Professional Documents
Culture Documents
Selecting Developmental
Surveillance and Screening
Tools
Dennis Drotar, PhD,*
Introduction
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 parents concerns about his or her childs
development, 2) documenting and maintaining a developmental history, 3) conducting
accurate observations of the childs 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 childs 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
Author Disclosure
Drs Drotar, Stancin,
Dworkin, and Sices
and Ms Wood have
disclosed that this
work was supported
by the
Commonwealth Fund
#20060127 Rating
Developmental
Screening
Instruments. This
commentary does not
contain a discussion
of an unapproved/
investigative use of a
commercial product/
device.
Professor of Pediatrics, Psychiatry and Psychology, Case Western Reserve University and Metro Health Medical Center,
Cleveland, Ohio.
Summary of recommendations for screening instruments for specific purposes based on the clinical relevance of the instrument, quality of standardization,
user friendliness, number and quality of validity studies, and availability of sensitivity and specificity for ages
as recommended by the AAP statement (8)
General information, including how to obtain the instruments, costs, parent reading levels, availability of
translation, use with electronic medical record, and
training needed to use the instrument
Information from the instruments manual or website
about the standardization sample and clinical application of the instrument
Scientific validity, as described in the test manual,
including sensitivity and specificity for specific ages
recommended by the AAP, reliability, and validity
Scientific validity based on published studies, including
sensitivity and specificity for age ranges recommended
by the AAP and ratings of studies reviewed based on
the Standards for Reporting of Diagnostic Accuracy,
(18) and a reference list of articles reviewed
Future Directions
Pediatric developmental screening instruments have
been available since the 1960s, (26) as has the need for
Table 1.
Purpose of Screening
Population to be Screened
Type of Instrument
Identification of general
developmental delay
Parental concerns-based
surveillance or screening
in various developmental
domains
Identification of general
developmental delay
Identification of general
developmental delay
Practitioner-administered
Identification of general
developmental delay
(language and
cognitive)
Practitioner-administered
Identification of language
delay
Parent report
Identification of language
delay
Practitioner-administered
Parent-administered
critical evaluation of their validity (27) and the importance of sound clinical application. (28) Instrument development and standardization, the establishment of
Recommendation and
Comments
Parents Evaluation of
Developmental Status (PEDS)
Comprehensive, user-friendly
manual
Validation in large, diverse
standardization sample
Published validation studies
Ages and Stages Questionnaire
(ASQ)
Comprehensive, user-friendly
manual
Validation in large, diverse
standardization sample,
including general and highrisk children
Published validation studies
Bayley Infant
Neurodevelopmental Screens
(BINS)
Comprehensive, user-friendly
manual
Large, diverse standardization
sample
Published validation study
available
Cognitive Adaptive Test 1 Clinical
Linguistic Auditory Milestone
Scale and Expressive
Language Scale (CAT CLAMS
Capute Scales)
User-friendly manual
Large standardization sample
Multiple published validation
studies available
Language Development Survey
(LDS)
Comprehensive manual
Validation in large, diverse
standardization sample
Multiple published validation
studies
Cognitive Adaptive Test/Clinical
Linguistic Auditory Milestone
Scale and Expressive
Language Scale (Capute
Scales, CLAMS)
User-friendly manual
Standardization sample
Multiple published validation
studies
Modified Checklist for Autism in
Toddlers (M-CHAT)
User information available on
website
Published validation study
available
Manual
Forms for
administration and
scoring
(photocopiable)
Total: $199.00
Manual
Forms for
administration and
scoring
Standardized
materials to
conduct
assessment
Total: $325.00
Manual
Forms for
administration and
scoring (n20)
Standardized
materials to
conduct
assessment
Total: $350.00
Forms for
administration and
scoring (n50)
Total: $30.00
Problems
ASEBA/Research Center for
Manual
Children, Youth, and Families Forms for
1 South Prospect St.
administration and
Burlington, VT 05401-3456
scoring (n50)
802-264-6432
Total: $65.00
www.aseba.org/products/
cbc11-5.html
Screening for Autism and Pervasive Developmental Disorders
Modified Checklist for www.firstsigns.org/
Public Domain Free
Autism in Toddlers
downloads/Downloads_
(M-CHAT)
archive/m-chat.PDF
Capute Scales:
Cognitive Adaptive
Test/Clinical
Linguistic Auditory
Milestone Scale
Expressive and
Receptive
Language Scale
(CAT/CLAMS)
Parents Evaluations
of Developmental
Status (PEDS)
Bayley Infant
Harcourt Assessment, Inc.
Neurodevelopmental Attn: Customer Service
Screens (BINS)
P.O. Box 599700
San Antonio, TX 78259
800-211-8378
http://harcourtassessment.com
Instrument
How To Obtain Measure
Screening For General Developmental Problems
Ages and Stages
Paul H. Brooks Publishing Co.
Questionnaire
PO Box 10624
(ASQ)
Baltimore, MD 21285-0624
800-638-3775
www.brookespublishing.com
Cost of Materials,
Manual, and Relevant
Forms for
Administration and
Scoring
10
5 to 10
X N/A
2 to 10
15 to 20
5 to 10
10 to 15
Time
(min)
X N/A
X N/A
N/A X
N/A X
X N/A
Administered
To: Parent/
Child
5th grade
5th grade
N/A
N/A
4th to 6th
grade
Parent
Reading
Level
Yes
Yes
Yes
Yes
No
Yes
Spanish
Chinese
Japanese
French, Italian,
Romanian, Dutch,
Turkish,
Portuguese, Greek
Vietnamese, Arabic,
Swahili,
Indonesian,
Chinese, Taiwanese,
French, Somali,
Portuguese,
Malaysian, Thai,
Laotian
Russian
Chinese
Portuguese
French
Korean
Translations
Other
Web-link Program
www.web-link.org
Yes
No
No
Yes
Used With
Electronic
Medical Record
www.utmem.edu/
pediatrics/general/
clinical/m-chatscoring.pdf
Workshops, inservice
(Contact: Leslie
Rescorla through
ASEBA)
Manual only
On Location
Web-based at
www.agesandstages.com/
Training Available
Table 2.
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 childrens 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
childrens 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)
Summary
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.
ACKNOWLEDGMENTS. 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.
References
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4. Sices L, Feudtner C, McLaughlin J, Drotar D, Williams M. How
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8. Council on Children With Disabilities; Section on Developmental Behavioral Pediatrics; Bright Futures Steering Committee; Medical Home Initiatives for Children With Special Needs Project
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Pediatrics in Review Vol.29 No.10 October 2008 e57