Fall 1999
Articles
Reviews
1998 Award Recipients
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Developmental and Behavioral Screening
Frances Page Glascoe, Ph.D. Nashville, TN
Henry Shapiro, M.D., St. Petersburg , FL
Overview
About 16% of children have disabilities such as speech-language impairments, mental
retardation, learning disabilities, and emotional/behavioral disturbance. Although such
children are twice as likely to seek health care than children without disabilities, only
half are detected prior to school entrance. The reasons are understandable: Most
disabilities are subtle and children who have them often appear to be developing normally
especially at younger ages.
Nevertheless, underdetection is unfortunate because it eliminates the possibilities of
early intervention. Children who participate in early intervention programs prior to
kindergarten are more likely to graduate from high school, hold jobs, live independently
and to avoid teen pregnancy or delinquency. These positive outcomes save society between
$30,000 to $100,000 per child.
In order to improve pediatricians’ ability to detect children with developmental
and emotional/behavioral problems, the American Academy of Pediatrics Committee on
Children with Disabilities recommends the use of standardized screening tests at each well
visit. However, most pediatricians find the more popular measures too lengthy to give
routinely. Many such measures also lack accuracy and fail to sensitively identify children
with difficulties.
Fortunately, several recently published tools are far more suitable for busy pediatric
offices because they are both quick and accurate. Several take only a few minutes to give
and improve on existing detection rates by 25% to 30%.
Who Should Be Screened?
Contrary to some beliefs, low-income parents and those with limited education can
complete parent-report screens. The results can be as useful as screens completed by
parents with higher levels of education. Asking parents (in their primary language) if
they would prefer to have someone go through the measure with them should circumvent
literacy barriers.
On a similar note, screening tests work best in populations with moderate levels of
risk for disabilities, such as low income, limited education, families with lots of other
risk factors such as mental health problems, single parents, many children in the home,
and unemployment.
It is possible to identify groups with very high or very low levels of risk by noting
the presence or absence of parental concerns. It is not a good idea to administer
additional secondary screens to these high and low risk groups. Sensitivity or specificity
will fall out of the acceptable ranges of 70% to 80%. If a clinician is able to discover
whether a parent is concerned or not, referral or non-referral decisions can be made
immediately in approximately 80 per cent of the cases, with additional screening reserved
for the remaining 20 per cent.
Nevertheless, eliciting parents’ concerns is tricky in itself. Parents’ do
not respond well to some terms (e.g., do you have any worries about your child’s
development?) For this reason, one tool, described below, uses carefully standardized and
validated questions.
Pitfalls of Screening
There are three major pitfalls of screening:
- Waiting until a problem is observable. Clinicians often use screening tools only
after they've noticed a problem. If the problem is obvious, referring may be the best
response. Screening such children may compound rather than reduce the error in both
clinical judgment and screening tools.
- Ignoring screening results. Many times, screening test results are not taken
seriously and children who fail are not referred but rather viewed with a wait and see
attitude. Good screens are right 70 to 80 per cent of the time. There is no evidence to
support "temporizing" in such a situation, and harm could result from delayed
diagnosis and intervention.
- Relying on informal methods. Informal tools such as checklists often contain
items sure to miss most kids with problems (such as the checklists on many encounter
forms). These are often based on instruments such as the original Denver Developmental
Screening Test, which missed up to 50 per cent of mental retardation and 70 per cent of
language impairment. Checklists provide no validated criteria for referrals, and have
unknown reliability. Validated and standardized tools carry the burden of proof that
informal measures lack. We would never select tools for blood lead or other medical
screens with questionable or unknown levels of accuracy. Why do we do this with
development?
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Summary
Developmental and Behavioral screening is a well-developed technology.
These instruments are superior to informal methods that are now being
used in many offices. Many instruments are also available in Spanish,
and some in other languages. We have listed a number of valid and reliable
screening instruments
that are suitable for office use.
We are planning an online discussion group for screening along the lines of the
successful DBP Discussion List, with CME credit available. For more information, send
email to Henry L. Shapiro, M.D. or write to the address at the end of this newsletter.
More information about individual screening tests is available online on the Pediatric
Development and Behavior Homepage.  |
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