ImprovetheHealthofAllChildren Disorders in the Medical ... · integral to developmental...
Transcript of ImprovetheHealthofAllChildren Disorders in the Medical ... · integral to developmental...
POLICY STATEMENT
Identifying Infants and YoungChildren With DevelopmentalDisorders in the Medical Home:An Algorithm for DevelopmentalSurveillance and ScreeningCouncil on Children With Disabilities
Section on Developmental Behavioral Pediatrics
Bright Futures Steering Committee
Medical Home Initiatives for Children With Special Needs Project Advisory Committee
ABSTRACTEarly identification of developmental disorders is critical to the well-being ofchildren and their families. It is an integral function of the primary care medicalhome and an appropriate responsibility of all pediatric health care professionals.This statement provides an algorithm as a strategy to support health care profes-sionals in developing a pattern and practice for addressing developmental concernsin children from birth through 3 years of age. The authors recommend thatdevelopmental surveillance be incorporated at every well-child preventive carevisit. Any concerns raised during surveillance should be promptly addressed withstandardized developmental screening tests. In addition, screening tests should beadministered regularly at the 9-, 18-, and 30-month visits. (Because the 30-monthvisit is not yet a part of the preventive care system and is often not reimbursableby third-party payers at this time, developmental screening can be performed at 24months of age. In addition, because the frequency of regular pediatric visitsdecreases after 24 months of age, a pediatrician who expects that his or herpatients will have difficulty attending a 30-month visit should conduct screeningduring the 24-month visit.) The early identification of developmental problemsshould lead to further developmental and medical evaluation, diagnosis, andtreatment, including early developmental intervention. Children diagnosed withdevelopmental disorders should be identified as children with special health careneeds, and chronic-condition management should be initiated. Identification of adevelopmental disorder and its underlying etiology may also drive a range oftreatment planning, from medical treatment of the child to family planning for hisor her parents.
INTRODUCTIONEarly identification of developmental disorders is critical to the well-being ofchildren and their families. It is an integral function of the primary care medicalhome1 and an appropriate responsibility of all pediatric health care professionals.Delayed or disordered development can be caused by specific medical conditions
www.pediatrics.org/cgi/doi/10.1542/peds.2006-1231
doi:10.1542/peds.2006-1231
All policy statements from the AmericanAcademy of Pediatrics automaticallyexpire 5 years after publication unlessreaffirmed, revised, or retired at orbefore that time.
KeyWordsdevelopment, developmental disorders,developmental screening, disabilities,children with special health care needs,early intervention, medical home
AbbreviationsAAP—American Academy of PediatricsCPT—Current Procedural Terminology
PEDIATRICS (ISSN Numbers: Print, 0031-4005;Online, 1098-4275). Copyright © 2006 by theAmerican Academy of Pediatrics
PEDIATRICS Volume 118, Number 1, July 2006 405
Organizational Principles to Guide andDefine the Child Health Care System and/orImprove the Health of All Children
and may indicate an increased risk of other medicalcomplications. Delayed or disordered development mayalso indicate an increased risk of behavior disorders orassociated developmental disorders. Early identificationshould lead to further evaluation, diagnosis, and treat-ment. Early intervention is available for a wide range ofdevelopmental disorders; their prompt identification canspur specific and appropriate therapeutic interventions.Identification of a developmental disorder and its under-lying etiology may also affect a range of treatment plan-ning, from medical treatment of the child to family plan-ning for his or her parents.
Current detection rates of developmental disordersare lower than their actual prevalence, which suggeststhat the challenges to early identification of childrenwith developmental disorders have not been over-come.2–4 A recent survey of American Academy ofPediatrics (AAP) members revealed that despite publica-tion of the 2001 policy statement “DevelopmentalSurveillance and Screening of Infants and Young Chil-dren”5 and national efforts to improve developmentalscreening in the primary care setting, few pediatriciansuse effective means to screen their patients for de-velopmental problems.2 This 2006 statement replacesthe 2001 policy statement and provides an algorithmas a strategy to support health care professionals in de-veloping a pattern and practice of attention to develop-ment that can and should continue well beyond 3 yearsof age.
We recommend that developmental surveillance, asdescribed later, be incorporated at every well-childvisit. Any concerns raised during surveillance shouldbe promptly addressed. In addition, standardized de-velopmental screening tests should be administeredregularly at the 9-, 18-, and 30-month* visits. Pediatrichealth care professionals may also find it useful toconduct school-readiness screening before the child’sattendance at preschool or kindergarten. These recom-mendations represent our consensus; further research toevaluate the effectiveness of the proposed approachand available screening tools is encouraged. Separaterecommendations aimed at the screening of children forbehavioral and emotional disorders are also under con-sideration by the AAP and are not included in this doc-ument.
The detection of developmental disorders is an in-tegral component of well-child care. Title V of theSocial Security Act (42 USC Chapter 7, Subchapter V§§701-710 [1989]) and the Individuals With DisabilitiesEducation Improvement Act (IDEA) of 2004 (Pub L No.108-446) reaffirm the mandate for child health pro-
fessionals to provide early identification of, and inter-vention for, children with developmental disabilitiesthrough community-based collaborative systems. Themedical home is the ideal setting for developmentalsurveillance and screening of children and adolescents.Parents expect their medical home, as the site of theirchild’s continuous and comprehensive care, to be inter-ested in children’s development throughout childhoodand adolescence, to competently identify developmentalstrengths and weaknesses, and to be knowledgeable ofavailable community resources to facilitate referralswhen needed.
Developmental screening is included in the AAP“Recommendations for Preventive Pediatric HealthCare”6 or “periodicity schedule” and is further recom-mended by the 2 current AAP compilations of well-childcare guidelines: Bright Futures7 and Guidelines for HealthSupervision III.8 In collaboration with other experts inchild health care, the AAP is currently revising BrightFutures: Guidelines for Health Supervision of Infants, Chil-dren, and Adolescents. It is hoped that the third edition ofBright Futures being developed by the AAP and the re-vised periodicity schedule will be consistent with therecommendations of this document.
Note Regarding LanguageWithin the context of this document, clear distinctionshave been drawn among (1) surveillance, the process ofrecognizing children who may be at risk of developmen-tal delays, (2) screening, the use of standardized tools toidentify and refine that recognized risk, and (3) evalua-tion, a complex process aimed at identifying specificdevelopmental disorders that are affecting a child. Thesedefinitions build on existing definitions.9 In a furthereffort to ensure clarity throughout the document, wehave purposefully avoided the term “assessment.” Al-though the Individuals With Disabilities Education Im-provement Act of 2004—and others—use “assessment”as a synonym for “evaluation,” this usage is not univer-sally shared.
“Developmental delay” is used in this statement forthe condition in which a child is not developing and/orachieving skills according to the expected time frame.The terms “delayed development,” “disordered develop-ment,” and “developmental abnormality” are used syn-onymously. “Developmental disorder” and “develop-mental disability” refer to a childhood mental or physicalimpairment or combination of mental and physical im-pairments that result in substantial functional limitationsin major life activities.10
THE ALGORITHM†
1. Pediatric Patient at Preventive Care VisitDevelopmental concerns should be included as one ofseveral health topics addressed at each pediatric pre-
*Because the 30-month visit is not yet a part of the preventive care system and is often notreimbursable by third-party payers at this time, developmental screening can be performed at24 months of age. In addition, because the frequency of regular pediatric visits decreases after24months of age, a pediatricianwho expects that his or her patients will have difficulty attend-ing a 30-month visit should conduct screening during the 24-month visit. †Numbers and headings refer to steps in the algorithm (Fig 1).
406 AMERICAN ACADEMY OF PEDIATRICS
ventive care visit throughout the first 5 years of life(see Fig 1).6 Many children are born with risk factorsthat predispose them to delayed development and de-velopmental disorders; other children will show delayedor disordered development in early childhood, which ifundetected and untreated, can contribute to early schoolfailure and attendant social and emotional problems.Some children will have delayed development attribut-able to a specific medical condition for which medicaltreatments may be indicated. Early therapeutic interven-tion may be available for a wide range of developmentaldisorders.
2. Perform SurveillanceDevelopmental surveillance is a flexible, longitudinal,continuous, and cumulative process whereby knowl-
edgeable health care professionals identify children whomay have developmental problems. Surveillance can beuseful for determining appropriate referrals, providingpatient education and family-centered care in support ofhealthy development, and monitoring the effects of de-velopmental health promotion through early interven-tion and therapy.
A great breadth and depth of information is consid-ered in comprehensive developmental surveillance; it isimportant to note, however, that much of this informa-tion (eg, static risk factors such as low birth weight,results of previous screenings) will accumulate withinthe child’s health record, where it can be reviewed andflagged as necessary before the visit.
There are 5 components of developmental surveil-
FIGURE 1Developmental surveillance and screening algorithmwithin a pediatric preventive care visit. a Because the 30-month visit is not yet a part of the preventive care system and is often notreimbursable by third-party payers at this time, developmental screening can be performed at 24 months of age.
PEDIATRICS Volume 118, Number 1, July 2006 407
lance: eliciting and attending to the parents’ concernsabout their child’s development; documenting andmaintaining a developmental history; making accurateobservations of the child; identifying risk and protectivefactors; and maintaining an accurate record of docu-menting the process and findings.
Eliciting and Attending to the Parents’ ConcernsParents and child health professionals have valuableobservation skills, and they share the goal of ensuringoptimal health and developmental outcome for thechild. In the optimal situation, the child health profes-sional elicits parental observations, experiences, andconcerns and recognizes that parental concerns mandate
serious attention. The literature suggests that posingsimple questions to parents related to concerns aboutthe child’s development, learning, or behavior can elicitquality information.11–13 Health care professionals mightask, for example, “Do you have any concerns about yourchild’s development? Behavior? Learning?” Asking par-ents specifically about their child’s behavior can yieldvaluable information regarding development, becauseparents do not necessarily differentiate between behav-ior and development, and developmental delays oftenmanifest through behavior. The absence of parental con-cern does not preclude the possibility of serious devel-opmental delays.14 The health care professional mustattend to all aspects of developmental surveillance.
408 AMERICAN ACADEMY OF PEDIATRICS
Maintaining a Developmental History“What changes have you seen in your child’s develop-ment since our last visit?” A developmental history,updated through this or similar questions, should be acomponent of any history taken during a well-child visitand can assist a child health professional in identifyingdevelopmental abnormalities that warrant further inves-tigation. Age-specific queries, such as asking whetherthe child is walking or pointing, are also valuable.
In addition to attending to delayed development—whereby children acquire skills more slowly than theirpeers—child health professionals should give equal con-sideration to other developmental abnormalities.15 Devi-ations in development, whereby children develop skillsout of the usual sequence, are recognized in disorderssuch as cerebral palsy and autism. Dissociation—differ-ing rates of development in different developmentalspheres—commonly occurs with developmental disor-ders. Children with mental retardation or autistic spec-trum disorders, for example, commonly display normalmotor skills and delayed language development. Con-versely, children with cerebral palsy of the spastic diple-gic type often display delayed motor skills with normallanguage function. Regression, the loss of developmentalskills, is a very serious developmental problem sugges-tive of an active, ongoing neurologic problem.
Making Accurate and Informed Observations of the ChildAs trained and experienced professionals, pediatriciansand other child health professionals have the expertiseand comparative knowledge to identify developmentalconcerns. A careful physical and developmental exami-nation within the context of the preventive care visit isintegral to developmental surveillance.16 Limited evi-dence suggests that observation of the parent-child in-teraction may aid in identifying children with delayeddevelopment.17
Identifying the Presence of Risk and Protective FactorsA risk assessment is an important part of developmentalsurveillance. Environmental, genetic, biological,16,18 so-cial, and demographic factors19 can increase a child’s riskfor delays in development. Multiple risk factors can am-plify each other.20,21 Children with established risk fac-tors may be referred directly for developmental evalua-tion or may require developmental surveillance at morefrequent intervals than children without risk factors.
Child health professionals should identify protectivefactors as well as risk factors in children’s lives. Strongconnections within a loving, supportive family, alongwith opportunities to interact with other children andgrow in independence in an environment with appro-priate structure, are important assets in a child’s life.These factors, associated with resiliency in older chil-dren, are important components in each family’s story.22
Documenting the Process and FindingsMedical charts, in paper or electronic form, shoulddocument all surveillance and screening activitiesduring preventive care visits. In addition, specific actionstaken or planned, such as scheduling an earlier follow-up visit, scheduling a visit to discuss developmental con-cerns more fully, or referrals to medical specialists orearly childhood programs and specialists, should also benoted. A paper medical chart might contain a “develop-mental growth chart” on which the results of develop-mental surveillance and formal screens are recorded inrelationship to the child’s age and the dates at the timethe findings were obtained. An electronic chart, on theother hand, may allow for the development of a form onwhich developmental findings and plans are recordedand from which prompts for further action may occurautomatically. Recent technologies that automate devel-opmental risk assessments within the waiting roomthrough computer-interpreted paper forms or informa-tion kiosks are also increasingly commonplace. We en-courage continued development and scientific evalua-tion of these technologies given their potential tofacilitate the process of developmental surveillance andscreening.
3. Does Surveillance Demonstrate Risk?The concerns of both parents and child health profes-sionals should be included in determining whether sur-veillance suggests that the child may be at risk of de-velopmental problems. If parents or the child healthprofessional express concern about the child’s develop-ment, a developmental screening to address the concernspecifically should be conducted. This screening mayrequire a separate visit; if so, the visit should be held assoon as possible.
Reassurance has a role in the clinical encounter butvaries depending on the progress and outcome of devel-opmental surveillance. Reassurance should be rooted inand reference the findings of developmental surveil-lance. If, for example, developmental surveillance indi-cates that the child is at low risk of a developmentaldisorder, reassurance can be offered with caution and aplanned outcome. Specific, simple, age-specific develop-mental goals can be identified, and parents can be en-couraged to schedule recheck appointments if the childis not attaining those goals. In reassuring the parents, thepediatrician should emphasize the importance of contin-ual surveillance and screening.
4. Is This a 9-, 18-, or 30-Month* Visit?All children, most of whom will not have identifiablerisks or whose development appears to be proceedingtypically, should receive periodic developmental screen-ing using a standardized test. In the absence of estab-lished risk factors or parental or provider concerns, ageneral developmental screen is recommended at the 9-,
PEDIATRICS Volume 118, Number 1, July 2006 409
TABLE1
Develop
men
talScreening
Tools
Description
AgeRange
No.ofItems
AdministrationTime
Psychometric
Propertiesa
ScoringMethod
Cultural
Considerations
Purchase/Obtainm
ent
Inform
ation
KeyReferences
Generaldevelopmental
screeningtool
Ages&Stages
Questionnaires(ASQ)
Parent-com
pleted
ques-
tionnaire;seriesof19
age-specific
questionnairesscreening
communication,gross
motor,fine
motor,
problem-solving,and
personaladaptiveskills;
resultsinpass/failscore
fordom
ains
4–60
mo
3010–15min
Normed
on2008
children
fromdiverseethnicand
socio
econom
icback-
grounds,inclu
ding
Spanish
speakin
g;sensitivity:0.70–0.90
(moderatetohigh);
specificity:0.76–0.91
(moderatetohigh)
Riskcategorization;
providesacutoff
scorein5do-
mainsofdevelop-
mentthatindi-
catespossible
need
forfurther
evaluation
English,Spanish,
French,and
Korean
versions
available
PaulH.BrookesPublish-
ingCo:800/638-3775;
www.brookespublishing.
com
SquiresJ,PotterL,BrickerD.
TheA
SQUser’sGuide.
2nded.Baltim
ore,MD:
PaulH.BrookesPublishing
Co;1999
BattelleDevelopm
ental
InventoryScreening
Tool,2nd
ed(BDI-ST)
Directlyadministered
tool;
designedtoscreen
personal-social,adaptive,
motor,com
munication,
andcognitivedevelop-
ment;resultsinpass/fail
scoreandageequiv-
alent;canbe
modified
forchildrenwith
special
needs
Birth
to95
mo
100
10–15min(�
3yold)
or20–30min
(�3yold)
Normed
on2500
children,
demographicinfor-
mationmatched
2000
USCensusdata;
additionalbiasreviews
performed
toadjustfor
genderandethnicity
concerns;sensitivity:
0.72–0.93(moderateto
high);specificity:0.79–
0.88
(moderate)
Quantitative;scaled
scoresinall5
domainsare
comparedwith
cutoffstodeter-
mineneed
for
referral
English
andSpanish
versionsavailable
RiversidePublishingCo:
800/323-9540;
www.riverpub.com
NewborgJ.Battelle
Developm
entalInventory.
2nded.Itasca,IL:Riverside
Publishing;2004
BayleyInfantNeuro-
developm
ental
Screen
(BINS)
Directlyadministered
tool;
seriesof6
itemsets
screeningbasic
neuro-
logicfunctions;receptive
functions(visual,
auditory,and
tactile
input);expressive
functions(oral,fine,and
grossm
otorskills);and
cognitiveprocesses;
resultsinriskcategory
(low,m
oderate,high
risk)
3–24
mo
11–13
10min
Normed
on�1700
children,stratified
onage,tomatch
the2000
USCensus;sensitivity:
0.75–0.86(moderate);
specificity:0.75–0.86
(moderate)
Riskcategorization;
childrenare
graded
aslow,
moderate,or
high
riskineach
of4conceptual
domainsby
use
of2cutoffscores
English
andSpanish
versionsavailable
PsychologicalCorp:
800/211-8378;
www.harcourtassessm
ent.
com
AylwardGP.Bayley
Infant
Neurodevelopm
ental
Screener.San
Antonio,TX:
PsychologicalCorp;1995;
AylwardGP,VerhulstSJ,
BellS.Predictiveutilityof
theBSID-IIInfantNeuro-
developm
entalScreener
(BINS)riskstatusclas-
sifications:clinicalin
ter-
pretationandapplication.
DevM
edChildNeurol.2000;
42:25–31
BriganceScreens-II
Directlyadministered
tool;
seriesof9
formsscreen-
ingarticulation,expres-
siveandreceptive
language,grossmotor,
finemotor,general
know
ledgeandpersonal
socialskillsandpre-
academ
icskills
(when
appropriate);for0–23
mo,canalsouseparent
report
0–90
mo
8–10
10–15min
Normed
on1156
children
from29
clinicalsitesin
21states;sensitivity:
0.70–0.80(moderate);
specificity:0.70–0.80
(moderate)
Allresultsarecri-
terionbased;no
normativedata
arepresented
English
andSpanish
versionsavailable
CurriculumAssociates
Inc:800/225-0248;
www.curriculumassociates.
com
GlascoeFP.TechnicalReport
fortheBriganceScreens.
North
Billerica,MA:
CurriculumAssociatesInc;
2005;Glascoe
FP.The
BriganceInfant-Toddler
Screen
(BITS):standard-
izationandvalidation.J
DevBehavPediatr.2002;23:
145–150
Child
Developm
ent
Inventory(CDI)
Parent-com
pleted
ques-
tionnaire;m
easures
social,self-help,motor,
language,and
general
developm
entskills;
resultsindevelopm
ental
quotientsand
age
equivalentsfordifferent
developm
entaldom
ains;
suitableform
orein-
depthevaluation
18mo–6y
300
30–50min
Normativesampleinclu
ded
568childrenfromsouth
StPaul,M
N,aprimarily
white,workin
gclass
community;Doigetal
inclu
ded43
children
fromahigh-riskfollow-
upprogram,which
inclu
ded69%with
high
schooleducationorless
and81%Medicaid;
sensitivity:0.80–1.0.
(moderatetohigh);
specificity:0.94–0.96
(high)
Quantitative;
providesage
equivalentsin
each
domainas
wellasSDs
English
andSpanish
versionsavailable
BehaviorScienceSystems
Inc:612/850-8700;
www.ch
ilddevrev.com
IretonH.ChildDevelopm
ent
InventoryM
anual.
Minneapolis,MN:Behavior
ScienceSystem
sInc;1992;
DoigKB,M
aciasM
M,
SaylorCF,CraverJR,
Ingram
PE.The
Child
Developm
entInventory:a
developm
entaloutcome
measureforfollow-upof
thehigh
riskinfant.
JPediatr.1999;135:358–
362
410 AMERICAN ACADEMY OF PEDIATRICS
TABLE1
Continue
dDescription
AgeRange
No.ofItems
AdministrationTime
Psychometric
Propertiesa
ScoringMethod
Cultural
Considerations
Purchase/Obtainm
ent
Inform
ation
KeyReferences
Child
Developm
ent
Review
-Parent
Questionnaire
(CDR
-PQ)
Parent-com
pleted
ques-
tionnaire;professional-
completed
child
developm
entchart
measuressocial,self-
help,m
otor,and
language
skills
18moto5y
6open-ended
questions
anda26-item
possible-
problemschecklistto
becompleted
bythe
parent,fo
llowed
by99
itemscrossingthe5
domains,which
may
beused
bytheprofes-
sionalasan
observationguideor
parent-interviewguide
10–20min
Standardizedwith
220children
aged
3–4yfromprimarily
white,workin
gclassfamilies
insouthStPaul,M
N;sensitivity:0.68(low);
specificity:0.88
(moderate)
Riskcategorization;
parents’responses
tothe6
questions
andproblems
checklistareclas-
sified
asindicat-
ing(1)noprob-
lem;(2)apossible
problem;or(3)a
possiblemajor
problem
English
andSpanish
versionsavailable
BehaviorScience
System
sInc
IretonH.ChildDevelopm
ent
ReviewManual.
Minneapolis,MN:Behavior
ScienceSystem
s;2004
Denver-IIDevelop-
mentalScreening
Test
Directlyadministered
tool;
designedtoscreen
expressiveandreceptive
language,grossmotor,
finemotor,and
personal-
socialskills;resultsinrisk
category(normal,
questionable,abnormal)
0–6y
125
10–20min
Normed
on2096
term
children
inColorado;diversified
intermsofage,placeof
residence,ethnicity/cultural
background,and
maternal
education;sensitivity:0.56–
0.83
(lowtomoderate);
specificity:0.43–0.80(lowto
moderate)
Riskcategorization;
passorfailfor
each
question,
andthesere-
sponsesarecom-
paredwith
age-
basednormsto
classifychildrenas
inthenormal
range,suspect,or
delayed
English
andSpanish
versionsavailable
DenverDevelopm
ental
Materials:
800/419-4729;
www.denverii.com
FrankenburgWK,CampBW
,VanNatta
PA.Validity
oftheDenverDevelop-
mentalScreening
Test.
ChildDev.1971;42:475–
485;GlascoeFP,Byrne
KE,
AshfordLG,Johnson
KL,
ChangB,Strickland
B.AccuracyoftheDenver-II
indevelopm
ental
screening.Pediatrics.1992;
89:1221–1225
InfantDevelopm
ent
Inventory
Parent-com
pleted
ques-
tionnaire;m
easures
social,self-help,motor,
andlanguage
skills
0–18
mo
4open-ended
questions
followed
by87
items
crossingthe5domains
5–10
min
Studiedin86
high-risk8-mo-
oldsseen
inaperinatal
follow-upprogramand
comparedwith
theBayley
scales;sensitivity:0.85
(moderate);specificity:0.77
(moderate)
Riskcategorization;
delayedornot
delayed
English
andSpanish
versionsavailable
BehaviorScience
System
sInc
CreightonDE,SauveRS.The
MinnesotaInfantDevelop-
mentInventoryinthe
developm
entalscreening
ofhigh-riskinfantsat8
mo.
CanJBehavSci.1988;20
(specialissue):424–433
Parents’Evaluationof
Developm
entalStatus
(PEDS)
Parent-interviewform;
designedtoscreen
for
developm
entaland
behavioralproblems
needingfurther
evaluation;single
responseform
used
for
allages;maybe
usefulas
asurveillancetool
0–8y
102–10
min
Standardizedwith
771children
fromdiverseethnicand
socio
econom
icbackgrounds,inclu
ding
Spanish
speakin
g;sensitivity:0.74–0.79
(moderate);specificity:
0.70–0.80(moderate)
Riskcategorization;
providesalgo-
rithm
toguide
need
forreferral,
additionalscreen-
ing,orcontinued
surveillance
English,Spanish,
Vietnamese,
Arabic,Sw
ahili,
Indonesian,
Chinese,
Taiwanese,
French,Som
ali,
Portuguese,
Malaysian,Thai,
andLaotian
versionsavailable
Ellsw
orth&Vandermeer
PressLLC:
888/729-1697;
www.pedstest.com
Language
andcognitive
screeningtools
CaputeScales(also
know
nasCognitive
AdaptiveTest/Clinical
LinguisticAuditory
MilestoneScale
�CAT/CLAMS�)
Directlyadministered
tool;
measuresvisual-m
otor/
problemsolving(CAT),
andexpressiveand
receptivelanguage
(CLAMS);resultsin
developm
entalquotient
andageequivalent
3–36
mo
100
15–20min
Standardizedon
1055
North
Americanchildrenaged
2–36
mo;correlationshigh
with
BayleyScalesofInfant
Developm
ent;sensitivity:
0.21–0.67inlow-riskpop-
ulation(low)and
0.05–0.88
inhigh-riskpopulations
(lowtohigh);specificity:
0.95–1.00inlow-risk
population(high)and0.82–
0.98
inhigh-riskpopulations
(moderatetohigh)
Quantitative(devel-
opmentalage
levelsand
quotient)
English,Spanish,and
Russianversions
available
PaulH.Brookes
PublishingCo
VoigtRG,Brow
nFR
III,Fraley
JK,etalConcurrentand
predictivevalidity
ofthe
cognitiveadaptivetest/
clinicallinguisticand
auditorymilestonescale
(CAT/CLAMS)andthe
MentalDevelopmental
Indexo
fthe
BayleyScales
ofInfantDevelopm
ent.
ClinPediatr(Phila).2003;42:
427–432
PEDIATRICS Volume 118, Number 1, July 2006 411
Communicationand
SymbolicBehavior
Scales-
Developmental
Profile(CSBS-DP):
InfantToddler
Checklist
Standardized
toolfor
screeningofcom-
municationand
symbolicabilitiesu
pto
the24-m
olevel;the
InfantToddlerChecklist
isa1-page
parent-
completed
screening
tool
6–24
mo
245–10
min
Standardized
on2188
North
American
childrenaged
6-24
mo;correlations:
0.39–0.75with
Mullen
Scalesat2yofage;
sensitivity:0.76–0.88
inlow-and
at-risk
childrenat
2yofage(m
oderate);
specificity:0.82–0.87
inlow-and
at-risk
childrenat
2yofage(m
oderate)
Riskcategorization
(concern/no
concern)
English
version
available
PaulH.Brookes
Publish
ingCo
WetherbyAM
,PrizantBM.
Communicationand
SymbolicBehaviorScales:
DevelopmentalProfile.
Baltimore,MD:PaulH.
BrookesP
ublishing
Co;
2002
EarlyLanguage
Mile-
stoneScale(ELM
Scale-2)
Assessesspeech
andlan-
guagedevelopm
ent
frombirth
to36
mo
0–36
mo
431–10
min
Smallcross-sectionalstan-
dardizationsampleof191
children;235childrenfor
speech
intellig
ibilityitem;
sensitivity:0.83–1.00
inlow-
andhigh-riskpopulations
(moderatetohigh);
specificity:0.68–1.00inlow-
andhigh-riskpopulations
(lowtohigh)
Quantitative(age
equivalent,per-
centile,standard
score)
English
versionavail-
able
Pro-Ed
Inc:
800/897-3202;
www.proedinc.com
Coplan
J.EarlyLanguage
MilestoneScale.Austin,TX:
Pro-Ed
Inc;1993;CoplanJ,
GleasonJR.Test-retestand
interobserverreliabilityof
theEarlyLanguage
Mile-
stoneScale,second
edition.JPediatrHealth
Care.1993;7:212–219
Motorscreeningtools
EarlyMotorPattern
Profile(EMPP)
Physician-adm
inistered
standardexam
inationof
movem
ent,tone,and
reflexd
evelopment;
simple3-pointscoring
system
6–12
mo
155–10
min
Singlepublished
reportof
1247
high-riskinfants;
sensitivity:0.87–0.92
(moderatetohigh);
specificity:0.98
(high)
Riskcategorization
(normal/suspect/
abnormal)
English
versionavail-
able
Seekeyreferences
MorganAM
,Aldag
JC.Early
identificationofcerebral
palsy
usingaprofileof
abnormalmotorpatterns.
Pediatrics.1996;98:692–697
MotorQuotient(MQ)
Usessim
pleratio
quotient
with
grossm
otormile-
stonesfordetecting
delayedmotor
developm
ent
8–18
mo
11totalm
ilestones;
1pervisit
1–3min
Singlepublished
reportof144
referredchildren;sensitivity:
0.87
(moderate);specificity:
0.89
(moderate)
Quantitative
(develop-
mentalage
levels
andquotient)
English
versionavail-
able
Seekeyreferences
CaputeAJ,ShapiroBK.The
motorquotient:amethod
forthe
earlydetectionof
motordelay.Am
JDisChild.
1985;139:940–942
Autismscreeningtools
ChecklistforAutism
inToddlers(CHA
T)Parent-com
pleted
questionnaireor
interviewanddirectly
administered
items
designedtoidentify
childrenatrisko
fautism
fromthegeneral
population
18–24mo
14(No.ofquestions/
items�averaged
�)5min
Originalstandardization
sampleinclu
ded41
siblings
ofchildrenwith
autismand
50controls18
moofagein
GreatBritain;6-yfollow-up
on16
235childrenvalidated
usingAD
I-RandICD-10
criteria
resultedinlow
sensitivity,highspecificity;
revisedversioninprocessof
beingnormed
(�Q-CHA
T�);
sensitivity:0.38–0.65
(low);
specificity:0.98–1.0(high)
Riskcategorization
(pass/fail)
English
versionavail-
able
Publicdomain:
www.nas.org.uk/
profess/chat
Baird
G,Charman
T,Baron-
CohenS,etal.A
screening
instrumentforautismat
18moofage:a6-yfollow-
upstudy.JAmAcad
Child
AdolescPsychiatry.2000;39:
694–702;Baron-CohenS,
AllenJ,GillbergC.Can
autismbe
detected
at18
mo?Theneedle,the
haystack,and
theCH
AT.
BrJPsychiatry.1992;161:
839–843
Modified
Checklistfor
AutisminToddlers
(M-CHA
T)
Parent-com
pleted
ques-
tionnairedesignedto
identifychildrenatrisko
fautismfromthegeneral
population
16–48mo
23(No.ofquestions/
items�averaged
�)5–10
min
Standardizationsamplein-
cluded1293
children
screened,58evaluated,and
39diagnosedwith
anautisticspectrumdisorder;
validated
usingAD
I-R,
ADOS-G,CA
RS,DSM
-IV;
sensitivity:0.85–0.87
(moderate);specificity:
0.93–0.99(high)
Riskcategorization
(pass/fail)
English,Spanish,
Turkish,Chinese,
andJapanese
versionsavailable
Publicdomain:
www.firstsigns.com
Dumont-M
athieu
T,FeinD.
Screeningforautism
inyoungchildren:theModi-
fiedChecklistforAutism
inToddlers(M-CHA
T)and
otherm
easures.Ment
RetardDevD
isabilResRev.
2005;11:253–262;Robins
DL,FeinD,BartonML,
GreenJA.The
Modified
ChecklistforAutism
inToddlers:aninitialstudy
investigatingtheearly
detectionofautismand
pervasivedevelopm
ental
disorders.JAutism
Dev
Disord.2001;31:131–144
412 AMERICAN ACADEMY OF PEDIATRICS
TABLE1
Continue
dDescription
AgeRange
No.ofItems
AdministrationTime
Psychometric
Propertiesa
ScoringMethod
Cultural
Considerations
Purchase/Obtainm
ent
Inform
ation
KeyReferences
PervasiveDevelop-
mentalDisorders
ScreeningTest-II
(PDD
ST-II),Stage
1-PrimaryCare
Screener
Parent-com
pleted
ques-
tionnairedesignedto
identifychildrenatrisko
fautismfromthegeneral
population
12-48mo
22(No.ofquestions/
items�averaged
�)10-15mintocom-
plete;5mintoscore
Validated
usingextensive
multim
ethoddiagnostic
evaluationson
681childrenat
risko
fautisticspectrum
disordersand
256childrenwith
mild-to-m
oderateother
developm
entaldisorders;no
sensitivity/specificitydata
reportedforscreening
ofan
unselected
sample;sensitivity:
0.85-0.92(moderatetohigh);
specificity:0.71–0.91
(moderatetohigh)
Riskcategorization
(pass/fail)
English
version
available
PsychologicalCorp
SiegelB.Pervasive
Develop-
mentalDisordersScreening
Test-II(PDDST-II):Early
Childhood
Screenerfor
AutisticSpectrumDisorders.
SanAntonio,TX:Harcourt
AssessmentInc;2004
PervasiveDevelop-
mentalDisorders
ScreeningTest-II
(PDD
ST-II),Stage
2-Developm
ental
ClinicScreener
Parent-com
pleted
ques-
tionnaire;designedto
detectchildrenatrisko
fautismfromotherdevel-
opmentaldisorders
12–48mo
14(No.ofquestions/
items�averaged
�)10–15mintocom-
plete;5mintoscore
Validated
usingextensive
multim
ethoddiagnostic
evaluationson
490children
with
confirmed
autistic
spectrumdisorder(autism
,pervasivedevelopm
ental
disorder-nototherwise
specified,orAsperger
syndrome)and194children
who
wereevaluatedforautistic
spectrumdisorderbutw
hodid
notreceiveadiagnosison
the
autisticspectrum;no
sensitivity/specificitydata
reportedforscreening
ofan
unselected
sample;sensitivity:
0.69–0.73(moderate);speci-
ficity:0.49–0.63
(low)
Riskcategorization
(pass/fail)
English
version
available
PsychologicalCorp
SiegelB.Pervasive
Develop-
mentalDisordersScreening
Test-II(PDDST-II):Early
Childhood
Screenerfor
AutisticSpectrumDisorders.
SanAntonio,TX:Harcourt
AssessmentInc;2004
ScreeningToolfor
AutisminTw
o-Year-
Olds(STAT)
Directlyadministered
tool;
designedassecond-level
screen
todetectchildren
with
autismfromother
developm
entaldisor-
ders;assessesbehaviors
in4social-com
municative
domains:play,request-
ing,directingattention,
andmotorimitation
24–35mo
12(No.ofquestions/
items�averaged
�)20
min
Twosampleswereused:fo
rdevelopm
entphase,3children
with
autism,33withoutautism
;forvalidationsample,12
chil-
dren
with
autism,21without
autism;validated
usingCA
RS,
ADOS-G,andDSM-IV
criteria;
second-levelscreen;requires
trainingworkshopbeforeadmin-
istration;sensitivity:0.83–0.92
(moderatetohigh);specificity:
0.85–0.86(moderate)
Riskcategorization
English
version
available
Wendy
Stone,PhD,
author:triad@
vanderbilt.edu
StoneWL,CoonrodEE,
OusleyOY.Briefreport:
ScreeningToolforAutism
inTw
o-Year-Olds(STAT):
developm
entand
pre-
liminaryd
ata.JAutism
Dev
Disord.2000;30:607–612;
StoneWL,CoonrodEE,
TurnerLM
,PozdolSL.
Psychometricpropertiesof
theSTAT
forearlyautism
screening.JAutism
Dev
Disord.2004;34:691–701;
StoneWL,OusleyOY.STAT
Manual:Screening
Toolfor
AutisminTw
o-Year-Olds.
unpublished
manuscript,
VanderbiltUn
iversity,1997
SocialCom
munication
Questionnaire(SCQ
)(formerlyAutism
ScreeningQues-
tionnaire-ASQ)
Parent-com
pleted
ques-
tionnaire;designedto
identifychildrenatrisko
fautisticspectrumdis-
ordersfromthegeneral
population;basedon
itemsintheAD
I-R
�4y
40(No.ofquestions/
items�averaged
�)5–10
min
Validated
usingtheAD
I-Rand
DSM-IV
on200subjects(160
with
pervasivedevelopm
ental
disorder,40withoutpervasive
developm
entaldisorder);for
useinchildrenwith
mentalage
ofatleast2
yandchronologic
age
�4y;availablein2forms:
lifetimeandcurrent;sensitivity:
0.85
(moderate);specificity:
0.75
(moderate)
Riskcategorization
(pass/fail)
English
andSpanish
versionsavailable
WesternPsychological
Corp:www.
wpspublish.com
RutterM
,BaileyA,LordC.The
SocialCom
munication
Questionnaire(SCQ
)Manual.LosAngeles,CA
:WesternPsychological
Services;2003
TheAA
Pdoesnotapprove/endorseanyspecifictoolforscreening
purposes.Thislistisnotexhaustive,andothertestsmaybe
available.AD
I-RindicatesA
utism
Diagnostic
Interview-R;IC
D-10,InternationalClassificationofDiseases,10threvision;AD
OS-G,Au
tismDiagnostic
ObservationSchedule-Generic;CARS,Childhood
AutismRatingScale;DSM
-IV,Diagnostic
andStatisticalManualofM
entalDisorders,FourthEdition.
aSensitivityandspecificitywerecategorized
asfollows:low
�69
orbelow;m
oderate
�70
to89;high
�90
orabove.
PEDIATRICS Volume 118, Number 1, July 2006 413
18-, and 30-month* visits. Consideration of a number offactors, including the time available to focus on devel-opmental concerns during a routine pediatric visit, led tothese recommended ages.
● Nine months of age: At 9 months of age, many issuesinvolving motor skills development can be reliablyidentified. A 9-month screening provides an addi-tional opportunity to attend to the child’s visual andhearing abilities. Early communication skills may beemerging—evidence suggests symptoms of autism,such as lack of eye contact, orienting to name beingcalled, or pointing, may be recognizable in the firstyear of life.23,24 Early intervention to address specificdevelopmental disorders is available to infants frombirth and should be accessed to address any delaysdetected at 9 months.25 At-risk 9-month-old infantsshould also be referred to early intervention programsif not previously referred. The 9-month preventivecare visit also provides a good opportunity for thechild health professional to educate parents about de-velopmental screening and to encourage parents topay special attention to communication and languageskills. Social and nonverbal communication, includingvocalizations and gestures, are important aspects ofemerging communication that can be assessed at 9months. Because of the rapid development of motor,language, and cognitive skills, parents should be en-couraged to express any concerns they have abouttheir child’s progress rather than waiting until the18-month visit. The AAP brochure Is Your One-YearOld Communicating With You?26 might be distributed atthe 9-month visit to educate parents about communi-cation and target any concerns they have. (If practiceshave eliminated the 9-month visit, this screeningshould be performed at the 12-month visit.)
● Eighteen months of age: Delays in communicationand language development are often evident by 18months of age. Mild motor delays that were undetec-ted at the 9-month screening may be more apparent at18 months of age. Medical interventions for motordisorders have been shown to be effective in childrenat 18 months of age, and effective early interventionfor delayed language development is also available.27
In addition to a general developmental screening tool,an autism-specific tool should be administered to allchildren at the 18-month visit.28 Symptoms of autismare often present at this age, and effective early inter-vention strategies are available.29
● Thirty months* of age: By 30 months of age, mostmotor, language, and cognitive delays may be identi-fied with screening instruments, leading to evaluationof and intervention for those children with delayeddevelopment. A 30-month visit focusing on child de-velopment and developmental screening would allow
the health care provider to devote special attention tothis area. Therefore, addition of this preventive carevisit to the periodicity schedule is being considered byBright Futures.
When child health professionals use only clinical impres-sions rather than formal screening, estimates of chil-dren’s developmental status are much less accurate.30
Including developmental screening tools at targeted de-velopmental ages is intended to enhance the precision ofthe developmental surveillance process. These recom-mended ages for developmental screening are suggestedonly as a starting point for children who appear to bedeveloping normally; surveillance should continuethroughout childhood, and screenings should be con-ducted anytime that concerns are raised by parents, childhealth professionals, or others involved in the care of thechild. At the 4-year visit, a screening for school readinessis appropriate.
5a and 5b: Administer Screening ToolDevelopmental screening is the administration of a briefstandardized tool that aids the identification of childrenat risk of a developmental disorder. Many screeningtools can be completed by parents and scored by non-physician personnel; the physician interprets the screen-ing results.
Developmental screening does not result in either adiagnosis or treatment plan but rather identifies areas inwhich a child’s development differs from same-age norms.Developmental screening that targets the area of con-cern is indicated whenever a problem is identified duringdevelopmental surveillance. Because development isdynamic in nature and surveillance and screening havelimits, periodic screening with a validated instrumentshould occur so that a problem not detected by surveil-lance or a single screening can be detected by subse-quent screening. Repeated and regular screening is morelikely than a single screening to identify problems, espe-cially in later-developing skills such as language. Waitinguntil a young child misses a major milestone such aswalking or talking may result in late rather than earlyrecognition, increasing parental dissatisfaction and anx-iety and depriving the child and family of the benefits ofearly identification and intervention.
Table 1 provides a list of developmental screening tools;a discussion of how to choose an appropriate screening toolis included in “Implementing the Algorithm.”
6a and 6b: Are the Screening-Tool ResultsPositive/Concerning?When the results of the periodic screening tool arenormal, the child health professional can inform theparents and continue with other aspects of the preven-tive visit. Normal screening results provide an opportu-nity to focus on developmental promotion. However,when a screening tool is administered because of con-
414 AMERICAN ACADEMY OF PEDIATRICS
cerns about development, an early return visit to provideadditional developmental surveillance should be sched-uled even if the screening-tool results do not indicate arisk of delay.
7. Make Referrals for Developmental and Medical Evaluationsand Early Developmental Intervention/Early ChildhoodServicesIf screening results are concerning, the child should bescheduled for developmental and medical evaluations.These evaluations may occur at a different visit or seriesof visits or often in a different setting by other profes-sionals. The separate box in which these steps are placedin the algorithm (Fig 1) is intended to represent thepossibility that these actions will occur at a different timeand location. However, they should be scheduled asquickly as possible, and professionals should coordinateactivities and share findings.
8. Developmental and Medical Evaluations
Developmental EvaluationWhen developmental surveillance or screening identifiesa child as being at high risk of a developmental disorder,diagnostic developmental evaluation should be pursued.This evaluation is aimed at identifying the specific de-velopmental disorder or disorders affecting the child,thus providing further prognostic information and al-lowing prompt initiation of specific and appropriateearly childhood therapeutic interventions.
Children with neurodevelopmental disorders also of-ten have other associated developmental or behaviordisorders.31–33 Identification of these disorders can lead tofurther evaluation and treatment. Pediatric subspecial-ists such as neurodevelopmental pediatricians, develop-mental and behavioral pediatricians, child neurologists,pediatric physiatrists, or child psychiatrists can performthe developmental diagnostic evaluation, as can otherearly childhood professionals in conjunction with thechild’s primary care provider. Such early childhood pro-fessionals include early childhood educators, child psy-chologists, speech-language pathologists, audiologists,social workers, physical therapists, and occupationaltherapists, ideally working with families as part of aninterdisciplinary team and with the medical home.
Medical EvaluationIn addition to the developmental evaluation, a medicaldiagnostic evaluation to identify an underlying etiologyshould be undertaken. This evaluation should considerbiological, environmental, and established risk factorsfor delayed development.34–37 Vision screening and ob-jective hearing evaluation; review of newborn metabolicscreening and growth charts; and an update of environ-mental, medical, family, and social history for additionalrisk factors are integral to this evaluation.
A comprehensive medical evaluation is essential
whenever a delay is confirmed. This evaluation variessomewhat with the risk factors and findings and mayinclude brain imaging, electroencephalogram (EEG), ge-netic testing, and/or metabolic testing.37
Identification of an etiology may provide parents witha greater depth of understanding of their child’s disabil-ity. Identifying an etiology also can affect various aspectsof treatment planning, including specific prognostic in-formation, genetic counseling around recurrence riskand family planning, specific medical treatments for im-proved health and function of the child, and therapeuticintervention programming.38 An underlying etiologywill be identified in approximately one quarter of casesof delayed development, with higher rates (�50%) inchildren with global developmental delays and motordelays and lower rates (�5%) in children with isolatedlanguage disorders.39
This evaluation can be performed by a trained andskilled pediatrician; a pediatric subspecialist such as aneurodevelopmental pediatrician, child neurologist, ordevelopmental/behavioral pediatrician; or through affil-iated medical professionals such as pediatric geneticistsor physiatrists. The primary care provider within themedical home should develop an explicit comanage-ment plan with the specialist(s).
Early Developmental Intervention/Early Childhood ServicesEarly intervention programs can be particularly valuablewhen a child is first identified to be at high risk ofdelayed development, because these programs oftenprovide evaluation services and can offer other servicesto the child and family even before an evaluation iscomplete.25 These services can include developmentaltherapies, service coordination, social work services, as-sistance with transportation and related costs, familytraining, counseling, and home visits. The diagnosis of aspecific developmental disorder is not necessary for anearly intervention referral to be made. Child health pro-fessionals should realize that a community-based earlyintervention evaluation may not address children withspecific medical risks, and further developmental andmedical evaluation will often be necessary for childrenwith established delays.
Establishing an effective and efficient partnershipwith early childhood professionals is an important ingre-dient of successful care coordination for children withinthe medical home. The partnership is built on sharedinterest in the developmental outcomes of children andrecognition of the different skill sets of child healthprofessionals and educators. For additional informationregarding care coordination, see the AAP policy state-ment “Care Coordination in the Medical Home: Integrat-ing Health and Related Systems of Care for ChildrenWith Special Health Care Needs.”40
Given the variety of community settings in whichhealth care is provided, the pediatrician may consult
PEDIATRICS Volume 118, Number 1, July 2006 415
early childhood professionals who work in specializedhealth care centers, university centers, early interven-tion programs, early childhood educational programs, orprivate practices. Whenever possible, communitiesshould coordinate resources; this is especially true inpreventing delays in care or unnecessary duplication ofservice.
The child’s medical charts, whether electronic or pa-per, should be organized to create a system that guaran-tees continuity of care, especially when the child is re-ferred to specialists and/or community agencies. Inaddition, a means of incorporating information about achild’s developmental status from sources outside themedical home should be available. The child health carechart should be designed to alert the clinician if furtherattention is needed between regular periodic visits.
9. Is a Developmental Disorder Identified?If a developmental disorder is identified, the child shouldbe identified as a child with special health care needs,and chronic-condition management should be initiated(see No. 10 below). If a developmental disorder is notidentified through medical and developmental evalua-tion, the child should be scheduled for an early returnvisit for further surveillance, as mentioned previously.More frequent visits, with particular attention paid toareas of concern, will allow the child to be promptlyreferred for further evaluation if any additional evidenceof delayed development or a specific disorder emerges.
10. Identify as a Child With Special Health Care Needs andInitiate Chronic-Condition ManagementWhen a child is discovered to have a significant devel-opmental disorder, that child becomes a child with spe-cial health care needs even if that child does not have aspecific disease etiology identified. Such a child shouldbe identified by the medical home for appropriate chron-ic-condition management and regular monitoring andentered into the practice’s children and youth with spe-cial health care needs registry.41 Every primary care prac-tice should create a registry for the children in the prac-tice who have special health care needs.
The medical home provides a triad of key primarycare services including preventive care, acute illnessmanagement, and chronic-condition management. Aprogram of chronic-condition management providesproactive care for children and youth with special healthcare needs, including condition-related office visits, writ-ten care plans, explicit comanagement with specialists,appropriate patient education, and effective informationsystems for monitoring and tracking.
Management plans should be based on a comprehen-sive needs assessment conducted with the family. Man-agement plans should include relevant, measurable, andvalid outcomes. These plans must be reviewed on aregular basis and updated as necessary. The child health
professional should actively participate in all care-coor-dination activities for children who have complex healthconditions in addition to developmental problems. De-cisions regarding appropriate therapies and their scopeand intensity should be determined in consultation withthe child’s family, therapists, and educators (includingearly intervention or school-based programs) and shouldbe based on knowledge of the scientific evidence fortheir use.
Children with established developmental disordersoften benefit from referral to community-based familysupport services such as respite care, parent-to-parentprograms, and advocacy organizations. Some childrenmay qualify for additional benefits such as supplementalsecurity income, public insurance, waiver programs, andstate programs for children and youth with specialhealth care needs (Title V). Parent organizations, such asFamily Voices, and condition-specific associations canprovide parents with information and support and canalso provide an opportunity for advocacy.
IMPLEMENTING THE ALGORITHM
Choosing Developmental Screening ToolsAlthough all developmental screening tools are designedto identify children with potentially delayed develop-ment, each one approaches the task in a different way.There is no universally accepted screening tool appro-priate for all populations and all ages. Currently avail-able screening tools vary from broad general develop-mental screening tools to others that focus on specificareas of development, such as motor or communicationskills. Their psychometric properties vary widely in char-acteristics such as their standardization, the comparisongroup used for determining sensitivity and specificity,and population risk status.
Broad screening tools should address developmentaldomains including fine and gross motor skills, languageand communication, problem solving/adaptive behav-ior, and personal-social skills. Screening tools also mustbe culturally and linguistically sensitive. Many screeningtools are available, and the choice of which tool to usedepends on the population being screened, the types ofproblems being screened for in that population, admin-istration and scoring time, any administration trainingtime, the cost of the tool, and the possibilities for ade-quate payment.
Screening tests should be both reliable and valid, withgood sensitivity and specificity.
● Reliability is the ability of a measure to produce con-sistent results.
● The validity of a developmental screening test relatesto its ability to discriminate between a child at a de-termined level of risk for delay (ie, high, moderate)and the rest of the population (low risk).
416 AMERICAN ACADEMY OF PEDIATRICS
● Sensitivity is the accuracy of the test in identifyingdelayed development.
● Specificity is the accuracy of the test in identifyingindividuals who are not delayed.
If a test incorrectly identifies a child as delayed, it willresult in overreferrals. If a test incorrectly identifies achild as normal, it results in underreferrals. For devel-opmental screening tests, scoring systems must be de-veloped that minimize underreferrals and overreferrals.Trade-offs between sensitivity and specificity occurwhen devising these scoring systems. Sensitivity andspecificity levels of 70% to 80% have been deemedacceptable for developmental screening tests.42 Thesevalues are lower than generally accepted for medicalscreening tests because of the challenges inherent inmeasuring child development and the absence of specificcurative and clearly effective treatments. However, com-bining developmental surveillance and periodic screen-ing increases the opportunity for identification of unde-tected delays in early development. Overidentification ofchildren using standardized screening tools may indicatethat this group of children includes some with below-average development and/or significant psychosocialrisk factors.43 These children may benefit from othercommunity programs as well as closer monitoring oftheir development by their families, pediatric health pro-fessionals, and teachers or caregivers.
Table 1 provides a list of developmental screeningtools and their psychometric testing properties. Thesescreening tools vary widely in their psychometric prop-erties. This list is not exhaustive; other standardized,published tools are available. We look forward to furtherevaluation/validation of available screening instrumentsas well as the continued development of new tools withstronger properties. Child health professionals are en-couraged to familiarize themselves with a variety ofscreening tools and choose those that best fit their pop-ulations, practice needs, and skill level.
Incorporating Surveillance and Screening in theMedical HomeA quality-improvement approach may be the most ef-fective means of building surveillance and screening el-ements into the process of care in a pediatric office.44
Improving developmental screening and surveillanceshould be regarded as a “whole-office” endeavor and notsimply a matter of clinician continuing education or theaddition of tasks to well-child visits. Front-desk proce-dures, such as appropriate scheduling for screening visitsand procedures for flagging children with establishedrisk factors, need to be explicitly designed by the officestaff. Nonphysician staff may need training in the ad-ministration of developmental screening tools. The inputof consumers is crucial to developing an effective systemand can be accomplished by adding a parent to an office
planning team, by using parent focus groups, or by ad-ministering parent questionnaires. Specific to develop-mental screening could be consumer opinion about pref-erences for completing questionnaires in the office orbefore the visit, how they would like to be informedabout the results of screening, how parents of childrenwith identified conditions associated with developmen-tal delay would like to have their children’s develop-ment monitored, or feedback on parental satisfactionwith their child’s developmental screening or feedbackon the referral process.
Screening PaymentSeparate Current Procedural Terminology (CPT)45 codes(see Table 2) exist for developmental screening (96110:developmental testing; limited) and testing (96111: de-velopmental testing; extended). The relative values forthese codes are published in the Medicare Resource-Based Relative Value Scale and reflect physician work,practice expenses, and professional liability expenses.Table 2 outlines the appropriate codes to use when bill-ing for the processes described in the algorithm. Healthplans are encouraged to adhere to CPT guidelines andprovide coverage and payment for developmentalscreening and testing.
Billing processes related to developmental screeningand surveillance should be carefully reviewed to ensurethat appropriate CPT codes are used to document screen-ing procedures and ensure proper payment. CPT code96110 for limited developmental testing does not in-clude any payment for medical provider services. Theexpectation is that a nonphysician will administer thescreening tool to the parent and then score their re-sponses. The physician reviews and interprets thescreening results; the physician’s work is included in theevaluation and management code used for the child’svisit. Medicaid may not pay separately for developmen-tal screening when provided as part of early and periodicscreening, diagnostic, and treatment services. If non-Medicaid carriers are involved, the preventive care codeis used with the modifier 25 appended and 96110 listedfor each screening tool administered. The CPT code 96111,extended developmental testing, includes medical providerwork. This code would more appropriately be used whenthe medical provider observes the child performing a taskand demonstrating a specific developmental skill.
The codes in Table 2 may be applicable to the phasesof developmental surveillance, screening, and evalua-tion described in the proposed algorithm (Fig 1).
SUMMARYDevelopmental surveillance should be a component ofevery preventive care visit. Standardized developmentalscreening tools should be used when such surveillance
PEDIATRICS Volume 118, Number 1, July 2006 417
identifies concerns about a child’s development and forchildren who appear to be at low risk of a developmentaldisorder at the 9-, 18-, and 30-month* visits.
When a child has a positive screening result for adevelopmental problem, developmental and medicalevaluations to identify the specific developmental disor-ders and related medical problems are warranted. Inaddition, children who have positive screening results
for developmental problems should be referred to earlydevelopmental intervention and early childhood ser-vices and scheduled for earlier return visits to increasedevelopmental surveillance.
Children diagnosed with developmental disordersshould be identified as children with special health careneeds; chronic-condition management for these chil-dren should be initiated.
TABLE 2 CPT Codes for Developmental Screening
Services/Step in Algorithm Notes CPT Code Comments
Pediatric preventive care visit All preventive care visits should include developmentalsurveillance; screening is performed as needed or atperiodic intervals
99381–99394 (EPSDTa)
Developmental screening The expectation is that the screening tool will becompleted by a parent or nonphysician staffmember and reviewed by the physician
96110 Limited developmental testing, withinterpretation and report
Developmental/medicalevaluation
If performed by the physician as an outpatient officevisit
99210–99215b or 96110; or96111 if objectivedevelopmental testing isperformed
99214 is used for evaluationsperformed by the physician thatare detailed and moderatelycomplex or take at least 25 min(with over half spent counseling);99215 is used for evaluations thatare comprehensive and highlycomplex or take �40 min (withover half spent counseling) 99244is used for “moderate activities” ofup to 60 min; 99245 is used for“high” activity of up to 80 min
Outpatient consultation; typically performed by atertiary, local out-of-office referral source or anotherphysician with the requisite skills in the samepractice as the referring physician; the request forconsultation must be recorded in the patient’s chart;services/procedures and consulting physician’simpressions must be recorded; time spentcounseling and coordinating care should bespecifically documented; these codes include“reporting” of the consulting physician, if completedby letter or office notes
99241–99245
If a more extensive report is developed, this code isused; these costs may not be reimbursable
99080
Developmental disorder identified For follow-up visits with the patient and parents tocomplete the consultation or to discuss the resultsof the initial consultation; for rendering opinionsand addressing questions, not assuming care; oncecare is assumed, established office-visit coding is used
99241–99245
Identify as a child with specialhealth care needs, and initiatechronic-condition manage-ment
Children with special health care needs are likely torequire expanded time and a higher level of medicaldecision-making found in these “higher-level”outpatient codes; these codes are appropriate forservices in the office and for outpatient facilityservices for established patients; these codes may bereported using time alone as the factor if more thanhalf of the reported time is spent in counseling
99211–99215 99213; 99214; 99215 (see above)
Prolonged services At any point during the algorithm when outpatientoffice or consultation codes are used, prolongedphysician service codes may be reported in additionwhen visits require considerably more time thantypical for the base code alone; both face-to-faceand non–face-to-face codes are available in CPT
99354 99354 for first 30–74 min ofoutpatient face-to-faceprolonged services
99355 99355 for each additional 30 min99358 99358 for first 30–74 min of non–
face-to-face prolonged services99359 99359 for each additional 30 min
Extended developmental testing/evaluation
Used for extended developmental testing typicallyprovided by the medical provider (often up to 1 h)including the evaluation interpretation and report
96111 Reported in addition to evaluationand management (E/M) servicesprovided on the same date
a EPSDT (EarlyandPeriodicScreening,Diagnosis, andTreatment) is the federalMedicaidprogramforpreventive services. Statesmay requirephysicians tousedifferentcodes to report theseservices. Ingeneral,for non-Medicaid commercial insurers, the evaluation and management CPT codes for preventive medicine services (99381-99394) are used for the basic service (history, physical examination, andcounseling/anticipatory guidance), with separate CPT codes reported additionally for the additional screening of hearing, vision, development, laboratory services, and immunization administration.b CPT evaluation andmanagement code levels are selected on the basis of the amount of physicianwork (history, physical examination, andmedical decision-making) and/or time used in the encounter.
418 AMERICAN ACADEMY OF PEDIATRICS
RECOMMENDATIONS
For the Medical Home
1. Perform developmental surveillance at every pre-ventive visit throughout childhood, and ensure thatsuch surveillance includes eliciting and attending toparents’ concerns, obtaining a developmental history,making accurate and informed observations of thechild, identifying the presence of risk and protectivefactors, and documenting the process and findings.
2. Administer a standardized developmental screeningtool for children who appear to be at low risk ofa developmental disorder at the 9-, 18-, and or 30-month* visits and for those whose surveillanceyields concerns about delayed or disordered develop-ment.
3. Schedule early return visits for children whose sur-veillance raises concerns that are not confirmed by adevelopmental screening tool.
4. Refer children about whom developmental concernsare raised to early intervention and early-childhoodprograms.
5. Coordinate developmental and medical evaluationsfor children who have positive screening results fordevelopmental disorders.
6. Initiate a program of chronic-condition managementfor any child identified with a developmental disorder.
7. Document all surveillance, screening, evaluation, andreferral activities in the child’s health chart.
8. Establish working relationships with state and localprograms, services, and resources.
9. Use a quality-improvement model to integrate sur-veillance and screening into office procedures and tomonitor their effectiveness and outcomes.
For Policy and Advocacy
10. Provide appropriate payment for developmentalsurveillance, screening, and evaluation.
11. Teach child health professionals, through trainingand continuing education programs, to conduct de-velopmental surveillance and screening as an inte-gral responsibility of the medical home.
For Research and Development
12. Develop information systems and data-gatheringtools to automate the algorithm recommended bythis policy statement for ease and consistency of use.
13. Expand the evidence base for the effectiveness ofdevelopmental surveillance activities.
14. Improve the effectiveness of developmental screen-ing tools in the identification of children with de-velopmental disorders in the medical home.
15. Expand the evidence base for the use and effective-ness of the proposed algorithm, including the opti-mal timing of the recommended developmentalscreening.
POLICY REVISION COMMITTEE (PRC)
COUNCIL ON CHILDRENWITH DISABILITIES
John C. Duby, MDPaul H. Lipkin, MD, PRC Chairperson
SECTION ON DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS
Michelle M. Macias, MDLynn M. Wegner, MD
BRIGHT FUTURES STEERING COMMITTEE
Paula Duncan, MDJoseph F. Hagan, Jr, MD
MEDICAL HOME INITIATIVES FOR CHILDRENWITH SPECIAL NEEDS
PROJECT ADVISORY COMMITTEE
W. Carl Cooley, MDNancy Swigonski, MD, MPH
LIAISONS
Paul G. Biondich, MD, MSPartnership for Policy Implementation (PPI)
Donald Lollar, EdDCenters for Disease Control and Prevention
STAFF
Jill AckermannAmy Brin, MAMary Crane, PhD, LSWAmy Gibson, MS, RNStephanie Mucha Skipper, MPH, Principal StaffDarcy Steinberg-Hastings, MPH
CONSULTANT
Melissa Capers, MA, MFA
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