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In Focus: Addressing the "New Morbidity" in Pediatrics Through Developmental Screening

By Vida Foubister

Most parents assume that pediatricians are using standardized guidelines to assess their children's development and behavior during well-child visits—a critical step for the early identification and treatment of any suspected delays. Unfortunately, the research suggests otherwise.

Past physician surveys have found that only about 20 percent of physicians routinely use developmental screening tests. Even this number, says Paul H. Dworkin, M.D., professor and chair of pediatrics at the University of Connecticut School of Medicine and physician-in-chief at Connecticut Children's Medical Center, is an "overestimate," with the true figure closer to "10 percent or less."

These low screening rates mean there are many missed opportunities to intervene early and promote children's health, learning, and school readiness. The Centers for Disease Control and Prevention (CDC) estimates that about 17 percent of children under age 18 have a developmental or behavioral disability, such as autism or attention-deficit/hyperactivity disorder. However, less than 50 percent of these children are identified as having these problems before they start school.

Numbers such as these highlight the need to expand pediatricians' focus beyond immunization and injury prevention, which have significantly lowered the childhood death rate over the past decade, to the "new morbidity" of social difficulties, behavioral problems, and developmental difficulties. But, while instituting developmental screening might seem simple on its face, there are multiple barriers. Among them is getting pediatricians, family physicians, and other child health care professionals to recognize the need for formal developmental screening.

Many doctors believe that, by pulling several items from screening tools such as the Denver Developmental Screening Test, a widely used test that was originally released in the 1960s and has since been revised, they are sufficiently evaluating their patients. But the Denver test is not well validated and, even if administered in its entirety—a process that takes about 20 minutes—it misses up to 70 percent of children with language impairment and 50 percent with intellectual delays, says Frances Page Glascoe, Ph.D., a professor of pediatrics at Vanderbilt University.

"Traditionally, what pediatricians and practices have done is ask patients questions, review some [developmental] milestones, do a physical exam, and put it all together," says Laura Sices, M.D., M.S., assistant professor of pediatrics at Boston University School of Medicine/Boston Medical Center. It can identify some children "but, on a global level, it's not very effective. We're missing a lot of kids."

Other factors that contribute to the low rates of routine screening include a perceived lack of time, with the average well-child visit lasting less than 20 minutes; limited reimbursement for using validated screening tools, which providers must pay a fee to use; and necessary changes to a practice's workflow to implement standardized screening. There is also a concern that, once identified, children with possible developmental problems may not find intervention services in their communities.

Continued Push
The American Academy of Pediatrics (AAP), in more than one policy statement, has recommended that providers incorporate developmental surveillance and screening into their well-child preventive care visits. Its most recent statement, in 2006, recommends ongoing developmental surveillance of children and the administration of standardized developmental screening tests at nine-, 18-, and 30- or 24-month visits.

The AAP defines developmental surveillance as "a process in which health care professionals aim to identify children who may have developmental problems" and developmental screening as "the administration of a brief standardized tool aiding the identification of children at risk of a developmental disorder." Says Dworkin: "Developmental screening tests should not be used in a single administration, pass/fail manner, but rather as an aide to supplement ongoing surveillance."

There is evidence to back up the AAP policy. "If we identify children early and get them into early intervention programs, their outcomes are so much better," says Glascoe, the creator of the Parents' Evaluation of Developmental Status (PEDS), a parent-completed developmental screening tool. "Some studies have shown that for every dollar spent on prevention, our society saves $17." These savings come from reductions in the rates of teen pregnancy, high school drop-out, unemployment, and criminal activity.

The academy launched a nine-month pilot project, called D-PIP or the Developmental Surveillance and Screening Policy Implementation Pilot, to examine the feasibility of implementing the screening tests among 17 pediatric practices. A preliminary qualitative evaluation of the practices' experiences found that most preferred to use parent-completed surveys rather than professionally completed surveys, which demand more of providers' time (see Screening Options, below). "In my experience, most practices will only consider conducting developmental screening if they can envision a way of doing it that won't add to the duration of the visit and won't turn clinic schedules/clinic flow on its head," says Tracy King, M.D., M.P.H., assistant professor of pediatrics at Johns Hopkins School of Medicine, who has been involved in evaluating the project's outcomes. In addition, the ease of implementation was found to vary among the practices due to factors such as the number of physicians, presence of support staff, and types of patients served.

This small feasibility study was not able to document a substantial increase in the rates of identification of children with suspected delays. But King believes this could be due to the small number of charts reviewed or the "self-selected nature of these practices," which might have been doing better than their peers at baseline. "As they say, further research is needed," she says.

Other initiatives to encourage the implementation of developmental screening have resulted in substantial increases in the number of children screened, as well as increased referrals to early intervention programs. Some state Medicaid agencies, for example those in Hawaii and Massachusetts, have implemented policies requiring the use of validated developmental and behavioral screens at well-child visits in response to lawsuits against the agencies. As a result, Hawaii had 6.71 percent of children ages 0 to 2 enrolled in early intervention programs in 2005, compared with a national average of 2.4 percent. (The Massachusetts policy, which requires every well visit for children 0 to 21 years to include a validated behavioral health screen, went into effect Jan. 1.)

Multiple Initiatives
State efforts to expand developmental screening include ABCD, or Assuring Better Child Health and Development, which The Commonwealth Fund initially launched in four states in 2000. Among them, North Carolina has seen a greater number of referrals to early intervention, leading the legislature to increase its funding for the program by $7 million.

"We helped practices develop a process to integrate [developmental screening tools] smoothly into well-child care," says Marian Earls, M.D., medical director of Guilford Child Health, Inc., in Greensboro, N.C. As a result, the early intervention penetration rate increased from 2.9 to 4.9 percent among children from birth to three years of age; at the same time, the age of identification decreased, with referrals for children at or below 12 months of age increasing from 40 percent to 53 percent.

ABCD II rolled out in 2004 with five states and focused on children's socioemotional development. It was followed last July by the ABCD Screening Academy. A partnership of the National Academy for State Health Policy (NASHP) and The Commonwealth Fund, the Screening Academy brought Medicaid and AAP representatives from 21 states together to build on the experience of the first two initiatives. "The purpose of the pilots and demonstrations and the Screening Academy is to develop the core from which to spread the practice, to identify changes needed to develop faculty that can talk to others—all the things you really need when you go to a more reluctant practice to convince them they ought to give it a try," says Neva Kaye, a senior program director at NASHP. As a result of this effort, 79 practices have implemented new workflow processes in their offices to incorporate standardized developmental screening.

In the Greenville, S.C.–area, a local initiative funded by the Duke Endowment, Promoting Resources in Developmental Education (PRIDE), started work in 2004 to make three key groups aware of the need for screening in children from birth to age 5: parents, child care providers, and pediatric offices. To date, 5,400 families have signed up to receive developmental milestone cards every three to six months. These cards highlight skills that children should have mastered at different ages and suggest activities to help children that haven't acquired them to do so. More than 900 child care providers have completed five-hour training sessions explaining early childhood development and signs of delays.

Among pediatricians, 16 of the 17 practices in the county participated in an initial meeting and chose to implement standardized screening using the PEDS. These practices received support through a PRIDE physician office liaison; they also were given PEDS questionnaires and a notebook with background information on developmental screening, guidelines on how to bill for these services, and local resources for referring children for whom developmental concerns were identified.

As a result, about 70 percent of physicians in these practices began routinely using development screens within the first three years of the program. Still, integrating standardized screening into office routines is not easy. "What we learned is that, over time, there is some attrition. There's certainly a need for a booster visit from the liaison to the program to keep it going," says Desmond Kelly, M.D., medical director, division of developmental-behavioral pediatrics at the Gardner Family Center for Developing Minds, Children's Hospital of the Greenville Hospital System.

Kelly says they anticipate receiving continued funding for the program and are currently considering expanding it to providers in surrounding counties who have expressed an interest in participating. Further work might seek to build links between pediatric offices and the services they need to refer to, such as early intervention and other developmental services. This is another area that often needs attention.

"Primary care physicians are not used to making those referrals, and [early intervention] staff are not used to giving information back as a result of those referrals," explains Kaye.

Looking Forward
Beaufort Pediatrics in South Carolina instituted developmental screening for children prior to the release of the 2006 AAP statement; the practice also screens for maternal depression, availability of family and community resources, domestic abuse, substance abuse, and socioeconomic distress, says Francis E. Rushton, M.D., a long-time pediatrician at the practice.

He believes these developmental and behavioral screens enable physicians to focus on the biggest concerns among children and adolescents today, such as the fact that 30 percent of local children are not ready to learn when they start first grade. "If you look at where we're failing in pediatrics, it makes more sense to focus on the behavioral and developmental issues, and maybe on nutrition," says Rushton. "Formal developmental and behavioral screening forces you to make that a priority in anticipatory guidance with the family, making sure there are not some developmental issues that need to be addressed."

Further, the screening procedures implemented at Beaufort Pediatrics identified concerns that would otherwise have been missed, such as a suicidal mother of a newborn and another new mother whose break up with a boyfriend left her and her baby homeless. Alison Schonwald, M.D., a developmental behavioral pediatrician at Children's Hospital Boston, says these types of experiences also helped to spread the use of PEDS among physicians at Children's. "Many of the providers had an 'Aha!' moment where there was a kid picked up that wouldn't have been picked up if they didn't have the parent survey," she says. "That was hard to deny."

The fact that standardized screening, depending on the tool chosen, typically does not lengthen an average visit also helps garner physician support. For example, the average well-child visit at Martha Eliot Health Center, a community health center in Jamaica Plain affiliated with Children's, decreased from 18 to 16 minutes after it implemented routine screening using the PEDS. Although this decrease wasn't statistically significant, the screen didn't add time, says Schonwald. "It adds structure to what you were already doing."

Developmental surveys introduce another piece of paper into the office, but once the necessary workflow changes are made to accommodate it, they can help to organize visits around a child's development, thus making routine well-child visits more efficient and effective. Says Kaye: "It eliminates the 'hand on the doorknob' questions."

Other proposed changes to pediatrics and family medicine, including the use of electronic health records (EHRs) and a shift to providing care within a medical home, are likely to help practices implement standardized developmental screening. Once in place, both EHRs and the medical home approach will better enable physicians and their office staff to handle the care coordination and case management required after developmental problems are identified.

"Practices are moving slowly in the direction of team-based care, and I don't think the screening protocol that we have now would work well if we didn't have someone on the team who was going to deal with the positive findings," says Rushton.

Screening Options

Interested in implementing standardized developmental and behavioral screening but not sure where to start? "There is no one test that is most applicable to all practices, but there is a process by which practices can select the tools that best fit their needs," says Paul H. Dworkin, M.D., professor and chair of pediatrics at the University of Connecticut School of Medicine and physician-in-chief at Connecticut Children's Medical Center.

The options include parent- or professionally completed surveys, with some available in multiple languages and/or electronically. The costs of these screening tools vary, as do their validity, appropriate ages for screening, and the time required for completion.

The Web sites listed below were designed to help guide providers through the selection process. Covered topics range from the rationale for screening to guidelines for billing for reimbursement.

Still, "these instruments do not take the place of the pediatrician's knowledge of the child prior to the exam," adds Dennis Drotar, Ph.D., professor of pediatrics and psychology at Cincinnati Children's Hospital Medical Center. "The pediatrician's own observations and judgment are still very important."

The sites are:

Developmental-Behavioral Pediatrics Online (

Developmental Screening Tool for Primary Care Providers (

Pediatric Developmental Screening: Understanding and Selecting Screening Instruments (

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