High Quality Developmental Screening

Description

Getting ready to change screening practices

Learning objectives

Economics of screening

Know the long potential cost savings associated with early detection of developmental disabilities.

Screening and public policy

Understand public policy related to screening, and strategies to improve screening practices in primary care.

Change is never easy, especially when we are the ones – prompted by new knowledge, different circumstances, patient dissatisfaction or changed expectations – who must change. While a challenge, change also provides an opportunity for leadership.

Such is the case with developmental screening. The imminent change is routine high-quality developmental screening for all young children. The evidence is clear: Developmental delays, disabilities, and learning, behavioral and social-emotional problems are much more common than most people realize, affecting one in every six children across all economic levels, and all racial and ethnic groups.

Seventeen percent of all children have a developmental delay at one time or another. And about 16 percent have a speech-language impairment, mental retardation, learning disability, or emotional or behavioral disturbance. Identifying problems in infants, toddlers and preschoolers – and then providing effective interventions and supports – can dramatically improve a child’s health, learning, and social and emotional development in ways that are unlikely, often impossible, just a few years later.

National authorities

As the National Academy of Sciences said in From Neurons to Neighborhoods, “Compensating for missed opportunities, such as the failure to detect early difficulties or the lack of exposure to environments rich in language, often requires extensive intervention, if not heroic efforts, later in life”. Study after study shows that intervention prior to kindergarten has huge academic, social, and economic benefits, including savings to society of $30,000 to $100,000 per child.

While undoubtedly substantial, the dollars saved are not the only measure of value – especially to the one-in-25 households with a disabled preschooler. The science of developmental screening has matured. Unlike 10 or 15 years ago, pediatricians now have many high-quality developmental screening tools from which to choose.

As the AAP says in a 2001 policy statement:

"The best instruments have good psychometric properties, including adequate sensitivity, specificity, validity, and reliability, and have been standardized on diverse populations. Parent report instruments, such as the Parents' Evaluation of Developmental Status (PEDS), Ages and Stages Questionnaires (ASQ), and Child Development Inventories (CDI), have excellent psychometric properties and the advantage of requiring much less time from the pediatrician than instruments that require direct examination. But medical practice has not yet caught up with this new evidence."

Few pediatricians always use a screening tool. Most rely on clinical judgment, even though this method identifies less than 30 percent of children with mental retardation, learning disabilities, language impairments, or other developmental disabilities, and less than 50 percent of children with serious emotional and behavioral disturbances. In this context, more parents are becoming vocal about early screening, and policymakers (often parents or grandparents themselves) are both listening and raising questions of their own. With this new reality, what’s a practitioner to do?

Here are five concrete ways pediatricians can lead on this critical child health issue:

Step One

Upgrade your own practice to incorporate routine high-quality developmental screening, engaging front-office staff and nurses as key allies. For example, while many parents can fill out the simple and highly accurate forms on their own, some will need help because of literacy or language barriers. These common-sense and high-quality tools immediately catch 70 to 80 percent of children with problems.

Step Two

Speak out, linking early identification and intervention to school readiness. PTA’s, community groups, health agencies and local talk shows are perfect venues for the early-screening message, especially from a trusted local pediatrician. Communities concerned about student achievement (and which ones aren’t?) should resonate to the message that preschool-age children with unidentified and unaddressed disabilities, delays and problems quickly become school-age children unprepared for success. Recognizing this, for example, Los Angeles County has identified the degree to which preschool children who need special education actually receive it as a core indicator of school readiness.

Step Three

Encourage high-quality developmental screening in non-pediatric settings, such as child care and preschool programs. This will provide important information, community support, more informed parents and the best opportunity to follow-up with children who have suspected problems.

Step Four

Engage professional colleagues as partners and leaders. For example: Just this year the federal Centers for Medicare and Medicaid Services increased the value (“RVU” or “Relative Value Unit”) for developmental screening (#96110). Yet this improvement has not resulted in widespread increased physician reimbursement for screening, and is unlikely that it will until medical groups press for this change. Support increased funding for preschool special education – that is, funding for IDEA (Individuals with Disabilities Education Act) for children from birth through age 5. Despite overwhelming evidence of the effectiveness of early intervention, the federal per-child IDEA contribution for children ages 3 through 5 is less than half that for school-age children, and the gap is widening. This dismal picture would change if medical associations, educators and communities worked together to support increased funding for the youngest children with problems and developmental delays – IDEA for infants and toddlers (also known as “Part C”) and IDEA for 3-5 year-olds (also known as “Part B, Section 619”).

Step Five

Help the upcoming generation of pediatricians be prepared to do high-quality developmental screening. For example, does your medical school or residency placement provide training in such evidence-based tools as the PEDS, ASQ and CDI? Or are they still teaching the inferior Denver? You could also provide residents and interns with opportunities to conduct high-quality developmental screenings.

Sure, good developmental screening requires change. But it doesn’t require longer office visits, mounds of paperwork, or mastering complicated new skills. Rather, it can begin with parents (perhaps with a little help from office staff) filling out a short screening tool that you can then use to more effectively address a child’s most critical issues. While telling a parent that his or her child may have a problem is never easy, physicians now have the tools to spot problems and provide an effective “stitch in time” well before the developmental train has pulled out of the station. Now, that’s leadership!

The AAP policy statement on Developmental Surveillance and Screening of Infants and Young Children states: “the Denver-II screening test is used widely but has modest sensitivity and specificity depending on the interpretation of questionable results.” The American Academy of Neurology and the Child Neurological Society are even more direct in their 2000 statement, Screening and Diagnosis of Autism: “Because of the lack of sensitivity and specificity, the Denver-II (DDST-II) and the Revised Denver Pre-Screening Developmental Questionnaire (R-DPDQ) are not recommended for appropriate primary-care developmental surveillance.”

About the author

Margaret Dunkle is a senior fellow with the Center for Health Research Services and Policy, Department of Health Policy at George Washington University. She is the winner of the American Academy of Pediatrics’ Section on Developmental and Behavioral Pediatrics’ Dale Richmond Award for contributions to the field by a non-physician.

References

Lavigne JV, Binns HJ, Christoffel KK, et al. Behavioral and emotional problems among preschool children in pediatric primary care: Prevalence and pediatricians' recognition. Pediatrics. 1993;91:649-657. [143]
Glascoe, F. P. and H. L. Shapiro (2002) Developmental Screening. Medium: Website. Available: December 1, 2002. [174]
American Academy of Pediatrics (2001). Developmental surveillance and screening of infants and young children. Pediatrics 108(1): 192-6. [1]
Glascoe, F.P. (2000). Early detection of developmental and behavioral problems. Pediatrics in Review, 21, 272-280. [154]
Shonkoff, J. P., D. Phillips, et al. (2000). From neurons to neighborhoods : the science of early child development. Washington, D.C., National Academy Press. [189]
Boyle, Coleen A., Decoufle, P., and Yeargin-Allsopp, M. Prevalence and Health Impact of Developmental Disabilities in US Children. Pediatrics. 1994: 94(3):399-402. [215]
Los Angeles County Board of Supervisors. Minutes, July 15, 2003: Unanimous Adoption of the Framework for Tracking and Measurement of the Core Set of School Readiness Indicators (Framework), as recommended by the Los Angeles County Children’s Planning Council. [221]
US Department of Education 2004 Budget Request, February 3, 2003, assessed on June 4, 2003, www.ed.gov/offices/OUS/Budget04/04summary/section2bhtml#spednational. (The Administration proposed a budget for 2004 that would provide an average of $1,426 per child for the nearly 6.6 million children in Part B, ages 3-21, and $602 per child for the 648,200 children ages 3-5 in the preschool program.) [222]