This long-awaited American Academy of Pediatrics (AAP) clinical report should be praised for recommending a “universal system,” whereby primary care providers (PCPs) periodically screen in a planned manner for “conditions that affect children’s early and long-term development and achievement, followed by ongoing care.”1 Similar to my proposed revisions for the 2006 AAP algorithm published in 2011,2 a unifying framework is provided for PCPs to better follow multiple AAP surveillance and screening algorithms for developmental, behavioral and/or social-emotional, autism-specific, motor-specific, sensory, and psychosocial problems. As recommended back in 2011,2 key updates to this report better emphasize (1) the promotion of developmental-behavioral wellness into the early detection process and (2) bidirectional care coordination and other follow-up steps when surveillance and screening justify a referral for further evaluation and interventions (eg, home visiting, parenting programs, early intervention or education programs, child care, preschools, medical subspecialists, and mental health providers).
One criticism is about recommending an autism-specific screen in isolation at 24 months. A more evidence-based approach is to administer a broad-band developmental screen, ideally in combination with an autism-specific screen. Robins and Dumont-Mathieu’s3 data and a comprehensive narrative review2 support this dual-screening strategy at 24 months because the accuracy (sensitivity, specificity, positive predictive value, and negative predictive value) of popular, properly validated, broad-band developmental-behavioral screens (Ages and Stages Questionnaires, Ages and Stages Questionnaires: Social-Emotional, Parents’ Evaluation of Developmental Status, and Parent’s Evaluation of Developmental Status: Developmental Milestones) is superior to detecting the 15% to 22% of children responsive to early intervention with a wide array of developmental-behavioral problems compared with the accuracy of the most popular autism-specific screen (the Modified Checklist for Autism in Toddlers, Revised with Follow-Up) to detect 1.5% to 2.2% of children with autism spectrum disorder, who often have co-occurring developmental-behavioral disorders.1–3 Furthermore, a large general population study revealed a concerning number of children with false-positive autism-specific screens (even at 24 months) who are often diagnosed with co-occurring developmental-behavioral disorders or disabilities.4 Although the AAP recommends a broad-band developmental screening at 30 months, the reality is that well-child care compliance in the United States is better at 24 months than 30 months.
A second criticism is about not formally recommending a kindergarten readiness or broad-band developmental-behavioral screening at 4 years. Per the abstract (the only part payers and insurance companies seem to read), “special attention to surveillance is recommended at the 4- to 5-year well-child visit.”1 Although there may not currently be strong evidence for a screening at 4 years, PCPs should read between the lines of this report and routinely administer a parent-completed kindergarten readiness screen, one that accurately measures social-emotional development. “Special attention to surveillance” essentially equates to inefficient office flow procedures with post-visit screening. Given that a child’s developmental-behavioral risks factors and the prevalence of disorders increase with age2,5 and given the need to carefully monitor children previously identified with concerns,2,5 a sizable percentage of 4- and 5-year-olds will be deemed at risk and will need a screening after the AAP’s 6 components of surveillance has been performed with special attention. Understand that many 4-year-olds with diagnosable developmental-behavioral problems and/or significant psychosocial risk factors were likely missed during the birth to two-year period or were previously identified but never linked to evidence-based services.2,5 Finally, as astutely stated in this report, PCPs should know that “the act of [previsit, parent-centered] screening itself provides engagement conversations and builds relationships with families.”
CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.