To assess the degree to which a national sample of pediatric practices could implement American Academy of Pediatrics (AAP) recommendations for developmental screening and referrals, and to identify factors that contributed to the successes and shortcomings of these efforts.
In 2006, the AAP released a policy statement on developmental surveillance and screening that included an algorithm to aid practices in implementation. Simultaneously, the AAP launched a 9-month pilot project in which 17 diverse practices sought to implement the policy statement's recommendations.
Quantitative data from chart reviews were used to calculate rates of screening and referral. Qualitative data on practices' implementation efforts were collected through semistructured telephone interviews and inductively analyzed to generate key themes.
Nearly all practices selected parent-completed screening instruments. Instrument selection was frequently driven by concerns regarding clinic flow. At the project's conclusion, practices reported screening more than 85% of patients presenting at recommended screening ages. They achieved this by dividing responsibilities among staff and actively monitoring implementation. Despite these efforts, many practices struggled during busy periods and times of staff turnover. Most practices were unable or unwilling to adhere to 3 specific AAP recommendations: to implement a 30-month visit; to administer a screen after surveillance suggested concern; and to submit simultaneous referrals both to medical subspecialists and local early-intervention programs. Overall, practices reported referring only 61% of children with failed screens. Many practices also struggled to track their referrals. Those that did found that many families did not follow through with recommended referrals.
A diverse sample of practices successfully implemented developmental screening as recommended by the AAP. Practices were less successful in placing referrals and tracking those referrals. More attention needs to be paid to the referral process, and many practices may require separate implementation systems for screening and referrals.
Strengthening the Pediatrician’s Role in Developmental Screening, Evaluation, and Referral
Alfred L. Scherzer, MD, EdD Departments of Pediatrics and Preventive Medicine, Stony Brook University, School of Medicine, Stony Brook, New York The author has indicated he has no financial relationship relevant to this article to disclose.
The recent report on implementing AAP recommended developmental screening of children for delays, referral for further evaluation, and possible intervention(1), should be of high priority interest to the pediatric community. Some 85% of children were screened during the study period, and 14% of these were found to have “failed”. Yet only 61% of this group was actually referred for further studies and appropriate intervention if indicated.
Early evaluation enables distinction between simple delay, disability, and a possible progressive or degenerative condition (2). Moreover, there is clear benefit in improving family understanding and inter-personal relationships through clarifying failure in development (3). Finally, the benefits of enhanced home care management, reduced deficits, and improved function as a result of early intervention are all well documented(4-5). Yet in this study there was certainly less than acceptable referral, and reason for concern.
There are two facets of the report that particularly warrant closer scrutiny. They relate to the screening instruments themselves, and the pivotal role of physician participation. Firstly, there is the issue of the parent screening process. While it is true that 85% of the practices studied actually implemented developmental screening, a variety of parent- completed screening instruments were employed in the process. Moreover, both failure rates and referral frequency varied with the instrument utilized. Obviously, it is very difficult to assess relevance of the identification process without a standardized and uniform screening procedure. Change to such an instrument would be essential in future replication of this type of study to allow unvaried statistical comparison.
Secondly, although the practices were selected on the basis of strong interest expressed in developmental screening, and the lack of referral may be partly related to administrative issues, there should be considerable concern about actual physician participation in the entire evaluation and referral process. The study report does not indicate if a “failed” screen elicited specific clinical review or confirmation by the physician. It is also apparent that the significance of a “failure” was at the discretion of the practitioner – either to disregard its possible relevance, to clinically probe further, and/or to follow through with referral for further evaluation and possible intervention. One can interpret this to mean that among the practitioners there was either a dearth of sensitivity or acceptance of the parent screens, the value of referral as a next important step was not appreciated or accepted, or implementing referral was not considered an important or high priority. All of which suggests that even in this selected consortium of American practices there may indeed be significant limitations in pediatrician attitudes, understanding, acceptance, and awareness of the early identification and intervention process.
Existing studies continue to confirm this concern that pediatrician attitudes and understanding are major factors limiting effective early identification and referral(6), in spite of educational efforts of the AAP, CME programs, residency training, and many other avenues. This is increasingly relevant as children with attention deficits, behavior problems, and learning disabilities become an enlarging segment of the pediatric population(7-9). In addition to the AAP recommended screening algorithm(10), and various other educational efforts already in place, perhaps it is time to consider use of a simple check-off reminder form of developmental milestones as part of routine pediatric care, especially for infants and young children. Early milestones have been shown to be significant predictors of development(11), and such a procedure has been used effectively elsewhere (12).
Physician recording of milestones in this manner would be either through parent report or child observation. When a child meets or exceeds the agreed upon number of recorded “failures”, the physician would be reminded/directed to refer for further evaluation. Parent education and early intervention would follow as needed. This check-off procedure would not result in a significant time burden for the physician as it should be an integral part of the examination.
There are several potential benefits. It would enable more clinical focus on the delayed child during the evaluation, confirm or clarify development concerns reported on the parent screens, and help to narrow the current gap observed between identification and referral. Most important, it could help to augment other professional education efforts to strengthen the pediatrician’s developmental perspective. Finally, even false positive children constitute an important at-risk group warranting further evaluation(13).
It would be essential for subsequent follow-up studies to document physician attitudes and motivation in this area. This could enable a more realistic assessment of the extent to which they can think developmentally in the course of routine pediatric practice.
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Conflict of Interest:
None declared