Meeting Purpose:
The general objective was to determine how CDC can best contribute to the
goal of promoting optimal child development within public and private
health systems through creating a change in the way general
pediatricians address and manage the developmental needs of children.
More specifically, we sought to discuss how to create a feasible method of
practice that would allow for implementation of the recent developmental
screening recommendations established by the American Academy of
Pediatrics (AAP) Committees, through focusing on:
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current practice
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known barriers to implementing developmental screening nationally
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lessons learned from previous efforts
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potential opportunities for improvement
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inclusion of screening and counseling to encourage positive development
along with identifying and treating potential developmental delays
Rationale for the meeting:
A plethora of neurobiological, behavioral, and social science research has
significantly advanced our appreciation and understanding of the
importance of early life experiences on early brain development and
human behavior. The potential to improve developmental outcomes in
children through planned interventions is now well established. Because
nearly all children under 5 years-of-age participate in well-child care,
the healthcare setting is an ideal place for assuring optimal
development of children. Currently, however, the practice of
developmental screening, and promotion of optimal development, in
primary pediatric care practice varies tremendously and is less than
optimal in most places.
Changing medical practice is challenging and will require a highly
collaborative approach. The change has already begun with the issuance
of AAP Committee statements, extensive work in the field, and the
increasing recognition of the importance of early development on later
behaviors and life outcomes. Furthering this work by developing a
standard of practice that is feasible to conduct within the setting of
well-child care, proving its effectiveness and cost effectiveness,
making it available, providing support for its use, and monitoring
outcomes is critical to advancing our goals.
It became clear, through discussions between CDC’s National Center on Birth
Defects and Developmental Disabilities, AAP, and Center for Child
Well-being, that there are a number of key stakeholders who need to be
consulted and involved in the effort to promote developmental screening.
In addition, we need more thorough discussion about what activities are
already ongoing, and what gaps exist. To gather this information, we
proposed to have a small meeting of 10-15 key stakeholders and experts
in the field.
Location of meeting
Conference Center, Task Force for Child Survival and Development, Decatur,
GA. The meeting was hosted by the Center for Child Well-being, a program
of the Task Force.
Time of meeting
8/19/02 from 1:00-5:00 PM and 8/20/02 from 8:30 AM-12:30 PM
List of Attendees
Issues discussed:
Current State of Developmental Screening–
Barry Zuckerman & Camille Smith
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History of Developmental Screening: Significant changes over the years were
passage of PL 94-142 in 1976, Bright Futures, Early and Periodic
Screening, Diagnosis, and Treatment, Healthy Steps, Early Head Start,
pediatric training in child development, and the creation of
psychometrically sound instruments
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Current Practice:
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Models of Practice/Schedule of practice
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Instruments – several instruments were mentioned such as the Parents'
Evaluations of Developmental Status (PEDS), Ages and Stages, etc.
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Referrals (further diagnostics and assessments, other services that are
available to the child, Part C, Head Start, etc.)
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In summary, even though there have been advances over the years, the
limited amount of evidence available suggests that the delivery of
developmental screening suffers from significant inadequacies including
inconsistent delivery, failure to use validated assessment tools, lack
of confidence in advising concerned parents, available resources, and
inadequate training.
Barriers to Developmental Screening and
Appropriate Follow-Up Care or Services – Frances Glascoe & Martha Rogers
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Training: Physicians feel that they are inadequately trained in child
development and administration and interpretation of screening
instruments. There needs to be more attention paid to clinical judgment.
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Cost/Reimbursement: Physicians feel that they are inadequately compensated
for their time or that they cannot address developmental issues because
they will not be reimbursed for it.
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Time: There is not enough time in the office for screening.
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Staff: Inadequately staffed.
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Lack of knowledge: Need to gain more knowledge in referrals and community
program resources
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Lack of knowledge: Need to gain more knowledge about effective
intervention/treatments after positive screen and improve communication
between physician referral source (for example, physicians often don’t
know what happens to the child that they referred).
In summary, there was much discussion about mechanisms of getting
pediatricians to understand that developmental screening is an essential
part of well-child care. Participants discussed the notion that systemic
change is fundamentally important for the integration of developmental
screening into current health practices.
DAY 2
Federal Partners Presentations
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Current Activities: Maternal and Child Health Bureau (MCHB), Office of
Special Education Programs (OSEP), Part C Activities, Head Start
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Future Plans of each of these agencies were discussed
What can be done and how do we get there?
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Avoiding historical pitfalls: Instead of looking for one quick, inexpensive
way of better service provision we need to examine the system of
developmental services
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Changes at the level of well-child care
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Physician time and reimbursement
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Develop efficient models of practice and of practice support
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Make tested screening tools available
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Prioritize, systematize, and rationalize the schedule and content of
well-child care
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Training
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Continuing medical education.
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Train in adoption of specific clinical procedures including screening and
parent education.
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Science-based education in developmental disabilities.
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Consultation and technical assistance.
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Residency training programs.
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Faculty training
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Curricular materials
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Coordination of resources
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Map referral resources
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Develop standards for resource availability
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Educate physicians about existing resources
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Promote effective communication between community resources and physicians
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Provide easily accessible, reliable care coordination
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Need for data
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Evidence for clinical effectiveness of developmental services.
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Benchmark and routinely collect data on children’s developmental status,
outcomes of services, and parents’ needs for service.
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Demonstrate cost effectiveness and cost benefit of good quality preventive
and developmental care.
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Need for Systemic view
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Strategies for Systemic Change
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Promote adoption of new standards of care
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Support the acquisition of requisite professional skills
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Provide models and tools to restructure well-child care
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Facilitate adequate reimbursement for services
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Foster links between pediatricians and other community resources for
families
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Increase the demand for comprehensive, good quality care
Parents in the Middle: Process of Pediatric Care:
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Pediatric practices are in a unique position to identify children with and
at risk for developmental problems, to evaluate their developmental
status, and to initiate appropriate interventions. Additionally,
pediatricians have the opportunity to recognize the manifestations of
stressors in parenting, evaluate the risks involved, and determine the
necessary interventions.
Pediatric care -> Parenting Behaviors -> Child outcomes
Concluding comments:
At the end of the meeting, each participant was asked to state his/her view
on what CDC’s number one priority should be in promoting developmental
screening in pediatric well-child care. These are summarized in the
Potential Opportunities for CDC to Improve the Practice of Developmental
Pediatrics in Primary Care.
Potential Opportunities for CDC to Improve the Practice of Developmental
Pediatrics in Primary Care
Improving Practice at the Provider Level
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Design a model system of practice that includes cost effective screening
for developmental problems and promotes optimal development that is
integrated within the current system of well-child care.
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Work with a consortium of primary care practices to determine feasibility,
costs, outcomes, and parent/provider satisfaction.
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Produce tool kit for technology transfer to other practices.
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Work with professional organizations to translate these lessons learned
into best practices policy documents.
Improving Practice at the Community Level
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Develop state-wide, multidisciplinary resource centers that would provide a
variety of services including training, increased awareness and
advocacy, research, and coordination and linkage of intervention
services.
Improving Pre-service Training
Addressing Reimbursement Issues
Improve Likelihood of Incorporation into Managed
Care Systems
Improve Advocacy
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Convene parent and other groups that may be working toward improving the
state of a particular developmental problem.
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Organize these groups into a consortium for greater effectiveness.
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Assist consortium in finding non-governmental support for advocacy issues.
Improve the Collection and Use of Data for
Monitoring and Program Evaluation
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Compile list of existing data systems that collect elements of interest
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Develop mechanism for reporting compiled data (annual publication)
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Develop effective distribution plan for data
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Look at data issues from both national, state, and community perspectives
Increase Awareness
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Develop communication plan(s) for increasing education and awareness to the
public, parents, professionals, and community organizations.