Incorporating a parent-completed developmental screening tool into 12- and 24-month well-child office visits in a busy practice increased referrals for further evaluation by 224% in a recent study.

The finding underscores the need for increased attention to providing developmental screening in the office setting, as is recommended by the American Academy of Pediatrics, according to Dr. Kevin Marks, one of the study authors.

Indeed, a July 2006 AAP policy statement calls for formal, systematic, developmental screening at 9 months, 18 months, and between 24 and 30 months of age, and for developmental surveillance at every pediatric visit (Pediatrics 2006;118: 405–20), Dr. Nancy Murphy, chair of the AAP Council on Child Development, and associate professor of pediatrics at the University of Utah, Salt Lake City, said in an interview.

The formal screening is particularly important, because it seems that the very children who benefit the most from early intervention—such as children with mild delays, children from low socioeconomic backgrounds, and younger children with early signs of autism—often are the same children whom physicians fail to identify in a timely manner without the help of universal, periodic, standardized developmental screening, said Dr. Marks of PeaceHealth Medical Group in Eugene, Oregon, where the study was conducted.

For their study, Dr. Marks and his colleagues asked 1,428 caregivers who brought a child in for a 12- or 24-month visit to complete the validated Ages and Stages Questionnaire (ASQ) in the office or to take it home and mail it back; 54% did so. Twenty health care workers—18 board-certified pediatricians and 2 nurse practitioners—who were blinded to the ASQ results, also evaluated the patients using the Pediatric Developmental Impression (PDI), a tool developed especially for the study to capture physician clinical impression of development.

Children with previously diagnosed developmental delays or disorders were excluded from the study.

A total of 107 referrals (82 unique cases) were sent to a local Part C Individuals with Disabilities Education Act (IDEA) early childhood development agency for further evaluation based on the combined ASQ and PDI results, compared with only 33 referrals made in a control year (224% increase). Based on the PDI alone, 68% of the 107 referred during the study period would not have been referred based on clinical impression alone.

Thirty-eight of the patients referred qualified for special services, an additional 44 were scheduled for developmental monitoring because of “suspect development that may lead to future eligibility,” and 25 did not qualify for services or monitoring under strict state IDEA eligibility requirements, Hollie Hix-Small, Ph.D., of the University of Oregon, Eugene, and her colleagues (including Dr. Marks) reported (Pediatrics 2007;120:381–9). Two of the study authors, Jane Squires, Ph.D., and Dr. Robert Nickel, are ASQ authors who receive publication royalties.

Of note, 96% of the referrals made based on the PDI were children who qualified for developmental services as determined following referral, suggesting that physicians should “trust their intuitions about a child's developmental status if they suspect a delay,” Dr. Marks said in an interview.

Referral based on the PDI was significantly predicted by suspected communication delay (odds ratio 136.50) and gross motor delay (odds ratio 58.80).

However, physicians must realize their observational limitations since 37 of 82 early intervention-eligible or monitored children would have been missed on physician impression alone, he added.

The findings of the study prompted a permanent—and more extensive—change in the practice's developmental screening protocol, Dr. Marks said.

“We quickly changed to a 12-, 24-, and 36-month universal ASQ screening schedule and will soon likely add on the 18-month ASQ,” Dr. Marks said, noting that the greatest effects of the use of the ASQ in the office-setting in the study were seen in the 12-month-old children. For example, 5 referrals were made in the 12-month age group in the control year, compared with 33 based on the ASQ in the screening year and a total of 40 based on the combined ASQ and PDI referrals in the screening year; in the 24-month-old age group, 28 referrals were made in the control year, compared with 44 based on the ASQ in the screening year and a total of 67 based on the combined ASQ and PDI referrals in the screening year.

“We have also been heavily encouraging Medicaid, younger [under 21 years old] and Spanish-speaking parents to fill out the ASQ before or immediately after the well-child visit,” he said, explaining that this tactic has improved the poststudy ASQ return rates.

While the 54% return rate is adequate for study purposes, it is important that a better rate be achieved in routine practice, he noted.

The approach used in the study—completing the ASQ in the office or mailing it back later—proved feasible.

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Physicians should 'trust their intuitions about a child's developmental status if they suspect a delay.' DR. MARKS

Parent-Completed Tool IDs Development Issues