BACKGROUND: Early identification of developmental delays is essential for optimal early intervention. An American Academy of Pediatrics (AAP) 2002 Periodic Survey of Fellows found <25% of respondents consistently used appropriate screening tools. Over the past 5 years, new research and education programs promoted screening implementation. In 2006, the AAP issued a revised policy statement with a detailed algorithm. Since the 2002 Periodic Survey, no national surveys have examined the effectiveness of policy, programmatic, and educational enhancements.
OBJECTIVE: The goal of this study was to compare pediatricians' use of standardized screening tools from 2002 to 2009.
METHODS: A national, random sample of nonretired US AAP members were mailed Periodic Surveys (2002: N = 1617, response rate: 55%; 2009: N = 1620, response rate: 57%). χ2 analyses were used to examine responses across survey years; a multivariate logistic regression model was developed to compare differences in using ≥1 formal screening tools across survey years while controlling for various individual and practice characteristics.
RESULTS: Pediatricians' use of standardized screening tools increased significantly between 2002 and 2009. The percentage of those who self-reported always/almost always using ≥1 screening tools increased over time (23.0%–47.7%), as did use of specific instruments (eg, Ages & Stages Questionnaire, Parents' Evaluation of Developmental Status). No differences were noted on the basis of physician or practice characteristics.
CONCLUSIONS: The percentage of pediatricians who reported using ≥1 formal screening tools more than doubled between 2002 and 2009. Despite greater attention to consistent use of appropriate tools, the percentage remains less than half of respondents providing care to patients younger than 36 months. Given the critical importance of developmental screening in early identification, evaluation, and intervention, additional research is needed to identify barriers to greater use of standardized tools in practice.
WHAT'S KNOWN ON THIS SUBJECT:
Early identification of developmental delays is essential for optimal early intervention. Increasingly, developmental screening is recognized as a key component of high-quality care. The American Academy of Pediatrics has issued policy statements supporting the importance of developmental screening along with implementation strategies.
WHAT THIS STUDY ADDS:
Despite increased policy, research, and educational efforts to support implementation of standardized developmental screening, no national surveys have assessed whether use of formal tools has increased. This study examines changes between 2002 and 2009 in pediatricians' developmental screening practices.
Early identification of children with developmental delays is essential to providing optimal early intervention services. In the 2003 National Survey of Children's Health, 10% to 20% of parents of children aged 5 years and younger expressed concern about their child's development.1 Results from the national Early Childhood Longitudinal Study–Birth Cohort indicate that at 24 months of age, nearly 14% of children have developmental delays that are likely to make them eligible for early intervention services as specified in the Individuals With Disabilities Education Improvement Act.2
In recognition of both the importance of early identification of children with developmental disabilities and the need for more methodical assessments, in 2001 the American Academy of Pediatrics (AAP) put forth recommendations that all children should receive standardized developmental screening as part of well-child care.3 Screening was defined as a “brief assessment procedure designed to identify children who should receive more intensive diagnosis or assessment.” However, the implementation of these recommendations was slow. A 2002 AAP survey of its members regarding the use of developmental screening tools and referrals to early intervention found that only 23% of pediatricians consistently used effective standardized screening instruments to assess their patients for developmental problems.4 In a 2004 national survey of primary care practitioners, Sices et al5 found that in the absence of standardized screening, both pediatricians and family physicians were inconsistent in their referral patterns for children with possible developmental delays. The main barriers cited in preventing the use of such tools included time limitations, lack of staff to perform screening, inadequate reimbursement, and lack of confidence in their ability to screen.
Over the next few years, many new research and educational programs were launched to implement the 2001 screening recommendations. Programs included the Assuring Better Child Health and Development program,6 which encompassed the North Carolina effort that gradually introduced standardized screening throughout the state.7 Other projects include Bright Futures,8,9 Child Find Demonstration Projects, the TRACE program, and the Healthy Steps for Young Children Program.10 The goal of all of these projects has been to facilitate the implementation of developmental screening into pediatric well-child care.
In 2006, the AAP issued a revised policy statement, including a detailed developmental screening algorithm, in an effort to clarify how and when developmental screening should take place.11 Recommendations included using “good” (sensitivity and specificity) standardized developmental screening tools at the 9-, 18-, and 30-month visits as part of appropriate well-child care in the medical home. The policy statement provided additional support for the importance of such screening along with implementation strategies.
After the 2006 AAP statement was issued, a developmental surveillance and screening policy implementation pilot study assessed the feasibility of implementing the recommendations in a variety of practice settings.12 Results revealed that nearly all participating study practices had successfully implemented the AAP's recommendations on developmental surveillance and screening. However, at the same time, using a national sample, Rosenberg et al2 reported that only 10% of children with developmental delays were receiving services for their developmental needs.
Since the report of Sand et al4 detailing the 2002 AAP Periodic Survey results, there has been substantial research and education in the area of implementing developmental screening as part of well-child care, as well as more specific recommendations for screening and guidance13,14 to support implementation. In 2004, the Current Procedural Terminology code for developmental testing (96110) was also valued for the first time in the Medicare resource-based relative value scale physician fee schedule.15 Despite these efforts, no national surveys have assessed whether these efforts have improved use of formal screening tools. In this study, we examine changes between 2002 and 2009 in pediatricians' developmental screening practices using the AAP's Periodic Survey of Fellows.
Periodic Surveys, conducted by the AAP's Division of Healthy Services Research, are national, random sample surveys of nonretired, US AAP members. The 2002 Periodic Survey (survey 53) was mailed to 1617 potential respondents between May and September 2002; the 2009 Periodic Survey (survey 74) was sent to 1620 possible respondents from February to July 2009. Both surveys were approved by the AAP's institutional review board. All survey mailings included a letter of introduction from the AAP's executive director and a postage-paid return envelope. Potential participants received up to 7 repeated mailings to encourage survey completion and return.
Among other topics, the 2002 and 2009 surveys included an identical item regarding use of developmental screening tools (“How often do you or your staff use the following methods or tools to identify children birth through 35 months of age at risk for developmental delay or problems?”). A subset of questions followed to ask about specific assessment methods and tools: clinical assessment (ie, history and physical examination) without the use of a screening instrument/checklist; clinical assessment guided by the Denver Developmental Screening Test or other instrument; informal (eg, office-generated) checklist filled out by parents; informal (eg, office-generated) checklist completed by the AAP member or staff; formal screening using a specific instrument (eg, Bayley Infant Neurodevelopmental Screener, Denver II, Ages & Stages Questionnaire, Parents' Evaluation of Developmental Status, other [specify]).
Respondents could select >1 item, and 3 response choices (always/almost always, sometimes, or rarely/never) were included for each item. A combined variable was also created to indicate whether the respondent used ≥1 formal screening tools always or almost always.
Analyses excluded pediatricians who practiced general pediatrics <10% of the time (2002: n = 222; 2009: n = 282) and those who reported ≥1% of their time (2002: n = 26; 2009: n = 17) in a developmentally oriented subspecialty (eg, developmental/behavioral pediatrics, neurology, neonatology, perinatology, genetics). All respondents included in the analyses reported they provide health supervision/preventive care to children younger than 36 months of age and reported assessing for developmental risk (2002: n = 594; 2009: n = 560).
χ2 analyses were used to compare the use of the individual formal screening tools across survey years. A multivariate logistic regression model was also developed to compare differences in using ≥1 formal screening tools across survey years while controlling for various individual and practice-characteristic variables (physician age, gender, practice type, practice location, percentage reporting high/low proportion of patients with public insurance, practice region, and training status). Odds ratios and 95% confidence intervals were reported.
Overall response rates for Periodic Survey 53 (2002) and Periodic Surveys 74 (2009) were 55% and 57%, respectively.
Table 1 presents demographic and practice characteristics for all respondents included in the analyses; there were no significant differences across surveys.
Use of Standardized Screening Tools
Pediatricians' use of standardized screening tools increased significantly from 2002 to 2009 (Table 2). The percentage of those who self-reported always/almost always using ≥1 screening tools increased over time (23.0%–47.7%); likewise, the percentage of those who reported use of clinical assessment without a formal tool decreased (71.0%–60.5%).
Use of specific instruments also increased from 2002 to 2009 (Table 2). In particular, a significantly greater percentage of pediatricians reported using the Ages & Stages Questionnaire and the Parents' Evaluation of Developmental Status in 2009 than 2002. In both years, some pediatricians reported conducting formal screening with “other” tools. In 2009, 57 respondents specified they used the Modified Checklist for Autism in Toddlers. Twenty-two respondents specified other tools, such as Bright Futures; Early Periodic Screening, Diagnosis and Treatment Programs; a formal screening tool on the electronic medical record; the Prescreening Developmental Questionnaire (PDQ); the Communication and Symbolic Behavior Scales–Developmental Profile; and the Ireton Child Development Chart. In 2002, 20 respondents specified the use of certain tools; for example, Bright Futures/Bright Futures guidelines; Cognitive Adaptive Test/Clinical Linguistic Auditory Milestone Scale; Early Language Milestone Scale; Early Periodic Screening, Diagnosis and Treatment Programs; and the PDQ, the PDQ II, and the revised form of the PDQ. In 2009, respondents also reported greater use of informal checklists completed by parents than in 2002 (27.9% vs 15.3%, respectively; P < .000).
The difference in the use of ≥1 formal screening tools across survey years remained significant within the multivariate model (odds ratio: 2.99 [95% confidence interval: 2.17–4.13]). None of the other physician and practice characteristics examined were statistically significant related to use of formal screening tools (Table 3).
Findings from a recent AAP Periodic Survey of Fellows suggest encouraging trends in pediatricians' use of appropriate developmental screening tools. The percentage of pediatricians who reported using ≥1 standardized tools more than doubled between 2002 and 2009, demonstrating significant improvement after changes in AAP policy, enhanced guidance on reimbursement, and increased emphasis on developmental screening through research and educational programs as well as the new Bright Futures9 guidelines.
Despite these gains, however, there remains room for improvement. Approximately half of the pediatricians reported that they did not routinely use the recommended formal screening tools with patients younger than 36 months of age. Many continue to rely on informal checklists completed by the pediatrician, office staff, and/or parents.
Findings from the present study are limited in several ways. First, estimates of standardized screening tool usage are based on physician self-report rather than observed documentation or chart review. Social desirability may have motivated pediatricians to over-report their application of these instruments given current attention to the importance of early identification of developmental delay. We lack parent-reported data to corroborate whether formal developmental screenings are being conducted. Obtaining information from parents is particularly important because parents do have concerns about their children's growth and development, and they expect their health care providers to address these issues and concerns.16 Recent findings from the 2007 National Survey of Children's Health indicate that >40% of parents of children aged 4 months through 5 years reported ≥1 concerns about their child's physical, behavioral, or social development.17 When the 2000 National Survey of Early Childhood Health asked parents of children ages birth through 35 months if their child had ever received a “developmental assessment,” >40% of parents reported no.18 Parents who did report receiving a developmental assessment were more likely to be satisfied with their child's medical care.
Second, the present inquiry does not allow us to determine who is administering these tools and whether screening is being conducted appropriately. Also unknown is the outcome of screening (eg, referral patterns, follow-up).
In 2009, Sheldrick and Perrin19 noted that screening has become accepted as a “core element of pediatric practice.” However, they also argued that instruments must not only be scientifically valid but also practical, in terms of administration time and cost, for the office setting. It is plausible that barriers such as these continue to impede increased use of appropriate screening methods. In addition, another barrier identified in early studies remains problematic today: the lack of a gold standard formal screening tool for young children.20,–,22 As Sices noted,23 there are a variety of tools available, but many of these instruments are limited in sensitivity and specificity.
Increasingly, developmental screening is recognized as a key component of high-quality care; thus, it is likely the interest in appropriate screening methods and use of standardized tools will continue to grow.24 A notable development in quality measurement is that the initial recommended core set of children's quality measures for voluntary use by Medicaid and the Children's Health Insurance Program, mandated under the Children's Health Insurance Program Reauthorization Act, includes “screening using standardized screening tools for potential delays in social and emotional development.”25
The past decade has brought about a significant increase in the number of standardized screening tools available for young children as well as the adoption of these tools by pediatricians. Unaddressed, developmental delays can negatively affect children's future health and educational attainment.26 Appropriate screening is critical to early identification, evaluation, and intervention for developmental delays. Because pediatricians are the most frequent point of contact for the health needs of young children, additional work is needed to identify and address remaining barriers to even greater use of formal tools in pediatric practice.
We acknowledge the helpful comments of William Cull, PhD, and Paul H. Lipkin, MD, on an earlier version of this manuscript.
- Accepted March 11, 2011.
- Address correspondence to Linda Radecki, MS, Department of Research, American Academy of Pediatrics, 141 Northwest Point Blvd, Elk Grove Village, IL 60007. E-mail:
The views represented here are those of the authors and do not necessarily reflect the views of the American Academy of Pediatrics.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
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