Developmental Screening

The importance of developmental screening in the primary care setting was emphasized in the recent American Academy of Pediatrics (AAP) Policy Statement “Identifying Infants and Young Children with Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening” published in Pediatrics in July 2006. The policy statement recommends that developmental surveillance be done at every well child preventive visit. If surveillance identifies a developmental concern, a standardized developmental screening tool should be used. In addition, in order to detect delays in children at low risk, screening tools should be used at the 9-month, 18-month, and 24- or 30-month well child visits.²

The developmental domains that need to be assessed cover four main areas: (1) motor, which includes gross motor and fine motor development; (2) communication, which includes speech and expressive and receptive language; (3) cognition, which includes language as well as visual-motor coordination and problem solving; and (4) social-emotional, which includes temperament and behavioral responses to people and the surrounding environment. Specific details on age-specific milestones for each of these categories can be found in the chapters describing the age-specific well child visits.

Developmental Surveillance

It is important to understand the difference between developmental surveillance and developmental screening. Surveillance is the ongoing process that is longitudinal and cumulative and helps primary care providers identify children who may be at risk for developmental delay. Surveillance includes eliciting and attending to parents’ concerns about their child’s development; documenting and maintaining a developmental history; making accurate observations of the child; identifying risk and protective factors, which include the child’s environment, genetic, social, and demographic factors; and maintaining an accurate record and documenting the process and findings.²

Developmental screening refers to the administration of a brief standardized validated instrument that is both sensitive and specific for detecting developmental delays. The screen will hopefully identify children with subtle delays who would have otherwise been missed. If surveillance points to possible risks or this is a 9-month, 18-month, or 24- to 30-month visit, a development screen should be performed. In addition, the AAP in collaboration with Bright Futures also recommends that a specific autism screen be performed at the 18- and 24-month visits.³ (See the age-specific well child visit chapters for more details.) It is important to note that these tests are only screens; therefore children may be identified as not meeting certain developmental milestones who are actually within the range of normal. All results must be interpreted within the context of the primary care provider’s knowledge of the child’s medical history and environment, social, and historical risks.

Choosing the correct instrument to use can also be somewhat complicated. Factors that play into this decision include the screen’s reliability, validity, sensitivity, and specificity. In addition, different screens rely on obtaining information from either the parent or the child or both. Depending on the format of the screen, ease of use, time for administration, and parental literacy level may also play a role in the primary care provider’s decision regarding various screening tools. A list of several screening tools can be found in both Nelson Textbook of Pediatrics, 18th edition (Chapter 15, Developmental Screening and Surveillance) and the AAP’s policy statement regarding developmental surveillance and screening.²