Development and implementation of developmental screening tools in primary care

Introduction

Estimates suggest that 15-20 percent of children in the United States are affected by developmental and behavioral disabilities (Boyle et al., 2011; Merikangas et al., 2010). Despite evidence for the importance of early intervention, less than one third of children with such disabilities are diagnosed before they enter school (Sand et al., 2005). As a result, use of evidence-based screening instruments (typically in the form of brief questionnaires for parents) are widely recommended in order to improve detection by pediatricians (Council on Children with Disabilities, 2006), and surveys of physicians suggest that use has increased markedly in the past decade (Radecki, Sand-Loud, O'Connor, Sharp & Olson, 2011).

To be useful to pediatricians, screening tools must be valid indicators of increased risk of developmental and behavioral disabilities, but they must also be feasible in a primary care context (Sheldrick & Perrin, 2009). Ideally, a screening tool should accurately address a range of domains of interest, such as developmental milestones, internalizing and externalizing behaviors, autism symptoms and family risk factors. Moreover, it should be short and easy to administer and to score, possible for parents with varying education levels to complete, as well as low-cost to pediatricians and amenable to flexible administration, including via computers or paper-and-pencil formats. Ideally the instrument should allow for repeated administrations over the course of recurring health supervision visits. Notably, several of these requirements stand in tension with one another: a fully comprehensive screening tool that accurately detects all forms of developmental-behavioral problems is likely to be long, but length limits feasibility. Historically, different screening tools have addressed this tension in different ways. For example, the Ages & Stages Questionnaire, 3rd edition (ASQ-3; Squires, Bricker & Potter, 2009) is a well-validated developmental screening tool, but it requires that parents have access to materials such as blocks and crayons to administer correctly. Moreover, screening social/emotional problems requires administration of a different form known as the Ages & Stages Questionnaire: Social/Emotional (ASQ:S/E; Squires, Bricker & Twombly, 2002). Because each form includes approximately 40 questions, the two are seldom administered together. In contrast, the Parents' Evaluation of Developmental Status (PEDS; Glascoe, 1997) emphasizes feasibility. Ten questions about parents' concerns are designed to screen for both behavioral and developmental problems. Responses are then categorized following a scoring guide, and additional assessment is recommended in some cases.

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