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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

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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).

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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 by guest on March 23, 2020www.aappublications.org/newsDownloaded from

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.


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-,


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)


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);


(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


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);


(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);


(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


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


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�)


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


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);


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;


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;


(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


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�);


(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;



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


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


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);


(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)


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


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


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.


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-


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


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).


● 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


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.


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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DOI: 10.1542/peds.2006-12312006;118;405Pediatrics

Children With Special Needs Project Advisory CommitteePediatrics, Bright Futures Steering Committee and Medical Home Initiatives for

Council on Children With Disabilities, Section on Developmental BehavioralMedical Home: An Algorithm for Developmental Surveillance and ScreeningIdentifying Infants and Young Children With Developmental Disorders in the

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