Developmental surveillance and screening

Abbey Alkon

Each child achieves developmental milestones at his or her own pace, although the sequence of developmental milestones is generally incremental and stepwise in all children. Screening children for developmental delay and emotional and behavioral difficulties is one of the most challenging aspects of well-child care. Screening is an important step toward referral for evaluation and diagnosis of developmental delay and emotional and behavioral problems, and health care professionals are mandated by the Individuals with Disabilities Education Act (IDEA) and Title V of the Social Security Act to provide screening, early identification, and intervention for children with developmental delays and disabilities.¹

In the United States, 12% to 16% of children have at least one developmental delay.² The most common childhood developmental and behavioral problems identified are speech and language delay, hearing loss, emotional and behavioral concerns, learning disabilities, delay in developmental milestones, and mental retardation.³ Health care providers can identify young children with developmental and mental health problems early in life by providing surveillance at every well-child visit and implementing standardized developmental screening tests at the 9-month, 18-month, and 24- or 30-month well-child visit.¹ Timely identification of developmental and behavioral problems and prompt referral for early intervention can lead to interventions that resolve or lessen the impact of a delay or disability on the functioning of the child and family. Effective interventions in early childhood increase a child’s readiness for school entry and for optimum learning in the classroom.

Pediatric Pearls

The care environment vastly impacts the development of a child’s full potential.

Developmental surveillance in early childhood

The first component of a developmental screening program is developmental surveillance. Developmental surveillance includes eliciting parental concerns, collecting and documenting a developmental history, and identifying risks and protective factors for developmental delay or emotional and behavioral problems in the child’s environment. Observations of the child’s development include speech and language skills, communication and social skills, activity level, and parent/child relationship. It is important to identify strengths in the parent and caregiver that are protective factors in the child’s developmental progress. The primary care provider must include input from parents, other caregivers, and teachers in childcare and school settings to make informed observations of the child’s developmental progress and accurately document the ongoing developmental surveillance in the health record.

Surveillance for vision and hearing includes asking parents about any concerns they may have about their infant or young child’s developing vision or response to voices or sounds in the environment. Observable normal visual behaviors include fixing on and following near faces at 6 to 8 weeks of age; visually tracking at 4 months of age, including seeing the parent or caregiver at a distance of 5 feet; and visually fixating at 5 months on a 1-inch cube or small object at 12 inches.⁴ Health care providers should ask parents about their child’s ability to hear quiet sounds and turn and locate voices. All children referred for emotional and behavioral concerns should also have formal vision and hearing screening tests conducted to identify deficits or delays. Reviews of screening practices for vision and hearing are presented in Chapters 11 and 12, respectively.

Speech refers to the mechanics of oral communication, and language encompasses the understanding, processing, and production of communication during the early developmental years and throughout childhood. Surveillance of speech and language skills in childhood includes eliciting any parental concerns about communication problems, dysfluency, stuttering, articulation disorders, or an unusual voice quality.⁵ Approximately 10% to 15% of children 2 years of age have language delays, and 4% to 5% remain language delayed after 3 years of age.⁶ Early referral and intervention is key to optimizing speech and language development in early childhood. Health care providers need to conduct ongoing surveillance at each health encounter and identify children with parental concerns about speech and language development. Table 3-1 presents normal developmental speech and language patterns in infancy and early childhood.

TABLE 3-1

Normal Range of Developmental Speech and Language Patterns in Infancy and Early Childhood

Age	Preverbal Communication to Developing Language and Attention to Speech Sounds
8 weeks	Grunting, crying, cooing
4 months	Squeals, yells, repeating vowel sounds or sounds in repeated patterns Turns head to look at the speaker by 4 months
6 months	More complex consonant-vowel combinations (“da,” “ba”) Vocal play with parent or caregiver repeating sounds Responding to own and family names by 6 months
8 to 10 months	Multisyllable babble (vowel-consonant combinations) Appears to listen to conversation of others by 8 months Looks at or gives common objects used at home by 8 months Wordlike sounds with intonation by 9 months Jargon Waves bye-bye and/or plays pat-a-cake by 10 months
10 to 12 months	Infant learned favored sounds of parent’s and caregiver’s language
12 to 13 months	Emergence of first word ranges from 8 to 18 months (mean 13 months) Consonant-vowel word by 12 months Single words, other than mama/dada, with consistent meaning by 12-13 months Infant communicates actively by pointing
13 to 15 months	Follows familiar requests by 12 to 15 months
18 to 20 months	Understands about 50 words Speaks about 20 words
24 months	Median speaking vocabulary 300 words 10th percentile speaking 60 words 90th percentile speaking 500 words

Data from Sharma A: Developmental examination: birth to 5 years, Arch Dis Child Educ Pract Ed 96:162-175, 2011; Davies D: Child development: a practitioner’s guide, ed 3, New York, 2011, Guildford Press.