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Implementing Developmental Screening and Referrals: Lessons Learned from a National Project


Most pediatric practices participating in an American Academy of Pediatrics pilot program to implement recommended screening for developmental problems were successful in doing so. However, far fewer were similarly successful in placing and tracking referrals for follow-up care.

The Issue

Because the early detection of developmental disorders can lead to improved outcomes for children and families, and because such disorders are often under-identified, the American Academy of Pediatrics (AAP) recommends that developmental screening and surveillance be conducted at well-child visits and that children judged to be at risk for developmental delays be referred for further evaluation and early-intervention services. To help accelerate adoption, the AAP launched a pilot project to evaluate how successful practices were in implementing their recommendations and to identify the factors that practice staff felt contributed to the successes or shortcomings of their efforts. This study examined a nine-month implementation period at 17 pediatric practices.

Key Findings

  • IMPORTED: __media_AD32827BECED4A36A3595F9B7385F7F0_w_220_h_260_as_1.gif Most of the participating pediatric practices selected screening instruments that are completed by parents, rather than providers, citing concerns about slowing the flow of patients through the clinic.
  • During the study period, monthly screening rates across practices increased from 68 percent to 86 percent of children at recommended screening visits.
  • Practices divvied up developmental screening responsibilities among staff; nonetheless, many clinics found it more difficult to screen during busy periods and times of staff turnover.
  • Fourteen percent of all children screened had a failed screen, suggesting they were at risk for developmental delay. 
  • Overall, practices reported referring only 61 percent of children with failed screens to a specialist for follow-up care. Many practices struggled to track referrals; practices that did track them found many families did not follow through with recommended referrals.

Addressing the Problem

The results of this study suggest that effective developmental screening requires implementing two distinct systems: one for screening and another for referrals. The researchers found that implementing systems for screening was feasible within the pediatric primary care setting. However, implementing systems for referrals involves a separate set of tasks, most of which occur after the clinic visit and are often handled by different staff members. In this study, practices that did not implement a separate system for referrals could not reliably determine how many children were connected to needed services. The clinics that did implement systems found referral tracking both time- and labor-intensive, and difficult to maintain over the long term. Shortcomings in referral processes may account for the gap that has been documented between routine screening and improved outcomes.

About the Study

The authors conducted a study of 17 pediatric primary care practices in 15 states over nine months. Quantitative data from chart reviews were used to calculate rates of screening and referral. Qualitative data on practices' implementation efforts were collected through semi-structured telephone interviews with staff members.

The Bottom Line

While many practices have incorporated developmental screening into their pediatric care, they have been less successful in placing and tracking referrals. Future studies and pilot projects should focus on the referral process, which may require a separate implementation process.

Publication Details



T. M. King, S. D. Tandon, M. M. Macias et al., "Implementing Developmental Screening and Referrals: Lessons Learned from a National Project," Pediatrics, Feb. 2010 125(2):350–60.