Building an Effective System of Developmental Screening and Diagnosis, Greenville, SC

Description

This article describes a pilot program in South Carolina which promotes developmental screening.

The Division of Developmental-Behavioral Pediatrics at the Children's Hospital in Greenville South Carolina, in collaboration with community agencies, has recently piloted programs to enhance developmental screening and diagnosis.

Promoting Resources in Developmental Education (PRIDE)

It is 3 year project funded by the Duke Endowment through a partnership of the Children's Hospital, the Center for Developmental Services (a co-location of agencies serving children with developmental disorders), the regional office of the state's early intervention system (BabyNet), the local school district's Child Find and Parents-as-Teachers program, and a parent-to-parent mentoring program for parents of children with special health care needs.

The goal of PRIDE is earlier identification and intervention for children in Greenville County with developmental delays and improved support for their parents. The program has targeted key players in the lives of infants and toddlers as follows: Parents sign up around the time of their child's birth to receive milestone cards every three to six months during the first three years that describe the key developmental attainments and activities to promote development at that age, and red flags for potential developmental problems.

Parents are instructed to discuss any concerns with their physician. Primary Care Physicians are provided with information and tools (the Parents Evaluation of Developmental Status - PEDS) to improve their system of developmental screening.

Liaison with Physician Offices

A nurse practitioner employed by PRIDE as the "physician office liaison" works closely with practices, initially by setting up lunch meetings with physicians and staff that are also attended by the PRIDE developmental-behavioral pediatrician. With the agreement of the physicians the liaison then assists the office staff in implementing the system and provides a "Resource Guide" with information on local developmental services and forms to facilitate referrals. Child care providers have the opportunity to attend educational sessions (for credit hours) where they learn about child development, signs of developmental problems, and services that are available for these children.

The training sessions are provided in collaboration with local programs that promote higher quality child care and early education (Success By 6 and First Steps) and the attendees receive "toolkits" with information on the topics discussed. Initial results of the program indicate success with 16 of 17 local pediatric practices (who previously had no standardized system of developmental screening) now utilizing the PEDS.

Results

Over the first 18 months of the program referrals to early intervention have increased almost 100% and to the school's Child Find program by 30%. Other service providers have seen increases in new referrals of up to 30%.

The average age of referral to early intervention has also dropped slightly. Increasing rates of referral have also raised the likelihood of even longer waiting lists for tertiary level developmental-behavioral pediatric evaluations. To address this challenge the division has received a grant from the Commonwealth Fund to study the feasibility and cost-effectiveness of a model of "mid-level" developmental-behavioral pediatrics assessment (as a step between telephone triage/ record review and comprehensive diagnostic evaluation) for children under 6 years.

Children referred with ill-defined or non-specific developmental concerns are evaluated by a developmental pediatric nurse practitioner and social worker utilizing a standard protocol and reliable measures of development and behavior, each spending 45 minutes face-to-face with patient and family.

Screening Tools

The assessment includes medical history, physical examination, and social-emotional and developmental assessment. Instruments utilized include the Infant-Toddler Social and Emotional Assessment (ITSEA) for children under two years of age; Behavior Assessment System for Children, Second Edition (BASC-2) Parent Rating Scale-Preschool (PR SP) for 2 to 6 year-olds; and the Developmental Assessment of Young Children (DAYC).

For children 16 to 30 months with language delays the Modified Checklist for Autism in Toddlers (MCHAT) is also administered. Data are entered directly into tablet computers and the database program presents a summary of critical findings in each domain assessed. Findings are entered into algorithms that direct recommendations for further evaluation or interventions (in consultation with supervising clinicians where necessary).

A brief letter/report with recommendations is mailed to the parents and referring physician and follow-up calls are made after 3 months to determine outcome of recommendations and satisfaction with the process. Preliminary findings indicate overall satisfaction among parents and referring physicians.

Due to shorter wait-times, patients are accessing needed therapeutic interventions earlier. For up to three quarters of those receiving mid-level assessments comprehensive developmental-behavioral pediatric evaluation is still recommended. However, these evaluations take less time and are more focused and efficient than if they are the patient's first encounter with the specialist physicians.

Dr Desmond Kelly is Medical Director of the Division of Developmental-Behavioral Pediatrics at the Children's Hospital of the Greenville Hospital System in Greenville, South Carolina, and is a GHS Professor of Clinical Pediatrics at the University of South Carolina School of Medicine. Dr Kelly is a past member of the Executive Committee of the AAP Section of Developmental and Behavioral Pediatrics and currently serves on the Subboard of Developmental-Behavioral Pediatrics of the American Board of Pediatrics. For more information on PRIDE, contact dkelly@ghs.org