OBJECTIVES. The purpose of this study was to examine the feasibility and effectiveness of implementation of validated developmental screening by using the Parents' Evaluation of Developmental Status in 2 urban pediatric practices.
DESIGN AND METHODS. We implemented the Parents' Evaluation of Developmental Status at Boston Children's Hospital Primary Care Center and at Joseph Smith Community Health Center as quality improvement initiatives. Each practice offered screening to all of the patients attending well-child care visits between 6 months and 8 years of age. The implementation process was investigated by using preimplementation and postimplementation surveys and a focus group of pediatric primary care providers. To assess outcomes, such as changes in identification rates and referrals for developmental and behavioral concerns, we reviewed medical charts of all of the 2- and 3-year-olds present at Children's Hospital Primary Care Center well-child care visits in the periods before and after screening implementation.
RESULTS. Providers found routine screening easier than expected and feasible to conduct in a busy primary care setting. The practice change resulted in screening of 61.6% of eligible children. Compared with same-aged children before screening, after screening was implemented more behavioral concerns were detected in the 2-year-old group, and more children with developmental concerns were identified in the 3-year-old group. Referral rates for additional evaluation increased only for 3-year-olds, although the types of referrals (ie, audiology and early intervention) were consistent as those found before screening started.
CONCLUSIONS. Implementation of validated screening by using the Parents' Evaluation of Developmental Status was feasible in large, urban settings. Effectiveness was demonstrated via chart review documenting an increased rate of identification of developmental and behavioral concerns. Perceived obstacles, such as the time requirement, should not prevent widespread adoption of screening.
- developmental delay
- developmental screening
- developmental surveillance
- early intervention
- Parents' Evaluation of Developmental Status
The American Academy of Pediatrics (AAP) recommends developmental surveillance at every well-child primary care visit, with use of validated developmental screening tools at 9, 18, and 30 months and when otherwise indicated.1 The AAP policy statement includes lists of many tools that can help improve identification of children at risk for developmental delay. However, routine developmental screening with validated tools represents a significant change in practice and brings with it a number of obstacles, both perceived and actual, that prevent widespread adoption.2,3
A growing literature addresses the real-life challenges and successes of implementing routine developmental screening in pediatric practices using validated, standardized tools. Rydz et al4 reported on the implementation of the Ages & Stages Questionnaire (ASQ) and the Child Development Inventory for 18-month well-child care (WCC) visits. Of the screeners distributed to parents, 58.8% of the ASQs and 48% of the Child Development Inventories were returned completed at the visit, and >90% of parents reported that the screeners were easy or very easy to complete. Similarly, Hix-Small et al5 reported a 54% completion rate for the ASQ distributed to parents during 12- and 24-month WCC visits. Approximately 97% of parents were able to complete the ASQ without assistance.
On a larger scale, the ASQ was integrated into primary care pediatric settings across 10 North Carolina counties as part of the Commonwealth Fund-supported Assuring Better Child Health and Development Project.6,7 At baseline, only 15.5% of eligible children were screened at their WCC visits; by the third year of the project, ∼70.0% of eligible children were being screened. Providers reported using the completed ASQ to guide their discussions with parents and felt that parents appreciated spending the time to discuss their child's development. The authors attribute the success of their program to their careful attention to workflow and to the involvement and training of office staff.
Despite consistently positive reports on the feasibility of integrating developmental screeners, studies have been mixed on the usefulness of screeners in identifying developmental delays in a practice setting. Rydz et al4 found that children with developmental delays were not accurately identified by screening with the ASQ and that provider impression did not improve accuracy of those screens. In fact, when a subset of the screened children was assessed with the Battelle Developmental Inventory (BDI), 66% of the children who failed the ASQ passed the BDI, and 29% of the children who passed the ASQ failed the BDI. The authors suggested that the surprisingly low specificity may have been because of the 3-month time lag between the screening and the gold-standard assessment or because of the in-clinic use of a screening tool that was originally designed as a take-home questionnaire.
The controversy sparked by the report of Rydz et al4 highlights the importance of matching the profile and administration of a screening tool with the needs of the population and practice.8,9 In high-volume practices, particularly those serving a more low-income, urban population, the tight workflow may not allow parents the 15 to 20 minutes needed to complete a longer screener, such as the ASQ, and the high number of no-shows makes it impractical to mail parents a screener ahead of time to complete first at home. The Parents' Evaluation of Developmental Skills (PEDS) is a validated screening tool that can be completed by parents in ≤5 minutes in the clinic.10 This single-page, 10-item screener fits well into the flow of activity in a busy, urban practice.
To our knowledge, no publications exist describing real-world use of the PEDS within large, urban practices. This study provides new information about the real-world experience of adopting routine, validated developmental screening into busy urban practices, focusing on both feasibility and effectiveness.
This was a 12-month quality improvement study to evaluate the implementation of a routine developmental screening tool in 2 distinct primary care practice settings (Fig 1). We used quantitative techniques (surveys and cross-sectional chart review) preimplementation and postimplementation to assess the feasibility of implementation and the effectiveness of this practice change. We used qualitative techniques (focus group process discussion and field notes) to understand the implementation process in richer detail. This study was approved as a quality improvement project by Children's Hospital Boston's Committee on Clinical Investigation.
Setting and Participants
In January 2006, we began implementing the PEDS at 2 clinical sites, each serving a largely urban population. Children's Hospital Primary Care Center (CHPCC) is the primary care pediatric practice of Children's Hospital Boston and serves 12 000 children with ∼35 000 visits per year. Sixty-four percent of the clinical population resides in the surrounding Boston neighborhoods, 40% are black, 35% are Latino, and 65% qualify for free care or Medicaid. CHPCC employs 11 full- or half-time staff pediatricians, 7 part-time staff pediatricians, and 3 full- or part-time pediatric nurse practitioners. In addition, 70 residents maintain a weekly continuity care clinic session within CHPCC.
Joseph Smith Community Health Center (JSCHC) provides multispecialty services, including pediatrics and family medicine, to a multiethnic, multilingual, mostly urban population. The 13 providers (pediatricians, family physicians, and nurse practitioners) care for 1851 children, delivering ∼10 000 visits per year. Eighty percent of children qualify for free care/Medicaid, 6% are black, and 54% are Latino.
After patients registered for the medical visit, a medical assistant brought them from the waiting room to collect vital signs. At that time, the assistant provided the parent or guardian with a PEDS survey. The survey was provided with a clipboard and pen, and the assistant could read guided text attached to the clipboard that read, “Please complete this survey. Your provider would like to know how your child is doing.” Parents then returned to the waiting room or were brought to an examination room, where they had time to complete the survey before the provider arrived. Medical assistants were instructed to provide the PEDS at every WCC visit for children between the ages of 6 months and 9 years. Providers were not asked to find a PEDS survey and complete it with the parent if it was not already completed when they entered the examination room but rather to address the flaw in the arranged system with the staff. Most providers delivered developmental surveillance rather than formal screening in the instances when a PEDS was not completed.
The PEDS is a 10-item parent survey that detects risks for developmental concerns in children from birth through 8 years of age.8 Eight of the open-ended questions target a specific area of development, whereas 2 ask for more general concerns. Psychometric data document that the PEDS identifies 74% to 80% of children with disabilities (sensitivity) and 70% to 80% of children without disabilities (specificity). It is validated both in English and Spanish, and translations into multiple languages are available. The PEDS, written at a fifth-grade reading level, can be completed in <5 minutes. It is among the developmental screening tools listed in the AAP 2006 developmental screening and surveillance policy statement.1
Statistically derived “predictive concerns” indicate heightened risk for developmental needs leading to eligibility for publicly funded services; at each age, particular parent concerns (ie, expressive language and fine motor skills) are coded as “predictive” or “nonpredictive,” thus guiding the referral algorithm. Children with 1 predictive concern are 8 times more likely than a child with no predictive concerns to have needs eligible for services; those with 2 predictive concerns are 20 times more likely.
The PEDS algorithm directs children with 1 predictive concern to an intermediate level assessment, as a step to further clarify the risk of developmental or behavioral need and the indication for formal, comprehensive evaluation. To address this need for intermediate-level assessment, we developed a second-stage screening (SSS) service at both sites. For children <2.9 years of age, an early intervention provider conducted screening using the Michigan Scales of Child Development. The Massachusetts Department of Public Health reimbursed for the screen, and the clinics donated space (1 room for ∼1 session per week). For children 2.9 to 5.9 years of age, an educational specialist conducted SSS using the Brigance screens; for children 6.0 to 9.0 years of age, the Wide Range Achievement Test-IV, Vanderbilt Attention Scales, and the Pediatric Symptom Checklist were used. Parents were not charged for these services, and no reimbursement was sought for the educational specialist, whose salary was paid by alternate funding. Children identified at SSS with skills below normed cutoffs were referred for early intervention services or public school evaluations, facilitated by the screener. Referring primary care providers were informed by e-mail of the SSS findings and whether the child was in need of outside testing. The SSS, thus, allowed us to reduce the number of referrals for more complete evaluation by screening out children with less suspicious profiles.
Providers were instructed to score and respond to the PEDS as recommended in the manual and the scoring algorithm; 2 predictive concerns generated a referral for formal evaluation, 1 predictive concern lead to SSS, and nonpredictive concerns were first addressed with in-office counseling. However, clinician judgment was meant to be incorporated so that more evaluation was arranged if the clinician was concerned, regardless of a reassuring screener. Every parent concern was considered and discussed, but provider concern was able to instigate more assessment than the algorithm indicates. For the purpose of our study, parents' concerns about language, motor skills, and socialization were considered “developmental,” whereas “behavioral” concerns included tantrums, sleeping, and feeding challenges. These categories were created for data analysis and did not impact survey administration or scoring.
Before implementation, 1 author (Dr Schonwald) conducted 45- to 60-minute PEDS training sessions with CHPCC and JSCHC providers and clinic staff. The training reviewed literature about current identification rates, evidence that the PEDS is effective, and administration and scoring of sample surveys. Providers were taught the meaning of the “predictive concerns,” which increase the likelihood that a child will have a disability creating eligibility for services. The scoring and management algorithms were reviewed, with the expectation that the providers would comply with the formal PEDS scoring and the recommended decision tree. For the initial 2 weeks of screening, trained staff members were accessible to providers (and staff) on site or by pager/ e-mail to answer questions about administration, scoring, and referrals. After 2 weeks, providers no longer asked questions face to face, although ongoing e-mail consultation was offered and occasionally used. Each site was also provided with resource notebooks to facilitate decision support for referrals. Organized according to the PEDS algorithm, notebooks included local referral contact information and parent handouts. At CHPCC, the information was also available online at the clinic internal Web site.
Data Collection and Analysis
To learn more about feasibility of the implementation process, we used provider surveys (at CHPCC and JSCHC) and a focus group (at CHPCC). To assess effectiveness of the PEDS implementation, we conducted a medical chart review (at CHPCC).
Before PEDS training and implementation, providers at both sites were asked to complete anonymous surveys. Survey domains included provider knowledge regarding developmental screening (9 items), provider attitudes toward developmental screening (15 items), and providers' current developmental screening practices (5 items). Item response formats included 5-item Likert scale, yes or no, and multiple choice. Demographic items included gender, years in practice, and training. Surveys were repeated again 4 months after initial implementation of routine screening.
To learn about the providers' impressions and reactions to the PEDS implementation, we conducted a focus group of the CHPCC providers. An invitation to participate in the focus group was sent to staff members who attend a weekly provider meeting. The focus group was conducted 9 months postimplementation and included 5 participants: 4 staff pediatricians and 1 nurse practitioner. Participation was entirely voluntary. No incentives were offered for participation. The group was guided by 1 of the investigators (Dr Bridgemohan), who does not have any professional associations with the CHPCC providers. Two observers took notes during the focus group. The interview was also audio taped to provide clarification for any points of disagreement in the 2 sets of notes. The focus group questions were semistructured, developed after analysis of provider survey data.
Data from the focus group were analyzed using standard qualitative methodology.11–13 Two investigators (Drs Schonwald and Bridgemohan) independently read the transcript to identify themes that emerged from the participants' comments. They then jointly developed a coding scheme based on these themes. The data were then reorganized into sections using the coding scheme. Two investigators (Drs Bridgemohan and Chan) then reread the transcripts to verify the reorganized data and to identify broader concepts. Discrepancies were resolved through discussion by 3 investigators (Drs Schonwald, Bridgemohan, and Chan). To enhance validity, data were triangulated through review of provider notes during charts review, informal discussions with clinic staff throughout the implementation, and formal discussions about infrastructure and the process of implementation during monthly research team meetings.
Medical Chart Review
To assess use of the PEDS, we reviewed medical charts for all of the 2- and 3-year-old well-child visits in CHPCC for 2 separate birth groups. We generated the lists of eligible children by querying the electronic scheduling system. The pre-PEDS birth group consisted of children who were 20 to 40 months of age within the 4-month period (July 1, 2005, to October 31, 2005) ending 2 months before PEDS implementation (to prevent effects generated by PEDS training sessions). The post-PEDS group consisted of children who were 20 to 40 months of age within the 4 months (April 1, 2006, to July 31, 2006) after the PEDS had been in routine use for 3 months (to allow for an initial implementation “learning curve”). There were no children who were selected for both cohorts.
Using a structured medical chart abstraction form, a trained research assistant abstracted data from both the written and electronic medical charts for the pre-PEDS and post-PEDS groups defined above. Because of limited research assistant availability, only medical charts based at CHPCC were reviewed. Variables abstracted included both parent concerns documented on the PEDS and provider comments about developmental and behavioral concerns; outcome measures included both parent and provider concerns documented in the record. Subsequent referrals for these developmental and behavioral concerns were also recorded. To better estimate identification of “new” concerns, any medical chart with a documented developmental concern in a 3-year-old visit was further reviewed to see whether that concern had been noted at a previous visit; if so, the concern was not deemed a new concern. Because a great deal of developmental change occurs between the 12- and 18-month visits and the 2 year visit, we considered any concern at the 2-year visit as a “new concern;” we did not look for concerns documented before the 2-year visit.
After the first 20 medical charts were reviewed by the research assistant, 2 authors (Drs Schonwald and Bridgemohan) independently reviewed these charts for accuracy. Item-by-item agreement for each of the 20 charts across all 3 of the reviewers exceeded 99%. After medical chart review was complete, 2 authors addressed all of the remaining questions on charts flagged by the research assistant. Common difficulties included deciphering a provider's handwriting, interpreting acronyms, and clarifying whether specific referrals were considered “developmental.” For example, a number of parents were concerned with intoeing, identified as a gross motor concern on the PEDS, and then referred to orthopedics. Only 1 medical chart could not be found.
Survey and medical chart data were entered into a Microsoft Excel database (Microsoft Corp, Redmond, WA) and then analyzed in Stata (Stata Corp, College Station, TX) by using 1- and 2-tailed χ2 test, t tests, and Fisher's exact test as appropriate.
Description of Providers and Patient Population
Thirty providers at CHPCC and JSCHC (88.2%) responded to the pre-PEDS survey and 24 (70.6%) to the post-PEDS survey. Responding providers were 73.0% women; 63.0% were staff physicians (pediatric and family practice), who had been in practice an average of 13.5 ± 8.5 years (range: 1.0–35.0 years).
We reviewed medical charts for a total of 616 children, 338 pre-PEDS and 278 post-PEDS. Average ages of the children overall, as well as in the 2-year-old and 3-year-old groups separately, were the same for the pre-PEDS and post-PEDS periods (Table 1).
Despite the routine use of the PEDS as the standard of care for developmental screening in CHPCC, we found that only 61.4% of 2-year-olds and 61.6% of 3-year-olds were screened with the PEDS in the postimplementation chart review. Because this was a quality improvement study, we did not ask parents to complete a separate demographics survey. Therefore, we do not know if the characteristics of the parents who completed the survey were comparable with the general patient population.
Provider Attitudes, Knowledge, and Practice
Providers' confidence in their own ability to screen for developmental and behavioral concerns increased 3 months after implementation (Table 2). There was no change in attitude toward the importance of routine screening, use of a standard tool, or effectiveness of the PEDS. Providers were equally likely on the pre-PEDS and post-PEDS surveys to report no reluctance to screen because of limited access to community resources. Before PEDS, 17% of providers agreed with the statement, “It takes too much time to screen for developmental and behavioral concerns during well-child visits”; 4% agreed post-PEDS, although the change in scores was not statistically significant.
Providers reported significant change in practice in the post-PEDS survey. Providers more strongly endorsed that they screened for developmental and behavioral concerns at every well-child visit using a standard tool (Table 2). They did not report a change in rate of surveillance for developmental and behavioral concerns at every well-child visit. They also did not change their opinions on whether the PEDS improved their ability to assess development and behavior, although their pre-PEDS opinions were already quite favorable.
Focus group participants were very positive about using the PEDS during WCC visits. They consistently stated that the PEDS was easy to use and that use of the PEDS actually saved time during the visit. Use of the PEDS provided an organized structure for discussing parent concerns and identified concerns ahead of time, rather than at the end of the visit, allowing providers to plan for discussion accordingly. They also noted that the PEDS led to identification and discussion of other, nondevelopmental concerns. Several participants stated that using the PEDS increased their ability to identify children with developmental problems. They felt that the system of SSS was very helpful and allowed them to refer children on for further testing. The major concerns with using the PEDS related to operations problems, for example, patients needing the assistance of an interpreter. These data were supported by field observations completed by the research team during the implementation phase. The major difficulties discussed by participants related to the failure of the surveys being completed at each visit before their entry into the examination room (parents forgot, were watching small children, or were doing something else), rather than reluctance of support staff or clinical staff to use the screening or refusal of parents to complete the forms.
Among the 616 children whose charts were reviewed, providers identified new developmental and behavioral concerns for a total of 149 children (Fig 2); 143 children had a new developmental concern identified, and 61 had a new behavioral concern identified. Nearly all of the children with a behavioral concern also had a developmental concern. Although 30 of the 149 children with a new concern identified were already receiving services, the new concern was not the issue being addressed by the existing services and was, thus, considered truly new.
Across age groups, there was a significant increase in the identification of both developmental concerns (20.7% vs 26.3%; χ2 = 2.64; P = .05) and behavioral concerns (8.0% vs 12.2%; χ2 = 3.08; P = .04) after PEDS implementation, but the pattern of change differed by age. Among 2-year-olds, the rates of identification of behavioral concerns doubled (7.1% vs 14.2%; χ2 = 3.98; P = .02), but identification of developmental concerns did not change. In contrast, among 3-year-olds, identification of developmental concerns increased (11.2% vs 19.2%; χ2 = 3.97; P = .02), whereas behavioral concern identification rates were unchanged. (Fig 2).
To understand whether increases in identification rates in the post-PEDS periods were attributable to use of the tool or to educational efforts and greater awareness of developmental needs contaminating the post-PEDS phase, we compared 2 groups of post-PEDS children: those who had a completed PEDS compared with those who did not. Among 3-year-olds, there were twice as many concerns identified among children who were screened with the PEDS, which neared statistical significance (P = .058; Fig 3).
Referrals were made only for developmental concerns and not for behavioral concerns, because these tended to be addressed through counseling by the provider at the visit, in accordance with the PEDS algorithm and common practice. Of the 616 children whose medical charts were reviewed, 63 (10.2%) were referred for further evaluation or treatment. Overall referral rates for 2-year-olds remained similar pre-PEDS and post-PEDS implementation, whereas referral rates increased for 3-year-olds (Table 3).
Of the 63 referrals made during the target visit, 15 were made for children with no new concerns. Instead, these 15 referrals were made for concerns identified at the previous visit. The remaining 48 referrals were made for children with a developmental concern newly identified at the target visit, yielding a 33.6% referral rate among the 143 children with new developmental concerns. Referral rates for children with new concerns were not significantly different pre-PEDS versus post-PEDS, either overall or for the separate age groups (Table 3). For an additional 14 children with new concerns (10 pre-PEDS and 4 post-PEDS), the provider and parent discussed a referral, but a referral was not made at the target visit.
It was possible that a child's ongoing participation in developmental services decreased the likelihood that a provider would generate a referral for a new concern. Therefore, we removed the 30 children already receiving services and reanalyzed the referral rates. Although, as expected, this recalculation increased the percentage of children referred, there continued to be no significant change between the pre-PEDS and post-PEDS periods for either age group (Table 3).
Types of Concerns Identified and Referrals Made
In general, the types of developmental-behavioral concerns identified did not differ significantly after the PEDS was implemented. In the 2-year-old group, the most common developmental concern was language, and the most common behavioral concerns were tantrums and aggression. The most common types of new developmental concerns identified in the 3-year- old group were language and learning. Sleep and tantrums were the most common new behavioral concerns in 3-year-olds. There were no changes in the specific types of developmental or behavioral concerns identified after the PEDS was implemented.
The most common types of referrals for 2-year-olds were to audiology and early intervention. For 3-year-olds, the most common types of referrals were school-based testing and audiology. The types of referrals made for new developmental or behavioral concerns did not change after the PEDS was implemented.
A second-stage developmental screening process (SSS) was established as part of introducing the PEDS to the practices; it was not present before use of the PEDS. After the PEDS was implemented, 19% of referrals for 2-year-olds and 22% for 3-year-olds were for SSS. Interestingly, before the PEDS was implemented, 20% of referrals for 3-year-olds were to a developmental specialist, such as a developmental-behavioral pediatrician. After the PEDS was implemented, there were no referrals to a developmental specialist, which suggests that providers chose to begin with the available SSS instead of referring directly to a developmental specialist for further evaluation.
This quality improvement initiative succeeded in incorporating validated developmental screening into real-life practice settings and increased identification rates of children with developmental and behavioral concerns without burdening practitioners. This system resulted in screening 61% of targeted children, without extending the perceived length of visits and apparently saving time for some. Use of the screen increased identification rates of behavioral concerns in 2-year-olds and developmental concerns in 3-year-olds. Despite the increase in identification rates, there was no significant increase in overall rates of referrals. We suspect that providers continued to exercise clinical judgment when deciding whether to refer or manage within the office setting.
This implementation project, like others, addresses many perceived obstacles preventing practitioners from embracing universal screening with validated tools, such as an increased time burden or increased referral rates. In addition to previously described feasibility of implementation in large group settings, via statewide efforts, and using alternate validated tools, we now present evidence of feasibility of implementing the PEDS in urban practices.
Unexpected benefits emerged as major themes derived from secondary analysis of focus group participant responses. First, PEDS implementation may result in more parent-centered care. Providers felt better able to respond to parent concerns, additional topics were discussed, the visit seemed more structured, and additional resources were available through the clinical support infrastructure of the program. Second, quality of care seemed to improve. When parents completed the PEDS, concerns were identified earlier in the visit. Physicians felt that they better identified developmental problems. Using the PEDS made them aware of problems that they might have missed before using the system. Using the PEDS improved the efficiency of visits and allowed for more appropriate follow-up care. Third, physicians reported feeling empowered by the screening program. Physicians reported improved knowledge about child development and the importance of screening. They were positive about their ability to use and interpret the screening results and to arrange for further evaluation and/or care for their patients. Admittedly, these self-selected focus group participants may have been more favorably biased toward the PEDS. However, their responses are consistent with the results of the survey administered to nearly all of the providers.
Within the first year of implementing the PEDS, 61% of 2- and 3-year-old WCC visits had a completed PEDS. Earls and Hay,7 who describe a quality improvement initiative most similar to ours, reported a 35% completion rate in the first year of their program and a 62% completion rate in the second year. We attribute our more rapidly acquired completion rate to our application of lessons learned elsewhere: extensive preimplementation planning with provider and staff input, strong support from leadership, and constant presence of the project champion. Both CHPCC and JSCHC continue to use the PEDS for developmental screening in WCC, although the presence of the project champion has been gradually withdrawn over time.
As expected, challenges also surfaced. In our setting, success depended on logistic factors, such as getting the PEDS forms completed before the visit with the physician. We suspect that the 39% noncompletion rate at CHPCC reflects some of the logistic challenges in launching universal screening in a large urban group practice with close to 90 providers. In addition, as many as 30% of CHPCC patients arrive late for their appointments or in the presence of a surrogate caretaker. We do not know why noncompleters failed to complete the survey. We also do not know if the noncompleters differed demographically from the completers.
We did not rescore the PEDS administered to 2- and 3-year-olds in the post-PEDS period, so we cannot confirm that providers scored the PEDS or followed the referral algorithm correctly. This is less of a concern for the current study, where our focus was on the feasibility of implementing the PEDS and its initial effectiveness in identifying concerns. However, in a separate study tracking the outcome of referrals, we have evaluated the accuracy of providers' use of the PEDS. Those results will be presented separately.14
Availability of SSS also was an important support in our implementation efforts. Direct developmental assessment for targeted children, provided here as SSS, has been highlighted previously as a necessary ingredient for successful routine screening. For example, Healthy Steps, a national initiative that focuses on the importance of the first 3 years of life, includes a specialist with “special training in child development” working within the pediatric practice.15 Similarly, the Commonwealth Fund review of the current state-of-the-art on pediatric linkages for developmental care includes the need for “midlevel developmental assessment” as 1 of its 7 recommendations for enhancing developmental care linkages in communities, states, and nationwide.16 In our study, our providers benefited from the opportunity to engage in office-based discussion of children with mild-to-moderate concerns, who were referred previously to outside and largely inaccessible specialists.
There is some concern that the presence of SSS itself may induce referrals, creating a bias in the identification and referral patterns. However, our data do not support this concern. We did not find an increase in the referral rate after the introduction of the PEDS and SSS. In fact, in contrast to the pre-PEDS period, we found that no children in the post-PEDS period were referred directly to specialty centers, suggesting that SSS served as an alternate referral option. The greater convenience of onsite SSS, compared with outside specialty centers, may result in more parents following through on a referral for further developmental evaluation. We currently are evaluating the outcomes of referrals made in the post-PEDS period.14
The logistics of a midlevel screening can be challenging, and this may limit the use of our program as a model for others. However, local early intervention programs may collaborate with practices to facilitate intermediate evaluations for children <3 years of age. Direct screening of skills for children >3 years of age remains a challenge for most providers, who likely lack access to expertise, funding, testing materials, and space required. Creative collaborations with area practices, schools, universities, and training programs could address this need. Alternative screening tools (such as ASQs) have been offered as a second level screen, after a positive PEDS survey, because the ASQ surveys parents about specific skills rather than asking open-ended questions about concerns; the ASQ scoring algorithm does not necessitate a direct screen. However, this 2-tiered approach has not been validated.
In contrast to perceived barriers and to some previously published reports, our real-life initiative led to increased identification rates of children with developmental and behavioral concerns at certain ages and did not cause an overwhelming increase in outside referrals.2,5 It is possible that the increase in identification could have resulted from enhanced provider awareness or recording practices. However, when we looked at identification rates in the post-PEDS period alone, we still found a higher identification rate in the cases where the PEDS was used compared with cases where the PEDS was not used.
Identification rates of developmental concerns increased in 3-year-olds, whereas behavioral concerns increased in 2-year-olds. We suspect that our high baseline rate of identification for developmental concerns in 2-year-olds prevented a significantly increased rate of identification after PEDS. Hix-Small et al5 reported that provider impression alone resulted in a 10.6% identification rate for developmental concerns in 1- and 2-year olds, in contrast to our baseline, provider-only rate of 30.2% for 2-year-olds. Before using the PEDS, our providers used developmental milestone questions, largely derived from the Denver II, which were asked at each well-child visit to review a child's development. Using this common practice, why did we identify more 2-year-olds than 3-year-olds at baseline with developmental concerns? Pediatric providers may be more adept at identifying language and other developmental deficits in 2-year-olds compared with older toddlers. Furthermore, the relative ease of referring to early intervention (in contrast to referrals for children ages 3–5 to the public school system) could also contribute to the higher baseline rates of identification of 2-year-olds. In contrast to the high baseline rate of developmental concerns in 2-year-olds, both baseline pre-PEDS and follow-up post-PEDS behavioral concerns in 2-year-olds were low. This may reflect poor documentation or indicate a need for even more aggressive detection. Regardless of the reason, our results suggest that adding a standardized screener can improve identification rates even in settings with existing routine developmental surveillance practices.
The types of concerns raised remained consistent before and after PEDS. Use of routine developmental screening is meant to increase the identification rate of a broad range of needs, rather than the rate of a specific disorder. This different mode of detection (survey rather than observation or milestone review) may access an array of new information from parents who otherwise are less revealing, may illuminate needs in children with more subtle difficulties in any area, or may pick up those children whose needs are not evident during the busy office visit.
With broad screening, not all concerns necessitate referrals; for example, in our study no children with behavior concerns were referred to outside providers at the first pass. We suspect that these children were not referred because the primary care provider counseled within the office setting. Enhanced parent guidance around limit setting, appropriate developmental expectations, responding to a child's cues, and positive reinforcement for desired behaviors can potentially improve parent-child relationships and enhance the foundations for a child's self-concept, regulation, and independence.17
Our study extends the growing literature regarding implementation of standardized screening tools into primary care by depicting the experiences and outcomes in 2 urban settings. It is unlikely that randomized, controlled trials will clarify a single best tool or method for efficient and effective screening for all practitioners. Rather, the cumulative experiences shared across regions, practice settings, and with varying tools inform providers of the feasibility and effectiveness of the range of methods available for transforming developmental screening into an evidence-based practice.
This study was supported by the Massachusetts Developmental Disabilities Council, the National Institute for Developmental Disabilities Research, and the Maternal Child Health Bureau.
We thank Drs Judith Palfrey, Joanne Cox, Leonard Rappaport, and Carol Eastman for their guidance and investment; Katherine Engel, LICSW, Molly Meyers, MEd, and Taylor Silver for their project support; the Children's Hospital Primary Care Center and Joseph Smith Community Health Center families, providers, and staff for their participation and input; and Christina Harding for data collection and entry.
- Accepted May 30, 2008.
- Address correspondence to Alison Schonwald, MD, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115. E-mail:
The authors have indicated they have no financial relationships relevant to this article to disclose.
What's Known on This Subject
Developmental screening using validated tools is an AAP-recommended practice. Providers are reluctant to implement a new tool, citing many perceived obstacles. Previous studies report feasibility and effectiveness of screening in statewide consortia, private practices, and with alternate screening tools.
What This Study Adds
This is a “real-world” implementation of a commonly used developmental screening tool (PEDS) and demonstrates that the AAP screening recommendations can be met (feasible) and result in the expected change (effective) in large urban clinic settings.
- ↵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 (1):405– 420
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- ↵Rydz D, Srour M, Oskoui M, et al. Screening for developmental delay in the setting of a community pediatric clinic: a prospective assessment of parent-report questionnaires. Pediatrics.2006;118 (4). Available at: www.pediatrics.org/cgi/content/full/118/4/e1178
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- ↵Lipkin PH. Should general pediatricians not select the Ages & Stages questionnaire in light of the Rydz et al study? In reply. Pediatrics.2007;120 (2):459
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- ↵Healthy Steps for Young Children. Healthy Steps specialist protocol. Available at: www.healthysteps.org/healthysteps/homepage.nsf/All/HSS-protocol.html. Accessed August 12, 2007
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