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Article

cognition and learning

Selecting Developmental
Surveillance and Screening
Tools
Dennis Drotar, PhD,*

Introduction

Terry Stancin, PhD, Paul

The importance of surveillance and screening for developmental problems in primary care
has been well recognized in scholarly reviews and practice guidelines. (1) The need for
early detection of developmental problems in infants and young children in primary
pediatric care settings stems from the high prevalence of such problems and the potential
for early intervention for the child and family. Frequent longitudinal contact with young
children and their families at critical times in their early development provides pediatricians
and other practitioners with important opportunities to conduct developmental surveillance and screening to detect clinically significant developmental problems and institute
early intervention. (1)(2)(3)(4) Early identification and referral to early intervention
programs can ameliorate the negative consequences of developmental problems on
children, families, and society. (3) However, studies have indicated consistently that many
infants and young children who have clinically significant developmental delays are not
detected in pediatric primary care. (1)(3)(4) As a consequence, critical opportunities for
early intervention for young children who are at risk for developmental problems may be
lost. (2)(5)(6)(7)
To address this need, the American Academy of Pediatrics (AAP) developed a policy
statement for identifying infants and young children who have developmental delays and
disorders. (8) This statement is a significant advance in the clinical application of developmental screening in several respects. One is the recommendation to address parental
concerns about development as one of several health topics in routine pediatric preventive
care visits throughout the first 5 years after birth. Developmental surveillance, defined as a
flexible, longitudinal, continuous, and cumulative process, is recommended for inclusion
at every pediatric visit.
The five components of developmental surveillance described in the AAP statement
include: 1) eliciting and attending to the parents concerns about his or her childs
development, 2) documenting and maintaining a developmental history, 3) conducting
accurate observations of the childs development, 4) identifying risk and protective factors,
and 5) documenting the process and findings from developmental surveillance. The AAP
also recommends a close connection between developmental surveillance and the use of
developmental screening instruments. If surveillance indicates a concern about the presence of developmental problems, developmental screening, defined as the use of a
standardized tool to identify and describe the level of the childs risk for developmental
delay, should be conducted. (8) Finally, the AAP recommends that developmental
screening of all children be conducted at 9-, 18-, and 30-month visits (or at 24 months if
a 30-month visit is not part of the preventive schedule in the practice). (8)
Unfortunately, barriers such as time, costs, and practice management constraints can
limit implementation of the AAP recommendations. (1)(3)(4)(9)(10)(11) Another important potential barrier to implementation involves the selection of specific developmental screening instruments. Practitioners dilemmas concerning the selection of developmental screening instruments are heightened by their large numbers and variety. For
example, available instruments vary considerably with respect to: 1) primary purpose (eg,
screening for general developmental delay versus specific disorders such as autism),
2) method of administration (eg, parent- versus practitioner-administered), 3) reliability

H. Dworkin, MD, Laura


Sices, MD, Susan
Wood**

Author Disclosure
Drs Drotar, Stancin,
Dworkin, and Sices
and Ms Wood have
disclosed that this
work was supported
by the
Commonwealth Fund
#20060127 Rating
Developmental
Screening
Instruments. This
commentary does not
contain a discussion
of an unapproved/
investigative use of a
commercial product/
device.

*Professor of Pediatrics, Cincinnati Childrens Hospital Medical Center, Cincinnati, Ohio.

Professor of Pediatrics, Psychiatry and Psychology, Case Western Reserve University and Metro Health Medical Center,
Cleveland, Ohio.

Professor of Pediatrics, University of Connecticut School of Medicine, Farmington, Conn.

Assistant Professor of Pediatrics, Boston University School of Medicine, Boston, Mass.


**Coordinator, Division of Behavioral and Developmental Pediatrics, Rainbow Babies & Childrens Hospital, Cleveland, Ohio.
e52 Pediatrics in Review Vol.29 No.10 October 2008

cognition and learning

and validity (eg, sensitivity and specificity for detection of


children who have clinically significant developmental
problems), (12) and 4) costs and feasibility for use in
specific settings.
To identify the most valid and feasible screening instruments for their practices, practitioners need detailed
information and guidance concerning scientific data and
feasibility. We conducted a comprehensive review of scientific research and practical considerations for developmental
screening instruments to guide selection and application of
screening instruments in a range of practice settings. (13)
This guide has been posted on the Commonwealth Fund
Website (http://www.commonwealthfund.org). (13) The
purpose of this report is to describe these guides and their
application. It is important to note that these guides focus
on general developmental screening and screening for autism and language delays and do not include screening for
socioemotional concerns in young children. The latter is an
important topic that requires separate consideration.

Relevant Questions Regarding Use of the


Guides for Surveillance and Screening
Instruments
Our review indicates that no single developmental
screening instrument is suitable for all clinical purposes
and practices. To make the best informed decisions
about selection and use of screening instruments, practitioners need to consider the following issues: 1) the
primary purpose of an instrument, 2) characteristics of
patients and families seen in their practices, 3) practicebased resources and experience in using screening instruments, and 4) availability of community resources for
evaluation and early intervention for developmental
problems that are identified by screening.

Primary Purpose of Administration of


Instruments
A practitioners choice of specific instruments should be
tied closely to an instruments specific purpose. For
example, practitioners should consider whether they intend to use an instrument primarily to facilitate developmental surveillance or screening. Another important
consideration is whether a practice desires an instrument
to detect general developmental delay or specific developmental disorders.

Characteristics of Patients and Families in


Specific Practice Settings
The characteristics of patients and families who are seen
in a specific practice also influence the selection of screen-

developmental surveillance and screening

ing instruments. In particular, the base rates of general


developmental problems or specific disorders in individual practices should be considered because these characteristics influence the sensitivity and specificity of specific
measures. Instruments that have the highest sensitivity,
specificity, or predictive values to detect specific developmental problems that are highly prevalent in individual
practices are the most valid for that practice. (14) However, unless a practice has a system in place to document
the prevalence of specific diagnoses of developmental
disorders, it may be very difficult to estimate the base
rates of developmental problems. In such instances,
knowing practice-specific rates of risk factors that are
associated with higher probabilities of developmental
problems, such as prematurity, may facilitate estimation
of base rates. (13)
A number of available developmental screening instruments are based on parent report. (13) Parent report
instruments have varying reading levels and availabilities
of translation for different languages. To ensure the most
valid administration, reading levels required by screening
instruments should match those of parents who complete them. In addition, instruments should be translated
into languages that are familiar to parents who use the
instruments to ensure a valid application.

Practice-based Resources and Experiences


Concerning Specific Screening Instruments
Developmental screening instruments vary widely in the
time of administration and the resources that are required for their administration, scoring, and interpretation. Practitioners must consider administration time as
well as the initial and ongoing costs of manuals, instruments, and scoring materials. To make the most informed choice of instruments, practitioners also need to
consider the potential revenue that can be generated to
pay for the use of developmental screening tools. For this
reason, the practices history of and potential for reimbursement for codes such as 96110 (developmental
screening) are most relevant.
Individual practitioners and practices may have very
different levels of experience in using specific instruments. Experienced practices have a significant advantage in selecting and implementing such instruments. In
addition, practices can consult information from published reports, (15)(16)(17) state AAP organizations,
and academic pediatric residency programs when making
decisions about specific instruments and implementing a
practice-based surveillance and screening program.
Pediatrics in Review Vol.29 No.10 October 2008 e53

cognition and learning

developmental surveillance and screening

Availability of Community Resources for


Evaluation and Early Intervention
Developmental screening instruments do not provide a
specific diagnosis or treatment plan but do identify areas
in which the childs development differs from age-related
norms. To have an optimal impact on the childs development, surveillance and screening should be followed
by specific clinical actions, such as referral for evaluation
and treatment or early intervention. (8) For this reason,
the availability of and collaboration with community
resources for additional evaluation and early intervention
programs are important to enhance the potential impact
of developmental screening on childrens development.

What Are Included in the Guides for


Developmental Screening?
The guides for developmental screening, each of which is
categorized to reflect the primary use of the instrument
for screening for general developmental problems, language problems, or autism, include the following:

Summary of recommendations for screening instruments for specific purposes based on the clinical relevance of the instrument, quality of standardization,
user friendliness, number and quality of validity studies, and availability of sensitivity and specificity for ages
as recommended by the AAP statement (8)
General information, including how to obtain the instruments, costs, parent reading levels, availability of
translation, use with electronic medical record, and
training needed to use the instrument
Information from the instruments manual or website
about the standardization sample and clinical application of the instrument
Scientific validity, as described in the test manual,
including sensitivity and specificity for specific ages
recommended by the AAP, reliability, and validity
Scientific validity based on published studies, including
sensitivity and specificity for age ranges recommended
by the AAP and ratings of studies reviewed based on
the Standards for Reporting of Diagnostic Accuracy,
(18) and a reference list of articles reviewed

Specific Recommendations for Use of


Developmental Surveillance and
Screening Instruments
Table 1 provides a summary of the primary recommendations for the instrument selection organized by the pure54 Pediatrics in Review Vol.29 No.10 October 2008

pose of the instruments. These recommendations are based


on a combination of clinical relevance (eg, user friendliness
and feasibility) and scientific validity based on standardization data reported in the test manual and published studies
based on the instruments, especially those that documented
sensitivity and specificity for screening at the ages recommended by the AAP. (8) Table 2 includes general descriptive information about the instruments described in Table
1. Interested readers should consult http://www.
commonwealthfund.org for additional information on the
validity of instruments, screening standards, and implementation recommendations.
Practitioners who are interested in an instrument to
use for developmental surveillance should consider the
Parents Evaluation of Developmental Status (PEDS),
(19) which has been validated for this purpose. Practitioners who wish to screen for general developmental delay
should consider whether they want to use parent-based
or practitioner-based instruments. The Ages and Stages
Questionnaire (ASQ) (20) and PEDS (19) are recommended as parent report measures for screening for
general developmental delay.
A second question that needs to be considered in
choosing instruments is whether the screening is for a
general pediatric population or a high-risk population
that contains a high percentage of children who are at
biologic risk (preterm birth) or environmental risk (economic disadvantage). Practitioners who are screening for
developmental delay in a high biologic or environmental
risk population may wish to consider the ASQ (20) (if
a parent-administered instrument is desired) and the
Bayley Infant Neurodevelopmental Screener (BINS)
(21) (up to age 24 months) or the Cognitive Adaptive
Test/Clinical Linguistic Auditory Milestone Scale
(CAT/CLAMS) if a practitioner-administered instrument is desired. (22)
Finally, practitioners who are interested in identifying
specific developmental delays have several choices, depending on the specific disorders. The Language Development Survey (LDS), (23) a parent-administered instrument, and the Clinical Linguistic Auditory Milestone
Scale (CLAMS), (22) a practitioner-administered instrument, should be considered for identification of language disorders. The Modified Checklist for Autism in
Toddlers (M-CHAT), (24) a parent-administered instrument, should be considered for the identification of
autism. (25)

Future Directions
Pediatric developmental screening instruments have
been available since the 1960s, (26) as has the need for

cognition and learning

Table 1.

developmental surveillance and screening

Recommendations for Selection of Specific Screening Instruments

Purpose of Screening

Population to be Screened

Type of Instrument

Identification of general
developmental delay

General primary care


population

Parental concerns-based
surveillance or screening
in various developmental
domains

Identification of general
developmental delay

General primary care


population or broad
high-risk prematurity

Parental report of multiple


skills in various
developmental domains

Identification of general
developmental delay

High-risk: Preterm and lowbirthweight population;


low socioeconomic
status

Practitioner-administered

Identification of general
developmental delay
(language and
cognitive)

High risk: Preterm and lowbirth-weight population;


low socioeconomic status

Practitioner-administered

Identification of language
delay

General primary care


population

Parent report

Identification of language
delay

High-risk preterm, lowbirthweight population

Practitioner-administered

Screening for autism and


developmental delay

General primary care


population

Parent-administered

critical evaluation of their validity (27) and the importance of sound clinical application. (28) Instrument development and standardization, the establishment of

Recommendation and
Comments
Parents Evaluation of
Developmental Status (PEDS)
Comprehensive, user-friendly
manual
Validation in large, diverse
standardization sample
Published validation studies
Ages and Stages Questionnaire
(ASQ)
Comprehensive, user-friendly
manual
Validation in large, diverse
standardization sample,
including general and highrisk children
Published validation studies
Bayley Infant
Neurodevelopmental Screens
(BINS)
Comprehensive, user-friendly
manual
Large, diverse standardization
sample
Published validation study
available
Cognitive Adaptive Test 1 Clinical
Linguistic Auditory Milestone
Scale and Expressive
Language Scale (CAT CLAMS
Capute Scales)
User-friendly manual
Large standardization sample
Multiple published validation
studies available
Language Development Survey
(LDS)
Comprehensive manual
Validation in large, diverse
standardization sample
Multiple published validation
studies
Cognitive Adaptive Test/Clinical
Linguistic Auditory Milestone
Scale and Expressive
Language Scale (Capute
Scales, CLAMS)
User-friendly manual
Standardization sample
Multiple published validation
studies
Modified Checklist for Autism in
Toddlers (M-CHAT)
User information available on
website
Published validation study
available

validity, and clinical application reflect a continually


evolving process. Many instruments that were used well
at one point in time no longer are as applicable, based on
Pediatrics in Review Vol.29 No.10 October 2008 e55

e56 Pediatrics in Review Vol.29 No.10 October 2008

Ellsworth & Vandermeer


Press, Ltd.
PO Box 68164
Nashville, TN 38206
615-226-4460
www.pedstest.com

Paul H. Brooks Publishing Co.


PO Box 10624
Baltimore, MD 21285-0624
800-638-3775
www.brookespublishing.com

Manual
Forms for
administration and
scoring
(photocopiable)
Total: $199.00
Manual
Forms for
administration and
scoring
Standardized
materials to
conduct
assessment
Total: $325.00
Manual
Forms for
administration and
scoring (n20)
Standardized
materials to
conduct
assessment
Total: $350.00
Forms for
administration and
scoring (n50)
Total: $30.00

Xavailable, information not available, N/Anot applicable

Problems
ASEBA/Research Center for
Manual
Children, Youth, and Families Forms for
1 South Prospect St.
administration and
Burlington, VT 05401-3456
scoring (n50)
802-264-6432
Total: $65.00
www.aseba.org/products/
cbc11-5.html
Screening for Autism and Pervasive Developmental Disorders
Modified Checklist for www.firstsigns.org/
Public Domain Free
Autism in Toddlers
downloads/Downloads_
(M-CHAT)
archive/m-chat.PDF

Screening for Language


Language
Development
Survey (LDS)

Capute Scales:
Cognitive Adaptive
Test/Clinical
Linguistic Auditory
Milestone Scale
Expressive and
Receptive
Language Scale
(CAT/CLAMS)
Parents Evaluations
of Developmental
Status (PEDS)

Bayley Infant
Harcourt Assessment, Inc.
Neurodevelopmental Attn: Customer Service
Screens (BINS)
P.O. Box 599700
San Antonio, TX 78259
800-211-8378
http://harcourtassessment.com

Instrument
How To Obtain Measure
Screening For General Developmental Problems
Ages and Stages
Paul H. Brooks Publishing Co.
Questionnaire
PO Box 10624
(ASQ)
Baltimore, MD 21285-0624
800-638-3775
www.brookespublishing.com

Cost of Materials,
Manual, and Relevant
Forms for
Administration and
Scoring

10

5 to 10

X N/A

2 to 10

15 to 20

5 to 10

10 to 15

Time
(min)

X N/A

X N/A

N/A X

N/A X

X N/A

Administered
To: Parent/
Child

5th grade

5th grade

N/A

N/A

4th to 6th
grade

Parent
Reading
Level

Yes

Yes

Yes

Yes

No

Yes

Spanish

Chinese
Japanese

French, Italian,
Romanian, Dutch,
Turkish,
Portuguese, Greek

Vietnamese, Arabic,
Swahili,
Indonesian,
Chinese, Taiwanese,
French, Somali,
Portuguese,
Malaysian, Thai,
Laotian

Russian
Chinese

Portuguese

French
Korean

Translations
Other

Web-link Program
www.web-link.org

Yes

No

No

Yes

Used With
Electronic
Medical Record

www.utmem.edu/
pediatrics/general/
clinical/m-chatscoring.pdf

Workshops, inservice
(Contact: Leslie
Rescorla through
ASEBA)

Training and research


materials available on
website at
www.pedstest.com

Manual only

Training video at http://


harcourtassessment.com/

On Location
Web-based at
www.agesandstages.com/

Training Available

General Information Concerning Screening Instruments (instruments are listed in


alphabetical order within categories)

Table 2.

cognition and learning


developmental surveillance and screening

cognition and learning

data from more recent standardization samples, demonstrations of validity, and the development of newer measures based on parental report.
The recommendations presented in this report are
based on an extensive scientific review of evidence on
available developmental screening measures. It is anticipated that additional screening measures will emerge as
additional research is conducted. One of the most important future directions is to extend clinical and scientific
knowledge about application of developmental screening instruments to pediatric practices and state-level
screening programs. Additional data are needed in many
areas, including feasibility and cost effectiveness of different screening instruments in various practice settings.
Important but as yet unanswered questions include:
How do practitioners and practices implement various
instruments in the context of clinical care? What are the
experiences of the practices in obtaining reimbursement
for this screening? What is the level of family satisfaction
with developmental screening? What is the impact of
false-positive screening results?
Another important area of future research concerns
the validity of the screening instruments in practice settings. With some notable exceptions, (15)(16)(17) there
have been few demonstrations of the validity of screening
instruments in practice settings. Moreover, additional
studies of the validity (sensitivity and specificity) of developmental screening instruments with different populations are particularly important. Our review identified
32 studies that assessed the validity of instruments recommended here, but few of these were conducted in
clinical practice settings. Such studies are particularly
important because the sensitivity and specificity of developmental screening instruments depend on the base
rates of developmental problems in specific practices. For
this reason, data from individual practices and programs
are very much needed to establish the validity of screening instruments in clinical populations.
A final critical area for future research and clinical care
concerns the impact of developmental screening on childrens developmental outcomes. For example, does routine developmental screening result in increased referral
and engagement of children and families in early intervention programs in practice settings? Do screening and
subsequent involvement in early intervention enhance
childrens developmental outcome and functioning?
Such research will build on studies that already have
indicated positive effects of developmental screening and
early intervention. (2)(5)(7)

developmental surveillance and screening

Summary
The high prevalence of developmental problems in pediatric practice coupled with the opportunity for early
intervention underscore the importance of developmental screening and surveillance in pediatric primary care.
The selection of valid screening instruments is necessary
to identify developmental delay and developmental disorders in accord with the 2006 policy statement of
the AAP. (8) A number of validated general and
condition-specific developmental screening instruments
are applicable to primary care practice. Becoming aware
of available screening instruments will help pediatric
practitioners make informed selections of the specific
tools that can identify and serve best the needs of children and families of their particular practices.
ACKNOWLEDGMENTS. This work was supported by
the Commonwealth Fund #20060127 Rating Developmental Screening Instruments. The intellectual and technical support provided by Ed Schor and his colleagues at
the Commonwealth Fund is gratefully acknowledged.
Finally, the assistance provided by Desiree Rayl in typing
and processing this manuscript is appreciated.

References
1. Sand N, Silverstein M, Glascoe FP, Gupta VB, Tonniges TP,
OConnor KG. Pediatricians reported practices regarding developmental screening: do guidelines work? Do they help? Pediatrics.
2005;116:174 179
2. Anderson LM, Shinn C, Fullilove MT, et al. The effectiveness of
early childhood development programs. A systematic review. Am J
Prev Med. 2003;24(3 suppl):32 46
3. Sices L, Feudtner C, McLaughlin J, Drotar D, Williams M. How
do primary care physicians identify young children with developmental delays? A national survey. J Dev Behav Pediatr. 2003;24:
409 417
4. Sices L, Feudtner C, McLaughlin J, Drotar D, Williams M. How
do primary care physicians manage children with possible developmental delays? A national survey with an experimental design.
Pediatrics. 2004;113:274 282
5. Bailey DB Jr, Hebbeler K, Spiker D, Scarborough A, Mallik S,
Nelson L. Thirty-six-month outcomes for families of children who
have disabilities and participated in early intervention. Pediatrics.
2005;116:1346 1352
6. Hill JL, Brooks-Gunn J, Waldfogel J. Sustained effects of high
participation in an early intervention for low-birth-weight premature infants. Dev Psychol. 2003;39:730 744
7. Vanagt HME, Van der Stege HA, Ridder-Sluiter HD, Verhoeven LTW, De Koning HJ. A cluster-randomized trial of screening
for language delay in toddlers: effects on school performance and
language development at age 8. Pediatrics. 2007;120:13171323
8. Council on Children With Disabilities; Section on Developmental Behavioral Pediatrics; Bright Futures Steering Committee; Medical Home Initiatives for Children With Special Needs Project
Advisory Committee. Identifying infants and young children with
Pediatrics in Review Vol.29 No.10 October 2008 e57

cognition and learning

developmental surveillance and screening

developmental disorders in the medical home: an algorithm for


developmental surveillance and screening. Pediatrics. 2006;118:
405 420
9. Dobrez D, Sasso AL, Holl J, Shalowitz M, Leon S, Budetti P.
Estimating the cost of developmental and behavioral screening of
preschool children in general pediatric practice. Pediatrics. 2001;
108:913922
10. Halfon N, Hochstein M, Sareen H, OConner K, Inkelas M,
Olson L. Barriers to the provision of developmental assessments
during pediatric health supervision. Presented at the Pediatric
Academy Societies Annual Meeting, May 2001. Available at:
www.aap.org/research/periodicsurvey/ps46pas4.htm
11. Halfon N, Regalado M, Sareen H, et al. Assessing development
in the pediatric office. Pediatrics. 2004;113(6 suppl):1926 1933
12. Aylward GP, Stancin T. Screening and assessment tools. Measurement and psychometric considerations. In: Wolraich M, Dworkin P, Perrin E, eds. Developmental Behavioral Pediatrics: Evidence
and Practice. Philadelphia, Pa: Elsivier; 2008:123129
13. Drotar D, Stancin T, Dworkin P. Pediatric Developmental Screening: Understanding and Selecting Screening Instruments. New York,
NY: The Commonwealth Fund; 2008. Available at: http://www.
commonwealthfund.org/publications/publications_show.htm?doc_id
614864
14. Camp BW. Evaluating bias in validity studies of developmental/behavioral screening tests. J Dev Behav Pediatr. 2007;
28:234 240
15. Earls MF, Hay SS. Setting the stage for success: implementation of developmental and behavioral screening and surveillance in
primary care practicethe North Carolina Assuring Better Child
Health and Development (ABCD) Project. Pediatrics. 2006;118:
e183 e188
16. Hix-Small H, Marks K, Squires J, Nickel R. Impact of implementing developmental screening at 12 and 24 months in a pediatric practice. Pediatrics. 2007;120:381389
17. Pinto-Martin JA, Dunkle M, Earls M, Fliedner D, Landes C.
Developmental stages of developmental screening: steps to imple-

e58 Pediatrics in Review Vol.29 No.10 October 2008

mentation of a successful program. Am J Public Health. 2005;95:


1928 1932
18. Bossuyt PM, Reitsma JB, Bruns DE, et al. The STARD statement for reporting studies of diagnostic accuracy: explanation and
elaboration. Ann Intern Med. 2003;138:W1W12
19. Glascoe FP. Collaborating with parents. In: Using Parents
Evaluation of Developmental Status to Detect and Address Developmental and Behavioral Problems. Nashville, Tenn: Ellsworth &
Vandermeer Press, LLC; 2002
20. Squires J, Potter L., Bricker D. The ASQ Users Guide. Baltimore, Md: Paul H. Brookes Publishing Co; 1999
21. Aylward GP. Bayley Infant Neurodevelopmental Screener. San
Antonio, Tex: The Psychological Corporation Harcourt Brace and
Company; 1995
22. Accardo P, Capute AL. The Capute Scale. Cognitive Adaptive
Test/Clinical Linguistic and Auditory Milestone Scale. Baltimore,
Md: Paul H. Brookes Publishing Co; 2005
23. Achenbach TM, Rescorla LA. Manual for the ASEBA Preschool
Forms and Profiles. Child Behavioral Checklist for Ages 1125
Language Development SurveyCaregiverTeacher Report. An
Integrated System of Multi-informant Assessment. Burlington, Vt:
ASEBA; 2000
24. Robins DL, Dumont-Mathieu TM. Early screening for autism
spectrum disorders: update on the Modified Checklist for Autism in
Toddlers and other measures. J Dev Behav Pediatr. 2006;27(2 suppl):
S111S119
25. Johnson CP, Myers SM. Identification and evaluation of
children with autism spectrum disorders. Pediatrics. 2007;120:
11831215
26. Frankenburg WK, Dodds JB. The Denver developmental
screening test. J Pediatr. 1967;71:181191
27. Thorpe HS, Werner EE. Developmental screening of preschool children: a critical review of inventories used in health and
educational programs. Pediatrics. 1974;53:362370
28. Solnit AJ. Editorial: the risks of screening. Pediatrics. 1976;57:
646 647