Screening and Surveillance

Regularly monitoring children for developmental, behavioral and emotional problems is an important part of preventive health care (AAP policy statement, 2001). In addition, the medical home plays a critical role in the success of neonatal metabolic and hearing screening programs. The health care provider should be familiar with screening tools and techniques and community resources for the following issues:

• Developmental delay and mental retardation
• Autism spectrum disorders
• Cerebral palsy and related neuromuscular disorders
• Speech and Language disorders
• Behavioral and mental health disorders
• Hearing and vision impairment
• Metabolic disorders

Developmental disabilities. The most important technique for the early identification of preschool children with developmental delay, autism, cerebral palsy and speech and language disorders is repeated use of a general developmental screen at different ages. The use of a parent-completed screen is recommended since it involves little professional time and gives a much more complete picture of the child’s skills. The Ages and Stages Questionnaires (ASQ)², the Minnesota Child Development Inventories (CDI, Infant Development, Early Child Development and Preschool Developmental Inventories)^5-8 and the Pediatric Evaluation of Developmental Status (PEDS)⁴ are three such measures. The ASQ and CDI are recommended since they provide much more comprehensive information with little increase in professional time. This information may be very helpful in determining the most appropriate referral. The PEDS includes 10 questions that elicit general parental concerns only. The PEDS may be the best choice for the health care provider who plans to refer most children whose parents note a concern to Early Intervention (EI) staff for further evaluation.

Targeted screens also are available to assist in the identification of children with possible autism spectrum disorders (e.g., the Checklist for Autism in Toddlers ¹), cerebral palsy (e.g., the Alberta Infant Motor Scale ⁹) and speech and language disorders (e.g., the MacArthur Communicative Development Inventories ³). Use of a targeted screen can provide additional information to the health care provider that may help determine the most appropriate referral. Further information about general and targeted developmental screening tools and recommendations for developmental screening and surveillance is available from Nickel & Squires, Developmental Screening and Surveillance, in Nickel and Desch (Eds.), The Physician’s Guide to Caring for Children with Disabilities and Chronic Conditions, Paul H. Brookes Publishing, 2000.

If you have questions about the development or the behavior of a preschool-age child in your practice, contact the Early Intervention (EI, services for children birth through 2 years) and Early Childhood Special Education (ECSE, services for children 3 through 5 years) provider in your community. EI/ECSE staff can review the services available, take referral information and contact the family to arrange for eligibility testing. Additional information on services in Oregon including referral and contact information is available on the web site of the Oregon Department of Education.

Behavioral and emotional problems. Previous studies have reported that primary care providers under-identify young children with behavioral and emotional problems. In addition, parents who have behavioral concerns about their child may not mention those concerns during a well child appointment. Use of a formal behavioral screen will invite parents to share concerns with the health care provider and provide more complete information to assist in determining whether this is a transient issue, an on-going problem or a possible mental health disorder. The regular use of a general developmental screen is the most important technique for the early identification of young children with behavioral and emotional problems. In addition, targeted behavioral screens are available such as the Devereaux Childhood Assessment ¹¹ and the Ages and Stages Questionnaires: Social –Emotional (ASQ:SE)¹⁰. Further information about screening for behavioral and emotional problems and specific behavioral screening tools is available from Perrin & Stancin (2002), “A continuing dilemma: whether and how to screen for concerns about children’s behavior, Pediatrics in Review 23(8): 264-282. One innovative approach to this issue has been incorporating the services of a mental health professional into the primary care office. Review the state and local resource guides in this section for contact information on the mental health professionals who serve children and families in your community.

Hearing impairment. The early identification of infants and young children with hearing loss can help minimize the associated speech and language delays. The American Academy of Pediatrics (AAP) and the Joint Committee on Infant Hearing (JCIH) recommend that all newborns receive hearing screening, and many states have passed legislation mandating universal neonatal hearing screening (e.g., OR House Bill 3246). Further information on the newborn hearing screening program in Oregon is available on the web site of Oregon Public Health Services, Department of Human Services. This site lists the hospitals that have screening programs, other screening facilities for infants born in hospitals without screening programs, facilities that provide diagnostic testing, and contact numbers for early intervention services for children who have hearing impairments.

The role of the primary health care provider is to work with families to assure follow-up testing for those infants that fail the newborn screen and prompt referral to services for those children who have hearing impairments on diagnostic testing. Health professionals must be familiar with the resources for screening, diagnostic testing and early intervention in their communities. In addition, health care providers must know the risk factors for progressive and late onset hearing loss and refer appropriate children for audiologic testing.

Vision impairment. The AAP also supports universal preschool vision screening although recent studies estimate that fewer than 25% of children actually are screened.* The recommendation of the AAP is that all children receive screening of visual acuity at the earliest age practical and no later than age 3. All children who screen positive should be referred to a pediatric ophthalmologist or other appropriately trained eye care specialist for diagnosis, treatment and follow-up. The AAP is participating in an initiative to assess the barriers to screening and follow-up and to promote preschool vision screening. The Lions Club of Oregon provides a mobile screening unit, a low vision clinic and an eyeglasses program for qualified low income Oregonians. Further information about screening techniques for visual acuity, strabismus and other ocular disorders is available from Desch, “Vision and Hearing Impairments,” in Nickel and Desch (Eds.), The Physician’s Guide to Caring for Children with Disabilities and Chronic Conditions, Paul H. Brookes Publishing, 2000.

Metabolic disorders. The newborn screening program in Oregon screens newborns for metabolic, endocrine and hemoglobin disorders. The goal of the program is prompt identification of infants who need immediate treatment to prevent developmental delay and mental retardation or serious illness and death. The screening program includes hypothyroidism, galactosemia, phenylketonuria (PKU), biotinidase deficiency, maple syrup urine disease (MSUD), congenital adrenal hyperplasia (CAH), and hemoglobinopathies such as sickle cell anemia. Further information is available on the web site of Oregon Public Health Services, Department of Human Services. Diagnostic testing and treatment services for children with metabolic disorders are available from the Metabolic program at the Child Development and Rehabilitation Center (CDRC), Oregon Health & Science University (OHSU). Diagnostic testing for children with endocrine and hematologic disorders is readily available through multiple sources and specialty clinics are held at Doernbecher Children’s Hospital and Emanuel Hospital in Portland as well as several outreach sites.

References:

1. Baron-Cohen, S, Allen, J, & Gillberg, C. (1992). Can autism be detected at 18 months? British Journal of Psychiatry, 161, 839-843.
2. Bricker, DD, Squires, J, Mounts, L, et al. (1999). Ages & Stages Questionnaires (ASQ): A parent-completed, child-monitoring system (2nd ed.). Baltimore: Paul H. Brookes Publishing Co.
3. Fenson, L, Dale, PS, Rexnick, JS, et al. (1993). MacArthur Communicative Development Inventories (CDI). San Diego: Singular Publishing Co.
4. Glascoe, PF. (1997b). Parents' Evaluation of Developmental Status: Administration and scoring manual. Nashville, TN: Ellsworth & Vandermeer Press.
5. Ireton, H. (1984). Preschool Developmental Inventory. Minneapolis, MN: Behavior Science Systems.
6. Ireton, H. (1988). Early Child Development Inventory. Minneapolis, MN: Behavior Science Systems.
7. Ireton, H. (1992). Child Development Inventories. Minneapolis, MN: Behavior Science Systems.
8. Ireton, H. (1994). Infant Development Inventory. Minneapolis, MN: Behavior Science Systems.
9. Piper, MC, Pinnell, LE, Darrah, J, et al. (1994). Construction and validation of the Alberta Infant Motor Scale (AIMS). Canadian Journal of Public Health, 83 (Suppl. 2), S46-S50.
10. Squires, J, Bricker, D, Twombly L. (2002). Ages and Stages Questionnaires: Social-Emotional. Baltimore, MD: Paul H Brookes Publishing Co.
11. Devereux Foundation. (1998). Devereux Early Childhood Assessment (DECA). Lutz, FL: Psychological Assessment Resources.