When people are told that something may be affecting their brain, there is often an immediate assumption that a scan will show visible damage. In clinical practice, however, many of the cognitive, academic, emotional, and behavioral difficulties observed in both children and adults often occur without any clear abnormalities on MRI or CT imaging. Understanding the distinction between structural and functional brain changes is crucial for accurate diagnosis, effective intervention, and informed advocacy.
Structural brain changes refer to physical or anatomical alterations in the brain tissue itself. These changes are typically visible on neuroimaging and may result from conditions such as stroke, traumatic brain injury, tumors, cortical malformations, neurodegenerative processes, or surgical intervention. Because these changes affect the brain’s physical structure, they are often conceptualized as problems with the brain’s “hardware.” Structural abnormalities can be associated with specific patterns of impairment, depending on their location; however, outcomes vary widely due to neural plasticity and individual differences in cognitive reserve.
Functional brain changes, in contrast, involve how the brain operates rather than how it is physically formed. In these cases, standard imaging may appear entirely normal, yet the individual experiences real and persistent difficulties in daily functioning. Functional changes reflect inefficiencies in neural networks, problems with communication between brain systems, or dysregulation of cognitive and emotional processes. Conditions such as ADHD, learning disabilities, epilepsy-related cognitive effects, anxiety disorders, post-concussion symptoms, medication side effects, sleep disruption, and chronic stress commonly involve functional rather than structural changes. These patterns affect the brain’s “software,” influencing how efficiently information is processed, regulated, and sustained over time.
One of the most common misconceptions in medicine and education is that normal imaging equates to normal functioning. Neuroimaging is designed to detect structural abnormalities, not to measure how the brain performs under cognitive load, across extended periods, or in complex real-world environments. As a result, individuals may be told that “everything looks normal” while continuing to struggle with attention, memory, processing speed, emotional regulation, academic performance, or endurance. This disconnect can be particularly confusing and frustrating for families and patients seeking answers.
This is where neuropsychological evaluation plays a critical role. Neuropsychology focuses on how the brain functions in practice by assessing attention, memory, language, executive functioning, processing speed, and emotional regulation through standardized, performance-based measures. Rather than relying solely on structural findings, neuropsychologists interpret patterns to understand how efficiently neural systems are working together. These evaluations provide essential insight into functional brain changes that are not captured on scans or EEGs.
Distinguishing between structural and functional brain changes has important clinical and educational implications. When functional difficulties are misunderstood or minimized due to normal imaging, individuals may experience delayed diagnosis, inadequate support, or inappropriate expectations. Functional brain changes are no less real or impactful than structural ones, particularly in children whose brains are still developing and in individuals managing chronic neurological or medical conditions.
Ultimately, neuropsychology bridges the gap between medical findings and everyday functioning. By translating brain-based patterns into meaningful explanations and practical recommendations, neuropsychologists help individuals, families, schools, and treatment teams understand not just what the brain looks like, but how it actually works. A normal scan does not necessarily reflect a normal experience, and recognizing functional brain changes is often the key to effective intervention and improved quality of life.
Laura Brockman, PsyD
NJ Temporary Permit #: 253-033
Postdoctoral Fellow