My Concerns About the AAP Clinical Report on “Motor Delays: Early Identification and Evaluation”

The authors should be congratulated for their expert guidance on promptly identifying motor delays and disorders. I support their emphasis on a 48-month broadband/general developmental screening for kindergarten readiness. Nonetheless, I have some concerns.

Introduction: “The most commonly used developmental screening tools (the Ages & Stages Questionnaire [ASQ] and Parents’ Evaluation of Developmental Status [PEDS]) have not been validated on children with motor delays.” Yes, additional research is needed; however, studies suggest clinicians can rely on the results of the ASQ as a whole but not solely on the failed gross or fine motor domains to identify neuromotor delays.^1,2  Other research supports the ASQ’s ability to detect gross motor delays³  and cerebral palsy.⁴  The PEDS user’s manual (already referenced in this clinical report) suggests that it adequately detects motor delays. Although 1 study found the PEDS lacks sufficiently high sensitivity for detecting motor disorders, children receiving early intervention were not excluded, and parents satisfied with services often do not have ongoing concerns.⁵  Nonetheless, the ASQ and PEDS work better in combination with a proper neuromotor examination.

As shown in Fig 1 and Step 3a, the 5 components of developmental surveillance, paraphrased from the original, are as follows: (1) eliciting and attending to caregivers’ concerns, (2) maintaining a developmental history, (3) making accurate observations about the child (and parent-child interactions), (4) identifying risk and protective factors, and (5) maintaining an accurate record of the process and findings. In practice, surveillance does not stop here. It should be reconceptualized to also encompass (6) promoting developmental-behavioral wellness, (7) interpreting/discussing screening results with caregivers, (8) referring to early intervention/early childhood special education and other beneficial community programs, (9) providing referral care coordination, (10) responding to concerning screens or surveillance with supplemental screens and/or medical tests, (11) reviewing referral feedback reports and recommendations while tracking early intervention/early childhood special education eligibility status, and (12) monitoring progress and the need for additional services after initiating chronic condition management for special health care needs (not to mention the decision-making steps in between). Whereas many of these processes were addressed in their algorithm or its main text, component 9 was glaringly missing.

Step 3b: “The aforementioned 2006 policy statement on developmental surveillance and screening provides a list of developmental screening tools and a discussion of how to choose an appropriate screening tool.” Seven years later, numerous studies have been published and tools have been revised or newly developed. Up-to-date, peer-reviewed, higher-quality references on which screening tools to select were missing in action.

Step 9b: Assessment of creatine phosphokinase and thyroid stimulating hormone are recommended for every child with a suspected motor delay and normal or low muscle tone. Perhaps the benefits of this recommendation outweigh its costs, but no study (and certainly not this clinical report) has carefully examined this issue in a scientific manner. This recommendation could potentially lead to large numbers of low-yield blood tests in young children.

Steps 10 and 12a: “Referral care coordination” is not properly emphasized in this algorithm or the main text as a key component of developmental-behavioral surveillance when numerous studies suggest this is exactly what is needed.

The American Academy of Pediatrics should consider revising and unifying its 4 compartmentalized algorithms for identifying and addressing general developmental, autism spectrum, social-emotional/mental health, and motor delays/disorders so a more evidence-based, parent/patient-centered and practical flowchart is offered to clinicians who perform developmental-behavioral surveillance and screening in children aged 0 through 5 years.