Lowering Developmental Screening Thresholds and Raising Quality Improvement for Preterm Children

Department of Pediatrics, PeaceHealth Medical Group, 1162 Willamette, Eugene, OR 97401, USA.
PEDIATRICS (Impact Factor: 5.47). 06/2009; 123(6):1516-23. DOI: 10.1542/peds.2008-2051
Source: PubMed


To determine: 1) if preterm children were referred, identified and received early intervention (EI)/ early childhood special education (ECSE) services at rates equivalent to term children after implementation of a universal, periodic Ages and Stages Questionnaire (ASQ) surveillance and screening system; 2) if pediatricians sufficiently lowered their screening thresholds with preterm children;and 3) if quality improvement opportunities exist.
Secondary analysis was performed on 64 lower-risk, mostly late-preterm and 1363 term children who originally presented to their 12- or 24-month well- visits. Higher-risk preemies already involved with an EI agency/ identified with a delay were excluded. Board-certified pediatricians (N=18), and nurse practitioners (N = 2), blind to the ASQ results, were secondary participants. Differences between preterm and term developmental agency referrals were examined comparing Pediatric Developmental Impression to the ASQ under natural clinic conditions using a combined in-office or mail-back data collection protocol. Medical record and county EI/ECSE follow-up outcomes were conducted at 36 to 60 months.
At 12 and 24 months, preterm (versus term) referral rates were 9.5%(versus 5.6%) with Pediatric Developmental Impression and 26.2% (versus 8.1%) with the ASQ. By 36 to 60 months, 37.5% of preterm (20.8% term) children were referred to EI/ECSE; of which, 50.0% of preterm (42.4% term) children were eligible for services, 54.2%of preterm children were identified with a developmental-behavioral disorder and 29.2% of preterm (20.8% term) children did not follow-up. For ASQ-only preterm referrals,55.6% were subsequently diagnosed with a developmental delay and/or disorder.Preterm children were 2 times more likely to be eligible than term children [corrected].
Combined referral, quality improvement and outcome data suggests that clinicians should lower their threshold for administering a psychometrically sound developmental screen when providing surveillance for ex-preemies. Quality improvement opportunities exist with diligent developmental surveillance and a more collaborative, standardized, reliable and interpersonal referral process.

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    • "ADHD has a significant impact on the development of affected children, and carries long-term implications such as learning difficulties, academic underachievement, expulsion from school, and school refusal (Willoughby, 2003). Despite strong evidence for the effectiveness of early identification and intervention (Greenhill et al., 2006; Marks et al., 2009), the implementation of diagnosis and treatment programs for children with ADHD in community settings, such as primary care providers (Rushton et al., 2004; Stevens, 2005) and schools (Sayal et al. 2012), is clearly insufficient. It is estimated that only 28-50% of the children with ADHD are treated by a pediatric or adolescent specialist (Sayal et al., 2010). "

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    • "Other studies, however, have demonstrated that the referral rate of infants should be rather liberal. In one study, following 1363 term children not referred for or identified with delay, the referral rates were 5.6% or 8.1% according to pediatric or ASQ assessment respectively, at 12- or 24-month well-child visits [17]. In the 36-60 months follow-up, 20.8% received referrals of which 42.4% were eligible for services. "
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    • "These and other studies provided support for the approach that sees ADHD as an early developmental disorder . It supports that the need of pediatricians to provide more diligent surveillance and actively lower their thresholds for administering a quality screening of preterm children in order to identify children in need of early intervention [Marks et al., 2009]. "
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