Selecting Developmental Surveillance and Screening Tools

The importance of surveillance and screening for developmental problems in primary care has been well recognized in scholarly reviews and practice guidelines. (1) The need for early detection of developmental problems in infants and young children in primary pediatric care settings stems from the high prevalence of such problems and the potential for early intervention for the child and family. Frequent longitudinal contact with young children and their families at critical times in their early development provides pediatricians and other practitioners with important opportunities to conduct developmental surveillance and screening to detect clinically significant developmental problems and institute early intervention. (1)(2)(3)(4) Early identification and referral to early intervention programs can ameliorate the negative consequences of developmental problems on children, families, and society. (3) However, studies have indicated consistently that many infants and young children who have clinically significant developmental delays are not detected in pediatric primary care. (1)(3)(4) As a consequence, critical opportunities for early intervention for young children who are at risk for developmental problems may be lost. (2)(5)(6)(7)To address this need, the American Academy of Pediatrics (AAP) developed a policy statement for identifying infants and young children who have developmental delays and disorders. (8) This statement is a significant advance in the clinical application of developmental screening in several respects. One is the recommendation to address parental concerns about development as one of several health topics in routine pediatric preventive care visits throughout the first 5 years after birth. Developmental surveillance, defined as a flexible, longitudinal, continuous, and cumulative process, is recommended for inclusion at every pediatric visit.The five components of developmental surveillance described in the AAP statement include: 1) eliciting and attending to the parent's concerns about his or her child's development, 2) documenting and maintaining a developmental history, 3) conducting accurate observations of the child's development, 4) identifying risk and protective factors, and 5) documenting the process and findings from developmental surveillance. The AAP also recommends a close connection between developmental surveillance and the use of developmental screening instruments. If surveillance indicates a concern about the presence of developmental problems, developmental screening, defined as the use of a standardized tool to identify and describe the level of the child's risk for developmental delay, should be conducted. (8) Finally, the AAP recommends that developmental screening of all children be conducted at 9-, 18-, and 30-month visits (or at 24 months if a 30-month visit is not part of the preventive schedule in the practice). (8)Unfortunately, barriers such as time, costs, and practice management constraints can limit implementation of the AAP recommendations. (1)(3)(4)(9)(10)(11) Another important potential barrier to implementation involves the selection of specific developmental screening instruments. Practitioners’ dilemmas concerning the selection of developmental screening instruments are heightened by their large numbers and variety. For example, available instruments vary considerably with respect to: 1) primary purpose (eg, screening for general developmental delay versus specific disorders such as autism), 2) method of administration (eg, parent- versus practitioner-administered), 3) reliability and validity (eg, sensitivity and specificity for detection of children who have clinically significant developmental problems), (12) and 4) costs and feasibility for use in specific settings.To identify the most valid and feasible screening instruments for their practices, practitioners need detailed information and guidance concerning scientific data and feasibility. We conducted a comprehensive review of scientific research and practical considerations for developmental screening instruments to guide selection and application of screening instruments in a range of practice settings. (13) This guide has been posted on the Commonwealth Fund Website (http://www.commonwealthfund.org). (13) The purpose of this report is to describe these guides and their application. It is important to note that these guides focus on general developmental screening and screening for autism and language delays and do not include screening for socioemotional concerns in young children. The latter is an important topic that requires separate consideration.Our review indicates that no single developmental screening instrument is suitable for all clinical purposes and practices. To make the best informed decisions about selection and use of screening instruments, practitioners need to consider the following issues: 1) the primary purpose of an instrument, 2) characteristics of patients and families seen in their practices, 3) practice-based resources and experience in using screening instruments, and 4) availability of community resources for evaluation and early intervention for developmental problems that are identified by screening.A practitioner's choice of specific instruments should be tied closely to an instrument's specific purpose. For example, practitioners should consider whether they intend to use an instrument primarily to facilitate developmental surveillance or screening. Another important consideration is whether a practice desires an instrument to detect general developmental delay or specific developmental disorders.The characteristics of patients and families who are seen in a specific practice also influence the selection of screening instruments. In particular, the base rates of general developmental problems or specific disorders in individual practices should be considered because these characteristics influence the sensitivity and specificity of specific measures. Instruments that have the highest sensitivity, specificity, or predictive values to detect specific developmental problems that are highly prevalent in individual practices are the most valid for that practice. (14) However, unless a practice has a system in place to document the prevalence of specific diagnoses of developmental disorders, it may be very difficult to estimate the base rates of developmental problems. In such instances, knowing practice-specific rates of risk factors that are associated with higher probabilities of developmental problems, such as prematurity, may facilitate estimation of base rates. (13)A number of available developmental screening instruments are based on parent report. (13) Parent report instruments have varying reading levels and availabilities of translation for different languages. To ensure the most valid administration, reading levels required by screening instruments should match those of parents who complete them. In addition, instruments should be translated into languages that are familiar to parents who use the instruments to ensure a valid application.Developmental screening instruments vary widely in the time of administration and the resources that are required for their administration, scoring, and interpretation. Practitioners must consider administration time as well as the initial and ongoing costs of manuals, instruments, and scoring materials. To make the most informed choice of instruments, practitioners also need to consider the potential revenue that can be generated to pay for the use of developmental screening tools. For this reason, the practice's history of and potential for reimbursement for codes such as 96110 (developmental screening) are most relevant.Individual practitioners and practices may have very different levels of experience in using specific instruments. Experienced practices have a significant advantage in selecting and implementing such instruments. In addition, practices can consult information from published reports, (15)(16)(17) state AAP organizations, and academic pediatric residency programs when making decisions about specific instruments and implementing a practice-based surveillance and screening program.Developmental screening instruments do not provide a specific diagnosis or treatment plan but do identify areas in which the child's development differs from age-related norms. To have an optimal impact on the child's development, surveillance and screening should be followed by specific clinical actions, such as referral for evaluation and treatment or early intervention. (8) For this reason, the availability of and collaboration with community resources for additional evaluation and early intervention programs are important to enhance the potential impact of developmental screening on children's development.The guides for developmental screening, each of which is categorized to reflect the primary use of the instrument for screening for general developmental problems, language problems, or autism, include the following: Table 1 provides a summary of the primary recommendations for the instrument selection organized by the purpose of the instruments. These recommendations are based on a combination of clinical relevance (eg, user friendliness and feasibility) and scientific validity based on standardization data reported in the test manual and published studies based on the instruments, especially those that documented sensitivity and specificity for screening at the ages recommended by the AAP. (8) Table 2 includes general descriptive information about the instruments described in Table 1. Interested readers should consult http://www.commonwealthfund.org for additional information on the validity of instruments, screening standards, and implementation recommendations.Practitioners who are interested in an instrument to use for developmental surveillance should consider the Parents’ Evaluation of Developmental Status (PEDS), (19) which has been validated for this purpose. Practitioners who wish to screen for general developmental delay should consider whether they want to use parent-based or practitioner-based instruments. The Ages and Stages Questionnaire (ASQ) (20) and PEDS (19) are recommended as parent report measures for screening for general developmental delay.A second question that needs to be considered in choosing instruments is whether the screening is for a general pediatric population or a high-risk population that contains a high percentage of children who are at biologic risk (preterm birth) or environmental risk (economic disadvantage). Practitioners who are screening for developmental delay in a high biologic or environmental risk population may wish to consider the ASQ (20) (if a parent-administered instrument is desired) and the Bayley Infant Neurodevelopmental Screener (BINS) (21) (up to age 24 months) or the Cognitive Adaptive Test/Clinical Linguistic Auditory Milestone Scale (CAT/CLAMS) if a practitioner-administered instrument is desired. (22)Finally, practitioners who are interested in identifying specific developmental delays have several choices, depending on the specific disorders. The Language Development Survey (LDS), (23) a parent-administered instrument, and the Clinical Linguistic Auditory Milestone Scale (CLAMS), (22) a practitioner-administered instrument, should be considered for identification of language disorders. The Modified Checklist for Autism in Toddlers (M-CHAT), (24) a parent-administered instrument, should be considered for the identification of autism. (25)Pediatric developmental screening instruments have been available since the 1960s, (26) as has the need for critical evaluation of their validity (27) and the importance of sound clinical application. (28) Instrument development and standardization, the establishment of validity, and clinical application reflect a continually evolving process. Many instruments that were used well at one point in time no longer are as applicable, based on data from more recent standardization samples, demonstrations of validity, and the development of newer measures based on parental report.The recommendations presented in this report are based on an extensive scientific review of evidence on available developmental screening measures. It is anticipated that additional screening measures will emerge as additional research is conducted. One of the most important future directions is to extend clinical and scientific knowledge about application of developmental screening instruments to pediatric practices and state-level screening programs. Additional data are needed in many areas, including feasibility and cost effectiveness of different screening instruments in various practice settings. Important but as yet unanswered questions include: How do practitioners and practices implement various instruments in the context of clinical care? What are the experiences of the practices in obtaining reimbursement for this screening? What is the level of family satisfaction with developmental screening? What is the impact of false-positive screening results?Another important area of future research concerns the validity of the screening instruments in practice settings. With some notable exceptions, (15)(16)(17) there have been few demonstrations of the validity of screening instruments in practice settings. Moreover, additional studies of the validity (sensitivity and specificity) of developmental screening instruments with different populations are particularly important. Our review identified 32 studies that assessed the validity of instruments recommended here, but few of these were conducted in clinical practice settings. Such studies are particularly important because the sensitivity and specificity of developmental screening instruments depend on the base rates of developmental problems in specific practices. For this reason, data from individual practices and programs are very much needed to establish the validity of screening instruments in clinical populations.A final critical area for future research and clinical care concerns the impact of developmental screening on children's developmental outcomes. For example, does routine developmental screening result in increased referral and engagement of children and families in early intervention programs in practice settings? Do screening and subsequent involvement in early intervention enhance children's developmental outcome and functioning? Such research will build on studies that already have indicated positive effects of developmental screening and early intervention. (2)(5)(7)The high prevalence of developmental problems in pediatric practice coupled with the opportunity for early intervention underscore the importance of developmental screening and surveillance in pediatric primary care. The selection of valid screening instruments is necessary to identify developmental delay and developmental disorders in accord with the 2006 policy statement of the AAP. (8) A number of validated general and condition-specific developmental screening instruments are applicable to primary care practice. Becoming aware of available screening instruments will help pediatric practitioners make informed selections of the specific tools that can identify and serve best the needs of children and families of their particular practices.This work was supported by the Commonwealth Fund #20060127 Rating Developmental Screening Instruments. The intellectual and technical support provided by Ed Schor and his colleagues at the Commonwealth Fund is gratefully acknowledged. Finally, the assistance provided by Desiree Rayl in typing and processing this manuscript is appreciated.