Many Pediatricians Skip Developmental Screening, Study Finds

Norra MacReady

July 10, 2018

Fewer than one third of young children receive a recommended parent-completed developmental screening, and the rate of developmental surveillance during healthcare visits is "not substantially higher," the authors of a cross-sectional analysis warn.

All in all, "only 1 in 5 children received both screening and surveillance," and in no case were they higher than 39.1% when analyzed according to various demographic and healthcare-related characteristics, Ashley H. Hirai, PhD, from the Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, Maryland, and colleagues write.

The researchers published their findings online July 9 in JAMA Pediatrics. They say the rates of developmental screening and surveillance in the United States remain low despite more than a decade of policy initiatives.

The study used data from the 2016 National Survey of Children's Health, the only nationally representative source of data on standardized developmental screening, to examine the current prevalence and variation of recommended screening and surveillance. The investigators limited the analysis to children from 9 through 35 months of age, as that is the age range for developmental screening recommended by several professional and policy-making organizations.

Of a weighted population of 9 million eligible children, 2.7 million (weighted 30.4%; 95% confidence interval [CI], 28.0% - 33.0%) had undergone developmental screening, which consists of a three-item questionnaire completed by the parent or caregiver at the request of a physician or other health professional.

From that same population, 3.3 million (weighted, 37.1%; 95% CI, 34.4% - 39.8%) had undergone developmental surveillance or monitoring by a health professional, measured by asking parents or caregivers whether the clinician had inquired about any concerns regarding the child's learning, development, or behavior. Only 19.2% of children underwent both developmental screening and surveillance.

For a closer analysis, the authors randomly selected 5668 children who had undergone one or both examinations. Valid parental or caregiver responses were available for 5492 (96.9%) children on the developmental screening instrument and for 5652 of the children (99.7%) who had undergone developmental surveillance.

On this analysis, the likelihood of screening or surveillance did not differ significantly by age or sex. However, the weighted percentage of non-Hispanic white children who underwent developmental screening (34.4%; 95% CI, 31.7% - 37.1%) was higher than that of Hispanic children (24.3%; 95% CI, 18.5% - 31.3%) or non-Hispanic black children (24.8%; 95% CI, 16.7% - 35.2%) who underwent the evaluation (P < .001 for both comparisons). The same pattern was seen in the analysis for developmental surveillance (P < .03 for both comparisons).

Similarly, children from households in which English was the primary language, with two married parents, or in which at least one parent had a college degree or more, also were significantly more likely to have undergone screening and/or surveillance, as were children from families that had private insurance compared with public or no insurance.

All but two of these factors remained significantly associated with screening or surveillance after adjustment with logistic regression models: race/ethnicity and insurance status.

Children with a medical home were more likely to undergo screening (adjusted rate ratio, 1.34; 95% CI, 1.13 - 1.57) and surveillance (adjusted rate ratio, 1.24; 95% CI, 1.08 - 1.42), "corresponding to an 8 to 9 absolute percentage point increase," the researchers write.

This study is thought to be the first to report an adjusted association between a medical home and rates of developmental screening. "Thus," they explain, "efforts to promote continuous and comprehensive primary care within a medical home may result in improved quality and use of preventive services, including developmental screening and surveillance."

In addition, among children with special healthcare needs, 39.1% (weighted; 95% CI, 31.4% - 47.4%) underwent screening compared with 29.7% (weighted; 95% CI, 27.2% - 32.3%) who did not have special needs (P = .02). This was also true of developmental surveillance, undergone by 53.3% of children with special needs (weighted; 95% CI, 44.8% - 61.6%) and 35.6% without special needs (weighted; 95% CI, 32.9% - 38.5%; P < .001).

For both screening and surveillance, the authors noted more than a 40-point spread across states. "The prevalence of screening ranged from 17.2% in Mississippi to 58.8% in Oregon, corresponding to a rate ratio of 3.4," they write. "Similarly, developmental surveillance ranged from 19.1% in Mississippi to 60.8% in Oregon."

The state-level variation indicates "continued potential for improvement," they conclude. "Systems-level quality improvement efforts that integrate the medical home and build on lessons learned from state-based initiatives will be necessary to achieve universal screening and surveillance that optimizes early identification, intervention, and developmental trajectories for children with delays."

They also suggest that more attention be paid to language barriers and cultural competencies, given the relatively low rate of screening among children from non-English-speaking households and of non-white ethnicity.

The authors have disclosed no relevant financial relationships.

JAMA Pediatr. Published online July 9, 2018. Abstract

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