The Value of the Mini-Mental State

Examination in Childhood: A

Preliminary Study
R.A. Ouvrier, MD, BS, BSc(Med),
I.C. Williams, MB, BS, FRACP

FRACP; R.F. Goldsmith, BSc(Hons); S. Ouvrier;

Abstract
The Mini-Mental State Examination

(MMSE), a screening test of higher mental function, has been modified slightly for
pediatric outpatient setting. The test, which takes 5 to 10 minutes to administer, covers a range of cognitive
functions including orientation, attention-concentration, memory, language, and constructional ability. In a preliminary
study, we have found that the test can be applied from the age of 4 years. Highly significant correlations were found
between the MMSE score and chronologic age (r
.57; P < .001), reading age (r .79; P < .001), and mental age (r .83;
P < .001). MMSE scores reach a plateau at a mental age of approximately 10 years. The MMSE is a suitable instrument for
screening higher mental function in children at the age of 4 years and above and can be readily incorporated into the
routine neurologic examination of children. (
J Child Neurol 1993;8:145-148).
use

in

generally accepted that examination of the

higher mental state should be a routine part of
complete neurologic examination and of the pedi-

is

atric examination of any child presenting with a disturbance of development, of thinking processes, of

memory, or with a learning disability. Despite this,

there is very little information concerning normal
values for screening tests of higher mental functions
in children. In the past 2 years, while working in a
pediatric neurology clinic, the authors have undertaken a pilot study of the use of the Mini-Mental
State Examination (MMSE), a widely used screening
test of cognitive function in adults. The preliminary
findings are reported in this paper.

Patients and Methods

patients tested attended one of the authors private

outpatient clinics. There were 83 boys and 34 girls, rang-

The 117
or

Received Oct 6, 1992. Accepted for publication Nov 20, 1992.

From the Department of Neurology, The Childrens Hospital, Camperdown, Australia.
Address correspondence to Dr R.A. Ouvrier, Department of
Neurology, The Childrens Hospital, Bridge Road, Camperdown
2050, Australia.

age from 4.0 to 15.0 years. The MMSE was administered at the conclusion of the neurologic examination.
Several minor modifications of the original test were incorporated, mainly to assist younger children attempting the
test. These included the use of a practice word (cat) for
younger or retarded children in the backward spelling test
(item 5) (Appendix). Older children were first asked to
spell world forward and then to spell it backward. The
items to be memorized in the registration test (item 3) and
the phrase in item 8 were each repeated twice by the examiner before the patient was asked to repeat them. The intersecting pentagon diagram of item 12 was of a simpler
design than that used by Folstein and coworkers. Finally,
the test was scored from the possible total score of 35,
rather than the total of 30 advised by Folstein et al.~ The
Schonell reading testz was administered to 68 of the patients. Results of formal psychometric testing, using the revised form of the Wechsler Intelligence Scale for Children
or Wechsler Preschool and Primary Scale of Intelligence,
were known for 32 of the patients. Their mental age was
calculated by multiplying their chronologic age at the time
of MMSE testing by their Wechsler Full Scale intelligence
quotient and then dividing by 100.
Twenty-nine of the 117 patients were used as &dquo;quasicontrols.&dquo; These 29 patients included otherwise normal individuals with intermittent headaches, functional visual
problems, tremor, or mild Tourette syndrome, and children referred for neurologic examination after remote mild
head trauma. Two of the 29 children were normal siblings
of patients referred for other reasons.
The results were analyzed using nonparametric statistical analysis by the Mann-Whitney U test and linear re-

ine in

gression analysis.

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TABLE 1
Correlation of Mini-Mental State Examination Scores with

*P <

tP

Age

Variables -

.001.
.005.

<

fP < .02.
Results
Correlations are shown in Table 1. For the whole
group of 117 children, significant correlations for the
MMSE score were found with age (r
.57; P < .001)
with
in
the
57
children
so far
(Figure 1),
reading age
tested (r
.79; P < .001), and with mental age in the
32 children tested (r
.83; P < .001) (Figure 2).
In the smaller group of 29 control patients,
=

highly significant

correlations with MMSE

found for age (r

.78; P < .001) (Figure
with reading age in the 11 children tested (r
=

were

<

score

3)
=

for all

.57)...

(r

.83)

.75;

.005).

score

Using regression analysis, the predicted mental

age at a given MMSE score can be determined by the
following equation for children between the ages of
4 and 10 years (chronologic age).
Mental Age
2.68 + 0.25 MMSE

and

It is apparent from Figures 1 (whole group) and

3 (controls) that scores reach a plateau at approximately 9 years chronologic age or at a mental age of
approximately 10 years in the IQ-tested group. In-

FIGURE 1
Correlation of age with MMSE

deed, the correlation of MMSE score with age for the

control group rose from .78 to .90 when only children under 10 years of age were considered.

patients (r

Discussion
Numerous psychological testing batteries are available for detailed evaluation of the cognitive function
of children, but these tests require considerable

FIGURE 2
Correlation of mental age with MMSE score for those patients who had IQ testing (r
.83). Mental age = age x
=

IQ/100.

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would then lead to more appropriate referrals for

detailed cognitive testing by a clinical psychologist.
In this preliminary study, the MMSE, modified
slightly for pediatric use, has been shown to be
readily applicable in a clinical setting. The test can
be applied at all ages from 4 years onward. Total
scores reach a plateau at about 9 or 10 years of age,
presumably corresponding to normal adult scores.
Above the age of 10 years, values below 27 of 35
suggest either mental retardation or dementia. Precise definition of lower limits of normal at various
ages will have to await the acquisition of normative
data. With such data, it should also be possible to
define the range of normal at various ages for subtests of the scale including measures of orienta-

tion, memory, concentration,

FIGURE 3
Correlation of age with MMSE

(r

score

in control

patients

.78).

training to administer and interpret and usually require an hour or longer for administration. They are
therefore quite unsuitable for incorporation into routine neurologic or pediatric clinical examinations.
The MMSE was developed for the screening of
higher mental functions in psychiatric patients but is
now mainly used as a screen for dementia. The test,
which takes 5 to 10 minutes to administer, covers a
range of cognitive functions including orientation,
attention-concentration, memory, language, and
constructional ability. In adult medical inpatients,
the test has a sensitivity of 87% and a specificity of
3
82% for impairment of cognitive function.3
Because children with learning disabilities, mental retardation, and other disturbances of higher
function often present to pediatricians and neurologists, there is a need for a rapid screening test of
higher function that can be administered in the clinicians office or at the bedside and for which accurate
normative data are established. Such tests would assist in the early detection of cognitive problems and

language functions,

and constructional ability. Such values have not previously been described for a test that is readily applicable to the pediatric clinical setting.
Apart from its value in detecting global or specific deficits of higher function (such as memory defects, dyscalculia, or reading difficulties), we have
found the test to be useful in following the recovery
of children after acute brain insults such as encephalitis and in the serial evaluation of possible dementia
in suspected degenerative disorders.
Quantitative normative data for the test are currently being acquired. We consider that the MMSE is
a suitable instrument for the screening of higher
mental function in children above the age of 4 years
and that it can be readily incorporated into the routine neurologic examination of children.

References
1. Folstein MF, Folstein SE, McHugh PR: "Mini-Mental State." A
practical method for grading the cognitive state of patients for
the clinician. J Psychiatr Res 1975;12:189-198.
2. Schonell FJ, Goodacre E: The Psychology and Teaching of Reading.
Edinburgh, Oliver & Boyd, 1974, pp 211-217.
3. Anthony JC, Le Resche L, Niaz U, et al: Limits of the MiniMental State as a screening test for dementia and delirium
among hospital patients. Psychol Med 1982;12:397-408.

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APPENDIX

Mini-Mental State Examination

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