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To the Editor.—
I congratulate Sand et al1 for their report in the July 2005 issue of Pediatrics. The article documents how difficult it is for pediatricians to implement the evidence-based guidelines for developmental screening and surveillance. Why is it so difficult?
Methods and guidelines for developmental screening2 have changed dramatically in the last 15 years. During this time, the Individuals With Disabilities Education Act (IDEA) increased early education and family support services for children with developmental needs from birth to 3 years of age. Physicians are not yet focusing on early identification of children who will benefit from these services. Approximately half of the physicians in the Sand et al study completed training before IDEA and are using the old tool of clinical assessment (71%). Although some use the Denver II (14%), which was standardized in 1989, they may not be aware of the newer parent-completed tools of the Ages and Stages Questionnaire (ASQ) (7%), developed in 1995, and the Parent Evaluation of Developmental Status (3%), developed in 1998. These physicians are not required to recertify every 7 years (initiated in 1986). Unless they have special interest in development, they may miss the continuing education and community advocacy opportunities for additional learning. Sand et al3 have reported that residents are still not being trained about IDEA and developmental screening. The fact that Sand et al1 found no difference in developmental screening in the younger, more recently trained pediatricians emphasizes how crucial it is to initiate training in developmental screening and surveillance and in early education services in current curricula. Similar to practicing pediatricians, training programs also have difficulty implementing the guidelines.
Pediatricians are only now being trained in practice-based learning and improvement.4 Working with the National Initiative for Children's Healthcare Quality, we are being trained in "plan, do, study, act" cycles to monitor and improve practice goals. Marion Earls in North Carolina coached her pediatric and family practice colleagues to implement the ASQ at 6, 12, 24, 36, and 48 months of age5 and increased the rate of identification of children with delays from the state from 2.9% to 7%.6 Collaborative Web-based resources, such as those available at www.eqipp.org,7 encourage continuous improvement and "starting small and testing quickly." It is a huge task to screen development "always" or "almost always."1 It is a task that is never completed. The task needs to be made easier for pediatricians to have success. We are starting a pilot project with the ASQ at all 15-month well-child visits. Although all 19 forms are available, we will monitor use only at the 15-month visit. Targeting 1 age is far from ideal,8 but it will allow us to study barriers on a smaller scale. Small steps in the right direction may provide the satisfaction needed to allow successful implementation of a larger target in the next "plan, do, study, act" cycle.
Guidelines provide us with evidence-based recommendations and are especially valuable when information and technology evolve quickly. Practice-based learning and improvement methods will provide the necessary framework for physicians in practice and in residency programs to develop strategies to use standardized screening tools more often in developmental care. We encourage physicians to start.
REFERENCES
Related articles in Pediatrics:
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