Introduction
As our nation reaches historic levels of health coverage for children, there is increased interest in further ensuring access to the care needed for children to reach their full potential. Years of research have confirmed the critical importance of the earliest years of a child’s development.[note]See for example, Institute of Medicine. From Neurons to Neighborhoods: The Science of Early Childhood Development. (The National Academies Press. 2000), available at https://doi.org/10.17226/9824 or Center on the Developing Child at Harvard University (2016). From Best Practices to Breakthrough Impacts: A Science-Based Approach to Building a More Promising Future for Young Children and Families. Retrieved from www.developingchild.harvard.edu.[/note] The first months and years of a child’s life are marked by rapid growth and early brain development that pave the way for school readiness and overall physical and social emotional health impacting them well into adulthood. Early identification and treatment of developmental delays can help children access the services and supports they need to reach their full potential. Routine screening for all children is an important gateway to ensure those identified with certain delays or needs receive early intervention or other appropriate services that can help them meet developmental milestones and enter school ready to learn.
As many as one in four children under age 6 may be at moderate or high risk for developmental, behavioral, or social delays[note]U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, “The Health and Well-Being of Children: A Portrait of States and the Nation 2011-2012,” (U.S. Department of Health and Human Services, 2014), available at: http://mchb.hrsa.gov/nsch/2011-12/health/child/childs-health-status/risk-developmental-delay.html.[/note]. Larger shares of young children of color are at risk for delays compared with their white peers[note]Ibid (2).[/note]. Young children living in poverty (100 percent of the federal poverty line, or FPL) are more than twice as likely to be at high risk of developmental delay than those in families with incomes more than double the poverty line (above 200 percent FPL).[note]Child Trends: Data Bank, “Screening and Risk for Developmental Delay: Indicators of Child and Youth Well-Being,” (Child Trends, July 2013), available athttps://www.childtrends.org/indicators/screening-and-risk-for-developmental-delay/.[/note]
Routine, universal developmental screenings as recommended by pediatric and child development experts work to identify children with or at risk of such delays. A screen is the first step in a process to uncover an issue that warrants a closer, more detailed evaluation. That evaluation may, in turn, determine whether a child and their family should be referred to early intervention services or other supports. Yet more consequential than a screen itself is what happens once a child is identified as needing referrals and additional services. Children with developmental delays wait, on average, nine months after a parent’s stated concern to receive follow-up assessments and supports.[note]G. Kenney and J. Pelletier, “Improving the Lives of Young Children: The Role of Developmental Screenings in Medicaid and CHIP,” (Urban Institute, December 2010), available at https://www.urban.org/sites/default/files/publication/29436/412275-Improving-the-Lives-of-Young-Children-.PDF[/note] This wait could have serious implications: The sooner children get to early intervention and treatment, the sooner their delays can be successfully addressed. Ensuring children receive developmental screenings, specifically, marks one step toward identifying and addressing their needs. For example, a child with speech challenges that go unchecked could enter preschool or kindergarten behind. A screening could detect hearing challenges, a speech disorder, or other delays. Early identification and treatment can mitigate negative impacts on a child’s development and improve their ability to thrive in school.
What are developmental screenings?
Use of the term “developmental screening” can denote different things to different people in different sectors. A child’s growth and development should be regularly measured to identify any delays or problems that require further monitoring or intervention. Developmental screening differs from the broader monitoring or “surveillance” that should occur during every regular checkup, where a healthcare, community, or school-based professional observes the child and asks parents about their physical and cognitive progress.[note]“Developmental Monitoring and Screening,” Centers for Disease Control and Prevention, available at http://www.cdc.gov/ncbddd/childdevelopment/screening.html [/note] As defined and recommended by the American Academy of Pediatrics (AAP), developmental screening entails using a validated, standardized tool during well-child visits at regular intervals to determine if a child is meeting developmental milestones at various ages and stages.
Developmental screening tools focus on issues such as motor, communications, problem-solving and social development.[note]Examples of commonly used standardized tools include the Ages and Stages Questionnaires (ASQ), the Parents’ Evaluation of Developmental Status (PEDStest), and the Survey of Well-being of Young Children (SWYC). A full list is available at US Department of Health and Human Services, “Birth to 5: Watch Me Thrive! A Compendium of Screening Measures for Young Children,” (US Department of Health and Human Services, March 2014), available at https://www.acf.hhs.gov/sites/default/files/ecd/screening_compendium_march2014.pdf[/note] These tools usually consist of an evidence-based parent questionnaire or series of questions answered by parents or caregivers, as the most frequent observer of their child’s developmental progress.[note]US Department of Health and Human Services, “Birth to 5: Watch Me Thrive! A Compendium of Screening Measures for Young Children,” (US Department of Health and Human Services, March 2014), available at https://www.acf.hhs.gov/sites/default/files/ecd/screening_compendium_march2014.pdf[/note] Research has shown that using a validated screening tool, beyond surveillance alone, to ask parents about their child’s development can more accurately identify a child’s risk of a developmental delay or disability.[note]C. Bethell., et al., “Rates of Parent-centered Developmental Screening: Disparities and Links to Services Access,” Pediatrics (2011): 146-155. Also see Guevara, J., et al., “Effectiveness of Developmental Screening in an Urban Setting, Pediatrics, (2013): 30-37, available at http://pediatrics.aappublications.org/content/131/1/30.[/note] This means that rather than asking typical questions, the professional uses a validated tool that has been research tested in health care practices and other community settings and has shown consistent results, compared to surveillance. Screening results that signal concerns prompt further follow-up, which could include a range of actions, from gathering additional child and family history, asking follow-up questions, close monitoring, referrals to specialists for diagnosis and treatment, or others.
AAP’s Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents[note]Bright Futures Guidelines (Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. American Academy of Pediatrics; 2017). Periodicity schedule available at https://www.aap.org/en-us/documents/periodicity_schedule.pdf Periodicity schedule available at https://www.aap.org/en-us/documents/periodicity_schedule.pdf[/note], provides medical providers with an evidence-based template for preventive care screenings and well-child visits. Bright Futures recommends as a best practice that a developmental screening occur at pediatric well-child visits when a child is 9 months, 18 months and 30 months old.[note]American Academy of Pediatrics. “Identifying infants and young children with developmental disorders in the medical home: An algorithm for developmental surveillance and screening,” Pediatrics, (2006): 405–420.[/note]
Pediatricians also use well-child visits as opportunities to screen and address the broader social, economic, educational, environmental, and related needs of the children and families they serve. The Bright Futures Guidelines recommend a full host of child health screenings that are important for child development, including check-ups for vision, hearing, social/emotional health, and autism. The 2017 update of the guidelines also recommends that pediatricians screen for social determinants of health, such as poverty and food insecurity, as well as for parent or caregiver depression or mental health, which can also greatly affect a child’s development.[note] See for example: American Academy of Pediatrics, “Poverty and Child Health in the United States,” (American Academy of Pediatrics, 2016), available at http://pediatrics.aappublications.org/content/pediatrics/early/2016/03/07/peds.2016-0339.full.pdf.
[/note] This broader range of physical, developmental and social-emotional screens offers the most thorough look at a child’s overall development. This brief, however, refers to the narrower AAP definition of developmental screenings, which excludes autism screenings. This specific definition is also reflected in the available state-level survey data detailed below and in the appendices.