Screening Infants and Young Children for Developmental Disabilities

Committee on Children With Disabilities

Early identification of children with developmental that there is no significant problem, or to a decision
disabilities leads to effective therapy of conditions for that further observation is warranted.1 The act of
which definitive treatment is available. However, screening also serves the purpose of clearly commu-
even in those instances in which the condition cannot nicating to parents the pediatricians interest in the
be fully reversed, early intervention improves chil- development as well as the physical health of the
drens outcomes and enables families to develop the child.2 If appropriate, the pediatrician should foster
strategies and obtain the resources for successful fam- awareness and acceptance of the possible develop-
ily functioning. Much of the impact of early interven- mental disability.
tion results from fostering a more comfortable and Public Law 99-457 (reauthorized as Pub L 102-119,
developmentally appropriate interaction between the The Individuals with Disabilities Education Act)3
parents and their child with a disability. mandates early identification of, and intervention for,
developmental disabilities. Since the passage of that
law, the emphasis in screening has shifted to a
DEFINITION
younger age, with the current focus being on infants
Screening is a brief assessment procedure de-
and children birth through 2 years of age.3 This is an
signed to identify children who should receive more
age at which the pediatrician is very closely involved
intensive diagnosis or assessment.1 Early childhood
with children and families and is in a position to have
developmental screening does not consist of admin-
significant impact on the course of the childs devel-
istering a single instrument at one point in time, but
opment. Public Law 99-457 and The Individuals with
rather is a set of processes and procedures used over
Disabilities Education Act have also led to the devel-
time. The following guidelines are recommended
opment of community systems for tracking of high-
by the Task Force on Screening and Assessment of
risk infants and resources for referring infants and
the National Early Childhood Technical Assistance
young children for intervention. The emphasis on ear-
System:
her identification creates the opportunity to provide
S Screening should be viewed as a service and part the benefits of early intervention, but also poses
of the intervention process. greater challenges in the sphere of screening. Parents
. Screening processes, procedures, and instruments expect their pediatricians to give them guidance on
should only be used for their intended purpose. developmental issues, but will turn to other commu-
. Multiple sources of information should be utilized. nity systems if the pediatrician does not fill this role.
. Screening should be performed on a recurrent or Children and families are best served when pediatri-
periodic basis. cians screening efforts are coordinated with the
. Screening should be viewed as only one path to tracking and intervention services available in the
further assessment and the acquisition of services, community.
with social and medical risk factors also being con-
sidered in decisions about evaluation and interven-
ISSUES IN METHODOLOGY
tion.
. Procedures should be reliable and valid. Delays or deviations in development may come
. Family members should be included as part of the to the attention of professionals and parents because
process. the child is known to have risk factors by history,
. Screening is more effective when familiar tasks and has physical findings or medical conditions likely to
settings are used. be associated with delays, or manifests delays at the
I Procedures must be culturally sensitive. time of observation. The first two factors are as use-
. Screening should be performed by individuals ful in a very young child as in an older one, but
with training in the procedures. some developmental delays are more difficult to as-
sess early. A delay in a skill becomes evident only
Screening does not measure a childs intelligence
at the age when that developmental milestone is ex-
quotient, rather it is aimed at identifying those chil-
pected. For example, motor skills, which change
dren who may need more comprehensive evalua-
rapidly in the first 2 years, are the easiest milestones
tions. Such evaluations may lead to the development
to observe, but are the least predictive for future in-
of an interdisciplinary comprehensive plan of reme- telligence. Language skills are usually identified
diation for a child with a disability, to a realization later but are better predictors of future intelligence
and school performance.4
PEDIATRICS (ISSN 0031 4005). Copyright 1994 by the American Acad- Developmental disabilities encompass a spectrum
emy of Pediatrics. of problems of varying kinds and severity. Although

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PEDIATRICS Vol. 93 No. 5 May 1994 863
broad agreement exists as to what constitutes clear- . Examination of specific developmental attain-
cut delay or deviation, there is not complete consen- ments
sus among professionals, or between parents and . Use of all encounters for observing and recording
physicians, as to the severity at which evaluation and developmental status
intervention become appropriate and when devia- . Screening of vision and hearing to rule out sensory
tions from norms are sufficient to warrant further impairment as a cause of the delay
clinical attention. The central dilemma for the pedia- . Observation of parent-child interaction.
trician who screens patients is that identification must
REQUIRED SKILLS AND PROCEDURES
precede services, and the act of identifying a child as
one who needs further assessment for developmental To screen for developmental disabilities and inter-
disabilities provokes anxiety in parents. This concern vene with the identified children and their families,
may create a tendency to identify only markedly de- the primary pediatrician must have the clinical skills
layed children, denying other children potential ac- and institute the procedures listed below:
cess to needed care. I . Maintain and update her or his knowledge about
The limited ability of infant tests, whether intended developmental issues, risk factors, screening tech-
for screening or definitive diagnosis of intellectual niques, and community resources for consultation
functioning, to predict future function has led to con- and intervention
troversy concerning their use. However, when phy- 2. Acquire skills in the administration and interpre-
sicians use only clinical impressions, estimates of chil- tation of a formal developmental screening tech-
drens developmental status are often inaccurate.5 nique
The advantage of screening instruments is that they 3. Develop a strategy to provide periodic screening in
state their norms explicitly, serve as a reminder to the the context of office-based primary care, including
pediatrician to observe development, and are an ef- the following:
ficient way to record the observations. . Developmental screening of all children in the
The Denver-Il, which is a successor to the Denver practice
Developmental Screening Test, is a brief, validated . Recognizing abnormal appearance and function
test with which many pediatricians are familiar.6 Al- during health care maintenance examinations
though it has been criticized for having limited speci- . Recognizing high-risk medical and environmen-
ficity and therefore risks overreferring, it has high tal situations while taking routine medical and
rates of sensitivity and identifies delayed children social histories
correctly in a high proportion of cases.7 Because the . Actively seeking observations and concerns
Denver II is intended to be used in the context of a from parents about their childs development
process that includes other sources of information . Recognizing troubled parent-child interaction
and multiple points in time, it is a useful part of the from history or observation
screening. The Early Language Milestones is another . Performing periodic rescreenings of practice
instrument suitable for office screening that was de- populations to discover the possible emergence
signed for identifying delays in language in children of new risk situations or the childs difficulty in
less than 3 years of age.8 A recent review of commonly meeting more advanced developmental expec-
used screening instruments is available. Although tations
there is still a paucity of adequately validated tests 4. Maintain updated information on existing commu-
that are brief and can be used for infants, the growing nity resources for serving infants and children at
interest in assessment of infants and young children risk for, or with, developmental delays and their
will likely result in the development of new instru- families;
ments and methods. 5. Maintain linkages with these resources and coor-
Because the screening process selects those children dinate patient care with them;
who will receive the benefits of more intensive evalu- 6. Increase parents awareness of developmental dis-
ation or of treatment after evaluation, all children abilities and of resources for intervention by such
should be screened for developmental disabilities. methods as display and distribution of educational
Screening is not the same as evaluation, diagnosis, or materials in the office; and
planning of treatment and represents the first step 7. Be available to families to interpret consultants
leading to a multidisciplinary evaluation. In the op- findings.
timal situation, each child should have a defined
Ongoing involvement with the family permits the
medical home for primary care, and screening pro-
pediatrician to respond to parental concerns about the
cedures should be incorporated into the ongoing
childs development when such concerns exist. When
health care of the child. parents are not aware of a delay that is present, the
pediatrician can guide them toward closer observa-
SCREENING PROCESS tion of their child and thus enable them to recognize
the delay. Referral for evaluation and services can
Essential components of the screening process are
take place only after the pediatrician has succeeded in
as follows:
this challenging task. At that point the pediatricians
. Sensitive attention to parental concerns role shifts to one of involvement in the evaluation
. Thoughtful inquiry about parental observations as appropriate, referral to available community re-
. Observation of a wide variety of the childs be- sources for intervention and family support, assis-
haviors tance in understanding the evaluation results, assess-

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DISABILITIES guest on March 30, 2017
ment and coordination of services, and monitoring Renee C. Wachtel, MD
the childs developmental progress as part of the on- Philip R. Ziring, MD
going pediatric care. LIAISON REPRESENTATIVES
Connie Garner, RN, MSN, EdD, US Dept of
CONCLUSION Education Programs
Early identification of children with developmental Debbie Gaebler, MD, American Academy of
disabilities can lead to treatment or amelioration of Physical Medicine and Rehabilitation

the severity of a disability and its impact on the func- Joseph C. Hollowell, MD, Center for Disease
Control and Center for Environmental Health
tioning of the child and family. Because developmen-
and Injury Control
tal screening is a process that selects those children
Merle McPherson, MD, Maternal and Child Health
who will receive the benefits of more intensive evalu-
Bureau, Dept of Health & Human Services
ation, or of treatment, all infants and children should
SECTION LIAISON
be screened for developmental disabilities, otherwise
Harry Gewanter, MD, Section on Rheumatology
some may be denied access to needed care. Successful
early identification of developmental disabilities re- CONSULTANT
Avrum Katcher, MD
quires the pediatrician to be skilled in the use of
screening techniques and of developmental surveil-
lance, to actively seek parental concerns about devel- REFERENCES
opment, and to create linkages with available re-
I . Meisels Si, Provence S. Screening Assess,nent. Guidelines for Identifijing
sources in the community. Because community
Young Disabled and Developmentally Vulnerable Children and Their Families.
systems vary from one locality to another and may Washington, DC: Zero to Three/National Center for Clinical Infant
change over time, the physicians information must Programs; 1989
be updated on a regular basis. Children and families 2. Kaminer R, Jedrysek E. Early identification of developmental disabili-
ties. Pediatr Ann. 1982;11:427-437
are best served when the primary pediatrician pro-
3. Individuals With Disabilities Education Act of 1991 (Pub L No. 102-119)
viding health supervision services collaborates with 4. Stevenson 1. Predictive value of speech and language screening. Dcv
the tracking and intervention services available in Med Child Neurol. 1984;26:528-538
the community. 5. Dworkin PH. Developmental screening: still expecting the impossible?
Pediatrics. 1992;89:1253-1255

COMMITrEE ON CHILDREN WITH DISABILITIES, 1993 to 1994 6. Frankenburg WK, Dodds J, Archer P. Shapiro H, Bresnick B. Denver-Il
Screening Manual. Denver, CO: Denver Developmental Materials, Inc;
James Perrin, MD, Chair
1990
Gerald Erenberg, MD
7. Glascoe FP, Byrne KE, Ashford LG, Johnson KL, Chang B, Strickland B.
Ruth K. Kaminer, MD
Accuracy of the Denver-lI in developmental screening. Pediatrics. 1992;
Robert La Camera, MD 89:1221 -1225
John A. Nackashi, MD 8. CoplanJ, GleasonJR, Ryan R, Burke MG, Williams ML. Validation of an
John R. Poncher, MD early language milestone scale in a high-risk population. Pediatrics.
Virginia Randall, MD 1982;70:677-683

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AMERICAN ACADEMY OF PEDIATRICS 865
 Screening Infants and Young Children for Developmental Disabilities
Committee on Children With Disabilities
Pediatrics 1994;93;863
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright 1994 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
Online ISSN: 1098-4275.

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 Screening Infants and Young Children for Developmental Disabilities
Committee on Children With Disabilities
Pediatrics 1994;93;863

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
/content/93/5/863

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright 1994 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 0031-4005. Online ISSN: 1098-4275.

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