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Early Detection of Developmental and Behavioral
Problems
Frances Page Glascoe, PhD*
OBJECTIVES:
After completing this article, readers should be able to:
1. List the percentage of children who drop out of school and have
undetected disabilities or known environmental risk factors.
2. Describe the ways in which early intervention is effective.
3. Delineate methods of detecting disabilities and development delays.
4. Describe the percentage of children in whom assessment tools can
detect disabilities correctly.
5. Determine how often children should undergo developmental testing.
6. Describe the role of parents in detecting and addressing developmen-
tal and behavioral problems.
Epidemiology and Issues for
Clinicians
Approximately 15% to 18% of chil-
dren in the United States have
developmental or behavioral disabil-
ities. An additional 7% to 10%
experience substantive school failure
and drop out before completing high
school. Overall, one in four children
has serious psychosocial problems.
To ensure that these children are
detected early and their difficulties
addressed, the American Academy
of Pediatrics’ Committee on Chil-
dren with Disabilities recommends
that pediatricians use validated
screening tools at each health super-
vision visit.
Many pediatricians find it diffi-
cult to comply with this recommen-
dation because of minimal reim-
bursement, young patients’ limited
compliance with requests to stack
blocks or answer questions, time
constraints, and concerns about the
accuracy and length of well-known
screening tools. Finally, children
who are at environmental risk for
developmental delays and subse-
quent school failure due to poverty,
limited parental education, and simi-
lar risk factors do not always
receive health supervision visits.
Accordingly, they are unavailable at
times when pediatricians typically
are most vigilant in their search for
developmental problems.
UNDERDETECTION
Most physicians depend on clinical
judgment rather than screening tools.
Unfortunately, research shows that
clinical judgment detects fewer than
30% of children who have mental
retardation, learning disabilities, lan-
guage impairments, and other devel-
opmental disabilities. Clinical judg-
ment also identifies fewer than 50%
of children who have serious emo-
tional and behavioral disturbances.
Use of improved classification sys-
tems, such as the Primary Care ver-
sion of the American Psychiatric
Association’s Diagnostic and Statis-
tical Manual (DSM-PC), may lead
to higher identification rates,
although research on this possibility
is needed.
Why is the identification of psy-
chosocial problems so poor? One
culprit may be the developmental
checklists typically embedded in
pediatric encounter forms. Although
these contain different tasks for
patients of different ages, checklists
are neither validated nor standard-
ized. None provides proof that spe-
cific items measure important skills,
and none has scoring criteria that
enable clinicians to determine how
many failed items is too many.
Should the child who misses one out
of the typically four or five tasks
listed (eg, puts two words together,
stands on one foot for 10 seconds)
be referred? Two of five? Three of
five? No one knows. Physicians
never would use such haphazard and
unproven methods for screening
blood lead levels, thalassemia, or
hypothyroidism. Why do we accept
less for development and behavior?
Even when screening tests are
used, many clinicians administer
them only after noticing a problem,
rather than using them with asymp-
tomatic patients, as recommended.
Other contributions to limited detec-
tion include nonstandardized appli-
cations of standardized measures,
such as administration of only
selected items on the Denver Devel-
opmental Screening Test-II. These
violations to test validity also may
leave professionals without clear
information on children’s develop-
mental and behavioral status.
THE CONTRIBUTION OF
DEVELOPMENT
The nature of developmental prob-
lems adds to the challenges of early
detection. Young children’s symp-
toms are often subtle and difficult to
discriminate from normal develop-
ment. For example, most children
who have disabilities talk, but they
may not talk well. They usually
read, but may not read well. Simi-
larly, a child who has serious atten-
tional or behavioral problems may
be obedient and focused during a
brief office visit. Few children who
have disabilities are dysmorphic or
show other symptoms likely to be
apparent on physical examination.
Development is also a “moving
target.” Developmental disabilities
develop just as normal development
does. It is impossible to determine
that a 12-month-old child has a lan-
guage impairment until vocabulary
or word combinations fail to emerge
or emerge only in an attenuated
state. Learning disabilities and atten-
tion deficit disorder rarely are
detected until 4 to 7 years of age,
when children initially are exposed
to reading instruction and other
structured academic tasks. Not
apparent until 2 to 3 years of age is
the adverse impact of environmental
risk factors, including single parent-
hood, less than a high school educa-
tion for the parent, limited social
*Associate Professor of Pediatrics, Division
of Child Development, Vanderbilt University
School of Medicine, Nashville, TN.
ARTICLE
272 Pediatrics in Review Vol. 21 No. 8 August 2000
support, parental mental health prob-
lems (eg, depression), poverty, fre-
quent life events (eg, household
moves), more than three children in
the home, an authoritarian parenting
style in which children are the recip-
ients of abundant commands but
little conversation, and minority
status.
The Value and Availability of
Early Intervention
Early intervention is effective
because development is malleable
and readily affected by the environ-
ment. In large part, early interven-
tion works by systematically remov-
ing external risk factors. Early
intervention programs place children
in developmentally enriching set-
tings, train parents in responsiveness
and effectiveness, and provide con-
tinuous positive redirection and
focused building of skills.
Two years of intervention prior to
kindergarten produces substantial
economic, academic, and social ben-
efits and saves society between
$30,000 and $100,000 per child (see
Meisels and Shonkoff in Suggested
Reading for additional information).
Children receiving early intervention
are more likely to complete high
school, maintain jobs, live indepen-
dently, and avoid teen pregnancy
and criminality. Recognizing these
positive outcomes, Congress enacted
the Individuals with Disabilities
Education Act, which ensures the
national availability of early inter-
vention and public school special
education for children up to age 22
who either have disabilities or have
a high degree of biologic risk. Chil-
dren at environmental risk typically
are not eligible for these programs,
but they are served by other feder-
ally funded services, such as Chap-
ter I, Head Start, and other develop-
mental stimulation programs.
The benefits of early intervention
clearly depend on early detection,
which requires that clinicians know
how to identify accurately patients
who have disabilities. Because time
and reimbursement are limited, clini-
cians also should know how to iden-
tify patients quickly. Fortunately, a
number of recently published mea-
sures offer both accuracy and
brevity.
Standards for
Developmental/Behavioral
Screening Measures
Hundreds of assessment measures
are on the market in the United
States, and their publication is an
unregulated industry in which no
governmental agencies or scholarly
societies prevent tests of poor qual-
ity from being advertised and sold.
Accordingly, clinicians must be
familiar with standards for screening
measures so they can select tools
that have appropriate levels of accu-
racy. Such tests bear the burden of
proof that the majority of children
who do or do not have problems
will be identified correctly.
Because of the malleability and
age-related manifestations of devel-
opment, standards for developmen-
tal/behavioral screening tests are
somewhat lower than is accepted for
medical screens. Even so, good
developmental/behavioral tools have
sensitivity to psychosocial problems
of 70% to 80% and specificity to
normal development of 70% to 80%.
Although 20% to 30% of children
will be over-referred, false-positive
identifications often are children
whose intellectual, language, or aca-
demic skills are below average.
These children may not qualify for
special education, but they still need
unique care from clinicians (eg, their
parents will benefit from suggestions
for developmental promotion and
children will benefit from Head
Start or other developmental stimu-
lation programs, summer school,
tutoring, and vigilant clinical moni-
toring to detect emerging disabili-
ties). The 20% to 30% of children
who have disabilities and are not
detected by the single administration
of a screening measure are likely to
be identified subsequently if clini-
cians comply with the recommenda-
tion of the Committee on Children
with Disabilities and screen develop-
ment repeatedly at all health super-
vision visits.
The Value of Tools Relying
on Information from Parents
The most effective tools for use in
primary care are those that rely on
information from parents. Parent-
based tools eliminate the need to
obtain cooperation from children
who are noncompliant, afraid,
asleep, or even sick. Such tests can
be completed in waiting rooms, sent
home in preparation for a follow-up
appointment, or administered by
interview or over the telephone
when illiteracy is likely or when
families do not make regular health
supervision visits. Many parent-
based tools are published in Spanish
and other languages. Most screens
relying on information from parents
are far briefer than tools that elicit
children’s skills directly and can be
equally accurate. Finally, some mea-
sures have options for directly elicit-
ing skills from children when com-
munication between parent and
provider is problematic (eg, new
foster parents or nonprimary care-
takers who may not know much
about the child).
The question has been raised
whether information from parents
can be trusted. What about parents
who are less educated, live in iso-
lated rural areas, have little parent-
ing experience, or appear highly
anxious or depressed? Research
shows that almost all parents, if pre-
sented with well-constructed ques-
tions, can give accurate information
about their child, regardless of dif-
ferences in socioeconomic status,
geographic location, or parental
well-being. One of the reasons is
that parents usually derive their
responses by comparing their child
to others, often while waiting for
pediatric care. Comparison is a sim-
ple intellectual task, which seems to
explain why almost all parents can
provide quality information about
their children. Nevertheless, parents
who have limited education often
have limited literacy, and they may
respond randomly to questionnaires
or omit many items. To circumvent
this, it always is wise to ask parents
before giving them forms whether
they would like to complete mea-
sures on their own or have someone
go through them with them.
Developmental and
Behavioral Screening Tools
for Primary Care
Several high-quality tools relying on
parent report (descriptions of chil-
dren’s behavior, skills, and environ-
ments) are described in Table 1. All
CHILD DEVELOPMENT
Developmental Assessment
Pediatrics in Review Vol. 21 No. 8 August 2000 273
TABLE 1. Accurate Developmental and Behavioral Screening Tests That Rely on Information From Parents
SCREENS AGE RANGE DESCRIPTION SCORING ACCURACY* TIME FRAME
Developmental
Child Development Inventories
(formerly Minnesota Child
Development Inventories)
Behavior Science Systems
Box 580274
Minneapolis, MN 55458
612-929-6220 ($41.00)
3 to 72 mo Three separate instruments, each
having 60 yes-no descriptions. Can
be mailed to families, completed
in waiting rooms, or administered
by interview or by direct
elicitation. A 300-item assessment-
level version may be useful in
follow-up studies or subspeciality
clinics and produces age-
equivalent and cutoff scores in
each domain.
A single cutoff tied
to 1.5 standard
deviations below
the mean.
Sensitivity in detecting
children who have
difficulties is
excellent (greater
than 75% across
studies), and
specificity in
correctly detecting
normally developing
children is good
(70% across studies).
About 10 min
Ages and Stages Questionnaire
(formerly Infant Monitoring System)
Paul H. Brookes, Publishers
PO Box 10624
Baltimore, Maryland 21285
1-800-636-3775 ($130)
0 to 60 mo Clear drawings and simple directions
help parents indicate children’s
skills. Separate copyable forms of
10 to 15 items for each age range
(tied to health supervision visit
schedule). Can be used in mass
mail-outs for child-find programs.
Single pass/fail
score.
Sensitivity ranges
from 70% to 90% at
all ages except the
4-month level.
Specificity ranges
from 76% to 91%.
About 7 min
Parents’ Evaluations of Developmental
Status (PEDS)
Ellsworth & Vandermeer Press, Ltd.
PO Box 68164
Nashville, TN 37206
Phone: 615-226-4460
Fax: 615-227-0411
http://www.pedstest.com
($38.99 English materials)
Birth to 8 y 10 questions eliciting parental
concerns. Waiting room, interview,
and Spanish versions. Written at
the 5th grade level. Identifies
when to refer; provide a second
screen; counsel; or monitor
development, behavior, and
academic progress.
Identifies when to
refer, screen,
counsel, reassure,
or monitor more
vigilantly.
Sensitivity ranging
from 74% to 79%
and specificity
ranging from 70%
to 80% across age
levels.
About 2 min
CHILD DEVELOPMENT
Developmental Assessment
274 Pediatrics in Review Vol. 21 No. 8 August 2000
Table 1. Accurate Developmental and Behavioral Screening Tests That Rely on Information From Parents—Continued
SCREENS AGE RANGE DESCRIPTION SCORING ACCURACY* TIME FRAME
Behavioral/Emotional
Eyeberg Child Behavior Inventory
Psychological Assessment Resources
P.O. Box 998
Odessa FL 33556
1-800-331-8378 ($63.00)
2
1
⁄
2
to 11 y
(best used to
age 4)
A total of 36 short statements of
common behavior problems. More
than 16 suggests referral for
behavioral interventions. Fewer
than 16 enables the measure to
function as a problems list for
planning in-office counseling and
selecting handouts.
Single refer/nonrefer
score for
externalizing
problems (eg,
conduct, attention,
aggression).
Sensitivity 80%,
specificity 86%.
About 7 min
Pediatric Symptom Checklist
Jellinek MS, Murphy JM, Robinson
J, et al. Pediatric Symptom Checklist:
Screening school age children for
psychosocial dysfunction.
J Pediatr. 1998;112:201–209 (the test
is included in the article) and in the
book Collaborating With Parents
Ellsworth & Vandermeer Press, Ltd.
PO Box 68164
Nashville, TN 37206
Phone: 615-226-4460
Fax: 615-227-0411
($69.99)
4 to 16 y 35 short statements of problem
behaviors, including both
externalizing (conduct) and
internalizing (depression, anxiety,
adjustment). Ratings of never,
sometimes, or often are assigned a
value of 0, 1, or 2. Scores totaling
28 or more suggest referrals. Item
patterns can help decide whether
mental health services (best for
internalizing disorders) or behavior
interventions (for externalizing
disorders) are needed.
Single refer/nonrefer
score, although
forthcoming
research may
illustrate how to
identify children
who have
depression from
those who have
conduct and
attentional
problems.
All but one study
showed high
sensitivity (80% to
95%), but somewhat
scattered specificity
(68% to 100%).
About 7 min
Family Psychosocial Screening.
Kemper KJ, Kelleher KJ. Family
psychosocial screening: instruments
and techniques. Ambul Child Health.
1996;4:325–339 (the measures are
included in the article) and in the
book Collaborating with Parents
Ellsworth & Vandermeer Press, Ltd.
PO Box 68164
Nashville, TN 37206
Phone: 615-226-4460
Fax: 615-227-0411
($69.99)
Screens parents
and is best
used along
with the
previously
listed screens.
A two-page clinic intake form that
identifies psychosocial risk factors
associated with developmental
problems, including: a four-item
measure of parental history of
physical abuse as a child, a six-
item measure of parental substance
abuse, and a three-item measure of
maternal depression.
Refer/nonrefer
scores for each
risk factor.
All studies showed
sensitivity and
specificity to larger
inventories greater
than 90%.
About 15 min
*Sensitivity is the percentage of children correctly detected who have problems. Minimum standards for sensitivity are 70% to 80%. Specificity is the percentage of children correctly detected who
have no problems. Minimum standards for specificity are 70% to 80%.
Adapted with permission from Glascoe FP, Collaborating with Parents: Using Parents’ Evaluation of Developmental Status to Detect and Address Developmental and Behavioral Problems in
Children. Nashville, Tenn: Ellsworth & Vandermeer Press, Ltd; 1998.
CHILD DEVELOPMENT
Developmental Assessment
Pediatrics in Review Vol. 21 No. 8 August 2000 275
meet standards for screening test
accuracy, and all take 10 or fewer
minutes to complete. One of the
tools is the standard clinic intake
form used at the University of
Washington in Seattle. It detects
environmental risk factors for devel-
opmental problems, such as limited
parental education, parental mental
health problems (including depres-
sion), history of abuse as a child
(which is associated with too per-
missive or too punitive parenting),
limited social support, and substance
abuse. Imbedded within the form are
questions about parental interest in
seeking services for these problems,
which makes it easier for clinicians
to offer focused in-office counseling
and referrals. The children of these
parents may be identified by devel-
opmental/behavioral screening mea-
sures, but identifying children who
have a high degree of environmental
risk helps clinicians know when to
suggest developmental stimulation
activities and other services (eg,
Head Start, quality child care, fam-
ily training, and social work/mental
health intervention).
The Parents’ Evaluation of
Developmental Status (PEDS) was
developed out of four cross-
validation studies on a nationally
representative sample of families.
This tool is especially useful in pri-
mary care because it is brief and
makes use of parents’ concerns or
judgments about their child’s devel-
opmental and behavioral status.
Probabilities of disabilities are
assigned to parental complaints. This
information, which takes about
2 minutes to elicit and interpret,
enables physicians to determine the
need to refer and where, when to
provide advice about child-rearing
and developmental stimulation,
when to provide reassurance, when
children should be monitored more
vigilantly, and when additional
screening is needed. Thus, this
evidenced-based triage tool and
guidance system helps to manage a
wide range of psychosocial issues
that arise in pediatric offices while
also offering a high degree of accu-
racy in selecting among the many
possible responses to parental com-
plaints. A completed PEDS response
form is presented in Figure 1.
Use of the PEDS
CLINICAL ADVANTAGES
Although many clinicians routinely
ask questions not unlike those pre-
sented in PEDS, research shows that
parents do not respond well to alter-
native wordings. For example, “Do
you have any worries about your
child’s development?” is not effec-
tive because only 50% of parents
understand the word “development”
and because the word “worries” is
too onerous. Parents do not always
respond the first time they are asked
about their concerns. Across several
studies, about 40% of parents
reported having concerns but not
sharing them with their child’s clini-
cian. Finally, when parents do
respond to informal questions about
concerns, they are not always fully
prepared to discuss them. Parents,
unlike professionals, may not think
about development as a series of
domains (eg, expressive and recep-
tive language, fine and gross motor,
personal-social). For these reasons,
PEDS gives parents multiple oppor-
tunities to express their concerns
and prompts them to consider how
their children are doing in each area.
This helps the parent who initially
complains about obedience, for
example, to consider whether the
child hears well enough; has the
motor skills, memory, or attention to
comply with requests; or has the
language skills to understand what
he or she was asked to do.
FIGURE 1. Sample PEDS response form.
CHILD DEVELOPMENT
Developmental Assessment
276 Pediatrics in Review Vol. 21 No. 8 August 2000
PEDS also provides much-needed
guidance on scoring and interpreting
parents’ concerns. For example,
many parents present their concerns
tentatively (eg, “I used to be wor-
ried, but I think he’s doing better
now” or “She’s my first, so I’m not
really sure but....”). Research
shows that unless such responses are
categorized as concerns, develop-
mental delays will be underdetected.
Interpretation of parents’ concerns
also is challenging because only
some concerns are strong predictors
of problems. Further, the predictive
concerns change according to the
age of the child. To account for this,
PEDS includes a longitudinal score
form that illustrates the changing
nature of predictive concerns and
includes a column for each age at
which the American Academy of
Pediatrics recommends a health
supervision visit. The PEDS score
form then directs clinicians to one
of five paths on the PEDS Interpre-
tation Form (Fig. 2). The interpreta-
tion form provides a single con-
tinuous record of developmental/
behavioral surveillance, anticipatory
guidance, and developmental promo-
tion efforts.
PEDS AND PROBABILISTIC
DECISION-MAKING
Path A (Fig. 2) is followed when
parents have two or more checks in
the shaded boxes, which indicate
that there are multiple significantly
predictive concerns. Their children
have 20 times the risk of disabilities
compared with children whose par-
ents do not have concerns, and
almost 70% of affected children
meet criteria for special education
services or perform below average
in language, intelligence, and aca-
demics. Referrals for diagnostic
evaluations are needed, and further
screening should be avoided because
it leads to under-referrals.
The PEDS interpretation form
also helps test users decide on the
necessary broad types of evalua-
tions. Almost 80% of children
requiring audiologic and speech-
language evaluations to determine
eligibility for special services have
parents who raise two or more con-
cerns about receptive language,
school, social, or self-help skills.
More than 70% of children whose
parents raise two or more concerns
in other areas need an assessment by
a psychologist or educational diag-
nostician (who can give educational
or adaptive behavior measures) to
determine eligibility. Even with this
referral guidance, clinicians should
use their judgment to decide if men-
tal health services, occupational or
physical therapy, Head Start, or
other interventions also are needed.
Path B is followed when parents
have a single significant concern
(65% of the time parents are con-
cerned about expressive language
FIGURE 2. Sample PEDS interpretation form.
CHILD DEVELOPMENT
Developmental Assessment
Pediatrics in Review Vol. 21 No. 8 August 2000 277
skills). Their children have eight
times the risk of disabilities; 46%
have either disabilities or below-
average achievement. Although it is
possible to refer this entire group for
diagnostic testing because of their
moderate but not high rate of dis-
abilities, over-referrals can be
reduced by administering a second
developmental screening test. The
results of screening tests are used to
determine which children need refer-
rals for developmental evaluations
and which children and parents need
suggestions for promoting
development.
Busy clinicians may wish to refer
to the public schools or to child-find
services for additional screening or
they can send families home with
one of the other tools listed in Table
1 in preparation for a follow-up
appointment. Research showed that
many children in Path B who
received passing scores on screening
still performed in the below-average
range on diagnostic measures. This
suggests that children in Path B (and
Path A) who are found ineligible for
early intervention programs should
be enrolled in early stimulation pro-
grams or quality preschools if possi-
ble to prevent potentially emerging
problems. Otherwise, the develop-
ment of children on Path B should
be monitored frequently (eg, twice a
year) because of their continuing
risk for delays and emerging prob-
lems. Their parents also should be
advised about techniques for stimu-
lating areas of development critical
for school success, such as language
and cognitive skills.
Path C is followed when parents
have nonsignificant concerns (83%
of the time these are about behav-
ior). Their children have only
1.3 times the risk of developmental
problems (7%). Administering addi-
tional developmental screening tests
to this group produces excessive
over-referrals (because the error
inherent in screening is compounded
for very low or very high prevalence
samples). This suggests that the best
response is to advise parents about
behavior management and discipline.
However, families who do not
respond well to brief advice may
have children who have undiagnosed
mental health problems. In such
cases, behavioral/emotional screen-
ing can help identify which children
need referrals for mental health ser-
vices. Several such screens, again
relying on information from parents,
are listed in Table 1. Families whose
children pass such screening but
continue to demonstrate problematic
behavior need referrals for some-
what less intensive services, such as
parent training classes or behavior
intervention programs.
Path D is followed when parents
have no concerns, but there are
obvious communication barriers,
such as speaking a foreign language
not spoken by the clinician or
appearing to have mental health or
language impairments. Their chil-
dren have almost five times the risk
of disabilities; 54% either meet cri-
teria for special education services
or are below average in intelligence,
language, or academic skills. Due to
this moderate level of risk for dis-
abilities and academic difficulties,
additional screening is needed (pref-
erably with measures in which chil-
dren’s skills are elicited directly
rather than via a screening test rely-
ing on parental report). Clinicians
may find it most effective to refer
this group to the public schools or
to child-find services for additional
screening because translators or
social workers are more likely to be
available. Children who fail screen-
ing and are referred for diagnostic
testing but who are found not to
qualify for programs require vigilant
observation, and their parents need
suggestions for promoting develop-
ment. These children have a high
likelihood of below-average intellec-
tual, linguistic, or academic perfor-
mance and a high concomitant risk
for school failure. After-school liter-
acy programs, summer school, and
tutoring also may be needed.
Path E is followed when parents
have no concerns and no apparent
communication barriers. Only 5% of
these children have disabilities, and
only 11% score below average.
Additional screening is not needed
because it leads to excessive over-
referrals. Reassuring parents that
their child appears to be developing
normally and providing routine
monitoring during subsequent health
superivision visits appear sufficient
for this group.
Summary
There are many approaches to orga-
nizing pediatric offices so that
screening tests can be used effec-
tively for detection of problems and
monitoring and counseling families.
Table 2 lists methods that many
pediatricians and residents have
found effective and efficient. By
following some of these suggestions
and using one or more parent-based
tools, clinicians should be able to
detect and address children’s psy-
chosocial problems quickly and
accurately while maintaining patient
flow and working within the time
constraints of primary care. Such
efforts will have substantial long-
term impact on the developmental
and behavioral health of pediatric
patients and their families.
SUGGESTED READING
Glascoe FP. Collaborating with Parents:
Using Parents’ Evaluation of Developmen-
tal Status to Detect and Address Develop-
mental and Behavioral Problems in Chil-
dren. Nashville, Tenn: Ellsworth &
Vandermeer Press, Ltd; 1998
Meisels SJ, Shonkoff JP, eds. Handbook of
Early Childhood Intervention. Cambridge,
England: Cambridge University Press;
1990
Parker S, Zuckerman B, eds. Behavioral and
Developmental Pediatrics: A Handbook
for Primary Care. Boston, Mass: Little
Brown & Company; 1995
Wolraich ML, ed. Disorders of Development
and Learning: A Practical Guide to
Assessment and Management. 2nd ed. St.
Louis, Mo: Mosby-Year Book, Inc; 1996
CHILD DEVELOPMENT
Developmental Assessment
278 Pediatrics in Review Vol. 21 No. 8 August 2000
TABLE 2. Organizing Pediatric Offices for Developmental/Behavioral Promotion and Detection*
1. Ask parents to complete parent-report instruments while in waiting or examination room.
2. To avoid incomplete, incorrect, or nonreturned parent report screens, ask parents if they would like to
complete the measure on their own or have someone go through it with them. Almost all poor readers will
select the latter.
3. Consider mailing parent-report tests in advance of health supervision visits so that physicians need only
score and interpret during the visit. This often improves the quality of parental report because it allows
families sufficient time to respond more thoughtfully. Advance mailings also are helpful with families
whose English is limited because they usually can find someone in the community to help translate items.
4. Set up a return visit devoted to screening when developmental concerns are raised unexpectedly toward the
end of an encounter. A similar alternative is to have office staff call families after such an encounter and
administer a screen over the telephone.
5. Tape-record directions and items on parent-report instruments and use simplified answer sheets to
circumvent illiteracy. This may be particularly helpful for parents whose primary languages are not spoken
by office staff. Refugee resettlement workers may be able to assist in producing foreign language translations.
6. Train office staff to administer, score, and even interpret screening tests.
7. Pool resources with partners so that the practice can hire a developmental specialist to administer screening
tests (and perhaps provide parent counseling, run parent training groups, assist with group health
supervision visits, diagnostic evaluations, and referrals).
8. Recruit education majors or train volunteers to administer screening tests periodically and set a regular
screening day in your office.
9. Maintain a current list of telephone numbers for local service providers (eg, speech-language centers, school
psychologists, mental health centers, private psychologists and psychiatrists, parent training classes). The
availability of brochures describing services may promote parental follow-through on referral suggestions.
The following Website lists child-find/disabilities coordinators state by state: http://www.nectas.unc.edu/
10. Encourage professionals involved in hospital-based care (eg, child-life workers) to screen patients.
11. Collaborate with local service providers (eg, child care centers, Head Start programs, public health clinics,
department of human services workers) to establish community-wide child-find programs that use valid,
accurate screening instruments.
12. Keep parent information sheets handy. My clinic keeps them in plastic binders (so that originals are not
lost). When an issue arises, I retrieve the original handout, copy it, read it on the way back to the
examination room (to refresh myself on the contents), and go through the highlights with parents. Good
sources for parent information include:
●
Barton Schmitt. Instructions for Patient Education. (W.B. Saunders Co., Independence Square West,
Philadelphia, Pa 19106)
●
Wyckoff and Unell. Discipline Without Shouting or Spanking. (Simon & Schuster, 1230 Avenue of the
Americas, NY, NY 10020)
●
Downloadable handouts from the American Academy of Child and Adolescent Psychiatry at
http://www.aacap.org/web/aacap/factsFam/. These include 51 fact sheets written in Spanish, French, and
English on such topics as divorce, disaster recovery, how to choose a psychiatrist.
●
Downloadable handouts from the Ambulatory Pediatric Association for developmental promotion and
other nonmedical issues at http://www.ambpeds.org/ParentHandouts/APAHandoutsTOC.html
13. Use screens as designed, adhering to standard wording, scoring, and decision-making. Violating test
standardization decreases validity and increases the likelihood of underdetection.
14. It is possible that experienced pediatricians memorize test items and internalize norms, which may lead
them to rely heavily on clinical judgment. Because human reasoning is not infallible and judgment can drift
over time, professionals should test their decisions periodically by comparing them with the results of
standardized screening tests.
*Adapted with permission from Glascoe FP, Collaborating with Parents: Using Parents’ Evaluation of Developmental Status to Detect
and Address Developmental and Behavioral Problems in Children. Nashville, Tenn: Ellsworth & Vandermeer Press, Ltd; 1998.
CHILD DEVELOPMENT
Developmental Assessment
Pediatrics in Review Vol. 21 No. 8 August 2000 279
PIR QUIZ
Quiz also available online at
www.pedsinreview.org.
9. The prevalence of developmental or
behavioral disabilities in the United
States is approximately:
A. 1% to 5%.
B. 5% to 10%.
C. 15% to 20%.
D. 25% to 30%.
E. 35% to 40%.
10. A major barrier preventing consis-
tent developmental/behavioral
screening at health supervision
visits is a lack of:
A. Adequate reimbursement for
screening.
B. Intervention programs for
referral once a delay is found.
C. Parental concerns about develop-
mental and behavioral issues.
D. Professional interest by the
clinician.
E. Reliable screening tests.
11. When physicians rely on their own
clinical judgment to detect develop-
mental disabilities, their accuracy
rate has been shown to be:
A. less than 10%.
B. 20% to 30%.
C. 40% to 50%.
D. 60% to 70%.
E. better than the detection rate of
behavioral problems.
12. A true statement about strategies for
detecting developmental disabilities
is that:
A. A diagnostic developmental
evaluation should be performed
on all children living in high-
risk environments.
B. A physical examination to
search for dysmorphic features
is more helpful in detecting
subtle developmental problems
than are screening tests.
C. Developmental surveillance is
necessary only in those children
who are at biologic and environ-
mental risk for a developmental
disorder.
D. Screening tests are used best in
children whose parents already
have a concern about develop-
mental or behavioral issues.
E. Screening tests are designed to
be applied to all children in a
clinical practice.
13. “Early intervention,” defined as
developmental intervention in chil-
dren ages birth to 3 years who have
disabilities,:
A. Has never been shown to be
effective.
B. Is financially dependent on
parent fees.
C. Is mandated by public law.
D. Is not yet available in most
communities.
E. Usually is hospital-based.
14. Parental concerns about their child’s
development:
A. Are not influenced by parental
mental illness.
B. Are usually accurate.
C. Do not need to be validated with
a diagnostic evaluation.
D. Need not be taken seriously.
E. Will always be expressed
regardless of the manner in
which questions are asked.
15. A helpful practice that will facilitate
efficient developmental/behavioral
screening is to:
A. Abandon screening after the
child has passed three consecu-
tive tests.
B. Defer screening of all children
to a developmental specialist.
C. Rely solely on testing performed
in a health clinic environment.
D. Train office staff to administer,
score, and interpret screening
tests.
E. Use only those portions of a
screening test that relate directly
to the parent’s concern.
CHILD DEVELOPMENT
Developmental Assessment
280 Pediatrics in Review Vol. 21 No. 8 August 2000