Marian Earls, Sherry Shackelford Hay, M.P.A.
M. F. Earls and S. S. Hay, Setting the Stage for Success: Implementation of Developmental and Behavioral Screening and Surveillance in Primary Care Practice, Pediatrics, July 2006 118(1):e183e188
Nationally, about 16 percent of children have some form of disability, including speech and language delays, mental retardation, learning disabilities, and emotional or behavioral problems. Among low-income children, such problems are even more common.
Screening and surveillance can identify developmental and behavioral problems and help children get the services they need. Even for children without problems, screening offers a way for providers to solicit parents' concerns and for families to learn about age-appropriate behavior and development. But screening is not part of routine primary care—only 30 percent of children needing services are identified by the time they begin school.
In "Setting the Stage for Success: Implementation of Developmental and Behavioral Screening and Surveillance in Primary Care Practice," (Pediatrics, July 2006), Marian F. Earls, M.D., of Guilford Child Health and the University of North Carolina School of Medicine, and Sherry Shackelford Hay, M.P.A., of the North Carolina Office of Research, Demonstrations, and Rural Health Development, present strategies for integrating developmental screening into pediatric offices. The strategies are drawn from lessons learned in North Carolina, which has developed a comprehensive system to significantly increase screening rates.
North Carolina's ABCD Project
North Carolina's efforts were supported by The Commonwealth Fund's Assuring Better Child Health and Development (ABCD) initiative, which is dedicated to strengthening the capacity of the health care system to support the early development of children from low-income families. Beginning in 2000, North Carolina set out to: 1) implement an efficient, practical office process for screening; 2) promote early identification and referral; and 3) facilitate practices' ability to access early intervention and other community services.
After pilot testing, the developmental screening program was formalized through adoption of a statewide Medicaid policy in 2004. All North Carolina providers are now required to screen children for developmental disorders at periodic visits with a standardized screening tool—most chose either the Ages and Stages Questionnaire (ASQ) or the Parents Evaluation of Developmental Status (PEDS). Since the start of the program, there has been a steady increase in the proportion of children screened for developmental problems.
Physicians Are Key to Implementation
The authors attribute North Carolina's success to the fact that it was led by physicians. This factor influenced the choice of screening tools: both the ASQ and PEDS instruments are inexpensive, parent-completed surveys that require little staff time and can easily fit into the office flow. A list of other suitable tools is available at www.dbpeds.org.
Participating practices identified several steps to successfully incorporating developmental services into their offices. These include: identifying a physician champion to maintain the initiative as a priority; selecting a screening tool; identifying system supports, including community partners; conducting staff orientations, such as nursing and office staff; and sharing process and out-come data at regular intervals.
Resources for Replication
The model spread through the state partly through the efforts of a physician champion, who led an ABCD advisory group and participated in child welfare committees. The state also worked to identify care management resources in local communities to support practices.
In addition, the ABCD project team developed resources to guide practices in implementing developmental screening and surveillance. These include:
While some features of North Carolina's programs are unique, such as its existing Medicaid case management system, the lessons and resources can inform efforts in practices across the country to expand developmental surveillance and improve the quality of pediatric care.
Facts and Figures