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of Child Neurology

Use of the Modified Mini-Mental State Examination With Children

Penny S. Besson and Elise E. Labbé
J Child Neurol 1997 12: 455
DOI: 10.1177/088307389701200708

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Original Article

Use of the Modified Mini-Mental State

Examination With Children
Penny S. Besson, MS; Elise E. Labbé, PhD

ABSTRACT

The validity and reliability of the modified version of the Mini-Mental State Examination with children was examined. The
Modified Mini-Mental State Examination was administered to 99 children between 4 and 12 years of age (45 males and 54
females) to assess expected scores for nonclinical children and with a clinical sample. Concurrent validity was assessed
through correlations of Modified Mini-Mental State Examination scores with Wechsler Intelligence scores and Child
Behavior Checklist scores. The Modified Mini-Mental State Examination was administered to 26 children on two occa-
sions to determine test-retest reliability Means and standard deviations of scores are reported by age and grade level.
Test-retest reliability coefficients were positively significant. For the nonclinical sample, Modified Mini-Mental State
Examination scores were significantly and positively correlated with Verbal IQ and Child Behavior Checklist scores.
Modified Mini-Mental State Examination scores were significantly correlated with Verbal IQ scores in the total and clini-
cal samples. (J Child Neurol 1997;12:455-460).

Examination of cognitive function should be a routine part
of neurologic examinations for children presenting with
learning disabilities or disturbances in development, think-
ing process, or memory. 1>2 To date there has been only one
published study concerning the use of mental status exam-
inations with children.2 Ouvrier and colleagues (1993)2 con-
ducted a preliminary study assessing the Mini-Mental State
Examination when used with children. The subjects in the
study were 117 patients ranging in age from 4 to 15 years.
All patients were referred to a pediatric neurology clinic, and
the Mini-Mental State Examination was administered at the
conclusion of the examination. Numerous changes in admin-
istration and scoring of the Mini-Mental State Examination
were incorporated by the researchers to make the test eas-
ier for younger children. Data from a subgroup of 29 of the
children were separately analyzed to form a &dquo;quasi&dquo; control
Received Dec 27, 1995. Received revised August 26, 1996. Accepted for pub-
lication Sept 3, 1996.
From the Department of Psychology, University of South Alabama, Mobile,
AL.
Address correspondence to Dr Elise E. Labbé, Department of Psychology,
University of South Alabama, Mobile, AL 36688.
group and intelligence test scores were known for 32 of the
children.
Results indicated significant correlations between Mini-
Mental State Examination scores and age, Full Scale IQ
scores, and Mental Age for the sample as a whole. Corre-
lations with age were greater for the control group. The
authors reported that Mini-Mental State Examination scores
tended to reach a ceiling at approximately 9 years of age.
This is contradictory to findings in studies with adults, in
which the 8th year of education tended to mark a ceiling
point.3-5 Ouvrier and colleagues suggested that a cut-off
score of 27 (on a 35-point scale) be used for children aged
10 years and older. However, the authors provided no cri-
teria for evaluating the performance of younger children.
Studies of adults have suggested using a cut-off score of 24,
on a 30-point scale.s
In the present study, the Modified Mini-Mental State
Examination was administered. The inclusion of questions
concerning similarities between two objects or concepts
(verbal abstract reasoning) in the modified version may be
valuable in assessing higher cognitive functions that should
be developmentally present in children older than 6 years. 1
Use of the Modified Mini-Mental State Examination also
allows for a greater range of item difficulty and scores and
may eliminate the ceiling effect seen in the preliminary
study. The Modified Mini-Mental State Examination also
provides standardized directions for administration and

455
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456
scoring to ensure comparability between administrations.
Standardization may be more important when using such
a test with children because of the great variability of per-
formance seen in children.
Although many tests are available to assess cognitive
functioning in children, these tests usually are quite long and
require special training for administration and interpretation.
Such tests may therefore be difficult to incorporate into rou-
tine pediatric examinations. Should the Modified Mini-Men-
tal State Examination prove to be a valid screening measure
of cognitive functioning in children, this test could easily be
incorporated into the examination of children referred to
a specialty clinic. This study was designed to gather pre-
liminary data on the Modified Mini-Mental State Examina-
tion when used with children. Our second goal was to
evaluate test-retest reliability of the Modified Mini-Mental
State Examination. Finally, we wanted to evaluate the con-
current validity of the Modified Mini-Mental State Exami-
nation by comparing intellectual functioning measured
using Wechsler scales and behavioral functioning measured
using the Child Behavior Checklist to scores of the Modi-
fied Mini-Mental State Examination.
METHOD
Subjects
Subjects consisted of 99 children between the ages of 4 and 12 years
(mean, 7.48; SD, 2.53). The total sample included 45 boys and 54
girls. Subjects were divided into nonclinical and clinical samples
for separate data analysis.
Nonclinical Sample
The subjects in the nonclinical sample consisted of 79 children
whose parents volunteered them for participation in the study.
The sample included 36 boys and 43 girls. The mean age of the nor-
mal sample was 7.08 years (SD, 2.41). Volunteers were recruited
through local schools, community and media advertisements, and
the Well Child program at the University of South Alabama Pedi-
atric Clinic. All subjects were free of neurologic impairment as
reported by parents and medical history.
Clinical Sample
The clinical sample consisted of 20 subjects,
11 girls. The mean age for the clinical sample
Table 1. Diagnoses of Clinical Subjects
*Six subjects were diagnosed in more than one category.
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including 9 boys and
was 9.1 years (SD,
2.38). Subjects were referred to the Psychological or Neurological
Clinics at the University of South Alabama for psychological or neu-
rologic testing, or both. Distribution of clinical subjects by med-
ical or psychological diagnoses is presented in Table 1. Psychological
diagnoses were made using the DSM-IV criteria.
Materials
Modified Mini-Mental State Examination
The Modified Mini-Mental State Examination consists of 15 ques-
tionsdesigned to assess the individual’s cognitive functioning.
The areas theorized to be measured by the test include registration,
recall, attention and calculation, temporal orientation, spatial ori-
entation, and language. The test required approximately 15 minutes
to administer and was scored on a 100-point scale using standard
scoring instructions.’7
Wechsler Intelligence Scales
The Wechsler Preschool and Primary Scale of Intelligence-Revised
(WPPSI-R) was administered to 4- and 5-year-old children, and
the Wechsler Intelligence Scale for Children (WISC), Third Edition,
was administered to older children. Verbal, Performance, and Full-
Scale IQ scores were obtained for comparison with Modified Mini-
Mental State Examination scores.
Child Behavior Checklist
The Child Behavior CheckliSt8 is a questionnaire designed to
assess behavior in school,
home, and social environments. Behav-
ioral profiles obtained provide clinicians and researchers with a
comprehensive overview of a particular child’s behavior prob-
lems. The Behavior Problems scale consists of 118 items scored
from 0 to 2 points, depending on the frequency of the reported
behavior. The parental report form, which required approximately
20 minutes to complete, was used in the present study. Separate
forms were provided for boys and girls of different ages. A global
score based on the Total Behavior Problems index was calcu-
lated for comparison with Modified Mini-Mental State Examina-
tion scores.
Procedure
All tests were administered by a psychologist or trained psychol-
ogy graduate students. All reported testing was completed in one
session, except in cases of reliability measurement, for which an
additional session was arranged for readministration of the Mod-
ified Mini-Mental State Examination. Standard administration and
scoring procedures were followed for all tests.
Nonclinical Sample
Parents or guardians who responded to information about the
study published in local newspapers were contacted by the primary
investigator. The purpose of the study and expectations for par-
ticipation were fully explained, and an appointment for testing was
arranged. Upon arrival for their child’s appointment, parents were
given a consent form to read and sign and were then asked to com-
plete the medical history questionnaire, demographic information
questionnaire, and the Child Behavior Checklist. These children

were given an intelligence test along with the Modified Mini-Men-
tal State Examination. Order of administration of tests was alter-
nated to counter-balance any possible order effects: for half of the
subjects, the intelligence test was administered prior to the admin-
istration of the Modified Mini-Mental State Examination, and for
the remaining subjects, the Modified Mini-Mental State Examina-
tion was administered prior to the administration of the intelligence
test. An additional appointment was then made for readministra-
tion of the Modified Mini-Mental State Examination.
For children who participated through area schools and day-
care centers; consent forms, medical history and demographic
questionnaires, and a cover letter documenting scheduled testing
dates were sent home with selected students. Administration of the
Modified Mini-Mental State Examination was conducted at the
school after all forms had been returned.
For those children who participated through the Well Child
program at the University of South Alabama, parents were
approached by the primary investigator while they were waiting
to see their pediatrician. The child was then brought to an examina-
tion room so the test could be administered without disturbance.
Clinical Sample
Parents who brought their children to the Psychological or Neu-
rological Clinics at the University of South Alabama for testing were
asked to allow their child to participate in the study. If permission
for participation was given, the parent was asked to read and sign
the consent form and was given the medical history and demo-
graphic questionnaires and the Child Behavior Checklist to com-
plete. The subjects in this group were administered the Modified
Mini-Mental State Examination at the same time as scheduled
intelligence testing. When initial testing was completed, some par-
ents were asked to schedule another testing appointment for re-
administration of the Modified Mini-Mental State Examination in
order to obtain information on stability of scores. All testing and
diagnosing of clinical subjects was completed by either a psy-
chologist (Neurological Clinic) or trained psychology graduate
students under the supervision of a licensed psychologist (Psy-
chological Clinic). Subject diagnoses were based on evaluations
that included complete psycho-educational test batteries, parental
interviews, and behavioral observations.
RESULTS
For all samples, scores on the Modified Mini-Mental State
and Mini-Mental State Examinations were significantly cor-
related (for all samples, r = .97, P .00). For the total sam-
=
ple, scores on the Modified Mini-Mental State Examination
ranged from 16 to 96 (mean, 66.27; SD, 23.78). Pearson cor-
relation coefficients were shown to be significant between
both Modified Mini-Mental State Examination score and
age (r = .81, P = .000) and Modified Mini-Mental State Exam-
ination score and grade (r = .81, P = .000). Means and stan-
dard deviations of scores at each age level by sample are
presented in Table 2. Separate analysis of scores by gender
were not calculated because statistical analyses revealed a
nonsignificant relationship between these variables.
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457
Table 2. Distribution of Modified Mini-Mental
State Examination Scores by Age
Reliability of Modified Mini-Mental State Examination
scores was assessed by calculating Pearson product-moment
correlation coefficients between scores obtained on the
first (Modified Mini-Mental State Examination,) and second
(Modified Mini-Mental State Examinatior~) administrations
of the test. For all samples, test-retest scores were shown
to be significantly correlated (nonclinical sample: r .96,=
P = .000; clinical sample: r .97, P .000; total sample:
= =
r = .96, P .000). Reliability of scores was also analyzed by
=
retest group, and yielded significant correlations at 1-week,
2-week, and 4-week retest intervals (1-week retest: r .99, =
P .00; 2-week retest: r .97, P .00; 4-week retest: r .85,
= = = =
P .O1). As only one subject fell into the 3-week retest cat-
=
egory, this interval could not be analyzed.
Measures of concurrent validity were assessed by ana-
lyzing the relationship between Modified Mini-Mental State
Examination total scores and other measures of function-
ing. For the total sample, significant correlations were found
between Modified Mini-Mental State Examination total
scores and Wechsler Verbal IQ scores (r .31, P .04). There
= =
were no significant correlations between Modified Mini-
Mental State Examination scores and Performance IQ, Full
Scale IQ, or Child Behavior Checklist Total Behavior Prob-
lems scores for the total sample.
For the nonclinical sample, Modified Mini-Mental State
Examination scores were significantly correlated with both
Verbal IQ scores and Child Behavior Checklist Total Behav-
ior Problems scores (Modified Mini-Mental State Exami-
nation vs Verbal IQ: r .46, P .01; Modified Mini-Mental
= =
State Examination vs Child Behavior Checklist: r = .44, P =
.03). For the clinical sample, Modified Mini-Mental State
Examination scores correlated significantly with Verbal IQ
scores (r .55, P .03). No other significant correlations
= =
between measures of functioning were found in this sample.
To further analyze variability of scores by age and grade
and determine whether scores on the Modified Mini-Men-
tal State Examination reach a ceiling at a certain age or grade
level, scores were plotted by age and grade using the regres-
sion approach and visually examined for a plateau. Figures
1 and 2 present plots of Modified Mini-Mental State Exam-
ination scores by age and grade for the total sample. These
458
Figure 1. The relationship between age and Modified Mini-Mental
State Examination total scores for the entire sample.The solid line rep-
resents the linear least square best fit.
plots suggest that Modified Mini-Mental State Examination
scores reach a plateau at approximately 9 years of age and
at the sixth grade level. The resulting linear regression equa-
tion for predicting Modified Mini-Mental State Examina-
tion score based on grade level was y 34.721 + 8.198x, the =
equation for age was y 9.534 + 7.581x.
= Test scores for the Modified Mini-Mental State Examination
A 1-test for independent measures was performed to
determine whether Modified Mini-Mental State Examination
scores obtained by the clinical sample were significantly
different from scores obtained by the normative sample.
Results indicate no significant difference between these
groups. There was also no significant relationship between
Modified Mini-Mental State Examination scores and diag-
nostic category.
Post-hoc analyses indicating possible relationships
between Modified Mini-Mental State Examination scores and
demographic variables were also conducted. Significant
correlations were found between these scores and race, edu-
cational level of parents, and family income level for the total
and normal samples. In the clinical sample, Modified Mini-
Mental State Examination scores were significantly corre-
lated with parent’s educational level, but not with race or
income. Table 3 presents a correlation matrix for these
variables.
Table 3. Correlations Between Modified Mini-Mental State
Examination Scores and Demographic Variables
MOED = mother’s educational level; FAED = father’s educational level;
Income = family annual income level.
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Figure 2. The relationship between grade and Modified Mini-Men-
tal State Examination total scores for the entire sample. Grades pre-
K through seventh are represented by the numbers 1 through 9,
respectively. The solid line represents the linear least square best fit.
DISCUSSION
Reliability of Modified Mini-Mental State Examination scores
was assessed through test-retest correlation coefficients.
appear to be reliable for both clinical and nonclinical sam-
ples across 1-, 2-, and 4-week retest intervals. The stability
of these scores over time provides more meaningful inter-
pretation of results.
As in previous studies with adults, :1,4 the present study
found that children’s Modified Mini-Mental State Examina-
tion scores are significantly related to both age and educa-
tion. Reported means and standard deviations by age may
thus be used as a criterion against which a particular child’s
performance on the test can be measured.
As in the previous study by Ouvrier and colleagues2
using the Mini-Mental State Examination, the present study
found that regression plots suggest that scores on the Mod-
ified Mini-Mental State Examination appear to reach a
plateau at approximately 9 years of age. However, in both
the previous and present study the majority of the children
were 9 years of age or younger. This plateau may thus result
from sampling distribution rather than a true ceiling effect,
especially for the Modified Mini-Mental State Examination.
Although Ouvrier and colleagues2 did not report the distri-
bution of scores by age, in the present study no perfect
scores were obtained on the Modified Mini-Mental State
Examination. This may indicate the possibility of increase
of Modified Mini-Mental State Examination scores with age
if more older children were included in the samples. Regres-
sion equations reported may also be used to measure a par-
ticular child’s performance on the Modified Mini-Mental
State Examination by comparing predicted score at the
child’s age level to obtained score. For example, predicted
score 9.534 + 7.581 (age). Thus, for a 9-year-old child, the
=
predicted score would be 77.76, and if that child scored sig-
nificantly lower than that, there may be cause for concern
and indication for further testing. Determination of which

scores differed significantly may be a basis for further
or be
research, may determined using the accepted measure
of scores that are more than 1.5 standard deviations below
the mean for the child’s age.
Validity of Modified Mini-Mental State Examination
scores was assessed by comparing those scores with other
established measures of intellectual and behavioral func-
tioning, as well as with clinical diagnoses. Although men-
tal state examination scores were found to correlate
significantly with both Verbal IQ and Full Scale IQ scores
in both nonclinical and clinical adults,6>9 the present study
found that scores on the Modified Mini-Mental State Exam-
ination correlated significantly with only Verbal IQ scores
in children. This may have been a result of the heavy reliance
of the mental status examination on verbal abilities, as
most questions require verbal response and all directions
are oral and thus rely heavily on verbal comprehension.
Alternately, these results may suggest that mental status
examinations for children are measuring something other
than intellectual abilities, and therefore will not necessar-
ily correlate highly with Full Scale IQ scores.
Modified Mini-Mental State Examination scores were
significantly correlated with Child Behavior Checklist Total
Behavior Problems T-scores for children in the nonclinical
sample. These correlations were not found for children in
the clinical sample. It is possible that the clinical group
was a more homogeneous sample than the nonclinical group
and this may have resulted in nonsignificant correlations with
behavioral tests. Furthermore, behavioral problems may
not have surfaced and interfered with the child’s perfor-
mance, because the Modified Mini-Mental State Examina-
tion required the child to attend to the examiner for only a
brief period of time.
Previous studies using the Mini-Mental State Exami-
nation with adult populations have found that the test is able
to distinguish between nonclinical and diagnostic groups. 6,10
However, these findings were not replicated in the present
study. Results of an independent group’s t-test revealed no
significant differences of Modified Mini-Mental State Exam-
ination scores between the nonclinical sample and the clin-
ical sample. However, only 20% of subjects in the present
study comprise the clinical sample. Thus the nonsignifi-
cant result may be due to the skewed distribution of the sam-
ple. An examination of Table 3 indicates that mean scores
for the clinical sample are lower than mean scores for the
nonclinical sample at all age levels. Thus, increasing the size
of the clinical sample to more closely approximate the size
of the nonclinical sample may yield significant differences
of Modified Mini-Mental State Examination scores between
these two groups.
An analysis of scores obtained by the clinical sample
showed no significant relationship between subjects’ diag-
noses and scores on the Modified Mini-Mental State Exam-
ination. This again may be an effect of sampling distribution,
because 50% of the clinical sample was diagnosed as men-
tally retarded and 40% of the clinical sample was diagnosed
with attention-deficit disorder. However, because mental
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459
status examinations are not designed to be diagnostic instru-
ments, they should not be expected to distinguish between
diagnostic groups.
Based on the results of previous research with
adultsll-13 indicating that Mini-Mental State Examination
scores were affected by socioeconomic status and eth-
nicity, analysis of the relationship between Modified Mini-
Mental State Examination scores and demographic
variables was also conducted. Results indicated that these
scores were significantly correlated with race, family
income level, and educational level of parents for chil-
dren in the nonclinical sample. These results may con-
found the validity of mental status examinations as
measures of cognitive functioning. However, because the
test is designed as a screening instrument for identifying
cognitive impairment, possible confounding factors to
predictive validity are most important in clinical samples.
The present study found no significant relationship between
Modified Mini-Mental State Examination scores and either
race or family income level for children in the clinical
sample, indicating that scores may have more predictive
validity among clinical groups. Although Modified Mini-
Mental State Examination scores were significantly cor-
related with parent’s educational level for children in the
clinical sample, educational level of parents has been
shown to affect the intellectual functioning of children, and
would therefore affect scores on any measure of a child’s
intellectual functioning. 14
Results of the present study suggest that the Modified
Mini-Mental State Examination may prove to be a useful
screening measure for children, especially in cases in which
a child’s impairment may preclude or interfere with other
measures of functioning that require sustained attention
and concentration. This is the first study to provide data on
central tendency and variability of scores at each age level
that may be used as preliminary norms. An individual child’s
performance on the test can then be compared to this data.
However, the small size and relatively homogeneous nature
of the present sample restricts interpretation of results.
Further research is needed before any definitive conclusions
can be drawn and results should be interpreted cautiously.
Future projects should employ larger and more varied
samples. This study provides the basis for further research
on the Modified Mini-Mental State Examination that would
add significantly to the available information on the valid-
ity of this instrument as a screening measure for both adults
and children.
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