BACKGROUND: In 2006, the American Academy of Pediatrics recommended developmental screening of young children with a standardized screening tool as a routine component of well-child care.
OBJECTIVES: To assess the national and state prevalence of standardized, parent-completed developmental screening (DS-PC) in the previous 12 months and evaluate associations between screening and receipt of an early-intervention plan or mental health services for children at higher risk.
METHODS: Data from the 2007 National Survey of Children's Health were used. Nested t tests were used to compare each state to national prevalence. Logistic and multilevel regression models evaluated variations and associations with DS-PC.
RESULTS: Nationally, 19.5% of children received a DS-PC in the previous 12 months, although the figure varied from 10.7% to 47% across the United States. Prevalence did not rise above 26.7% for any socioeconomic subgroup of children and was highest for younger, black, and publicly insured children and lowest for uninsured children and children with gaps in insurance coverage. Equally high-risk children varied twofold in their probability of receiving early intervention or needed mental health services according to whether they had received a DS-PC.
CONCLUSIONS: There is a significant gap between the developmental screening that is recommended and what is reported nationally. When children are not screened consistently, opportunities for early identification, intervention, and treatment may be delayed. Gaps in screening and wide variations across states present considerable opportunities for cross-state learning to improve quality on this critical component of preventive pediatric care. Measurement systems for assessing prevalence and impact of screening require continued evaluation and development.
- early childhood
- developmental screening
- state variations
- well-child care
- early intervention
- mental health
- National Survey of Children's Health
- parent survey
In 2006 the American Academy of Pediatrics (AAP) issued a policy statement recommending that pediatricians screen all young children for risk of developmental, behavioral, and social delays at 9, 18, and 24 or 30 months of age. The policy statement set forth screening algorithms and methods, including those that use standardized parent-completed tools such as the Ages & Stages Questionnaire (ASQ) and the Parent's Evaluation of Developmental Status (PEDS), among others.1
Previous studies have shown that screening for developmental risk is not routinely implemented in primary care settings, that screening that does occur often does not use standardized protocols and tools, and that screening often is not implemented for all children. When standardized screening does take place, it is often through the use of parent-completed tools.2,–,5 However, the 2000 AAP Periodic Survey of Fellows revealed that providers who did report conducting routine screening most commonly used clinical observation rather than standardized assessment tools or protocols. According to the 2000 National Survey of Early Childhood Health, the first national survey in the Untied States to address whether young children had ever had a developmental assessment, only 42% of children younger than 4 years had parents who recalled that their child's doctor or other health care provider ever told them that he or she was performing a developmental assessment. A similar proportion of children younger than 4 years (39%) had parents who recalled that the provider ever had the child perform specific tasks commonly done in the context of a developmental assessment.6,7 Although focused on observational-oriented developmental assessment and counted screening occurring at any time in the span of the child's life (versus in the previous year), these findings pointed to significant gaps in developmental screening.
The Commonwealth Fund's multistate Assuring Better Child Development (ABCD) screening academy8 and healthy development collaborative and the AAP's Developmental Surveillance and Screening Policy Implementation Project are examples of efforts initiated to close the gap in both screening and appropriate follow-up and care coordination for children at risk.3 Initial evidence suggests that the provision of standardized developmental screening can be increased and that validated parent-completed tools are commonly found to be the most efficient, feasible, and patient-centered tools.8,9 A recently published study from the Developmental Surveillance and Screening Policy Implementation Project showed that 15 of the 17 participating pediatric practices selected parent-completed tools as most feasible.3
Until recently, the use of uniform, population-based data to assess national and state-level prevalence and disparities in screening nationally has been lacking. Because developmental screening is endorsed as a core measure for assessing quality of care under the Child Health Insurance Program Reauthorization Act, such population-based and state-specific data are highly relevant. Similarly, data have been lacking on how screening influences the receipt of early intervention (EI) and mental and behavioral health services for children who are at risk for or have a developmental or behavioral problem.10
With this work we sought to close the information gap and provide a baseline assessment of screening and impact on service access by reporting findings from the 2007 National Survey of Children's Health (NSCH), which included items specifically designed to assess the prevalence of screening young children for their risk for developmental, behavioral, and social delays by using parent-completed developmental screening (DS-PC). Although the AAP recommendations emphasize screening during the first 30 months of life, we include children through the age of 5 years (71 months), because recommendations also clearly state that surveillance should continue throughout childhood and that school-readiness screening should be performed.11,12 In addition to prevalence and disparities, we also evaluated whether receipt of a DS-PC in the previous 12 months was associated with accessing needed health services and whether children with emotional and behavioral problems received needed mental health services or those identified as high risk for development delays had an EI plan.
Study Data and Key Variables
The NSCH data used in this study were collected between April 2007 and July 2008.13,14 The NSCH is directed and funded by the Maternal and Child Health Bureau of the Health Resources and Services Administration It is administered by the National Center for Health Statistics in conjunction with the National Immunization Survey using the State and Local Area Integrated Telephone Survey mechanism. The survey sample represented at least 1700 children from each state and the District of Columbia (1725–1932 cases per state). All estimates from the NSCH data are adjusted for nonresponse bias and weighted to represent the noninstitutionalized population of children aged 0 to 17 years in each state, resulting in an estimated 24.48 million children aged 0 to 5 years.13,–,15
The 2007 NSCH produced the only national data that allow the calculation of state-level estimates of the prevalence of developmental screening for young children using a standardized measure. Anchored to recommendations to conduct standardized screening beginning at 9 months of age, the NSCH assessed screening for children from 10 to 71 months of age. To ensure that children had the opportunity to be screened by a doctor or other health care provider, screening was assessed only for the 97% of children who also had at least 1 health care visit in the 12 months before the survey (n = 22 883); 90% of these children also had at least 1 preventive care visit. The prevalence of screening was calculated by using 3 survey items included in the NSCH and specifically designed and tested to capture the use of AAP-recommended, parent-completed standardized screening tools.16,–,19 The DS-PC measure was designed and tested in both English and Spanish by the Child and Adolescent Health Measurement Initiative and further tested for Spanish translation by the National Center for Health Statistics.20 These items ask whether, in the previous 12 months, a doctor or other health provider had the parent/respondent fill out a questionnaire about specific concerns or observations they may have had about their child's development, communication, or social behaviors and, if so, whether this questionnaire included developmentally appropriate age-related questions about the child's language development and social behaviors. The DS-PC items (listed in Table 1) were iteratively validated and refined through in-depth cognitive interviews with parents of young children who received services in pediatric practices known to systematically use or not use standardized, parent-completed developmental, behavioral, and social screening tools (N = 36).20 Numerous studies have shown that parents are valid reporters of their child's developmental status and provision of communication-dependent aspects of clinically recommended care such as developmental screening.16,–,21
Variables that assess needed mental health services and whether the child had an EI plan were constructed by using standard NSCH measure-scoring protocols.13,14 Children were identified as needing mental health services on the basis of the validated and highly specific children with special health care needs (CSHCN) screener item that asked whether a child currently had a chronic mental, emotional, or developmental health condition that required treatment or counseling.22,23 The proportion of those children who reportedly received any type of mental health service at all was then calculated to construct the “received any needed mental health services” variable. Provision of an EI plan or Individualized Family Services Plan (IFSP) was assessed on the basis of respondent's report of whether a child had either of these plans and did not distinguish between whether the EI plan/IFSP was provided through the child's state EI program (Part C) or through other means. An IFSP documents and guides the EI process for children with disabilities and their families and is the vehicle through which effective EI is implemented by states in accordance with Part C of the Individuals With Disabilities Education Act (IDEA).11 According to Part C, states must provide services to any child “under 3 years of age who needs EI services” (IDEA 2004, §632[A]).10
To evaluate whether DS-PC was more or less likely on the basis of a child's level of risk for developmental, behavioral, or social delays, each child was categorized as being at no/low, moderate, or high risk on the basis of items asked at the time of survey administration and derived from the research version of the PEDS.16 Children categorized as being at high risk are the focus of the analyses presented here. A final measure of child health status and risk was whether a child had a special health care need identified with the CSHCN screener.22
Receipt of a preventive care visit, or well-child visit, was based on parent reports of how many times during the previous 12 months (or since the child's birth) the child saw a doctor, nurse, or other health care provider for preventive medical care such as a physical examination or well-child checkup.21 Other variables used to assess disparities and control for confounding factors in predicting provision of a DS-PC included child's age, gender, race, and ethnicity; primary household language; household income; mother's educational level; whether the child had public insurance, had private insurance, or was uninsured; and insurance gaps in the previous 12 months.
A final state-level variable assessed whether the state had narrow, medium, or broad eligibility criteria for state-sponsored EI services and was obtained directly from a 2009 report issued by the National Center for Children in Poverty.24 Our interest here was to assess if either prevalence of screening or EI plans was associated with state eligibility criteria.
DS-PC prevalence rates were calculated for the nation, for each of the 50 states and the District of Columbia, and for subgroups of children on the basis of each of the study variables listed above and in Tables 2 and 3. Nested t tests were used to evaluate state versus national differences in the prevalence of DS-PC. McNemar's χ2 tests were conducted to evaluate the statistical significance of differences in DS-PC prevalence across subgroups of children. A multilevel logistic regression model was fit to examine the association between individual child, family, and health care characteristics and the receipt of DS-PC, which allowed for variations across states in these associations and assessed state variation in DS-PC prevalence that remained after accounting for these individual child-level factors. The association between receiving a DS-PC and whether a child had an EI plan or IFSP was also evaluated by using multilevel regression analysis that included child's age, gender, race, household income, type of insurance, special-needs status, and developmental risk status as independent variables. An additional regression analysis was used to examine the association between receiving a DS-PC and whether children with emotional, behavioral, or developmental (EBD) problems who required treatment or counseling received any of these needed mental health services. We used MLwiN 2.025,26 for multilevel analyses, and we used SPSS's Complex Sample Module 17.0 (SPSS Inc, Chicago, IL) for all other analyses. All statistical analyses included an adjustment to standard errors to account for weighting, clustering, stratification, and increased variability that result from the NSCH's complex sampling design. Only significant adjusted odds ratios (aORs) are reported below and documented further in Table 4.
National and State Prevalence
The national prevalence of standardized DS-PC among children aged 10 through 71 months was 19.5% and ranged from 10.7% in Pennsylvania to 47.0% in North Carolina. Among the 50 states and the District of Columbia, 29 states had a DS-PC prevalence that was lower than the national rate. Differences between the rates of 8 of these states and the national rate were statistically significant (District of Columbia, California, Oregon, New Jersey, Alabama, New York, Delaware, and Pennsylvania: P < .05). Twenty-two states had a prevalence rate that was higher than the national rate, and 9 of them had a rate that was statistically higher than the national rate (North Carolina, Minnesota, West Virginia, New Mexico, Tennessee, Louisiana, Hawaii, Wisconsin, and Colorado: P < .05) (Fig 1). Approximately 42% of the variation observed in DS-PC prevalence across states remained after accounting for the impact of individual child-level characteristics and state variations in these characteristics.25,26
Prevalence and Variations According to Child Demographic and Health Characteristics
Nationally, the prevalence of DS-PC did not rise above 26.7% for any of the numerous subgroups of children evaluated. Prevalence was highest for children younger than 12 months (26.7%), black children (24.4%), and children with public-sector health insurance (23.6%). Children whose mother's education was less than high school were as likely to have received a DS-PC as those whose mother had higher educational levels (Tables 3 and 4).
Although the difference was not large, CSHCN (23.9%) were more likely to receive a DS-PC compared with children who did not have a special health care need (23.9% vs 18.9%; P < .05). Children who were identified at the time of survey administration as being at high risk for developmental, behavioral, or social delays were only somewhat more likely to have received a DS-PC in the previous year compared with children categorized as being at low or no risk (23.4% vs 19.7%; P < .05) (Tables 3 and 4).
After adjusting for other factors when using multilevel regression analysis, higher prevalence of DS-PC remained statistically significant for (1) children younger than 12 months compared with children aged 36 to 71 months (aOR: 1.43), (2) black, non-Hispanic children compared with white children (aOR: 1.24), and (3) Hispanic children whose primary household language was Spanish compared with white children (aOR: 1.73). Children at high (versus low or no) risk for developmental, behavioral, or social delays and/or who qualified as having a special health care need also had somewhat greater odds of having received a DS-PC (aOR: 1.27 and 1.26, respectively) (Table 4).
Prevalence and Variations According to Type of and Gaps in Health Insurance
The prevalence of DS-PC was substantially higher for publicly insured children compared with uninsured (23.6% vs 14.8%; P < .05) and privately insured (23.6% vs 17.8%; P < .05) children. Children with no gaps in health insurance coverage in the previous 12 months were also more likely to receive a DS-PC (20.1% vs 16.5%; P < .05) (Tables 3 and 4). Publicly insured children continued to have a higher likelihood of receiving a DS-PC after adjusting for other child demographic, health, and health care system variables (aOR: 1.30) (Table 4).
Associations With Access to Preventive Care and Mental Health Services
Children who had at least 1 preventive care visit during the previous 12 months (or since birth) were more than twice as likely to receive a DS-PC compared with children who had at least 1 health care visit but no visits for preventive care (19.8% vs 9.2%; P < .05; aOR 1.65) (Tables 2⇑–4). Similarly, children identified at the time of survey administration as having EBD problems that required treatment or counseling and who had received any type of needed mental health treatment or counseling services were more likely to have received a DS-PC compared with children with EBD problems who similarly needed but did not receive these services (38.9% vs 21.9%; odds ratio: 2.27 [95% confidence interval (CI): 1.17–4.40]) (Tables 2 and 3). Stated differently, it is important to point out that children with EBD problems that required mental health treatment or counseling were more likely to have received at least some needed services if they also received a DS-PC compared with similar children with EBD problems who did not receive a DS-PC (57.2% vs 37.1%; P = .015) (Fig 2). This association was especially pronounced among children with EBD problems that required treatment or counseling who also qualified as being at high risk on the PEDS. These children were 2.15 times more likely (58.5% vs 27.2%; P = .002) to have received at least some treatment or counseling if they had a DS-PC compared with children who did not receive a DS-PC. This difference remained after adjusting for child's age, gender, household income, and type of health insurance (aOR 3.29 [95% CI: 1.36–8.00]) and for the larger group of children who were identified as being at either moderate or high risk for developmental, behavioral, or social delays (aOR 3.12 [95% CI: 1.47–6.63]).
Association With an EI Plan or IFSP
Children whose doctor or other health care provider implemented a DS-PC with children in the previous year were more than twice as likely to also have an EI plan or IFSP compared with children who were not screened (8.6% vs 3.6%; P < .05) (Table 2 and Table 3; Fig 3). Children who received a DS-PC and who also met criteria for being at high risk for developmental, behavioral, or social delays were nearly twice as likely to have an EI plan or IFSP compared with similar children at high risk who did not receive a DS-PC (34.7% vs 18.4%; P < .05) (Tables 2 and 3). This discrepancy was even more marked among children younger than 36 months, who are the focus of eligibility for state-supported Part C EI services (6.4% vs 2.0%; P < .05). Finally, children with current EBD problems that required treatment or counseling and who also met criteria for being at high risk for developmental, behavioral, or social problems (arguably a subgroup with a high proportion of children who require an EI plan/IFSP) were 1.35 times more likely to have an EI plan/IFSP if they had received a DS-PC in the previous year (80.5% vs 59.6%; P = .02).
Regression analyses confirmed the association between having had a DS-PC in the previous year and currently having an EI plan or IFSP. Specifically, the odds that a child aged 1 to 5 years (12–71 months) had an EI plan or IFSP were 2.41 times greater if they received a DS-PC from their doctor or other health care provider, after adjusting for the child's age, gender, race/ethnicity, primary household language, household income, type of health insurance, and developmental risk and special-needs status. Children who lived in a state categorized by the National Center for Children in Poverty as having broad eligibility for state-sponsored EI services were not more likely to receive a DS-PC or have an EI plan or IFSP.
The provision of developmental screening is now widely viewed as an important step toward early identification and provision of treatments aimed at promoting healthy developmental trajectories for children. Standardized DS-PC is increasingly selected as a feasible, valid, and parent-centered method for screening in pediatric practices and other settings.3,8,27 As anticipated, data from the 2007 NSCH indicates that DS-PC was not commonly conducted in the United States in 2007, the year after the AAP recommendations on developmental screening were released. Fewer than 20% of all US children younger than 6 years met criteria for having had a DS-PC in 2007, and no subgroup's rate rose higher than 26.7%. Considering these findings, we urge continued promotion and monitoring of developmental screening in pediatric health care settings and the development of policy- and community-level systems to support primary care–based screening.
The AAP recommends that pediatric providers implement developmental screening with all children as part of well-child care, not just those whom health care providers judge to be at risk for developmental and behavioral problems. Our finding that approximately three-quarters of children at high risk for developmental, behavioral, or social delays or who had an EBD problem that required treatment or counseling had not received a standardized screening supports the idea that observation-based assessment of risk in the primary care setting is not sufficient; standardized screening is important and seems to, in fact, facilitate the early access to needed care that it is intended to promote. When these children at higher risk were screened they were much more likely to have received services. Because children are normally referred for more in-depth assessment and EI services on the basis of screening by health care providers, the finding that children at high risk who received a DS-PC were approximately twice as likely to receive EI services compared with children at equally high risk who did not receive a DS-PC is especially supportive of AAP screening recommendations.
State differences in the socioeconomic or health status of children accounted for only a portion of the variation in DS-PC prevalence across states (10.7%–47.0%), which suggests that state policy plays an important role. Only 9 states performed better than average nationally, which indicates that a more systematic approach to performance improvement is needed across all states and is a call for screening in pediatric practices to be integrated into the many initiatives underway to improve well-child care overall.27,–,29
Much higher rates of DS-PC in North Carolina indicate that improving developmental screening practices is possible. Over the last 8 years, North Carolina has instituted a number of integrated and purposeful policy, practice, and improvement efforts specifically focused on improving screening.9 This state-level model for increasing screening, anchored in provider-level quality improvement and linked with supportive state-level policy changes, served as an example for the 28 states that participated in the Commonwealth Fund's Assuring Better Child Development II (2004–2007) and Screening Academy (2008–2009) initiatives to improve early identification of children with or at risk for developmental problems.8 At the same time, it is important to recognize that even in the best performing states, absolute rates of screening are low compared with AAP recommendations.
Given the timing of the 2007 NSCH data collection, shortly after the 2006 AAP statement was released, our findings can serve as a standardized (and therefore comparable) national and across-state baseline assessment of rates of screening with parent-completed tools such as the Ages & Stages Questionnaire and PEDS. Since 2007, many state and national efforts have increased the focus on standardized developmental screening. For example, since 2007 many state health agencies have adopted policies to reimburse for the provision of a developmental screening using standardized parent-completed instruments. Other states have required providers to conduct standardized screening for children enrolled in state-sponsored health insurance programs such as Medicaid or the Children's Health Insurance Program (CHIP). A Massachusetts' Medicaid policy that requires primary care providers to implement standardized behavioral screening at each well-child visit is an example of this trend among state health agencies.30 These efforts were reinforced further in 2008 when the Maternal and Child Health Bureau–sponsored Bright Futures recommendations, which included recommendations for periodic screening using standardized instruments, were released by the AAP.31 Most recently, in September 2009, the Children's Health Insurance Program Reauthorization Act (CHIPRA), the National Advisory Council on Healthcare Research and Quality Subcommittee on Quality Measures for Children's Healthcare in Medicaid, and CHIP nominated “assessing the prevalence screening for developmental, behavioral and social delays” as a measure for state-based monitoring of quality of care.32 The DS-PC measure used in this study has been endorsed for voluntary use by the National Quality Forum (NQF), pending final public comment and board ratification (expected in the summer of 2011). Findings from this study can assist the tracking of the impact of state-level efforts and help to further understand the relationship between screening and access to EI services and health outcomes in the absence of any other standardized methods across all states for doing so. Comparison of these 2007 findings with 2011 NSCH data will indicate the extent to which increased national emphasis on developmental screening has influenced preventive child health care practice during the intervening years.
It is important to note that the DS-PC items are worded to anchor to screening initiated by a child's doctor and health care provider. Testing of the DS-PC measure suggests that it might pick up some number of screenings conducted by persons the parent may not perceive to be a “doctor or other health care provider,” such as community health providers. As such, the rates presented here may somewhat overestimate primary pediatric care–based screening. Moreover, the DS-PC was not designed to assess cases in which child care workers or teachers (eg, Head Start teacher) completed a screening tool themselves on the basis of their interaction with the child. Our findings are also not specifically intended to capture rates of nonstandardized, observation-based developmental screening by health care providers that do not involve asking parents about their concerns or observations about their child's development and behavior, which are reported as being high among pediatric providers.33,34
Our findings provide both good news and bad news. The bad news is that fewer than 20% of young children routinely received DS-PC. Although some variation exists, the generally low level of performance is more important than the small variations found on the basis of social demographics, health service, and insurance factors. The good news is that the findings reveal a much higher rate of EI plans for children at high risk and receipt of needed mental health services for children who did receive a DS-PC, which suggests that screening may promote higher rates of use of needed services. Other good news is that the more positive performance by states such as North Carolina indicates that systematic statewide improvement processes might be effective for improvement.
This study was supported by the Commonwealth Fund and received additional support from Maternal and Child Health Bureau under Cooperative Agreement 1-US9-MC06980-01.
- Accepted March 14, 2011.
- Address correspondence to Christina Bethell, PhD, MBA, MPH, Child and Adolescent Health Measurement Initiative, Department of Pediatrics, School of Medicine, Oregon Health & Science University, 707 SW Gaines Ave, Mailcode CDRC-P, Portland, OR 97219. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
- AAP —
- American Academy of Pediatrics
- PEDS —
- Parent's Evaluation of Developmental Status
- EI —
- early intervention
- DS-PC —
- parent-completed developmental screening
- NSCH —
- National Survey of Children's Health
- CSHCN —
- children with special health care needs
- IFSP —
- Individual Family Service Plan
- EBD —
- emotional, behavioral, or developmental
- aOR —
- adjusted odds ratio
American Academy of Pediatrics, Council on Children With Disabilities, Section on Developmental and Behavioral Pediatrics, Bright Futures Steering Committee, and Medical Home Initiatives for Children With Special Needs. Identifying infants and young children with developmental disorder in the medical home: an algorithm for developmental surveillance and screening [published correction appears in Pediatrics. 2006;118(4):1808–1809]. Pediatrics. 2006;118(1):405–420
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- Copyright © 2011 by the American Academy of Pediatrics