Published online April 2, 2007
PEDIATRICS
Vol. 119
No. 4
April 2007, pp.
862-863
(doi:10.1542/peds.2006-3770)
Issues With the New Developmental Screening and Surveillance Policy Statement: In Reply
Paul H. Lipkin, MD
on behalf of the AAP Policy Revision
Committee on Developmental Surveillance and Screening
Chair
AAP Policy Revision Committee on Developmental Surveillance and Screening
and Council on Children With Disabilities
Kennedy Krieger Institute
Johns Hopkins University School of Medicine
Baltimore, MD 21205
In writing the new policy statement on developmental surveillance and screening,1 the American Academy of Pediatrics (AAP) Council on Children With Disabilities, Section on Developmental and Behavioral Pediatrics, Bright Futures Steering Committee, Medical Home Initiatives for Children With Special Needs Project Advisory Committee, and the Partnership for Policy Implementation joined together to forge a new policy that could address the recognized barriers to implementation of screening.2 As is clear from the title of the policy, we chose to highlight the need for early identification and create a system for surveillance and screening for the first 3 years of life. Although we emphasized implementation from birth to 30 months, we stated clearly in the policy that surveillance should continue throughout childhood and that school-readiness screening should be performed at 4 years of age.1(p414) The third edition of the Bright Futures guidelines (in press) also includes the 9-, 18-, and 30-month developmental screening, as recommended in the algorithm for those visits.
We support the use of high-quality instruments in screening, as Drs Glascoe and Squires urge. However, they suggest a 2-stage system of "gated screening." We have learned from pediatricians that such a process is difficult to implement because of issues of staff limitations, reimbursement, and time.2 Therefore, we instead chose to develop a model, centered on principles first put forth by Dr Paul Dworkin,3 that involves brief and repeated surveillance coupled with age-targeted formal instrument-based screening. We believe such a system is readily implementable in the medical office setting, is appropriate to current models of screening and clinical practice, and addresses the recognized barriers to developmental screening.
The policy statement is a guideline to clinicians and not a comprehensive review. The list of screening instruments, therefore, was intended also to guide the clinician in making a choice. The table consisted of instruments that did indeed meet standards for test construction and were appropriate for primary care. During review, our committee recognized limitations of all of the currently available instruments and therefore included some instruments that offered unique characteristics such as domain- and disorder-specific screening. We recommend that the child health care provider review the table and choose instruments that conform best to his or her population's needs. The pediatrician must consider multiple issues when choosing an instrument, and we tried to include such information in our table. We believe that limiting our readers to a small choice of instruments would be inappropriate. Additional information on screening instruments can be found in the literature.4, 5 In addition, a comprehensive review of developmental surveillance and screening instruments is currently in progress by Dr Dennis Drotar and colleagues through a grant provided by the Commonwealth Fund (www.cmwf.org/grants/grants_show.htm?doc_id=316732).
The terminology used in the policy statement was settled on by consensus. Drs Glascoe and Squires' first-stage broadband screen can conform to our model of surveillance. Rather than using the terms "broadband" and "narrow band" as they use in their model, we instead felt it most helpful to the health care provider to subdivide the instruments into the categories of "general" (synonymous with broadband), "domain specific" and "disorder specific" (narrow-band).
The best practices for developmental surveillance and screening are still being refined. Although the literature is dominated by general screening instruments, we do not know if using these tools is better than using instruments that target specific areas of development (such as motor or language) or specific disabilities (such as autism), so we included all of these in our table. At the current time, there is clear interest in the disability-specific approach in autism6 and hearing impairment.7 There are also no data that directly assess concordance between the caretaker-completed questionnaires and the hands-on screeners. Moreover, we do not know how factors such as socioeconomic status, age, or biomedical variables bias parent report. We hope that future projects will elucidate the best approach to take so that children with specific disabilities are best identified.
Drs Glascoe and Squires suggest that there are errors in our table. We appreciate the information provided to readers on the Brigance screens. The Denver-II data were based on a review of the extensive literature investigating this widely used instrument, and the information on its norming on 2096 children is correctly stated in our table.
In conclusion, the Policy Revision Committee for Developmental Surveillance and Screening, which represents both general pediatricians and subspecialists, strove to create a new policy that could effectively identify children with developmental disorders in early childhood. Through creation of a process that addresses the recognized barriers, we hope that this model offers pediatricians and other child health care providers a system that can be easily implemented to achieve this goal. We also hope that the algorithm will provide pediatricians with additional guidance on the subsequent developmental and medical evaluation, community-based intervention referral, and medical home chronic-condition management that such children with special health care needs deserve to ensure their achieving maximal health and well-being in their lives.
REFERENCES
- 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.
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- Dworkin PH. British and American recommendations for developmental monitoring: the role of surveillance.
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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
