Implementing the Algorithm
Choosing Developmental Screening Tools
Although all developmental screening tools are designed to identify children with potentially delayed development, each one approaches the task in a different way. There is no universally accepted screening tool appropriate for all populations and all ages. Currently available screening tools vary from broad general developmental screening tools to others that focus on specific areas of development, such as motor or communication skills. Their psychometric properties vary widely in characteristics such as their standardization, the comparison group used for determining sensitivity and specificity, and population risk status.
Broad screening tools should address developmental domains including fine and gross motor skills, language and communication, problem solving/adaptive behavior, and personal-social skills. Screening tools also must be culturally and linguistically sensitive. Many screening tools are available, and the choice of which tool to use depends on the population being screened, the types of problems being screened for in that population, administration and scoring time, any administration training time, the cost of the tool, and the possibilities for adequate payment.
Screening tests should be both reliable and valid, with good sensitivity and specificity.
- Reliability is the ability of a measure to produce consistent results.
- The validity of a developmental screening test relates to its ability to discriminate between a child at a determined level of risk for delay (i.e., high, moderate) and the rest of the population (low risk).
- Sensitivity is the accuracy of the test in identifying delayed development.
- Specificity is the accuracy of the test in identifying individuals who are not delayed.
If a test incorrectly identifies a child as delayed, it will result in overreferrals. If a test incorrectly identifies a child as normal, it results in underreferrals. For developmental screening tests, scoring systems must be developed that minimize underreferrals and overreferrals. Trade-offs between sensitivity and specificity occur when devising these scoring systems. Sensitivity and specificity levels of 70% to 80% have been deemed acceptable for developmental screening tests. These values are lower than generally accepted for medical screening tests because of the challenges inherent in measuring child development and the absence of specific curative and clearly effective treatments. However, combining developmental surveillance and periodic screening increases the opportunity for identification of undetected delays in early development. Overidentification of children using standardized screening tools may indicate that this group of children includes some with below-average development and/or significant psychosocial risk factors. These children may benefit from other community programs as well as closer monitoring of their development by their families, pediatric health professionals, and teachers or caregivers.
Table 1 in the original guideline document provides a list of developmental screening tools and their psychometric testing properties. These screening tools vary widely in their psychometric properties. This list is not exhaustive; other standardized, published tools are available. The guideline developers look forward to further evaluation/validation of available screening instruments as well as the continued development of new tools with stronger properties. Child health professionals are encouraged to familiarize themselves with a variety of screening tools and choose those that best fit their populations, practice needs, and skill level.
Incorporating Surveillance and Screening in the Medical Home
A quality-improvement approach may be the most effective means of building surveillance and screening elements into the process of care in a pediatric office. Improving developmental screening and surveillance should be regarded as a "whole-office" endeavor and not simply a matter of clinician continuing education or the addition of tasks to well-child visits. Front-desk procedures, such as appropriate scheduling for screening visits and procedures for flagging children with established risk factors, need to be explicitly designed by the office staff. Nonphysician staff may need training in the administration of developmental screening tools. The input of consumers is crucial to developing an effective system and can be accomplished by adding a parent to an office planning team, by using parent focus groups, or by administering parent questionnaires. Specific to developmental screening could be consumer opinion about preferences for completing questionnaires in the office or before the visit, how they would like to be informed about the results of screening, how parents of children with identified conditions associated with developmental delay would like to have their children's development monitored, or feedback on parental satisfaction with their child's developmental screening or feedback on the referral process.
Refer to the original guideline document for Current Procedural Terminology (CPT) codes for developmental screening and other information related to screening payment.