Objectives

  • Identify the importance of early and appropriate screening for potential developmental delay.
  • Apply an action/process and decision sequence from the American Academy of Pediatrics Algorithm for Developmental Surveillance and Screening.
  • Identify two developmental screening requirements for a Texas Health Steps medical checkup.
  • Identify one standardized developmental screening tool.

Texas Health Steps and Developmental Screening

The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) service is Medicaid's comprehensive preventive child health (medical, dental, and case management) for individuals from birth through age 20. In Texas, EPSDT is known as Texas Health Steps. EPSDT is defined by federal law as part of the Omnibus Budget Reconciliation Act (OBRA) of 1989 legislation and includes periodic screening, vision, hearing, and dental preventive and treatment services. In addition, Section 1950(r)(5) of the Social Security Act requires that any medically necessary health-care service listed in the Act be provided to Texas Health Steps (EPSDT) recipients even if the service is not available under the State's Medicaid plan to the rest of the Medicaid population. These additional services are available through the Comprehensive Care Program (CCP).

According to federal regulations, an EPSDT exam must include:

  1. comprehensive health and developmental history, including physical and mental health and development;
  2. comprehensive unclothed physical examination;
  3. immunizations appropriate for age and health history;
  4. laboratory tests appropriate to age and risk, including lead toxicity screening; and
  5. health education, including anticipatory guidance.

Texas Health Steps providers may be required to perform additional services or screening during a medical check-up, as described in the Texas Medicaid Provider Procedures Manual (TMPPM).

Visit the U.S. HHS Health Resources and Services Administration website for more information about federal requirements of EPSDT.

Developmental Surveillance and Screening

The authors of “Selecting Developmental Surveillance and Screening Tools” (Pediatrics in Review, 2008) noted that the importance of developmental surveillance and screening has been well established in scholarly reviews and practice guidelines. Early detection of clinically significant developmental problems facilitates early intervention, which can reduce negative consequences of developmental delays or disorders for the child and family and maximize the child's developmental potential.

In 2010, the American Academy of Pediatrics (AAP) reaffirmed their 2006 Policy Statement titled Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening. In this statement, the authors recommend that primary care providers incorporate developmental surveillance in every well-child preventive care visit, that any concerns raised during surveillance be promptly addressed with standardized screening tools, and that screening tools should be used according to the recommended schedule.

The Policy Statement describes developmental surveillance as a flexible, longitudinal, continuous, and cumulative process whereby knowledgeable health-care professionals identify children who may have developmental problems. According to the AAP, there are five components of developmental surveillance:

  1. Eliciting and attending to the parent's concerns about their child's development.
  2. Documenting and maintaining a developmental history.
  3. Making accurate observations of the child.
  4. Identifying the risk and protective factors.
  5. Maintaining an accurate record and documenting the process and findings.

Developmental screening is the administration of a standardized tool that helps to identify children who might have a developmental disorder or delay. Screening tools incorporate the observations of parents or caregivers and health-care providers to assess whether a child is meeting developmental milestones. Conducting developmental screening does not provide conclusive evidence of developmental disorder or delay, or result in a diagnosis. Rather, screening identifies areas in which a child's development differs from same-age norms.

This algorithm, which helps to determine when to shift from surveillance to standardized screening, is the central component of the AAP Policy Statement.

Developmental Surveillance and Screening Algorithm Within a Pediatric Preventive Care Visit

Developmental Surveillance and Screening Algorithm Within a Pediatric Preventive Care Visit

Source: American Academy of Pediatrics

Use the following link to view the full AAP 2006 Policy Statement, Identifying Infants and Young Children With Developmental Disorders in the Medical Home.

Why We Screen

The AAP states that early identification of developmental disorders is critical to the well being of children and their families. It is an integral function of the primary care medical home and an appropriate responsibility of all pediatric health-care professionals. Delayed or disordered development can be caused by specific medical conditions and may indicate an increased risk of other medical complications. Developmental delays or disorders may also indicate an increased risk of behavior disorders or associated developmental disorders. According to the AAP, integrating developmental surveillance and screening into preventive care visits gives providers an ideal opportunity to offer anticipatory guidance to the family as well as facilitate early detection.

Early identification should lead to further evaluation, diagnosis, and treatment. Early intervention is available for a wide range of developmental disorders; their prompt identification can spur specific and appropriate therapeutic interventions. Identification of a developmental disorder and its underlying etiology may also affect a range of treatment planning, from medical treatment of the child to family planning for his or her parents.

Immediate and Long-Term Effects of Early Detection of Developmental Delays

According to the CDC, many developmental delays are not being identified in early childhood. In the United States, 17 percent of children have a developmental or behavioral disability, such as autism, intellectual disabilities, and Attention-Deficit/Hyperactivity Disorder (ADHD). In addition, many children have delays in language or other areas, which also impact school readiness. However, less than 50 percent of these children are identified as having a problem before starting school, by which time significant delays may have already occurred and opportunities for early treatment have been missed.

Research has demonstrated that early detection of developmental disabilities and appropriate intervention can significantly improve functioning and reduce the need for lifelong interventions. For example, children with autism identified early and enrolled in early intervention programs show significant improvements in their language, cognitive, social, and motor skills, as well as in their future educational placement. Children who participate in early intervention programs prior to kindergarten are more likely to graduate from high school, hold jobs, live independently, and avoid teen pregnancy, delinquency, and violent crime. These positive outcomes save society between $30,000 and $100,000 per child.

Many disabilities are subtle, and children who have them may appear to be developing normally, especially at younger ages. Screening is designed for the asymptomatic child, who is thought to be developing normally. Children with obvious problems should be referred promptly for early intervention.

Surveys have indicated that parents and caregivers want information and guidance from their health-care provider about their child's development, but studies sponsored by the AAP show that 65 percent of pediatricians feel inadequately trained in assessing children's developmental status.

Test your Knowledge

The best reason(s) to use a scientifically validated screening instrument in your practice (such as those approved by Texas Health Steps) is/are:

Your answer is correct!
Section 3 will provide suggestions about how to integrate developmental screening tools into a medical practice.

Sorry, your answer is incorrect.
Section 3 will provide suggestions about how to integrate developmental screening tools into a medical practice.

Texas Health Steps Screening Requirements

Similar to health-care plans, Texas Health Steps has based the developmental screening requirements contained in the Medical Checkups Periodicity Schedule for Infants, Children, and Adolescents (Birth Through 20 Years of Age) on the AAP's recommendations. The Texas Health Steps Periodicity Schedule specifies timing for the delivery of all well-child checkups. Note that this schedule may be updated, and providers should always refer to the latest schedule available which may be found at the DSHS Texas Health Steps website under the Provider Information link.

According to the 2010 updated Periodicity Schedule, developmental surveillance or screening is a required component of each checkup for patients birth through 6 years of age. Checkups at 9, 18 and 24 months, and 3 and 4 years of age require the use of a standardized screening tool of the provider's choice. The Ages and Stages Questionnaire (ASQ), Ages and Stages Questionnaire: Social and Emotional (ASQ SE), or Parent Evaluation of Developmental Status (PEDS) screening tool may be used and submitted for separate reimbursement. If other developmental screening tools are used, the provider may not submit for reimbursement. Checkups at 18 months also require a standardized screening tool for autism. The Modified Checklist for Autism in Toddlers (M-CHAT) is one tool that may be used and is the only tool for autism that may be reimbursed.

A standardized screen is not required for checkups at other ages listed on the Texas Health Steps Periodicity Schedule; however, developmental surveillance is required at these visits and includes a review of milestones (gross and fine motor skills; communication skills, speech-language development; self help/care skills; social, emotional, and cognitive development; and mental health).

Listed below are three samples of standardized, validated tests that may be included as evidence-based best practice. The use of ASQ, ASQ-SE, PEDS and M-CHAT is mandatory as of September 1, 2011. Providers may use ASQ-SE by itself if desired.

The following table provides a guideline of screening ages and their corresponding appropriate screening tools.

Texas Health Steps-Recommended Standardized Screening Tools

Screening Ages Developmental Screening Tools Autism Screening Tools
9 months ASQ or PEDS  
12 months ASQ or PEDS if not completed at 9 months or if provider/parental concern  
18 months ASQ or PEDS M-CHAT
24 months ASQ or PEDS  
30 months ASQ or PEDS if not completed at 24 months or if provider/parental concern  
3 years ASQ or ASQ-SE or PEDS  
4 years ASQ or ASQ-SE or PEDS  

Note: AAP Guidelines state that the M-CHAT should also be performed at 24 months; however, Texas Health Steps providers will not be reimbursed for a second M-CHAT screening without documentation of the rationale in the medical record for the additional screen.

A developmental screen requiring use of a standardized screening tool is limited to once a year outside of a Texas Health Steps checkup when medically necessary and should only be completed for a diagnosis of suspected developmental delay or to evaluate a change in the patient's developmental status. When a developmental screen is provided outside of a Texas Health Steps checkup, documentation supporting the medical necessity must be maintained in the patient's medical record, or the reimbursement will be subject to recoupment. Refer to the current TMPPM and/or the latest Provider Bulletins or Banner messages for further information.

For more information about developmental screening, enroll in the Texas Health Steps provider education module, Developmental Screening.

Benefits of Using Surveillance and Standardized Screening Tools

The AAP describes both developmental surveillance and screening as best practices that support the early detection of developmental delays or disabilities. Because development is dynamic in nature and surveillance and screening have limits, periodic screening with a validated instrument should occur so a problem not detected by surveillance or a single screening can be detected by subsequent screening.

Formal, validated screening instruments offer these advantages:

Furthermore, informal tools, such as checklists on many encounter forms, miss many developmental problems. These are often based on instruments (such as the original Denver Developmental Screening Test), which missed up to 50 percent of intellectual impairment and 70 percent of language impairment.

Clinical judgment alone detects fewer than 30 percent of children who have developmental disabilities (Macias, 2006). The validated screening tools provide objective measures to detect possible problems.

One broad category of screening uses the health-care provider's observations of the child completing age-appropriate tasks. Another category of screening uses parent questionnaires, which can be completed independently by parents or caregivers who have adequate literacy, or the health-care provider can administer any of the recommended questionnaires as an interview. The recommended screening tools described below consist of parent questionnaires that are scored and interpreted by the provider.

Recommended Screening Tools

The AAP, the American Academy of Neurology (AAN), the Child Neurology Society, the First Signs organization, dedicated to the early identification of children with developmental delays, and many others rate the ASQ and PEDS as high quality developmental screening tools.

The AAN specifically recommends tools with abundant psychometric support, such as national standardization, reliability (of several types), validation against criterion diagnostic tests, and accuracy, i.e., sensitivity and specificity of 70 percent or greater. The ASQ, PEDS, and M-CHAT Screens fulfill these criteria.

Ages and Stages Questionnaire (ASQ)

The ASQ is for children 1 month to 6 years of age and includes a review of communication, gross motor skills, fine motor skills, and problem solving skills. A second screen, the Ages and Stages Questionnaire: Social-Emotional (ASQ-SE) screens for personal-social issues (self-regulation, compliance, communication, adaptive functioning, autonomy, affect, and interaction with people). Parents/caregivers complete the questionnaires and then professionals, paraprofessionals, or a clerical staff member can score them. ASQ questionnaires are designed for specific age levels, and they are available in Spanish and English.

Some specific ASQ benefits include:

ASQ is designed to be easy to use by staff with varying levels of education and expertise, and it can be learned with little training. To help providers implement ASQ into their practice, the ASQ program offers video training tools that show staff how to screen, score, and interpret results. For providers wanting further training, the ASQ program also offers flexible on-site training for providers and their staff.

Steps for using ASQ:

Click the following link to download the ASQ Questionnaire.

Once you have the scores:

Parent's Evaluation of Developmental Status (PEDS)

PEDS is both an evidence-based surveillance tool and a screening test that is designed for children birth to 8 years of age. It contains ten short questions that elicit parent or caregiver perspectives on their child for each developmental domain. One parent response form is used for all age ranges, and it is available in several languages. Parents or caregivers can complete the form in five minutes; providers can complete scoring and interpret the results in two minutes.

Steps for using PEDS:

  1. Have the parent or caregiver answer the questions on the PEDS Response Form. The questions elicit parent or caregivers perspective on their child for each developmental domain.
  2. Find the appropriate column for the child's age, categorize parent or caregiver concerns, and mark the box in the column for the types of concerns present. Shaded checkboxes indicate concerns that are predictive of disabilities. Unshaded checkboxes are concerns that, while important to parents, do not predict developmental problems. Totals are recorded at the bottom for shaded and unshaded checkboxes. The types and frequencies of parent concerns lead to one of five evidence-based decision-making paths.

PEDS Score Form

PEDS Score Form

Source: Parents' Evaluation of Developmental Status

  1. On the back of the PEDS Score Form is an Interpretation Form with an algorithm for deciding whether to refer, screen further, watch carefully, counsel parent or caregiver, or simply reassure them. The space on the right of the form is for recording these clinical decisions and action steps.

Click here for more information about PEDS.

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