Published online April 2, 2007
PEDIATRICS Vol. 119 No. 4 April 2007, pp. 861-862 (doi:10.1542/10.1542/peds.2006-3530)

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LETTER TO THE EDITOR

Issues With the New Developmental Screening and Surveillance Policy Statement

Frances Page Glascoe, PhD
Department of Pediatrics
Vanderbilt University
Nashville, TN 37232-3573

Jane Squires, PhD
Early Intervention Program
College of Education
University of Oregon
Eugene, OR 97403

To the Editor.—

The American Academy of Pediatrics Council on Children With Disabilities deserves much commendation for its revised statement on early detection of developmental problems.¹ The focus on surveillance enables providers to consider factors that are known to promote or deter children's development such as family well-being, dimensions of psychosocial risk, and resilience. Addressing these factors may help prevent many problems from developing. The council wisely noted that occasional administration of validated screening tests is also essential for making careful decisions about the needs of children and families.

Nevertheless, the new policy failed to embrace—indeed, it scarcely mentioned—the need for validated screening with children older than 30 months. Given that developmental problems surface throughout the preschool, elementary, and adolescent years, surely the council did not mean to suggest that 30 months was a proscribed limit on the use of accurate screening tools. The woefully low detection rates of children with disabilities on the part of primary care providers (30%)² speaks urgently to the need for careful measurement with quality instruments, not ad hoc checklists. Just as we would measure temperature with a thermometer rather than a hand to the forehead, we must also carefully measure children's development, and measure it repeatedly, if we are to ensure their access to the innumerable benefits of early intervention. We urge the council to amend their statement so that it recommends quality screening at each annual well-child visit after 24 (or 30) months of age.

Of somewhat lesser importance, but concerning nonetheless, is the list of tools in their Table 1. Generalist providers are likely to be confused by the vast array of options, many of which are not suitable for primary care. The table would be greatly enhanced if the measures could be sorted as follows:

1. broadband screens that are appropriate for primary care, that is, screens that take less time than that usually allotted to a well-child visit (eg, Ages and Stages Questionnaire, Parents' Evaluation of Developmental Status, Infant-Toddler Checklist);
   
2. broadband screens that exceed well-visit time frames but are still useful in primary care settings and use a gated screening process, in which nurse practitioners or developmental specialists are available to screen selected children more extensively (eg, Battelle Developmental Inventory Screening Test-II, Brigance Screens-II, Bayley Infant Neurodevelopmental Screener, etc);
   
3. narrow-band measures that serve only as second-stage screens because of their focus on a single domain (eg, Early Language Milestone Scale, Checklist for Autism in Toddlers, Modified Checklist for Autism in Toddlers, Capute scales); and
   
4. narrow-band measures that require specialty training to administer (eg, Screening Tool for Autism in 2-Year-Olds, Early Motor Profile).
   

There are also several errors in their table that are in need of correction:

1. The Brigance screens are incorrectly reported as criterion-referenced only. This is not the case. The screens produce quotients (age-equivalent) and cutoff scores that result from 2 extensive standardization and validation studies.^{3, 4}
   
2. Data on the sensitivity and specificity of the Denver-II are incorrectly reported.⁵ When children with questionable scores are nominated for referral, the Denver-II sensitivity was 83% (high), but specificity was 43% (poor). Given that few children with questionable results are referred, the more realistic figures are 56% sensitivity (poor) and 80% specificity (high). By amalgamating results, readers are left with the false impression that a parsimonious and acceptable balance between sensitivity and specificity can be found. Because most primary care providers only administer selected items, the accuracy of the Denver-II may be further compromised. Yet, information on this common application was not included in their table. Finally, the Denver-II was not normed in 2096 but rather in 1992.
   
3. The year of test standardization is inconsistently reported, which is critical because US population demographics are changing rapidly. Indeed, the National Council on Measurement in Education recommends restandardization every 10 years.⁶ Test purchasers need to know which measures are current and which are not.
   

It would be ideal if the council identified those instruments that clearly met standards for test construction, are appropriate for primary care (normed under such conditions, in the last decade), and have both sensitivity and specificity of 70%. Because few individuals have a background in psychometry, the data presented are unlikely to be readily interpreted by most readers. The American Academy of Pediatrics needs to offer guidance to its members about what constitutes a quality measure. We realize there may be a conflict of interest in our statement, given the screening measures we have researched,^* but psychometry is a process that takes hard work, great expense, and a willingness to reinvest revenues to prove that tests are accurate and current. We encourage other test authors to adhere to this process.

FOOTNOTES

^* Dr Glascoe is the author of the Parents' Evaluation of Developmental Status (PEDS), Developmental Milestones, Safety Word Inventory and Literacy Screener, and the Brigance Infant and Toddler Screen; and Dr Squires is the author of the Ages & Stages Questionnaire-2 (ASQ: Social-Emotional).

REFERENCES

1. American Academy of Pediatrics, Council on Children With Disabilities; Section on Developmental Behavioral Pediatrics; Bright Futures Steering Committee; Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics. 2006;118 :405 –420[Abstract/Free Full Text]
2. Rydz D, Shevell MI, Majnemer A, Oskoui M. Developmental screening. J Child Neurol. 2005;20 :4 –21[Abstract/Free Full Text]
3. Glascoe FP. Technical Report for the Brigance Screening Tests. Curriculum Associates, Inc: North Billerica, MA; 1996
4. Glascoe FP. Technical Manual for the Brigance Screens. Curriculum Associates, Inc: North Billerica, MA; 2006
5. Glascoe FP, Byrne KE, Chang B, Strickland B, Ashford L, Johnson K. The accuracy of the Denver-II in developmental screening. Pediatrics. 1992;89(6 pt 2) :1221 –1225
6. American Educational Research Association, American Psychological Association, National Council on Measurement in Education. Standards for Educational and Psychological Testing. Washington, DC: American Educational Research Association; 1999

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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Glascoe, F. P. Articles by Squires, J. Search for Related Content PubMed PubMed Citation Articles by Glascoe, F. P. Articles by Squires, J. Related Collections Office Practice Social Bookmarking                         What's this?