1. The Timely Diagnosis of Developmental Delay
Karen Montgomery-Reagan, D.O. FACOP, FAAP
Ohio University Heritage College of Osteopathic Medicine
Department of Pediatrics

2. Developmental delay occurs when a child exhibits a significant delay in the acquisition of milestones. Deviation in development is
A. child has differing rates of development in different developmental domains
B. child loses previously acquired skills or milestones
C. child has a delay in two or more domains
D. child develops milestones outside of typical acquisition sequence

3. Identify the incorrect statement
A. 66% of the children entering school are identified with a delay
B. 5% of world’s children under age of 14 have some type of moderate to severe developmental delay
C % of children in US have a developmental/behavioral problem under 18 years of age
D. Development impairment impacts the family and community

4. Objectives Understand reasoning for timely developmental diagnosis
Understand the difference between screening and surveillance
Introduce use of screening tools in the primary care office

5. PCP is the point of “first contact” for any new health concerns
Developing a therapeutic relationship with my patients; treating several generations within a family and following patients over many years; counseling patients“
Having the implicit trust of my patients to direct their [preventive] care and treat their diseases. The privilege of having families count on me as one of their own and especially to share the growing up of their children.”
Articles from Canadian Family Physician are provided here courtesy of College of Family Physicians of Canada

6. Who Says What
USPSTF -- neither recommends for or against use of screening tools
AAFP -- is in agreement with the USPSTF needing evidence
The Individuals with Disabilities Education Act Amendments of and Title V of Social Security Act -- mandate that health care professionals provide early identification and intervention for development delay working with community collaborative systems
Center for Disease Control and Prevention recommends the use of a brief developmental assessment to identify children who should receive intensive diagnosis or evaluation (2005)
AAP –- recommends surveillance combined with standardized screening at well-child visits.

7. Childhood Development
Trajectory of achieving physical, cognitive, communications, social-emotional, and self-help milestones within a specific age range.
Delays – childhood mental or physical impairment or combination of mental and physical impairment that result in functional limitations in major life activities
Developmental disabilities – impairment in one or more developmental domains

8. Definitions Global Delay – a delay in 2 or more developmental delays
Deviations – occurs when a child develops milestone/skill outside of typical sequence
Dissociation – occurs when a child has widely differing rates of development in different domains
Regression – child loses acquired skills or milestones

9. Early Identification of Children with Developmental Delay
12-16% of children in the United States have at least one development delay
Only 3% will be diagnosed before 3 years of age
Only 1/3 by time the child enters kindergarten
Late detection results in opportunity lost for “early intervention”

10. What does late detection mean for the child, parent and society
Early interventions
Improvement in language/communication
Cognitive
Social-emotional
Family better able to meet the needs of the child
Decreased need for costly special education services

11. Barriers for primary care
Cost
Lack of time
Reimbursement
Insufficient training
Over identification concern
Availability of referral options
Limited services in the community

12. Coordinated Systems of Health Care
In the End
The USPSTF states -- it is ultimately the responsibility of the physician to seek out and address parental concerns about their child’s development
Substantial opportunities exist to help monitor the development of child in the US
Protocols for developmental monitoring
Use of validated developmental screening tools

13. Medical Home Parents’ expectation of their child’s medical home
Continuous and comprehensive care
Identify abnormality in development
Be knowledgeable of community resources
Facilitate referrals
AAP: Bright Futures: guidelines for health supervision of infants, children and adolescents

14. Bright Futures

15. Surveillance vs Screening
Developmental Surveillance
Recognizing children who may be at risk of developmental delays
Developmental Screening
Administration of a brief standardized tool for possible identification of child at risk of a developmental disorder

16. Components of Surveillance
Eliciting and attending to the parents’ concerns about their child’s development
Documenting and maintaining a development history
Making accurate observations of the child
Identifying the risk and protective factors
Maintaining an accurate record and documenting the process and findings

17. Recommendation from the AAP
Developmental Surveillance at every well-child visit
Developmental Screening using formal, validated tools at 9, 18, 30 (24)
When a parent or provider has concern then formal screening performed

18. General Screening Tools validated
Ages and stages questionnaire (ASQ-3)
Ages and stages questionnaire: Social-Emotional (ASG-SE2)
Parents' Evaluation of Developmental Status (PEDS)
Parents’ Evaluation of developmental status- Development Milestones (Peds-DM)
Modified checklist for Autism in Toddlers (M-Chat-R/F)
Patient Health Questionnaire-9 (PHQ-9)
Edinburgh Postnatal Depression scale
Hunger Vital Sign

19. Administration of Development Tool
Two types of formal screening tools
Parent-Completed
Parent completes the questionnaire
Time efficient and reduce cost
5-10 minutes for parent to complete
Directly administered
Direct observation and parent input
In-Depth information
Useful as secondary stage screening

20. Ages and Stages Questionnaires

21. Administration of Development Tool
Ages and Stages Questionnaire (ASQ)
21 age-specific questionnaires
Five developmental domains
Fine and gross motor, language/communication, problem solving/adaptive behavior, personal/social preformation
6 items in each area
Section of 10 questions to query parental concern
4-6 grade reading level
Takes 1-5 minutes to score
Specificity 86%; Sensitivity 85%; reliability 0.94
Agesandstages.com

27. No “wait and see” approach
Children who pass screening provides an opportunity to promote developmentally appropriate activities and discuss future milestones
Children wo fail screening need close follow up or further testing
Early intervention referral should not be delayed or know as “wait and see”
Early treatment improves the quality of life for child and parents and less costly to society

28. Why 9 18 and 30 (24) month screen?
9 months – issues with motor skills identified and early communication skills
18 months – issues with communication and language are evident by this age
30 months – most motor, language, cognitive delays identified with screening tools
Remember through surveillance that screenings should be administered if concerns raised by parents, PCP, or other care givers

29. Abnormal Screen Evaluation and Referral
Comprehensive Medical Evaluation
Early Childhood Professionals
Pediatric subspecialists
Early intervention programs
Public school special education (3 year old)

30. Medical Home Interdisciplinary Team
Provider
Childhood educators
Child psychologist
Speech-language pathologists
Audiologists
Social workers
Physical therapists
Occupational therapists

31. Evaluation and Referral
Primary Care Tests
Vision and hearing
Metabolic testing
Lead and iron level
Genetic testing
EEG
Brain imaging

32. Diagnostic Developmental Testing
Bayley Scales of Infant and Toddler Development
Woodcock-Johnson Psychoeducational
Stanford-Binet intelligence scale
Battellle Developmental Inventory
Brigance System

33. Developmental Disorder
Child with special health care needs which initiates chronic-condition management
Medical Home should recognize and provide appropriate chronic-condition management with regular monitoring
Medical Home develops a registry for children in the practice who have special care needs
Medical Home provides a triad of primary care services: preventative care, acute illness management and chronic-condition management

34. Incorporating Screening in the office of Primary Care
Use a quality-improvement approach
Developmental screening is “whole-office” endeavor

35. Screening Payment CPT codes
Developmental screening limited
Developmental testing extended
Medicare Resource Based Relative Value Scale -- codes and reflect physician work, practice expenses

36. Screening Payment, cont’d.
CPT Code
Tests it Includes
Reimbursement
96127
ASQ-SE, PHQ-9, Conners
$4.21 to $7.29
96161
EPDS
$4.07 to $5.18
96110
M-Chat and ASQ
$3.75 to $9.62

40. Summary Surveillance -- component of every visit
Screening tools – surveillance identifies a concern and at 9, 18, and 30 month visit
Screening positive – further testing is warranted
Children with developmental disorders identified with special health care needs – chronic-condition management

41. Citations
American Academy of Pediatrics; Council on Children with Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee and Medical Home Initiatives for Children with Special Needs Project Advisory Committee. (2006). Identifying Infants and Young Children with Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening. Pediatrics, 118(1), doi: /peds
Division of Human Development and Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention. (2018). Developmental Monitoring and Screening for Health Professionals. Retrieved from