Tweaks Proposed for AAP Developmental-Behavioral Screening Algorithm

Many "detected" and "at-risk" children are falling through the cracks when it comes to referring and interlinking children with suspected developmental-behavioral problems to early intervention and other community services.

At least one group of researchers believes that revisions to the 2006 American Academy of Pediatrics developmental surveillance and screening algorithm are needed to optimize the early detection, prevention, and ongoing monitoring of developmental-behavioral problems. In the September issue of Clinical Pediatrics, Dr. Kevin Marks and his colleagues argue that a more detailed action plan is needed (Clin. Pediatr. 2011;50:853-68).

Specifically, they argue that promotion of behavioral and developmental wellness should be formally included as an action step, that referrals for certain high-risk children should be automatic, and that greater emphasis should be placed on care coordination following a referral for early intervention services.

"As physicians, we play a key role in the early detection of developmental and behavioral problems in children prior to kindergarten entrance. We have the privilege and ability to create opportunities for parents to access services for their children, but there is much work to be done to ensure that these referrals occur in keeping with the six quality aims of the Institute of Medicine, which call for referrals to be made in a safe, equitable, effective, timely, parent-centered, and efficient manner," Dr. Marks, a general pediatrician and pediatric hospitalist in Eugene, Ore., said in an interview.

The comprehensive review of the current literature conducted by Dr. Marks and his colleagues showed that children with a concerning screening test are not consistently referred and interlinked to early intervention services. Furthermore, due to a variety of reasons, only about half of those referred ultimately are deemed eligible for early intervention despite performing well below average and exhibiting numerous predictive academic and psychosocial risk factors.

"Pediatricians are frequently missing young children with suspected developmental delays, social-emotional problems, and autism."

Currently there are three separate algorithms for general pediatricians to follow from three separate AAP statements, which were published in 2006, 2007, and 2010. Together they recommend universal postpartum maternal depression screening in the first year; general developmental screening at 9, 18, and 24 months; autism-specific screening at 18 and 24 months; social-emotional screening whenever a general developmental or autism-specific screen is abnormal; kindergarten readiness screening at 4 years; and mental health/psychosocial function screening at 5 years and every well-visit thereafter.

"Our findings reinforce many of the previous recommendations within various AAP statements in regard to periodic screening with well-standardized, reliable and accurate tools that measure general development and social-emotional/behavioral development, as well as autism-specific and family psychosocial screening tools," Dr. Marks said.

Areas where the findings support revisions, however, include:

• The promotion of developmental and behavioral wellness. An example is literacy counseling through the Reach Out and Read program, which has been shown to improve outcomes. Consistently incorporating positive parenting and strength-based counseling into developmental-behavioral surveillance and screening makes the process more safe, effective, and parent-centered, he said.

Many pediatricians who follow the AAP/Bright Futures guidelines are already doing this, but the point, according to Dr. Marks, is that developmental-behavioral promotion needs to be viewed as key component of surveillance.

• The automatic referral of children with a medical or psychosocial condition or risk factor associated with a high probability of future developmental delay. Screening certain high-risk groups can be deemphasized because the likelihood of these children needing early intervention is sufficiently high so automatic referral is justifiable, Dr. Marks said. Examples of medical risk factors include very low birth weight infants (born weighing less than 1,500 g), those exposed in-utero to harmful substances such as alcohol, methamphetamine or heroin, and those with a genetic syndrome associated with a future developmental delay. A psychosocial risk factor would include those children who have been abused or neglected.

• The automatic referral of children in whom the pediatrician confidently suspects a developmental delay and/or disorder, even when standardized screening results are "typical" or "questionable." The literature shows that pediatrician impression has good specificity but poor sensitivity, meaning that when a pediatrician confidently detects a delay, they are almost always correct; however, they miss the large majority of delays using their less structured surveillance alone, Dr. Marks said.

• The automatic referral of children in whom a psychometrically sound screening tool is found to be positive or concerning. Such tools include the Ages & Stages Questionnaire (ASQ) or the Parents’ Evaluation of Developmental Status (PEDS) for general developmental screening; the ASQ:Social-Emotional for social emotional screening; and the Modified Checklist for Autism in Toddlers (M-CHAT) in combination with its Follow-up Interview for autism-specific screening. Of special note, when an autism-specific screen like the M-CHAT is positive, Dr. Marks said, a referral for an expensive, comprehensive autism-specific evaluation is not necessarily recommended (in the absence of a positive M-CHAT Follow-up Interview).

"When the M-CHAT is positive, an early intervention agency referral is indicated but clinicians need to be careful about how to best explain this result to parents. Clinicians need to combine their less structured surveillance with the results of the M-CHAT to determine the need for an expensive, comprehensive autism-specific evaluation and early intervention plan," he said.

• The use of system-wide programs to help support health care providers with previsit screening and referral care coordination. The nearly 50% of screening test positive referred children who are subsequently deemed ineligible for early intervention services can still benefit from participation in evidence-based community programs that are not supported by the Individuals with Disabilities Education Act (IDEA), such as the Triple P: Positive Parenting Program or Head Start. Whenever a screening test is positive and/or an early intervention referral is generated, the practitioner and a system-wide care coordination program should provide at-risk children with a "back-up plan."

• Early return office visits. Greater emphasis should be placed on early return office visits (in addition to an early intervention referral) whenever a psychometrically sound screening test – particularly an autism-specific screening test – is abnormal at an AAP-recommended well-child visit. Return visits ideally should be scheduled within a month, and parents should be asked if connection with the referral source has been made, Dr. Marks said.

Also, more in-depth assessments with secondary developmental-behavioral and/or medical screening tests should be conducted at this visit, and feedback data from referral sources should be reviewed if possible, with prompt action taken on their recommendations, he added.

For their study, Dr. Marks and his colleagues reviewed 250 articles on a dozen relevant topics and concluded that the current AAP algorithm is indeed in need of revisions that incorporate these six provisions. So they developed a proposed revision of the developmental and behavioral algorithm.

"It’s clear when you look closely at the literature over the past 5 years that pediatricians are frequently missing young children with suspected developmental delays, social-emotional problems, and autism. Busy pediatricians, who typically use informal milestone checklists at 20-minute well-child checks, have a tendency to minimize parents’ concerns and dismiss the need for a community referral – perhaps out of their innate need to reassure," said Dr. Marks.

"Meanwhile," Dr. Marks said, "when pediatricians do decide to refer, there are frequently unnecessary delays in early intervention services due to inefficient communication between medical homes and early intervention agencies or negative parental perceptions about the referral. Especially for overwhelmed, high-risk families, a ‘sugar-coated’ or ‘straight talking’ clinician-parent conversation really needs to occur prior to the referral."

Combined with what may be a "wishful thinking approach" on the part of parents who suspect there is a problem, this is causing unnecessary delays in referrals of early intervention for children with suspected delays, he said.

Mapping out the steps for screening and surveillance in greater detail and adding the proposed action steps has the potential for improving outcomes, he said.

In their article, he and his colleagues also noted that their proposed changes to AAP policy would likely "increase the need for a collaborative or integrated medical home model of care."

Dr. Marks had no disclosures to report in regard to his research. Coauthor Frances Page Glascoe, Ph.D. is the author of, and receives royalties for, the Parent’s Evaluation of Developmental Status (PEDS) and PEDS: Developmental Milestones.

Many "detected" and "at-risk" children are falling through the cracks when it comes to referring and interlinking children with suspected developmental-behavioral problems to early intervention and other community services.

At least one group of researchers believes that revisions to the 2006 American Academy of Pediatrics developmental surveillance and screening algorithm are needed to optimize the early detection, prevention, and ongoing monitoring of developmental-behavioral problems. In the September issue of Clinical Pediatrics, Dr. Kevin Marks and his colleagues argue that a more detailed action plan is needed (Clin. Pediatr. 2011;50:853-68).

Specifically, they argue that promotion of behavioral and developmental wellness should be formally included as an action step, that referrals for certain high-risk children should be automatic, and that greater emphasis should be placed on care coordination following a referral for early intervention services.

"As physicians, we play a key role in the early detection of developmental and behavioral problems in children prior to kindergarten entrance. We have the privilege and ability to create opportunities for parents to access services for their children, but there is much work to be done to ensure that these referrals occur in keeping with the six quality aims of the Institute of Medicine, which call for referrals to be made in a safe, equitable, effective, timely, parent-centered, and efficient manner," Dr. Marks, a general pediatrician and pediatric hospitalist in Eugene, Ore., said in an interview.

The comprehensive review of the current literature conducted by Dr. Marks and his colleagues showed that children with a concerning screening test are not consistently referred and interlinked to early intervention services. Furthermore, due to a variety of reasons, only about half of those referred ultimately are deemed eligible for early intervention despite performing well below average and exhibiting numerous predictive academic and psychosocial risk factors.

"Pediatricians are frequently missing young children with suspected developmental delays, social-emotional problems, and autism."

Currently there are three separate algorithms for general pediatricians to follow from three separate AAP statements, which were published in 2006, 2007, and 2010. Together they recommend universal postpartum maternal depression screening in the first year; general developmental screening at 9, 18, and 24 months; autism-specific screening at 18 and 24 months; social-emotional screening whenever a general developmental or autism-specific screen is abnormal; kindergarten readiness screening at 4 years; and mental health/psychosocial function screening at 5 years and every well-visit thereafter.

"Our findings reinforce many of the previous recommendations within various AAP statements in regard to periodic screening with well-standardized, reliable and accurate tools that measure general development and social-emotional/behavioral development, as well as autism-specific and family psychosocial screening tools," Dr. Marks said.

Areas where the findings support revisions, however, include:

• The promotion of developmental and behavioral wellness. An example is literacy counseling through the Reach Out and Read program, which has been shown to improve outcomes. Consistently incorporating positive parenting and strength-based counseling into developmental-behavioral surveillance and screening makes the process more safe, effective, and parent-centered, he said.

Many pediatricians who follow the AAP/Bright Futures guidelines are already doing this, but the point, according to Dr. Marks, is that developmental-behavioral promotion needs to be viewed as key component of surveillance.

• The automatic referral of children with a medical or psychosocial condition or risk factor associated with a high probability of future developmental delay. Screening certain high-risk groups can be deemphasized because the likelihood of these children needing early intervention is sufficiently high so automatic referral is justifiable, Dr. Marks said. Examples of medical risk factors include very low birth weight infants (born weighing less than 1,500 g), those exposed in-utero to harmful substances such as alcohol, methamphetamine or heroin, and those with a genetic syndrome associated with a future developmental delay. A psychosocial risk factor would include those children who have been abused or neglected.

• The automatic referral of children in whom the pediatrician confidently suspects a developmental delay and/or disorder, even when standardized screening results are "typical" or "questionable." The literature shows that pediatrician impression has good specificity but poor sensitivity, meaning that when a pediatrician confidently detects a delay, they are almost always correct; however, they miss the large majority of delays using their less structured surveillance alone, Dr. Marks said.

• The automatic referral of children in whom a psychometrically sound screening tool is found to be positive or concerning. Such tools include the Ages & Stages Questionnaire (ASQ) or the Parents’ Evaluation of Developmental Status (PEDS) for general developmental screening; the ASQ:Social-Emotional for social emotional screening; and the Modified Checklist for Autism in Toddlers (M-CHAT) in combination with its Follow-up Interview for autism-specific screening. Of special note, when an autism-specific screen like the M-CHAT is positive, Dr. Marks said, a referral for an expensive, comprehensive autism-specific evaluation is not necessarily recommended (in the absence of a positive M-CHAT Follow-up Interview).

"When the M-CHAT is positive, an early intervention agency referral is indicated but clinicians need to be careful about how to best explain this result to parents. Clinicians need to combine their less structured surveillance with the results of the M-CHAT to determine the need for an expensive, comprehensive autism-specific evaluation and early intervention plan," he said.

• The use of system-wide programs to help support health care providers with previsit screening and referral care coordination. The nearly 50% of screening test positive referred children who are subsequently deemed ineligible for early intervention services can still benefit from participation in evidence-based community programs that are not supported by the Individuals with Disabilities Education Act (IDEA), such as the Triple P: Positive Parenting Program or Head Start. Whenever a screening test is positive and/or an early intervention referral is generated, the practitioner and a system-wide care coordination program should provide at-risk children with a "back-up plan."

• Early return office visits. Greater emphasis should be placed on early return office visits (in addition to an early intervention referral) whenever a psychometrically sound screening test – particularly an autism-specific screening test – is abnormal at an AAP-recommended well-child visit. Return visits ideally should be scheduled within a month, and parents should be asked if connection with the referral source has been made, Dr. Marks said.

Also, more in-depth assessments with secondary developmental-behavioral and/or medical screening tests should be conducted at this visit, and feedback data from referral sources should be reviewed if possible, with prompt action taken on their recommendations, he added.

For their study, Dr. Marks and his colleagues reviewed 250 articles on a dozen relevant topics and concluded that the current AAP algorithm is indeed in need of revisions that incorporate these six provisions. So they developed a proposed revision of the developmental and behavioral algorithm.

"It’s clear when you look closely at the literature over the past 5 years that pediatricians are frequently missing young children with suspected developmental delays, social-emotional problems, and autism. Busy pediatricians, who typically use informal milestone checklists at 20-minute well-child checks, have a tendency to minimize parents’ concerns and dismiss the need for a community referral – perhaps out of their innate need to reassure," said Dr. Marks.

"Meanwhile," Dr. Marks said, "when pediatricians do decide to refer, there are frequently unnecessary delays in early intervention services due to inefficient communication between medical homes and early intervention agencies or negative parental perceptions about the referral. Especially for overwhelmed, high-risk families, a ‘sugar-coated’ or ‘straight talking’ clinician-parent conversation really needs to occur prior to the referral."

Combined with what may be a "wishful thinking approach" on the part of parents who suspect there is a problem, this is causing unnecessary delays in referrals of early intervention for children with suspected delays, he said.

Mapping out the steps for screening and surveillance in greater detail and adding the proposed action steps has the potential for improving outcomes, he said.

In their article, he and his colleagues also noted that their proposed changes to AAP policy would likely "increase the need for a collaborative or integrated medical home model of care."

Dr. Marks had no disclosures to report in regard to his research. Coauthor Frances Page Glascoe, Ph.D. is the author of, and receives royalties for, the Parent’s Evaluation of Developmental Status (PEDS) and PEDS: Developmental Milestones.

Many "detected" and "at-risk" children are falling through the cracks when it comes to referring and interlinking children with suspected developmental-behavioral problems to early intervention and other community services.

At least one group of researchers believes that revisions to the 2006 American Academy of Pediatrics developmental surveillance and screening algorithm are needed to optimize the early detection, prevention, and ongoing monitoring of developmental-behavioral problems. In the September issue of Clinical Pediatrics, Dr. Kevin Marks and his colleagues argue that a more detailed action plan is needed (Clin. Pediatr. 2011;50:853-68).

Specifically, they argue that promotion of behavioral and developmental wellness should be formally included as an action step, that referrals for certain high-risk children should be automatic, and that greater emphasis should be placed on care coordination following a referral for early intervention services.

"As physicians, we play a key role in the early detection of developmental and behavioral problems in children prior to kindergarten entrance. We have the privilege and ability to create opportunities for parents to access services for their children, but there is much work to be done to ensure that these referrals occur in keeping with the six quality aims of the Institute of Medicine, which call for referrals to be made in a safe, equitable, effective, timely, parent-centered, and efficient manner," Dr. Marks, a general pediatrician and pediatric hospitalist in Eugene, Ore., said in an interview.

The comprehensive review of the current literature conducted by Dr. Marks and his colleagues showed that children with a concerning screening test are not consistently referred and interlinked to early intervention services. Furthermore, due to a variety of reasons, only about half of those referred ultimately are deemed eligible for early intervention despite performing well below average and exhibiting numerous predictive academic and psychosocial risk factors.

"Pediatricians are frequently missing young children with suspected developmental delays, social-emotional problems, and autism."

Currently there are three separate algorithms for general pediatricians to follow from three separate AAP statements, which were published in 2006, 2007, and 2010. Together they recommend universal postpartum maternal depression screening in the first year; general developmental screening at 9, 18, and 24 months; autism-specific screening at 18 and 24 months; social-emotional screening whenever a general developmental or autism-specific screen is abnormal; kindergarten readiness screening at 4 years; and mental health/psychosocial function screening at 5 years and every well-visit thereafter.

"Our findings reinforce many of the previous recommendations within various AAP statements in regard to periodic screening with well-standardized, reliable and accurate tools that measure general development and social-emotional/behavioral development, as well as autism-specific and family psychosocial screening tools," Dr. Marks said.

Areas where the findings support revisions, however, include:

• The promotion of developmental and behavioral wellness. An example is literacy counseling through the Reach Out and Read program, which has been shown to improve outcomes. Consistently incorporating positive parenting and strength-based counseling into developmental-behavioral surveillance and screening makes the process more safe, effective, and parent-centered, he said.

Many pediatricians who follow the AAP/Bright Futures guidelines are already doing this, but the point, according to Dr. Marks, is that developmental-behavioral promotion needs to be viewed as key component of surveillance.

• The automatic referral of children with a medical or psychosocial condition or risk factor associated with a high probability of future developmental delay. Screening certain high-risk groups can be deemphasized because the likelihood of these children needing early intervention is sufficiently high so automatic referral is justifiable, Dr. Marks said. Examples of medical risk factors include very low birth weight infants (born weighing less than 1,500 g), those exposed in-utero to harmful substances such as alcohol, methamphetamine or heroin, and those with a genetic syndrome associated with a future developmental delay. A psychosocial risk factor would include those children who have been abused or neglected.

• The automatic referral of children in whom the pediatrician confidently suspects a developmental delay and/or disorder, even when standardized screening results are "typical" or "questionable." The literature shows that pediatrician impression has good specificity but poor sensitivity, meaning that when a pediatrician confidently detects a delay, they are almost always correct; however, they miss the large majority of delays using their less structured surveillance alone, Dr. Marks said.

• The automatic referral of children in whom a psychometrically sound screening tool is found to be positive or concerning. Such tools include the Ages & Stages Questionnaire (ASQ) or the Parents’ Evaluation of Developmental Status (PEDS) for general developmental screening; the ASQ:Social-Emotional for social emotional screening; and the Modified Checklist for Autism in Toddlers (M-CHAT) in combination with its Follow-up Interview for autism-specific screening. Of special note, when an autism-specific screen like the M-CHAT is positive, Dr. Marks said, a referral for an expensive, comprehensive autism-specific evaluation is not necessarily recommended (in the absence of a positive M-CHAT Follow-up Interview).

"When the M-CHAT is positive, an early intervention agency referral is indicated but clinicians need to be careful about how to best explain this result to parents. Clinicians need to combine their less structured surveillance with the results of the M-CHAT to determine the need for an expensive, comprehensive autism-specific evaluation and early intervention plan," he said.

• The use of system-wide programs to help support health care providers with previsit screening and referral care coordination. The nearly 50% of screening test positive referred children who are subsequently deemed ineligible for early intervention services can still benefit from participation in evidence-based community programs that are not supported by the Individuals with Disabilities Education Act (IDEA), such as the Triple P: Positive Parenting Program or Head Start. Whenever a screening test is positive and/or an early intervention referral is generated, the practitioner and a system-wide care coordination program should provide at-risk children with a "back-up plan."

• Early return office visits. Greater emphasis should be placed on early return office visits (in addition to an early intervention referral) whenever a psychometrically sound screening test – particularly an autism-specific screening test – is abnormal at an AAP-recommended well-child visit. Return visits ideally should be scheduled within a month, and parents should be asked if connection with the referral source has been made, Dr. Marks said.

Also, more in-depth assessments with secondary developmental-behavioral and/or medical screening tests should be conducted at this visit, and feedback data from referral sources should be reviewed if possible, with prompt action taken on their recommendations, he added.

For their study, Dr. Marks and his colleagues reviewed 250 articles on a dozen relevant topics and concluded that the current AAP algorithm is indeed in need of revisions that incorporate these six provisions. So they developed a proposed revision of the developmental and behavioral algorithm.

"It’s clear when you look closely at the literature over the past 5 years that pediatricians are frequently missing young children with suspected developmental delays, social-emotional problems, and autism. Busy pediatricians, who typically use informal milestone checklists at 20-minute well-child checks, have a tendency to minimize parents’ concerns and dismiss the need for a community referral – perhaps out of their innate need to reassure," said Dr. Marks.

"Meanwhile," Dr. Marks said, "when pediatricians do decide to refer, there are frequently unnecessary delays in early intervention services due to inefficient communication between medical homes and early intervention agencies or negative parental perceptions about the referral. Especially for overwhelmed, high-risk families, a ‘sugar-coated’ or ‘straight talking’ clinician-parent conversation really needs to occur prior to the referral."

Combined with what may be a "wishful thinking approach" on the part of parents who suspect there is a problem, this is causing unnecessary delays in referrals of early intervention for children with suspected delays, he said.

Mapping out the steps for screening and surveillance in greater detail and adding the proposed action steps has the potential for improving outcomes, he said.

In their article, he and his colleagues also noted that their proposed changes to AAP policy would likely "increase the need for a collaborative or integrated medical home model of care."

Dr. Marks had no disclosures to report in regard to his research. Coauthor Frances Page Glascoe, Ph.D. is the author of, and receives royalties for, the Parent’s Evaluation of Developmental Status (PEDS) and PEDS: Developmental Milestones.