In 2000, North Carolina was one of four states selected to participate in The Commonwealth Fund's Assuring Better Child Health and Development (ABCD) program to strengthen child development services for low-income children. At the time, North Carolina referred only 2 to 4 percent of children to early intervention services, even though 12 to 16 percent of young children nationally have some type of developmental or behavioral disorder. Marian Earls, M.D., medical director of Guilford Child Health in Greensboro, led a demonstration project that integrated developmental screening and case management into three Guilford clinics that serve low-income children.Today, this model of care has spread to 49 pediatric and family practices in North Carolina—and raised average referral rates for early intervention services to 7 or 8 percent. We asked Dr. Earls what she learned from the project, and about its potential for further replication.
When you first started looking at how Guilford clinics were handling child development services, what did you find?
Marian Earls: Clinics were supposed to be using the Denver Developmental Screening Test, which takes a nurse 20 to 30 minutes to administer. We found that the test was being given at only 3 to 5 percent of well-child visits, mostly because of staffing and time shortages.
You eventually chose the parent-completed Ages & Stages Questionnaire as part of the new model of delivering care. Why?
Earls: I always tell people that it wasn't rocket science: we looked at the different screening tools that were available, how specific the questions were, how long they took to complete, who had to complete it, and what language and reading level they were in. Ages & Stages met our needs. Parents are excellent reporters of their child's activities. Plus, it's a good way to involve them in a conversation about their child's care.
How did you get pediatricians interested in changing the way they approach child development?
Earls: With this project, physicians were involved from the beginning, and they had a say in how the new model would be integrated into their practice. We've found that using the screening tool can actually improve doctor–patient communication. If a doctor asks,"Your child is talking already, isn't he?," a parent might be put on the defensive. But the screening process formalizes these conversations and builds trust. One physician even told us that using Ages & Stages questions as a template for discussion has sped up his office visits.The questionnaire can also help pediatricians talk with parents about the bread-and butter issues—kids who don't sleep well, or don't behave in public places—that might not come up during a visit but can cause a lot of stress.
What kind of feedback have you gotten?
Earls: Many parents tell us they appreciate being asked about their child's development. Even for the 93 percent whose kids don't have problems, the screening can still provide useful information. The early intervention specialist we hired to oversee the screening process and coordinate referrals makes personal contact with parents of kids who are referred to the Head Start program as well as to speech pathologists and other services. She also lends support to families who are concerned about their child's development.
The Commonwealth Fund's ABCD initiative relies on change at the practice and community levels. How do you translate this to broader change throughout the state?
Earls: Getting physicians on board from the beginning was very important. If you want to change physician behavior, you really have to work on the ground. By next summer, Health Check [part of the state's Medicaid program], plans to make a recommendation to all pediatricians and family practitioners to employ a formal screening tool and start billing for it. Right now, the model is being used in practices that primarily have large numbers of Medicaid patients, but smaller practices with patients from all different parts of the community are starting to get interested.
