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Early Detection of Developmental and Behavioral Problems

Article  in  Pediatrics in Review · September 2000

DOI: 10.1542/pir.21-8-272 · Source: PubMed

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 ARTICLE

Early Detection of Developmental and Behavioral

Problems
Frances Page Glascoe, PhD*
blood lead levels, thalassemia, or
OBJECTIVES: hypothyroidism. Why do we accept
After completing this article, readers should be able to: less for development and behavior?
Even when screening tests are
1. List the percentage of children who drop out of school and have used, many clinicians administer
undetected disabilities or known environmental risk factors. them only after noticing a problem,
2. Describe the ways in which early intervention is effective. rather than using them with asymp-
3. Delineate methods of detecting disabilities and development delays. tomatic patients, as recommended.
4. Describe the percentage of children in whom assessment tools can
Other contributions to limited detec-
detect disabilities correctly.
5. Determine how often children should undergo developmental testing. tion include nonstandardized appli-
6. Describe the role of parents in detecting and addressing developmen- cations of standardized measures,
tal and behavioral problems. such as administration of only
selected items on the Denver Devel-
opmental Screening Test-II. These
UNDERDETECTION
violations to test validity also may
Epidemiology and Issues for leave professionals without clear
Clinicians Most physicians depend on clinical information on children’s develop-
Approximately 15% to 18% of chil- judgment rather than screening tools. mental and behavioral status.
dren in the United States have Unfortunately, research shows that
developmental or behavioral disabil- clinical judgment detects fewer than THE CONTRIBUTION OF
ities. An additional 7% to 10% 30% of children who have mental DEVELOPMENT
experience substantive school failure retardation, learning disabilities, lan- The nature of developmental prob-
and drop out before completing high guage impairments, and other devel- lems adds to the challenges of early
school. Overall, one in four children opmental disabilities. Clinical judg- detection. Young children’s symp-
has serious psychosocial problems. ment also identifies fewer than 50% toms are often subtle and difficult to
To ensure that these children are of children who have serious emo- discriminate from normal develop-
detected early and their difficulties tional and behavioral disturbances. ment. For example, most children
addressed, the American Academy Use of improved classification sys- who have disabilities talk, but they
of Pediatrics’ Committee on Chil- tems, such as the Primary Care ver- may not talk well. They usually
dren with Disabilities recommends sion of the American Psychiatric read, but may not read well. Simi-
that pediatricians use validated Association’s Diagnostic and Statis- larly, a child who has serious atten-
screening tools at each health super- tical Manual (DSM-PC), may lead tional or behavioral problems may
vision visit. to higher identification rates, be obedient and focused during a
Many pediatricians find it diffi- although research on this possibility brief office visit. Few children who
cult to comply with this recommen- is needed. have disabilities are dysmorphic or
dation because of minimal reim- Why is the identification of psy- show other symptoms likely to be
bursement, young patients’ limited chosocial problems so poor? One apparent on physical examination.
compliance with requests to stack culprit may be the developmental Development is also a “moving
blocks or answer questions, time checklists typically embedded in target.” Developmental disabilities
constraints, and concerns about the pediatric encounter forms. Although develop just as normal development
accuracy and length of well-known these contain different tasks for does. It is impossible to determine
screening tools. Finally, children patients of different ages, checklists that a 12-month-old child has a lan-
who are at environmental risk for are neither validated nor standard- guage impairment until vocabulary
developmental delays and subse- ized. None provides proof that spe- or word combinations fail to emerge
quent school failure due to poverty, cific items measure important skills, or emerge only in an attenuated
limited parental education, and simi- and none has scoring criteria that state. Learning disabilities and atten-
lar risk factors do not always enable clinicians to determine how tion deficit disorder rarely are
receive health supervision visits. many failed items is too many. detected until 4 to 7 years of age,
Accordingly, they are unavailable at Should the child who misses one out when children initially are exposed
times when pediatricians typically of the typically four or five tasks to reading instruction and other
are most vigilant in their search for listed (eg, puts two words together, structured academic tasks. Not
developmental problems. stands on one foot for 10 seconds) apparent until 2 to 3 years of age is
be referred? Two of five? Three of the adverse impact of environmental
*Associate Professor of Pediatrics, Division five? No one knows. Physicians risk factors, including single parent-
of Child Development, Vanderbilt University never would use such haphazard and hood, less than a high school educa-
School of Medicine, Nashville, TN. unproven methods for screening tion for the parent, limited social

272 Pediatrics in Review Vol. 21 No. 8 August 2000

 CHILD DEVELOPMENT
Developmental Assessment

support, parental mental health prob- Standards for who are noncompliant, afraid,
lems (eg, depression), poverty, fre- Developmental/Behavioral asleep, or even sick. Such tests can
quent life events (eg, household Screening Measures be completed in waiting rooms, sent
moves), more than three children in Hundreds of assessment measures home in preparation for a follow-up
the home, an authoritarian parenting are on the market in the United appointment, or administered by
style in which children are the recip- States, and their publication is an interview or over the telephone
ients of abundant commands but unregulated industry in which no when illiteracy is likely or when
little conversation, and minority governmental agencies or scholarly families do not make regular health
status. societies prevent tests of poor qual- supervision visits. Many parent-
ity from being advertised and sold. based tools are published in Spanish
Accordingly, clinicians must be and other languages. Most screens
The Value and Availability of relying on information from parents
Early Intervention familiar with standards for screening
measures so they can select tools are far briefer than tools that elicit
Early intervention is effective that have appropriate levels of accu- children’s skills directly and can be
because development is malleable racy. Such tests bear the burden of equally accurate. Finally, some mea-
and readily affected by the environ- proof that the majority of children sures have options for directly elicit-
ment. In large part, early interven- who do or do not have problems ing skills from children when com-
tion works by systematically remov- will be identified correctly. munication between parent and
ing external risk factors. Early Because of the malleability and provider is problematic (eg, new
intervention programs place children age-related manifestations of devel- foster parents or nonprimary care-
in developmentally enriching set- opment, standards for developmen- takers who may not know much
tings, train parents in responsiveness tal/behavioral screening tests are about the child).
and effectiveness, and provide con- somewhat lower than is accepted for The question has been raised
tinuous positive redirection and medical screens. Even so, good whether information from parents
focused building of skills. developmental/behavioral tools have can be trusted. What about parents
Two years of intervention prior to sensitivity to psychosocial problems who are less educated, live in iso-
kindergarten produces substantial of 70% to 80% and specificity to lated rural areas, have little parent-
economic, academic, and social ben- normal development of 70% to 80%. ing experience, or appear highly
efits and saves society between Although 20% to 30% of children anxious or depressed? Research
$30,000 and $100,000 per child (see will be over-referred, false-positive shows that almost all parents, if pre-
Meisels and Shonkoff in Suggested identifications often are children sented with well-constructed ques-
Reading for additional information). whose intellectual, language, or aca- tions, can give accurate information
Children receiving early intervention demic skills are below average. about their child, regardless of dif-
are more likely to complete high These children may not qualify for ferences in socioeconomic status,
school, maintain jobs, live indepen- special education, but they still need geographic location, or parental
dently, and avoid teen pregnancy unique care from clinicians (eg, their well-being. One of the reasons is
and criminality. Recognizing these parents will benefit from suggestions that parents usually derive their
positive outcomes, Congress enacted for developmental promotion and responses by comparing their child
the Individuals with Disabilities children will benefit from Head to others, often while waiting for
Education Act, which ensures the Start or other developmental stimu- pediatric care. Comparison is a sim-
national availability of early inter- lation programs, summer school, ple intellectual task, which seems to
vention and public school special tutoring, and vigilant clinical moni- explain why almost all parents can
education for children up to age 22 toring to detect emerging disabili- provide quality information about
who either have disabilities or have ties). The 20% to 30% of children their children. Nevertheless, parents
a high degree of biologic risk. Chil- who have disabilities and are not who have limited education often
dren at environmental risk typically detected by the single administration have limited literacy, and they may
are not eligible for these programs, of a screening measure are likely to respond randomly to questionnaires
but they are served by other feder- be identified subsequently if clini- or omit many items. To circumvent
ally funded services, such as Chap- cians comply with the recommenda- this, it always is wise to ask parents
ter I, Head Start, and other develop- tion of the Committee on Children before giving them forms whether
mental stimulation programs. with Disabilities and screen develop- they would like to complete mea-
The benefits of early intervention ment repeatedly at all health super- sures on their own or have someone
clearly depend on early detection, vision visits. go through them with them.
which requires that clinicians know
how to identify accurately patients
who have disabilities. Because time The Value of Tools Relying Developmental and
and reimbursement are limited, clini- on Information from Parents Behavioral Screening Tools
cians also should know how to iden- The most effective tools for use in for Primary Care
tify patients quickly. Fortunately, a primary care are those that rely on Several high-quality tools relying on
number of recently published mea- information from parents. Parent- parent report (descriptions of chil-
sures offer both accuracy and based tools eliminate the need to dren’s behavior, skills, and environ-
brevity. obtain cooperation from children ments) are described in Table 1. All

Pediatrics in Review Vol. 21 No. 8 August 2000 273

274
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 3 to 72 mo Three separate instruments, each A single cutoff tied Sensitivity in detecting About 10 min
(formerly Minnesota Child having 60 yes-no descriptions. Can to 1.5 standard children who have
CHILD DEVELOPMENT

Development Inventories) be mailed to families, completed deviations below difficulties is

Developmental Assessment

Behavior Science Systems in waiting rooms, or administered the mean. excellent (greater
Box 580274 by interview or by direct than 75% across
Minneapolis, MN 55458 elicitation. A 300-item assessment- studies), and
612-929-6220 ($41.00) level version may be useful in specificity in
follow-up studies or subspeciality correctly detecting
clinics and produces age- normally developing
equivalent and cutoff scores in children is good
each domain. (70% across studies).
Ages and Stages Questionnaire 0 to 60 mo Clear drawings and simple directions Single pass/fail Sensitivity ranges About 7 min
(formerly Infant Monitoring System) help parents indicate children’s score. from 70% to 90% at
Paul H. Brookes, Publishers skills. Separate copyable forms of all ages except the
PO Box 10624 10 to 15 items for each age range 4-month level.
Baltimore, Maryland 21285 (tied to health supervision visit Specificity ranges
1-800-636-3775 ($130) schedule). Can be used in mass from 76% to 91%.
mail-outs for child-find programs.
Parents’ Evaluations of Developmental Birth to 8 y 10 questions eliciting parental Identifies when to Sensitivity ranging About 2 min
Status (PEDS) concerns. Waiting room, interview, refer, screen, from 74% to 79%
Ellsworth & Vandermeer Press, Ltd. and Spanish versions. Written at counsel, reassure, and specificity

Pediatrics in Review
PO Box 68164 the 5th grade level. Identifies or monitor more ranging from 70%
Nashville, TN 37206 when to refer; provide a second vigilantly. to 80% across age
Phone: 615-226-4460 screen; counsel; or monitor levels.
Fax: 615-227-0411 development, behavior, and
http://www.pedstest.com academic progress.
($38.99 English materials)

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 21⁄2 to 11 y A total of 36 short statements of Single refer/nonrefer Sensitivity 80%, About 7 min
Psychological Assessment Resources (best used to common behavior problems. More score for specificity 86%.

Pediatrics in Review
P.O. Box 998 age 4) than 16 suggests referral for externalizing
Odessa FL 33556 behavioral interventions. Fewer problems (eg,
1-800-331-8378 ($63.00) than 16 enables the measure to conduct, attention,
function as a problems list for aggression).
planning in-office counseling and
selecting handouts.
Pediatric Symptom Checklist 4 to 16 y 35 short statements of problem Single refer/nonrefer All but one study About 7 min
Jellinek MS, Murphy JM, Robinson behaviors, including both score, although showed high
J, et al. Pediatric Symptom Checklist: externalizing (conduct) and forthcoming sensitivity (80% to
Screening school age children for internalizing (depression, anxiety, research may 95%), but somewhat

Vol. 21 No. 8 August 2000

psychosocial dysfunction. adjustment). Ratings of never, illustrate how to scattered specificity
J Pediatr. 1998;112:201–209 (the test sometimes, or often are assigned a identify children (68% to 100%).
is included in the article) and in the value of 0, 1, or 2. Scores totaling who have
book Collaborating With Parents 28 or more suggest referrals. Item depression from
Ellsworth & Vandermeer Press, Ltd. patterns can help decide whether those who have
PO Box 68164 mental health services (best for conduct and
Nashville, TN 37206 internalizing disorders) or behavior attentional
Phone: 615-226-4460 interventions (for externalizing problems.
Fax: 615-227-0411 disorders) are needed.
($69.99)
Family Psychosocial Screening. Screens parents A two-page clinic intake form that Refer/nonrefer All studies showed About 15 min
Kemper KJ, Kelleher KJ. Family and is best identifies psychosocial risk factors scores for each sensitivity and
psychosocial screening: instruments used along associated with developmental risk factor. specificity to larger
and techniques. Ambul Child Health. with the problems, including: a four-item inventories greater
1996;4:325–339 (the measures are previously measure of parental history of than 90%.
included in the article) and in the listed screens. physical abuse as a child, a six-
book Collaborating with Parents item measure of parental substance
Ellsworth & Vandermeer Press, Ltd. abuse, and a three-item measure of
PO Box 68164 maternal depression.
Nashville, TN 37206
Phone: 615-226-4460
Fax: 615-227-0411
($69.99)
CHILD DEVELOPMENT

*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
Developmental Assessment

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

275
Children. Nashville, Tenn: Ellsworth & Vandermeer Press, Ltd; 1998.
 CHILD DEVELOPMENT
Developmental Assessment

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- FIGURE 1. Sample PEDS response form.
opmental and behavioral status.
Probabilities of disabilities are
assigned to parental complaints. This Use of the PEDS respond to informal questions about
information, which takes about concerns, they are not always fully
2 minutes to elicit and interpret, CLINICAL ADVANTAGES prepared to discuss them. Parents,
enables physicians to determine the Although many clinicians routinely unlike professionals, may not think
need to refer and where, when to ask questions not unlike those pre- about development as a series of
provide advice about child-rearing sented in PEDS, research shows that domains (eg, expressive and recep-
and developmental stimulation, parents do not respond well to alter- tive language, fine and gross motor,
when to provide reassurance, when native wordings. For example, “Do personal-social). For these reasons,
children should be monitored more you have any worries about your PEDS gives parents multiple oppor-
vigilantly, and when additional child’s development?” is not effec- tunities to express their concerns
screening is needed. Thus, this tive because only 50% of parents and prompts them to consider how
evidenced-based triage tool and understand the word “development” their children are doing in each area.
guidance system helps to manage a and because the word “worries” is This helps the parent who initially
wide range of psychosocial issues too onerous. Parents do not always complains about obedience, for
that arise in pediatric offices while respond the first time they are asked example, to consider whether the
also offering a high degree of accu- about their concerns. Across several child hears well enough; has the
racy in selecting among the many studies, about 40% of parents motor skills, memory, or attention to
possible responses to parental com- reported having concerns but not comply with requests; or has the
plaints. A completed PEDS response sharing them with their child’s clini- language skills to understand what
form is presented in Figure 1. cian. Finally, when parents do he or she was asked to do.

276 Pediatrics in Review Vol. 21 No. 8 August 2000

 CHILD DEVELOPMENT
Developmental Assessment

PEDS also provides much-needed tation Form (Fig. 2). The interpreta- The PEDS interpretation form
guidance on scoring and interpreting tion form provides a single con- also helps test users decide on the
parents’ concerns. For example, tinuous record of developmental/ necessary broad types of evalua-
many parents present their concerns behavioral surveillance, anticipatory tions. Almost 80% of children
tentatively (eg, “I used to be wor- guidance, and developmental promo- requiring audiologic and speech-
ried, but I think he’s doing better tion efforts. language evaluations to determine
now” or “She’s my first, so I’m not eligibility for special services have
really sure but . . . .”). Research parents who raise two or more con-
shows that unless such responses are PEDS AND PROBABILISTIC cerns about receptive language,
categorized as concerns, develop- DECISION-MAKING school, social, or self-help skills.
mental delays will be underdetected. Path A (Fig. 2) is followed when More than 70% of children whose
Interpretation of parents’ concerns parents have two or more checks in parents raise two or more concerns
also is challenging because only the shaded boxes, which indicate in other areas need an assessment by
some concerns are strong predictors that there are multiple significantly a psychologist or educational diag-
of problems. Further, the predictive predictive concerns. Their children nostician (who can give educational
concerns change according to the have 20 times the risk of disabilities or adaptive behavior measures) to
age of the child. To account for this, compared with children whose par- determine eligibility. Even with this
PEDS includes a longitudinal score ents do not have concerns, and referral guidance, clinicians should
form that illustrates the changing almost 70% of affected children use their judgment to decide if men-
nature of predictive concerns and meet criteria for special education tal health services, occupational or
includes a column for each age at services or perform below average physical therapy, Head Start, or
which the American Academy of in language, intelligence, and aca- other interventions also are needed.
Pediatrics recommends a health demics. Referrals for diagnostic Path B is followed when parents
supervision visit. The PEDS score evaluations are needed, and further have a single significant concern
form then directs clinicians to one screening should be avoided because (65% of the time parents are con-
of five paths on the PEDS Interpre- it leads to under-referrals. cerned about expressive language

FIGURE 2. Sample PEDS interpretation form.

Pediatrics in Review Vol. 21 No. 8 August 2000 277

 CHILD DEVELOPMENT
Developmental Assessment

skills). Their children have eight response is to advise parents about Path E is followed when parents
times the risk of disabilities; 46% behavior management and discipline. have no concerns and no apparent
have either disabilities or below- However, families who do not communication barriers. Only 5% of
average achievement. Although it is respond well to brief advice may these children have disabilities, and
possible to refer this entire group for have children who have undiagnosed only 11% score below average.
diagnostic testing because of their mental health problems. In such Additional screening is not needed
moderate but not high rate of dis- cases, behavioral/emotional screen- because it leads to excessive over-
abilities, over-referrals can be ing can help identify which children referrals. Reassuring parents that
reduced by administering a second need referrals for mental health ser- their child appears to be developing
developmental screening test. The vices. Several such screens, again normally and providing routine
results of screening tests are used to relying on information from parents, monitoring during subsequent health
determine which children need refer- are listed in Table 1. Families whose superivision visits appear sufficient
rals for developmental evaluations children pass such screening but for this group.
and which children and parents need continue to demonstrate problematic
suggestions for promoting behavior need referrals for some-
development. what less intensive services, such as Summary
Busy clinicians may wish to refer parent training classes or behavior
to the public schools or to child-find intervention programs. There are many approaches to orga-
services for additional screening or Path D is followed when parents nizing pediatric offices so that
they can send families home with have no concerns, but there are screening tests can be used effec-
one of the other tools listed in Table obvious communication barriers, tively for detection of problems and
1 in preparation for a follow-up such as speaking a foreign language monitoring and counseling families.
appointment. Research showed that not spoken by the clinician or Table 2 lists methods that many
many children in Path B who appearing to have mental health or pediatricians and residents have
received passing scores on screening language impairments. Their chil- found effective and efficient. By
still performed in the below-average dren have almost five times the risk following some of these suggestions
range on diagnostic measures. This of disabilities; 54% either meet cri- and using one or more parent-based
suggests that children in Path B (and teria for special education services tools, clinicians should be able to
Path A) who are found ineligible for or are below average in intelligence, detect and address children’s psy-
early intervention programs should language, or academic skills. Due to chosocial problems quickly and
be enrolled in early stimulation pro- this moderate level of risk for dis- accurately while maintaining patient
grams or quality preschools if possi- abilities and academic difficulties, flow and working within the time
ble to prevent potentially emerging additional screening is needed (pref- constraints of primary care. Such
problems. Otherwise, the develop- erably with measures in which chil- efforts will have substantial long-
ment of children on Path B should dren’s skills are elicited directly term impact on the developmental
be monitored frequently (eg, twice a rather than via a screening test rely- and behavioral health of pediatric
year) because of their continuing ing on parental report). Clinicians patients and their families.
risk for delays and emerging prob- may find it most effective to refer
lems. Their parents also should be this group to the public schools or
advised about techniques for stimu- to child-find services for additional SUGGESTED READING
lating areas of development critical screening because translators or Glascoe FP. Collaborating with Parents:
for school success, such as language social workers are more likely to be Using Parents’ Evaluation of Developmen-
and cognitive skills. available. Children who fail screen- tal Status to Detect and Address Develop-
mental and Behavioral Problems in Chil-
Path C is followed when parents ing and are referred for diagnostic dren. Nashville, Tenn: Ellsworth &
have nonsignificant concerns (83% testing but who are found not to Vandermeer Press, Ltd; 1998
of the time these are about behav- qualify for programs require vigilant Meisels SJ, Shonkoff JP, eds. Handbook of
ior). Their children have only observation, and their parents need Early Childhood Intervention. Cambridge,
England: Cambridge University Press;
1.3 times the risk of developmental suggestions for promoting develop- 1990
problems (7%). Administering addi- ment. These children have a high Parker S, Zuckerman B, eds. Behavioral and
tional developmental screening tests likelihood of below-average intellec- Developmental Pediatrics: A Handbook
to this group produces excessive tual, linguistic, or academic perfor- for Primary Care. Boston, Mass: Little
over-referrals (because the error mance and a high concomitant risk Brown & Company; 1995
Wolraich ML, ed. Disorders of Development
inherent in screening is compounded for school failure. After-school liter- and Learning: A Practical Guide to
for very low or very high prevalence acy programs, summer school, and Assessment and Management. 2nd ed. St.
samples). This suggests that the best tutoring also may be needed. Louis, Mo: Mosby-Year Book, Inc; 1996

278 Pediatrics in Review Vol. 21 No. 8 August 2000

 CHILD DEVELOPMENT
Developmental Assessment

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.

Pediatrics in Review Vol. 21 No. 8 August 2000 279

 CHILD DEVELOPMENT
Developmental Assessment

PIR QUIZ
Quiz also available online at 13. “Early intervention,” defined as
www.pedsinreview.org. developmental intervention in chil-
dren ages birth to 3 years who have
9. The prevalence of developmental or disabilities,:
behavioral disabilities in the United A. Has never been shown to be
States is approximately: effective.
A. 1% to 5%. B. Is financially dependent on
B. 5% to 10%. parent fees.
C. 15% to 20%. C. Is mandated by public law.
D. 25% to 30%. D. Is not yet available in most
E. 35% to 40%. communities.
E. Usually is hospital-based.
10. A major barrier preventing consis-
tent developmental/behavioral 14. Parental concerns about their child’s
screening at health supervision development:
visits is a lack of: A. Are not influenced by parental
A. Adequate reimbursement for mental illness.
screening. B. Are usually accurate.
B. Intervention programs for C. Do not need to be validated with
referral once a delay is found. a diagnostic evaluation.
C. Parental concerns about develop- D. Need not be taken seriously.
mental and behavioral issues. E. Will always be expressed
D. Professional interest by the regardless of the manner in
clinician. which questions are asked.
E. Reliable screening tests.
15. A helpful practice that will facilitate
11. When physicians rely on their own efficient developmental/behavioral
clinical judgment to detect develop- screening is to:
mental disabilities, their accuracy A. Abandon screening after the
rate has been shown to be: child has passed three consecu-
A. less than 10%. tive tests.
B. 20% to 30%. B. Defer screening of all children
C. 40% to 50%. to a developmental specialist.
D. 60% to 70%. C. Rely solely on testing performed
E. better than the detection rate of in a health clinic environment.
behavioral problems. D. Train office staff to administer,
score, and interpret screening
12. A true statement about strategies for tests.
detecting developmental disabilities E. Use only those portions of a
is that: screening test that relate directly
A. A diagnostic developmental to the parent’s concern.
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.

280 Pediatrics in Review Vol. 21 No. 8 August 2000

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