eLetters to:

FROM THE AMERICAN ACADEMY OF PEDIATRICS: Council on Children With Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee, and 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] [Full text] [PDF]

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eLetters published:

annual formal mental health screenings

Walter L Harrison, MD   (30 October 2006)

Re: annual formal mental health screenings

Paul H. Lipkin   (13 December 2006)

Update on Developmental Surveillance and Screening Recommendations

Paul H. Lipkin, Michelle M. Macias, Paula Duncan, Joseph Hagan   (17 February 2009)

annual formal mental health screenings 30 October 2006
Walter L Harrison, MD, pediatrician MCAAP Send letter to journal: Re: annual formal mental health screenings wharrison{at}partners.org Walter L Harrison, MD	To the Editor: Although I am Chair of the Children’s Mental Health Task Force of the Massachusetts Chapter of the American Academy of Pediatrics, I am responding as an individual to the article, “Identifying Infants and Young Children with Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening1.” The Council on Children with Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Committee, and Medical Home Initiatives for Children with Special Needs Project Advisory Committee prepared this new policy statement from the AAP. While I agree wholeheartedly that there should be ongoing surveillance and screening of well children, I am concerned with the recommendation that formal screening tests only be done at the 9, 18, and 30-month visits; when surveillance demonstrates a risk; or when there is a red flag. I am concerned that insurers will look at the Academy’s Policy Statement and use it as a basis for reimbursement for formal screening only at the ages cited, or when a problem is identified. Epidemiologic studies have shown the prevalence of psychosocial dysfunction in primary care settings ranges from 8 to 12%. Many of these children are late in the course of their disorder or not recognized at all. Many effective early screening tools have been developed. Jellinek2 has demonstrated that using the Pediatric Symptom (PSC) checklist doubles the case finding rate of psychosocial emotional dysfunction for 4-16year olds. Other screening instruments effective for developmental, psychosocial formal screening including, but limited to the PEDS Tool, Ages and Stages, and the CRAFFT, can be used for diverse ages and specific concerns. Pediatricians should be screening (with the assurance of appropriate compensation) for psychosocial issues with the same diligence we apply to well child care or physical disorders. This has become a reality in Massachusetts since most major insurers now provide reasonable reimbursement to pediatricians for conducting formal developmental, psychosocial, emotional, mental health, and substance abuse screens, reimbursing them when there is a specific concern or an annual basis. Given the possible ramifications of the policy as now worded, the authors should provide clarification. Thank you so much. Walter Harrison, MD, FAAP, 1. Pediatrics Volume 118, Number 1, July 2006 2. Reference -Jellinek Conflict of Interest: None declared
Re: annual formal mental health screenings 13 December 2006
Paul H. Lipkin, Pediatrician Chair, AAP Policy Revision Committee and the Council on Children with Disabilities Send letter to journal: Re: Re: annual formal mental health screenings lipkin{at}kennedykrieger.org Paul H. Lipkin	Dr. Harrison has made a strong case for ongoing surveillance and screening of children for psychosocial problems throughout childhood, naming several well-accepted screening tools appropriate for such purposes. However, our policy statement makes clear that the recommendations we have made are aimed at the early identification of children with developmental disorders, not those with behavioral or psychosocial disorders. As stated on page 406, “Separate recommendations aimed at the screening of children for behavioral and emotional disorders are also under consideration by the AAP and are not included in this document.” This task is currently being undertaken by the AAP Task Force on Mental Health. With the early identification of children with developmental disorders in mind, we have recommended continuous developmental surveillance of children throughout childhood, and formal developmental screening at ages 9, 18, and 24 or 30 months of age. We specifically chose screening ages before 36 months with the hope and intent that children would be identified during the early critical years when they could qualify for federally-mandated early intervention services and when critical medical investigations could be pursued. While we have chosen three specific ages for screening before 36 months, we did not recommend that they only be done at these visits, as Dr. Harrison has stated. As written on page 414, “These recommended ages for developmental screening are suggested only as a starting point for children who appear to be developing normally; surveillance should continue throughout childhood, and screenings should be conducted anytime that concerns are raised by parents, child health professionals, or others involved in the care of the child. At the 4-year visit, a screening for school readiness is appropriate.” In summary, in order to achieve early identification of children with developmental disorders, we recommend continuous developmental surveillance of children throughout childhood and early formalized developmental screening at 9, 18, and 30 months. School readiness screening at age 4 is also justified. If developmental surveillance at any age reveals a concern about a child’s development, formal screening or evaluation should be initiated. Other recommendations regarding screening for behavior or psychosocial problems are forthcoming from the AAP Task Force on Mental Health. In regards to Dr. Harrison’s concerns regarding payment and reimbursement for these services, we believe that pediatricians and other child health care providers should be compensated for all surveillance and screening activities recommended by the AAP. Billing and coding guidelines for developmental surveillance and screening are offered in the policy statement to assist the pediatrician or other child health care provider. The ‘formal screening’ described by Dr. Harrison, if done by a test such as the PEDS, may conform to the statement’s new definitions of surveillance. Insurers and other health care funders should carefully review our definitions and the recommended methodologies for all of these activities as they consider reimbursement for these services. Conflict of Interest: None declared
Update on Developmental Surveillance and Screening Recommendations 17 February 2009
Paul H. Lipkin, Physician Kennedy Krieger Institute/ Johns Hopkins University School of Medicine, Michelle M. Macias, Paula Duncan, Joseph Hagan Send letter to journal: Re: Update on Developmental Surveillance and Screening Recommendations lipkin{at}kennedykrieger.org Paul H. Lipkin, et al.	To the Editor: As members of the authoring group for the AAP Policy Statement on Developmental Surveillance and Screening “Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening.”1, we are writing to clarify some common misunderstandings on the current recommendations regarding this practice and urge all pediatric health care providers to follow these recommendations: 1. Developmental surveillance should not only be performed at all well-child visits, but should continue into school-age, with performance of surveillance of school performance and behavior 1 (p. 419). 2. At any age, whenever surveillance suggests a developmental concern, the recommendation is to perform developmental screening using a standardized test1(pp. 409,419). 3. When a standardized screening procedure is completed and documented, CPT code 96110 should be billed to ensure proper payment1 (p. 417). 4. Standardized developmental screening is recommended on all children at 9, 18, and 24 or 30 months. School-readiness screening may also be useful before a child attend preschool or kindergarten at the 4 year old visit.1(pp. 406, 414). It should be noted, however, that the screening of children at age 4 years old has not been included in the “Recommendations for Preventive Pediatric Health Care” 2 or the Bright Futures guidelines3. Therefore, at this time, each clinician should perform either developmental surveillance or formal developmental screening to consider a child’s readiness for kindergarten at the 4 or 5 year old preschool preventive care visit. There are currently active efforts emerging to examine optimal methods for school readiness surveillance and screening by pediatric health care providers. The AAP has been working to assist pediatricians in implementing this policy. In a recent series of letters to the medical directors of major health insurance companies from Drs. Jay Berkelhamer, Renee Jenkins, and David Tayloe, Presidents of the AAP, insurance companies have been asked to assist families in coverage and payment of these services in their health care plan. These letters are available for AAP member review on the Private Payer Advocacy Page at http://www.aap.org/moc/reimburse/privatesector.htm.4 Paul H. Lipkin, M.D., FAAP Chairperson, AAP Policy Revision Committee on Developmental Surveillance and Screening; Immediate Past Chair, AAP Council on Children with Disabilities Michelle M. Macias, M.D., FAAP Chairperson, AAP Section on Developmental and Behavioral Pediatrics Paula Duncan, M.D., FAAP Chairperson, Bright Futures Policy Implementation Project Joseph Hagan, M.D., FAAP Member, Bright Futures Steering Committee References: 1. 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(1):405-420. 2. Committee on Practice and Ambulatory Medicine, Bright Futures Steering Committee. Recommendations for preventive pediatric health care. Pediatrics. 2007;120(6):1376. 3. Hagan JF, Shaw JS, Duncan PM. Bright Futures : Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008:616. 4. AAP - ACADEMY REIMBURSEMENT INITIATIVES. . http://www.aap.org/moc/reimburse/privatesector.htm. Accessed 12/22/2008, 2008. Conflict of Interest: None declared