Developmental Screening of Infants, Toddlers and Preschoolers

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Developmental Screening of Infants, Toddlers andPreschoolers

Three 18 month old children with their respective families have been seen at the outpatientpediatrics clinic since birth. All three children superficially appear normal, growing well on theirgrowth curves. The children have no dysmorphic features or other abnormal signs on physicalexam. They have not had any serious illness or hospitalization. The physicians in the clinic aremandated to do a check of development but they do this somewhat differently from physician tophysician. One physician uses a Denver II Developmental screen on selected visits. Onephysician uses a Parent Questionnaire (a particular one called the PEDS) routinely. Anotherphysician asks questions to her parents but does not use any formal developmental screeninginstrument.In actuality all three children have autism. All three families do not know their children havethis.The first child shows delays on the Denver II screen in the personal social area. With the DenverII, the parents are asked certain questions, and they relate he doesn't play pat-a-cake, indicatewants, wave bye-bye, imitate activities or help in the house at 18 months of age. On directobservation with the Denver II he doesn't play ball with the examiner. Also he is not saying anywords including "mama" or "dada" at 18 months of age. In the gross and fine motor areas hisdevelopment appears normal. He is referred to an early intervention program and is diagnosedwith autism.The mother of the second child answers "Yes" to three of the questions on the PEDS (Parents'Evaluation of Developmental Status) parent questionnaire: 1) Do you have any concerns abouthow your child understands what you say?, 2) Do you have any concerns about how your childbehaves? and 3) Do you have any concerns about how your child gets along with others?. Themother answers "no" to the other questions on the questionnaire. On further questioning thechild's family relates how she likes to play by herself, and is easy to care for as she doesn't needtoo much attention. They are worried that she doesn't talk as much as other children, with wordsbeing spoken but in ways that do not make sense. She is suspected to have autism, and is referredto a Developmental Behavioral Pediatrician who confirms the diagnosis after more elaborateevaluation. She is referred to an early intervention program.The physician who asks questions directly to families, finds the parents of the third child slightlyworried at the 18 month visit about the child not being cuddly and not seemingly not veryattached to them. They are told to interact more at home with their toddler. Later at three years of

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age, the parents are very worried about the child's language but are told that many children are"late talkers". When the child is five years of age the school notes the child's aloofness, poorreceptive and expressive language, and nonexistent social skills. The school psychologistevaluates the child and relates to the parents their child has autism. The parents become angry asthey find that many characteristics they have seen in the past two to three years are noted by theschool psychologist as signs of autism. They tell the psychologist that they feel that theirphysician should have figured this out earlier.An important aspect of caring for children in a medical context is that they grow in multipleways over time. There is an expectation that they will grow physically in size. They also developcognitively, behaviorally, socially and motorically.Unfortunately, there are a variety of medical conditions that are derangements in proper childdevelopment. These include common diagnoses such as mental retardation and languagedisorders. There are many more problems that are rare, such as most of the developmentaldisabilities with genetic etiologies. Other medical conditions, such as cancer, may impact childdevelopment because of the effects of chemotherapy on the brain, or because of child andparental stress. Developmental or behavioral conditions are thought to occur in 12 to 16% of children in the United States (1). Families expect physicians to identify developmental problemsin their children and then help manage these concerns (2).It is therefore particularly important for physicians to carefully and routinely evaluate childrenfor problems in development and behavior. Physicians such as pediatricians and familypractitioners have essential roles because of their frequent contact with children and theirfamilies. They have knowledge of normal and abnormal development unlike other professionalswho are in touch with families.Physicians commonly encounter children in well child visits, in the emergency room, and in thehospital. All of these contexts allow for some monitoring of a child's development, but the besttime to do developmental screening is in a primary care context. In the emergency room or in thehospital, a child may show developmental regression. Directly observed developmental behaviormay be different than when the child is well (3). Attention is focused on acute illness during ERand hospital conditions, which makes families less receptive to other aspects of child health anddevelopment. Families also have more trust with someone who gets to know their child andfamily well. They prefer hearing any bad news from their regularly seen provider (4).Identifying children with cognitive, behavioral, social or motor problems can be difficult.Problems in development may be subtle. Glancing at a child in the clinic may not identify theseproblems. Obvious and severe problems are actually rare compared to more commonly seen butsubtle problems. Also, children sometimes do not cooperate with assessments. Lastly,developmental expectations change with age. Risk factors change with time. A child that appearscompletely normal as an infant or toddler may not develop skills expected in the preschool orschool age group periods.

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But because a moderate percentage of children have developmental or behavioral problems, aphysician requires solid strategies for determining if a child has an important lag or problem indevelopment. The majority of children with developmental problems are not detected withoutstandardized screening tests. Informal "eyeballing" of children and informal questioning of parents do not work well. There is a good chance of missing problems because of the need of looking at multiple domains in development. A physician asking about walking and other motorskills may miss language and other cognitive deficits. Research from Great Britain where clinicalimpression is used rather than screening tests is revealing. It has been found that only about half the children who need to be identified are found using physician clinical impression without adevelopmental screening instrument (5). Also, asking questions about developmental milestoneswithout a screening tool finds less than 30% of children with developmental conditions (6).Therefore several instruments have been developed to increase identifying children withproblems. These tools should be used on whole populations of children as to not miss childrenwith subtle (and sometimes not so subtle) problems. Children need to be identified early so thatproblems can be managed properly. Goals of early management include optimizing the child'sdevelopment, and supporting families with these children well.The Denver II is a very popular screening tool used in the United States and worldwide. It wasdeveloped by Dr. William Frankenburg at the University of Colorado Health Sciences Center inDenver. It is an example of a "hands on" screening tool that also allows for parental report forselected items. However, most of the items require direct observation of the child trying to docertain tasks. There are 125 tasks arranged in four domains: personal-social, fine motor-adaptive,language and gross motor. However, only a few items in each domain are required to screen aparticular child at a selected age. It has several advantages including ease of administration,coverage of a good range of age groups to screen (from birth to about 6 years of age), and anormative sample that includes diversification of race, place of residence (urban, suburban, rural)and the mother's educational level (7). There are also very few screening tests that take less time(although clinicians still balk at the 20 minute administration time).One type of screening that is growing in popularity, and bolstered by recent research findings is astandardized parent questionnaire. Parents' concerns about children are important. Someconcerns, particularly with parental worries regarding speech-language, emotional, behavioral,fine motor and global problems were highly predictive of true problems (5). Concerns about theaccuracy and bias of parent reporting, parent reading level, and their understanding of conceptsregarding the standardized parent screening tools have not been shown to be major problemsafter research has been done regarding these tools. (6).The PEDS (Parents' Evaluation of Developmental Status) is a recently developed and wellresearched example of a standardized parental questionnaire. Parents complete the 10 itemquestionnaire in the waiting room. It takes about two minutes for the clinician to interpret thequestionnaire. The PEDS can guide the clinician in getting particular history from the parentsand guide what elements to include on the exam. The interpretation also helps guide the clinicianin whether to use a hands-on screening tool, give parental reassurance, monitor the child, ormake specific referrals to other specialists (6).

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