J Neurosurg Pediatrics 8:396–401,

8:000–000, 2011

Comparison of Hydrocephalus Outcome Questionnaire

scores to neuropsychological test performance in
school-aged children
Clinical article

Abhaya V. Kulkarni, M.D., Ph.D.,1 Ruth Donnelly, Ph.D., 2

and Iffat Shams, M.B.B.S., M.P.H.1

Divisions of 1Neurosurgery and 2Psychology, The Hospital for Sick Children, University of Toronto, Ontario,
Canada

Object. The Hydrocephalus Outcome Questionnaire (HOQ) is an established means of measuring quality of life,
but the cognitive component of this questionnaire has never been formally compared with gold-standard neuropsy-
chological test scores. The authors hypothesized that the HOQ Cognitive Health score would demonstrate a relatively
strong correlation with neuropsychological test scores, whereas much weaker correlations would be seen for HOQ
Physical and Social-Emotional Health scores.
Methods. A cross-sectional study of children with long-standing hydrocephalus presenting to The Hospital for
Sick Children’s Neurosurgery Clinic was performed between July 2006 and September 2008. Participating children
and families completed the HOQ and a battery of 21 standard neuropsychological tests and questionnaires. Pearson
correlation analysis was then performed.
Results. A total of 83 patients (81% participation) was accrued; the mean age was 11.5 ± 3.4 years (mean ± SD)
at the time of assessment. The mean age at hydrocephalus treatment was 1.3 ± 2.6 years. The mean overall HOQ score
was 0.69 ± 0.21. The HOQ Cognitive score had a moderate or strong correlation with 19 (90%) of 21 neuropsycho-
logical test scores, much more so than the HOQ Social-Emotional score (5 moderate or strong correlations, 24%) and
the HOQ Physical score (1 moderate correlation, 5%). For 19 neuropsychological tests (90%), the HOQ Cognitive
score had a stronger correlation than the other scores. The HOQ Cognitive score had particularly strong correlations
with the Verbal IQ, List Learning, Behavior Problems, and Metacognitive Abilities components.
Conclusions. Data from a wide-ranging representative sample of children with long-standing hydrocephalus
provide added evidence of the validity of the HOQ Cognitive score and the overall domain structure of the HOQ
itself. (DOI: 10.3171/2011.7.PEDS1179)

Key Words      •      pediatric hydrocephalus      •      health outcome      •      quality of life      •     

neuropsychology

H
ealth-related quality of life in childhood hy-
drocephalus is now recognized as an important
outcome to consider. We have previously devel-
oped the HOQ, which has provided a simple, reliable,
and valid way in which to measure HRQL in children
with hydrocephalus.17,18 Our group and others have since
used the HOQ in several research studies of HRQL.3,14–
16,19,20,22
Within the spectrum of HRQL, cognition is seen
Abbreviations used in this paper: HOQ = Hydrocephalus Out-
come Questionnaire; HRQL = health-related quality of life; WAIS-
III = Wechsler Adult Intelligence Scale–Third Edition; WISC-IV =
Wechsler Intelligence Scale for Children–Fourth Edition; WPPSI-III
= Wechsler Preschool and Primary Scale of Intelligence–Third Edi-
tion; WRAT-3 = Wide Range Achievement Test–Third Edition.
as a particularly relevant component for children with
hydrocephalus. The HOQ includes a cognitive health
component, for example, consisting of 12 questions. The
gold standard for objectively measuring cognitive perfor-
mance has long been through the use of neuropsycho-
logical tests, including traditional IQ testing and other
specific tests. We embarked on a study to assess detailed
objective neuropsychological performance in a diverse
group of children with treated hydrocephalus, and we
compared these results to those obtained from the more
subjective parent responses to questions from the HOQ.
We hypothesized that, although there might be areas for
which the HOQ scores mirror neuropsychological test re-
sults, there would probably also be areas for which these
measures would provide unique information. We hypoth-

396 J Neurosurg: Pediatrics / Volume 8 / October 2011

Neuropsychological outcome in children with hydrocephalus
esized that the HOQ Cognitive Health score in particu-
lar would demonstrate the strongest correlation with the
neuropsychological tests, whereas much weaker correla-
tions would be seen for HOQ Physical and Social-Emo-
tional Health scores. The HOQ Cognitive score questions
mainly revolve around parents’ appraisal of their child’s
learning, memory, and elements of the Executive Func-
tion component such as organization and attention. If our
hypotheses were correct, then that would add confidence
to the validity of the HOQ Cognitive score and the pro-
posed domain structure of the HOQ itself.
Methods
We recruited a consecutive sample of children be-
tween the ages of 5 and 18 years, in whom hydrocephalus
had been diagnosed and treated at least 6 months earlier,
from the neurosurgery outpatient clinic of The Hospital
for Sick Children, Toronto, between July 2006 and Sep-
tember 2008. These children had to have adequate skills
in English to complete testing, as evidenced by at least 2
years of English schooling. Children who had undergone
either a neuropsychological or psychological-educational
assessment within 1 year prior to participating in this
study were excluded, because this could have resulted in
artificially inflated scores. This protocol was approved by
the hospital’s research ethics board, and written consent
and assent were obtained from all participating families.
Assessment of HRQL
The child’s primary caregiver was asked to complete
the HOQ. The HOQ is a 51-item questionnaire with prov-
en reliability and validity in measuring health outcome
in children with hydrocephalus.17,18 We have previously
shown good correlations between the HOQ and several
independent measures of health,17 including the WRAT’s
Reading subtest,29 Strengths and Difficulties Question-
naires,12,13 and Functional Independence Measure for
Children,21 but we have not compared HOQ results to
performance on neuropsychological tests. The HOQ pro-
vides scores of Overall Health, Physical Health, Cognitive
Health, and Social-Emotional Health, all of which range
from 0 (worse outcome) to 1.0 (better outcome). Previous
work has suggested that, to be clinically meaningful, a
difference in HOQ scores needs to be approximately on
the order of 0.10 or greater, based on how parents per-
ceive differences in health status.14
Assessment of Neuropsychological Performance
Children were given a battery of neuropsychological
tests by a trained psychological assistant and supervised
by an experienced pediatric neuropsychologist. The tests
involved were the core tasks from a standard neuropsy-
chological evaluation and were an intensive and compre-
hensive assessment of the child’s cognitive functioning.
These are listed in Table 1 and in the Appendix, and all
are widely used and well-standardized instruments. The
testing lasted approximately 5 hours and included tests of
IQ, language, academics, memory, visual-motor and visu-
al-spatial skills, and visual information processing speed.
J Neurosurg: Pediatrics / Volume 8 / October 2011
We chose tests from the clinical test battery given
to children with hydrocephalus who are referred to the
Psychology division from the Neurosurgery division at
The Hospital for Sick Children. These tests had to either
encompass the entire age range of this study (5–18 years),
or they had to have upward or downward extensions with
similar formats and comparable outcome measures. A
few words are in order here to explain the intelligence
testing scores. We used different Wechsler intelligence
tests depending on the age of the child: the WPPSI-III;27
the WISC-IV;25 and the WAIS-III.24 However, to have
comparable scores among these 3 tests, we used 3 mea-
sures from each Wechsler test: the Verbal IQ Index score,
the Nonverbal IQ Index score, and the Processing Speed
IQ Index score. Each index score is summed over several
subtests within each domain of verbal and nonverbal in-
tellectual abilities and processing speed. We did not use
the Working Memory Index scores from the WAIS-III
and the WISC-IV because there is no comparable index
score on the WPPSI-III and also because the WAIS-III
Working Memory score includes a mental arithmetic sub-
test, and there is no similar subtest as part of the WISC-
IV Working Memory score.
Most of the tests that we used have more than 1 out-
come score. We selected the specific scores a priori that
we thought best reflected the child’s performance in the
particular area of interest. The full names of the tests and
the particular score or scores that we used from each test
can be found in the Appendix.
For the first 18 scores in this listing, higher values
indicate stronger performance by the child. The last 3
scores listed are the results from 2 different parent ques-
tionnaires, and higher scores indicate more problems in
the areas queried. One score is from a behavioral ques-
tionnaire,1 in which parents answered questions relat-
ing to their child’s possible difficulties in areas such as
anxiety, depression, social problems, attention problems,
and aggression. The other 2 scores are from an Execu-
tive Function questionnaire,11 in which parents answered
questions about their child’s everyday functioning in ar-
eas such as control of behaviors (behavioral regulation
score), and planning, organizing, self-monitoring, and
paying attention (metacognitive abilities score).
Statistical Analysis
The Pearson correlation was used to assess the asso-
ciation between the 3 HOQ subscores (Cognitive, Physi-
cal, and Social-Emotional) and each test of neuropsycho-
logical function. Similar to the suggestion by Cohen4 and
others,6 we defined a strong correlation as > 0.5, moderate
as 0.35–0.5, and weak/negligible as < 0.35.
We hypothesized that HOQ Cognitive Health scores
would have mostly strong or moderate correlation with
any of the first 18 measures of neuropsychological func-
tion listed above, whereas the HOQ Physical and Social-
Emotional Health scores would demonstrate mostly weak/
negligible correlation.
For the last 3 measures listed, higher scores indicate
poorer performance in these areas. Because a higher
score on the HOQ indicates better outcome, we expected
a relatively strong negative correlation between the Be-
397
 A. V. Kulkarni, R. Donnelly, and I. Shams
TABLE 1: Neuropsychological testing results

Pearson Correlation w/
Patient Test Population HOQ Cognitive HOQ Physical HOQ Social-Emotional
Test* Scores† Scores† Score Score Score
Verbal IQ index 93 ± 17 100 ± 15 0.54‡ 0.38 0.33
Nonverbal IQ index 87 ± 18 100 ± 15 0.43 0.32 0.25
Processing Speed IQ index 84 ± 17 100 ± 15 0.44 0.45 0.31
PPVT 96 ± 16 100 ± 15 0.45 0.30 0.25
EOWPVT 95 ± 16 100 ± 15 0.49 0.27 0.31
Ambiguous Sentences 8±4 10 ± 3 0.41 0.18 0.26
Oral Comprehension 99 ± 13 100 ± 15 0.44 0.23 0.24
Letter-Word ID 91 ± 21 100 ± 15 0.48 0.17 0.18
Calculation 83 ± 27 100 ± 15 0.50 0.27 0.27
Passage Comprehension 85 ± 19 100 ± 15 0.48 0.24 0.27
Stories Delayed 9±4 10 ± 3 0.38 0.26 0.39
Faces Delayed 9±4 10 ± 3 0.28 0.17 0.04
Design Memory 7±3 10 ± 3 0.43 0.25 0.20
Sentence Memory 10 ± 3 10 ± 3 0.44 0.17 0.24
List Learning 44 ± 15 50 ± 10 0.58‡ 0.30 0.36
List Memory Delayed −1 ± 1 0±1 0.47 0.17 0.32
Beery VMI 83 ± 17 100 ± 15 0.36 0.33 0.27
Spatial Relations 92 ± 14 100 ± 15 0.29 0.25 0.03
Behavior Problems 58 ± 12 50 ± 10 −0.53‡ −0.43 −0.53‡
Behavioral Regulation 57 ± 14 50 ± 10 −0.39 −0.29 −0.47
Metacognitive Abilities 62 ± 13 50 ± 10 −0.57‡ −0.31 −0.4

* See Appendix for test details. Abbreviations: EOWPVT = Expressive One-Word Picture Vocabulary Test; PPVT = Peabody
Picture Vocabulary Test; VMI = Visual-Motor Integration.
†  Values in the 2nd and 3rd columns represent the mean ± SD for the patient and test populations, respectively.
‡  Strong correlations (> 0.5).

havior Problems and the Social-Emotional HOQ scores.
We hypothesized that the last 2 measures listed (Be-
havioral Regulation and Metacognitive Abilities) would
have at least moderate negative correlations with both
the HOQ Social-Emotional and Cognitive scores. These
measures of executive function encompass such a broad
range of loosely defined abilities (such as initiation, plan-
ning, organizing, attention, and self-monitoring) that it
seems likely that both emotional and cognitive aspects
of a child’s functioning will be affected by strengths or
weaknesses in these areas.
All analyses were performed using the SPSS Ad-
vanced Statistics software package (version 17.0; SPSS,
Inc.).
Results
A total of 103 patients and their families were ap-
proached to participate in this study, of whom 83 (81%)
agreed to enroll. The most common reason for refusal to
participate was lack of available time to complete the in-
tensive neuropsychological testing. The characteristics of
the participants are shown in Table 2. The school grade
level of the children ranged from senior kindergarten to
Grade 12. Five children had hydrocephalus secondary to
a tumor, but none had received radiotherapy or chemo-
therapy. The mean HOQ scores were as follows: Overall
Health (0.69 ± 0.21), Cognitive Health (0.57 ± 0.29), Phys-
ical Health (0.79 ± 0.19), and Social-Emotional Health
(0.74 ± 0.19).
The results of the 21 neuropsychological measures
and their correlations with the HOQ scores are shown in
Table 1. An in-depth analysis and discussion of the pat-
tern of the neuropsychological test results is beyond the
scope of this paper and will not be attempted here, but
instead will be presented in a separate work. A summary
of the strengths of correlations between the neuropsycho-
logical scores and HOQ scores is shown in Table 3. In
general, the HOQ Cognitive score had a greater number
of strong correlations than either the HOQ Physical or So-
cial-Emotional scores. Also, for every test except Behav-
ioral Regulation, the HOQ Cognitive score had a stronger
correlation than the other scores.
Discussion
In a wide-ranging representative sample of children
with long-standing, treated hydrocephalus, our study
showed that the HOQ Cognitive score had a strong cor-
relation with several tests of neuropsychological function.

398 J Neurosurg: Pediatrics / Volume 8 / October 2011

Neuropsychological outcome in children with hydrocephalus
TABLE 2: Characteristics of 83 patients with long-standing
hydrocephalus
Characteristic Value*
mean age at assessment 11.5 ± 3.4 yrs
mean age at 1st op for hydrocephalus 1.3 ± 2.6 yrs
no. w/ ETV as primary procedure 9 (10.8)
no. w/ cause of hydrocephalus
  posterior fossa cyst 14 (16.9)
  IVH due to prematurity 12 (14.5)
  aqueductal stenosis 11 (13.3)
 myelomeningocele 10 (12.0)
  trauma/spontaneous hemorrhage 6 (7.2)
  congenital communicating hydrocephalus 6 (7.2)
 tumor 5 (6.0)
 postinfectious 4 (4.8)
  other cyst 4 (4.8)
  other cause 11 (13.3)
mean total days in hospital for initial treatment of hy- 16.2 ± 19.8
 drocephalus
mean total days in hospital for hydrocephalus compli- 18.4 ± 28.5
 cations
*  The mean values are presented ± SD; the remaining values are ex-
pressed as the number of patients, with the percentage in parentheses.
Abbreviations: ETV = endoscopic third ventriculostomy; IVH = intraven-
tricular hemorrhage.
Particularly strong correlations were shown with the Ver-
bal IQ, List Learning, Behavior Problems, and Metacog-
nitive Abilities components. We had previously shown a
strong correlation (0.59, Pearson test) between the HOQ
Cognitive score and the WRAT-329 in a sample of 90 chil-
dren with hydrocephalus as part of the initial validation
of the HOQ.17 Only the Reading subtest of the WRAT-3
was used in that study, because it requires the least physi-
cal ability from the children (the other subtests, Arithme-
tic and Spelling, have a written component), and it had
the highest test–retest reliability (0.93) of all the subtests,
along with excellent internal consistency (a = 0.91).29 It
was acknowledged, however, that the Reading subtest of
the WRAT-3 was a limited test of cognition. This sub-
test from the WRAT-3 just requires the child to decode
words, with no test of whether the words are understood,
and is almost identical in form to the Letter-Word ID test
we used in the current study. Therefore, we had yet to
show that the HOQ Cognitive score was a valid measure
of wider, more comprehensive aspects of cognition. That
was the primary purpose of this study: to assess the valid-
ity of the HOQ Cognitive score by using a wide range of
standardized neuropsychological tests, and to determine
whether the HOQ Cognitive score provided information
unique from the other HOQ subscores (Physical and So-
cial-Emotional scores). Our results suggest that the HOQ
Cognitive Health score is uniquely correlated with several
well-established measures of cognition and is thus unique
from HOQ Physical or Social-Emotional Health scores.
It was not expected that the HOQ Cognitive Health
J Neurosurg: Pediatrics / Volume 8 / October 2011
TABLE 3: Summary of strengths of correlations between HOQ
scores and neuropsychological tests
Correlation (no. of tests, %)
Test Component Strong Moderate Weak/Negligible
HOQ Cognitive 4 (19) 15 (71) 2 (10)
HOQ Physical 0 3 (14) 18 (86)
HOQ Social-Emotional 1 (5) 4 (19) 16 (76)
score would be very highly correlated with all or even
most neuropsychological tests. After all, we know that
when we report results from objective tests, we are com-
paring an individual child against comprehensive norms
collected from large numbers of same-age or same-grade
children. Therefore, when we say that, based on these ob-
jective results, a child is “within the average range” on
a test in which the scores are normally distributed, we
mean that the child falls within the middle 50% of a rep-
resentative sample of children. However, when a parent
completes the HOQ, they are asked to say how true each
statement is for their child, with no comparison group
specified. We do not know to what extent parent evalua-
tions could be affected by extrinsic factors such as their
general expectations for children who have hydrocepha-
lus, or whether they think their child is really trying, even
though they might have difficulty in some specific areas.
We conceptualize the HOQ to be measuring aspects of
quality of life, so we do not see it as a substitute for neu-
ropsychological tests, which generally are tests of func-
tion. Because the HOQ measures the effect of function on
quality of life, although the concepts being measured are
related, they are complementary rather than redundant.
Our study adds further confirmation of the validity
of the HOQ structure and the HOQ Cognitive score in
particular. Aside from showing the strong correlations of
HOQ Cognitive score with neuropsychological tests, it
is equally important that we have shown a much weaker
correlation between almost all of these tests and the HOQ
Physical and Social-Emotional scores. This suggests that
these other scores are in fact measuring something unique
and are not providing redundant, highly correlated infor-
mation. This adds validity to the hypothesized domain
structure of the HOQ.
We envision the primary use of the HOQ as a re-
search tool for the reliable measurement of quality of life
outcome in children with hydrocephalus. Although we
are now expanding its use to routine clinical monitoring
of patients, its role in clinical management remains to be
determined. As we gain more experience in the clinical
setting, we hope the HOQ might be able to help identify
patients who would benefit from more detailed neuropsy-
chological testing. Again, we do not see the HOQ as a
substitute for neuropsychological tests.
We acknowledge several limitations in our work. First,
despite this being one of the largest neuropsychological
studies of children with hydrocephalus, our sample size
remains relatively small. It is possible that, with more par-
ticipants, we might have discovered stronger correlations
in other areas. A second limitation is that ours is only a
single-center experience. Further tests of validation in oth-
399

er centers will be important to prove the reproducibility of
our work.
Conclusions
In a wide-ranging representative sample of children
with long-standing hydrocephalus, the HOQ Cognitive
Health score demonstrated mostly strong and moderate
correlations with a number of tests of neuropsychologi-
cal function. The HOQ Physical and Social-Emotional
Health scores demonstrated much weaker correlations.
These data provide added evidence of the validity of the
HOQ Cognitive score and the overall domain structure of
the HOQ itself.
Appendix
Details of tests and scores used in this study.
Verbal IQ index. For ages 5 years–5 years 11 months, WPPSI-
III Verbal IQ score; for ages 6 years–15 years 11 months, WISC-IV
Verbal Comprehension Index score; for ages ≥ 16 years, WAIS-III
Verbal Comprehension Index score.
Nonverbal IQ index. For ages 5 years–5 years 11 months,
WPPSI-III Performance IQ score; for ages 6 years–15 years 11
months, WISC-IV Perceptual Reasoning Index score; for ages ≥ 16
years, WAIS-III Perceptual Organization Index score.
Processing Speed IQ index. For ages 5 years–5 years 11
months, WPPSI-III Processing Speed score; for ages 6 years–15
years 11 months, WISC-IV Processing Speed Index score; for ages
≥ 16 years, WAIS-III Processing Speed Index score.
PPVT. Peabody Picture Vocabulary Test–Third Edition;9
receptive language vocabulary test.
EOWPVT. Expressive One-Word Picture Vocabulary Test–
Revised (2000 edition);10 expressive language vocabulary test.
Ambiguous Sentences. Subtest from the Test of Language
Competence–Expanded Edition;28 higher-order language test.
Oral Comprehension. Subtest from the Woodcock-Johnson
III Tests of Achievement30 (WJ-III); understanding orally presented
sentences.
Letter-Word ID. Subtest from the WJ-III; reading individual
words.
Calculation. Subtest from the WJ-III; test of math calculations.
Passage Comprehension. Subtest from the WJ-III; under-
standing written sentences.
Stories Delayed. For ages 5 years–15 years 11 months, Child­
ren’s Memory Scale5 (CMS), Stories subtest, 30-minute delayed
testing; for ages ≥ 16 years, WMS-III: Wechsler Memory Scale, ed
3,26 Stories subtest, 30-minute delayed testing. Memory for orally
pre­sented stories.
Faces Delayed. For ages 5 years–15 years 11 months, CMS,
Faces subtest, 30-minute delayed testing; for ages ≥ 16 years, WMS-
III, Faces subtest, 30-minute delayed testing. Memory for pictures
of faces.
Design Memory. Subtest from the WRAML2: Wide Range
Assessment of Memory and Learning, ed 2.23 Memory for designs
tested 10 seconds after presentation.
Sentence Memory. Subtest from the WRAML2. Immediate
memory for sentences presented orally.
List Learning. For ages 5 years–15 years 11 months, California
Verbal Learning Test–Children’s Version7 (CVLT-C); for ages ≥ 16
years, California Verbal Learning Test–28 (CVLT-II). Memory for
the list words recalled over all 5 oral presentations of the list.
List Memory Delayed. For ages 5 years–15 years 11 months,
CVLT-C; for ages ≥ 16 years, CVLT-II. Memory for list words free-
recalled 20 minutes after last recall of the list.
Beery VMI. The Beery-Buktenica Developmental Test of
Visual-Motor Integration, ed 5.2 Copying geometric shapes; visual
mo­­tor skills.
400
A. V. Kulkarni, R. Donnelly, and I. Shams
Spatial Relations. Subtest from the Woodcock-Johnson III
Tests of Cognitive Abilities.31 Ability to manipulate shapes mentally
but with no visual-motor component.
Behavior Problems. Child Behavior Checklist for Ages 6–18.1
Behavioral questionnaire filled out by the parent; Total Problems
score.
Behavioral Regulation. Behavior Rating Inventory of Execu­
tive Function11 (BRIEF); behavioral questionnaire filled out by the
parent. Overall rating of child’s ability to inhibit or shift behavior and
to control emotions.
Metacognitive Abilities. BRIEF; behavioral questionnaire
filled out by the parent. Overall rating of the child’s ability to initiate,
to plan and organize, to self-monitor, and to pay attention.
Disclosure
The authors report no conflict of interest concerning the mate-
rials or methods used in this study or the findings specified in this
paper. Funding for this study was provided by the SickKids Founda-
tion/Institute for Human Development, Canadian Institutes of Health
Research, and the SickKids Research Institute. The funding organi-
zations were completely independent of the design and conduct of
the study; collection, management, analysis, and interpretation of the
data; and preparation, review, and approval of the manuscript.
Author contributions to the study and manuscript prepara-
tion include the following. Conception and design: all authors.
Acquisition of data: all authors. Analysis and interpretation of
data: Kulkarni, Donnelly. Drafting the article: Kulkarni, Donnelly.
Critically revising the article: all authors. Reviewed submitted ver-
sion of manuscript: all authors. Approved the final version of the
manuscript on behalf of all authors: Kulkarni. Statistical analysis:
Kulkarni. Study supervision: Kulkarni.
Acknowledgments
The authors thank Margaret Wilkinson and Patricia Arseneau
for their invaluable assistance in administering and scoring the neu-
ropsychological tests.
Ethical Approval
Approval was obtained from the Institutional Review Board of
The Hospital for Sick Children, Toronto.
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Manuscript submitted March 2, 2011.
Accepted July 11, 2011.
Address correspondence to: Abhaya V. Kulkarni, M.D., Ph.D.,
Division of Neurosurgery, The Hospital for Sick Children, Uni-
versity of Toronto, Room 1503, 555 University Avenue, Toronto,
Ontario M5G 1X8, Canada. email: abhaya.kulkarni@sickkids.ca.
401