Development is a core element of every pediatric well-visit and should be assessed thoughtfully and systematically to intervene when necessary. Development and behavioral health disorders are currently among the top five chronic conditions causing functional impairment in pediatric patients.1 With our expertise and ability to compare within a population, it is the responsibility of pediatric health care providers to monitor and identify concerns as we care for children throughout their younger years.2 There are many different aspects of development, and it can be overwhelming to think about delving into each and every element at a time-limited visit. It is for this reason that standardization of developmental screening is so important and being confident in the tools we use is imperative. Early identification of developmental delays is essential to provide the best intervention available.2,3 Unfortunately, due to lack of standardization and ambiguity in testing, studies indicate that many infants and young children who have clinically significant developmental delays are not being identified in the primary care setting.4
There are many reasons why detecting delays early is so important. The National Early Childhood Longitudinal Study–Birth Cohort indicated that at age 2 years nearly 14% of children have some sort of developmental delay that qualifies them for early intervention services.3,5 Early detection of these delays allows for early intervention with therapeutic services, and those who are referred earlier are more likely to make gains in their developmental milestones.6 If intervention is instituted before entrance to kindergarten, many problems can be successfully managed or even resolved.5 Delayed or disordered development can also be indicative of other medical issues that may need to be addressed.2 About 25% of all children with developmental delay and about 50% of those with global delay will have an underlying medical etiology.2 This rate is lower (<5%) in those with only language delay.2 Identifying a developmental delay and its underlying etiology (if there is one) can help families with treatment planning, identify risk of other medical or behavioral problems, and provide prognosis.2 Developmental screening is important not only for improving health care for our patients, but it also increases parental satisfaction, leads to cost savings, and positively affects the lives of the children and their families when they are able to receive appropriate services.5
The History of Developmental Screening
It was not until 2001 that the American Academy of Pediatrics (AAP) recommended that all children receive standardized developmental screening as part of well-child care.3 Title V of the Social Security Act and the Individuals With Disabilities Education Improvement Act of 2004 reaffirmed the mandate for pediatric health care providers to attain early identification of and intervention for children with developmental disabilities.2 After these official recommendations were released, there was a significant increase in pediatricians' use of standardized screening tools.3 From 2002 to 2009, the percentage of those who reported always or almost always using screening tools increased from 23% to 47.7%.3 Prior to this, many providers were using clinical observation and informal checklists only.3
What does Developmental Screening Consist of?
There are many layers to the evaluation of developmental progression in children. These include risk assessments, surveillance, screening, and diagnosis. In 2006, the AAP developed an algorithm for developmental evaluation in children that includes a streamlined approach to the process of assessing development.7
Risk assessment includes evaluation of the environmental, genetic, biological, social, and demographic factors that may positively or negatively affect a child's development.2 Surveillance is a flexible, longitudinal, continuous, and cumulative process by which knowledgeable health care providers monitor and identify children who may have developmental delays or differences.2 Screening is the administration of a brief standardized tool that aids in the identification of children who are at risk of a developmental disorder.2 Screening does not result in a diagnosis, but rather identifies areas in which children differ from same-age norms and indicates the need for further evaluation.2 Concerns of both parents and providers should be considered in surveillance and subsequent screening when indicated.2,3 It is important to note that although more than 40% of parents of children up to age 5 years report developmental concerns, a lack of parental concern does not preclude the possibility of significant delays.2,3
Many different areas of development can be assessed with screening tools. These domains include gross motor development (movement and coordination of large muscles), fine motor development (movement and coordination of smaller muscles, including activities of daily living), language development (receptive and expressive communication involving both speech and nonverbal language), cognitive development (reasoning, memory, and problem solving skills), and social-emotional development (attachment, self-regulation, and interaction with others).6
There are two types of screening tools used in the clinical setting. The first are parent report tools, which measure parent concerns, skills and behavior, risk, protective factors, and a history of parent-child interactions.5 There are also practitioner-administered tools in which the provider directly elicits or observes skills and behaviors and the child-parent interaction.5
Many different types of providers may be involved in the screening and intervention process. Pediatricians, neurologists, developmental and behavioral providers, psychiatrists, and other pediatric subspecialists may perform the developmental screen or diagnostic evaluation.2 Intervention can involve many different people as well. Usually, an interdisciplinary team is assembled and may include early childhood educators, child psychologists, speech language pathologists, audiologists, social workers, physical therapists, occupational therapists, and others.2
Recommendations for Screening
The AAP describes five components of developmental surveillance, including (1) eliciting and attending to the parents' concerns about his or her child's development, (2) documenting and maintaining a developmental history, (3) conducting accurate observations of the child's development, (4) identifying risk and protective factors, and (5) documenting the process and findings from developmental surveillance.2,4 Surveillance is a continuous process and should be completed at every well-child visit.2 If surveillance indicates a concern, screening should be pursued with a standardized tool for assessing developmental delay as well as documentation of a child's risk for developmental problems.2,4 The AAP also recommends developmental screening with standardized tools for all children at age 9, 18, and 30 (or 24) months.4–6 They recommend autism screening at age 18 and 24 months and social/emotional screening whenever the autism screen is abnormal.5,6 Children should be assessed for kindergarten readiness at age 4 years, followed by yearly social/emotional, mental health, and psychosocial screening until adulthood.2,5 It is important to assess not only for delays in development, but also development of skills out of the typical order as well as regression in development as this may indicate a serious neurologic etiology.2
The screening tools themselves must meet several criteria to be considered adequate. They must have good sensitivity and specificity at levels of 70% to 80%, which is much lower than is generally acceptable due to the challenges in measuring child development.2,3 There also needs to be validation of the screens in a clinical setting.4 Screening tools should also cover several developmental domains including gross motor skills, fine motor skills, language and communication, problem solving and adaptive behaviors, and personal social skills.2 Screening tools must also be culturally and linguistically sensitive.2
Barriers to Screening
There are several issues that make standardized screening difficult in the primary care setting, with time limitation being one of the most cited.1,3 Providers report a lack of staffing to perform the screening, inadequate reimbursement for this time-consuming task, and lack of confidence in interpreting the screening results.3 There is also no universally accepted screening tool, making consistency across different populations and locations difficult.2,3 Pediatricians also admit to using clinical impressions or checklists to evaluate development, which are much less accurate than standardized screening tools that provide good specificity but poor sensitivity.2,3,5 Developmental screens can also provide false-negative or false-positive results, resulting in missed opportunities or unnecessary evaluations for some children.5
What Tools to Use
There are several standardized screening tools that are recommended for use in the clinical setting. Depending on the population and the setting, different screens are more appropriate in different situations. For identification of general developmental delay, the Parents' Evaluation of Developmental Status (PEDS) and Ages and Stages Questionnaire (ASQ) screens are recommended.4,5 For children who are considered high risk for developmental delays, the Bayley Infant Neurodevelopmental Screens and the Capute or Cognitive Adaptive Test (CAT)/Clinical Linguistic Auditory Milestone Scale (CLAMS) is recommended.4 For language development, the Language Development Survey (LDS), Capute, and CLAMS are the highest rated. For autism, the Modified Checklist for Autism in Toddlers (MCHAT) is the standard screening tool.4,5 There are many other more specialized screening tools available.7 The most commonly used screening tools are summarized in this article. For more in-depth evaluation of the available screening tools, please see the chart from the AAP.7
Ages and Stages Questionnaires
This is a parent-completed questionnaire for children age 4 to 60 months that takes about 10 to 15 minutes to complete.2,5 It covers all the main domains of development and has good sensitivity and specificity.2 This screen is appropriate for standard well-child developmental screening.2 A 2011 study found ASQ to be significantly more accurate than the PEDS screen in identifying developmental delays, especially in children older than age 30 months.5
Parents' Evaluation of Developmental Status
This is a parent-report form that is used to detect development and behavioral problems that may need further evaluation.2,5 There is a single form for all age groups (0–8 years) that takes anywhere from 2 to 10 minutes to administer.2,5 This screen tends to cast a “broad net,” so many children who screen positive will not qualify for intervention based on further evaluation.5 It has somewhat lower sensitivity and specificity than the ASQ.2
Bayley Infant Neurodevelopmental Screen
This is a provider-administered tool that screens for basic neurologic functions, receptive functions, expressive functions, and cognitive processes.2 It takes about 10 minutes to administer and is appropriate for children age 3 to 24 months.2 It has good specificity and sensitivity and is best used in populations that are deemed to be at high risk.2
Cognitive Adaptive Test/Clinical Linguistic Auditory Milestone Scale
This is a directly administered tool that measures visual-motor problem solving and expressive and receptive language. It is useful for children age 3 to 36 months and takes about 15 to 20 minutes to administer.2 It has low sensitivity but high specificity, making it helpful in high-risk populations and those with specific language concerns.2
Modified Checklist for Autism in Toddlers
This is a parent-completed questionnaire that takes about 5 to 10 minutes to complete and is appropriate for children age 16 to 48 months.2 It has moderate sensitivity and high specificity and is designed to identify children who are at risk of autism.2
Developmental surveillance should be an important part of every interaction we have with children in our care, and developmental screening should be a part of all well-child care that we provide our patients. Although the AAP recommends formal standardized screening at age 9, 18, and 30 months,4–6 the more often that screening is done, the more likely we are to identify developmental differences and delays in our patient population.
The importance of using standardized screening to evaluate pediatric patients has been proven, as informal observation and checklists do not identify many of those with developmental needs. The more we can standardize and become familiar with the tools that are available, the easier it will be to incorporate these into our everyday practice.
Early identification of developmental delays is so important because the earlier we identify these differences and provide resources for intervention, the better chance our patients have at being successful in advancing their development and in many cases overcoming the delay.
- Weitzman C, Wegner LSection on Developmental and Behavioral PediatricsCommittee on Psychosocial Aspects of Child and Family HealthCouncil on Early ChildhoodSociety for Developmental and Behavioral PediatricsAmerican Academy of Pediatrics. Promoting optimal development: screening for behavioral and emotional problems. Pediatrics.2015;135(2):384–395. https://doi.org/10.1542/peds.2014-3716 PMID: doi:10.1542/peds.2014-3716 [CrossRef]25624375
- Council on Children with Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee, Medical Home Initiatives for Children with Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics.2006;118(1):405–420. https://doi.org/10.1542/peds.2006-1231 PMID: doi:10.1542/peds.2006-1231 [CrossRef]16818591
- Radecki L, Sand-Loud N, O'Connor KG, Sharp S, Olson LM. Trends in the use of standardized tools for developmental screening in early childhood: 2002–2009. Pediatrics.2011;128(1):14–19. https://doi.org/10.1542/peds.2010-2180 PMID: doi:10.1542/peds.2010-2180 [CrossRef]21708798
- Drotar D, Stancin T, Dworkin PH, Sices L, Wood S. Selecting developmental surveillance and screening tools. Pediatr Rev. 2008;29(10):e52–e58. https://doi.org/10.1542/pir.29-10-e52 PMID: doi:10.1542/pir.29-10-e52 [CrossRef]18829768
- Marks KP, LaRosa AC. Understanding developmental-behavioral screening measures. Pediatr Rev. 2012;33(10):448–457. https://doi.org/10.1542/pir.33-10-448 PMID: doi:10.1542/pir.33-10-448 [CrossRef]23027599
- Scharf RJ, Scharf GJ, Stroustrup A. Developmental milestones. Pediatr Rev. 2016;37(1):25–37. https://doi.org/10.1542/pir.2014-0103 PMID: doi:10.1542/pir.2014-0103 [CrossRef]26729779
- American Academy of Pediatrics. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. https://pediatrics.aappublications.org/content/118/1/405.figures-only. Accessed September 23, 2019.