Developmental Screening in Children: Promoting Healthy Development and Catching Problems Early
Increased Risks for Developmental Delay During Early Childhood
The early years provide the foundation for a child’s future development in most aspects of life, including health, academics, and social and emotional well-being. Epidemiologic studies demonstrate that adverse early childhood experiences, premature birth, and inadequate physical and social support contribute to inequality between and within populations, and that interventions with the child and family can help mitigate the effects of adversity.[1-3] In the United States, poverty, nutritional problems, and chronic physical or mental health issues are prevalent; these modifiable factors contribute to inequality in health, development, and lifespan.[4,5]
A recent study by the Centers for Disease Control and Prevention found that in 2008, 15% of children in the United States were diagnosed with a developmental disability, including attention deficit disorder, intellectual disability, cerebral palsy, or autism, and the proportion of affected children was higher in low-income families. According to US Census statistics from 2010, 17.9% of children live in families with incomes at or below the poverty level. Poverty is often accompanied by limited food options, exposure to environmental hazards, chronic physical and mental health problems, and restricted learning opportunities. Only 47.6% of children 3 and 4 years of age attend preschool, and attendance is lower among children living in low-income families.
Another factor affecting child development is caretaker mental health, and 9% of mothers in the United States experience major depression during the year after giving birth.
The Role of Screening for Child Developmental Delay
Screening is a public health service intended to detect specific medical conditions, even in people who believe they are well or who do not perceive that they are at risk for or are affected by a condition. For screening to be effective, appropriate screening tests and preventive care or treatments must be available and acceptable to clinicians and families. Screening tools can be integrated into well-child checks to identify patients and families at risk for nutritional, physical, mental, developmental, and social support problems.
To efficiently screen patients in busy clinics, clinicians can select age-appropriate screening tests for issues that are prevalent in their patient populations and train staff to implement these tests routinely during periodic well-child visits (Appendix, Table 1). Staff should be trained to:
- Provide age-appropriate screening questionnaires to parents;
- Conduct age-appropriate, routine developmental screenings;
- Offer standardized age-appropriate health education;
- Assist clinicians and parents to help arrange referrals;
- Coordinate care between the practice and outside services; and
- Follow-up with community agencies.
The Maternal and Child Health Bureau and the American Academy of Pediatrics partnered to develop Bright Futures, a health promotion and disease prevention initiative that addresses children’s health needs in the context of family and community. Bright Futures offers excellent screening and health education practice aides.
Having staff complete routine screenings and health education during periodic well-child visits frees clinicians to confirm and review the results with parents, identify parental concerns, and focus on treatment plans while supporting a healthy child/parent relationship. The clinician can begin this portion of the patient visit by asking the parents, “Do you have any concerns or questions that you would like to discuss today?” Addressing parents’ concerns and supporting their decisions helps to develop a relationship that ultimately will benefit the child.
Next, confirm and review the screening test results with parents. The clinician can then provide treatment or refer patients to appropriate community resources for patients and families with similar problems. Training staff to use a practice-specific referral form that includes your practice information and the names and contact information of your referral partners will facilitate this process (Appendix, Table 2).
The staff member who completes your practice’s referral form should give a copy to the child’s parents, fax it with the required information to outside referral agencies, and inform the parents on how best to contact your practice and the referral agency in case they have questions or need to reschedule their appointment. Your practice may want to develop a tracking system to monitor high-risk families. Having staff coordinate referrals, obtain results and recommendations from the outside agencies, and ensure that the patient has a follow-up visit with the clinician will help the clinician to support and monitor the patient’s care and create a medical home.[9,10]
Nutritional and Environmental Issues
Nutritional and environmental issues, such as iron deficiency anemia and lead poisoning, affect a child’s health and ability to learn.[5,9] Nutritional and environmental issues may begin in the prenatal setting; adequate prenatal nutrition and healthcare for women with high-risk conditions, such as gestational diabetes, provide infants with a healthy start in life. Breastfeeding should be promoted for all infants, unless a contraindication is present.
Iron deficiency. Iron deficiency occurs in up to 15% of toddlers in the United States. Iron deficiency anemia and lead exposure during infancy and childhood have been found to have long-lasting detrimental effects on neurodevelopment.
Children should be universally screened for iron deficiency anemia at approximately 1 year of age. If the child is found to have mild anemia, standard clinical practice is to provide iron supplementation and repeat hemoglobin testing in 1-3 months. For all infants with anemia, measuring serum ferritin and C-reactive protein or reticulocyte hemoglobin is recommended.
Because of the cost and difficulties of acquiring venous blood from toddlers, standard clinical practice is to evaluate further children with severe anemia, those with a family history of hematologic illness, or infants who have a follow-up hemoglobin level less than 10.0 g/dL. Treatment will depend on the diagnosis. If iron deficiency anemia is diagnosed, management is iron supplementation and dietary education.
Exposure to lead and other chemicals. Risk assessment or screening for lead exposure should be done at 1 year of age unless local prevalence indicates that earlier screening is advisable. Lead testing also should be considered whenever a young child has persistent anemia, lives in housing built before 1977 (when lead was banned from being used in housing paint), or has developmental delay.
It is also prudent to ensure that patients are not exposed unnecessarily to other chemicals that can affect their health, such as pesticides on a field worker’s clothing. This can be mitigated by having the parent change clothes before returning home (see “Center for Environmental Research and Children’s Health” under “Web Resources” at the end of this article).
Nutrition. Every physical examination is an opportunity to monitor the child’s growth and offer nutritional advice. Families who are having difficulty providing food for their children should be referred to such agencies as the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), which is intended to safeguard the health of low-income pregnant, postpartum, and breastfeeding women; infants; and children up to age 5 years. WIC provides nutritious foods to supplement diets and information on healthy eating, including breastfeeding promotion and support. Assistance from the Supplemental Nutrition Assistance Program (formerly known as “food stamps”) also may be available for low-income families; currently, only 56.7% of eligible families are receiving such assistance.
Physical and Mental Health Problems, Including Developmental Delay
According to the 2009-2010 National Survey of Children with Special Health Care Needs, approximately 11.2 million children (ie, children in 1 in 5 households in the United States) have special healthcare needs. During periodic physical examinations, all children should be screened for vision, hearing, speech, and developmental delays; chronic health problems; and functional disabilities, including motor, communication, cognitive, and socioemotional problems.
Children with chronic physical and mental health issues, a history of in utero substance abuse exposure, high lead levels, child abuse, neglect, domestic violence, and developmental delay are generally eligible for early intervention services, as part of the Individuals with Disabilities Education Act (IDEA) Part C (birth to age 3 years) or part B (3 to 5 years).[12,13] These programs are state-required multidisciplinary services for children with developmental delays or at risk for delays.[12,13] Early intervention services offer the child and family treatment and support, giving the child the best chance to reach his or her potential.
Developmental surveillance should be incorporated into every well-child care visit.[9,14] The American Academy of Pediatrics identifies 5 components of developmental surveillance:
- Eliciting and attending to parental concerns;
- Documenting and maintaining a developmental history;
- Making accurate observations of the child;
- Identifying risk and protective factors; and
- Maintaining an accurate record documenting the child’s development.
If a parent or clinician determines that a child is at risk for a developmental problem, specific standardized screening should be implemented. This may be conducted in the medical home; by referral to a behavioral pediatrician; or by referral to programs that offer early intervention services, such as Babies Can’t Wait, state-funded programs for persons with disabilities (for example, the Lanterman Developmental Disabilities Services Act is part of California law that funds Regional Centers), or Early Head Start. In children with a positive screening result for a developmental problem, further developmental and medical evaluations are warranted to identify the specific disorder and refer for early intervention and family support services.
Currently, on the basis of the available scientific evidence, the American Academy of Pediatrics does not have enough evidence to support the implementation of communitywide routine screening for autism. At this time, the American Academy of Pediatrics recommends careful assessment and surveillance of all preschoolers who present with impairments in language or social or cognitive skills development for autism spectrum disorders. None of the currently available autism screening tests has been shown to have sufficient accuracy (ie, high sensitivity, high specificity, and high predictive value) in population-wide screening programs. In addition, neither proven therapies nor preventive measures exist for the universal treatment of children with autism. At this time, the World Health Organization recommends careful surveillance and assessment of all preschoolers for impairments in their development of language, social function, or cognitive skills, with further evaluation of these high-risk children using available standardized testing whenever a problem is suspected.
Family Problems and Social Support Issues
In the United States, up to 12% of all pregnant and postpartum women experience depression in a given year. The consequences of maternal depression include negative effects on the cognitive, social, emotional, and behavioral development of their child.
All parents of infants should be screened for depression (Appendix, Table 1) and offered intervention or referral to promote parental well-being and a healthy parent/child relationship. The US Preventive Services Task Force has endorsed a 2-question screen for depression:
Over the past 2 weeks:
- Have you ever felt down, depressed, or hopeless? and
- Have you felt little interest or pleasure in doing things?”
One “yes” answer is a positive screening result. Responses to a positive screening result range from reassurance to support and referral, depending on available resources, severity of depression, and duration of the parent’s symptoms.
Children need cognitive stimulation to learn. Creating a dialogue with the family about ways they can help their child to learn and helping families who have inadequate resources and social support to identify community resources should be incorporated into routine well-child visits. Such programs as Early Head Start and Head Start are federally funded community-based programs for low-income families with infants, toddlers, and preschoolers. They are designed to enhance the development of young children, and to promote healthy family functioning and school readiness through the provision of educational, health, nutritional, social, and other services. Currently in the United States, only 47.6% of children 3-4 years of age attend preschool, and local Head Start programs may have insufficient funding to provide services to all eligible children.
Apart from these programs, parenting classes may be offered through the local adult school or community college. Libraries often have programs for children and their families, as do such organizations as the YMCA or YWCA. Your practice also may want to participate in Reach Out and Read, an evidence-based literacy promotion program for primary care providers (see “Web Resources”).
Bright Futures recommends screening for domestic violence and violence exposure. Whenever problems are identified, referral to appropriate agencies, including law enforcement and child protective services, is mandated. Development of a support system for your practice — including agreements with local service providers, such as public health nurses, social workers, and mental health professionals — can facilitate assisting families with these issues. Early intervention services offer patient and family support, giving children the best chance to reach their potential.
The foundations of healthy early child development include good nutrition; stable, responsive relationships with caregivers; adequate cognitive stimulation; and a safe, supportive environment. Family medical services must support healthy development while offering family-centered, community-based, and culturally competent services. Incorporating screening and health promotion services into routine well-child visits affords early identification of problems, including nutritional, physical, mental, developmental, and social issues. Training staff and creating and using a practice-specific referral form will facilitate this process. By offering treatment, referral, and follow-up, you can help families have healthy lifestyles and optimize child development, mitigating the adverse effects of problems. By developing an ongoing supportive relationship with families and referral agencies, you will create a medical home for your patients.
Table 1. Recommended Screening Tools
Table 2. Suggested Format for Referrals
|Referral for Family Support Services
|Patient Name:Date of Birth:Primary Care Provider (PCP):Practice Contact:
We are referring our patient to your agency for:
Early Head Start/Head Start:
Mental Health Services/Family Support Services:
Follow-up Appointment With PCP:
PLEASE RETURN WITH YOUR RECOMMENDATIONS TO:
American Academy of Pediatrics: Bright Futures
Bright Futures provides recommendations for preventive pediatric healthcare.
Center for Environmental Research and Children’s Health (CERCH): The CHAMACOS Study
Parent education on preventing environmental exposures to toxic substances is available in the “health professionals” section.
National Head Start Association
Head Start provides a range of comprehensive education, health, nutrition, parent involvement, and family support services to serve primarily at-risk children and their families.
National Early Childhood Technical Assistance Center (NECTAC)
NECTAC provides contact information for state Part C coordinators and other early childhood resources.
National Dissemination Center for Children with Disabilities (NICHCY)
NICHCY provides information on disabilities, Individuals with Disabilities Education Act (IDEA), No Child Left Behind, and research-based information on effective educational practices.
Reach Out and Read
Reach Out and Read prepares America’s youngest children to succeed in school by partnering with medical providers to prescribe books and encourage families to read together.
- Walker SP, Wachs TD, Grantham-McGregor SM, et al. Inequality in early childhood: risk and protective factors for early child development. Lancet. 2011;378:1325-1338. Abstract
- Shonkoff JP, Garner AS; Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129:e232-e246. Abstract
- Engle PL, Fernald LC, Alderman H, et al; Global Child Development Steering Group. Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries. Lancet. 2011;378:1339-1353. Abstract
- US Census Bureau. American Community Survey Statistics. 2010.http://www.census.gov/acs/www/data_documentation/2010_release Accessed May 14, 2012.
- Satcher D. Ethnic disparities in health: the public’s role in working for equality. PLoS Med. 2006;3:e405.
- Boyle CA, Boulet S, Schieve LA, et al. Trends in the prevalence of developmental disabilities in US children, 1997-2008. Pediatrics. 2011;127:1034-1042. Abstract
- National Head Start Association. Benefits of Head Start and Early Head Start programs. http://www.nhsa.org
/files/static_page_files/399E0881-1D09-3519-AD56452FC44941C3/BenefitsofHSandEHS.pdf Accessed April 28, 2012.
- Center on the Developing Child, Harvard University. Maternal depression can undermine the development of young children. Working Paper No. 8. 2009.http://developingchild.harvard.edu/index.php/resources/reports_and_working_papers/working_papers/wp8 Accessed May 14, 2012.
- American Academy of Pediatrics/Bright Futures. Recommendations for Preventive Pediatric Health Care. 2008.http://pediatrics.aappublications.org/content/suppl/2007/12/03/120.6.1376.DC1
/Preventive_Health_Care_Chart.pdf Accessed July 10, 2012.
- Allen SG, Berry AD, Brewster JA, Chalasani RK, Mack PK. Enhancing developmentally oriented primary care: an Illinois initiative to increase developmental screening in medical homes. Pediatrics. 2010;126 Suppl 3:S160-S164.Abstract
- Baker RD, Greer FR; Committee on Nutrition, American Academy of Pediatrics. Clinical report: diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics. 2010;126:1040-1050. Abstract
- US Department of Education. The Individuals with Disabilities Education Act. October 5, 2011.http://www.nectac.org/idea/idea.asp Accessed April 28, 2012.
- US Department of Education. Early intervention program for infants and toddlers with disabilities.http://www.gpo.gov/fdsys/pkg/FR-2011-09-28/pdf/2011-22783.pdf Accessed April 28, 2012.
- Council on Children with Disabilities; Section on Developmental Behavioral Pediatrics; Bright Futures Steering Committee; 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;118:405-420. Abstract
- Al-Qabandi M, Gorter JW, Rosenbaum P. Early autism detection: are we ready for routine screening? Pediatrics. 2011;128:e211-e217.
- Earls MF; Committee on Psychosocial Aspects of Child and Family Health, American Academy of Pediatrics. Clinical report: incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics. 2010;126:1032-1039. Abstract
- US Preventive Services Task Force. Screening for depression in adults. 2009.http://www.ahrq.gov/clinic/pocketgd1011/gcp10s2c.htm#Depression Accessed April 28, 2012.