Child Development

Developmental Screening and Referral: a Call for Careful Reflection

By: Paul H. Dworkin, MD

Each month, I have the pleasure of meeting with first-year pediatric residents who are on their Developmental-Behavioral Pediatrics rotation at Connecticut Children’s Medical Center. I employ a case-based approach to enhance their understanding of the process of developmental surveillance and screening and to strengthen their skills in the early detection of children at risk for developmental delay.

To focus on the specific issue of developmental screening, I share the following brief vignette:

You are seeing an 18-month old for her routine well-child visit. She is accompanied to the visit by her mother, who reports no concerns. You administer a developmental screening tool as part of your routine assessment and note delays in the areas of language and fine motor skills.

In asking the residents to describe their most likely approach to this scenario, they invariably ask a number of questions: Has past surveillance and screening identified any developmental concerns? Is the child’s hearing normal? Does history or physical examination suggest any medical factors that may be adversely influencing the child’s development? Are the child and family adversely impacted by social circumstances or environmental factors? I explain that the pediatrician has followed this child from birth, that no medical, social, or environmental factors are identified to place this child at risk for delay, and that ongoing developmental monitoring through surveillance and screening has, to date, suggested a healthy developmental trajectory. In short, this child’s “positive” developmental screen is unanticipated and unexplained.

I then inquire as to the residents’ most likely next steps. In view of their relative inexperience, I am not surprised that most suggest the need to refer the child for further evaluation. While I acknowledge that this may be the “safest” route, I ask whether we may justify any other approach. Typically, one of the residents tentatively suggests the option of careful monitoring and follow up. I reinforce this thought by explaining that under certain, select circumstances, a plan that includes sharing the results with the parent, encouraging such home-based activities as reading to the child to promote language development, and carefully following up with the child in several months is reasonable and, perhaps, even most desirable. In defense of this approach, I cite the lack of any apparent risk factors for the child, the engagement of the family in ongoing child health surveillance, and such adverse consequences of over-referral as parental anxiety and concern, logistical challenges such as transportation and loss of work hours, family expense, and placing additional demand on over-burdened evaluation services. I also acknowledge the inherent limitations of developmental screening tools as a function of the wide variability in children’s developmental trajectories and the extent to which such tools tend to overstate the probability of a child who screens positive actually having a delay. The “take home message” from this vignette is the imperative of viewing screening results not in isolation, but rather in the context of all that is known of the child and family.

A recently published narrative review by a Boston-based colleague, Chris Sheldrick, in Academic Pediatrics (2017;17:464-470) provides a sophisticated and compelling rationale for greater clinical decision-making, including shared decision-making with parents and families, in developmental screening policies and practices. Sheldrick and his collaborator, Daryl Garfinkel, demonstrate that although positive predictive values (i.e., the likelihood that subjects with a positive screening test actually have the disorder) of developmental screening tools are often low, they overstate the probability of many children who screen positive truly having a delay. They further argue that positive screening results are not always sufficient to justify a referral. They demonstrate the extent to which recommended screening thresholds are seldom set to ensure that the benefits of referral will equal or exceed the costs and risk of harm. Perhaps most importantly, they advocate for screening research that encompasses not only the accuracy of specific screening instruments, but also the ability to improve decision making in the context of systems of care. We could not agree more!

We have long recommended the critical importance of viewing developmental screening in the context of an integrated, comprehensive approach to developmental promotion, early detection, referral and linkage, and interpreting screening results from the perspective of all that is known of the child and family. We are grateful to Sheldrick and Garfinkel for providing the psychometric rationale for such an approach.

Developmental screening is critically important to ensure that vulnerable children do not “slip through the cracks” of early detection. This review reminds us that policy and practice must ensure that this tool is wisely and effectively applied in the context of systems of care.

REFERENCE
Sheldrick RC, Garfinkel D.  Is a positive developmental-behavioral screening score sufficient to justify referral? A review of evidence and theory.  Acad Pediatr 2017;17:464-470.

Paul H. Dworkin, MD is the executive vice president for community child health at Connecticut Children’s, the director of Connecticut Children’s Office for Community Child Health and the founding director of the Help Me Grow® National Center. Dr. Dworkin is also a professor of pediatrics at the UConn School of Medicine.  Learn more »

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