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Description and Policy

 

By incorporating developmental surveillance and screening into preventive health care visits, the pediatrician has the ideal opportunity to offer anticipatory guidance to the family about supporting their child's development and to facilitate early detection of a disorder1. Understanding the importance of medical home in identifying developmental/behavioral issues ensures early treatment, access to early intervention programs, better school placement, and ultimately better developmental outcomes.

What is Developmental Surveillance?
Surveillance is the process of recognizing children who may be at risk of developmental delays. Developmental surveillance is a flexible, longitudinal, continuous, and cumulative process whereby knowledgeable health care professionals identify children who may have developmental problems. There are five components of developmental surveillance:
  • Eliciting and attending to the parents’ concerns about their child’s development
  • Documenting and maintaining a developmental history
  • Making accurate observations of the child
  • Identifying the risk and protective factors
  • Maintaining an accurate record and documenting the process and findings
What is Developmental Screening?
Developmental screening is the administration of a brief standardized tool aiding the identification of children at risk of a developmental disorder. Developmental screening that targets the area of concern is indicated whenever a problem is identified during developmental surveillance.

What Does the Academy Recommend?
The Academy recommends developmental surveillance at every well-child visit and developmental screening using formal, validated tools at 9, 18, and 30 months or whenever a parent or provider concern is expressed. Surveillance and screening activities should be performed within the medical home and coordinated with tracking and intervention services available in the community.

These recommendations are included in the comprehensive policy statement, which includes a clinical algorithm, titled: Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening. This policy was authored by the Council on Children With Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee and Medical Home Initiatives for Children With Special Needs Project Advisory Committee. It originally appeared in the July 2006 issue of Pediatrics, and has been reaffirmed in 2009 and again in 2014. This policy document is currently under revision.

Using the Algorithm
The algorithm below is from the aforementioned developmental surveillance and screening policy statement. Its purpose is to guide providers through the delivery of developmental surveillance and screening.

Algorithm
Printable Algorithm

1) Pediatric Patient at Preventive Care Visit
Developmental concerns should be included as one of several health topics addressed at each pediatric preventive care visit throughout the first five years of life.

2) Perform Surveillance
Developmental Surveillance is a flexible, longitudinal, continuous, and cumulative process whereby knowledgeable healthcare professionals identify children who may have developmental problems. There are 5 components of development surveillance: eliciting and attending to the parents’ concerns about their child’s development, documenting and maintaining a developmental history, making accurate observations of the child, identifying the risk and protective factors, and maintaining an accurate record and documenting the process and findings.

3) Does Surveillance Demonstrate Risk?
The concerns of both parents and child health professionals should be included in determining whether surveillance suggests the child may be at risk of developmental delay. If either parents or the child health professional express concern about the child’s development, a developmental screening to address the concern specifically should be conducted.

4) Is this a 9-, 18-, or 30-month visit?
All children should receive developmental screening using a standardized test. In the absence of established risk factors or parental or provider concerns, a general developmental screen is recommended at the 9-, 18-, and 30-month visits. Additionally, autism-specific screening is recommended for all children at the 18 and 24 month visits.

5a & 5b) Administer Screening Tool
Developmental screening is the administration of a brief standardized tool aiding the identification of children at risk of a developmental disorder. Developmental screening that targets the area of concern is indicated whenever a problem is identified during developmental surveillance.

6a & 6b) Are the Screening Tool Results Positive/Concerning?
When the results of the periodic screening tool are normal, the child health professional can inform the parents and continue with other aspects of the preventive visit. When a screening tool is administered as a result of concerns about development, an early return visit to provide additional developmental surveillance should be scheduled, even if the screening tool results do not indicate a risk of delay.

7) Make Referrals for: Developmental and Medical Evaluations & Early Developmental Intervention/Early Childhood Stories

8) Developmental and Medical Evaluations
If screening results are concerning, the child should be scheduled for developmental and medical evaluations. Developmental evaluation is aimed at identifying the specific developmental disorder or disorders affecting the child. In addition to the developmental evaluation, a medical diagnostic evaluation to identify an underlying etiology should be undertaken. Early Developmental Intervention/Early Childhood Services can be particularly valuable when a child is first identified to be at high risk of delayed development, because these programs often provide evaluation services and can offer other services to the child and family even before an evaluation is complete. Establishing an effective and efficient partnership with early childhood professionals is an important component of successful care coordination for children.

9) Is a Developmental Disorder Identified?
If a developmental disorder is identified, the child should be identified as a child with special health care needs and chronic condition management should be initiated (see number 10). If a developmental disorder is not identified through medical and developmental evaluation, the child should be scheduled for an early return visit for further surveillance. More frequent visits, with particular attention paid to areas of concern, will allow the child to be promptly referred for further evaluation if any further evidence of delayed development or a specific disorder emerges.

10) Identify as a Child With Special Health Care Needs: Initiate Chronic Condition Management
When a child is discovered to have a significant developmental disorder, that child becomes a child with special health care needs, even if that child does not have a specific disease etiology identified. Such a child should be identified by the medical home for appropriate chronic condition management and regular monitoring and entered into the practice’s children and youth with special health care needs registry.



Source:
  1. American Academy of Pediatrics; Council on Children With Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee and Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening. Pediatrics. 2006;118(1):405-420.

Additional DSS Information
Pediatrics Article (2010): Implementing Developmental Screening and Referrals: Lessons Learned From a National Project
Pediatrics Article (2011): Trends in the Use of Standardized Tools for Developmental Screening in Early Childhood: 2002–2009 and Abstract Presented at 2010 PAS Meeting
AAP News (2006): AAP policy, algorithm assist in early developmental screens
AAP News (2011): Pediatricians’ use of developmental screening tools on the rise
AAP News (2011): Efforts must continue to improve developmental screening rates, payment
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