Summary

Early identification of developmental disorders is an essential activity in every pediatric practice, but suffers from time constraints in office evaluation and the overlap between normal and potentially at-risk findings reported by parents and observed by the clinician. By systematically applying the graduated approach of developmental surveillance to every child, with more specific developmental testing at ages 9 months, 18 months, and 24 months or 30 months, children with developmental disorders can be identified at an early age. They can then be referred to early intervention providers and other programs to minimize subsequent developmental problems.

Educational objectives

At the conclusion of this activity, participants will be able to:

• Identify the graduated approach to screening for developmental problems
• Recognize children at risk for developmental disabilities that require early screening
• Refer to community resources for further evaluation and treatment once screening has identified children at risk for developmental problems

CME credit

This is an article from The Child's Doctor, Fall 2007 issue. You may take the quiz for learning purposes, but credits are no longer valid.

Author disclosures

Dr. Swisher has no industry relationships to disclose and does not refer to products that are still investigational or not labeled for the use in discussion.

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A developmental disability refers to a childhood mental or physical impairment or combination of mental and physical impairments that result in substantial functional limitation in major life activities. Developmental disorders can present in 2 general patterns, as seen in children with the following features.

"High frequency, limited morbidity" pattern:

• Learning disabilities
• Attention disorders
• Behavioral problems

"Low frequency, high morbidity" pattern:

• Multiple congenital anomalies
• Prenatal and perinatal problems
• Neurogenetic disorders

The former group may be more easily identified at the time of entering school, while the latter usually is referred for comprehensive evaluations very early in life.

Although there is a well-established program for further assessment and provision of therapy for the child at risk for developmental disabilities – the Early Intervention program – identification of children for further evaluation has several challenges related to the changing manifestations of the developing brain.

Complex genetic mechanisms are increasingly recognized as underlying the majority of developmental disabilities, including global delay and more specific learning disabilities such as dyslexia. The interaction of these genetic mechanisms with environmental stressors or toxins remains an area of controversy and active investigation. The genetic basis of autistic spectrum disorders, for example, has been extensively studied and is extraordinarily complex, with a failure of regulation of groups of genes in the normal complex pattern of postnatal brain development. This results in a disruption of normal language and socialization despite a not-infrequent history of near-normal early development.

In assessing a child for developmental disabilities, motor development is understandably assessed earlier and more specifically than language and social development. While motor function is usually rather well established and predictable by 2 years of age, language and cognition have a far more variable pattern of development. For this reason measures of language and cognition are not very predictable of subsequent performance until age 5 years. Therefore, it is often more appropriate to speak of the infant as a child "at risk" for developmental disabilities early in life, rather than as exhibiting a defined disorder. Surprisingly, most children with risk factors for developmental disabilities do not later manifest any disabilities, while most children with well-identified disabilities have no preexisting risk factors. Most of the commonly utilized screening tests for developmental disabilities have many false positive results and miss a considerable number of children with true delay.

Graduated approach to developmental surveillance and screening

In order of increasing complexity, surveillance is the process of recognizing children who may be at risk for developmental delays, screening is the use of standardized tools to identify and define that recognized risk, and evaluation is the complex process aimed at identifying specific developmental disorders.

While surveillance and screening can be managed as part of the routine of office pediatrics, a complete evaluation of the child usually requires the additional input of an interested pediatrician who can schedule extra office time, a developmental pediatrician, or child neurologist. There are separate CPT codes for billing developmental screening and developmental evaluations. These are outlined in the American Academy of Pediatrics (AAP) guidelines.[1]

In the recent policy statement regarding developmental screening in the pediatric office published in 2006,[1] AAP made the following recommendations:

• Developmental surveillance should be provided at every preventive visit through childhood, with adequate history (especially family and perinatal events), observations, and documentation.
• Standardized developmental testing should be provided for children who appear at low risk for a developmental disorder at the 9-, 18-, and 24- or (ideally) 30-month visits, or for children whose surveillance yields concerns about delayed or disordered development.
• Early return visits should be scheduled for children who have raised developmental concerns that are not initially confirmed by a developmental screening tool.
• Children who have raised developmental concerns should be referred to the local Early Intervention (birth to 3 years) or Early Childhood (3 to 6 years) programs.
• The pediatric office should coordinate developmental and medical evaluations for children who have positive screening results for developmental disorders.

In the usual pediatric setting, the yield from most general developmental screening tests is low because fortunately the incidence of such problems is low. It is important to provide graduated surveillance and screening however, to identify early the children at risk for developmental problems. We can view this graduated approach as an increasing level of professional input from informal screening (ie, surveillance) to routine formal screening (ie, standardized testing) to focused screening (ie, periodic screening of children at special risk for developmental problems).[2]

Children who by history are at risk for developmental problems will require formal screening at the onset. Examples of the prenatal or perinatal conditions that pose a risk for developmental disorders include birth weight less than 1500 g, persistent pulmonary hypertension, intrauterine growth retardation, maternal HIV, family history of childhood deafness and blindness, among others.[2] Postnatal risk factors include meningitis, brain-spinal cord trauma, lead poisoning, chronic serous otitis media, seizure disorder, severe chronic illness such as cancer or cystic fibrosis, and child abuse or neglect.[2]

Informal screening is based on observation of the child during a routine well-child visit, asking parents if they have concerns about their child's development, or observation of the child performing several developmental tasks appropriate to the child's age. In this approach, parent reports are often relied on more than direct observation.

Routine formal screening can be performed by a number of assessment tools, including a parent-completed screening system, a check sheet listing developmental milestones at specific ages, and specific developmental screening instruments requiring examination of the child. General developmental screening tests, such as the Denver Developmental Screening Test, are most effective in identifying young children with moderate to severe motor or cognitive deficits from any cause.[3] These tests must be taken in the context of the variable response of the developing brain in regard to specific tasks of language and cognition up to the age of 5 years. A list of several of the more popular tests is found in Table 1. The AAP lists many other screening tools.[1]

Developmental assessment must also take into account the patterns of behavior and socioemotional function demonstrated by the child. A pattern of greater intensity and persistence of common behaviors, such as feeding problems, crying, and temper tantrums, is often seen in children with developmental delays.[4] Also, the behavioral problem may be confused with a developmental disability and often needs a careful interdisciplinary evaluation to sort out.

It is very important to note that screening tests should not be used for diagnosis. It is incorrect to determine a gross motor level deficit from a general developmental screening test, or label a child as developmentally delayed or mentally retarded based on a screening. A failed developmental screening should lead to further assessment, just as an abnormal neonatal metabolic screening leads to expanded investigation.[2]

Screening plan by risk and age

Blackman[2] has provided a practical plan for screening infants, toddlers, and preschoolers. If children have congenital or chronic conditions such as spina bifida or multiple congenital anomalies that are most likely to be associated with developmental disorders, they should be immediately referred through the Early Intervention or similar programs for evaluation and appropriate care, in addition to other services such as genetic counseling. Developmental screening need not be done in the office setting, since a comprehensive evaluation will be performed. The Early Intervention program in Illinois is organized through 25 regional intake centers (Child and Family Connections) organized by zip code. The main number is 217.782.1981 or call 800.323.4769 regarding a specific referral.

Children who are at high risk for developmental problems, such as children with complications of prematurity or environmental neglect, should receive periodic screening at 6- to 12-month intervals. Children with low risk for developmental disabilities should have a parent-completed developmental questionnaire at 9 months, 18 months, and 24 months of age, as defined by AAP.[1]

Resources and procedures for assessment of children at risk for developmental disabilities aged 3 to 6 years are somewhat different from those for younger children. The comprehensive Early Intervention program, which provides multidisciplinary in-home assessment and treatment for infants and young children, transitions to the Early Childhood program at age 3 years.[5] At that time, the supervision of the evaluation and treatment process reverts from the regional Early Intervention program, which is more therapy-based, to the local school district, which tends to be more educationally based. Therefore the focus on particular aspects of physical and occupational therapy may be less, whereas speech and cognitive assessment may be more prominent. Referral to the Early Childhood program at age 3 requires a visit by the parents and child to the local public school.

Private insurance programs may provide limited support for physical, occupational, and speech programs, but complex interdisciplinary, developmental pediatric, or psychological evaluations are often not covered by private insurance. Teaching hospitals often provide a variety of diagnostic and therapeutic services for the Medicaid population, which may augment the Early Childhood programs.

Conclusion

One of the great pleasures of general pediatrics is the opportunity to follow a child from birth through adolescence and to confront some of the complex neurodevelopmental and behavioral issues, as well as the more defined and self-limited health issues. A surveillance program with coordination of developmental screening and interactions with colleagues in further evaluation is a way to further that end.

REFERENCES

[1.] American Academy of Pediatrics Council for Children with Disabilities. Identifying infants and young children with developmental disorders in the medical home. Pediatrics 2006;118:405-420.

[2.] Blackman JA. Developmental Screening. In: Levine MD, Corey WB, Crocker AC, eds. Developmental-Behavioral Pediatrics. 2nd ed. New York, NY: Saunders; 1992:617-624 (chapter 69).

[3.] Meisels SJ. Can developmental screening tests identify children who are developmentally at risk? Pediatrics 1989;83:578.

[4.] Oberklaid F, Dworkin PH, Levine MD. Developmental-behavioral dysfunction in preschool children: Descriptive analysis of a pediatric consultative model. Am J Dis Child 1979;133:1126.

[5.] Lipkin PH, Schertz M. An assessment of the efficacy of early interventional programs. In: Capute AJ, Accardo PJ, eds. Neurodevelopmental Disabilities in Infancy and Childhood. Baltimore: Brooks; 2006.