Early identification and intervention for developmental disorders are critical to the well-being of children and are the responsibility of all pediatric medical professionals. Screening for developmental disorders should be implemented via standardized developmental screening tests in all children at the 9-, 18-, and 30-month visits and when such surveillance identifies concerns about a child’s development, according to a summary from the American Academy of Physicians (AAP).1
Children with concerning results should be evaluated further to identify the specific developmental disorders and additional related medical problems. If diagnosed with a developmental disorder, children should be referred to early intervention and early childhood services and scheduled for earlier return visits to increase developmental surveillance, noted the AAP.
To help with screening, the AAP developed an algorithm that presents steps for screening a patient without identified risks for developmental problems at a health supervision visit.
- Step 1: Patients with or without identified risks or developmental problems arrive for a health supervision visit.
- Step 2: Identify whether this visit is a 9-, 18-, 24-, or 30-month visit.
- Step 3: Administer the screening test.
- Step 4: Perform physical examination and routine developmental surveillance (including risk factor assessment).
- Step 5: Identify whether the screening suggests a motor concern (if yes, see Step 7).
- Step 6: Identify whether the screen result is concerning.
- Step 7: Perform motor disorder evaluation.
- Step 8: Perform complete medical evaluation.
- Step 9: Perform or refer for developmental evaluation and refer to early intervention or early childhood education.
- Steps 10, 11, 12: If an unaddressed concern from surveillance is identified (Step 10,) document the concern in the patent’s record system (Step 11), and recommend an early return visit (Step 12).
- Step 13: Perform remainder of health supervision visit.
- Steps 14 and 15: If a developmental diagnosis is established (Step 14), initiate chronic condition management (Step 15).
Although these comprehensive recommendations and steps for screening provide adequate guidance for clinicians, they have not been uniformly embraced. According to the National Survey of Children’s Health, approximately 20% of children in 2007 and 30% of children in 2016 received standardized developmental screening .2,3 In a follow-up study conducted by the APP, researchers sought to examine trends in pediatricians’ reported screening and referral practices, as well as attitudes toward and barriers to these practices.4
The Periodic Survey collected data from a sample of non-retired AAP members (n=1638) and explored pediatricians’ knowledge, attitudes, and practices regarding screening and managing children for developmental delays or problems. Researchers analyzed the 2002 survey (response rate, 58%) and the 2016 survey (response rate, 47%).
Respondents were asked how often they or their staff used screening methods and tools to identify children from birth to age 35 months who are at risk for developmental delay/problems and/or autism spectrum disorder (ASD). The survey also included questions about who in the practice administered screens and reviewed results, as well as perceived barriers to screening for developmental delays.
The reported use of any standardized screening tool among pediatricians increased from 21% in 2002 to 63% in 2016. Screenings shifted from being primarily administered by the pediatrician (86%) in 2002 to other staff (60%) in 2016. However, the review and interpretation of the screenings were conducted by 96% of pediatricians in 2016.
The most common barrier to screening children for risk of developmental delay or ASD was time limitations, with 57% of pediatricians agreeing or strongly agreeing with the question in 2016. Time limitations, inadequate reimbursement for conducting a standardized screening, lack of office staff to perform screening, belief that screening is not an appropriate role for pediatricians, and lack of confidence in screening ability declined as reported barriers to screening from 2002 to 2016. Lack of treatment options for positive screen results increased from 9% to 21% from 2002 to 2016.
Pediatricians in 2002 self-reported referring 41% of their patients who were identified as being at risk for developmental problems to early intervention; this number increased to 59% in 2016 with pediatricians on average referring 22% of patients who were identified with developmental problems to specialists before referring them to early intervention. Pediatricians were more likely in 2016 than in 2002 to refer a patient to either early intervention or a specialist for global developmental delays, loss of developmental milestones, delayed speech, sensory impairment, abnormal muscle tone and/or motor delay, family concern, newborn failing a hearing screen, and risk for neglect or abuse.
“To further increase the rates of both developmental screening and referral of patients with concerns for treatment, increased attention should be focused on improving screening and referral systems,” the investigators concluded. “This may include the incorporation of screening tests and referral and tracking systems into electronic medical record systems, allowing for better tracking of child outcomes and feedback to the medical home.”
1. Lipkin PH, Macias MM; Council on Children with Disabilities; Section on Developmental and Behavioral Patterns. Promoting optimal development: identifying infants and young children with developmental disorders through developmental surveillance and screening. Pediatrics. 2020;145(1).
2. Six by ’15. Early childhood. Six by ’15 website. http://sixbyfifteen.org/six-goals-by-2015/early-childhood/. Updated 2015. Accessed March 12, 2020.
3. Centers for Disease Control and Prevention (CDC). Learn the signs. Act early. CDC website. www.cdc.gov/ncbddd/actearly/. Updated November 1, 2019. Accessed March 12, 2020.
4. Lipkin PH, Macias MM, Baer Chen B, et al. Trends in pediatricians’ developmental screening: 2002-2016 [published online March 2, 2020]. Pediatrics. doi:10.1542/peds.2019-0851 https://pediatrics.aappublications.org/content/early/2020/02/27/peds.2019-0851