Developmental Screening

David Rydz, BSc; Michael I. Shevell, MD,CM,FRCPC; Annette Majnemer, OT,PhD; Maryam Oskoui, MD,CM

Disclosures

J Child Neurol. 2005;20(1):4-21. 

In This Article

Abstract and Introduction

An estimated 5 to 10% of the pediatric population has a developmental disability. The current strategy to identify these children is through developmental surveillance, a continuous procedure in which the health professional observes the infant, takes a developmental history, and elicits any concerns that the caregiver might have. However, identification of delayed children is ineffective when based solely on routine surveillance. A necessary adjunct is developmental screening: the process of systematically identifying children with suspected delay who need further assessment. Screening tests greatly improve the rate of identification. With the advent of intervention programs and the support of organizations such as the American Academy of Pediatrics, the topic of developmental screening is a timely and essential one. This review aims to describe the properties of screening tests, to evaluate the available tools for developmental screening while providing a representative sample of the currently available developmental tests, and, finally, to evaluate the efficacy of intervention programs, a needed prerequisite to justify screening.

Developmental delay can be restricted to one stream of development (single domain) or to two or more streams of development (global developmental delay).[1,2,3,4,5,6] The domains of development can be conceptually categorized into four major areas:

  1. Motor[7,8] development encompasses both gross motor ability (the control of large groups of muscle involved in walking, sitting, or transferring from one position to another) and fine motor abilities (the manipulation of objects with the hands in order to eat, draw, play etc). Children progress through motor milestones in an orderly fashion, attaining these functions in a clear and sequential process. Motor delay is defined as a significant delay in motor abilities without a delay in other developmental categories.

  2. Language[7,8] performance, consisting of articulation, receptive and expressive language skills, and the use of nonverbal symbols, encompasses a major stream of development, arising from the interaction between innate communication abilities and environmental influences. Any significant delay in language or speech skills without a delay in other developmental domains is categorized as a developmental language disorder, developmental dysphasia, or specific language impairment.

  3. Adaptive or cognitive[7,8] development is a measure of the child's ability to problem solve through intuition, perception, and verbal and nonverbal reasoning. Moreover, it encompasses the ability not only to learn and understand but also to retain this information and apply it as needed.

  4. Personal or social[7,8] development encompasses the child's interactions, as shown by the formation and maintenance of relationships and responsiveness to the presence of others. Psychosocial delay presents itself over time as behavioral abnormalities that differ from normal behavioral responses by their quantity, severity, nature, and duration. Personal development involves the formation of self-help skills in various activities of daily living, such as feeding, dressing, and toileting.[7,8]

Generally, developmental delay is a term used to describe a child who does not reach developmental milestones at the expected age, even after allowing for the broad variation of normality. A classification scheme for neurodevelopment disabilities is provided in Table 1 estimated 5 to 10% of the pediatric population has a developmental disability.10 There has been increasing pressure to identify those children with developmental delay at an earlier age, with the current focus being on infants (birth to 2 years of age).[11] This has been spurred by several factors. First, the neuromaturational view that development is intrinsically preprogrammed and takes place in a predictable sequence that is essentially hardwired into the central nervous system and unchangeable by environment has become less influential.[12] Alternatively, a systems approach views the brain's development as dependent on environmental influences, suggesting that a favorable environment could enhance and optimize development.[12] Second, for children with developmental delay, intervention programs have been shown to be beneficial, maximizing developmental attainment, and, as such, Federal law PL-99457 (The Education of the Handicapped Act Amendments) enacted in 1986 in the United States, calls for "statewide, comprehensive, coordinated multidisciplinary, interagency programs of early intervention services for all handicapped children and their families."[13] It is believed that gains will be greatest if the child participates in intervention services as early as possible, a concept iterated in public laws such as the Individuals with Disabilities Education Act Amendments of 1997, which mandates early identification and intervention for children with developmental disabilities.[12,14] As a result of these influences, professional organizations such as the American Academy of Pediatrics are strongly endorsing the early identification of delayed children by health practitioners.[12,15]

Primary health care physicians play a crucial role in identifying children with developmental delays at a young age. They are in regular contact with the child from birth to adolescence and therefore can monitor development longitudinally, allowing for a better understanding of the child's immediate developmental trajectory.[16] Furthermore, they are usually aware of underlying social and familial factors at work in the child's immediate environment.[17] The strategy used by primary care providers to monitor a child's progress is termed developmental surveillance.

Developmental surveillance is an ongoing process of monitoring the status of a child by gathering information about the child's development and behavior from multiple sources, including skillful direct observation of the child's behavior and elicitation of concerns from parents and relevant professionals.[15,16] Moreover, the pediatrician will often take a relevant developmental history and use an age-appropriate checklist to record developmental milestones. In successful surveillance, development is viewed in the context of the child's overall well-being and is not isolated from other domains pertaining to child health and well-being. In this paradigm, developmental screening can also be included.

Both the American Academy of Pediatrics and the British Joint Working Party on Child Health Services recommend developmental surveillance as an effective means to identify children with delay.[18] Furthermore, listening to the caregiver's concerns encourages their active participation in their child's welfare. This simultaneously allows the pediatrician to assess parents' knowledge and attitude about their child's development and is an opportune time to share and exchange information and offer anticipatory guidance.[15,16,19] This will potentially improve the physician-parent relationship, fostering trust, and will lend itself to a more cooperative situation if developmental problems should indeed arise.[16]

Even though developmental surveillance is what the majority of physicians already do, research has shown that subjective clinical impressions are not entirely effective in assessing development. For example, in Great Britain, only 45 to 55% of children with developmental disabilities are detected before school entrance.[20] Using only clinical judgment detects fewer than 30% of children who have mental retardation, language disabilities, or other developmental problems.[21] Similarly, fewer than 50% of those with serious emotional and behavioral problems are detected before the age of 5 years.[22] Another study compared pediatricians' intuition against a complete standardized assessment for behavioral problems, demonstrating that pediatricians' sensitivity was low (~ 20%).[23]

Although developmental surveillance can be a powerful identification tool, fully implementing this strategy in the context of medical practice is difficult for several reasons. First, and perhaps most importantly, time constraints often do not allow the practitioner to implement surveillance, and it might be omitted altogether when dealing with more "acute" health problems.[20] In clinics in which visits have been trimmed to an average of 12 minutes, the primary care physician will simply not have enough time to perform all of the necessary steps for comprehensive developmental surveillance.[24] Second, because success in developmental surveillance is dependent on a continuous and ongoing process, it is not likely to work well for those infants receiving infrequent care by different care providers at different times.[25] Finally, the efficacy of this strategy is dependent on the practitioner's knowledge and experience. Inadequate training regarding developmental issues compromises the practitioner's skills in early identification[26] ; for instance, not eliciting parental concern properly can be a significant factor leading to missed early identification.[27,28]

An adjunct to developmental surveillance is developmental screening. Generally, screening refers to the process of proactively testing whole populations of children to identify those at high risk of clinically significant but, as yet, unsuspected deviations or delay from normality. Developmental screening tests are "a brief assessment procedure designed to identify children who should receive more intensive diagnosis or assessment."[29] Although it does not give a definite diagnosis, screening identifies a particular child for whom special attention and further detailed assessment should be pursued. Standardized screening tests help remind practitioners to dedicate time to developmental assessment and also provide a standardized structured format to assist clinicians in making skilled observations.[11,30] Developmental screening improves the accuracy with which children are identified when compared with decisions based only on clinical judgment.[23,28,31] Consequently, the inclusion of screening tests is seen as an advantageous paradigm to identify developmental impairment.

With the availability of appropriate intervention programs and the growing acknowledgment of the efficacy of these programs, there is a concomitant growing responsibility for health care professionals to provide appropriate screening services because (1) they are sometimes the only professionals in contact with the child between birth and 5 years of age[16]; (2) they have an accepted role of authority; (3) they have insight into the child's environment and thus can interpret the child's development and health in the context of the family and the social environment[17]; and (4) they are identified by law as the chief means to detect this disability.[14,15] Because research shows that up to half of childhood developmental delay is not detected until school age when using developmental surveillance, reviewing the concepts and benefits of developmental screening remains important.[21] Finally, given that several professional organizations, including the American Academy of Pediatrics, have recommended that "all infants and children should be screened for developmental delay," the topic of developmental screening is a pertinent and timely one.[11]

This article covers six issues: it (1) reiterates the pitfalls of developmental surveillance and the advantages of using screening instruments within the clinical setting; (2) explains the terminology necessary to successfully interpret the accuracy, validity, and reliability of screening tests; (3) states the standards used to judge the usefulness of these instruments; (4) offers guidelines that a professional in child care could take into account when choosing a developmental screening test; (5) describes several instruments from each developmental stream using the previously stated guidelines; and (6) justifies screening paradigms by stating the benefits not only to the child but also to the family and society as a whole.

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