Applied Neuropsychology: Child

ISSN: 2162-2965 (Print) 2162-2973 (Online) Journal homepage: http://www.tandfonline.com/loi/hapc20

Mini-Mental State Pediatric Examination (MMSPE)

standardization and normative data on Italian
children aged 36 to 72 months

Peviani Valeria, Scarpa Pina, Vedovelli Sara & Bottini Gabriella

To cite this article: Peviani Valeria, Scarpa Pina, Vedovelli Sara & Bottini Gabriella
(2018): Mini-Mental State Pediatric Examination (MMSPE) standardization and normative
data on Italian children aged 36 to 72 months, Applied Neuropsychology: Child, DOI:
10.1080/21622965.2018.1522590

To link to this article: https://doi.org/10.1080/21622965.2018.1522590

View supplementary material

Published online: 30 Oct 2018.

Submit your article to this journal

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=hapc20
APPLIED NEUROPSYCHOLOGY: CHILD
https://doi.org/10.1080/21622965.2018.1522590

Mini-Mental State Pediatric Examination (MMSPE) standardization and

normative data on Italian children aged 36 to 72 months
Peviani Valeriaa, Scarpa Pinab,c, Vedovelli Saraa, and Bottini Gabriellaa,b,c
a
Department of Brain and Behavioural Sciences, Universita degli Studi di Pavia, Pavia, Italy; bCognitive Neuropsychology Center, ASST
Grande Ospedale Metropolitano Niguarda, Milano, Italy; cMilan Center for Neuroscience, NeuroMi, Milano, Italy

ABSTRACT KEYWORDS
The MMSE (Mini-Mental State Examination), which is broadly used as a cognitive screening Cognitive screening; MMSE;
test for adults, has been successfully adapted and standardized for children of different normative scores; pediatric
nationalities. In the Italian clinical settings, the Mini-Mental State Pediatric Examination assessment; preschool age
(MMSPE) is being more and more used as cognitive screening tool for children. However,
the Italian norms for the MMSPE are available for the school age only. The current study
was aimed at providing clinicians with the Italian normative data of the MMSPE for pre-
school age. Here, we therefore adapted the MMSE to the preschool age. The MMSPE for
preschoolers assesses spatial and temporal orientation, verbal and visual memory, reading
prerequisites, numerical knowledge, praxis, body representation, and executive functions
through 16 items in a short period of time. It was administered to 305 Italian children aged
36 to 72 months. A Generalized Linear Model was fitted to explore predictors’ effects on the
MMSPE total score. Raw scores were adjusted for critical variables (child’s age and parental
mean education) and the 5th percentile cut-offs were obtained. With this study, we
extended the Italian normative data of the MMSPE, formerly available for school age only,
to preschool age population.

Introduction extremely useful in the neurological and psychiatric

Cognitive screening is a critical step of the neuro-
psychological assessment. Several tools are available to
evaluate adult patients, such as the Mini-Mental State
Examination (MMSE, Folstein, Folstein, & McHugh,
1975). As a main feature, it allows to collect informa-
tion about several neuropsychological domains within
a short time, providing an index of the global cogni-
tive functioning. Therefore, it is extensively used to
detect patients’ cognitive strengths and weaknesses in
order to provide guidance to the subsequent neuro-
psychological evaluation. Otherwise, when the neuro-
psychological assessment cannot be entirely carried
out, the MMSE may be helpful to frame the patient’s
cognitive level.
While the MMSE and other screening tools are
widely used to conduct a cognitive screening on adult
patients, only a few studies were aimed at providing
clinicians and psychologists with a similar tool for the
pediatric population. Nevertheless, we believe that a
comparable neuropsychological test would be
pediatric settings which require a multidisciplinary
approach for the diagnosis and treatment, involving
the cognitive assessment as well.
The Mini-Mental State Pediatric Examination
(MMSPE, Scarpa, Toraldo, Peviani, & Bottini, 2017)
represents a successful example of MMSE adaptation
to the Italian pediatric population. The MMSPE
explores orientation in space and time, verbal produc-
tion and comprehension, reading and calculation
learning prerequisites, working and verbal memory,
constructive ability, shape, and color recognition,
body awareness and executive functions. Three ver-
sions of the MMSPE have been designed and standar-
dized: the first one addressing Italian children
attending elementary school classes I and II, the
second one addressing Italian children attending elem-
entary school classes III to V and the last one address-
ing Italian children attending the middle school. The
MMSPE is being increasingly used by clinicians in
order to collect a global cognitive index, especially

CONTACT Peviani Valeria valeriacarmen.peviani01@universitadipavia.it Brain and Behavioural Sciences Department, Universita di Pavia, Piazza
Botta 11, Pavia 27100, Italy.
Supplemental data for this article can be accessed here.
ß 2018 Taylor & Francis Group, LLC
2 P. VALERIA ET AL.

Table 1. Cognitive domains addressed by the MMSPE for pre-schoolers.

Cognitive domain Tasks Score
Spatial and temporal orientation Name and surname 6
Age
Address
Date
Productive language Naming 3
Praxis and body representation Action execution 10
Figure copying
Drawing a human
Body parts location
Reading and writing prerequisite skills Phonological fusion 3
Phonological segmentation
One’s own name writing
Numerical knowledge Counting forward 3
Object Counting
Numerical judgment
Short and long term memory Word repetition 6
Word delayed recall
Visual memory and visual recognition Picture memory 3
Executive functions (adapted from Scarpa et al. (2006) Backward word repetition 6
Go-no go task
tot. 40

when young patients have attentional and motiv-
ational problems. However, MMSPE normative data
are available for the school age only (range 6 to 14).
So far, normative data for the preschool age have not
been provided.
Therefore, the current study was aimed at provid-
ing MMSPE Italian normative data for the preschool
age. To achieve this, we adapted the MMSPE items to
preschool age and we collected data from a large
Italian sample of children attending the kindergarten
in order to obtain normative scores.
While the MMSE and modified versions of the
MMSE have been successfully administered to school
age children in different countries ((Jain & Passi,
2005; Ouvrier, Hendy, Bornholt, & Black, 1999;
Rubial-Alvarez et al., 2007; Santos et al., 2012; Scarpa
et al., 2017; Shoji et al., 2002) only two studies report
the outcomes of MMSE administration to pre-
schoolers (3 to 6 years old). Shoji et al. (2002) admin-
istered the MMSE to a large sample of Japanese
children aged 3 to 11 with the purpose of exploring
when critical cognitive skills are acquired during the
development. Even more interestingly, Jain and col-
leagues (Jain & Passi, 2005) developed a modified ver-
sion of the MMSE and administered it to Indian
children aged 3 to 14. Both studies proved that
MMSE is a suitable tool to screen the general cogni-
tive functioning in the preschool age.
Data collection
The inclusion criteria were: (a) age between 36 to 72
months, (b) absence of intellectual disability or any
neuro-psychiatric disease, (c) absence of any visual or
auditory impairment, and (d) Italian as the
first language.
Participants were enrolled in kindergartens located
in Northern and Central Italy (both rural and urban
areas) after their parents or legal guardians had signed
their informed consent. Each child was individually
tested in a reserved room within their school struc-
ture. Parents and legal guardians were required to fill
a brief anamnestic questionnaire in order to collect
socio-demographic data (child’s birth date, mother’s
and father’s birth date and education in years of
schooling) and to ascertain the absence of any neuro-
psychiatric diagnosis.
Three-hundred-seven children were enrolled in the
study (2 resulted outliers), equally distributed among
the three-age classes (36 to 47, 48 to 59, 60 to
72 months).
The study was designed according to the ethical
standards of the Declaration of Helsinki and approved
by the Ethical Committee of the University of Pavia.
Test description
The MMSPE for preschoolers assesses the neuro-
psychological domains which are critical for cognitive
development (spatial and temporal attention, naming,
verbal short term and long term memory, visual rec-
ognition and memory, executive functions, body rep-
resentation, praxis, numerical knowledge, reading and
writing prerequisites). The item assessing the executive
functions has been adapted from the pediatric Frontal
Assessment Battery (Scarpa et al., 2006). The items
are summarized in Table 1.

Figure 1. MMSPE overall score (0–40) plotted against child’s age (months).
The MMSPE original version in Italian, as well as
its translation in English, is available as
Supplementary documentation.
Analysis
First, we used a quantile-quantile (QQ) plot to explore
the overall test score distribution and plotted the over-
all test score against age in order to assess linearity.
Two outliers were detected (below 2.5th percentile)
and removed from the sample. Whereas the overall
test score distribution was skewed toward the max-
imum score, we opted for a Generalized Linear Model
(GzLM) since a clear linear pattern emerged (see
Figure 1).
Second, we computed Pearson’s correlations among
predictors (child’s age and sex, father’s and mother’s
age and education) in order to check for collinearity
issues. As expected, a strong correlation arose between
father’s and mother’s age (r ¼ .704, p < .001) and
between father’s and mother’s age and education
(r ¼ .487, p < .001). Significant, although weaker corre-
lations, were found between the child’s age and both
the mother’s (r ¼ .154, p ¼ .009) and father’s (r ¼ .152,
p ¼ .010) age, as well as between mother’s age and
education (r ¼ .190, p ¼ .001), father’s age and moth-
er’s education (r ¼ .119, p ¼ .046) and mother’s age
and father’s education (r ¼ .162, p ¼ .007). As we had
already done in previous standardization studies
APPLIED NEUROPSYCHOLOGY: CHILD 3
(Scarpa et al., 2006), we computed the mean parental
education and the mean parental age in order to min-
imize collinearity issues.
As a third step, we fitted a GzLM with Tweedie
distribution and Log-link with child’s age, child’s sex,
parental education and age as predictors and 40-X as
the dependent variable, where X was the raw test
score. As only child’s age (v2(1) ¼ 314.621, p < .001)
and parental education (v2(1) ¼ 8.723, p ¼ .003)
showed to have a significant effect on the MMSPE
score, a second GzLM (best model) was fitted with
these latter two as predictors. Child’s gender
(v2(1) ¼ 0.338, p ¼ .561) and parental age
(v2(1) ¼ 2.143, p ¼ .143) did not have a significant
effect on MMSPE score.
Finally, cut-off scores (5th percentile) were com-
puted for 28 possible combinations of age and paren-
tal education (4 parental education levels x 7 child’s
age ranges).
We computed the analysis through SPSS 19.0 (IBM
Corp., 2010).
Results
Descriptive statistics of the sample (N ¼ 305) as well
as the overall test scores are reported in Table 2.
As mentioned previously, we fitted a GzLM to esti-
mate the effect of child’s age (v2(1) ¼ 205.682,
p < .001) and parental education (v2(1) ¼ 6.581,
4 P. VALERIA ET AL.

Table 2. Descriptive statistics of the sample. Table 3. MMSPE cut-offs (5th percentile).
Age range (months) Child’s age in months
36–47 48–59 60–72 Tot 36 42 48 54 60 66 72
N 99 101 105 305 Parental mean education
Gender 8 25.0 25.4 25.7 26.0 26.3 26.6 26.9
M 48 54 49 151 13 25.2 25.5 25.8 26.1 26.4 26.7 27.0
F 51 47 56 154 18 25.4 25.7 26.0 26.3 26.6 26.9 27.2
Age 22 25.5 25.8 26.1 26.4 26.7 27.0 27.3
Mean 41.87 54.12 66.09 54.29
SD 3.09 3.50 4.02 10.44
Mother Education reading and writing prerequisites, numerical know-
Mean 15.24 15.60 15.41 15.39
SD 2.95 2.90 3.77 3.25 ledge, body representation, visual memory, and execu-
Father Education tive functions, beside the classical domains such as
Mean 14.14 14.27 14.20 14.17
SD 3.52 3.50 3.28 3.42 spatial and time orientation, verbal memory, naming,
Mother Age and praxis.
Mean 37.01 37.92 38.78 37.89
SD 4.08 4.23 4.81 4.57 We obtained Italian cut-off scores (5th percentile)
Father Age by performing a GzLM that considered the outcome
Mean 39.78 40.26 42.05 40.86
SD 5.00 5.17 5.92 5.66 of 305 children aged between 36 and 72 months as a
Mean Parental Education dependent variable and socio-demographic variables
Mean 14.69 14.94 14.80 14.77
SD 2.82 2.77 3.03 2.89 as predictors. The best linear model showed that only
Mean Parental Age child’s age and parental mean education significantly
Mean 38.39 39.09 40.42 39.35
SD 4.19 4.26 4.98 4.75 predicted the MMSPE full score.
Overall MMSPE Score 0–38 Parental mean education significantly predicted the
Mean 22.24 29.18 34.83 28.78
SD 6.07 5.87 3.97 7.45 overall scores of the MMSPE for school-age as well
Median 22.00 30.00 35.00 30.00 (Scarpa et al., 2017). The current results have con-
Interquartile Range 9.50 9.00 6.0 11.5
firmed that such a factor has a strong influence even
during preschool age. Indeed, the role of parental edu-
p ¼ .010) on the overall MMSPE score. The following cation has been recognized to be critical for the devel-
equation was obtained: opment of several neuropsychological domains such
Total score ¼ 5:5160:051  ðchild’s ageÞ  0:032 as sustained and divided attention, visual integration
 ðparental educationÞ skills, episodic memory, associative memory, math
and reading skills, vocabulary, and verbal production
This equation allowed us to compute normality (Gibbs & Forste, 2014; Richels, Johnson, Walden, &
cut-offs (5th percentile) that were transformed into Conture, 2013; Scarpa et al., 2006; Schady, 2011).
raw cut-offs subtracting 40 (Table 3). Needless to say, the MMSPE does not provide an
exhaustive cognitive assessment, but it might be
Discussion extremely useful when an extensive neuropsycho-
logical evaluation could not be completely carried on,
The MMSE has been already adapted and standar-
such as, when severe attentional and behavioral prob-
dized for Australian, Japanese, Indian, Spanish, and
lems are present. The MMSPE could also represent a
Brazilian children sample (Jain & Passi, 2005; Ouvrier
useful tool to monitor the cognitive development of
et al., 1999; Rubial-Alvarez et al., 2007; Santos et al.,
children in clinical settings, over time. Future studies
2012; Shoji et al., 2002). Recently, a pediatric version
will be aimed at studying the validity and reliability of
of the MMSE, the MMSPE, has been administered to
the MMPSE and collecting data for specific clinical
a large normative sample of Italian school-age chil-
populations.
dren (Scarpa et al., 2017). Given the growing use of
With this study, we extended the Italian normative
the MMSPE for school age among Italian clinicians,
data of the MMSPE, previously available for the
we aimed at adapting the MMSPE to the preschool
school age only, to the pre-school population.
age and collecting normative data for Italian
preschoolers.
The main structure of MMSE, broadly used to
carry on a cognitive screening on adults, was main- Acknowledgments
tained and its items were adapted to the developmen- We are grateful to M.P. for helping with the data collection,
tal age. Hence, the MMSPE for preschoolers assesses and to M.M. and A.P. for the language revision.

Disclosure statement
No potential conflict of interest was reported by
the authors.
References
Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975).
“Mini-mental state”. A practical method for grading the
cognitive state of patients for the clinician. Journal of
Psychiatric Research, 12(3), 189–198. doi:10.1016/0022-
3956(75)90026-6
Gibbs, B. G., & Forste, R. (2014). Breastfeeding, parenting,
and early cognitive development. The Journal of Pediatrics,
164(3), 487–493. doi:10.1016/j.jpeds.2013.10.015
IBM Corp. Released. 2010. IBM SPSS statistics for windows,
version 19.0. Armonk, NY: IBM Corp.
Jain, M., & Passi, G. R. (2005). Assessment of a modified
mini-mental scale for cognitive functions in children.
Indian Pediatrics, 42(9), 907–912.
Ouvrier, R., Hendy, J., Bornholt, L., & Black, F. H. (1999).
SYSTEMS: School-Years Screening Test for the
Evaluation of Mental Status. Journal of Child Neurology,
14(12), 772–780. doi:10.1177/088307389901401202
Richels, C. G., Johnson, K. N., Walden, T. A., & Conture,
E. G. (2013). Socioeconomic status, parental education,
vocabulary and language skills of children who stutter.
Journal of Communication Disorders, 46(4), 361–374. doi:
10.1016/j.jcomdis.2013.07.002
Rubial-Alvarez, S., Machado, M. C., Sintas, E., de Sola, S.,
Bohm, P., & Pena-Casanova, J. (2007). A preliminary
APPLIED NEUROPSYCHOLOGY: CHILD 5
study of the mini-mental state examination in a Spanish
child population. Journal of Child Neurology, 22(11),
1269–1273. doi:10.1177/0883073807307098
Santos, L. H. C., Pimentel, R. F., Rosa, L. G. D., Muzzolon,
S. R. B., Antoniuk, S. A., & Bruck, I. (2012).
Cognitive and behavioral screening of children with
learning disabilities: A preliminary study. Revista
Paulista de Pediatria, 30(1), 93. doi:10.1590/S0103-
05822012000100014
Scarpa, P., Piazzini, A., Pesenti, G., Brovedani, P., Toraldo,
A., Turner, K., … Bottini, G. (2006). Italian neuro-
psychological instruments to assess memory, attention
and frontal functions for developmental age. Neurological
Sciences, 27(6), 381–396. doi:10.1007/s10072-006-0717-5
Scarpa, P., Toraldo, A., Peviani, V., & Bottini, G. (2017).
Let’s cut it short: Italian standardization of the MMSPE
(Mini-Mental State Pediatric Examination), a brief cogni-
tive screening tool for school-age children. Neurological
Sciences, 38(1), 157–162. doi:10.1007/s10072-016-2743-2
Schady, N. (2011). Parents’ education, mothers’ vocabulary,
and cognitive development in early childhood:
Longitudinal evidence from Ecuador. American Journal of
Public Health, 101(12), 2299–2307. doi:10.2105/ajph.2011.
300253
Shoji, M., Fukushima, K., Wakayama, M., Shizuka-Ikeda,
M., Ikeda, Y., Kawakami, A., … Abe, K. (2002).
Intellectual faculties in patients with Alzheimer’s disease
regress to the level of a 4–5-year-old child. Geriatrics &
Gerontology International, 2(3), 143–147. doi:10.1046/
j.1444-1586.2002.00040.x