AMERICAN ACADEMY OF PEDIATRICSCommittee on Children With Disabilities

Developmental Surveillance and Screening of Infantsand Young Children

ABSTRACT. Early identification of children with de-velopmental delays is important in the primary care set-ting. The pediatrician is the best-informed professionalwith whom many families have contact during the first 5years of a child’s life. Parents look to the pediatrician tobe the expert not only on childhood illnesses but also ondevelopment. Early intervention services for childrenfrom birth to 3 years of age and early childhood educa-tion services for children 3 to 5 years of age are widelyavailable for children with developmental delays or dis-abilities in the United States. Developmental screeninginstruments have improved over the years, and instru-ments that are accurate and easy to use in an officesetting are now available to the pediatrician. This state-ment provides recommendations for screening infantsand young children and intervening with families toidentify developmental delays and disabilities.

ABBREVIATIONS. IDEA, Individuals With Disabilities EducationAct; CHAT, Checklist for Autism in Toddlers.

BACKGROUND

Developmental and behavioral problems arecommonly seen by pediatricians and otherprimary care practitioners. According to a

recent estimate, 12% to 16% of American childrenhave developmental or behavioral disorders.1 Iden-tifying and addressing these concerns is of greatimportance so that appropriate intervention can beinstituted. The primary care practitioner’s office isthe only place where most children younger than 5years are seen and is ideal for developmental andbehavioral screening.

Developmental surveillance is an important tech-nique used by pediatricians. Dworkin defined devel-opmental surveillance as “a flexible, continuous pro-cess whereby knowledgeable professionals performskilled observations of children during the provisionof health care. The components of developmentalsurveillance include eliciting and attending to paren-tal concerns, obtaining a relevant developmental his-tory, making accurate and informative observationsof children, and sharing opinions and concerns withother relevant professionals.”2 Pediatricians oftenuse age-appropriate developmental checklists torecord milestones during preventive care visits aspart of developmental surveillance.

Screening is a “brief assessment procedure de-signed to identify children who should receive moreintensive diagnosis or assessment.”3 Developmentalscreening is aimed at identifying children who mayneed more comprehensive evaluation. It communi-cates the pediatrician’s interest in the child’s devel-opment, not just his or her physical health.4 Devel-opmental evaluation may lead to a definitivediagnosis, development of an interdisciplinary com-prehensive plan of remediation, realization that thereis no significant problem, or a decision that addi-tional observation is warranted.

The Individuals With Disabilities Education Act(IDEA) Amendments of 19975 mandate early identi-fication of, and intervention for, developmental dis-abilities through the development of community-based systems. Because the passage of IDEA, theemphasis of screening has shifted to identifying dis-abilities at a younger age, with the current focusbeing on infants and children from birth through 2years of age. At this age, the pediatrician is involvedvery closely with children and families and is in aposition to have significant impact on their function-ing. The IDEA requires physicians to refer childrenwith suspected developmental delays in a timelymanner to the appropriate early intervention system.

The pediatrician has specific roles within the sys-tem that are described in a recent policy statement bythe Committee on Children With Disabilities.6 Chil-dren and families are best served when pediatricians’screening efforts are coordinated with tracking andintervention services available in the community.Developmental surveillance and screening duringpreventive health care visits also provide the idealopportunity for the pediatrician to offer anticipatoryguidance to the family about supporting their child’sdevelopment.

STATEMENT OF THE PROBLEMThe emphasis on earlier identification creates the

opportunity to provide the benefits of early interven-tion but also poses greater challenges in screening.Parents expect their pediatricians to give them guid-ance on developmental issues but will turn to othercommunity systems if the pediatrician does not fillthis role. Lack of appropriate physician guidancemay result in delays in diagnosis and appropriateintervention. Detecting developmental delays earlyis challenging. Delays or deviations in developmentmay come to the attention of professionals and par-ents because a child is known to have risk factors byhistory, has physical findings or medical conditions

The recommendations in this statement do not indicate an exclusive courseof treatment or serve as a standard of medical care. Variations, taking intoaccount individual circumstances, may be appropriate.PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad-emy of Pediatrics.

192 PEDIATRICS Vol. 108 No. 1 July 2001

likely to be associated with delays, or manifests de-lays at the time of observation. A delay in a skillbecomes evident only at the age when a specificdevelopmental milestone is expected. Early recogni-tion of delays requires in-depth knowledge of theprecursors to the skill as well as clinical judgment.Waiting until a young child misses a major mile-stone, such as walking or talking, may result in laterather than early recognition. It is especially impor-tant to recognize delays in language skills early, be-cause early intervention may improve the outcomeof children with hearing loss and may enable earlierdiagnosis of children with mental retardation andpervasive developmental disorders.7,8 Universalhearing screening is especially important in the im-proving language skill outcome and is recommendedby the American Academy of Pediatrics.9

Mild delays and deviations are often hard to de-tect, because children develop in spurts and, at times,discontinuously. Developmental disabilities also en-compass a spectrum of problems of varying kindsand severity. Although there is broad agreement asto what constitutes clear-cut delay or deviation, thereis not complete consensus among professionals orbetween parents and physicians as to the severity atwhich evaluation and intervention become appropri-ate. The central dilemma for the pediatrician whoscreens patients is that identification must precedethe provision of services, and the act of identifying achild as one who needs a thorough evaluation fordevelopmental disabilities provokes anxiety in par-ents. This concern may create a tendency to identifyonly markedly delayed children, denying other chil-dren potential access to needed care.

Child development is a dynamic process and isoften hard to measure by its very nature. The variousstreams of development, including gross motor, finemotor, language, cognitive, and adaptive behavior,are interrelated and complex within themselves.Children develop skills variably and show a newskill inconsistently when first mastering it. A singletest at one point in time only gives a snapshot of thedynamic process, making periodic screening neces-sary to detect emerging disabilities as a child grows.

Developmental screening tests have inherent lim-itations that have led to controversy regarding theiruse. Developmental testing of young children,whether for screening or evaluation, has limited abil-ity to predict future functioning but is a valid andreliable way to assess skills in a variety of domains.Developmental screening tools undergo extensivetesting for validity, reliability, and accuracy and arestandardized using children and families who repre-sent the cultural, linguistic, and economic diversityof the intended population to be as accurate as pos-sible.

Sensitivity and specificity of developmentalscreening tools are measured by comparing the testresults to that of gold-standard developmental eval-uation tools. Good developmental screening testshave sensitivities and specificities of 70% to 80%largely because of the nature and complexity of mea-suring the continuous process of child develop-ment.10 This leads to overdetection and underdetec-

tion. Because screening needs to be periodic, a childnot detected by a single screening will be detected bya subsequent screening. Children who have beenoverreferred may benefit from other community pro-grams as well as a close watch on their development.However, when pediatricians use only clinical im-pressions rather than formal screening, estimates ofchildren’s developmental status are much less accu-rate.11,12

The advantages of developmental screening in-struments are that they state their norms explicitly,serve as a reminder to the pediatrician to observedevelopment, are an efficient way to record the ob-servations, and help the pediatrician identify morechildren with delays. The major disadvantage to thepediatrician is that they take time and effort to ad-minister and interpret, which are largely not reim-bursed. Therefore, developmental screening instru-ments are not widely used in pediatric practice.13–15

NEW DEVELOPMENTSThe science of developmental testing has im-

proved in the last 10 years, making it easier for thepediatrician to accurately and efficiently screen de-velopment. Parental report of skills and concern hadbeen considered too inaccurate to be used as ascreening tool alone. However, several studies haveshown that parental report of current skills is predic-tive of developmental delay.16–18 This has led to thedevelopment of parental report instruments thathave been well tested in economically and culturallydiverse populations and provide accurate informa-tion about development. Barriers to the use of parentreport instruments are the inability to read or under-stand the language. Both of these can be easily over-come through oral administration or translation. Theexplicit use of parental reports has the added advan-tage of parents being active participants in the eval-uation of their children and shows respect for theirexpertise.

Systematically eliciting parental concern about de-velopment is an important new method of identify-ing infants and young children with developmentalproblems. Parental concerns about language, fine-motor, cognitive, and emotional-behavioral develop-ment are highly predictive of true problems.19–22

Recently, Glascoe19 has shown that by asking aboutdevelopmental concerns systematically, the pediatri-cian can screen for developmental delays as effec-tively as by using formal developmental screeningtools that require developmental examination of thechild.

Pediatricians now have many developmentalscreening tools from which to choose. The best in-struments have good psychometric properties, in-cluding adequate sensitivity, specificity, validity,and reliability, and have been standardized on di-verse populations. Parent report instruments, such asthe Parents’ Evaluation of Developmental Status,23

Ages and Stages Questionnaires,24 and Child Devel-opment Inventories,25 have excellent psychometricproperties and the advantage of requiring much lesstime from the pediatrician than instruments that re-quire direct examination. Instruments such as the

AMERICAN ACADEMY OF PEDIATRICS 193

Denver-II screening test,26 Bayley Infant Neurode-velopmental Screener,27 Battelle Developmental In-ventory,28 Early Language Milestone Scale,29 andBrigance Screens30–32 involve direct examination ofthe child’s skills. The CAT-CLAMS is a promisingtest designed specifically for pediatricians to use inthe office that assesses the child’s cognitive and lan-guage skills independently and uses parental reportand direct testing of the child’s skills.33 These instru-ments are listed as examples and should not be con-sidered specific endorsements.

Each screening instrument has strengths andweaknesses. For example, the Denver-II screeningtest is used widely but has modest sensitivity andspecificity depending on the interpretation of ques-tionable results.34 Each test also needs to be admin-istered with adherence to specific instructions; oth-erwise, results are not valid. The choice of testingmethod may depend on risk factors in the popula-tion, time allotted for the procedure, availability ofother sources of developmental screening in the com-munity, and personal preference of the pediatrician.Recent reviews of commonly used screening instru-ments35–37 can help guide the pediatrician’s choice ofscreening instruments.

Screening for behavioral and psychosocial prob-lems in young children poses particular challenges.Children with developmental delays are at higherrisk for behavioral problems. Many developmentalscreening instruments for young children do not ad-dress these areas adequately. Asking specific ques-tions is most important. Tools such as the Tempera-ment and Atypical Behavior Scale,38 ChildBehavioral Checklist,37 The Carey TemperamentScales,40 Eyberg Child Behavior Inventory,41 Pediat-ric Symptom Checklist,42 and Family PsychosocialScreening,43 among others, are helpful in detectingbehavioral concerns.

Lately, there has been increased interest in screen-ing toddlers for autistic spectrum disorders becauseof a perceived rise in prevalence and availability ofearly diagnosis and intervention. The AmericanAcademy of Neurology and the Child NeurologySociety recently published a practice parameter thatrecommends use of developmental screening toolswith good sensitivity and specificity at every preven-tive care visit, use of specific probe questions forearly signs of autism, and use of specific autismscreening tools when concerns arise.44 Specific au-tism screening tools, such as the Checklist for Autismin Toddlers (CHAT),45 may help guide the pediatri-cian in additional diagnostic referral but may pro-vide false reassurance because of poor sensitivityand excellent specificity.46 Additional information onscreening young children for autism is contained inthe American Academy of Pediatrics policy state-ment and technical report “The Pediatrician’s Role inthe Diagnosis and Management of Autistic SpectrumDisorder in Children.”47,48 Developmental screeningprograms will take time and effort to administer inthe pediatric office setting. A recent cost-benefit anal-ysis of developmental screening approaches, includ-ing costs of administration, interpreting results, di-agnostic testing, and treatment, showed that the use

of parental reports was by far the least costly to thepediatrician in the short term.49 However, reim-bursement for developmental screening services isoften inadequate, especially when it is consideredpart of the preventive care visit rather than a sepa-rate service. A separate Current Procedural Terminol-ogy code exists for developmental screening (96110);however, reimbursement is inconsistent.50

RECOMMENDATIONSAll infants and young children should be screened

for developmental delays. Screening proceduresshould be incorporated into the ongoing health careof the child as part of the provision of a medicalhome, as defined by the Academy.51 To screen fordevelopmental delays or disabilities and intervenewith the identified children and their families, theprimary pediatrician providing the medical homeshould:

1. Maintain and update her or his knowledge aboutdevelopmental issues, risk factors, screening tech-niques, and community resources, such as earlyintervention, school, Title V, and other communi-ty-based programs, for consultation, referral, andintervention.

2. Acquire skills in the administration and interpre-tation of reliable and valid developmental screen-ing techniques appropriate for the population.

3. Develop a strategy to provide periodic screeningin the context of office-based primary care, includ-ing the following:• Recognizing abnormal appearance and func-

tion during health care maintenance examina-tions;

• Recognizing medical, genetic, and environmen-tal risk factors while taking routine medical,family, and social histories;

• Listening carefully to parental concerns and ob-servations about the child’s development dur-ing all encounters;

• Recognizing troubled parent-child interactionby reviewing history or by observation;

• Performing periodic screenings of all infantsand young children during preventive care vis-its; and

• Recognizing the importance that test proce-dures and processes be culturally sensitive andappropriate to the population.

4. Present the results of the screening to the familyusing a culturally sensitive, family-centered ap-proach.

5. With parental agreement, refer children with de-velopmental delays in a timely fashion to the ap-propriate early intervention and early childhoodeducation programs and other community-basedprograms serving infants and young children.

6. Determine the cause of delays or refer to appro-priate consultant for determination. Screen hear-ing and vision to rule out sensory impairments.

7. Maintain links with community-based resources,such as early intervention, school, and other com-munity-based programs, and coordinate care withthem.

194 DEVELOPMENTAL SURVEILLANCE AND SCREENING

8. Increase parents’ awareness of developmental dis-abilities and resources for intervention by suchmethods as display and distribution of educa-tional materials in the office.

9. Be available to families to interpret consultants’findings.

Ongoing involvement with the family permits thepediatrician to respond to parental concerns aboutthe child’s development when such concerns exist.When parents are not aware that a delay exists, thepediatrician can guide them toward closer observa-tion of the child and, thus, enable them to recognizethe delay. Referral for evaluation and services cantake place only after the pediatrician has succeededin this challenging task. At that point, the pediatri-cian’s role shifts to one of involvement in the evalu-ation as appropriate, referral to available communityresources for intervention and family support, assis-tance in understanding the evaluation results, assess-ment and coordination of services, and monitoringthe child’s developmental progress as part of theprovision of a medical home.

CONCLUSIONEarly identification of children with developmen-

tal delays or disabilities can lead to treatment of, orintervention for, a disability and lessen its impact onthe functioning of the child and family. Because de-velopmental screening is a process that selects chil-dren who will receive more intensive evaluation ortreatment, all infants and children should bescreened for developmental delays. Developmentalsurveillance is an important method of detecting de-lays. Moreover, the use of standardized developmen-tal screening tools at periodic intervals will increaseaccuracy. Pediatricians should consider using stan-dardized developmental screening tools that arepractical and easy to use in the office setting. Suc-cessful early identification of developmental disabil-ities requires the pediatrician to be skilled in the useof screening techniques, actively seek parental con-cerns about development, and create links withavailable resources in the community.

Committee on Children With Disabilities, 2000–2001

Adrian D. Sandler, MD, ChairpersonDana Brazdziunas, MDW. Carl Cooley, MDLilliam Gonzalez de Pijem, MDDavid Hirsch, MDTheodore A. Kastner, MDMarian E. Kummer, MDRichard D. Quint, MD, MPHElizabeth S. Ruppert, MD

LiaisonsWilliam C. Anderson

Social Security AdministrationBev Crider

Family VoicesPaul Burgan, MD, PhD

Social Security AdministrationConnie Garner, RN, MSN, EdD

US Department of Education

Merle McPherson, MDMaternal and Child Health Bureau

Linda Michaud, MDAmerican Academy of Physical Medicine andRehabilitation

Marshalyn Yeargin-Allsopp, MDCenters for Disease Control and Prevention

Section LiaisonsJ. Daniel Cartwright, MD

Section on School HealthChris P. Johnson, MEd, MD

Section on Children With Disabilities

StaffKaren Smith

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