]		13	56.52
Quality of Life in Epilepsy Inventory (QOLIE-31) [76]		8	34.78
Domain not assessed		4	17.39
Others EORTC-Quality Of Life Questionnaires, Strengths and Difficulties Questionnaire (SDQ), EQ-5D-5L [77], [78]		3 1 1 1	13.04 4.35 4.35 4.35
Psychopathology and Behavioral Functioning	Measures of emotional, behavioral, and psychopathological functioning assessing internalizing and externalizing symptoms, attention and executive behaviors, and overall psychosocial adjustment.
Child Behavior Checklist (CBCL) [79]		22	95.65
Conners Rating Scales [80]		19	82.61
Youth Self-Report (YSR) [79]		17	73.91
Behavior Rating Inventory of Executive Function (BRIEF-P / BRIEF-2) [81], [82]		11	47.83
Self-Administered Psychiatric Assessment for Children and Adolescents (SAFA) [83]		12	52.17
Others Personality Inventory for DSM-5 - PID-5 [84]		2 1	8.70 4.35

Abbreviations: ABAS, Adaptive Behavior Assessment System; BAFE, Batteria per l’Assessment delle Funzioni Esecutive; BIA, Batteria Italiana per l’Attenzione; BVL, Batteria per la Valutazione del Linguaggio; BVN, Batteria di Valutazione Neuropsicologica; DABS, Diagnostic Adaptive Behavior Scale; DP-3, Developmental Profile-Third Edition; FE-PS, Funzioni Esecutive in Età Prescolare; GAP-T, Griglia di Analisi delle Prassie Transitive; IDS-2, Intelligence and Development Scales-2; MABC-2, Movement Assessment Battery for Children-2; NEPSY-II, A Developmental Neuropsychological Assessment, Second Edition; OLC, Operazioni Logiche e Conservazione; PDMS-2, Peabody Developmental Motor Scales-Second Edition; PPVT, Peabody Picture Vocabulary Test; ROCF, Rey–Osterrieth Complex Figure; TCGB, Test di Comprensione Grammaticale per Bambini; TNL, Test Neuropsicologico Lessicale; TROG, Test for Reception of Grammar; VABS-II, Vineland Adaptive Behavior Scales, Second Edition; VMI, Developmental Test of Visual-Motor Integration.

3.4. Screening assessments for comorbidities

Screening for neurodevelopmental and psychiatric comorbidities was routinely integrated into clinical practice in most centers, although the specific conditions assessed varied across services. Overall, 19/23 respondents (82.6%) reported conducting systematic screening for comorbidities in people with epilepsy. ID was universally identified as a core target of assessment (23/23, 100%), followed by ADHD (12/23, 52.2%), specific learning disorders (10/23, 43.5%), and autism spectrum disorder (9/23, 39.1%). Mood disorders were less frequently included in routine screening pathways (8/23, 34.8%).

3.5. Assessment in severe ID

Assessment practices in the context of severe cognitive impairment appeared more heterogeneous. Approximately half of respondents (12/23, 52.17%) indicated that they do not routinely conduct formal assessments in patients with profound cognitive impairment, whereas 11/23 (47.83%) reported doing so. Across responses, there was clear convergence on the need for individualized and predominantly qualitative approaches, guided by clinical history and direct observation. When formal assessment was undertaken, raw scores were the most frequently used outcome metric (7/11, 63.6%), followed by developmental or mental age estimates (3/11, 27.3%), while corrected standardized scores were rarely used (1/11, 9.1%). Considerable heterogeneity was also observed in the instruments adopted, with the most frequently reported tools including the Vineland Adaptive Behavior Scales [21] (4/11, 36.4%), Griffiths Scales [16], [44] (3/11, 27.3%), Leiter-3 [12] (2/11, 18.2%), and Colored Progressive Matrices [85] (2/11, 18.2%).

Several other instruments, including the Bender Visual Motor Gestalt Test [86], Cognitive Assessment System (CAS) [87], Piagetian tasks (e.g., Uzgiris–Hunt scales) [88], Operazioni Logiche e Conservazione (OLC) [13], Wechsler Scales [5], SPIADD-G (specific protocol for intellectual and adaptive functioning) [89], Scala LAPMER (Level of Activity in Profound/Severe Mental Retardation) [90] were reported only by single centers.

4. Discussion

4.1. Neuropsychological assessment as a standard component of pediatric epilepsy care

This survey provides the first national overview of neuropsychological assessment practices within Italian pediatric epilepsy services. The most notable finding was not the specific tools adopted across centers, but rather the extent to which neuropsychological assessment appears to be integrated across the clinical pathway, supporting diagnosis, treatment planning, and prognostic evaluation. In fact, across participating centers, neuropsychologists were involved in diagnostic evaluations, longitudinal follow-up, treatment monitoring, assessment of neuropsychiatric comorbidities, and presurgical decision-making. These findings suggest that neuropsychology is no longer perceived as an ancillary service but rather as a routine component of comprehensive epilepsy care.

This observation is broadly consistent with contemporary recommendations emphasizing the role of neuropsychological assessment in diagnosis, treatment planning, and outcome monitoring throughout the disease trajectory [2], [91], [92], [93]. Importantly, our findings indicate that this role extends beyond cognitive profiling alone, encompassing behavioral, emotional, developmental, and adaptive functioning domains and psychological care that are increasingly recognized as integral components of epilepsy-related morbidity.

4.2. Shared clinical priorities despite procedural heterogeneity

A central finding of this survey was the coexistence of substantial variability in assessment procedures alongside remarkable consistency in clinical priorities. Across participating centers, the same core domains—including cognition, executive functions, language, memory, visuospatial abilities, and behavioral-emotional functioning—were routinely considered essential, despite considerable differences in the specific instruments selected to assess them.

This pattern may suggest that clinical reasoning is currently more standardized than test selection. Rather than relying on a single assessment battery, participating centers appear to adopt flexible, hypothesis-driven approaches tailored to developmental level, clinical presentation, and referral question, consistent with contemporary recommendations for individualized neuropsychological assessment [2], [3]. Such variability should not necessarily be interpreted as inconsistency in clinical practice but may instead reflect the complexity and heterogeneity of pediatric epilepsy.

The observed heterogeneity is also likely influenced by differences in local resources, staffing, and service organization. Nevertheless, the convergence observed across assessment goals suggests the existence of a shared conceptual framework underpinning clinical practice. This finding may be particularly relevant from an implementation perspective, indicating that harmonization efforts should focus not only on individual tools but also on promoting shared principles for assessment, interpretation, and clinical decision-making, always taking in account the aim of the neuropsychological visit. But which aspects of neuropsychological care should be standardized, and which should remain individualized? We believe that the two approaches are complementary rather than alternative [2], [3], [91], [93]. Standardization appears most valuable at the level of clinical indications, assessed domains, and diagnostic criteria. First, shared indications, including baseline screening close to epilepsy onset, provide a common reference point for monitoring developmental trajectories, treatment effects (e.g., ASM-related adverse effects), and potential gains following interventions such as epilepsy surgery, ketogenetic dietary therapies, or neuropsychological habilitation. Second, centers should agree on a minimum core set of domains, particularly those most vulnerable to epilepsy-related comorbidities and treatment effects. Third, shared criteria for defining cognitive impairment would improve the comparability of findings across centers [3].

Our findings also suggest that a de facto minimum core set of instruments has already emerged across Italian pediatric epilepsy centers. The Wechsler scales (95.7%), Griffiths scales (91.3%), and Vineland scales (87.0%) were consistently the most widely adopted measures, despite the absence of national recommendations on instrument selection. This convergence may provide a valuable starting point for future harmonization efforts.

By contrast, the selection of additional instruments should remain flexible and hypothesis-driven. Pediatric neuropsychological assessment must be tailored to the child's age, developmental level, functional abilities, and the specific clinical question. Guided by the clinical interview, medical history, and behavioral observations, clinicians should select complementary measures that address individual needs, including presurgical evaluation, educational planning, or the assessment of specific cognitive or behavioral concerns. Flexibility is also essential to ensure culturally and linguistically appropriate assessment. Future harmonization efforts should therefore focus on shared clinical indications, core assessment domains, diagnostic criteria, and build upon the de facto convergence already observed in the use of key instruments, while preserving the flexibility required for individualized pediatric care.

4.3. Beyond seizures: evidence of a multidimensional model of care

The widespread screening of neurodevelopmental and psychiatric comorbidities observed in this survey reflects the growing adoption of a multidimensional model of epilepsy [4], [94], [95]. Intellectual disability, ADHD, autism spectrum disorder, learning disorders, and emotional-behavioral difficulties were routinely considered by most participating centers, suggesting that neuropsychological assessment is increasingly used to characterize the broader neurobehavioral phenotype rather than focusing exclusively on seizure-related and cognitive outcomes.

This finding is consistent with current evidence demonstrating that cognitive, psychiatric, and psychosocial difficulties represent core components of the epilepsy phenotype and substantially contribute to long-term functioning and quality of life [4], [94], [95], [96], [97]. Importantly, many of these difficulties may precede seizure onset or emerge independently of traditional epilepsy-related variables [94], supporting contemporary conceptualizations of epilepsy as a complex neurodevelopmental and network-based disorder rather than a purely paroxysmal condition [3], [4].

Taken together, these findings suggest that current clinical practice is increasingly aligned with modern models of epilepsy care that emphasize the systematic assessment of cognitive, behavioral, emotional, and adaptive functioning alongside seizure management [2], [3], [4].

4.4. Future priorities: severe intellectual disability, digital innovation, and specialized training

Three areas emerged as priorities for future development. First, assessment practices for individuals with severe intellectual disability showed considerable variability across centers. Clinicians frequently reported relying on qualitative approaches, adaptive measures, and alternative scoring methods, reflecting the well-recognized limitations of conventional psychometric tools in this population [98]. The absence of shared approaches highlights the need for further methodological development and consensus-building, particularly in the context of developmental and epileptic encephalopathies.

Second, although respondents generally recognized the potential value of tele-neuropsychology, its implementation remained limited and was largely restricted to follow-up, psychoeducation, and feedback sessions. Similar concerns have been reported internationally and primarily relate to the availability of validated procedures, normative data, and technological resources [99], [100]. Available evidence, largely derived from adult populations, indicates that many standardized tests, particularly verbally mediated ones, can yield results comparable to in-person administration under controlled conditions, whereas visuomotor, constructional and timed tasks appear more sensitive to the testing modality [99], [100]. Evidence in pediatric populations remains limited. Remote testing of children also raises specific challenges, including variability in attention and compliance, the need for caregiver mediation, and the absence of norms for remote administration. In this context, the cautious approach of participating centers, which favored remote follow-up and feedback over formal testing, appears clinically appropriate. The gap observed between perceived utility and clinical adoption suggests that implementation efforts may represent the next major challenge in this area. Future developments in digital health, including artificial intelligence-assisted assessment and decision-support tools, may help address some of the current barriers to tele-neuropsychology, although substantial work remains necessary to establish their validity, feasibility, and clinical utility.

Finally, participants consistently emphasized the importance of specialized training, supervised clinical experience, and mentorship within expert epilepsy centers. These findings suggest that expertise in epilepsy neuropsychology continues to be acquired primarily through experiential learning and participation in specialized clinical networks. Although no formal guidelines specifically define training requirements for pediatric epilepsy neuropsychology, the ILAE Neuropsychology Task Force has recommended specialist training in clinical neuropsychology, complemented by epilepsy-specific expertise and, for clinicians working with children, competencies in developmental psychology and developmental neuropsychology [2]. The recurring themes identified in our survey—particularly structured education, supervised clinical experience, epilepsy-specific expertise, and multidisciplinary learning—are closely aligned with these recommendations and suggest that their implementation remains heterogeneous across centers. Professional organizations and collaborative initiatives may therefore play an important role in supporting future workforce development and dissemination of best practices.

4.5. Alignment with ILAE recommendations and practical implications

Taken together, the practices described by participating centers appear largely consistent with the ILAE recommendations for neuropsychological assessment in routine epilepsy care [2]. As envisaged by the ILAE, neuropsychologists were involved throughout the clinical pathway, from diagnosis and treatment monitoring to presurgical evaluation and the identification of neurobehavioral comorbidities [2], [91]. Assessments were mostly carried out by neuropsychologists (65.2%) and developmental psychologists (34.8%), often supported by trainees under supervision. Nevertheless, in two centers (8.7%) no psychologist or neuropsychologist was involved, highlighting an area for improvement.

The timing of assessment requires a more nuanced interpretation. The ILAE recommendations do not advocate comprehensive neuropsychological evaluation for every child with epilepsy; rather, they recommend routine screening of cognition, mood, and behavior at epilepsy onset, followed by comprehensive assessment when clinically indicated [2]. Our findings broadly reflect this stepped-care model: most centers (82.6%) reported systematic screening for comorbidities, whereas comprehensive neuropsychological assessment was offered routinely to all children in only one third of centers (34.8%) and was otherwise guided by specific clinical referral questions. Mood disorders, however, were included in routine screening by only about one third of centers (34.8%), despite their recognized clinical relevance in pediatric epilepsy [96].

These findings should also be interpreted in light of the study limitations. Our survey primarily captured practices from LICE-accredited and tertiary referral centers, which are generally better resourced and more frequently located in Northern Italy. Consequently, the present findings likely represent an optimistic estimate of current national practice and may not fully reflect the situation in non-accredited centers, community neuropsychiatry services, or less-resourced regions, where access to specialized neuropsychological care is likely to be more limited.

In light of these findings, we suggest three priorities for clinical practice: i) systematic screening of cognition and behavior at diagnosis for all children with epilepsy, with clear pathways to comprehensive assessment; (ii) promoting structured training opportunities in pediatric epilepsy neuropsychology and ensuring the availability of appropriately trained professionals across epilepsy centers; iii) the development of shared national indications. Particular attention should also be devoted to establishing consensus approaches for children with severe intellectual disability, an area in which current practice remains especially heterogeneous.

5. Limitations

This study has some limitations. First, the survey targeted specialized tertiary-level centers, namely LICE-accredited Centers for Childhood Epilepsy and RIN network centers, with an overall response rate of 59.0%. Centers with more structured neuropsychological services may have been more likely to respond, so our findings may overestimate the integration of neuropsychological assessment in pediatric epilepsy care. Moreover, since no national registry of facilities caring for children with epilepsy exists, the results may not generalize to non-accredited hospital units, community child neuropsychiatry services, or less-served geographical areas, where access to neuropsychological assessment may be more limited. Second, data were self-reported and could not be verified against clinical records. Third, the survey was developed ad hoc and not formally validated, although it underwent iterative expert review and pilot testing. Finally, the small sample size allowed only descriptive analyses.

6. Conclusion

Neuropsychological assessment is firmly embedded within pediatric epilepsy care across Italian centers and is routinely used to support diagnosis, treatment planning, longitudinal monitoring, and the identification of neurobehavioral comorbidities. Despite considerable variability in organizational models and assessment procedures, participating centers demonstrated substantial convergence regarding the domains assessed and the overall goals of evaluation. These findings suggest the presence of a shared clinical framework that is broadly consistent with contemporary models of epilepsy as a multidimensional neurodevelopmental condition. Future efforts should focus on strengthening training pathways, promoting harmonized approaches for complex populations such as individuals with severe intellectual disability, and supporting the thoughtful integration of digital technologies into routine clinical practice.

Declaration of generative AI and AI-assisted technologies in the manuscript preparation process

During the preparation of this work, the authors used ChatGPT for language support. The authors reviewed and edited the output as needed and take full responsibility for the content of the published article.

CRediT authorship contribution statement

Martina Paola Zanaboni: Writing – review & editing, Writing – original draft, Supervision, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Cinzia Correale: Writing – review & editing, Writing – original draft, Visualization, Supervision, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Tiziana Metitieri: Writing – review & editing, Methodology, Investigation, Conceptualization. Valentina Manfredi: Writing – review & editing, Investigation, Data curation. Francesca Offredi: Writing – review & editing, Investigation, Data curation. Alessandra Biolcati Rinaldi: Writing – review & editing, Investigation, Data curation. Tommaso Lo Barco: Writing – review & editing, Investigation, Data curation. Serena Mazzone: Writing – review & editing, Investigation, Data curation. Stefania Maria Bova: Writing – review & editing, Supervision, Methodology, Investigation. Simona Cappelletti: Writing – review & editing, Supervision, Project administration, Methodology, Investigation, Data curation, Conceptualization.

Ethics statement

We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary data

Supplementary data 1

Original Survey.

Data availability

The original contributions generated for this study are included in the article or its Supplementary Materials. Further inquiries can be directed to the corresponding author.